Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses

BACKGROUND

Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups.

METHODS

Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019-February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others-remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3-<12 h) or lengthier (12-168 h) hospital courses.

RESULTS

We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%) after short and 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83-1.13) and 0.94 (0.85-1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%) after short and 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90-0.98) and 0.95 (0.91-0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2-8.1% risk of 30-day mortality and 3.5-22.6% risk of 30-day readmission.

CONCLUSIONS

In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.

Association Between First-Time Neurologic Events and Metronidazole Treatment: A Case-Time Control Study

PURPOSE

Metronidazole, a widely used antimicrobial medication, has been linked to neurologic adverse drug reactions. This study investigates the association between metronidazole use and first-time neurologic events.

METHODS

We conducted a case-time-control study using data from the Danish National Patient Register and the National Prescription Register in years 2013 to 2021. Patients with a first-time diagnosis of encephalopathy, cerebellar dysfunction, or peripheral neuropathy were included. Conditional logistic regression analyses were performed to estimate the risk of neurologic events associated with metronidazole use.

FINDINGS

Out of 476,066 first-time metronidazole prescriptions, the 100-day cumulative incidence of peripheral neuropathy was 0.016%, and 0.002% for cerebellar dysfunction or encephalopathy. In the case-time control study, we identified 17,667 persons with a first-time neurologic event and were included for the analysis. The estimated odds ratio for the combined neurologic events was 0.98 (95% CI, 0.59-1.64, P = 0.95) with no statistically significant association across different subgroups and time windows.

IMPLICATIONS

Our findings suggest that metronidazole-induced neurologic events may be rarer than previously described, and we did not find any consistent or statistically significant association between metronidazole exposure. Nonetheless, clinicians should remain vigilant to potential neurologic risks in patients receiving metronidazole, to ensure its safe and effective use.

Incidence and Characteristics of the Hyperosmolar Hyperglycemic State: A Danish Cohort Study

OBJECTIVE

The hyperosmolar hyperglycemic state (HHS) is a rare and life-threatening complication of diabetes. We aimed to estimate the incidence of HHS and describe the clinical and biomarker profiles of patients with HHS, including subgroups with acidosis and acute kidney injury.

RESEARCH DESIGN AND METHODS

This nationwide, descriptive cohort study used Danish registry data during years 2016-2018 to identify acutely admitted patients fulfilling the hyperglycemia and hyperosmolarity criteria of HHS (glucose ≥33 mmol/L and osmolarity [2 × sodium + glucose] ≥320 mmol/L).

RESULTS

We identified 634 patients (median age, 69 years (first quartile; third quartile: 58; 79) who met the criteria of HHS among 4.80 million inhabitants aged ≥18 years. The incidence rates were 16.5 and 3.9 per 10,000 person-years among people with known type 1 (n = 24,196) and type 2 (n = 251,357) diabetes, respectively. Thirty-two percent of patients with HHS were not previously diagnosed with diabetes. Patients were categorized as pure HHS (n = 394) and combined HHS and diabetic ketoacidosis (HHS-DKA; n = 240). The in-hospital mortality rate for pure HHS was 17% and 9% for HHS-DKA.

CONCLUSIONS

The incidence of HHS was higher among patients with type 1 diabetes compared with type 2 diabetes. HHS is a spectrum of hyperglycemic crises and can be divided in pure HHS and HHS-DKA. In one-third of patients, HHS was the debut of their diabetes diagnosis.

Predicting Short-Term Mortality in Older Patients Discharged from Acute Hospitalizations Lasting Less Than 24 Hours

Purpose

Over coming decades, a rise in the number of short, acute hospitalizations of older people is to be expected. To help physicians identify high-risk patients prior to discharge, we aimed to develop a model capable of predicting the risk of 30-day mortality for older patients discharged from short, acute hospitalizations and to examine how model performance changed with an increasing amount of information.

Methods

This registry-based study included acute hospitalizations in Denmark for 2016-2018 lasting ≤24 hours where patients were permanent residents, ≥65 years old, and discharged alive. Utilizing many different predictor variables, we developed random forest models with an increasing amount of information, compared their performance, and examined important variables.

Results

We included 107,132 patients with a median age of 75 years. Of these, 3.3% (n=3575) died within 30 days of discharge. Model performance improved especially with the addition of laboratory results and information on prior acute admissions (AUROC 0.835), and again with comorbidities and number of prescription drugs (AUROC 0.860). Model performance did not improve with the addition of sociodemographic variables (AUROC 0.861), apart from age and sex. Important variables included age, dementia, number of prescription drugs, C-reactive protein, and eGFR.

Conclusion

The best model accurately estimated the risk of short-term mortality for older patients following short, acute hospitalizations. Trained on a large and heterogeneous dataset, the model is applicable to most acute clinical settings and could be a useful tool for physicians prior to discharge.

Socioeconomic outcomes beyond 30 years of age in a cohort born with very low birth weight

AIM

As survival of infants born prematurely has increased dramatically, questions on long-term consequences have emerged. Our aim was to investigate long-term effects of very low birth weight on socioeconomic outcomes.

METHODS

One hundred and fifty very low birth weight infants (VLBW) born from 1980 to 1982 at Rigshospitalet, Denmark, who had previously been followed up at age 2, 4 and 18 years, were compared to cohorts of low birth weight, normal birth weight (NBW) and a national population-based reference cohort. From the Danish national registers we obtained data regarding educational level, financial independence and living arrangements. In addition, we used the previously published results from the three cohorts.

RESULTS

The VLBW cohort had lower intelligence quotient and higher risk of significant school difficulties evaluated at age 4 and 18 years. When compared to the NBW cohort, at 30-36 years of age the VLBW cohort tended to have lower educational level, OR 1.7, 95% CI 0.8-3.9, were not financially independent OR 1.5, 95% CI 0.6-3.7, lived alone OR 2.0, 95% CI 1.0-3.8 and had higher rates of the combination of all three outcomes, OR 3.2, 95% CI 0.7-15.8.

CONCLUSIONS

We found trends towards poor socioeconomic outcomes in young adults born with VLBW. The relative disadvantages appeared smaller than that in childhood.

Association of COVID-19 Infection With Wearing Glasses in a High-Prevalence Area in Denmark and Sweden

Importance

Observational studies have indicated that glasses might protect against contracting COVID-19 through reduced airborne and contact transmission.

Objective

To investigate the association between wearing one's own glasses with contracting COVID-19 when adjusting for relevant confounders.

Design, Setting, and Participants

This cohort study was conducted during the first wave of the COVID-19 pandemic (June to August 2020) in Denmark and Sweden, where personal protective equipment was not recommended for the general population at the time. Employees at Falck, an international rescue corps with different job functions (ambulance, health care, office, and field staff, firefighters, and roadside assistance) participated in the study.

Exposures

The main exposure was wearing glasses (also including contact lenses and reading glasses), which was assessed in a questionnaire. Persons wearing glasses were compared with those who did not wear glasses (ie, nonusers). To adjust for potential confounders, information on age, sex, job function, and number of workday contacts were included.

Main Outcomes and Measures

The outcome was COVID-19 infection before (positive polymerase chain reaction test) or during the study period (biweekly voluntary tests with a rapid test). The investigated hypothesis was formulated after collecting the data.

Results

A total of 1279 employees in Denmark and 841 in Sweden were included (839 [39.6%] female and 1281 [60.4%] male; 20.5% were aged <40 years; 57.0%, 40-60 years, and 22.5%, >60 years). Of these, 829 individuals (64.8%) in Denmark and 619 (73.6%) in Sweden wore glasses. Wearing glasses was inversely associated with COVID-19 infection in the Swedish cohort (odds ratio [OR], 0.61 [95% CI, 0.37-0.99]; P = .047; seroprevalence, 9.3%) but not in the Danish cohort (OR, 1.14 [95% CI, 0.53-2.45]; P = .73; seroprevalence, 2.4%). Adjusting for age, sex, job function, and number of workday contacts in Sweden, wearing glasses no longer was associated with COVID-19 infection (OR, 0.64 [95% CI, 0.37-1.11]; P = .11). When stratifying by job function, a large difference was observed among office staff (OR, 0.20 [95% CI, 0.06-0.70]; P = .01) but not ambulance staff (OR, 0.83 [95% CI, 0.41-1.67]; P = .60) nor health care staff (OR, 0.89 [95% CI, 0.35-2.30]; P = .81).

Conclusions and Relevance

While wearing one's glasses was inversely associated with COVID-19 in Sweden in an unadjusted analysis, an association no longer was identified when adjusting for confounders. These results provide inconclusive findings regarding whether wearing one's own glasses is associated with a decreased risk of COVID-19 infections.

Profiling Bispebjerg Acute Cohort: Database Formation, Acute Contact Characteristics of a Metropolitan Hospital, and Comparisons to Urban and Rural Hospitals in Denmark

Purpose

To present a metropolitan cohort, Bispebjerg acute cohort (BAC), and compare patient characteristics and outcomes with patients from urban and rural hospitals in Denmark.

Patients and Methods

We linked data from seven Danish nationwide registries and included all acute contacts to non-psychiatric hospitals in the years 2016–2018. Acute hospital contacts to Bispebjerg and Frederiksberg Hospital constituted BAC, representing a solely metropolitan/urban catchment area. Patient characteristics and outcomes were compared to the rest of Denmark in an urban cohort (UrC) and a rural cohort (RuC), stratified by visit and hospitalization contact types.

Results

We identified 4,063,420 acute hospital contacts in Denmark and BAC constituted 8.4% (n=343,200) of them. BAC had a higher proportion of visits (65.1%) compared with UrC (52.1%) and RuC (45.3%). Patients in BAC more often lived alone (visits: BAC: 34.8%, UrC: 30.6%, RuC: 29.2%; hospitalizations: BAC: 50.8%, UrC: 36.7%, RuC: 37.2%) and had temporary CPR number (visits: BAC: 4.4%, UrC: 1.9%, RuC: 1.6%; hospitalizations: BAC: 1.5%, UrC: 0.9%, RuC: 0.8%). Visit patients in BAC were younger (BAC: 36, UrC: 42, RuC: 45 years, median), more often students (BAC: 18.0%, UrC: 14.0%, RuC: 12.5%), and had more contacts due to infectious diseases (BAC: 19.8%, UrC: 14.1%, RuC: 6.2%) but less due to injuries (BAC: 40.0%, UrC: 43.8%, RuC: 60.7%). Hospitalized patients in BAC had higher median age (BAC: 64, UrC: 61, RuC: 64 years) and fewer were in employment than in UrC (BAC: 26.1%, UrC: 32.1%, RuC: 28.1%). BAC Hospitalizations had a lower death rate within 30 days than in RuC (BAC: 3.0% [2.9–3.1%], UrC: 3.1% [3.0–3.1%], RuC: 3.4% [3.3–3.4%]), but a higher readmission-rate (BAC: 20.5% [20.3–20.8%], UrC: 17.3% [17.2–17.4%], RuC: 17.5% [17.5–17.6%]).

Conclusion

Significant differences between BAC, urban, and rural cohorts may be explained by differences in healthcare structure and sociodemographics of the catchment areas.

Citizen Responder Activation in Out-of-Hospital Cardiac Arrest by Time of Day and Day of Week

Background

We aim to examine diurnal and weekday variations in citizen responder availability and intervention at out‐of‐hospital cardiac arrest (OHCA) resuscitation.

Methods and Results

We included confirmed OHCAs where citizen responders were activated by a smartphone application in the Capital Region of Denmark between September 1, 2017 and August 31, 2018. OHCAs were analyzed by time of day (daytime: 07:00 am–03:59 pm, evening: 4:00–11:59 pm, and nighttime: 12:00–06:59 am) and day of week (Monday–Friday or Saturday–Sunday/public holidays). We included 438 OHCAs where 6836 citizen responders were activated. More citizen responders accepted alarms in the evening (mean 4.8 [95% CI, 4.4–5.3]) compared with daytime (3.7 [95% CI, 3.4–4.4]) and nighttime (1.8 [95% CI, 1.5–2.2]) (P<0.001), and more accepted alarms during weekends (4.3 [95% CI, 3.8–4.9]) compared with weekdays (3.4 [95% CI, 3.2–3.7]) (P<0.001). Proportion of OHCAs where at least 1 citizen responder arrived before Emergency Medical Services were significantly different between day (42.9%), evening (50.3%), and night (26.1%) (P<0.001), and between weekdays (37.2%) and weekends (53.5%) (P=0.002). When responders arrived before Emergency Medical Services, there was no difference of bystander cardiopulmonary resuscitation or defibrillation between daytime, evening, and nighttime (P=0.75 and P=0.22, respectively) or between weekend and weekdays (P=0.29 and P=0.12, respectively).

Conclusions

Citizen responders were more likely to accept OHCA alarms during evening and weekends, with the highest proportion of responders arriving before Emergency Medical Services in the evening. However, there was no significant difference in delivering cardiopulmonary resuscitation or early defibrillation among cases where citizen responders arrived before Emergency Medical Services.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03835403.

The increased susceptibility to airway infections after preterm birth does not persist into adolescence

INTRODUCTION

Preterm birth is associated with increased risk of airway infections in childhood, more frequent purchase of prescription antibiotics and hospital admissions for airway infections. With this study, we aimed to investigate whether this association persists into adolescence.

METHODS

We conducted a longitudinal observational register-based study of a national cohort of all infants born in Denmark in 1992-2007. We used purchase of antibiotics, including penicillins and macrolides, and hospital admissions as proxies for milder and more severe forms of airway infections respectively in 1995-2010. Associations between gestational age (GA), age, year and repeated cross-sectional evaluations of antibiotic purchase and hospital admissions were explored by logistic regression analyses.

RESULTS

We included 1,043,411 children in our study population. We found a statistically significant association between GA and prescription of antibiotics as well as hospital admissions due to airway infections. In the youngest age groups, children with higher GA had lower adjusted mean rates of prescribed antibiotics for airway infections, but from the age of 10-11 years the opposite trend was noted in what appears to be a dose-response relationship. During childhood, we found an inverse dose-response relationship where ex-preterms with GA 23-27 at age 4-5 years had twice the odds of hospital admission compared to children in the same age group born at term. During adolescence, these higher odds diminished and appeared equivalent among teenagers born at term and preterm. We only found statistically significant interactions between gestational age and age.

CONCLUSION

We confirmed that preterm birth is associated with higher rates of prescribed antibiotics and higher odds of hospitalization for airway infections during childhood. However, in adolescence we found that there was no increase in hospital admissions for airway infections among ex-preterms, whereas adolescents with low GA actually appeared to purchase less prescribed antibiotics. Whether this trend persists into adulthood and the physiological explanation therefor remains to be investigated.

Gastrointestinal sequelae and growth impairment at school age following necrotising enterocolitis in the newborn period

AIM

To evaluate gastrointestinal sequelae and growth impairment at school age in children who suffered from necrotising enterocolitis (NEC).

METHODS

This historic cohort study compared all surviving children born in Denmark between 1 January 2002 and 31 December 2011 with NEC in the newborn period, to surviving children without NEC, but same gestational age, birthweight and year of birth. Outcomes were investigated through a parental questionnaire, including gastrointestinal and growth-related outcomes. We performed exploratory ad hoc analysis, by adjusting for possible confounding and by dividing NEC children into surgical and medical.

RESULTS

In total, 163 children with NEC (50%) and 237 (36%) without NEC completed the parental questionnaire. Episodes of diarrhoea were more often reported in the NEC group (p = 0.0002). The increased risk seemed to be limited to those who underwent surgery for NEC. The absence from school (1.67 versus 1.31 days), rate of low height for age (17.9 versus 12.1%) and weight (29.9 versus 31.6 kg) did not differ significantly between children with NEC and children without NEC.

CONCLUSION

Our findings suggest that long-term gastrointestinal complications following NEC appeared to be of little clinical importance at the population level and therefore do not encourage specific routine follow-up.

Incidence and risk of necrotizing enterocolitis in Denmark from 1994-2014

Introduction. We suspected that the incidence of NEC in Denmark had increased during the last 20 years but hypothesized that this could be explained by the increased neonatal survival. Methods. We conducted a retrospective, observational cohort study of all registered liveborn infants in Denmark in the period from January 1, 1994 to December 31, 2014. Data were obtained from the Medical Birth Registry, National Patient Register, and Cause of Death register in Denmark. The primary outcome was the registration of NEC (ICD-10: DP77.9) during a hospital admission within 6 months after birth. The statistical analysis used ‘death before NEC’ as a competing risk. Results. The cohort consisted of 1,351,675 infants, of which 8,059 died. There was a strongly significant decreasing risk of death over the period for the all infants (p<0.0001 in all gestational age groups). In total, 994 infants were diagnosed with NEC which lead to an incidence of 7.4 per 10,000 live-born infants. During the observation period, the incidence increased from 6.3 to 7.9 per 10,000 births (p = 0.006). When accounting for ‘death before NEC’ as a competing risk, the increase could be explained by the increased neonatal survival. There was, however, a GA-group/epoch interaction (p = 0.008) in the cause-specific hazard ratios with a trend towards an increasing risk of NEC in the most preterm infants and a decreasing risk of NEC in the term infants. Conclusion. While the overall incidence of NEC increased over the study period, the overall risk of NEC did not increase when considering the increased survival. Nevertheless, there seemed to be an increased risk of NEC in the most premature infants which was masked by a decreased risk in the term infants. This study suggests that research to prevent NEC in the most preterm infants is more important now than ever.

Behavioural and neurodevelopmental impairment at school age following necrotising enterocolitis in the newborn period

AIM

The aim of this study was to evaluate long-term behavioural and neurodevelopmental complications of neonatal necrotizing enterocolitis at school age.

METHOD

This was a historic cohort study comparing all surviving children born in Denmark between 1st of January 2002 and 31st of December 2011 with a diagnosis of necrotizing enterocolitis to a group of children without necrotizing enterocolitis, but same gestational age, birth weight and year of birth. Outcomes were investigated through a parental questionnaire. The primary outcome was the Strength and Difficulties Questionnaire score and secondary outcomes were cerebral palsy and impaired head growth.

RESULTS

Response rates were 50% (163 of 328) and 36% (237 of 652) among children with and without necrotizing enterocolitis, respectively. There was a higher rate of abnormal Strength and Difficulties score (23.9 versus 17.8%), moderate/severe cerebral palsy (3.1 versus 0.9%) and small head circumference for age (11.7 versus 7.2%) among children with necrotizing enterocolitis. However, these differences were all statistically insignificant and did not change significantly by adjustment for potential confounders.

CONCLUSION

To our knowledge, this study includes the largest cohort of necrotizing enterocolitis children evaluated for possible long-term complications at school age. The increased risks of behavioural- and neurodevelopmental impairments were statistically insignificant, moderate in magnitude and may be of little clinical importance for management in the neonatal period or when planning follow-up.

[Health-related register-based research in Denmark]

Danish researchers have a unique possibility for producing high-quality observational studies through the Danish registers. The intention of this review is to provide an introduction to data sources, access and linkage of the Danish registers, primarily from Statistics Denmark, the Danish Health Data Authority and the Danish clinical quality databases. Authorisation to data access is given by each institution separately and requires permission by the Danish Data Protection Agency. Data can be linked by the unique Central Person Registry number. Known limitations and possibilities are discussed.

The increased purchase of asthma medication for individuals born preterm seems to wane with age: A register-based longitudinal national cohort study

Introduction

Preterm birth is associated with increased risk of respiratory symptoms in childhood, often treated with asthma medication. We designed a follow-up study to previous research and investigated whether the association of gestational age with purchasing asthma medication diminishes in adulthood.

Methods

We conducted a register-based study of a national cohort of all infants born in Denmark in 1980–2009 evaluating longitudinal data on individually prescribed asthma medication (both inhaled ß-2 receptor agonist and different controller treatment over 2-year periods) available from 1995–2011. We analyzed the effect of gestational age considering age, birth year, and perinatal variables using logistic regression with a Generalized Estimating Equations model. All data were unambiguously linked through the Civil Registration System.

Results

We included 1,819,743 individuals in our study population. We found an inverse dose-response relationship between gestational age and asthma medication in earlier age-groups with a gradual decrease in odds ratios with increasing age and loss of statistical significance in early adulthood (18–31 years). For our oldest generations, there was a significant effect of gestational age (p-value = 0.04), which became insignificant when adjusting for confounding and mediating factors (p = 0.44). There were significant interactions between gestational age and age (p<0.0001) and gestational age and birth year, but these were most important during childhood (0–11 years) and for our youngest generations (born after 1995).

Conclusion

The strong association between gestational age and purchase of prescription asthma medication weakens with age into early adulthood, in consistence with the results from our previous study. The risk for purchasing medication to treat asthma-like symptoms was higher in more recent birth years, but the effect of gestational age was small beyond 11 years of age. Gestational age per se did not seem to be significant for the development of asthma-like symptoms: most of its effect could be explained by other perinatal factors.

Long-term mortality and recurrence in patients treated for colonic diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The study aimed to investigate long-term mortality, recurrence, and death related to recurrence for patients admitted with acute diverticulitis with abscess formation (Hinchey stage Ib-II).

METHODS

The cohort was identified by linking administrative registers for all Danish citizens in years 2000-2012. Patients were identified from ICD-10 discharge codes and stratified according to treatment (antibiotics, percutaneous abscess drainage, or surgery).

RESULTS

From 6,641,672 persons, 3148 patients were identified with acute diverticulitis with abscess formation. Survival was comparable between treatment groups with a 1-year survival of 81-83% and a 5-year survival of 66-67% (p = 0.66). Glucocorticoid usage prior to admission increased risk of mortality with hazard ratio 1.64 (95%CI 1.39-1.93), 1.77 (1.20-2.63), and 1.92 (1.07-3.44) for the antibiotics, drainage, and operative treatment group, respectively. Drainage treatment increased risk of recurrence with sub-distribution hazard (SDH) of 1.52 (1.19-1.95) and operative treatment decreased risk with a SDH of 0.55 (0.32-0.93), both compared with antibiotic treatment (p = 0.0001). Recurrence occurred in 23.6% (18.5-30.1%) of patients in the drainage group, 15.5% (13.9-17.3%) in the antibiotics group, and 9.1% (5.1-16.1%) in the operative group. Recurrence-related mortality was 2.0% (0.9-4.4%) for the drainage group, 1.1% (0.7-1.8%) for the antibiotics group, and 0.6% (0.1-4.3%) for the operative group (p = 0.24). Most recurrences and recurrence-related mortality occurred within the first year after primary admission.

CONCLUSIONS

This study with complete national data revealed a high mortality and recurrence rate after diverticular abscesses. Survival was comparable between treatment groups, but patients treated with drainage had significantly higher risk of recurrence.

Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

PURPOSE

This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.

METHODS

PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.

RESULTS

Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.

CONCLUSIONS

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

Short-term mortality, readmission, and recurrence in treatment of acute diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The aim of the study was to investigate short-term mortality, readmission, and recurrence in a national cohort of patients with Hinchey Ib-II diverticulitis.

METHODS

The retrospective cohort-investigation was conducted using a database consisting of the entire Danish population (n = 6,641,672) in year 2000-2012, formed by linking the Danish Registers. Patients admitted with acute Hinchey Ib-II diverticulitis were identified from ICD-10 discharge codes and stratified according to treatment into an operative, drainage, and antibiotics group. The primary outcome was 30-day mortality from admission, secondary outcomes were mortality, readmission, and recurrence within 30 days post-discharge. The study was reported using RECORD guidelines.

RESULTS

A total of 3148 eligible patients were identified. The cohort had a mean age of 65.1 year, 25.6 % had previously been admitted with diverticulitis, and 48.1 % had registered comorbidities. Within 30 days from admission, 8.7 % of the patients died. Of patients discharged, 2.5 % died, 23.8 % was readmitted, and 5.9 % was readmitted due to diverticulitis within 30 days from discharge. In multivariate analyses, increasing age was associated with mortality at odds-ratio (95 % CI) 1.10 (1.09-1.12). Previous complicated and uncomplicated diverticulitis reduced mortality with odds-ratio 0.50 (0.33-0.76) and 0.73 (0.58-0.92), while uncomplicated diverticulitis also increased risk of recurrence with odds-ratio 1.51 (1.24-1.84). Glucocorticoid usage was associated with mortality with odds-ratio 1.49 (1.23-1.81) and readmission with odds-ratio 2.91 (1.24-6.80).

CONCLUSION

Acute diverticulitis with abscess formation is a severe and life-threatening condition. Direct comparisons of treatment groups were not possible due to possible confounding by indication.

Correlation between depression and burden observed in informal caregivers of people suffering from dementia with time spent on caregiving and dementia severity

OBJECTIVE

The aim of the study is to compare data on the examined population of informal caregivers of people suffering from dementia with previous studies, as well as to assess the correlation between (i) depression determined on the basis of the Center for Epidemiologic Studies Depression Scale and (ii) caregiver burden measured by means of the Zarit Caregiver Burden Scale and some chosen parameters, such as total time devoted to caregiving, time of caregiving in hours per week and level of dementia severity measured by Global Deterioration Scale.

PATIENTS AND METHODS

41 informal caregivers of people suffering from dementia from different backgrounds were evaluated using the Zarit Caregiver Burden Scale and the Center for Epidemiologic Studies Depression Scale. Demographic data about the time devoted to caregiving and the number of hours spend on caregiving weekly were gathered. The type of dementia and its stage were registered using the Global Deterioration Scale (GDS). With the aid of the Statistica StatSoft program, mutual correlations between the parameters were measured. The study was conducted within the framework of AAL UnderstAID--a platform that supports and helps to understand and assist caregivers in the care of a relative with dementia. The international project is co-founded by the Joint Programme Ambient Assisted Living (Grant code: ESR-aal 2012 5 107).

RESULTS

No significant correlations between the level of depression severity evaluated in caregivers and the total time of taking care of a demented person or time of caregiving in hours per week were observed. Similarly, no significant correlation between depression severity level and dementia severity level measured on the GDS scale were noted. There was also no significant correlation between Zarit Caregiver Burden Scale scores and the above-mentioned parameters.

CONCLUSIONS

The level of depression among caregivers do not depend on socio-demographic factors.

A specific and sensitive method for visualization of tumor necrosis factor in the murine central nervous system

We present here sensitive, simple and robust methods for detection of tumor necrosis factor (TNF) mRNA and TNF in histological sections and homogenates of brain tissue from mice subjected to focal cerebral ischemia or hippocampal axonal lesioning. Both types of lesions are characterized by induction of TNF synthesis in resident microglial cells, which in the ischemic lesions are supplemented by TNF synthesizing, blood-borne macrophages. In situ hybridization for TNF mRNA is performed using alkaline phosphatase-labelled oligodeoxynucleotide probes. These probes show excellent rendition of individual cells, and can successfully be combined with immunohistochemical procedures. We also describe a sensitive immunohistochemical method for detection of TNF, which can be combined with visualization of an additional antigen. The specificity of the histological procedures are confirmed by RT-PCR and Western blot analysis on homogenates prepared from microdissected brain regions. Advantages and disadvantages of the methods are discussed with emphasis on the specificity and sensitivity of the histological procedures. Our strategy for detection of TNF mRNA and protein provides a solid basis for clarifying the cellular synthesis, regulation and function of TNF in the normal, injured or diseased CNS. Furthermore, the methodology can readily be applied in studies of other cytokines and growth factors in the CNS.

Focal cerebral ischemia induces increased myelin basic protein and growth-associated protein-43 gene transcription in peri-infarct areas in the rat brain

Although oligodendrocytes are vulnerable to focal cerebral ischemia, remyelination of denuded or regenerating axons in the peri-infarct area has been observed in the central nervous system. We studied the expression of myelin basic protein (MBP), a major component of central nervous system myelin, in peri-infarct areas in adult rat brain after transient middle cerebral artery occlusion (MCAO) and correlated it to the expression of the growth-associated protein-43 (GAP-43), a marker for axonal regeneration and sprouting, using non-radioactive in situ hybridization techniques. Within the infarct, MBP messenger RNA (mRNA) had disappeared by 24 h, whereas myelin protein, identified by MBP and myelin oligodendrocyte glycoprotein (MOG) immunohistochemistry, appeared structurally intact until day 3. Peri-infarct oligodendrocytes increased their expression of MBP mRNA from 24 h to maximal levels at day 7, corresponding to the appearance of process-bearing MBP and occasional MOG-immunoreactive oligodendrocytes in parallel sections. Quantitative analysis revealed significant increases in the density of oligodendrocytes (up to 7.6-fold) and in the level of MBP mRNA expressed by individual cells. Parallel sections showed that increased expression of GAP-43 mRNA in neurons was concomitant to MBP mRNA upregulation in oligodendrocytes. While the mechanisms regulating oligodendrocyte survival and myelination signals are not clear at this point, axonal sprouting could putatively serve as a stimulus for the upregulation of oligodendrocyte cell numbers, differentiation state, and/or active myelination in the peri-infarct areas.

Microglia and macrophages are the major source of tumor necrosis factor in permanent middle cerebral artery occlusion in mice

The proinflammatory cytokine tumor necrosis factor (TNF) is known to be expressed in brain ischemia; however, its cellular and temporal appearance is not fully settled. In this study, nonradioactive in situ hybridization for murine TNF mRNA was performed on brain sections from adult C57x129 mice at 6 hours, 12 hours, 24 hours, 2 days, 5 days, or 10 days (six to eight mice per group) after induction of permanent focal cerebral ischemia. Cortical infarct volumes were estimated, and TNF mRNA-expressing cells were counted within the infarct and infarct border using Cast-Grid analysis. At 12 hours, a peak of 19.2 +/- 5.1 TNF mRNA-expressing cells/mm2 was counted, contrasting two to three times lower values at 6 and 24 hours (6.4 +/- 4.6 and 9.2 +/- 3.4 cells/mm2, respectively) and <2 cells/mm2 at 48 hours and later stages. The TNF mRNA-expressing cells were distributed along the entire rostrocaudal axis of the cortical infarcts and occasionally within the caudate putamen. At all time points, TNF mRNA colocalized with Mac-1-positive microglia/macrophages but not with Ly-6G (Gr-1)-positive polymorphonuclear leukocytes. Similarly, combined in situ hybridization for TNF mRNA and immunohistochemistry for glial fibrillary acidic protein at 12 and 24 hours revealed no TNF mRNA-expressing astrocytes at these time points. Translation of TNF mRNA into bioactive protein was demonstrated in the neocortex of C57B1/6 mice subjected to permanent middle cerebral artery occlusion. In summary, this study points to a time-restricted microglial/macrophage production of TNF in focal cerebral ischemia in mice.

Resident macrophages (ramified microglia) of the adult brown Norway rat central nervous system are constitutively major histocompatibility complex class II positive

A flow cytometric phenotype for isolated adult central nervous system (CNS) ramified microglia was previously defined (CD45low CD11b/c+) in the Lewis strain rat, that clearly distinguished these cells from all blood-derived leucocytes, the latter being CD45high. Consistent with the reported lack of major histocompatibility complex (MHC) expression in the CNS, isolated microglia were mostly MHC class II-. Employing these phenotypic criteria, we now show that a proportion of microglia in Brown Norway (BN) strain rats are constitutively MHC class II+. In spinal cord, up to 25% of microglia are distinctly positive and most have some level of expression. In situ staining of MHC class II+ microglial cells in BN rats indicates that positive cells are typical of ramified microglia on the grounds of both morphological appearance and anatomical location. In Lewis (LEW) rats, the few MHC class II-expressing cells isolated from the normal CNS are CD45high blood-derived cells and not resident microglia. After infection of both LEW and BN rats with a neurotropic murine hepatitis virus (MHV-JHM), MHC class II was rapidly upregulated on microglia in the BN but not in the LEW strain. In the latter, inflammatory cells were the predominant MHC class II-expressing population. Nevertheless, most microglia in the LEW strain could, after some delay, be induced to express MHC class II after transfer of an experimental autoimmune encephalomyelitis (EAE)-inducing encephalitogenic T cell line. Paradoxically, strains resistant to EAE (exemplified by the BN) contained more constitutive MHC class II-expressing microglia than susceptible ones, when a variety of strains were examined. The results clearly establish that the normal CNS may contain MHC class II-expressing cells that are a resident rather than a transient blood-derived population. It is significant that this expression is strain related, but there is no evidence that microglial cell constitutive MHC class II expression predisposes to EAE susceptibility.