LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge

Background

The LACE index scoring tool (Length of stay, Acuity of admission, Co-morbidities and Emergency department visits) has been designed to predict hospital readmissions. We evaluated the ability of the LACE index to predict age-specific frequent admissions and mortality.

Methods

Analysis of prospectively collected data of alive-discharge episodes between 01/04/2017 and 31/03/2019 in an NHS hospital. Data on 14,878 men and 17,392 women of mean age 64.0 years, SD = 20.5, range 18.0–106.7 years were analysed. The association of the LACE index with frequency of all-cause readmissions within 28 days of discharge and over a 2-year period, and with all-cause mortality within 30 days or within 6 months after discharge from hospital were evaluated.

Results

Within LACE index scores of 0–4, 5–9 or ≥ 10, the proportions of readmission ≥ 2 times within 28 days of discharge were 0.1, 1.3 and 9.2% (χ² = 3070, p < 0.001) and over a 2-year period were 1.7, 4.8 and 19.1% (χ² = 3364, p < 0.001). Compared with a LACE index score of 0–4, a score ≥ 10 increased the risk (adjusted for age, sex and frequency of admissions) of death within 6 months of discharge by 6.8-fold (5.1–9.0, p < 0.001) among all ages, and most strongly in youngest individuals (18.0–49.9 years): adjusted odds ratio = 16.1 (5.7–45.8, p < 0.001). For those aged 50–59.9, 60–69.9, 70–79.9 and ≥ 80 years, odds ratios reduced progressively to 9.6, 7.7, 5.1 and 2.3, respectively. Similar patterns were observed for the association of LACE index with mortality within 30 days of hospital discharge.

Conclusions

The LACE index predicts short-term and long-term frequent admissions and short-term and medium-term mortality, most pronounced among younger individuals, after hospital discharge.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

MRI in adult patients with aortic coarctation: diagnosis and follow-up

Aortic coarctation is a disease that usually presents in infancy; however, a proportion of patients present for the first time in adulthood. These lesions generally require repair with either surgery or interventional techniques. The success of these techniques means that increasing numbers of patients are presenting for follow-up imaging in adulthood, whether their coarctation was initially repaired in infancy or as adults. Thus, the adult presenting to the radiologist for assessment of possible coarctation or follow-up of coarctation repair is not an uncommon scenario. In this review, we present details of the MRI protocols and MRI findings in these patients so that a confident and accurate assessment can be made.

Association of micropapillary urothelial carcinoma of the bladder and BK viruria in kidney transplant recipients

INTRODUCTION

BK virus (BKV) is an ubiquitous human polyomavirus that establishes latency in urothelium. BKV is known to re-activate in immunosuppressed individuals, and is an increasingly important cause of nephropathy and graft loss in kidney transplant recipients. Animal studies have demonstrated BKV has a potential role as a tumor virus. However, its role in precipitating or facilitating oncogenesis in humans is still debated.

REPORT

We report 2 cases of aggressive micropapillary urothelial carcinoma of the bladder in kidney transplant recipients with persistent BK viruria and preserved graft function.

RESULTS

In both cases, polyomavirus immunohistochemistry performed on the tumor specimens was strongly positive, and limited to the malignant tissue. BKV DNA, viral protein 1, and large T antigen mRNA were detected in the tumor; however, no viral particles were seen on electron microscopy.

CONCLUSION

In one of the cases, BKV integration into the host genome was identified, leading to the truncation of the major viral capsid gene. This finding raises the concern that persisting BK viruria may be a risk factor for this aggressive form of bladder cancer. Further studies to determine screening and management strategies are required.

Multiple Mycobacterium antigens induce interferon-gamma production from sarcoidosis peripheral blood mononuclear cells

Studies of sarcoidosis immunology have noted oligoclonal T cell populations, suggesting cell-mediated immunity that is antigen-specific. Sarcoidosis immunology and pathology are most similar to mycobacterial infections. Mycobacterium tuberculosis infection in mice and humans reflects T helper 1 (Th1) immune responses to multiple cell wall and secreted antigens. We investigated if the oligoclonal immune response in individual sarcoidosis subjects could be elicited by multiple secreted mycobacterial antigens by performing ex vivo enzyme-linked immunospot assay (ELISPOT) on peripheral blood mononuclear cells (PBMC) from 30 sarcoidosis, 26 purified protein derivative negative (PPD-) control and 10 latent tuberculosis subjects (PPD+) to assess Th1 responses to mycobacterial superoxide dismutase A (sodA), catalase-peroxidase (katG) and early secreted antigenic target protein (ESAT-6). A significant difference was noted among the sarcoidosis and PPD- control subjects to ESAT-6 [12 of 30 versus one of 26 (P = 0.0014)], katG [nine of 30 versus none of 26 (P = 0.002)] and sodA [12 of 30 versus none of 26 (P = 0.002)]. There was no significant difference between sarcoidosis and PPD+ subjects. Twelve sarcoidosis subjects recognized two or more mycobacterial proteins, as well as multiple distinct epitopes within individual proteins. One sarcoidosis subject on whom we collected bronchoalveolar lavage (BAL) fluid and PBMC had no recognition of mycobacterial antigens using PBMC, but BAL fluid demonstrated strong Th1 immune responses to ESAT-6 and katG. Individual sarcoidosis subjects recognized not only multiple mycobacterial proteins, but multiple distinct peptides within a specific protein, thus demonstrating that multiple mycobacterial epitopes elicit the Th1 immune response observed. Immune responses by sarcoidosis T cells to mycobacterial proteins may have an important role in sarcoidosis pathogenesis.

Facilitating learning in the community with lecturer-practitioner posts

The purpose of this paper is to present a case study of the perspectives of their role of a group of community lecturer-practitioners and a community teacher, who referred to themselves as 'community facilitators'. A qualitative design was used and data were collected by semi-structured interviews. These were transcribed and content analysis was undertaken. All participants provided a liaison role between the college and the community practitioners, prepared students for their clinical experience and assisted in relating theory to practice. The participants described how they managed the role and how they supported each other. Developing small teams of facilitators may provide a bridge between teachers and practitioners and can serve as a basis for further study of the lecturer-practitioner role.

Establishing radiologic image transmission via a transmission control protocol/Internet protocol network between two teaching hospitals in Houston

The technical and management considerations necessary for the establishment of a network link between computed tomography (CT) and magnetic resonance imaging (MRI) networks of two geographically separated teaching hospitals are presented. The University of Texas Medical School at Houston Department of Radiology provides radiology residency training at its primary teaching hospital and at a second county-run hospital located approximately 12 miles away. A direct network link between the two hospitals was desired to permit timely consultative services to residents and professional colleagues. The network link was established by integrating the county hospital free-standing imaging network into the network infrastructure of the Medical School and the main teaching hospital. Technical issues involved in the integration were reassignment of internet protocol (IP) addresses, determination of data transmission protocol compatibilities, proof of connectivity and image transmission, transmission speeds and network loading, and management of the new network. These issues were resolved in a planned stepwise fashion and despite the fact that the system has a rate-limiting T1 segment between the county hospital and the teaching hospital the transmission speed was deemed suitable. The project has proven successful and can provide a guide for planning similar projects elsewhere. It has in fact made possible several new services for the teaching and research activities of the department's faculty and residents, which were not envisaged before the implementation of this connection.

Continuing education needs of community nurses, midwives and health visitors for supervising and assessing students

The objective of this study was to ascertain the changing educational needs of community nurses, midwives and health visitors in relation to the teaching, supervising and assessing of pre- and post-registration students. A questionnaire was sent to all education institutions providing community nursing experience in England (Whittaker et al. 1997), which allowed identification of three centres for in-depth study. Questionnaires were sent to practitioners (community nurses and midwives, health visitors and school nurses), their managers, and teachers of community courses in the three centres: 314 were returned. Eight semi-structured interviews were undertaken with volunteers in each of the study centres (n = 24). Extensive demands are being made on community staff to provide learning experiences for students on a wide range of courses. Practitioners reported that in order to fulfil their teaching and assessing functions they needed continuing education in matters which would assist them to provide research-based practice and education, teaching and assessing in the community and personal skills, for example assertiveness and counselling. Less than a quarter of practitioners were undertaking continuing education courses. However, opportunities for further academic study varied enormously and most practitioners had to study in their own time at their own expense.

A survey of community placements for educational programmes in nursing and midwifery

In this paper preliminary findings from the first stage of an English National Board (ENB) commissioned study investigating the educational needs of community practitioners in relation to their responsibilities for student learning are presented. A national postal survey of all educational centres offering nurse and/or midwifery education was undertaken in the latter half of 1993. Information was collected regarding the nature and planning of the community practice components of courses. The main methods of support for practitioners included the provision of the ENB 998/997 courses and liaison meetings between educational centres and community practice areas. Practitioners were often required to both supervise and assess students on practice placements, the length of these placements varying enormously. For those centres offering the mental health and learning disability branches of the Diploma in Higher Education in Nursing Studies (Project 2000), a significant proportion lacked teachers with specialist community qualifications. The investigation took place at a time of great upheaval, with 42% of centres reporting that they were in the process of amalgamation. The findings demonstrate that community nurses and midwives undoubtedly contribute to the education of nurse and midwife students and consequently have educational needs which must be addressed if they are to continue to supervise students.

The Colorectal Cancer Recurrence Support (CARES) System

Colorectal cancer has risen in incidence to become the second commonest form of cancer in Singapore. The primary treatment is surgery but up to 50% of patients still suffer from recurrence of the cancer after surgery. Early identification of recurrence will increase the effectiveness of therapy and the survival of patients. This paper describes the CARES (Cancer Recurrence Support) System, whose objective is to predict the recurrence of colorectal cancer, using Case-based Reasoning (CBR), and supported by other techniques such as data mining and natural language processing. The CARES System employs CBR to compare and contrast between the new and past colorectal cancer patient cases, and makes inferences based on those comparisons to determine the high risk patient groups. The features and functionality of the system are described.

Questions & answers in industrial relations

Can being at work make you sick? With ever-increasing workloads and constant pressure for change, midwives will understand all too clearly what Trades Union Congress General Secretary John Monks recently called "a pressure cooker work environment". Recent surveys by the TUC and a number of other trade unions show that employers are failing to take the matter of workplace stress seriously-notwithstanding the devastating effects it can have on the lives of their staff.

5-Fluorouracil and recombinant interferon alfa-2a: review of activity and toxicity in advanced colorectal carcinomas

Improved response rates in metastatic colorectal carcinoma recently have been observed for the combination of 5-fluorouracil (5-FU) and recombinant interferon alfa-2a (rIFN), compared to those obtained in historical trials of single-agent 5-FU. The mechanism of interaction between these agents has not been explored adequately but may relate to biochemical modulation of 5-FU by rIFN. Toxicities resulting from this combination have included fever, chills, myalgias, granulocytopenia, mucositis, diarrhea, skin rash, neurological symptoms, and hand-foot syndrome. Future studies of 5-FU with rIFN should investigate schedules aimed at reducing toxicity without compromising efficacy and also should explore mechanisms of enhanced activity.

The nurse's role in the withdrawal of medical treatment

Ethical issues involved in the withdrawal of medical treatment are discussed from a nursing perspective. Arguments pro and con are presented.

Call that code! Simulated code practices

This article deals with the planning and implementation of simulated code blue practice sessions for licensed staff. Use of situational role play utilizing the actual equipment is emphasized. Strategies for implementing a program as well as strengths and weaknesses of one such program are discussed.

Developmental control of Drosophila yolk protein 1 gene by cis-acting DNA elements

In this paper we have demonstrated that at least two tissue-specific cis-acting DNA elements are necessary for the normal developmental pattern of Drosophila yp1 gene expression. One of these elements is necessary for expression in the adult female follicle cells and the other is necessary for expression in adult female fat bodies. We have localized the fat body expression element to a 125-bp fragment that lies between nucleotides -196 and -321 of the yp1 gene. This small fragment has at least one of the characteristics of enhancer sequences because it can direct a heterologous Drosophila promoter to be transcribed with the yp1 fat body expression pattern.

The painful hip

Diagnosis of the cause of a painful hip joint can be difficult. Some conditions require urgent diagnosis and management but in many instances careful observation over a period of time constitutes good management of the patient.

Neonates at risk. Screening for deafness--practical or not?

Over a six-year period, 3,507 neonates in King George V Memorial Hospital, classified as being at risk for deafness, were screened for hearing. Although 144 failed to respond in the nurseries, 88 of them were cleared at a later test. The remainder, whether suspect, untraceable or still to return, would all be outside the neonatal period by now. No sensorineural impairment of hearing was detected in all neonates in the programme.