Many patients admitted with acute myocardial infarction (AMI) have considerable multimorbidity, sometimes associated with functional limitations. The Norton Scale Score (NSS) evaluates clinical aspects of well-being and predicts numerous clinical outcomes. We evaluated the association between NSS and long-term healthcare utilization (HU) following a non-fatal AMI.A retrospective observational study including AMI survivors during 1 January 2004 to 31 December 2015 with a filled NSS report. Data were recouped from the electronic medical records of the hospital and two Health Maintenance Organizations. Norton Scale Score ≤16 or >16 was defined as low or high respectively. The outcome was annual HU, encompassing length of hospital stay (LOS), emergency department (ED) visits, primary care, and other ambulatory service utilization during up to 10 years of follow-up. HU costs were compared between groups. Two-level models were built: unadjusted and adjusted for patients' baseline characteristics. The study included 4613 patients, 784 (17%) had low NSS. Patients with low NSS compared with patients with high NSS were older, had a higher rate of multimorbidity, and had significantly lower coronary angiography and revascularization rates. In addition, low NSS patients presented higher annual HU costs (4879 vs. 3634 Euro, P <0.001), primarily due to LOS, ED visits, and less frequent ambulatory services usage.In patients after non-fatal AMI, low NSS is a signal for higher long-term costs reflecting the presence of expensive comorbidities. Management disparity and impaired mobility may offset the real need of these patients. Therefore, the specific proactive nursing intervention in that population is recommended.
In the emergency department the physician is often confronted with the decision of where to hospitalize a patient presenting with chest pain and a possible acute myocardial infarction--in the cardiac care unit or in the internal medicine ward.To characterize the clinical factors involved in the triage disposition of patients hospitalized with AMI in Israel to either CCUs or IMWs and to determine to what extent the perceived probability of ischemia influenced the disposition decision.During a 2 month nationwide prospective survey in the 26 CCUs and 82 of the 94 IMWs in Israel, we reviewed the charts of 1,648 patients with a discharge diagnosis of AMI. The probability of ischemia at admission was determined retrospectively by the Acute Coronary Ischemia Time-Insensitive Predictive Instrument. Co-morbidity was coded using the Index of Coexistent Diseases.The ACI-TIPI score for patients admitted to CCUs or to IMWs was 76.2% and 57.7% respectively (P < 0.001). Multivariate analysis showed that young patients with a high probability of ischemia and low co-morbidity or functional impairment were more likely to be hospitalized in CCUs than in IMWs.In Israel, the factors that strongly influence the initial triage disposition of AMI patients to CCUs or IMWs are age, perceived probability of ischemia, status of co-morbid conditions and functional impairment.
Objective: Acute myocardial infarction (AMI) is associated with significant risk for long-term morbidity and healthcare expenditure. We investigated healthcare utilization and direct costs throughout 10 years following AMI. Methods: A retrospective study included AMI patients hospitalized in a tertiary medical center throughout 2002-2012. Data was obtained from computerized medical records. Hospitalizations, emergency department (ED), primary care and outpatient consulting clinic visits and other ambulatory services, following the AMI and their costs, were compared with the year preceding the AMI. Results: Overall 9548 patients were analyzed (age 66.6 ± 13.9 years, 67.8% men, 48.1% ST-elevation AMI). A significant increase in the utilization of all the evaluated services was observed in the first year following the AMI compared with the preceding year (p < .001 for each) and followed by a decline thereafter (p-for trend < .001 for each) except increased number of ED visits (p-for trend = .014). Annual per-patient costs throughout the first year following AMI (5592€) were significantly greater compared with the preceding year (3120€) and declined subsequently to 3216€ and 2760€ for years 2-5 and 6-10, respectively. Multivariate analysis showed that throughout the first half of the follow-up total costs were slightly higher and in the second half similar to the year preceding the AMI. Analysis of the relative costs showed that ambulatory services make up most of the expenditure. Conclusions: Healthcare utilization and economic expenditure peak throughout the first year and decline afterwards. For several services it remains higher for up to 10 years compared with the year preceding the AMI.
We have recently described the existence of a cytochrome P450-associated, mitochondrial-based 25-hydroxyvitamin D (25-OHD)-1-hydroxylation reaction in the chick macrophage-like cell line HD-11. Considering that this reaction is regulated by the same set of factors (ie. interferon-gamma, lipopolysaccharide, and glucocorticoids) that modulate expression of the macrophage nitric oxide synthase (mac NOS), we investigated the possibility that endogenous nitric oxide (NO) production may be linked to 1,25-dihydroxyvitamin D3 (1,25-(OH)2D) synthesis by HD-11 cells in vitro. To test this hypothesis we investigated the effects excluding from the extracellular medium the essential amino acid L-arginine, substrate for endogenous NO production, on the basal and stimulated expression of the HD-11 cell 25-OHD-1-hydroxylation reaction. Depletion of L-arginine from the extracellular medium for as little as 6 h resulted in a significant decrease (p < 0.02) in basal 1,25-(OH)2D synthesis; after 15 h in an L-arginine-free environment hormone production was reduced to < 10% of basal levels without any adverse affect on cell viability. Reintroduction of L-arginine, but not D-arginine, into the extracellular medium restored 1,25-(OH)2D3 synthetic capacity fully if done after < or = 6 h of incubation in the absence of L-arginine. Competitive inhibition of NOS with Nw-nitro-L-arginine methyl ester (p < 0.002) and Nw-nitro-L-arginine (p < 0.02) significantly inhibited 1,25-(OH)2D synthesis, indicating that macrophage NO generating capacity is functionally linked to endogenous synthesis of the active vitamin D metabolite.
Abstract Background Acute myocardial infarction (AMI) is associated with greater utilization of healthcare resources and financial expenditure. Objectives To evaluate temporal trends in healthcare resource utilization and costs following AMI throughout 2003–2015. Methods AMI patients who survived the first year following hospitalization in a tertiary medical center (Soroka University Medical Center) throughout 2002–2012 were included and followed until 2015. Length of the in-hospital stay (LOS), emergency department (ED), primary care, outpatient consulting clinic visits and other ambulatory services, and their costs, were evaluated and compared annually over time. Results Overall 8047 patients qualified for the current study; mean age 65.0 (SD = 13.6) years, 30.3% women. During follow-up, LOS and the number of primary care visits has decreased significantly. However, ED and consultant visits as well as ambulatory-services utilization has increased. Total costs have decreased throughout this period. Multivariate analysis, adjusted for potential confounders, showed as significant trend of decrease in LOS and ambulatory-services utilization, yet an increase in ED visits with no change in total costs. Conclusions Despite a decline in utilization of most healthcare services throughout the investigated decade, healthcare expenditure has not changed. Further evaluation of the cost-effectiveness of long-term resource allocation following AMI is warranted. Nevertheless, we believe more intense ambulatory follow-up focusing on secondary prevention and early detection, as well as high-quality outpatient chest pain unit are warranted.
Abstract Hypercalcemia in human granuloma-forming diseases like sarcoidosis results from the endogenous overproduction of 1,25-dihydroxyvitamin D [1,25-(OH)2D] by disease-activated tissue macrophages. The recent identification of an immortalized chick myelomonocytic cell line, HD-11, that constitutively expresses a 25-hydroxyvitamin D (25-OHD) 1-hydroxylation reaction has alleviated dependence on studying primary macrophage cultures with no replicative potential in vitro. In these experiments we established conditions for the maximal expression of the HD-11 cell 25-OHD3-1-hydroxylation reaction and localized this activity to the mitochondrial fraction. On a per cell basis, the activity of HD-11 cell 25-OHD3 1-hydroxylation reaction was comparable to that in primary cultures of chick renal tubular epithelial cells, which express the authentic renal 25-OHD3 1-hydroxylase. Maximal product yield was achieved after incubation of HD-11 cells with 200 nM 25-OHD3 for 3 h. Although adherent monolayers possessed 3- to 4-fold more capacity for hormone production than cells in suspension, suspended cells exhibited easily detectable 25-OHD3 catalytic activity (0.58 ± 0.08 pmol per 106 cells per h; ± SEM), 50% of which remained solubilized in a sonicate of suspended cells cleared of nuclei and plasma membrane. Subcellular localization disclosed 91% of the residual activity to be concentrated in the mitochondrial subfraction. A detergent-solubilized extract of this mitochondrial subfraction contained 1.9 ± 0.3 pmol 1,25-(OH)2D3 synthetic capacity per mg protein. The catalytic activity (1-hydroxylase activity) was concentrated 20.2-fold after chromatography on octyl-amino agarose and was associated with 0.054 nmol cytochrome P450 per mg protein. These data suggest that HD-11 cell 25-OHD3 1-hydroxylation reaction may be similar to the well-characterized 25-OHD3 1-hydroxylase expressed in the kidney.
