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Neeland IJ, Arafah A, Bourges-Sevenier B, Dazard JE, Albar Z, Landskroner Z, Tashtish N, Eaton E, Friswold J, Porges J, Nennstiel M, Davies A, Rahmani S, Howard QS, Forrest K, Sullivan C, Greene L, Al-Kindi SG, Rajagopalan S. Second-year results from CINEMA: A novel, patient-centered, team-based intervention for patients with Type 2 diabetes or prediabetes at high cardiovascular risk. Am J Prev Cardiol 2024; 17:100630. [PMID: 38223296 PMCID: PMC10787236 DOI: 10.1016/j.ajpc.2023.100630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024] Open
Abstract
Background The care for patients with type 2 diabetes mellitus (T2DM) necessitates a multidisciplinary team approach to reduce cardiovascular (CV) risk but implementation of effective integrated strategies has been limited. Methods and Results We report 2-year results from a patient-centered, team-based intervention called CINEMA at University Hospitals Cleveland Medical Center. Patients with T2DM or prediabetes at high-risk for CV events, including those with established atherosclerotic CVD, elevated coronary artery calcium score ≥100, chronic heart failure with reduced ejection fraction, chronic kidney disease (CKD) stages 2-4, and/or prevalent metabolic syndrome were included. From May 2020 through September 2022, 426 patients were enrolled in the CINEMA program. A total of 227 (54%) completed ≥1 follow-up visit after an initial baseline visit with median (IQR) follow-up time 4 [3], [4], [5], [6], [7] months with maximum follow-up time 19 months. Mean age was 60 years, 47 % were women, and 37 % were Black and 85% had prevalent T2DM, 48 % had established ASCVD, 29% had chronic HF, 27% had CKD and mean baseline 10-year ASCVD risk estimate was 25.1 %; baseline use of a SGLT2i or GLP-1RA was 21 % and 18 %, respectively. Patients had significant reductions from baseline in body weight (-5.5 lbs), body mass index (-0.9 kg/m2), systolic (-3.6 mmHg) and diastolic (-1.2 mmHg) blood pressure, Hb A1c (-0.5 %), total (-10.7 mg/dL) and low-density lipoprotein (-9.0 mg/dL) cholesterol, and triglycerides (-13.5 mg/dL) (p<0.05 for all). Absolute 10-year predicted ASCVD risk decreased by ∼2.4 % (p<0.001) with the intervention. In addition, rates of guideline-directed cardiometabolic medication prescriptions significantly increased during follow-up with the most substantive changes seen in rates of SGLT2i and GLP-1RA use which approximately tripled from baseline (21 % to 57 % for SGLT2i and 18 % to 65 % for GLP-1RA, p<0.001 for both). Conclusions The CINEMA program, an integrated, patient-centered, team-based intervention for patients with T2DM or prediabetes at high risk for cardiovascular disease has continued to demonstrate effectiveness with significant improvements in ASCVD risk factors and improved use of evidence-based therapies. Successful implementation and dissemination of this care delivery paradigm remains a key priority.
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Affiliation(s)
- Ian J. Neeland
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Ala’ Arafah
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
| | - Brendan Bourges-Sevenier
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Jean-Eudes Dazard
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
| | - Zainab Albar
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
| | - Zoe Landskroner
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Nour Tashtish
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Elke Eaton
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Janice Friswold
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Jodie Porges
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Matthew Nennstiel
- University Hospitals Health System, Cleveland, OH 44106, United States
| | - Amanda Davies
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Sara Rahmani
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Quiana S. Howard
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Katherine Forrest
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Claire Sullivan
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Lloyd Greene
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Sadeer G. Al-Kindi
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Sanjay Rajagopalan
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
- Division of Cardiovascular Medicine, University Hospitals Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
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Straus S, Moghaddam M, Zarrintan S, Willie-Permor D, Jagadeesh V, Malas M. Modality-specific outcomes of patients undergoing carotid revascularization in the setting of recent myocardial infarction. J Vasc Surg 2024; 79:88-95. [PMID: 37742732 DOI: 10.1016/j.jvs.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization. METHODS Data was collected from the Vascular Quality Initiative (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, prolonged length of stay (>2 days), and 30-day mortality. RESULTS The final cohort included 1217 CEA (54.2%), 445 TFCAS (19.8%), and 584 TCAR (26.0%) cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of American Society of Anesthesiologists class IV to V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079), death (P = .002), and 30-day mortality (P = .007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.36-5.35; P = .005) and stroke/death/MI (aOR, 1.67; 95% CI, 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes compared with CEA. Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR, 1.62; 95% CI, 1.18-2.23; P = .003 and aOR, 1.74; 95% CI, 1.31-2.32; P ≤ .001, respectively) and decreased risk of postoperative hypertension (aOR, 0.59; 95% CI, 0.36-0.95; P = .029 and aOR, 0.50; 95% CI, 0.36-0.71; P ≤ .001, respectively) compared with CEA. CONCLUSIONS Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.
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Affiliation(s)
- Sabrina Straus
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Marjan Moghaddam
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Sina Zarrintan
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Daniel Willie-Permor
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Vasan Jagadeesh
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA
| | - Mahmoud Malas
- Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA.
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McCullough-Hicks M, Thatikunta P, Mlynash M, Albers GW, Mijalski-Sells C. Visual review of acute stroke neuroimaging prior to transfer acceptance increases likelihood of endovascular therapy. J Stroke Cerebrovasc Dis 2023; 32:107157. [PMID: 37126905 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVES Demand for thrombectomy, and interhospital transfer to comprehensive stroke centers (CSCs), for acute stroke is increasing. There is an urgent need to identify patients most likely to benefit from transfer. We evaluated whether CSC providers' review of neuroimaging prior to transfer acceptance improved patient selection for thrombectomy and correlated with higher rates of treatment. MATERIALS AND METHODS A retrospective database of all patients transferred to Stanford's CSC for thrombectomy between 2015-2019 was used. Pre-acceptance images, when available for visual review, were reviewed by the CSC stroke team via virtual PACS, RAPID software, or LifeImage platforms. RESULTS 525 patients met inclusion criteria. 147 (28%) had neuroimaging available for review prior to transfer. Of those who did not recanalize en route, 267 (50.8%) underwent thrombectomy. Patients with imaging available for review prior to acceptance were significantly more likely to receive thrombectomy (68% vs 54%, RR 1.26; p=0.006, 95% CI 1.09-1.48). Patient images that were reviewed via RAPID were CT-based perfusion studies; these were more likely to receive thrombectomy (70% vs 54%, RR 1.30; p=0.01, 1.09-1.56). Patients who received EVT were more likely to have had pre-transfer vessel imaging, regardless of availability for visual review (76% vs 59%, RR 1.44; p<0.001, 1.18-1.76). CONCLUSIONS Patients with concern for acute stroke transferred for consideration of thrombectomy who had neuroimaging visually reviewed prior to transfer acceptance and did not recanalize by time of arrival were significantly more likely to undergo thrombectomy. Additional prospective studies are needed to confirm our findings.
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Affiliation(s)
| | - Prateek Thatikunta
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
| | - Michael Mlynash
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
| | - Gregory W Albers
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
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Navani RV, Dawson LP, Nehme E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Variation in Health Care Processes, Quality and Outcomes According to Day and Time of Chest Pain Presentation via Ambulance. Heart Lung Circ 2023:S1443-9506(23)00150-6. [PMID: 37100698 DOI: 10.1016/j.hlc.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous studies examining temporal variations in cardiovascular care have largely been limited to assessing weekend and after-hours effects. We aimed to determine whether more complex temporal variation patterns might exist in chest pain care. METHODS This was a population-based study of consecutive adult patients attended by emergency medical services (EMS) for non-traumatic chest pain without ST elevation in Victoria, Australia between 1 January 2015 and 30 June 2019. Multivariable models were used to assess whether time of day and week stratified into 168 hourly time periods was associated with care processes and outcomes. RESULTS There were 196,365 EMS chest pain attendances; mean age 62.4 years (standard deviation [SD] 18.3) and 51% females. Presentations demonstrated a diurnal pattern, a Monday-Sunday gradient (Monday peak) and a reverse weekend effect (lower rates on weekends). Five temporal patterns were observed for care quality and process measures, including a diurnal pattern (longer emergency department [ED] length of stay), an after-hours pattern (lower angiography or transfer for myocardial infarction, pre-hospital aspirin administration), a weekend effect (shorter ED clinician review, shorter EMS off-load time), an afternoon/evening peak period pattern (longer ED clinician review, longer EMS off-load time) and a Monday-Sunday gradient (ED clinician review, EMS offload time). Risk of 30-day mortality was associated with weekend presentation (Odds ratio [OR] 1.15, p=0.001) and morning presentation (OR 1.17, p<0.001) while risk of 30-day EMS reattendance was associated with peak period (OR 1.16, p<0.001) and weekend presentation (OR 1.07, p<0.001). CONCLUSIONS Chest pain care demonstrates complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs to improve care across all days and times of the week.
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Affiliation(s)
- Rohan V Navani
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/RohanNavani
| | - Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Emily Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Vic, Australia; Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Vic, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia.
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Lindberg F, Lund LH, Benson L, Schrage B, Edner M, Dahlström U, Linde C, Rosano G, Savarese G. Patient profile and outcomes associated with follow-up in specialty vs. primary care in heart failure. ESC Heart Fail 2022; 9:822-833. [PMID: 35170237 PMCID: PMC8934918 DOI: 10.1002/ehf2.13848] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/09/2022] [Accepted: 02/04/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Factors influencing follow-up referral decisions and their prognostic implications are poorly investigated in patients with heart failure (HF) with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction (EF). We assessed (i) the proportion of, (ii) independent predictors of, and (iii) outcomes associated with follow-up in specialty vs. primary care across the EF spectrum. METHODS AND RESULTS We analysed 75 518 patients from the large and nationwide Swedish HF registry between 2000-2018. Multivariable logistic regression models were fitted to identify the independent predictors of planned follow-up in specialty vs. primary care, and multivariable Cox models to assess the association between follow-up type and outcomes. In this nationwide registry, 48 115 (64%) patients were planned for follow-up in specialty and 27 403 (36%) in primary care. The median age was 76 [interquartile range (IQR) 67-83] years and 27 546 (36.5%) patients were female. Key independent predictors of planned follow-up in specialty care included optimized HF care, that is follow-up in a nurse-led HF clinic [odds ratio (OR) 4.60, 95% confidence interval (95% CI) 4.41-4.79], use of HF devices (OR 3.99, 95% CI 3.62-4.40), beta-blockers (OR 1.39, 95% CI 1.32-1.47), renin-angiotensin system/angiotensin-receptor-neprilysin inhibitors (OR 1.21, 95% CI 1.15-1.27), and mineralocorticoid receptor antagonists (OR 1.31, 95% CI 1.26-1.37); and more severe HF, that is higher NT-proBNP (OR 1.13, 95% CI 1.06-1.20) and NYHA class (OR 1.13, 95% CI 1.08-1.19). Factors associated with lower likelihood of follow-up in specialty care included older age (OR 0.29, 95% CI 0.28-0.30), female sex (OR 0.89, 95% CI 0.86-0.93), lower income (OR 0.79, 95% CI 0.76-0.82) and educational level (OR 0.77, 95% CI 0.73-0.81), higher EF [HFmrEF (OR 0.65, 95% CI 0.62-0.68) and HFpEF (OR 0.56, 95% CI 0.53-0.58) vs. HFrEF], and higher comorbidity burden, such as presence of kidney disease (OR 0.91, 95% CI 0.87-0.95), atrial fibrillation (OR 0.85, 95% CI 0.81-0.89), and diabetes mellitus (OR 0.92, 95% CI 0.88-0.96). A planned follow-up in specialty care was independently associated with lower risk of all-cause [hazard ratio (HR) 0.78, 95% CI 0.76-0.80] and cardiovascular death (HR 0.76, 95% CI 0.73-0.78) across the EF spectrum, but not of HF hospitalization (HR 1.06, 95% CI 1.03-1.10). CONCLUSIONS In a large nationwide HF population, referral to specialty care was linked with male sex, younger age, lower EF, lower comorbidity burden, better socioeconomic environment and optimized HF care, and associated with better survival across the EF spectrum. Our findings highlight the need for greater and more equal access to HF specialty care and improved quality of primary care.
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Affiliation(s)
- Felix Lindberg
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
| | - Lars H. Lund
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
| | - Lina Benson
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
| | - Benedikt Schrage
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
- Department of CardiologyUniversity Heart and Vascular Center Hamburg, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/KielHamburgGermany
| | - Magnus Edner
- Division of Family Medicine, Department of NeurobiologyCare Sciences and Society (NVS), Karolinska InstitutetStockholmSweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Cecilia Linde
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of MedicineKarolinska Institutet, Karolinska University HospitalSolnavägen 1:02Stockholm171 76Sweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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Elsayed N, Yei KS, Naazie I, Goodney P, Clouse WD, Malas M. The impact of carotid lesion calcification on outcomes of carotid artery stenting. J Vasc Surg 2021; 75:921-929. [PMID: 34592377 DOI: 10.1016/j.jvs.2021.08.095] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The impact of carotid artery lesion calcification on adverse events following carotid artery stenting is not well-studied. Few reports associated heavily calcified lesions with high risk of perioperative stroke following transfemoral carotid artery stenting (TFCAS). With the advent of transcarotid artery revascularization (TCAR), we aimed to compare the outcomes of these two procedures stratified by the degree of lesion calcification. METHODS Our cohort was derived from the Vascular Quality Initiative database for carotid artery stenting. Patients with missing information on the degree of carotid artery calcification were excluded. Patients were stratified into two groups: >50% (heavy) calcification and ≤50% (no/mild) calcification. The Student t test and the χ2 test were used to compare patients' baseline characteristics and crude outcomes, as appropriate. Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS A total of 11,342 patients were included. Patients with >50% calcification were older, had more comorbidities, and more contralateral occlusion. There were more patients with prior ipsilateral carotid endarterectomy in the ≤50% calcification group. In patients who underwent TCAR, there were no significant differences between those who had >50% vs ≤50% carotid calcification in the odds of in-hospital adverse outcomes. However, in patients with heavy calcification who underwent TFCAS, there was a 50% to 60% increase in the odds of stroke (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.04-2.5; P = .03), stroke/transient ischemic attack (TIA) (OR, 1.6; 95% CI, 1.1-2.3; P = .013), and stroke/death (OR, 1.5; 95% CI, 1.02-2.08; P = .039). Compared with TFCAS in patients with heavy calcification, TCAR was associated with a 40% to 90% reduction in the odds of contralateral stroke (OR, 0.13; 95% CI, 0.04-0.4; P = .001), contralateral stroke/TIA (OR, 0.3; 95% CI, 0.1-0.87; P = .024), any stroke/TIA (OR, 0.6; 95% CI, 0.38-0.91; P = .02), death (OR, 0.3; 95% CI, 0.13-0.72; P = .006), stroke/death (OR, 0.5; 95% CI, 0.32-0.8; P = .004), and stroke/death/myocardial infarction (OR, 0.58; 95% CI, 0.39-0.87; P = .008). There were no significant differences in the odds of stroke and myocardial infarction. CONCLUSIONS In this retrospective analysis of patients undergoing TFCAS vs TCAR in the Vascular Quality Initiative database, TCAR demonstrated favorable outcomes compared with TFCAS among patients with calcification greater than 50% of the carotid circumference. Advance burden of carotid artery calcification was associated with worse outcomes in patients undergoing TFCAS but not TCAR. These results are consistent with previously demonstrated superiority of flow reversal compared with distal embolic protection devices. Further research is needed to assess long-term outcomes and confirm the durability of TCAR in heavily calcified lesions.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Kevin S Yei
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Philip Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Medical Center Dr, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Medical Center, Charlottesville, Va
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif.
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Eitel C, Ince H, Brachmann J, Kuck KH, Willems S, Spitzer SG, Tebbenjohanns J, Iden L, Straube F, Hochadel M, Senges J, Tilz RR. Catheter ablation of supraventricular tachycardia in patients with and without structural heart disease: insights from the German ablation registry. Clin Res Cardiol 2021; 111:522-529. [PMID: 34106323 PMCID: PMC9054935 DOI: 10.1007/s00392-021-01878-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/25/2021] [Indexed: 11/11/2022]
Abstract
Aim To compare patient characteristics, safety and efficacy of catheter ablation of supraventricular tachycardia (SVT) in patients with and without structural heart disease (SHD) enrolled in the German ablation registry. Methods and results From January 2007 until January 2010, a total of 12,536 patients (37.2% with known SHD) were enrolled and followed for at least one year. Patients with SHD more often underwent ablation for atrial flutter (45.8% vs. 20.9%, p < 0.001), whereas patients without SHD more often underwent ablation for atrioventricular nodal reentrant tachycardia (30.2% vs. 11.8%, p < 0.001) or atrioventricular reentrant tachycardia (9.1% vs. 1.6%, p < 0.001). Atrial fibrillation catheter ablation procedures were performed in a similar proportion of patients with and without SHD (38.1% vs. 36.9%, p = 0.21). Overall, periprocedural success rate was high in both groups. Death, myocardial infarction or stroke occurred in 0.2% and 0.1% of patients with and without SHD (p = 0.066). Major non-fatal complications prior to discharge were rare and did not differ significantly between patients with and without SHD (0.5% vs. 0.4%, p = 0.34). Kaplan–Meier mortality estimate at 1 year demonstrated a significant mortality increase in patients with SHD (2.6% versus 0.7%; p < 0.001). Conclusion Patients with and without SHD undergoing SVT ablation exhibit similar success rates and low major complication rates, despite disadvantageous baseline characteristics in SHD patients. These data highlight the safety and efficacy of SVT ablation in patients with and without SHD. Nevertheless Kaplan–Meier mortality estimates at 1 year demonstrate a significant mortality increase in patients with SHD, highlighting the importance of treating the underlying condition and reliable anticoagulation if indicated. Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01878-z.
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Affiliation(s)
- Charlotte Eitel
- Department of Electrophysiology, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Hüseyin Ince
- Vivantes Klinika Am Urban und im Friedrichshain und Universitäres Herzzentrum Rostock, Rostock, Germany
| | | | - Karl-Heinz Kuck
- Department of Electrophysiology, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.,Asklepios Klinik St. Georg, Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Hamburg, Germany.,Universitäres Herzzentrum, Hamburg, Germany
| | | | | | - Leon Iden
- Segeberger KIiniken, Segeberg, Germany
| | - Florian Straube
- Munich Clinic Bogenhausen, Munich, Germany.,Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | | | - Jochen Senges
- Stiftung Institut Für Herzinfarktforschung, Ludwigshafen, Germany
| | - Roland R Tilz
- Department of Electrophysiology, University Heart Center Lübeck, Medical Clinic II, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.,Asklepios Klinik St. Georg, Hamburg, Germany
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8
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Sadiq H, Hoque L, Shi Q, Manning G, Crawford S, McManus D, Kapoor A. SUPPORT-AF III: supporting use of AC through provider prompting about oral anticoagulation therapy for AF. J Thromb Thrombolysis 2021; 52:808-816. [PMID: 33694097 DOI: 10.1007/s11239-021-02420-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 11/30/2022]
Abstract
Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8 months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.
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Affiliation(s)
- Hammad Sadiq
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Laboni Hoque
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Qiming Shi
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Gordon Manning
- University of Massachusetts Medical School, Worcester, MA, USA.,UMass Memorial Health Care, Worcester, MA, USA
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester, MA, USA
| | - David McManus
- University of Massachusetts Medical School, Worcester, MA, USA.,UMass Memorial Health Care, Worcester, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, Worcester, MA, USA. .,UMass Memorial Health Care, Worcester, MA, USA. .,Biotech One, University of Massachusetts Medical School, 365 Plantation Street, Suite 100, Worcester, MA, 01605, USA.
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9
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Ziaeian B, Xu H, Matsouaka RA, Xian Y, Khan Y, Schwamm LS, Smith EE, Fonarow GC. National surveillance of stroke quality of care and outcomes by applying post-stratification survey weights on the Get With The Guidelines-Stroke patient registry. BMC Med Res Methodol 2021; 21:23. [PMID: 33541273 PMCID: PMC7863276 DOI: 10.1186/s12874-021-01214-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/22/2021] [Indexed: 01/01/2023] Open
Abstract
Background The U.S. lacks a stroke surveillance system. This study develops a method to transform an existing registry into a nationally representative database to evaluate acute ischemic stroke care quality. Methods Two statistical approaches are used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample. Post-stratification survey weights are estimated using a raking procedure and Bayesian interpolation methods. Weighting methods are adjusted to limit the dispersion of weights and make reasonable epidemiologic estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national estimates are reported between the two post-stratification methods for anchored and non-anchored patient characteristics to evaluate estimation quality. Primary measures evaluated are patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge. Results A total of 1,388,296 acute ischemic strokes occurred between 2012 and 2014. Raking and Bayesian estimates of clinical data not available in administrative data are estimated within 5 to 10% of margin for expected values. Median weight for the raking method is 1.386 and the weights at the 99th percentile is 6.881 with a maximum weight of 30.775. Median Bayesian weight is 1.329 and the 99th percentile weights is 11.201 with a maximum weight of 515.689. Conclusions Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. These methods may be applied to other diseases or settings to better monitor population health. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01214-z.
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Affiliation(s)
- Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at University of California, 10833 LeConte Avenue, Room A2-237 CHS, Los Angeles, CA, 90095-1679, USA. .,Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, North Carolina, UK
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina, UK.,Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, UK
| | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina, UK.,Department of Neurology, Duke University Medical Center, Durham, North Carolina, UK
| | - Yosef Khan
- Healthcare Quality Research and Bioinformatics, American Heart Association, Dallas, TX, USA
| | - Lee S Schwamm
- Department of Neurology, Comprehensive Stroke Center Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at University of California, 10833 LeConte Avenue, Room A2-237 CHS, Los Angeles, CA, 90095-1679, USA.,Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles Medical Center, Los Angeles, California, USA
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10
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Weinberg JH, Sweid A, DePrince M, Roussis J, Herial N, Gooch MR, Zarzour H, Tjoumakaris S, Topley T, Wang A, Wydro G, Durland L, Elliot R, Fox J, Rosenwasser RH, Jabbour P. The impact of the implementation of a mobile stroke unit on a stroke cohort. Clin Neurol Neurosurg 2020; 198:106155. [PMID: 32818753 DOI: 10.1016/j.clineuro.2020.106155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the 'time is brain' concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline. METHODS We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020. RESULTS Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07+0:03, scene arrival to CT start was 0:10+0:03, CT start to teleneuro start was 0:05+0:03, teleneuro start to scene departure was 0:06+0:05, scene departure to hospital arrival was 0:12+0:06, and hospital arrival to arterial puncture was 2:59+1:01. The mean time of dispatch to arterial puncture was 3:34+1:02. The mean teleneuro consult duration was 0:04+0:02. The mean time of last know well (LKW) to tPA administration was 1:28+0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37+0:09 and scene arrival to tPA administration was 0:28+0:07. CONCLUSION MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown.
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Affiliation(s)
- Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Mauren DePrince
- Department of Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - John Roussis
- Department of Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Thomas Topley
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Alvin Wang
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Gerald Wydro
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Lawrence Durland
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Robert Elliot
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - James Fox
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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11
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Wang M, Rajan SS, Jacob AP, Singh N, Parker SA, Bowry R, Grotta JC, Yamal JM. Retrospective collection of 90-day modified Rankin Scale is accurate. Clin Trials 2020; 17:637-643. [PMID: 32755236 DOI: 10.1177/1740774520942466] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The 90-day modified Rankin Scale is a widely used outcome after stroke but is sometimes hard to ascertain due to loss to follow-up. Missing outcomes can result in biased and/or inefficient estimates in clinical trials. The aim of this study is to assess the validity of acquiring the 90-day modified Rankin Scale at a later point of time when the patient has been lost at 90 days to impute the missing value. METHODS Participants who had prospectively completed a 90-day modified Rankin Scale questionnaire on their own in the Benefits of Stroke Treatment Using a Mobile Stroke Unit study were randomly interviewed to recall the 90-day modified Rankin Scale at 6, 9, or 12 months after hospital discharge over the phone. Concordance between the two scores was assessed using kappa and weighted kappa statistics. Logistic regression was used to identify factors associated with inconsistent reporting of the 90-day modified Rankin Scale. RESULTS Substantial agreement was observed between in-the-moment and retrospective 90-day modified Rankin Scale recalled at 6, 9, or 12 months (weighted kappa = 0.93, 95% confidence interval: 0.89-0.98; weighted kappa = 0.93, 95% confidence interval: 0.85-1.00 and weighted kappa = 0.89, 95% confidence interval: 0.82-0.95, respectively). CONCLUSION Retrospective recall of 90-day modified Rankin Scale at a later time point is a valid means to impute missing data in stroke clinical trials.
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Affiliation(s)
- Mengxi Wang
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suja S Rajan
- Department of Management, Policy and Community Health, School of Public Health at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Asha P Jacob
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Noopur Singh
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephanie A Parker
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute at the Memorial Hermann Hospital, Houston, TX, USA
| | - Ritvij Bowry
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute at the Memorial Hermann Hospital, Houston, TX, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
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12
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Shim DH, Kim Y, Roh J, Kang J, Park KP, Cha JK, Baik SK, Kim Y. Hospital Volume Threshold Associated with Higher Survival after Endovascular Recanalization Therapy for Acute Ischemic Stroke. J Stroke 2020; 22:141-149. [PMID: 32027799 PMCID: PMC7005355 DOI: 10.5853/jos.2019.00955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 01/17/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Endovascular recanalization therapy (ERT) is becoming increasingly important in the management of acute ischemic stroke (AIS). However, the hospital volume threshold for optimal ERT remains unknown. We investigated the relationship between hospital volume of ERT and risk-adjusted patient outcomes. METHODS From the National Health Insurance claims data in Korea, 11,745 patients with AIS who underwent ERT from July 2011 to June 2016 in 111 hospitals were selected. We measured the hospital's ERT volume and patient outcomes, including the 30-day mortality, readmission, and postprocedural intracranial hemorrhage (ICH) rates. For each outcome measure, we constructed risk-adjusted prediction models incorporating demographic variables, the modified Charlson comorbidity index, and the stroke severity index (SSI), and validated them. Risk-adjusted outcomes of AIS cases were compared across hospital quartiles to confirm the volume-outcome relationship (VOR) in ERT. Spline regression was performed to determine the volume threshold. RESULTS The mean AIS volume was 14.8 cases per hospital/year and the unadjusted means of mortality, readmission, and ICH rates were 11.6%, 4.6%, and 8.6%, respectively. The VOR was observed in the risk-adjusted 30-day mortality rate across all quartile groups, and in the ICH rate between the first and fourth quartiles (P<0.05). The volume threshold was 24 cases per year. CONCLUSIONS There was an association between hospital volume and outcomes, and the volume threshold in ERT was identified. Policies should be developed to ensure the implementation of the AIS volume threshold for hospitals performing ERT.
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Affiliation(s)
- Dong-Hyun Shim
- Department of Neurology, Kyungpook National University Hospital, Daegu, Korea
| | - Youngsoo Kim
- Department of Neurosurgery, MH Yeonse Hospital, Changwon, Korea
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jongsoo Kang
- Department of Neurology, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Kyung-Pil Park
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea.,Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea
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13
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Panchangam C, White DA, Goudar S, Birnbaum B, Malloy-Walton L, Gross-Toalson J, Reid KJ, Shirali G, Parthiban A. Translation of the Frailty Paradigm from Older Adults to Children with Cardiac Disease. Pediatr Cardiol 2020; 41:1031-1041. [PMID: 32377892 PMCID: PMC7223568 DOI: 10.1007/s00246-020-02354-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/23/2020] [Indexed: 12/20/2022]
Abstract
Children and adolescents with cardiac disease (CCD) have significant morbidity and lower quality of life. However, there are no broadly applicable tools similar to the frailty score as described in the elderly, to define functional phenotype in terms of physical capability and psychosocial wellbeing in CCD. The purpose of this study is to investigate the domains of the frailty in CCD. We prospectively recruited CCD (8-17.5 years old, 70% single ventricle, 27% heart failure, 12% pulmonary hypertension; NYHA classes I, II and III) and age and gender matched healthy controls (total n = 56; CCD n = 34, controls n = 22; age 12.6 ± 2.6 years; 39.3% female). We measured the five domains of frailty: slowness, weakness, exhaustion, body composition and physical activity using developmentally appropriate methods. Age and gender-based population norms were used to obtain Z scores and percentiles for each measurement. Two-tailed t-tests were used to compare the two groups. The CCD group performed significantly worse in all five domains of frailty compared to healthy controls. Slowness: 6-min walk test with Z score -3.9 ± 1.3 vs -1.4 ± 1.3, p < 0.001; weakness: handgrip strength percentile 18.9 ± 20.9 vs 57.9 ± 26.0, p < 0.001; exhaustion: multidimensional fatigue scale percentile 63.7 ± 13.5 vs 83.3 ± 14.4, p < 0.001; body composition: height percentile 43.4 ± 29.5 vs 71.4 ± 25.2, p < 0.001, weight percentile 46.0 ± 36.0 vs 70.9 ± 24.3, p = 0.006, BMI percentile 48.4 ± 35.5 vs 66.9 ± 24.2, p = 0.04, triceps skinfold thickness 41.0 ± 24.0 vs 54.4 ± 22.1, p = 0.04; physical activity: pediatric activity questionnaire score 2 ± 0.6 vs 2.7 ± 0.6, p < 0.001. The domains of frailty can be quantified in children using developmentally appropriate methods. CCD differ significantly from controls in all five domains, supporting the concept of quantifying the domains of frailty. Larger longitudinal studies are needed to study frailty in CCD and examine if it predicts adverse health outcomes.Clinical Trial Registration: The ClinicalTrials.gov identification number is NCT02999438. https://clinicaltrials.gov/ct2/show/NCT02999438.
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Affiliation(s)
- Chaitanya Panchangam
- Department of Child Health, University of Missouri Health Care, Columbia, MO, USA. .,University of Missouri-Columbia, 500 N Keene St, Suite 207, Columbia, MO, 65201, USA.
| | - David A. White
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
| | - Suma Goudar
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
| | - Brian Birnbaum
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
| | - Lindsey Malloy-Walton
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
| | - Jami Gross-Toalson
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA
| | - Kimberly J. Reid
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA
| | - Girish Shirali
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
| | - Anitha Parthiban
- grid.239559.10000 0004 0415 5050The Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUMKC School of Medicine, Kansas City, MO USA
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14
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Blattner M, Price J, Holtkamp MD. Socioeconomic class and universal healthcare: Analysis of stroke cost and outcomes in US military healthcare. J Neurol Sci 2019; 386:64-68. [PMID: 29406969 DOI: 10.1016/j.jns.2018.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/01/2018] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Do socioeconomic disparities exist in the US military healthcare system with ischemic stroke admissions? METHODS Civilian healthcare in the United States is paid for by a variety of payers. Significant disparities exist in this system based upon socioeconomic status (SES). In contrast, the military healthcare system (MHS) is a universal healthcare system. Military rank is a SES surrogate. Data was collected from the MHS database for years 2010 through 2015. All admissions to military health care facilities with a primary diagnosis of ischemic stroke were reviewed. Military rank was compared for primary outcomes of: Disposition (In-hospital mortality and discharge destination setting) and IV tPA administration and for secondary outcomes of: Total cost of hospitalization and Length of hospital stay (LoS). All adjusted for relevant demographics and co-morbidities. RESULTS Military rank was identified with 1895 (52.3%) of the 3623 admissions. The ranks identified were: Junior Enlisted 100 (2.7%), Senior Enlisted/Warrant Officers 1390 (38.4%), Junior Officers 59 (1.6%) and Senior Officers 346 (9.6%). Statistically significant results included: Lower SES group/ranks were more likely to have poor discharge destination setting while the highest SES group/ranks and had lower rates of in-hospital mortality, shorter lengths of stay and higher hospitalization costs after controlling for relevant variables. CONCLUSION Higher military ranks (Higher SES) had shorter hospitalization stays, higher costs and less in-hospital mortality in the military's universal healthcare system. This suggests aggregate characteristics of SES plays a large role in the outcomes among SES groups.
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Affiliation(s)
- Matthew Blattner
- Walter Reed National Military Medical Center, Department of Neurology, United States.
| | - James Price
- Walter Reed National Military Medical Center, Department of Neurology, United States.
| | - Matthew D Holtkamp
- Carl R. Darnall Army Medical Center, Department of Medicine, United States.
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15
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Eitel C, Ince H, Brachmann J, Kuck KH, Willems S, Gerds-Li JH, Tebbenjohanns J, Richardt G, Hochadel M, Senges J, Tilz RR. Atrial fibrillation ablation strategies and outcome in patients with heart failure: insights from the German ablation registry. Clin Res Cardiol 2019; 108:815-823. [PMID: 30788620 DOI: 10.1007/s00392-019-01411-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Heart failure (HF) and atrial fibrillation (AF) often coexist, but data on the prognostic value of differing ablation strategies according to left ventricular ejection fraction (LVEF) are rare. METHODS AND RESULTS From January 2007 until January 2010, 728 patients with HF were enrolled in the multi-center German ablation registry prior to AF catheter ablation. Patients were divided into three groups according to LVEF: HF with preserved LVEF (≥ 50%, HFpEF, n = 333), mid-range LVEF (40-49%, HFmrEF, n = 207), and reduced LVEF (< 40%, HFrEF, n = 188). Ablation strategies differed significantly between the three groups with the majority of patients with HFpEF (83.4%) and HFmrEF (78.4%) undergoing circumferential pulmonary vein isolation vs. 48.9% of patients with HFrEF. The latter underwent ablation of the atrioventricular (AV) node in 47.3%. Major complications did not differ between the groups. Kaplan-Meier survival analysis demonstrated a significant mortality increase in patients with HFrEF (6.1% in HFrEF vs. 1.5% in HFmrEF vs. 1.9% in HFpEF, p = 0.009) that was limited to patients undergoing ablation of the AV node. CONCLUSIONS Catheter ablation strategies differ significantly in patients with HFpEF, HFmrEF, and HFrEF. In almost 50% of patients with HFrEF AV-node ablation was performed, going along with a significant increase in mortality rate. These results should raise efforts to further evaluate the prognostic effect of ablation strategies in HF patients.
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Affiliation(s)
- Charlotte Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Hueseyin Ince
- Vivantes Klinika Am Urban und im Friedrichshain und Universitäres Herzzentrum Rostock, Berlin, Germany
| | | | | | | | | | | | | | | | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Roland R Tilz
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Asklepios Klinik St. Georg, Hamburg, Germany
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Ward MJ, Collins SP, Liu D, Froehle CM. Preventable delays to intravenous furosemide administration in the emergency department prolong hospitalization for patients with acute heart failure. Int J Cardiol 2018; 269:207-212. [PMID: 30041982 DOI: 10.1016/j.ijcard.2018.06.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND We sought to examine whether factors impacting the time to emergency department (ED) administration of intravenous (IV) furosemide were associated with the duration of hospital admission for patients with acute heart failure (AHF). METHODS AND RESULTS We conducted a single-center, retrospective analysis of patients presenting to the ED and admitted between January 1, 2007 and December 31, 2014 who received a dose of IV furosemide. A Cox proportional hazards model was used to examine the likelihood that a patient would be discharged home alive, adjusting for patient demographics, AHF severity (low, moderate, high), laboratory result timing, and known AHF confounders. We identified 695 patients who met study criteria with 430 (61.9%) in the low-severity group. In the overall model, every 60-minute delay in IV furosemide administration was associated with an 8% lower chance of successful discharge home relative to someone who received early furosemide (aHR 0.93, 95%CI 0.87, 0.98, P = 0.012). Subgroup analysis suggests this association was most impactful in low-acuity patients. Our adjusted analysis suggests delaying furosemide administration until after serum creatinine results resulted in a 41% lower chance of successful discharge home relative to someone who had furosemide administered prior to creatinine results (aHR 1.41, 95%CI 1.07, 1,84). CONCLUSIONS AHF patients, particularly those with lower severity, may benefit from rapid administration of IV furosemide in the ED. This suggests that a key determinant of hospital visit duration in this low-risk cohort is decongestion, which occurs sooner when IV therapy is begun early in the ED stay regardless of serum creatinine.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, USA; Tennessee Valley VA Healthcare System, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, USA; Tennessee Valley VA Healthcare System, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, USA
| | - Craig M Froehle
- Carl H. Lindner College of Business, Department of Operations, Business Analytics and Information Systems, University of Cincinnati, and Department of Emergency Medicine, University of Cincinnati, USA
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Bouslama M, Rebello LC, Haussen DC, Grossberg JA, Anderson AM, Belagaje SR, Bianchi NA, Frankel MR, Nogueira RG. Endovascular Therapy and Ethnic Disparities in Stroke Outcomes. Interv Neurol 2018; 7:389-398. [PMID: 30410516 PMCID: PMC6216703 DOI: 10.1159/000487607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Ethnic disparities in stroke are well described, with a higher incidence of disability and increased mortality in Blacks versus Whites. We sought to compare the clinical outcomes between those ethnic groups after stroke endovascular therapy (ET). METHODS We performed a retrospective review of the prospectively acquired Grady Endovascular Stroke Outcomes Registry between September 1, 2010 and September 30, 2015. Patients were dichotomized into two groups - Caucasians and African-Americans - and matched for age, pretreatment glucose level, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Baseline characteristics as well as procedural and outcome parameters were compared. RESULTS Out of the 830 patients treated with ET, 308 pairs of patients (n = 616) underwent primary analysis. African-Americans were younger (p < 0.01), had a higher prevalence of hypertension (p < 0.01) and diabetes (p = 0.04), and had higher Alberta Stroke Program Early CT Score values (p = 0.03) and shorter times to treatment (p = 0.01). Blacks more frequently had Medicaid coverage and less private insurance (29.6 vs. 11.4% and 41.5 vs. 60.3%, respectively, p < 0.01). The remaining baseline characteristics, including baseline NIHSS score and CT perfusion-derived ischemic core volumes, were well balanced. There were no differences in the overall distribution of 90-day modified Rankin scale scores (p = 0.28), rates of successful reperfusion (84.7 vs. 85.7%, p = 0.91), good outcomes (49.1 vs. 44%, p = 0.24), or parenchymal hematomas (6.5 vs. 6.8%, p = 1.00). Blacks had lower 90-day mortality rates (18 vs. 24.6%, p = 0.04) in univariate analysis, which persisted as a nonsignificant trend after adjustment for potential confounders (OR 0.52, 95% CI 0.26-1.03, p = 0.06). CONCLUSIONS Despite unique baseline characteristics, African-Americans treated with ET for large vessel occlusion strokes have similar outcomes as Caucasians. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Raul G. Nogueira
- Departments of Neurology and Neurosurgery, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, Georgia, USA
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Upshaw JN, van Klaveren D, Konstam MA, Kent DM. Digoxin Benefit Varies by Risk of Heart Failure Hospitalization: Applying the Tufts MC HF Risk Model. Am J Med 2018; 131:676-683.e2. [PMID: 29284111 PMCID: PMC7643562 DOI: 10.1016/j.amjmed.2017.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Digoxin has been shown to reduce heart failure hospitalizations with a neutral effect on mortality. It is unknown whether there is heterogeneity of treatment effect for digitalis therapy according to predicted risk of heart failure hospitalization. METHODS AND RESULTS We conducted a post hoc analysis of the Digitalis Investigator Group (DIG) studies, randomized controlled trials of digoxin vs placebo in participants with heart failure and left ventricular ejection fraction ≤45% (main DIG study, n = 6800) or >45% (ancillary DIG study, n = 988). Using a previously derived multistate model to risk-stratify DIG study participants, we determined the differential treatment effect on hospitalization and mortality outcomes. There was a 13% absolute reduction in the risk of any heart failure hospitalizations (39% vs 52%; odds ratio 0.58; 95% confidence interval 0.47-0.71) in the digoxin vs placebo arms in the highest-risk quartile, compared with a 3% absolute risk reduction for any heart failure hospitalization (17% vs 20%; odds ratio 0.84; 95% confidence interval, 0.66-1.08) in the lowest-risk quartile. There were 12 fewer total all-cause hospitalizations per 100 person-years in the highest-risk quartile compared with an increase of 8 hospitalizations per 100 person-years in the lowest-risk quartile. There was neutral effect of digoxin on mortality in all risk quartiles and no interaction between baseline risk and the effect of digoxin on mortality (P = .94). CONCLUSIONS Participants in the DIG study at higher risk of hospitalization as identified by a multistate model were considerably more likely to benefit from digoxin therapy to reduce heart failure hospitalization.
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Affiliation(s)
- Jenica N Upshaw
- The CardioVascular Center, Tufts Medical Center, Boston, Mass.
| | - David van Klaveren
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; The Medical Statistics Department, Leiden University Medical Center, The Netherlands
| | | | - David M Kent
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass
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Budtz-Lilly J, Björck M, Venermo M, Debus S, Behrendt CA, Altreuther M, Beiles B, Szeberin Z, Eldrup N, Danielsson G, Thomson I, Wigger P, Khashram M, Loftus I, Mani K. Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries. Eur J Vasc Endovasc Surg 2018; 56:181-188. [PMID: 29482972 DOI: 10.1016/j.ejvs.2018.01.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/16/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes. MATERIALS AND METHODS RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (≥50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR. RESULTS There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p < .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001. Peri-operative mortality was lower in the highest volume centres (QI > 22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume. CONCLUSIONS Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.
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Affiliation(s)
- Jacob Budtz-Lilly
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg - Eppendorf, Hamburg, Germany
| | | | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, East Melbourne, Australia
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Gudmundur Danielsson
- National University Hospital of Iceland, Department of Surgery, Reykjavík, Iceland
| | - Ian Thomson
- Department of Vascular Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Pius Wigger
- Department of Cardiovascular Surgery, Kantonsspital Winterthur, Switzerland
| | - Manar Khashram
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Ian Loftus
- Department of Vascular Surgery, St George's University of London, London, UK
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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Sreekrishnan A, Dearborn JL, Greer DM, Shi FD, Hwang DY, Leasure AC, Zhou SE, Gilmore EJ, Matouk CC, Petersen NH, Sansing LH, Sheth KN. Intracerebral Hemorrhage Location and Functional Outcomes of Patients: A Systematic Literature Review and Meta-Analysis. Neurocrit Care 2017; 25:384-391. [PMID: 27160888 DOI: 10.1007/s12028-016-0276-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) has the highest mortality rate among all strokes. While ICH location, lobar versus non-lobar, has been established as a predictor of mortality, less is known regarding the relationship between more specific ICH locations and functional outcome. This review summarizes current work studying how ICH location affects outcome, with an emphasis on how studies designate regions of interest. METHODS A systematic search of the OVID database for relevant studies was conducted during August 2015. Studies containing an analysis of functional outcome by ICH location or laterality were included. As permitted, the effect size of individual studies was standardized within a meta-analysis. RESULTS Thirty-seven studies met the inclusion criteria, the majority of which followed outcome at 3 months. Most studies found better outcomes on the Modified Rankin Scale (mRS) or Glasgow Outcome Score (GOS) with lobar compared to deep ICHs. While most aggregated deep structures for analysis, some studies found poorer outcomes for thalamic ICH in particular. Over half of the studies did not have specific methodological considerations for location designations, including blinding or validation. CONCLUSIONS Multiple studies have examined motor-centric outcomes, with few studies examining quality of life (QoL) or cognition. Better functional outcomes have been suggested for lobar versus non-lobar ICH; few studies attempted finer topographic comparisons. This study highlights the need for improved reporting in ICH outcomes research, including a detailed description of hemorrhage location, reporting of the full range of functional outcome scales, and inclusion of cognitive and QoL outcomes.
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Affiliation(s)
- Anirudh Sreekrishnan
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Jennifer L Dearborn
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - David M Greer
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Fu-Dong Shi
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Audrey C Leasure
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Sonya E Zhou
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Charles C Matouk
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Nils H Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Lauren H Sansing
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA.
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Jangaard N, Sarkisian L, Saaby L, Mikkelsen S, Lassen AM, Marcussen N, Thomsen JL, Diederichsen ACP, Thygesen K, Mickley H. Incidence, Frequency, and Clinical Characteristics of Type 3 Myocardial Infarction in Clinical Practice. Am J Med 2017; 130:862.e9-862.e14. [PMID: 28159605 DOI: 10.1016/j.amjmed.2016.12.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cardiac death in a patient with symptoms and electrocardiographic changes indicative of myocardial ischemia but without available measurements of cardiac biomarkers is designated a type 3 myocardial infarction. We wanted to investigate the incidence, the frequency, and the characteristics of patients diagnosed as type 3 myocardial infarction. METHODS The occurrence of deaths in a well-defined geographic region was retrieved from the Danish Civil Registration System during a 1-year period from 2010 to 2011. Complementary data concerning causes of deaths were obtained from the Danish Register of Causes of Death, and ambulance and hospital patient files. Adjudication of the diagnosis was done by 2 local experts and one external senior cardiologist. RESULTS A total of 2766 of the 246,723 adult residents in the region had died. A type 3 myocardial infarction was diagnosed in 18 individuals, corresponding to an annual incidence of 7.3/100,000 person-years. During the same 1-year period, 488 patients had other types of myocardial infarction implying a 3.6% frequency of type 3 myocardial infarction (18 of 506) among all myocardial infarctions. CONCLUSION Type 3 myocardial infarction is a rare observation in clinical practice with an annual incidence below 10/100,000 person-years and a frequency of 3%-4% among all types of myocardial infarction. If autopsy data are included, the number of type 3 myocardial infarctions will increase.
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Affiliation(s)
| | - Laura Sarkisian
- Department of Cardiology, Odense University Hospital, Denmark
| | - Lotte Saaby
- Department of Cardiology, Odense University Hospital, Denmark
| | - Søren Mikkelsen
- Mobile Emergency Care Unit, Department of Anesthesiology and Intensive Care, Odense University Hospital, Denmark
| | - Anne Marie Lassen
- Department of Emergency Medicine, Odense University Hospital, Denmark
| | | | - Jørgen L Thomsen
- Institute of Forensic Medicine, Odense University Hospital, Denmark
| | | | | | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Denmark.
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Joy PS, Kumar G, Olshansky B. Syncope: Outcomes and Conditions Associated with Hospitalization. Am J Med 2017; 130:699-706.e6. [PMID: 28147231 DOI: 10.1016/j.amjmed.2016.12.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Syncope is a perplexing problem for which hospital admission and readmission are contemplated but outcomes remain uncertain. Our purpose was to determine the incidence of admissions and readmissions for syncope and compare associated conditions, in-hospital outcomes, and resource utilization. METHODS The 2005-2011 California Statewide Inpatient Database was utilized. Patients of age ≥18 years admitted under International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 ("syncope or collapse") were selected. Records with a primary discharge diagnosis of syncope were classified as primary syncope. Primary outcome was mortality and secondary outcome measures were cardiopulmonary resuscitation, mechanical ventilation, discharge disposition, length of stay, frequency of readmission and hospital charges. RESULTS An estimated 1.52 ± 0.02% admissions every year are related to syncope. Among admissions for syncope, in 42.1%, the cause remained unknown; 23% of syncope admissions were for recurrent episodes. The top 5 associated new diagnoses were hypokalemia (0.24%), ventricular tachycardia (0.17%), atrial fibrillation (0.16%), dehydration (0.12%), and hyponatremia (0.12%). Mortality rates are lower for primary vs secondary syncope (0.2% vs 1.4%; P <.0001). Greatest risk factors for mortality in primary syncope were pulmonary hypertension (odds ratio 12.3; 95% confidence interval, 3.34-45.04) and metastatic cancer (odds ratio 7.22; 95% confidence interval, 4.50-11.58). Major adverse events showed a decreasing trend for patients with multiple syncope admissions. Older patients and defibrillators or pacemaker recipients are admitted more often but experience negligible adverse events. Over a decade, median hospital charge for a single syncope admission has increased by 1.5 times. CONCLUSIONS Despite a good prognosis, syncope is a frequent cause for hospitalization, particularly in the elderly. Present evaluation strategies are expensive and lack diagnostic value.
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Affiliation(s)
- Parijat Saurav Joy
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City.
| | - Gagan Kumar
- Northeast Georgia Health System, Gainesville
| | - Brian Olshansky
- Division of Cardiology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
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Tobin JM, Ramos WD, Pu Y, Wernicki PG, Quan L, Rossano JW. Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation 2017; 115:39-43. [PMID: 28385639 DOI: 10.1016/j.resuscitation.2017.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/02/2017] [Accepted: 04/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cardiac arrest associated with drowning is a major public health concern with limited research available on outcome. This investigation aims to define the population at risk, and identify factors associated with neurologically favourable survival. METHODS The Cardiac Arrest Registry for Enhanced Survival (CARES) database was queried for patients who had suffered cardiac arrest following drowning between January 1, 2013 and December 31, 2015. The primary outcomes of interest were for favourable or unfavourable neurological outcome at hospital discharge, as defined by Cerebral Performance Category (CPC). RESULTS A total of 919 drowning patients were identified. Neurological outcome data was available in 908 patients. Neurologically favourable survival was significantly associated with bystander CPR (Odds Ratio (OR)=2.94; 95% Confidence Interval (CI) 1.86-4.64; p<0.001), witnessed drowning (OR=2.6; 95% CI 1.69-4.01; p<0.001) and younger age (OR=0.97, 95% CI 0.96-0.98; p<0.001). Public location of drowning (OR=1.17; 95% CI 0.77-1.79; p=0.47), male gender (OR=0.9, 95% CI 0.57-1.43; p=0.66), and shockable rhythm (OR=1.54; 95% CI 0.76-3.12; p=0.23), were not associated with favourable neurological survival. AED application prior to EMS was associated with a decreased likelihood of favourable neurological outcome (OR=0.38; 95% CI 0.28-0.66; p<0.001). In multivariate analysis, bystander CPR (adjusted OR 3.02, 95% CI 1.85-4.92, p<0.001), witnessed drowning (adjusted OR 3.27, 95% CI 2.0-5.36, p<0.001) and younger age (adjusted OR 0.97, 95% CI 0.96-0.98, p<0.001) remained associated with neurologically favourable survival. CONCLUSIONS Neurologically favourable survival after drowning remains low but is improved by bystander CPR. Shockable rhythms were uncommon and not associated with improved outcomes.
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Affiliation(s)
- Joshua M Tobin
- Division of Trauma Anesthesiology, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Suite 3451, Los Angeles, CA 90033, United States.
| | - William D Ramos
- Indiana University School of Public Health-Bloomington, 1025 E 7th St., Bloomington, IN 47405, United States
| | - Yongjia Pu
- Indiana University School of Public Health-Bloomington, 1025 E 7th St., Bloomington, IN 47405, United States
| | - Peter G Wernicki
- Florida State University, College of Medicine, 1115 W Call St., Tallahassee, FL 32304, United States
| | - Linda Quan
- University of Washington School of Medicine, MB.7.520 - Emergency Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, United States
| | - Joseph W Rossano
- Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104-4399, United States
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Abstract
BACKGROUND Cardiac implantable electronic device (CIED) infections are associated with hospitalization, mortality, increased costs, and adverse outcomes. OBJECTIVE Determine the burden of infections for CIEDs based on device type, associated comorbidities, and clinical characteristics over a 12-year period. METHODS Utilizing data from the National Inpatient Sample database for cases from 2000 through 2012, we identified procedures for device-related infection (DRI) using International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CIED removal with diagnosis codes for device-related infection or systemic infection. Cases were categorized into 4 groups: single-chamber pacemaker, dual-chamber pacemaker, cardiac resynchronization therapy (CRT) device, and intracardiac defibrillator (ICD). RESULTS Of 4,144,683 device-related procedures, 85,203 (2.06%) were associated with DRI. From 2000 through 2012, procedures related to DRI increased from 1.45% to 3.41% (P < .001). The risk of infection for CRT devices was the highest, peaking in 2012 (adjusted odds ratio [OR] 2.43, P < .001). During second half of the study, comorbidities associated with DRI were diabetes (OR: 1.11, P < .001), end-stage renal disease (OR: 3.23, P < .001), hematoma (OR: 2.44, P < .001), malnutrition (OR: 2.66, P < .001), venous thromboembolism (OR: 2.37, P < .001), chronic kidney disease (OR: 1.26, P < .001), and organ transplantation (OR: 2.37, P < .001). Charges associated with CRT DRIs increased nearly 2-fold in a decade. Higher inpatient mortality related to device infection were stroke (OR: 3.19, P < .001), end-stage renal disease (OR: 2.91, P < .001), malnutrition (OR: 2.67, P < .001), cirrhosis (OR: 2.05, P = .001), and organ transplantation (OR: 2.16, P < .001). CONCLUSION CIED infections are increasing for all device types and particularly for CRT devices. Precise reasons for rising DRI procedures remain unclear, although conditions leading to immune compromise appear significant.
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