Chronotherapy shortens hospitalization for bipolar depression: a single-center replication across three decades (1994-2024).

308 A Geriatric Emergency Medicine Assessment Team Reduces Hospital Length of Stay through Faster Discharge to Subacute Rehabilitation

A functional polymorphism in the transcriptional control region upstream of the coding sequence of the 5-hydroxytryptamine transporter (5-HTT) has been reported. This polymorphism has been shown to influence the antidepressant response to fluvoxamine and paroxetine. The authors tested the hypothesis that the allelic variation of the 5-HTT-linked polymorphic region (5-HTTLPR) could influence the response of depressed patients to total sleep deprivation. Sixty-eight drug-free inpatients with bipolar depression underwent a night of total sleep deprivation. 5-HTTLPR was genotyped in these patients. Changes in perceived mood were rated on a visual analogue scale and analyzed by using repeated measures analysis of covariance. Patients who were homozygotic for the long variant of 5-HTTLPR showed a significantly better mood amelioration after total sleep deprivation than those who were heterozygotic and homozygotic for the short variant. The influence of 5-HTTLPR on response to total sleep deprivation is similar to its observed influence on response to serotonergic drug treatments. This finding supports the hypothesis of a major role for serotonin in the mechanism of action of total sleep deprivation in depression.

To evaluate the effects of a fast-track esophagectomy protocol (FTEP) on esophageal cancer patients' safety, length of hospital stay (LOS), and hospital charges. FTEP involved transferring patients to the telemetry unit instead of the surgical intensive care unit (SICU) after esophagectomy. We retrospectively reviewed 708 consecutive patients who underwent esophagectomy for primary esophageal cancer during the 4 years before (group A; 322 patients) or 4 years after (group B; 386 patients) the institution of an FTEP. Postoperative morbidity and mortality, LOS, and hospital charges were reviewed. Compared with group A, group B had significantly shorter median LOS (12 days vs 8 days; P < 0.001); lower mean numbers of SICU days (4.5 days vs 1.2 days; P < 0.001) and telemetry days (12.7 days vs 9.7 days; P < 0.001); and lower rates of atrial arrhythmia (27% vs 19%; P = 0.013) and pulmonary complications (27% vs 20%; P = 0.016). Multivariable analysis revealed FTEP to be associated with shorter LOS (P < 0.001) even after adjustment for predictors like tumor histology and location. FTEP was also associated with a lower rate of pulmonary complications (odds ratio = 0.655; 95% confidence interval = 0.456, 0.942; P = 0.022). In addition, the median hospital charges associated with primary admission and readmission within 90 days for group B ($65,649) were lower than that for group A ($79,117; P < 0.001). These findings suggest that an FTEP reduces patients' LOS, perioperative morbidity, and hospital charges.

Source: Campbell AP, Tokars JI, Reynolds S, et al. Influenza antiviral treatment and length of stay. Pediatrics. 2021;148(4):e2021050417; doi:10.1542/peds.2021-050417Investigators from multiple institutions conducted a retrospective study to assess the effect of treatment with neuraminidase inhibitors (NAIs) on length of hospital stay (LOS) in children with influenza. Study data were abstracted from the Influenza Hospitalization Surveillance Network (FluServ-NET), a population-based surveillance network with data from 10 counties in different states and 5 entire states. Information on patients in the surveillance system, including demographics, patient characteristics, treatment with NAIs, symptom onset, and details on hospitalization were collected. Study participants were children <18 years old with laboratory-identified influenza who were divided into 2 cohorts for analysis. Cohort 1 included children with ≥1 medical condition and not admitted or transferred to an ICU who were hospitalized during the 2012–2013 influenza season. Cohort 2 were children with or without an underlying medical condition who were admitted to an ICU during 3 consecutive influenza seasons (2010–2011, 2011–2012, and 2012–2013). Exclusion criteria included missing information on receipt of NAIs, LOS <1 day, and symptom onset on or after ≥3 days prior to admission. Receipt of NAIs was classified as never, ≤2 days after onset of symptoms (early), or ≥3 days after symptoms (late). The primary study outcome was LOS, and the association of treatment with NAIs on LOS was evaluated using Cox regression after controlling for confounders.During the 2012–2013 influenza season, data on 1,924 children hospitalized with influenza were collected in FluServ-NET; 1,039 (54%) had ≥1 underlying medical condition. After applying exclusions, cohort 1 consisted of 309 children, of whom 199 (64.4%) received early NAI ≤2 days after treatment, 37 (12.0%) were treated ≥3 days after symptom onset, and 73 (23.6%) had no treatment with NAIs. After controlling for confounders, a shorter LOS was statistically associated with early NAI treatment (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.05, 1.80), but not late treatment (HR, 1.02; 95% CI, 0.67, 1.54). There were 299 children admitted to an ICU, included in cohort 2 analyses, with a median LOS of 5 days. NAIs were started ≤2 days after symptom onset in 168 (56%), ≥3 days after onset of symptoms in 45 (15%), and never in 86 (29%). In this cohort, early NAI treatment also was associated with shorter LOS (HR, 1.46; 95% CI, 1.11, 1.92), and late NAI treatment was not (HR, 1.20; 95% CI, 0.85, 1.69).The authors conclude that early treatment with NAIs in children with influenza was associated with shorter hospitalizations.Dr Doolittle has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Treatment with NAIs has been shown to reduce hospitalization among high-risk adults and children with influenza.1 NAIs also have been shown to reduce mortality among hospitalized adults when given ≤2 days after symptom onset but have not been associated with a reduction in mortality among children <16 years.2 Because of these studies and others, treatment with NAIs has been recommended for patients of all ages with influenza since 2009.3 However, since most studies of NAIs were performed on outpatients and adults, the experience among hospitalized children is limited.4 The current investigators close that gap.The investigators employed a large data set, controlled for confounding variables, and were careful to reject participants for whom NAI use was not known. Further, they studied children who would benefit the most from NAIs: those with ≥1 chronic illness and those admitted to the ICU. The most common chronic medical conditions included chronic lung and cardiac diseases such as asthma, neurologic diseases, prematurity, immunocompromise, and chronic metabolic or blood disorders. Interestingly, 48% of the chronic illness cohort and 37% of the ICU cohort were vaccinated for influenza. Vaccination status was not associated with LOS.The results of the current study affirm the Centers for Disease Control and Prevention (CDC) position to start early empiric treatment with NAIs on all patients suspected of influenza.3 Interestingly, the CDC also recommends NAIs in all hospitalized patients with influenza regardless of time of onset due to potential reduction in viral shedding and LOS.5Among children with influenza admitted to the ICU or with ≥1 chronic conditions, treatment with NAIs within ≤2 days of symptom onset is associated with a shorter LOS compared to those treated ≥3 days after symptom onset or not at all. (See AAP Grand Rounds. 2021;46[4]:39).6

There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures. The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies. A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant. In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.

BackgroundEarly mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.MethodsThis study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007–2012 and 2013–2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.ResultsParecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = −0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007–2018, but gender had no significant association with LOS during the period of 2013–2018. The 2013–2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1–2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.ConclusionIn this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

Analyses of seasonal variation of manic and depressive symptoms in bipolar disorder in retrospective studies examining admission data have yielded conflicting results. We examined seasonal variation of mood symptoms in a prospective cohort with long-term follow-up: the Collaborative Depression Study (CDS). The CDS included participants from five academic centers with a prospective diagnosis of bipolar I or II disorder. The sample was limited to those who were followed for at least 10 years of annual or semi-annual assessments. Time series analyses and autoregressive integrated moving average (ARIMA) models were used to assess seasonal patterns of manic and depressive symptoms. A total of 314 individuals were analyzed (bipolar I disorder, n = 202; bipolar II disorder, n = 112), with both disorders exhibiting the lowest frequency of depressive symptoms in summer and the highest around the winter solstice, though the winter peak in symptoms was statistically significant only with bipolar I disorder. Variation of manic symptoms was more pronounced in bipolar II disorder, with a significant peak in hypomanic symptomatology in the months surrounding the fall equinox. Significant seasonal variation exists in bipolar disorder, with manic/hypomanic symptoms peaking around the fall equinox and depressive symptoms peaking in the months surrounding the winter solstice in bipolar I disorder.

Background: Bipolar disorder (BD) is a severe psychiatric illness characterized by a chronic course and recurrent episodes, including residual depressive symptoms even during euthymic phases. These symptoms, although not meeting criteria for a depressive episode, are linked to relapse risk and impaired social functioning. This study aims to assess whether Virtual Reality Cognitive Remediation Training reduces depressive symptoms below the clinical threshold in individuals with BD. Methods: This post hoc analysis focuses on the secondary outcome (PHQ9) of a randomized-controlled trial. Participants were recruited from the Center of Liaison Psychiatry and Psychosomatics in Italy. The experimental group received Virtual Reality Cognitive Remediation, while the control group received standard treatment Results: Data from 39 individuals in the experimental group and 25 in the control group were analyzed. A greater reduction in PHQ-9 scores (>9) was observed in the experimental group (71.8% to 48.7%) compared to the control group. Significant improvements in total PHQ-9 scores and specific symptoms were noted in the experimental group compared to the control group. Conclusions: The study highlights the significant impact of virtual reality intervention on reducing depressive symptoms in bipolar disorder. This promising outcome underscores the potential preventive role of cognitive stimulation in relapse prevention. The intervention could offer valuable benefits for both treatment and prevention strategies in bipolar disorder.

To measure quality-of-care variables relevant to the treatment of community-acquired pneumonia and to determine their relative contribution to variation in length of hospital stay (LOS). One hundred cases of pneumonia requiring hospitalization from each of 7 institutions (2 community and 5 university teaching hospitals) were randomly selected (total sample, 700 cases). Demographic and clinical variables were abstracted using a standardized data instrument. Three quality-of-care measures were analyzed: (1) site of initial antibiotic treatment (emergency department vs floor), (2) door-to-needle time, and (3) appropriateness of antibiotic selection. Appropriate antibiotic selection was defined by the 1998 Infectious Disease Society of America guidelines for the treatment of hospitalized pneumonia cases. Regression modeling was used to determine associations between LOS and our quality-of-care (process) variables. The mean +/- SD LOS for this sample was 7.0 +/- 4.1 days. Prolonged LOS, defined as greater than or equal to the 75th percentile of the LOS distribution, was the dependent variable in our regression analysis and was greater than or equal to 9.0 days. After clinical and demographic variables were adjusted for, logistic regression modeling revealed that all 3 quality-of-care measures were associated with prolonged LOS: (1) initial antibiotic treatment in the emergency department (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.19-0.48); (2) appropriate antibiotic selection (OR, 0.55; 95% CI, 0.35-0.88); and (3) door-to-needle time (OR, 1.75 per 8 hours; 95% CI, 1.34-2.29). In a secondary analysis, we examined the clinical and demographic characteristics of the patients who were treated more rapidly in the emergency department compared with those who were treated on the inpatient floor. No clinically meaningful differences were observed between these groups. Unlike clinical and demographic variables, process-of-care variables are modifiable and amenable to quality improvement. We observed that rapid antibiotic initiation and appropriate antibiotic selection in the emergency department have a statistically significant association with shorter LOS. These findings suggest quality improvement targeted at these processes of care may improve resource utilization and reduce LOS for patients with community-acquired pneumonia.

To define appropriate antibiotic use for patients with a complicated urinary tract infection (UTI), we developed in a previous study a key set of 4 valid, guideline-based quality indicators (QIs). In the current study, we evaluated the association between appropriate antibiotic use for patients with a complicated UTI, as defined by these QIs, and length of hospital stay (LOS). A retrospective, observational multicenter study included 1252 patients with a complicated UTI, hospitalized at internal medicine and urology departments of 19 university and nonuniversity Dutch hospitals. Data from the patients' medical charts were used to calculate QI performance scores. Multilevel mixed-model analyses were performed to relate LOS to QI performance (appropriate use or not). We controlled for the potential confounders sex, age, (urological) comorbidity, febrile UTI, and intensive care unit admission <24 hours. Prescribing therapy in accordance with local hospital guidelines was associated with a shorter LOS (7.3 days vs 8.7 days; P = .02), as was early intravenous-oral switching (4.8 days vs 9.1 days; P < .001). There was an inverse relationship between the proportion of appropriate use in a patient (QI sum score/number of applicable QIs) and LOS (9.3 days for lower tertile vs 7.2 days for upper tertile; overall P < .05). Appropriate antibiotic use in patients with a complicated UTI seems to reduce length of hospital stay and therefore favors patient outcome and healthcare costs. In particular, adherence to the total set of QIs showed a significant dose-response relationship with a shorter LOS.

Intravenous Fluid Replacement Therapy and Hospital Outcomes for Vaso-Occlusive Episodes in Patients with Sickle Cell Disease

Over the past 15 years, there has been a rapid transformation in the way blunt aortic injuries (BAIs) are managed shifting from open thoracotomies to thoracic endovascular repairs (TEVAR). As a result of this change, we sought to describe our experience with open and endovascular repairs through a retrospective analysis of all trauma patients admitted with BAI to our Level I trauma center from 2002 to 2011. Demographic data, type of repair, complications, length of stay (LOS) data, and mortality were identified. No difference was noted in age, sex, Injury Severity Score, or Glasgow Coma Scale score between the two groups. There were also no differences in the number of acute complications or mortality. Intensive care unit (ICU) LOS was significantly shorter in the TEVAR group (20 vs 9 days, P < 0.05). Additionally, there was a trend toward shorter hospital LOS (28 vs 18 days, P = 0.07) and ventilator length of stay (12 vs 5 days, P = 0.171). In summary, endovascular repair of BAI is safe and has no increased rate of acute complications or mortality. ICU LOS is much shorter with TEVAR, and there was a trend toward shorter ventilator and hospital LOS, all of which may result in decreased cost. Still, more needs to be learned about potential long-term complications.

Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence. A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group. Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021). In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Dopaminergic augmentation of sleep deprivation effects in bipolar depression

Introduction/BackgroundEnhanced Recovery After Surgery Programs (ERP) include multimodal approaches of perioperative patient´s clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). By...