Clinical outcomes of pacemaker implantations before and after cancer diagnosis

Background

Cardiotoxicity caused by anticancer treatment affects cardiac conduction. Clinical outcomes of pacemaker patients with newly diagnosed cancer are insufficiently understood.

Purpose

The aim was to investigate the effect of anticancer therapy on pacemaker properties.

Methods

All patients with pacemaker and confirmed cancer diagnosis treated with chemotherapy at our tertiary university hospital were included in this study. The pacemaker database (containing pacemaker related information) was matched with hospital-wide electronic health records (containing cancer types, comorbidities and echo data). Survival data were retrieved from the Statistics Austria Federal Institute. Clinical and pacemaker data of patients with previously diagnosed cancer requiring pacemaker implantation (Group A) were compared to patients with pre-existing pacemaker followed by cancer diagnosis (Group B).

Results

Out of 972 included patients, 295 patients (30.3%) had the pacemaker implantation after their first cancer diagnosis (Group A), and 677 patients (69.7%) had already a pacemaker before their first cancer diagnosis (Group B). Cancer types are displayed in Figure 1. The following cancer types were associated with increased likelihood for pacemaker implantation after cancer diagnosis (Group A): kidney cancer (OR 2.07, 95% CI 1.12 to 3.83, P=0.02), lymphomas (OR 2.27, 95% CI 1.21 to 4.26, P=0.01), and eye cancer (OR 9.29, 95% CI 1.03 to 83.50, P=0.047). Patients in Group A were older at pacemaker implantation (76.0 years [IQR 68.0–82.2] vs. 72.1 years [IQR 64.3–78.0], P<0.001), and single-chamber pacemakers were less frequent (21.8% vs. 32.1%, P=0.001). Pacemaker implantation due to bradycardic atrial fibrillation was less frequent in Group A (15.6% vs. 21.8%, P=0.03), but implantation due to an “unspecified” indication was increased (20.6% vs. 12.7%, P=0.002). Patients in Group A had lower pacing threshold at baseline but had a stronger increase in pacing threshold during the follow-up as indicated in Table 1. No differences regarding left or right ventricular function, left or right end-diastolic diameter, or mitral or tricuspid regurgitation were detected between the groups. Patients in Group A had smaller left atria (59.7±10.7mm vs. 63.9±24.0mm, P=0.02) and smaller right atria (57.9±10.4mm vs. 61.2±11.8mm, P=0.001). Patients with cancer diagnosis requiring pacemaker had worse 10-year survival (31.2% vs. 51.1%, log-rank P<0.001) as shown in Figure 1.

Conclusion

Kidney cancer, lymphoma, and cancer of the eye were associated with increased probability of pacemaker implantation after cancer diagnosis. The significant increase in pacing threshold in patients undergoing chemotherapy could be associated with chemotherapy-induced cardiotoxicity.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 Future and Emerging Technologies Programme Figure 1. Cancer types and survivalTable 1. Baseline characteristics

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

OBJECTIVE

Early diagnosis or rule-out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE-ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high-sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule-out and prolonged observation with repeated hsTnt testing at a high-volume tertiary care emergency department.

PATIENTS AND METHODS

We conducted a pre- and post-changeover analysis 3 months before and 3 months after transition from less (hsTnt cut-off 30 ng/L, 3-hour rule-out) to more conservative (hsTnt cut-off 14 ng/L, 1-hour rule-out) guidelines in 2015, comparing proportions of patients requiring repeated testing.

RESULTS

We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early-rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision.

CONCLUSION

The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

Pacemaker lead-associated tricuspid regurgitation in patients with or without pre-existing right ventricular dilatation

Background

Transcatheter tricuspid valve intervention became an option for pacemaker lead-associated tricuspid regurgitation. This study investigated the progression of tricuspid regurgitation (TR) in patients with or without pre-existing right ventricular dilatation (RVD) undergoing pacemaker implantation.

Methods

Patients were included if they had implantation of transtricuspid pacemaker lead and completed echocardiography before and after implantation. The cohort was divided in patients with and without RVD (cut-off basal RV diameter ≥ 42 mm). TR was graded in none/mild, moderate, and severe. Worsening of one grade was defined as progression. Survival analyses were plotted for 10 years.

Results

In total, 990 patients were analyzed (24.5% with RVD). Progression of TR occurred in 46.1% of patients with RVD and in 25.6% of patients without RVD (P < 0.001). Predictors for TR progression were RV dilatation (OR 2.04; 95% CI 1.27–3.29; P = 0.003), pre-existing TR (OR 4.30; 95% CI 2.51–7.38; P < 0.001), female sex (OR 1.68; 95% CI 1.16–2.43; P = 0.006), single RV lead (OR 1.67; 95% CI 1.09–2.56; P = 0.018), mitral regurgitation (OR 2.08; 95% CI 1.42–3.05; P < 0.001), and enlarged left atrium (OR 1.98; 95% CI 1.07–3.67; P = 0.03). Survival-predictors were pacemaker lead-associated TR (HR 1.38; 95% CI 1.04–1.84; P = 0.028), mitral regurgitation (HR 1.34; 95% CI 1.02–1.77; P = 0.034), heart failure (HR 1.75; 95% CI 1.31–2.33; P < 0.001), kidney disease (HR 1.62; 95% CI 1.25–2.11; P < 0.001), and age ≥ 80 years (HR 2.84; 95% CI 2.17–3.71; P < 0.001).

Conclusions

Patients with RVD receiving pacemaker suffered from increased TR progression, leading to decreased survival.

Graphic abstract

Soluble urokinase-type plasminogen activator receptor predicts peripheral artery disease severity and outcomes

Soluble urokinase-type plasminogen activator receptor (suPAR) is associated with chronic kidney disease (CKD) severity and peripheral artery disease (PAD). We hypothesize an association of PAD severity and suPAR in patients without advanced CKD and further risk stratification according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. For study purposes, suPAR was measured in 334 PAD patients (34% women, age 69 (62–78) years, eGFR 68 ± 20 mL/min/1.72 m²) by commercial ELISA. Patients were followed for 10 years to assess long-term all-cause survival by Cox regression. Higher suPAR levels were associated with lower ankle–brachial index (R = −0.215, p = 0.001) in patients with PAD without media-sclerosis (n = 236). suPAR levels inversely correlated with decreased glomerular filtration rate (R = −0.476, p < 0.001) and directly correlated with urinary albumin-to-creatinine ratio (R = 0.207, p < 0.001). Furthermore, higher suPAR levels associated with a higher KDIGO risk score (p < 0.001). Baseline suPAR was significantly associated with all-cause mortality (HR 1.40 (95% CI 1.16–1.68), p < 0.001) over 10 years. suPAR remained associated with mortality (HR 1.29 (1.03–1.61), p = 0.026) after multivariable adjustment for age, sex, cardiovascular risk factors, and eGFR. Future research may define a standard role for suPAR assessment in PAD’s work-up and treatment, especially in patients with CKD.

Sex Differences and Long-Term Outcome in Patients With Pacemakers

Introduction: Evidence of sex-related differences in patients with pacemakers regarding comorbidities is insufficiently investigated. The aim of this study was to determine the relationship of cardiovascular comorbidities and sex category with properties of pacemaker implantation, pacemaker follow-up, and long-term survival.

Methods: This retrospective, single-center cohort study consisted of 6,362 pacemaker-patients (39.7% female) enrolled between May 2000 and April 2015. Functional pacemaker parameters were registered at regular pacemaker controls. Survival status and cause of death were analyzed in relation to comorbidities, implanted pacing devices, and echocardiography. Survival analyses were plotted for a 10-year follow-up.

Results: Patients with hypertension or hyperlipidemia had higher rates of implantations due to sick sinus syndrome (28.6 vs. 25.5% without hypertension, P < 0.001; 30.7 vs. 25.7% without hyperlipidemia, P < 0.001), while endocarditis was associated with higher rates of implantations due to AV block (46.7 vs. 33.4%, P < 0.001). Patients with valvular heart disease had higher rates of pacemaker implantation due to bradycardic atrial fibrillation (24.9 vs. 21.0% without valvular heart disease, P < 0.001). Ventricular pacing threshold increased in both sexes during the follow-up and was higher in women in the final follow-up (0.94 vs. 0.91 V in men, P = 0.002). During the 10-years follow-up, 6.1% of women and 8.6% of men underwent lead replacement (P = 0.054). Device and lead replacement rates were increased if the comorbidities coronary artery disease, heart failure, hypertension, hyperlipidemia, valvular heart disease, previous stroke/TIA, atrial arrhythmias, chronic kidney disease, or endocarditis were present. Diabetes and previous CABG increase the rates of device replacement, but not the rate of lead replacement. Severe tricuspid regurgitation after implantation of pacemaker was present in more men than women (14.4 vs. 6.1%, P < 0.001). In a multivariate COX regression, the following variables were associated with independent decrease of 10-year survival: hypertension (HR 1.34, 95% CI 1.09–1.64), chronic kidney disease (HR 1.83, 95% CI 1.53–2.19), tricuspid regurgitation after pacemaker implantation (HR 1.48, 95% CI 1.26–1.74). Survival was independently increased in female sex (HR 0.83, 95% CI 0.70–0.99) and hyperlipidemia (HR 0.81, 95% CI 0.67–0.97).

Conclusions: Cardiovascular comorbidities influenced significantly pacemaker implantations and long-term outcome.

Trial Registration:ClinicalTrials.gov Unique identifier: NCT03388281.

Pacemaker lead-induced progression of primary vs. secondary tricuspid regurgitation

Background

Currently no data are available whether the implantation of right ventricular (RV) pacemaker (PM) lead worsens preexisting primary or secondary (functional due to RV dilatation, RVD) tricuspid regurgitation (TR).

Purpose

The aim of the present retrospective analysis was to assess TR after PM implantation with a RV lead.

Methods

Patients with PM implantation (n=990) were enrolled if they had routine echocardiography including assessment of TR before first implantation and immediately after. RVD and severity of TR were characterized visually. Based on RVD in baseline echocardiography, patients were divided into 2 groups: with primary TR (without preexisting RVD, n=743) or secondary TR (with preexisting RVD, n=243).

Results

Lead-induced worsening of TR was present in both groups (Table 1). Progression from mild/moderate to severe TR was observed in 6.7% of patients with primary TR, compared to 25.6% of patients with secondary TR (P=0.001). Using an ordinal regression model, the probability to progress to severe TR with primary TR was 14.8% (95% CI 11.0%-19.7%), compared to 41.6% (95% CI 40.3%-42.8%) with secondary TR (P&lt;0.001).

Conclusion

Preexisting secondary TR was associated with higher rates of lead-induced progression to severe TR compared to primary TR. Leadless pacing or tricuspid valve clipping post-PM implantation could be an option for patients with preexisting secondary TR and indication for a PM.

Table 1. Patient characteristics.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): This study was supported by the European Union's Horizon 2020 Future and Emerging Technologies Programme [Grant number 732170].

Peripheral arterial disease and type 2 diabetes: Older patients still exhibit a survival benefit from glucose control

OBJECTIVE

To investigate a possible beneficial effect of strict glycaemic control on all-cause mortality in patients with peripheral arterial disease and type 2 diabetes mellitus.

METHODS

A total of 367 mainly older peripheral arterial disease patients [age: 69 (62-78) years, 34% women, Fontaine stage I-II] were categorized according to glycaemic control, that is, (a) no type 2 diabetes mellitus, (b) strict glucose control (HbA1c < 53 mmol/mol) and (c) lenient glucose control (HbA1c ⩾ 53 mmol/mol) at inclusion and by mean HbA1c over the first study year. Mortality was analysed using Kaplan-Meier and Cox-regression analyses after 7 years.

RESULTS

The combination of type 2 diabetes mellitus and peripheral arterial disease reduced survival from 78.8% to 68.9% in comparison to patients without type 2 diabetes mellitus (p = 0.023). Patients with strict glucose control (75%) were associated with increased survival in comparison to patients with lenient glucose control (58.9%) stratified by mean HbA1c (p = 0.042). Baseline cardiovascular risk factors were similar in those type 2 diabetes mellitus patients. In this peripheral arterial disease cohort HbA1c (hazard ratio: 1.3, 1.04-1.63), age (hazard ratio: 1.7, 1.3-2.3) and C-reactive protein (hazard ratio: 1.5, 1.2-2.0) remained independent associates for mortality adjusted for cardiovascular risk factors and diabetes duration.

CONCLUSION

Older patients with peripheral arterial disease and type 2 diabetes mellitus still benefit from strict glucose control in a cohort of patients with similar distribution of cardiovascular risk factors.

Empagliflozin in posttransplantation diabetes mellitus: A prospective, interventional pilot study on glucose metabolism, fluid volume, and patient safety

The safety and efficacy of sodium-glucose cotransporter 2 inhibitors in posttransplantation diabetes mellitus is unknown. We converted stable kidney transplant patients to 10 mg empagliflozin, aiming at replacing their insulin therapy (<40 IU/d). N = 14 participants (the required sample size) completed the study visits through 4 weeks and N = 8 through 12 months. Oral glucose tolerance test (OGTT)-derived 2-hour glucose (primary end point) increased from 232 ± 82 mg/dL (baseline) to 273 ± 116 mg/dL (4 weeks, P = .06) and to 251 ± 71 mg/dL (12 months, P = .41). Self-monitored blood glucose and hemoglobin A1c were also clinically inferior with empagliflozin monotherapy, such that insulin was reinstituted in 3 of 8 remaining participants. Five participants (2 of them dropouts) vs nine of 24 matched reference patients developed bacterial urinary tract infections (P = .81). In empagliflozin-treated participants, oral glucose insulin sensitivity decreased and beta-cell glucose sensitivity increased at the 4-week and 12-month OGTTs. Estimated glomerular filtration rate and bioimpedance spectroscopy-derived extracellular and total body fluid volumes decreased by 4 weeks, but recovered. All participants lost body weight. No participant developed ketoacidosis; 1 patient developed balanitis. In conclusion, although limited by sample size and therefore preliminary, these results suggest that empagliflozin can safely be used as add-on therapy, if posttransplant diabetes patients are monitored closely (NCT03113110).

Clinical characteristics of a large cohort of patients with positive culture of Fusobacterium necrophorum

Background: Fusobacterium necrophorum is a rare pathogen, mostly affecting young adults, causing infections of the head and neck, typically described as the Lemierre's syndrome. Today this symptom complex has become increasingly rare and has almost turned to a 'forgotten disease'. Methods: We performed a retrospective, descriptive study to identify the clinical features of patients with positive culture of F. necrophorum. Additionally, the antibiotic susceptibility profile of the pathogens was analysed. Results: During a period of 22 years 36 patients with at least one isolate of F. necrophorum were identified. Mostly tonsillar and peritonsillar abscesses were found, 10 patients were identified with bacteraemia, but only 4 patients presented with symptoms like sore throat, fever and swollen cervical lymph nodes, which may suggest Lemierre's. Most of the isolates (33/35) showed sensitivity to all tested antibiotics. Conclusion: Appropriate techniques are needed to detect F. necropho rum, especially from throat swabs, in the microbiological laboratory. Current clinical and microbiological practice may lead to under-diagnosis of infections caused by F. necrophorum. Further research is needed to define the colonization rate and to optimize methods for detection as well as identification of virulence.

Epidemiology of Urinary Tract Infections in HIV Positive Patients at a Tertiary Care University Hospital in Central Europe (2011 - 2016)

OBJECTIVES

There is limited published data concerning the recent epidemiology of urinary tract infections (UTI) in HIV-patients, thus we analysed independent risk factors for UTI in HIV positive individuals and antimicrobial resistance rates of E. coli to antimicrobial agents commonly used in UTI. To determine the prevalence of symptomatic urinary tract infections (UTI) in HIV-patients, we performed a retrospective case-control study.

METHODS

We included 313 HIV-patients, 101 with UTI and 212 age and gendermatched controls, attending the HIV outpatient clinic at the Vienna University Hospital (VUH) over a period from January 2011 to September 2016. The patients' specific data was gathered from the electronic database of the VUH. The statistical analysis was performed using SPSS Software Version 20.0.

RESULTS

HIV infected individuals with CD4 count >200 cells/mm3 were less likely than HIV infected individuals with CD4 count <200 cells/mm3 to experience UTI (OR 0.811, 95% CI 0.712-0.923 vs. OR 2.555, 95% CI 1.553 - 4.205, respectively). The in vitro resistance rate of E. coli to antimicrobial agents was as follows: ciprofloxacin (41%), mecillinam (20.5%), trimethoprim (61%), ampicillin (67%), ampicillin/ clavulanic acid (23%), cefuroxime (17%), nitrofurantoin (2%), amikacin (0%) and gentamicin (9.5%).

CONCLUSION

Immunological status (CD4 count) is an important parameter for risk assessment of UTIs in HIV-patients. The increased resistance rate of E. coli to commonly used antimicrobial agents needs to be considered when it comes to the management of UTI, additionally, surveillance strategies should be implemented in HIV-patients.

Automated tube voltage selection in pediatric non-contrast chest CT

BACKGROUND

Modern CT scanners provide automatic dose adjustment systems, which are promising options for reducing radiation dose in pediatric CT scans. Their impact on patient dose, however, has not been investigated sufficiently thus far.

OBJECTIVE

To evaluate automated tube voltage selection (ATVS) in combination with automated tube current modulation (ATCM) in non-contrast pediatric chest CT, with regard to the diagnostic image quality.

MATERIALS AND METHODS

There were 160 non-contrast pediatric chest CT scans (8.7±5.4 years) analyzed retrospectively without and with ATVS. Correlations of volume CT Dose Index (CTDIvol) and effective diameter, with and without ATVS, were compared using Fisher's z-transformation. Image quality was assessed by mean signal-difference-to-noise ratios (SDNR) in the aorta and in the left main bronchus using the independent samples t-test. Two pediatric radiologists and a general radiologist rated overall subjective Image quality. Readers' agreement was assessed using weighted kappa coefficients. A p value <0.05 was considered significant.

RESULTS

CTDIvol correlation with the effective diameter was r = 0.62 without and r = 0.80 with ATVS (CI: -0.04 to -0.60; p = 0.025). Mean SDNR was 10.88 without and 10.03 with ATVS (p = 0.0089). Readers' agreement improved with ATVS (weighted kappa between pediatric radiologists from 0.1 (0.03-0.16) to 0.27 (0.09-0.45) with ATVS; between general and each pediatric radiologist from 0.1 (0.06-0.14) to 0.12 (0.05-0.20), and from 0.22 (0.11-0.34) to 0.36 (0.24-0.49)).

CONCLUSION

ATVS, combined with ATCM, results in a radiation dose reduction for pediatric non-contrast chest CT without a loss of diagnostic image quality and prevents errors in manual tube voltage setting, and thus protecting larger children against an unnecessarily high radiation exposure.

YKL-40 levels increase with declining ankle-brachial index and are associated with long-term cardiovascular mortality in peripheral arterial disease patients

BACKGROUND AND AIMS

YKL-40 is an inflammatory marker secreted by macrophages and is expressed in atherosclerotic plaques. YKL-40 increases in coronary artery disease (CAD) with poor coronary collateral vessel development. Higher levels are linked to reduced survival in CAD patients. Studies evaluating YKL-40 in patients with peripheral arterial disease (PAD) are scarce. This study aims to elucidate a possible link between YKL-40 and PAD severity as well as cardiovascular long-term mortality.

METHODS

YKL-40 was measured at baseline in 365 elderly PAD patients (age 69 ± 10.4, 33.7% women, Fontaine stage I-II) by bead-based multiplex assay. Patients were followed for seven years to assess long-term cardiovascular and all-cause survival by Kaplan-Meier and Cox regression.

RESULTS

YKL-40 levels were associated with declining ankle-brachial index (ABI) in PAD patients without Moenckeberg's mediasclerosis (R = -0.189, p=0.002). PAD patients with mediasclerosis exhibited higher YKL-40 levels (p=0.002). Baseline YKL-40 levels were significantly associated with cardiovascular mortality (HR 1.52 (1.21-1.91), p < 0.001) and all-cause mortality (HR 1.45 (1.20-1.75), p < 0.001) over a seven-year observation period. After multivariable adjustment for gender, patient age, known carotid artery disease, known coronary artery disease, smoking status, systolic blood pressure, HbA_1c, low density lipoprotein cholesterol, estimated glomerular filtration rate, aspartate aminotransferase, and C-reactive protein, YKL-40 remained significantly associated with cardiovascular (HR 1.34 (1.02-1.75), p=0.033) and all-cause mortality (HR 1.25 (1.01-1.55), p=0.039).

CONCLUSIONS

Increased YKL-40 levels are independently associated with poor long-term cardiovascular survival in peripheral arterial disease patients. Furthermore, YKL-40 correlates with patients' ABI in PAD in the absence of mediasclerosis.

Angiopoietin-2 and Survival in Peripheral Artery Disease Patients

Survival of peripheral arterial disease (PAD) patients increased over the last decade due to increased use of secondary preventive medication and rapid revascularization of PAD patients. Angiogenetic markers such as vascular endothelial growth factor (VEGF), angiopoietin-2 (Ang-2) and its receptor Tie-2 might be useful markers to assess the residual risk for mortality in PAD patients. The aim of this study was to evaluate angiogenetic markers for the prediction of mortality in a PAD cohort. For this purpose, 366 patients (mean age: 69 ± 10 years) with PAD Fontaine stage I or II were included and followed up over a 5-year study period. Serum Ang-2, Tie-2 and VEGF levels were measured by bead-based multiplex assay. All-cause mortality and major cardiovascular events (MACE) including all-cause death, non-fatal stroke and non-fatal myocardial infarction were analysed by Kaplan–Meier and Cox regression analyses after 5 years. Ang-2 was associated with Tie-2 (R = 0.151, p = 0.006) and VEGF levels (R = 0.160, p = 0.002). However, only Ang-2 was linked to all all-cause mortality in PAD patients (hazard ratio [HR]: 1.55 [1.23–2.15], p = 0.008) even after adjustment for age and gender, haemoglobin A1c, low-density lipoprotein cholesterol, systolic blood pressure and glomerular filtration rate (HR: 1.44 [1.03–2.00], p = 0.032). Furthermore, an association of Ang-2 and MACE in PAD patients (HR: 1.36 (1.03–1.78), p = 0.028) was found. This result implies that Ang-2 might be used as an additional marker to stratify PAD patients to predict poor mid-term life expectancy.

The Strategic Approach of Managing Healthcare Data Exchange in Austria

Objectives: The exchange of electronic medical data between healthcare providers constitutes an integral part of modern medicine, and its importance is growing. Efficient application on a national level requires a uniform approach to the management of healthcare data exchange, avoiding isolated solutions that are expensive and also incompatible.

Methods: In this communication we explain the basic concepts of establishing a nationwide framework to guide healthcare data exchange in Austria. To achieve this goal, a three-step approach was adopted: (i) creating general guidelines to direct electronic medical data exchange; (ii) defining detailed standards for electronic messages; (iii) organizing pilot projects to implement these standards, and further improving the general guidelines based on the results of the pilot projects.

Results: We present the MAGDA-LENA framework which guides healthcare data exchange in Austria, and compare it with the US framework HIPAA. We describe several communication scenarios for which concrete message standards were developed in recent years, based on the MAGDA-LENA framework. We further discuss the implementation of these standards in four pilot projects.

Conclusions: The strategic approach of managing healthcare data exchange presented in this paper is expected to have a substantial impact on medical informatics in Austria over the next few years.

eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations

Background: Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented.

Objectives: To assess the completeness of information documented electronically compared with manually during patient visits.

Methods: The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared.

Results: In all categories, clinical documentation was more complete in the EHR group.

Conclusions: In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.

Citation: Mitsch C, Huber P, Kriechbaum K, Scholda C, Duftschmid G, Wrba T, Schmidt-Erfurth U. Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations. Appl Clin Inform 2015; 6: 478–487

http://dx.doi.org/10.4338/ACI-2015-03-RA-0028

Center-based patient care enhances survival of elderly patients suffering from peripheral arterial disease

OBJECTIVES

Recent advances in catheter-based intervention in patients with symptomatic peripheral arterial disease (PAD) have halved mortality. Mortality of PAD patients still remains high compared to other clinical forms of atherosclerosis. Intensified patient care might increase adherence to medical management and benefit the survival of PAD patients.

METHODS

Two patient cohorts were compared in a longitudinal prospective follow-up study. 370 PAD patients were included in the intensified center-based vascular medicine group (VMC group) and 332 PAD patients were treated by their usual primary care physician (PCP group). Survival in both groups was compared by Kaplan-Meier and Cox-regression analyses after 5 years.

RESULTS

Survival of patients in the VMC group was 90.8% compared to 66% in the PCP group. Thus, survival was improved by 24.9% by center-based care (absolute risk CI: 19-30.7%; 38% relative risk). PCP treatment increased all-cause mortality by a hazard ratio of 3.7 (95% CI: 2.5-5.5; p < .001). Mortality in the VMC group was significantly associated with the non-modifiable risk factors age, C-reactive protein, and nephropathy in multivariable analyses.

CONCLUSION

These data imply that multi-morbid elderly PAD patients still benefit by intensified specialist care compared to the usual primary care setting. KEY MESSAGES Center-based patient care improves survival in patients with peripheral arterial disease; mortality was reduced from 82 to 21 events per 1000 patient-years (rate ratio 0.26). Mortality was related to age (HR 1.46), CRP (HR 1.36), and nephropathy (HR 2.7). A multifactorial approach combining adequate drug prescription, accomplishment of agreed goals and repetitive training to initiate, implement, and persist treatment adaptations was applied.

Hypothyroidism and Hyponatremia: Rather Coincidence Than Causality

BACKGROUND

Hypothyroidism is referred to be a rare but possible cause of hyponatremia. However, there is only poor evidence supporting this association. Since hyponatremia and hypothyroidism are both common conditions themselves, co-occurrence does not have to be causal.

METHODS

To address a potential relationship, a retrospective analysis of data from the Division of Endocrinology of the Medical University of Vienna from April 2004 to February 2016 was performed. A total of 8053 hypothyroid patients (48 ± 18 years of age; 71% female) with thyrotropin >4.0 μIU/mL and available blood tests for free thyroxine and sodium (Na⁺) within maximal ± seven days were included and screened for hyponatremia. Patients' records were searched for concomitant disease and medication when Na⁺ concentration was <135 mmol/L.

RESULTS

Hyponatremia was present in 448/8053 (5.56%) patients. Analysis of medical history revealed potential alternative causes of hyponatremia in 442/448 (98.88%) patients (i.e., side effects of medication, concomitant underlying disease, or other endocrine disorders). This distribution did not differ between patients suffering from clinical or subclinical hypothyroidism. No case of clinically relevant hyponatremia (Na⁺ < 130 mmol/L), present in 111/448 (24.78%) patients could be attributed only to hypothyroidism. There was a very weak but statistically significant trend toward a positive association between thyroid function and serum Na⁺ levels (Na⁺/thyrotropin: R = 0.022, p = 0.046; Na⁺/free thyroxine: R = -0.047, p < 0.001).

CONCLUSION

The results suggest that hypothyroid patients with moderate to severe hyponatremia often have other potential explanations for their low serum Na⁺ concentrations in routine care.

Serum Creatinine Back-Estimation in Cardiac Surgery Patients: Misclassification of AKI Using Existing Formulae and a Data-Driven Model

BACKGROUND AND OBJECTIVES

A knowledge of baseline serum creatinine (bSCr) is mandatory for diagnosing and staging AKI. With often missing values, bSCr is estimated by back-calculation using several equations designed for the estimation of GFR, assuming a "true" GFR of 75 ml/min per 1.73 m(2). Using a data set from a large cardiac surgery cohort, we tested the appropriateness of such an approach and compared estimated and measured bSCr. Moreover, we designed a novel data-driven model (estimated serum creatinine [eSCr]) for estimating bSCr. Finally, we analyzed the extent of AKI and mortality rate misclassifications.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data for 8024 patients (2833 women) in our cardiac surgery center were included from 1997 to 2008. Measured and estimated bSCr were plotted against age for men and women. Patients were classified to AKI stages defined by the Kidney Disease Improving Global Outcomes (KDIGO) group. Results were compared with data from another cardiac surgery center in Zurich, Switzerland.

RESULTS

The Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration formulae describe higher estimated bSCr values in younger patients, but lower values in older patients compared with the measured bSCr values in both centers. The Pittsburgh Linear Three Variables formula correctly describes the increasing bSCr with age, however, it underestimates the overall bSCr level, being in the range of the 25% quantile of the measured values. Our eSCr model estimated measured bSCr best. AKI stage 1 classification using all formulae, including our eSCr model, was incorrect in 53%-80% of patients in Vienna and in 74%-91% in Zurich; AKI severity (according to KDIGO stages) and also mortality were overestimated. Mortality rate was higher among patients falsely classified into higher KDIGO stages by estimated bSCr.

CONCLUSIONS

bSCr values back-estimated using currently available eGFR formulae are inaccurate and cannot correctly classify AKI stages. Our model eSCr improves the prediction of AKI but to a still inadequate extent.

Clinical Decision Support for the Classification of Diabetic Retinopathy: A Comparison of Manual and Automated Results

The management of diabetic retinopathy, a frequent ophthalmological manifestation of diabetes mellitus, consists of regular examinations and a standardized, manual classification of disease severity, which is used to recommend re-examination intervals. To evaluate the feasibility and safety of implementing automated, guideline-based diabetic retinopathy (DR) grading into clinical routine by applying established clinical decision support (CDS) technology. We compared manual with automated classification that was generated using medical documentation and an Arden server with a specific medical logic module. Of 7169 included eyes, 47% (n=3373) showed inter-method classification agreement, specifically 29.4% in mild DR, 38.3% in moderate DR, 27.6% in severe DR, and 65.7% in proliferative DR. We demonstrate that the implementation of a CDS system for automated disease severity classification in diabetic retinopathy is feasible but also that, due to the highly individual nature of medical documentation, certain important criteria for the used electronic health record system need to be met in order to achieve reliable results.

eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations

BACKGROUND

Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented.

OBJECTIVES

To assess the completeness of information documented electronically compared with manually during patient visits.

METHODS

The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared.

RESULTS

In all categories, clinical documentation was more complete in the EHR group.

CONCLUSIONS

In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.

Non-linear significant relationship between use of glycopeptides and isolation of vancomycin-resistant Enterococcus species in a university hospital setting

BACKGROUND

Emergence of colonization and infection with vancomycin-resistant enterococci (VRE) has become a worldwide challenge. To investigate whether the increasing incidence of VRE isolation can be correlated with use of glycopeptides in the hospital setting, we conducted a hospital-wide two-year study in the university hospital of Vienna.

METHODS

Within the period from January 2011 through December 2012 all patients with isolation of invasive or non-invasive VRE were retrospectively included. Specialty-specific data concerning the consumption of vancomycin and teicoplanin, fluoroquinolones and third generation cephalosporins in defined daily doses (DDDs) from June 2010 through May 2012 were extracted from the hospital pharmacy computer system. To assess the relationship between the usage of those antibiotics and the incidence of VRE (VRE-rate per 10 000 patients) a Poisson regression was performed.

FINDINGS

In the study period 266 patients were colonized or infected with VRE. Specialty-specific VRE isolation was as follows: general surgical units (44 patients), bone marrow transplant unit (35 patients), general medical units (33 patients), cardiothoracic surgery (27 patients), nephrology (26 patients), haematooncology (22 patients), gastroenterology (17 patients), urology (17 patients), and the infectious diseases unit (11 patients). Hospital-wide consumption of glycopeptides was higher for teicoplanin than for vancomycin (26 242 versus 8677 DDDs). Specialty-specific VRE incidence significantly increased with the use of glycopeptides, fluoroquinolones or third generation cephalosporins (p < 0.001). The results of the Poisson regression for vancomycin (p = 0.0018) and teicoplanin (p < 0.0001) separately were both highly significant. Spearman's correlation coefficient indicated a strong correlation between the two variables (rho = 0.8).

CONCLUSION

Overall usage of glycopeptides, fluoroquinolones or third generation cephalosporins contributed to the emergence of VRE in the hospital setting.

Severe Clostridium difficile infection: incidence and risk factors at a tertiary care university hospital in Vienna, Austria

BACKGROUND

Clostridium difficile infection (CDI) is the major cause of hospital-acquired bacterial diarrhoea. The incidence of CDI has been increasing in Canada, the US and Europe and severe cases are becoming more common.

METHODS

A retrospective cohort study investigating all patients with an episode of CDI present at the Vienna University Hospital between 01 January 2012 and 31 December 2012 was conducted. All microbiologically confirmed C. difficile toxin positive cases were included, ribotyped and analysed regarding their clinical course.

RESULTS

A total of 278 patients with CDI were recorded, with an overall CDI incidence of 5.23 per 10,000 patients-days. Around 84,5 % (235/278) of CDI cases would have been classified as severe CDI according to European Society of Clinical Microbiology and Infectious Diseases (ESCMID) if all criteria were used. According to Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (SHEA/IDSA) guidelines only 16.5 % (46/278) could be classified as severe; with a severe CDI incidence of 4.41 and 0.86 per 10,000 patient-days, respectively. Multivariate analysis showed only a co-morbidity index of ≥ 3 (p = 0.013) as independent risk factor for severe CDI. No link between ribotype 027 and severity or clustering was observed in our study population.

CONCLUSIONS

Special attention in terms of restrictive antibiotic prescription should be given to patients having a Charlson co-morbidity ≥ 3 at the time of hospital admission. SHEA/IDSA guidelines were more accurate than ESCMID criteria in predicting severe CDI in our collective, of mostly severely ill patients, in a tertiary care hospital setting.

Early basal insulin therapy decreases new-onset diabetes after renal transplantation

No effective interventions to reduce risk for new-onset diabetes after transplantation (NODAT), a condition associated with postoperative hyperglycemia and reduced patient and graft survival, have been established. In this 1-year, proof-of-concept clinical trial, we randomly assigned 50 renal transplant recipients to immediate-postoperative isophane insulin for evening blood glucose ≥140 mg/dl (treatment group) or short-acting insulin and/or oral antidiabetic agents for blood glucose ≥180-250 mg/dl (standard-of-care control group). We included only patients without a history of diabetes who received tacrolimus. By the third postoperative evening, all patients in the treatment group had blood glucose ≥140 mg/dl and were subsequently treated with basal insulin; during the first 3 weeks after transplantation, the mean ± SD daily insulin dosage was 17±11 IU/d. Among controls, 23 (92%) of 25 had blood glucose ≥200 mg/dl and 18 (72%) of 25 received standard-of-care antihyperglycemic treatment. Asymptomatic hypoglycemia occurred five times in the treatment group and once in the control group. Throughout follow-up, the treatment group had 73% lower odds of NODAT (odds ratio, 0.27) than the control group, and hemoglobin A1c was on average 0.38% lower in the treatment group than the control group. Twelve months after transplantation, all patients in the treatment group were insulin-independent, whereas 7 (28%) of 25 controls required antidiabetic agents. The groups did not differ for insulin sensitivity, but the treatment group showed better β-cell function throughout the 1-year follow-up. In conclusion, this study suggests regimens that include basal insulin significantly reduce the odds for NODAT after renal transplantation, presumably via insulin-mediated protection of β cells.

A tool for the design of clinical forms supporting end-user integration

Computer-based forms are a common input medium for recording medical data by the electronic mode. Efficient documentation requires that the forms satisfy the specific needs and habits of clinical end-users in the collection of data. This can be effectively achieved by integrating the clinician in the process of designing the forms. However, most development environments used for the implementation of clinical forms are customized for computer specialists and are too technical in nature to be used by clinicians. We present a tool for the development of clinical forms, which supports the integration of end-users in the design process of the forms. The tool is customized for users from the medical domain, allowing interactive and intuitive development of forms based on the configuration of predefined components instead of programming. Clinicians may even design highly functional, complex forms autonomously without having to involve computer specialists at all. All collected data are stored on the basis of a generic data model favouring data retrieval. The described application has been successfully used at the University of Vienna and Graz medical schools since 1997 and 1999, respectively.

Analysis of EHRs for research, quality management and health politics

Lifelong electronic health records can supply valuable information for research, quality management and health politics in addition to supporting treatment of patients. Based on experiences with scientific data analysis in a university hospital environment, requirements on cross-institutional analysis of electronic health records in a healthcare system are discussed. The concept of archetypes can play a key role in this context. Archetypes can be utilized in data analysis for visualization, semantic linkage and finally for standardized data transfer.

[Guidelines for the planning and implementation of telemedical applications]

Before a telemedical application can be implemented in practice, various technical, organisational, and legal questions have to be solved. The answers to these questions are, however, in most cases not very obvious. Telemedicine guidelines which could provide a path to follow currently exist only for selected medical fields and are frequently customized for particular medical and technical scenarios. The use of existing telemedicine guidelines in Austrian health care is further complicated by the fact that most of them are based on foreign legal systems. This paper therefore aims to develop general telemedicine guidelines which are appropriate for all application areas of telemedicine in Austrian health care. From nine existing telemedicine guidelines for individual medical fields, two generally applicable guidelines were derived. The corresponding abstraction process was based on a categorization of telemedical applications, which is oriented on the communication partners involved. The derived, general guidelines address seven typical problem domains in the practical application of a telemedical application. As opposed to the existing guidelines, they (1) are independent of special medical fields and are therefore appropriate for all application areas of telemedicine -- also in medical fields where no specific guidelines have existed before; (2) are adapted to the Austrian legal system; (3) provide additional insight for medical fields where specific guidelines have already existed, as they can benefit from recommendations of other medical fields where equivalent telemedical applications are employed.

The strategic approach of managing healthcare data exchange in Austria

OBJECTIVES

The exchange of electronic medical data between healthcare providers constitutes an integral part of modern medicine, and its importance is growing. Efficient application on a national level requires a uniform approach to the management of healthcare data exchange, avoiding isolated solutions that are expensive and also incompatible.

METHODS

In this communication we explain the basic concepts of establishing a nationwide framework to guide healthcare data exchange in Austria. To achieve this goal, a three-step approach was adopted: (i) creating general guidelines to direct electronic medical data exchange; (ii) defining detailed standards for electronic messages; (iii) organizing pilot projects to implement these standards, and further improving the general guidelines based on the results of the pilot projects.

RESULTS

We present the MAGDA-LENA framework which guides healthcare data exchange in Austria, and compare it with the US framework HIPAA. We describe several communication scenarios for which concrete message standards were developed in recent years, based on the MAGDA-LENA framework. We further discuss the implementation of these standards in four pilot projects.

CONCLUSIONS

The strategic approach of managing healthcare data exchange presented in this paper is expected to have a substantial impact on medical informatics in Austria over the next few years.

ArchiMed: a medical information and retrieval system

ArchiMed is a highly flexible medical data storage and retrieval system which adds sophisticated clinical research support to a standard hospital information system (HIS). Currently, the HIS of Vienna General Hospital-University Hospital (2000 beds) stores the clinical data of over 2 million patients. While this system supports patient care (e.g., ADT, clinical chemistry, diagnosis, procedures), it has no features to facilitate research, such as the management of clinical studies. ArchiMed is designed to support clinical research. It includes an independent database, which mirrors virtually all the information held in the HIS while also allowing new data to be collected independently and to be added to the database. Flexible retrieval and analysis of data contained in the database are then possible. Thus, existing patient data can be smoothly incorporated into a study together with data collected specifically for research purposes. The system has already been successfully installed in the departments of surgery and soon in other departments as well.