Romero‐Brufau, Santiago

Objective Create a score to identify patients at risk of death or hospice placement who may benefit from goals of care discussion earlier in the hospitalisation. Design Retrospective cohort study to develop a risk index using multivariable logistic regression. Setting Two tertiary care hospitals in Southeastern Minnesota. Participants 92 879 adult general care admissions (50% male, average age 60 years). Primary and secondary outcome measures Our outcome measure was an aggregate of inhospital death or discharge to hospice. Predictor variables for the model encompassed comorbidities, nutrition status, functional status, demographics, fall risk, mental status, Charlson Comorbidity Index and acuity of illness on admission. Resuscitation status, race, geographic area of residence and marital status were added as covariates to account for confounding. Results Inhospital mortality and discharge to hospice were rare, with incidences of 1.2% and 0.8%, respectively. The Hospital End-of-Life Prognostic Score (HELPS) demonstrated good discrimination (C-statistic=0.866 in derivation set and 0.834 in validation set). The patients with the highest 5% of scores had an 8% risk of the outcome measure, relative risk 12.9 (10.9–15.4) when compared to the bottom 95%. Conclusions HELPS is able to identify patients with a high risk of inhospital death or need for hospice at discharge. These patients may benefit from early goals of care discussions.

BACKGROUNDThe use of rapid response systems (RRS), which were designed to bring clinicians with critical care expertise to the bedside to prevent unnecessary deaths, has increased. RRS rely on accurate detection of acute deterioration events. Early warning scores (EWS) have been used for this purpose but were developed using heterogeneous populations. Predictive performance may differ in medical vs surgical patients.OBJECTIVETo evaluate the performance of published EWS in medical vs surgical patient populations.DESIGNRetrospective cohort study.SETTINGTwo tertiary care academic medical center hospitals in the Midwest totaling more than 1500 beds.PATIENTSAll patients discharged from January to December 2011.INTERVENTIONNone.MEASUREMENTSTime‐stamped longitudinal database of patient variables and outcomes, categorized as surgical or medical. Outcomes included unscheduled transfers to the intensive care unit, activation of the RRS, and calls for cardiorespiratory resuscitation (“resuscitation call”). The EWS were calculated and updated with every new patient variable entry over time. Scores were considered accurate if they predicted an outcome in the following 24 hours.RESULTSAll EWS demonstrated higher performance within the medical population as compared to surgical: higher positive predictive value (P < .0001 for all scores) and sensitivity (P < .0001 for all scores). All EWS had positive predictive values below 25%.CONCLUSIONSThe overall poor performance of the evaluated EWS was marginally better in medical patients when compared to surgical patients.

Abstract Transient neonatal zinc deficiency ( TNZD ) has a clinical presentation similar to that of acrodermatitis enteropathica but is caused by a low zinc concentration in maternal breast milk. TNZD becomes clinically evident during breastfeeding and is resolved by weaning and the introduction of complementary nutrition. We present a 4‐month‐old girl with TNZD due to a new autosomal dominant mutation (663delC) in the maternal SLC 30A2 gene not previously described in the literature.

Background— Clinical outcomes after stent placement in patients with a history of metal allergy remain incompletely understood. We performed a single-center retrospective study to evaluate such outcomes. Methods and Results— Twenty-nine allergic patients who underwent coronary stent implantation were compared with a nonallergic group (n=250) matched for demographics and a propensity score for allergy to metal. Hypersensitivity to nickel was reported in 26 of 29 and chromium in 9 of 29. Patch testing performed in 11 of 29 patients was positive in all. Comparing allergy versus control subjects, there were no differences in number of segments treated (1.4±0.7 versus 1.5±0.7), stents placed (1.7±1.1 versus 1.6±0.9), and frequency of drug-eluting stent usage (52% versus 60%). In-hospital death (0% versus 0%), myocardial infarction (MI, 4% versus 3%, P =0.27), and 30-day death (3% versus 0%, P =0.53) and MI (3% versus 4%, P =0.71) were statistically similar. There were no differences in 4-year death (12% versus 13%), target lesion revascularization (TLR, 13 versus 17%, P =0.54), or death/MI/TLR (24% versus 34%, P =0.20). Clinically driven repeat angiography in 12 of 29 allergy patients revealed binary restenosis rates of 27% in bare metal stents and 0% in drug-eluting stents, with mean diameter in-stent restenosis of 36% and 8%, respectively. There was no change in circulating eosinophil and lymphocyte counts after stenting in the allergy group (0.19–0.20, P =0.67, and 1.90–1.79, P =0.59, respectively). Conclusions— A history of metal allergy was not associated with adverse early or late outcomes in this single-center study.