Publications by Year: 2018

OBJECTIVE: To investigate whether hospital readmission after admission for heart failure (HF), myocardial infarction (MI), and pneumonia varies by season.

DATA SOURCES: All patients in 2005-2009 Healthcare Cost and Utilization Project State Inpatient Databases for New York and California hospitalized for HF, MI, or pneumonia.

STUDY DESIGN: The relationship between discharge season and unplanned readmission within 30 days was evaluated using multivariate modified Poisson regression.

PRINCIPAL FINDINGS: Cohorts included 869,512 patients with HF, 448,945 patients with MI, and 813,593 patients with pneumonia. While admissions varied widely by season, readmission rates only ranged from 25.0 percent (spring) to 25.6 percent (winter) for HF (p > .05), 18.9 percent (summer) to 20.0 percent (winter) for MI (p < .001), and 19.4 percent (spring) to 20.3 percent (summer) for pneumonia (p < .001). In adjusted models, in New York, there was lower readmission in spring and fall (RR: 0.98, 95% CI: 0.96-0.99 for both) after admission for HF and higher readmission in spring (RR: 1.04, 95% CI: 1.01-1.07) after MI. In California, there was lower readmission in spring and winter (RR: 0.95, 95% CI: 0.93-0.96 and RR: 0.96, 95% CI: 0.94-0.98, respectively) after pneumonia.

CONCLUSIONS: Given marked seasonality in incidence and mortality of HF, MI, and pneumonia, the modest seasonality in readmissions suggests that readmissions may be more related to non-seasonally dependent factors than to the seasonal nature of these diseases.

BACKGROUND: Chemical peels have shown efficacy in the treatment of acne, photoaging, and pigmentary dyschromias; however, studies evaluating side effects, particularly in patients with skin of color, are limited.

OBJECTIVE: We sought to determine the frequency of side effects and complications associated with superficial chemical peels in patients with skin types III-VI.

METHODS: A 5-year single center retrospective analysis was performed.

RESULTS: Of 473 chemical peel treatments included in this study, 18 (3.8%) were associated with short-term (≤2 weeks) or long-term (>2 weeks) complications. The most frequent complications were crusting (2.3%), postinflammatory hyperpigmentation (1.9%), and erythema (1.9%). All side effects resolved within 8 months of treatment and were located on the face. When stratified by season, side effects were noted to be less common during the winter. In the adjusted model, Fitzpatrick skin type VI was associated with a higher odds of side effects (odds ratio 5.14, 95% confidence interval 1.21-21.8; P = .0118).

LIMITATIONS: Single center retrospective design.

CONCLUSION: In this study, superficial chemical peels performed on patients with skin types III-VI had a relatively low complication rate, and skin type VI had higher odds of experiencing an adverse event. Side effects were noted to be less frequent during the winter months.

Patients discharged on oral anticoagulant (OAC) therapy after percutaneous coronary intervention (PCI) represent a complex population and are at higher risk of early readmission. The reasons and predictors of early readmission in this group have not been well characterized. We identified patients in an integrated health care system who underwent PCI between 2009 and 2014 and were readmitted within 30 days within this health care system. Of the 9,357 patients surviving to discharge after the index PCI, 692 were readmitted within 30 days (7.4%). At the time of readmission, 143 had been discharged from the index PCI hospitalization on OACs (96.5% on warfarin) and 549 had not been discharged on OACs, with readmission rates of 12.9% and 6.7%, respectively (p<0.01). The most common reason for readmission among all patients was chest pain syndromes (21.7% on OACs, 34.4% not on OACs). However, bleeding represented the next most frequent cause of readmission among patients on OACs (14.0% on OACs vs 6.0% not on OACs, p<0.01). Among patients on OAC therapy, peripheral arterial disease (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.07-2.57, p = 0.02) and nonelective PCI (OR 1.91, 95% CI 1.17-3.12, p<0.01) were found to be independent predictors of 30-day readmission. During rehospitalization, compared to patients not on OACs, patients on OACs suffered a higher unadjusted rate of mortality (6.3% vs 1.8%, p<0.01) and a longer length of stay (6.4 ± 7.1 days vs 4.9 ± 6.8 days, p = 0.02). In conclusion, patients discharged on OAC therapy after PCI are commonly readmitted, with bleeding representing a major reason. These readmissions are associated with high mortality and longer lengths of stay. Interventions targeted towards optimizing discharge planning for these complex patients are needed to potentially reduce readmissions.

BACKGROUND: Few contemporary studies have assessed the management and outcomes of patients with massive and submassive pulmonary embolism. Given advances in therapy, we report contemporary practice patterns and event rates among these patients.

METHODS: We analyzed a prospective database of patients with massive and submassive pulmonary embolism. We report clinical characteristics, therapies, and outcomes stratified by pulmonary embolism type. Treatment escalation beyond systemic anticoagulation was defined as advanced therapy. Cox proportional hazards regression was used to identify predictors of 90-day mortality.

RESULTS: Among 338 patients, 46 (13.6%) presented with massive and 292 (86.4%) with submassive pulmonary embolism. The average age was 63 ± 15 years, 49.9% were female, 32.0% had malignancy, and 21.9% had recent surgery. Massive pulmonary embolism patients received advanced therapy in 71.7% (30.4% systemic thrombolysis, 17.4% catheter-directed thrombolysis, 15.2% surgical embolectomy) and had greater 90-day mortality rates compared with submassive pulmonary embolism patients (41.3% vs 12.3%, respectively; P < .01). Most massive pulmonary embolism deaths (78.9%) occurred in-hospital, whereas mortality risk persisted after discharge for submassive pulmonary embolism. After multivariable adjustment, massive pulmonary embolism was associated with a 5.23-fold greater hazard of mortality (95% confidence interval, 2.70-10.13; P < .01). Advanced therapies among all pulmonary embolism patients were associated with a 61% reduction in mortality (95% confidence interval, 0.20-0.76; P < .01).

CONCLUSIONS: Among contemporary massive and submassive pulmonary embolism patients, mortality remains substantial. Advanced therapies were frequently utilized and independently associated with lower mortality. Further investigation is needed to determine how to improve outcomes among these high-risk patients, including the optimal use of advanced therapies.

OBJECTIVE: To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft.

DESIGN: Randomized controlled trial.

SETTING: Private or commercial aircraft between September 2017 and August 2018.

PARTICIPANTS: 92 aircraft passengers aged 18 and over were screened for participation. 23 agreed to be enrolled and were randomized.

INTERVENTION: Jumping from an aircraft (airplane or helicopter) with a parachute versus an empty backpack (unblinded).

MAIN OUTCOME MEASURES: Composite of death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing.

RESULTS: Parachute use did not significantly reduce death or major injury (0% for parachute v 0% for control; P>0.9). This finding was consistent across multiple subgroups. Compared with individuals screened but not enrolled, participants included in the study were on aircraft at significantly lower altitude (mean of 0.6 m for participants v mean of 9146 m for non-participants; P<0.001) and lower velocity (mean of 0 km/h v mean of 800 km/h; P<0.001).

CONCLUSIONS: Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.

BACKGROUND: Although individual cardiac biomarkers are associated with heart failure risk and all-cause mortality in HIV-infected individuals, their combined use for prediction has not been well studied.

METHODS AND RESULTS: Unsupervised k-means cluster analysis was performed blinded to the study outcomes in 332 HIV-infected participants on 8 biomarkers: ST2, NT-proBNP (N-terminal pro-B-type natriuretic peptide), hsCRP (high-sensitivity C-reactive protein), GDF-15 (growth differentiation factor 15), cystatin C, IL-6 (interleukin-6), D-dimer, and troponin. We evaluated cross-sectional associations of each cluster with diastolic dysfunction, pulmonary hypertension (defined as echocardiographic pulmonary artery systolic pressure ≥35 mm Hg), and longitudinal associations with all-cause mortality. The biomarker-derived clusters partitioned subjects into 3 groups. Cluster 3 (n=103) had higher levels of CRP, IL-6, and D-dimer (inflammatory phenotype). Cluster 2 (n=86) displayed elevated levels of ST2, NT-proBNP, and GDF-15 (cardiac phenotype). Cluster 1 (n=143) had lower levels of both phenotype-associated biomarkers. After multivariable adjustment for traditional and HIV-related risk factors, cluster 3 was associated with a 51% increased risk of diastolic dysfunction (95% confidence interval, 1.12-2.02), and cluster 2 was associated with a 67% increased risk of pulmonary hypertension (95% confidence interval, 1.04-2.68), relative to cluster 1. Over a median 6.9-year follow-up, 48 deaths occurred. Cluster 3 was independently associated with a 3.3-fold higher risk of mortality relative to cluster 1 (95% confidence interval, 1.3-8.1), and cluster 2 had a 3.1-fold increased risk (95% confidence interval, 1.1-8.4), even after controlling for diastolic dysfunction, pulmonary hypertension, left ventricular mass, and ejection fraction.

CONCLUSIONS: Serum biomarkers can be used to classify HIV-infected individuals into separate clusters for differentiating cardiopulmonary structural and functional abnormalities and can predict mortality independent of these structural and functional measures.