Background Episodes of patient deterioration on hospital units are expected to increasingly contribute to morbidity and healthcare costs. Objective To determine if real-time alerts sent to the rapid response team (RRT) improved patient care. Design Randomized, controlled trial. Setting Eight medicine units (Barnes-Jewish Hospital). Patients 571 patients. Intervention Real-time alerts generated by a validated deterioration algorithm were sent real-time to the RRT (intervention) or hidden (control). Measurements ICU transfer, hospital mortality, hospital duration. Results ICU transfer (17.8% versus 18.2%; odds ratio, 0.972; 95% CI, 0.635–1.490) and hospital mortality (7.3% versus 7.7%; odds ratio, 0.947; 95% CI, 0.509–1.764) were similar for the intervention and control groups. The number of patients requiring transfer to a nursing home or long-term acute care hospital was similar for patients in the intervention and control groups (26.9% versus 26.3%; odds ratio, 1.032; 95% CI, 0.712–1.495). Hospital duration [8.4 ± 9.5 days versus 9.4 ± 11.1 days; P = 0.038] was statistically shorter for the intervention group. The number of RRT calls initiated by the primary care team was similar for the intervention and control groups (19.9% versus 16.5%; odds ratio, 1.260; 95% CI, 0.823–1.931). Conclusions Real-time alerts sent to the RRT did not reduce ICU transfers, hospital mortality, or the need for subsequent long term care, however hospital length of stay was modestly reduced.

BackgroundHospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined.MethodsTo determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications.ResultsThe final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17–1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643–0.679]).ConclusionsThe number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.

Biodiesel is regarded by many as a "greener" alternative fuel to petroleum diesel with potentially lower health risk. However, recent studies examining biodiesel particulate matter (PM) characteristics and health effects are contradictive, and typically utilize PM generated by passenger car engines in laboratory settings. There is a critical need to analyze diesel and biodiesel PM generated in a "real-world" setting where heavy duty-diesel (HDD) engines and commercially purchased fuel are utilized. This study compares the mass concentrations, chemical composition and cytotoxicity of real-world PM from combustion of both petroleum diesel and a waste grease 20% biodiesel blend (B20) at a community recycling center operating HDD nonroad equipment. PM was analyzed for metals, elemental/organic carbon (EC/OC), polycyclic aromatic hydrocarbons (PAHs), and nitro-polycyclic aromatic hydrocarbons (N-PAHs). Cytotoxicity in a human lung epithelial cell line (BEAS-2B) following 24h exposure to the real-world particles was also evaluated. On average, higher concentrations for both EC and OC were measured in diesel PM. B20 PM contained significantly higher levels of Cu and Mo whereas diesel PM contained significantly higher concentrations of Pb. Principal component analysis determined Mo, Cu, and Ni were the metals with the greatest loading factor, suggesting a unique pattern related to the B20 fuel source. Total PAH concentration during diesel fuel use was 1.9 times higher than during B20 operations; however, total N-PAH concentration was 3.3 times higher during B20 use. Diesel PM cytotoxicity was 8.5 times higher than B20 PM (p<0.05) in a BEAS-2B cell line. This study contributes novel data on real-world, nonroad engine sources of metals, PAH and N-PAH species, comparing tailpipe PM vs. PM collected inside the equipment cabin. Results suggest PM generated from burning petroleum diesel in nonroad engines may be more harmful to human health, but the links between exposure, composition and toxicity are not straightforward.

The high mobility group transcription factor SOX9 is expressed in stem cells, progenitor cells, and differentiated cell-types in developing and mature organs. Exposure to a variety of toxicants including dioxin, di(2-ethylhexyl) phthalate, 6:2 chlorinated polyfluorinated ether sulfonate, and chlorpyrifos results in the downregulation of tetrapod Sox9 and/or zebrafish sox9b. Disruption of Sox9/sox9b function through environmental exposures or genetic mutations produce a wide range of phenotypes and adversely affect organ development and health. We generated a dominant-negative sox9b (dnsox9b) to inhibit sox9b target gene expression and used the Gal4/UAS system to drive dnsox9b specifically in cardiomyocytes. Cardiomyocyte-specific inhibition of sox9b function resulted in a decrease in ventricular cardiomyocytes, an increase in atrial cardiomyocytes, hypoplastic endothelial cushions, and impaired epicardial development, ultimately culminating in heart failure. Cardiomyocyte-specific dnsox9b expression significantly reduced end diastolic volume, which corresponded with a decrease in stroke volume, ejection fraction, and cardiac output. Further analysis of isolated cardiac tissue by RT-qPCR revealed cardiomyocyte-specific inhibition of sox9b function significantly decreased the expression of the critical cardiac development genes nkx2.5, nkx2.7, and myl7, as well as c-fos, an immediate early gene necessary for cardiomyocyte progenitor differentiation. Together our studies indicate sox9b transcriptional regulation is necessary for cardiomyocyte development and function.