Clinical risk prediction model for 30-day all-cause re-hospitalisation or mortality in patients hospitalised with heart failure

BACKGROUND

This study aimed to develop a risk prediction model (AUS-HF model) for 30-day all-cause re-hospitalisation or death among patients admitted with acute heart failure (HF) to inform follow-up after hospitalisation. The model uses routinely collected measures at point of care.

METHODS

We analyzed pooled individual-level data from two cohort studies on acute HF patients followed for 30-days after discharge in 17 hospitals in Victoria, Australia (2014-2017). A set of 58 candidate predictors, commonly recorded in electronic medical records (EMR) including demographic, medical and social measures were considered. We used backward stepwise selection and LASSO for model development, bootstrap for internal validation, C-statistic for discrimination, and calibration slopes and plots for model calibration.

RESULTS

The analysis included 1380 patients, 42.1% female, median age 78.7 years (interquartile range = 16.2), 60.0% experienced previous hospitalisation for HF and 333 (24.1%) were re-hospitalised or died within 30 days post-discharge. The final risk model included 10 variables (admission: eGFR, and prescription of anticoagulants and thiazide diuretics; discharge: length of stay>3 days, systolic BP, heart rate, sodium level (<135 mmol/L), >10 prescribed medications, prescription of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, and anticoagulants prescription. The discrimination of the model was moderate (C-statistic = 0.684, 95%CI 0.653, 0.716; optimism estimate = 0.062) with good calibration.

CONCLUSIONS

The AUS-HF model incorporating routinely collected point-of-care data from EMRs enables real-time risk estimation and can be easily implemented by clinicians. It can predict with moderate accuracy risk of 30-day hospitalisation or mortality and inform decisions around the intensity of follow-up after hospital discharge.

Improving Health Outcomes for People With Cancer in Rural and Regional Areas by Embedding Evidence-Based Smoking-Cessation Strategies Into Usual Care: A Study Protocol

Background: Smoking following a diagnosis of cancer is a powerful clinical risk indicator, with known poorer health outcomes and associated health care costs. In Australia, smoking rates are higher in rural and regional areas. There are established and effective interventions to promote smoking cessation after a diagnosis of cancer yet these are not in routine practice. Aim: This protocol paper reports on a study that aims to embed evidence-based smoking cessation strategies for people with cancer who are current smokers into routine care, resulting in in system wide improvements, an implemented program and model for further dissemination. Methods: Across three rural/regional sites, and with partners Quit Victoria and Western Alliance, this study employs a variety of methodologies to embed smoking cessation support to improve outcomes for people with cancer who currently smoke. Specifically, the project will embed a system of responsibilities and training in rural and regional health services to routinely engage people with cancer who smoke in support services. The program will: · Promote routine delivery of smoking cessation care by trained oncology staff (oncologists/nurses/ allied health) · Establish referral pathways to Quitline · Correspond with general practitioners, to: i) outline the benefits of quitting in this context, ii) promote access to nicotine replacement therapy and iii) support quitting in the community. · Improve routine recording of smoking status and documentation of provision of brief intervention (personalised advice given, resources provided) and outcomes. Participants: are oncology staff and general practitioners across three health services: Ballarat Health Service, East Grampians Health Service (Ararat), Wimmera Health Care Group (Horsham), all located in Victoria, Australia. Data collection will occur across four sources: 1) Oncology staff: qualitative and quantitative data collection understanding confidence and views on provision on cessation advice; 2) Monitoring Quitline calls, 3) Interview with local general practitioners and 4) Medical record reviews to explore frequency of recording of smoking status. Data will be collected pre/postintervention. Results: The project is underway with the intervention manuals in development. The project is due for completion in 2020. Conclusion: This project takes a health services approach to integration of smoking cessation support in routine care for people with cancer in rural and regional areas. This program of work has capacity to determine best approaches to integrate smoking cessation into routine care, resulting in reduced mortality and morbidity, improved effectiveness of anticancer treatments, and reduced health care costs; by establishing internationally relevant, embedded health care interventions.

Applications of redundancy analysis for the detection of chemical response patterns to air pollution in lichen

The lichens Ramalina celastri (Spreng.) Krog & Swinsc., Punctelia microsticta (Müll. Arg.) Krog and Canomaculina pilosa (Stizenb.) Elix & Hale were transplanted simultaneously to 17 urban-industrial sites in a northwestern area of Córdoba city, Argentina. The transplantation sites were set according to different environmental conditions: traffic, industries, tree cover, building height, topographic level, position in the block and distances from the river and from the power plant. Three months later, chlorophyll a, chlorophyll b, phaeophytin a, soluble proteins, hydroperoxy conjugated dienes, malondialdehyde concentration and sulfur accumulation were determined, and a pollution index was calculated for each sampling site. Redundancy analysis was applied to detect the variation pattern of the lichen variables that can be 'best' explained by the environmental variables considered. The present study provides information about both the specific pattern response of each species to atmospheric pollution, and environmental conditions that determine it. As regards pollutants emission sources R. celastri showed a chemical response associated mainly with pollutant released by the power plant and traffic. P. microsticta and C. pilosa responded mainly to industrial sources. Regarding environmental conditions that affect the spreading of air pollutants and their incidence on the bioindicator, the topographic level and tree cover surrounding the sampling site were found to be important for R. celastri, tree cover surrounding the sampling site and the building height affected P. microsticta, while building height did so for C. pilosa.

Atmospheric quality and distribution of heavy metals in Argentina employing Tillandsia capillaris as a biomonitor

The atmospheric quality and distribution of heavy metals were evaluated throughout a wide region of Argentina. In addition, the biomonitor performance of Tillandsia capillaris Ruiz & Pav. f. capillaris was studied in relation to the accumulation of heavy metals and to its physiologic response to air pollutants. A sampling area of 50,000 km2 was selected in the central region of the Argentine Republic. This area was subdivided into grids of 25 x 25 km. Pools of T. capillaris, where present, were collected at each intersection point. From each pool three sub-samples were analyzed independently. Furthermore, five replicates were collected at 20% of the points in order to analyze the variability within the site. The content of Co, Cu, Fe, Ni, Mn, Pb and Zn was determined by Atomic Absorption Spectrometry. Chemical-physiological parameters were also determined to detect symptoms of foliar damage. Chlorophylls, phaeophytins, hydroperoxy conjugated dienes, malondialdehyde and sulfur were quantified in T. capillaris. Some of these parameters were used to calculate a foliar damage index. Data sets were evaluated by one-way ANOVA, correlation analysis, principal component analysis and mapping. Geographical distribution patterns were obtained for the different metals reflecting the contribution of natural and anthropogenic emission sources. According to our results it can be inferred that Fe, Mn and Co probably originated in the soil. For Pb, the highest values were found in the mountainous area, which can be attributed to the presence of Pb in the granitic rocks. Ni showed mainly an anthropogenic origin, with higher values found in places next to industrial centers. For Zn the highest values were in areas of agricultural development. The same was observed for Cu, whose presence could be related to the employment of pesticides. The foliar damage index distribution map showed that the central and southeastern zones were the ones where the major damage in the bioindicator was found. The central zone coincides with the city of Córdoba whereas the southeastern area is strictly agricultural, so the high values found there could be related to the use of pesticides.

Relationship between foliar chemical parameters measured in Melia azedarach L. and environmental conditions in urban areas

A diagnostic study was done on Melia azedarach L. in relation to atmospheric pollutants in Córdoba city, Argentina. The study area receives regional pollutants, and it was categorized taking into account traffic level, industrial level, location of the sample point in relation to the corner, treeless condition, building type, topographic level and distance to the river. Water content and Specific Leaf Area (SLA) were calculated; and concentrations of soluble proteins, sulphur, hydroperoxy conjugated dienes (HPCD), chlorophylls (Total Chl) and pheophytins (Total Paeoph) were determined in leaf samples. HPCD correlated positively with industry, topographic level and distance to the river, and with a combination of the environmental variables (ECI); pigments correlated negatively with traffic level and with ECI; Total Phaeoph/Total Chl ratio correlated positively with traffic, building and ECI. On the basis of our results, traffic level, industrial level, building type, topographic level and distance to the river are the environmental variables to bear in mind when selecting analogous sampling points in a passive monitoring program. An approximation to predict tree injury may be obtained by measuring water content, soluble proteins, sulphur, HPCD and pigments as they are responsible for the major variability of data. This study revealed that M. azedarach was sensitive to air pollutants from traffic and industry. Thus, in those sampling sites with the maximum score for traffic level, industrial level and ECI, the highest values of the parameters that indicate foliar damage together with the least pigment concentration were observed.

[Decompensated diabetes mellitus and hyperchloremic metabolic acidosis: a case with both pathologies]

Diabetic ketoacidosis is manifested by elevated blood glucose levels, ketosis and metabolic acidosis with increased anion gap. A transitory hyperchloremic acidosis, with normal anion gap, can appear. We report a 21 years old female with a type 2 diabetes mellitus, admitted to the emergency room of a general hospital with hyperglycemia, absence of ketonemia, severe hypokalemia and hyperchloremic metabolic acidosis. Initially, she was diagnosed and treated as a severe diabetic ketoacidosis. Normal blood glucose levels were rapidly achieved but electrolyte and acid base alterations persisted, leading to the suspicion that another associated condition was causing the acidosis and hypokalemia. Urinary pH and anion gap measurement, the study of renal acidification and a bicarbonate overload test lead to the diagnosis of a distal renal tubular acidosis, secondary to a Sjögren syndrome, that was confirmed with a Schirmer test and positive anti Ro antibodies. In this diabetic patient, the acute hyperglycemia intensified the hypokalemia of her distal renal tubular acidosis and unchained the acute metabolic condition.

Exploring Chemical Variables in Ligustrum lucidum Ait. F. Tricolor (Rehd.) Rehd. in Relation to Air Pollutants and Environmental Conditions

/ A diagnostic study was done on Ligustrum lucidum Ait. f. tricolor (Rehd.) Rehd. in relation to atmospheric pollutants in Cordoba city, Argentina. The study area receives regional pollutants and was categorized taking into account traffic level, industrial density, type of industry, location of the sample point in relation to the street corner, treeless condition, and topographic level. Dried weight/fresh weight ratio (DW/FW) and specific leaf area (SLA) were calculated, and concentrations of chlorophylls, carotenoids, total sulfur, soluble proteins, malondialdehyde (MDA), and hydroperoxy conjugated dienes (HPCD) were determined in leaf samples. Sulfur content correlates positively with traffic density and SLA correlates negatively with some combinations of the categorical variables; MDA correlates positively with topographic level and total protein concentration correlates negatively with treeless condition. On the basis of our results, traffic, location of trees, type of industry, situation of a tree with respect to others, and topographic level are the environmental variables to bear in mind when selecting analogous sampling points in a passive monitoring program. An approximation to predict tree injury may be obtained by measuring DW/FW ratio, proteins, pigments, HPCD, and MDA as they are responsible for the major variability of data.KEY WORDS: L. lucidum Ait. f. tricolor (Rehd.) Rehd.; Air pollution; Sulfur accumulation; Pigments; Urban environment; Argentina

Heart rate variability and inappropriate sinus tachycardia after catheter ablation of supraventricular tachycardia

Sinus tachycardia has been reported after radiofrequency catheter ablation of supraventricular tachycardia. Frequently, these patients require beta-blocking agents for symptomatic control. The purpose of this study was to evaluate prospectively the incidence of inappropriate sinus tachycardia and heart rate variability after ablation of atrioventricular nodal reentrant tachycardia and accessory pathways. Patients undergoing ablation had 24-h ambulatory monitoring ECG (Holter) performed before the procedure, on the day of the ablation, and 3 months afterwards. There were 170 patients, mean age 48 +/- 23 years; 93 were female. A complete study of the 24-h Holter with analysis of heart rate variability: SD, rMSSD, pNN50, high and low frequency was obtained. There was a low prevalence of inappropriate sinus tachycardia after the ablation procedure (10 of 170 patients: five with four atrioventricular nodal reentry, with posteroseptal accessory pathways and one of the latter following ablation of the left accessory pathway). There was no modification of time and frequency domain parameters of heart rate variability in the remaining patients who underwent radiofrequency ablation. Holter monitoring 3 months after ablation showed that parameters of heart rate and heart rate variability had normalized in patients who had developed inappropriate sinus tachycardia. Inappropriate sinus tachycardia may be initiated by both radiofrequency ablation of atrioventricular nodal reentrant tachycardia and radiofrequency ablation of posteroseptal accessory pathways. Specific damage to the posteroseptal region is responsible for these changes, which usually recover spontaneously after 3 months.

[Prevalence of thinness and excessive fatness in a group of school children of the city of Cordoba, Argentina]

Findings of a nutritional evaluation study, using triceps skinfold, are reported. The study was carried out in 1,615 school-children from 5 to 12 years, pertaining to the low socioeconomic status of the city of Córdoba, Argentina. Measurements were done during the years 1983 and 1984 by Center's examiners with a Lange caliper, according to international anthropometric methodology. Interintra observer technical error was found to be within tolerance limits reported by other authors. Local standards were used to determine the prevalence of thinness and excessive fatness, by comparing them to tricep skinfold of each child, and selecting those children where this parameter presented values less than or equal to 10th percentile and fatness greater than or equal to 90th percentile. Furthermore, comparison between median triceps skinfold of the examined group, the local standards and Frisancho's norms for US population was also made. Results revealed that: a) the prevalence of thinness (19.9%) was almost twice the percentage expected for a normal population; in contrast, occurrence of excessive fatness (6.4%) was found to be below the expected value; b) prevalence of thinness was not statistically associated to age nor sex; c) frequency of excessive fatness was significantly higher in the 8-11 year-old male group (8, 9%, p much less than 0.0005) and in the girls group (10.8%), P much less than 0.005) the prevalence of fatness in girls increased with age, and figures revealed that from eight years onwards this exceeded the expected percentage, and d) median triceps skinfold of the group under study was generally below local and foreign norms. It is concluded that potential or real nutrition problems as those mentioned above, may be grossly identified using the triceps skinfold as the single anthropometric indicator.