Reducing Readmission of Hospitalized Patients With Depressive Symptoms: A Randomized Trial

PURPOSE

To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support.

METHODS

This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge.

RESULTS

We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes.

CONCLUSIONS

Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention.

Women who experience a myocardial infarction at a young age have worse outcomes compared with men: the Mass General Brigham YOUNG-MI registry

AIMS

There are sex differences in presentation, treatment, and outcomes of myocardial infarction (MI) but less is known about these differences in a younger patient population. The objective of this study was to investigate sex differences among individuals who experience their first MI at a young age.

METHODS AND RESULTS

Consecutive patients presenting to two large academic medical centres with a Type 1 MI at ≤50 years of age between 2000 and 2016 were included. Cause of death was adjudicated using electronic health records and death certificates. In total, 2097 individuals (404 female, 19%) had an MI (mean age 44 ± 5.1 years, 73% white). Risk factor profiles were similar between men and women, although women were more likely to have diabetes (23.7% vs. 18.9%, P = 0.028). Women were less likely to undergo invasive coronary angiography (93.5% vs. 96.7%, P = 0.003) and coronary revascularization (82.1% vs. 92.6%, P < 0.001). Women were significantly more likely to have MI with non-obstructive coronary disease on angiography (10.2% vs. 4.2%, P < 0.001). They were less likely to be discharged with aspirin (92.2% vs. 95.0%, P = 0.027), beta-blockers (86.6% vs. 90.3%, P = 0.033), angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (53.4% vs. 63.7%, P < 0.001), and statins (82.4% vs. 88.4%, P < 0.001). There was no significant difference in in-hospital mortality; however, women who survived to hospital discharge experienced a higher all-cause mortality rate (adjusted HR = 1.63, P = 0.01; median follow-up 11.2 years) with no significant difference in cardiovascular mortality (adjusted HR = 1.14, P = 0.61).

CONCLUSIONS

Women who experienced their first MI under the age of 50 were less likely to undergo coronary revascularization or be treated with guideline-directed medical therapies. Women who survived hospitalization experienced similar cardiovascular mortality with significantly higher all-cause mortality than men. A better understanding of the mechanisms underlying these differences is warranted.

Cardiovascular Mortality After Type 1 and Type 2 Myocardial Infarction in Young Adults

BACKGROUND

Type 2 myocardial infarction (MI) and myocardial injury are associated with increased short-term mortality. However, data regarding long-term mortality are lacking.

OBJECTIVES

This study compared long-term mortality among young adults with type 1 MI, type 2 MI, or myocardial injury.

METHODS

Adults age 50 years or younger who presented with troponin >99th percentile or the International Classification of Diseases code for MI over a 17-year period were identified. All cases were adjudicated as type 1 MI, type 2 MI, or myocardial injury based on the Fourth Universal Definition of MI. Cox proportional hazards models were constructed for survival free from all-cause and cardiovascular death.

RESULTS

The cohort consisted of 3,829 patients (median age 44 years; 30% women); 55% had type 1 MI, 32% had type 2 MI, and 13% had myocardial injury. Over a median follow-up of 10.2 years, mortality was highest for myocardial injury (45.6%), followed by type 2 MI (34.2%) and type 1 MI (12%) (p < 0.001). In an adjusted model, type 2 MI was associated with higher all-cause (hazard ratio: 1.8; 95% confidence interval: 1.2 to 2.7; p = 0.004) and cardiovascular mortality (hazard ratio: 2.7; 95% confidence interval: 1.4 to 5.1; p = 0.003) compared with type 1 MI. Those with type 2 MI or myocardial injury were younger and had fewer cardiovascular risk factors but had more noncardiovascular comorbidities. They were significantly less likely to be prescribed cardiovascular medications at discharge.

CONCLUSIONS

Young patients who experience a type 2 MI have higher long-term all-cause and cardiovascular mortality than those who experience type 1 MI, with nearly one-half of patients with myocardial injury and more than one-third of patients with type 2 MI dying within 10 years. These findings emphasize the need to provide more aggressive secondary prevention for patients who experience type 2 MI and myocardial injury.

Systematic review protocol examining the influence of surgeon personality on perioperative decision making in abdominal surgery

INTRODUCTION

There is limited published literature exploring how the personality traits of surgeons may influence preoperative decision making, particularly in the context of visceral/abdominal surgery. Multiple validated personality scoring systems exist and have been used to describe surgeon personalities previously. The degree to which each trait is expressed by abdominal surgeons is neither currently known, nor the impact of these traits on postoperative outcomes. The protocol has been written in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.

METHODS AND ANALYSIS

The search strategy has been developed by a Health Scientist Librarian in collaboration with the review team. The search was conducted on 1st October 2019.Database subject headings and text words relating to 'abdominal/general surgeons', 'personality', 'postoperative outcomes' and 'decision making' formed the basis of our literature search strategy; the MEDLINE, EMBASE, PsycInfo and Cochrane databases will be searched. Three reviewers will independently screen and appraise articles, with a fourth reviewer utilised if disagreements arise.A systematic narrative synthesis will be performed, with information presented in text and table format. These will summarise the findings and characteristics of any included studies. Using guidance from the Centre for Reviews and Dissemination, the reviewers will describe the potential relationship and findings between studies using the narrative synthesis. Studies will only be reported if they are felt to have low or mid-levels of bias. Studies felt to display high levels of bias will be excluded.

ETHICS AND DISSEMINATION

This study does not require ethical approval. The formal systematic review will be submitted for peer reviewed publication and presented at relevant conferences. The methods may inform future reviews in other surgical specialties regarding surgeon personality.

PROSPERO REGISTRATION NUMBER

CRD42019151375.

Cardiovascular Risk and Statin Eligibility of Young Adults After an MI: Partners YOUNG-MI Registry

BACKGROUND

Despite significant progress in primary prevention, the rate of MI has not declined in young adults.

OBJECTIVES

The purpose of this study was to evaluate statin eligibility based on the 2013 American College of Cardiology/American Heart Association guidelines for treatment of blood cholesterol and 2016 U.S. Preventive Services Task Force recommendations for statin use in primary prevention in a cohort of adults who experienced a first-time myocardial infarction (MI) at a young age.

METHODS

The YOUNG-MI registry is a retrospective cohort from 2 large academic centers, which includes patients who experienced an MI at age ≤50 years. Diagnosis of type 1 MI was adjudicated by study physicians. Pooled cohort risk equations were used to estimate atherosclerotic cardiovascular disease risk score based on data available prior to MI or at the time of presentation.

RESULTS

Of 1,685 patients meeting inclusion criteria, 210 (12.5%) were on statin therapy prior to MI and were excluded. Among the remaining 1,475 individuals, the median age was 45 years, there were 294 (20%) women, and 846 (57%) had ST-segment elevation MI. At least 1 cardiovascular risk factor was present in 1,225 (83%) patients. The median 10-year atherosclerotic cardiovascular disease risk score of the cohort was 4.8% (interquartile range: 2.8% to 8.0%). Only 724 (49%) and 430 (29%) would have met criteria for statin eligibility per the 2013 American College of Cardiology/American Heart Association guidelines and 2016 U.S. Preventive Services Task Force recommendations, respectively. This finding was even more pronounced in women, in whom 184 (63%) were not eligible for statins by either guideline, compared with 549 (46%) men (p < 0.001).

CONCLUSIONS

The vast majority of adults who present with an MI at a young age would not have met current guideline-based treatment thresholds for statin therapy prior to their MI. These findings highlight the need for better risk assessment tools among young adults.

Attention-deficit hyperactivity disorder and fluctuating asymmetry in another college sample

Attention deficit/hyperactivity disorder (AD/HD) represents a developmental lag that may be reflected in fluctuating asymmetry (FA), i.e., differences from perfect symmetry in traits that display bilateral symmetry. Burton et al. (2003 Am. J. Hum. Biol. 15:601-619) found a statistical trend for FA to increase (as dermatoglyphic index or as total index) as the behavioral measure for AD/HDness (Rasch logit values derived from the Wender Utah Rating Scale, or WURS) increased in males but not in females. The objective here was to do a similar study in an independently collected sample of college students (n = 222; 61 male, 161 female) not selected for AD/HD, looking at FA vs. symptoms for AD/HD based on Rasch versions of responses to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (Barkley and Murphy 1998 Attention-Deficit Hyperactivity Disorder, New York: Guilford Press, p. 95-96) and the more comparable shortened WURS. FAs were lowest for body and ear height, and highest for eye width and nose width, and ranged from 0.01 +/- 0.001 (mean +/- SE) for foot and ankle widths to 0.13 +/- 0.01 in eye and nose widths for both sexes; the sexes did not differ significantly. Males displayed higher AD/HD symptom rates overall. There was a significant correlation between body FA and the WURS measure in females after Bonferroni correction (P = 0.002, r(2) = 0.058). Thus, AD/HD symptoms levels increased with an increase in body FA in female college students not selected for AD/HD.

Latex allergy and latex sensitization in children and adolescents with meningomyelocele

BACKGROUND

The high prevalence of clinical latex allergy and latex sensitization in children with meningomyelocele has been widely reported. It has also been noted that these same children have a higher than expected prevalence of atopic disease. It would be useful to have a safe, sensitive, and specific skin test to detect latex sensitivity and to know how well this test compares with available in vitro tests. It would likewise be helpful to know as fully as possible the characteristics of the individual and to evaluate the relative importance of factors suspected to contribute to clinical latex allergy and latex sensitization in this population.

METHODS

A group of 116 children and adolescents 1 to 20 years of age were recruited for the study. An extensive history of latex allergy, atopic diseases, and surgical procedures was taken on all subjects. Each subject had either a latex skin test or an in vitro study for latex-specific IgE, and 67 subjects had both tests simultaneously. Eighty-five subjects had epicutaneous skin tests to a panel of environmental allergens.

RESULTS

Overall, 25 of 116 (21.5%) subjects had a history of clinical latex allergy, and 51 of 116 (44%) were sensitized to latex. The sensitivity and specificity of skin tests for clinical latex allergy were slightly greater than for the in vitro test (100% vs 95.8% and 82.3% vs 68.9%, respectively). The positive predictive value and negative predictive value of skin testing for clinical latex allergy were also greater (67.6% vs 50% and 100% vs 98.1%, respectively). Age was found to be a significant variable for both latex allergy and latex sensitization. The number of surgical procedures undergone and the presence of positive skin test responses to environmental allergens were significantly correlated with latex sensitization but not with clinical allergy to latex.

CONCLUSIONS

A sensitive, specific, and safe skin test for latex sensitivity appears superior to in vitro testing for latex allergy. Age, number of surgical procedures, and the presence of positive allergen skin test responses are significantly correlated with latex sensitization. Age alone is significantly correlated with clinical allergy to latex.

Town population change in the Republic of Ireland: the need for an urban policy review

"This article argues for the adoption of a co-ordinated urban planning policy in the Republic of Ireland where towns now accommodate 64% of the total population. A review of trends in town population change for the years 1986-91 suggests that the ad hoc approach to planning urban employment and service provision that exists currently is inadequate to prevent major disparities in population distribution becoming exacerbated between large and small settlements and between regions within the state. These disparities are the result in part of fundamental economic restructuring which is related to international trends but they also reflect the gradual withdrawal by the Irish Government from regional planning from the mid-1980s on. By way of introduction to the discussion of the empirical evidence, an earlier phase of Irish urban and employment planning is reviewed briefly."

Childhood growth, physical activity, and peak bone mass in women

Peak bone mass is an important determinant of the risk of osteoporotic fracture, and preventive strategies against osteoporosis require a clear understanding of the factors influencing bone gain in early life. We report a longitudinal study aiming to identify the relationships between childhood growth, lifestyle, and peak bone mass in women. One hundred and fifty-three women born in a British city during 1968-1969 were traced and studied in 1990. Data on their growth in childhood was obtained from linked birth and school health records; current bone mineral measurements were made by dual X-ray absorptiometry. There were statistically significant associations between weight at 1 year and BMC (but not BMD) at the lumbar spine (r = 0.32, p < 0.01) and femoral neck (r = 0.26, p < 0.01). These remained significant after adjusting for current weight. There were also strong relationships between childhood height measurements and adult BMC at the two skeletal sites. Physical activity was the major lifestyle determinant of BMD after allowing for body build. We conclude that infant growth and physical activity in childhood are important determinants of peak bone mass in women. Growth primarily determines the size of the skeletal envelope, and its trajectory is established by age 1 year. Activity, in contrast, modulates the mineral density within the skeletal envelope and may contribute to the consolidation of bone following the end of linear growth.

Population change in the Republic of Ireland 1981-1991: trends and spatial patterns

"Demographic trends in the Republic of Ireland have gradually moved closer to Western European norms during the past two decades. Birth rates have continued to fall and internal migration flows have become diversified. External migration has continued to play an important role in population change, however, and in the most recent census period has contributed to net decline. Geographical patterns of change within the state reflect a concentration of growth in the environs of the larger centres of population." (SUMMARY IN FRE)

Informational and psychosocial needs of women choosing conservative surgery/primary radiation for early stage breast cancer

Recent advances in the treatment of early stage breast cancer give women a choice of treatments. Prospective and retrospective studies demonstrate the comparable efficacy of treatment with a modified radical mastectomy and treatment with conservative surgery and primary radiation. While the number of women with early stage breast cancer choosing the latter treatment continues to increase, there is a paucity of information in the nursing literature assessing the informational and psychosocial needs of this group. This article reports the results of a questionnaire assessing the informational and psychosocial needs of patients choosing breast conservation surgery, and the future implications of these results for the nursing profession.

Disease expression of ankylosing spondylitis in males and females

The clinical features of 35 female patients with ankylosing spondylitis were compared with 70 male controls individually matched for disease duration. Mean age of onset and presenting symptoms were similar in both groups. No differences were observed as regards spinal symptoms, chest expansion, peripheral arthritis, extraarticular features or functional outcome. However, males had significantly greater spinal radiological change that was positively associated with hip arthritis. Our findings suggest that although axial disease is more severe in males the overall pattern of clinical disease is similar in both sexes.

Real-time movie imaging from a single cardiac cycle by NMR

Using a 1-m-bore superconductive magnet at 0.1 T, whole-body transverse images through adult humans have been obtained at repetition times of 57 ms. The techniques used were minor variations of echo-planar imaging (EPI) employing large pulsed gradients to provide complete coverage of the plane in phase space, and low-angle RF excitation sequences allowing rapid repetition of the experiment. In addition active magnetic screening of the gradient coils was implemented to protect the surrounding magnet from the eddy currents induced by the necessarily fast switching of the large gradient fields.

Transectional echo planar imaging of the heart in cyanotic congenital heart disease

Echo planar imaging is that form of magnetic resonance imaging which gives very short image acquisition times. The method has been used to produce images of the infant heart which are free of cardiorespiratory motion artefact, despite tachypnoea and tachycardia. EPI transections of the normal heart are compared with transections in truncus arteriosus, tetralogy of Fallot, right heart hypoplasia and transposition of the great arteries. The diagnosis of the cause of cyanosis in these infants was established by the noninvasive EPI method and validation of the findings may be found in transectional postmortem analyses reported in the literature.

Echo planar imaging of normal and abnormal connections of the heart and great arteries

Echo planar imaging (EPI) is that form of magnetic resonance imaging which provides very short image acquisition times. EPI also provides very rapid sequential imaging. The EPI method is ideal for imaging the heart and thoracic content because images are devoid of cardio-respiratory motion artefact. Previously an analysis of transectional images has been presented. This paper is concerned with the study of the heart by the use of EPI constructions in the sagittal and coronal planes. Defining connections between ventricle and great artery is of cardinal importance in paediatric cardiology. EPI constructions in the normal heart, transposition, truncus arteriosus and right heart hypoplasia are presented and discussed.