90-day Intervals Research Articles

Propensity-Matched Comparison of 90-Day Complications in Robotic-Assisted Versus Non-Robotic Assisted Lumbar Fusion.

Retrospective single center propensity-matched observational cohort study that included patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. To compare 90-day complication rates between robotic-assisted and non-robotic-assisted lumbar spinal fusions in propensity-matched cohorts. A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted enabling technology. Of 146 robotic-assisted cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1 to 3 level lumbar fusion without robotic assistance based on age, sex, body mass index, smoking status, American Society of Anesthesiologist grade, number of surgical levels, primary versus revision, and surgical approach (posterior-only or anterior-posterior). We excluded tumor, trauma, infection, or deformity cases. Outcomes included surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals, including reoperations, and readmissions within 90 days. All cause intraoperative complication rates were similar between non-robotic-assisted (5.3%) and robotic-assisted groups (10.5%, P = 0.366). Immediate postoperative medical complication rate was also similar between non-robotic-assisted (6.1%) and robotic-assisted groups (1.8%, P = 0.089). Thirty-day complication rates, 90-day complication rates, reoperation rates, and readmission rates showed no difference between non-robotic-assisted and robotic-assisted groups. There was no difference between return to OR for infection between the cohorts (non-robotic-assisted: 6 [5%] vs. robotic-assisted: 1 [0.8%], P = 0.119). There was however improved length of stay (LOS) in the robotic-assisted group compared with non-robotic-assisted group (2.5 vs. 3.17 days, P = 0.018). In propensity-matched cohorts, patients undergoing 1- to 3-level robotic-assisted posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared with non-robotic-assisted patients. There findings differ from a prior administrative database study as the robotic-assisted group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection.Level of Evidence: 2.

TMRpni Decreases Long-term Narcotic Use in Amputees: A Case Control Study

PURPOSE: “TMRpni” is a novel management strategy combining the well-described technique of targeted muscle reinnervation (TMR), which coapts a sensory or mixed nerve to a motor nerve, with the more recently described regenerative peripheral nerve interface (RPNI) technique, in which the coaptation is insulated with an autologous free muscle graft.1 The goal of this combined procedure is to optimally reduce neuroma and phantom limb pain in amputees. The purpose of this study was to evaluate the effect of TMRpni on opioid consumption after amputation. We hypothesized that TMRpni decreases chronic opioid consumption. METHODS: We performed a retrospective case control study evaluating opioid refills within 30 days of surgery, after 30 days, and after 90 days. The cases comprised all patients who underwent amputation at a single center from April 2019 to February 2021 with immediate or delayed TMRpni. These were then age matched 1:1 with patients who underwent same level amputation without TMR or RPNI between January 2015 and December 2020. Data collected included patient demographics, comorbidities, operative details, and pre- and postoperative opioid use. IBM SPSS Version 25 was used to perform the statistical analysis with the Fisher T test. RESULTS: 32 patients underwent TMRpni during the study period and were matched to 32 controls. Two controls were eliminated due to incomplete data. There were 13 TMRpni patients (43%) and 15 control patients (50%) who refilled narcotics within 30 days (P = 0.79), and 9 TMRpni patients (30%) and 11 control patients (37%) still using narcotics after 30 days (P = 0.78). However, at the 90-day interval following surgery, there were significantly fewer TMRpni patients requiring opioid pain medication than the control group (7% versus 33%, P = 0.02). CONCLUSIONS: This study demonstrates that the combination technique of TMRpni may decrease chronic opioid use in amputees. Continued study is indicated to further elucidate the potential benefits of TMRpni in amputees and to optimize patient selection and technique. The long-term efficacy and how it compares with TMR versus RPNI alone remain unknown. REFERENCE: 1. Kurlander DE, Wee C, Chepla KJ, et al. TMRpni: combining two peripheral nerve management techniques. Plast Reconstr Surg Glob Open. 2020;8(10):e3132.

Adherence and persistence to rivaroxaban in non-valvular atrial fibrillation patients receiving 30- or 90-day supply prescription fills

Background It is unclear whether 90-day supply fills with rivaroxaban result in better adherence and persistence compared to 30-day supply fills. We assessed patients’ adherence and persistence to rivaroxaban at 12- and 24-months in nonvalvular atrial fibrillation (NVAF) patients whose rivaroxaban prescriptions were filled every 30- vs. 90-days. Methods Using the IBM MarketScan Commercial and Medicare Supplemental data sets, we identified adult NVAF patients with ≥12-months of continuous insurance coverage who filled a prescription in May 2018 and their immediate subsequent prescription for rivaroxaban for the same days’ supply. We propensity score-matched 30- and 90-day rivaroxaban interval fill patients and compared the percentage with a proportion of days covered (PDC) ≥80%, mean PDC, and percentage persistent to rivaroxaban therapy over 12- and 24-months of follow-up. Results Following propensity score matching, 2237 patients were included in the rivaroxaban 30- and 90-day supply fill cohorts. The proportion of patients with a PDC ≥80% was greater in the 90-day vs. 30-day cohort at both 12-months (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.54–1.97) and 24-months (OR = 1.78, 95%CI = 1.58–2.00), as were mean PDC values (absolute difference in mean PDC = 9.4%, 95%CI = 8.2–10.7% at 12-months and 11.2%, 95%CI = 9.5–12.9% higher at 24-months, respectively). Persistence to rivaroxaban was not found to significantly differ between the 30- and 90-day supply cohorts at 12- or 24-months (assuming a 30-day permissible gap); however, greater persistence was observed with 90-day fills at both time points when a 14-day gap was utilized (HR = 1.22, 95%CI = 1.10–1.36 at 12-months and HR = 1.12, 95%CI = 1.02–1.22 at 24-months). Conclusions Dispensing 90-day supply fills with rivaroxaban appears to increase the proportion of patients achieving acceptable (PDC ≥80%) adherence as well as mean adherence compared to 30-day supply fills. Ninety-day rivaroxaban fills may also result in improved persistence vs. 30-day fills.

ACUTE-ON-CHRONIC LIVER FAILURE IS INDEPENDENTLY ASSOCIATED WITH LOWER SURVIVAL IN PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS.

Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%. The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP. Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis. All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi-bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval. The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.

73. Comparison of 90-day complications in propensity matched robotic-assisted vs nonrobotic-assisted lumbar fusion: robotic assistance does not increase the complication rate

<h3>BACKGROUND CONTEXT</h3> A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted (RA) enabling technology. The authors reported increased fixation-related complications (3%) and infection rates (19%) in RA surgeries. Although there is ample evidence regarding improved pedicle screw accuracy with RA surgery, the complication profile has been called into question. <h3>PURPOSE</h3> The objective of the study is to compare 90-day complication rates between RA and nonrobotic-assisted (NRA) lumbar spinal fusions in propensity-matched cohorts. <h3>STUDY DESIGN/SETTING</h3> Retrospective single center observational propensity-matched observational cohort study. <h3>PATIENT SAMPLE</h3> Patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. <h3>OUTCOME MEASURES</h3> Surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals. Additionally, reoperations and readmissions within 90 days. <h3>METHODS</h3> Of 146 RA cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1-3 level lumbar fusion without robotic assistance based on age, sex, BMI, smoking status, surgical approach (posterior-only or anterior-posterior), ASA grade, revision vs primary, number of surgical levels, and number of interbody levels. We excluded tumor, trauma, infection or deformity cases. Continuous variables were compared using unpaired t-tests and categorical variables were compared using Fisher's exact test with significance set at 0.05. <h3>RESULTS</h3> Consistent with propensity matching, there was no difference in patient demographics and baseline characteristics between groups. Neither group had intraoperative fixation-related complications or required a return to OR for malpositioned screws. All cause intraoperative complication rates were similar between NRA (5.3%) and RA groups (10.5%, p=0.366). Immediate postoperative medical complication rate was also similar between NRA (6.1%) and RA groups (1.8%, p=0.089). Thirty-day complication rates (NRA:15.8% vs RA:12.3%, p=0.446), 90-day complication rates (NRA:15.8% vs RA:14.9%, p=0.854), reoperation rates (NRA:6.1% vs RA:3.5%, p=0.354), and readmission rates (NRA:7.0% vs RA:6.1%, p=0.789) showed no difference between NRA and RA groups. There was no difference between return to OR for infection between the cohorts (NRA:6 [5%] vs RA:1 [0.8%], p=0.119). There was, however, improved length of stay (LOS) in the RA group compared to NRA group (2.5 vs 3.17 days, p=0.018). <h3>CONCLUSIONS</h3> In propensity-matched cohorts, patients undergoing 1- to 3-level level RA posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared to NRA patients. There findings differ from a prior administrative database study as the RA group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Treatment response in dogs with naturally occurring grade 3 elbow osteoarthritis following intra-articular injection of 117mSn (tin) colloid

The radionuclide 117mSn (tin-117m) embedded in a homogeneous colloid is a novel radiosynoviorthesis (RSO) device for intra-articular (IA) administration to treat synovial inflammation and mitigate osteoarthritis (OA) in dogs. A study to evaluate tin-117m colloid treatment response in dogs with OA was conducted at two centers, the School of Veterinary Medicine at Louisiana State University, and at a referral practice in Houston, Texas. The tin-117m colloid was administered per-protocol to 14 client-owned dogs with radiographically confirmed, grade 3 OA in one or both elbow joints. Dog owners and attending clinicians assessed the level of pain at baseline (BL) and the post-treatment pain response at 90-day intervals for one year. Owners assessed treatment response according to a pain severity score (PSS) and a pain interference score (PIS) as defined by the Canine Brief Pain Inventory. Clinicians reported a lameness score using a 0-5 scale, from no lameness to continuous non-weight bearing lameness, when observing dogs at a walk and a trot. The rate of treatment success as determined by improved mean PSS and PIS scores reported by dog owners was >70% at all time points. Clinicians reported an improved mean pain score from BL at post-treatment Days 90 (p<0.05), 180, and 270. The dog owner and clinician assessments of treatment success were significantly correlated (p>0.05) at Day 90 and Day 180 time points. Results indicated that a single IA dose of tin-117m colloid provided a significant reduction in pain and lameness and improved functionality for up to a full year, with no adverse treatment related effects, in a high percentage of dogs with advanced, clinical OA of the elbow joint.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis.

Retrospective cohort study. The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Longitudinal Evaluation of Renal Function in Multiple Myeloma

Background: Renal impairment (RI) is frequent in patients with Multiple Myeloma (MM), yet no substantial data exist on the long-term course of renal function throughout the disease. Further, it remains unknown whether factors determinable at diagnosis might predict the course of renal function in MM.Methods: Estimated glomerular filtration rate (eGFR) values (n=22,457) were used to create renal function trajectories in 243 newly diagnosed MM patients throughout a 5-year observation period. For each 90-day interval, the eGFR mean was calculated as the area under the eGRF curve. Baseline epidemiological and laboratory factors were used for stratified analysis.Results: The cohort exhibited a mean eGFR of 61.9±24.5 ml/min/1.73m2 at diagnosis; 40.2% had an eGFR below 60 ml/min/1.73m2. An initial overall increase of 2.81±8.97 ml/min/1.73m2 within the first 90-day period was observed (Figure 1). Thereafter, a steady overall eGFR decline (mean change -0.19±6.57 ml/min/1.73m2 per period) was observed, resulting in a net mean decrease of 3.58 ml/min/1.73m2 after 5 years. Patients with an eGFR below 45 ml/min/1.73m2 at diagnosis tended to improve most throughout the observation period (+15.15 ml/min/1.73m2; Figure 2). While a lower eGFR at diagnosis was associated with higher age and lower hemoglobin, these factors as well as the percentage of bone marrow plasma cell infiltration and total serum protein were not predictive of renal function. This also applied for the specific sub-type of paraprotein.Conclusions: Renal impairment is extraordinarily frequent in MM patients both at diagnosis and throughout the disease course. In the presented cohort, kidney function followed a non-linear course; after an initial amelioration in most patients, a continuous decline of eGFR was observed. Established surrogate parameters for negative outcome did not serve as predictive markers for the course of renal function in this cohort.However, patients with the lowest initial eGFR and highest MM disease burden exhibited a strong potential for renal improvement. [Display omitted] DisclosuresGisslinger:AOP Orphan Pharmaceuticals AG: Consultancy, Honoraria; Takeda: Honoraria; Novartis: Consultancy, Honoraria; PharmaEssentia: Consultancy, Honoraria; Shire: Honoraria; Janssen Cilag: Honoraria. Krauth:Janssen Cilag: Honoraria; Novartis: Honoraria; Celgene: Honoraria; BMS: Honoraria; Takeda: Honoraria; Amgen: Honoraria; AOP Orphan Pharmaceuticals AG: Honoraria.

Liver Transplantation in Croatia: "David Among Goliaths".

Liver Transplantation in Croatia: "David Among Goliaths".

Variation of anti-A and anti-B titers in group O potential blood donors: A pilot study.

Resuscitation with fresh whole blood is vital to preserving life on the battlefield. Transfusing low titer O whole blood (LTOWB), defined as anti-A and anti-B titer levels of <1:256, is safe because LTOWB alleviates the risk for hemolytic transfusion reactions. Because of possible variations in titer levels over time, a study was needed using US Navy and Marine Corps personnel to assess how these titers change across two assessments. Retrospective data from group O marines and sailors (M = 25 years of age; range, 19-35 years) stationed in the San Diego region were acquired from the Armed Services Blood Program and the Composite Health Care System. Of 972 group O donors between January 2016 and November 2019, 55 donors with 2 samples were identified (N = 55). Analysis included contrasting rates of high (≥1:256) and low (<1:256) anti-A and anti-B titers on the initial and second blood tests, along with the time between testings. The average time between testing was 332 days (range, 35-1,121 days), which far exceeded the recommended 90-day interval (p < 0.00001). Only 45% met the 90-day recommendation. Titer status changed frequently, from low to high (anti-A, 18%; anti-B, 13%; LTOWB to not LTOWB, 21%) or from high to low (anti-A, 62%; anti-B, 78%; not LTOWB to LTOWB, 62%). Anti-A and anti-B titers change frequently enough to warrant testing immediately before deployment and even during deployment. The observed time elapsed between testing is unacceptably long. The present pilot study provides a foundation for a larger formal study to more fully characterize titer changes over repeated testing. Diagnostic test, level IV.

National Media Coverage of the Veterans Affairs Waitlist Scandal: Effects on Veterans' Distrust of the VA Health Care System.

On April 23, 2014, US media outlets broadcast reports of excessive wait times and "secret" waitlists at some Veterans Affairs (VA) hospitals, precipitating legislation to increase Veterans' access to private sector health care. The aims were to assess changes in Veterans' distrust in the VA health care system before and after the media coverage and explore sex and racial/ethnic differences in the temporal patterns. Veterans completed semistructured interviews on health care satisfaction from June 2013 to January 2015, including a validated scale of health system distrust (range: 1-5). We used linear splines with knots at 90-day intervals to assess changes in distrust before and after April 23, 2014 ("day 0") in linear mixed models. To explore sex and racial/ethnic differences in temporal patterns, we stratified models by sex and tested for interactions of race/ethnicity with time. For women (n=600), distrust scores (mean=2.09) increased by 0.45 in days 0-90 (P<0.01), then decreased by 0.45 in days 90-180 (P<0.01). Among men (n=575), distrust scores (mean=2.05) increased by 0.18 in days 0-90 (P=0.059). Distrust levels were significantly higher for Black versus White women (time adjusted mean difference=0.21) and for Black and Hispanic versus White men (differences=0.26 and 0.18). However, the temporal patterns did not vary by race/ethnicity for women or men (interaction P=0.85 and 0.21, respectively). Health system distrust increased in women following media coverage of VA access problems and was higher in Black/Hispanic versus White Veterans at all time periods. Such perceptions could influence Veteran decisions to seek health care in the community rather than VA.

Identifying risks factors in thoracolumbar anterior fusion surgery through predictive analytics in a nationally representative inpatient sample.

Anterior thoracolumbar (TL) surgical approaches provide more direct trajectories compared to posterior approaches. Proper patient selection is key in identifying populations that may benefit from anterior TL fusion. Here, we utilize predictive analytics to identify risk factors in anterior TL fusion in patients with trauma and deformity. In this retrospective cohort study of patients receiving anterior TL fusion (between and including T12/L1), population-based regression models were developed to identify risk factors using the National Readmission Database 2016-2017. Readmissions were analyzed at 30- and 90-day intervals. Risk factors included hypertension, obesity, malnutrition, smoking, alcohol use, long-term opioid use, and frailty. Multivariate regression models were developed to determine the influence of each risk factor on complication rates. A total of 265 and 375 patients were identified for the scoliosis and burst fracture cohorts, respectively. In patients with scoliosis, alcohol use was found to increase the length of stay (LOS) (p = 0.00061) and all-payer inpatient cost following surgery (p = 0.014), and frailty was found to increase the inpatient LOS (p = 0.0045). In patients with burst fractures, malnutrition was found to increase the LOS (p < 0.0001) and all-payer cost (p < 0.0001), obesity was found to increase the all-payer cost (p = 0.012), and frailty was found to increase the all-payer cost (p = 0.031) and LOS (p < 0.0001). Patient-specific risk factors in anterior TL fusion surgery significantly influence complication rates. An understanding of relevant risk factors before surgery may facilitate preoperative patient selection and postoperative patient triage and risk categorization.

Effects of graded increases in ethanol consumption on biochemical markers of bone turnover in young adult male cynomolgus macaques.

Chronic heavy alcohol use is often associated with reduced bone mineral density and altered bone turnover. However, the dose response effects of ethanol on bone turnover have not been established. This study examined the effects of graded increases of ethanol consumption on biochemical markers of bone turnover in young adult male cynomolgus macaques (Macaca fascicularis). For this study, 6.6-year-old (95% CI: 6.5, 6.7) male macaques were subjected to three 30-day sessions of increased ethanol intake over a 90-day interval. During the first 30 days, the monkeys drank a predetermined volume of ethanol corresponding to 0.5g/kg/day, followed by 1.0g/kg/day and 1.5g/kg/day. Osteocalcin, a marker of bone formation, and carboxyterminal cross-linking telopeptide of type 1 collagen (CTX), a marker of resorption, were measured during each 30-day session. In addition, the ratio of osteocalcin to CTX was determined as a surrogate measure of global turnover balance. Mean osteocalcin decreased by 2.6ng/mL (1.8, 3.5) for each one-half unit (0.5g/kg/day) increase in dose (p<0.001). Mean CTX decreased by 0.13ng/mL (0.06, 0.20) for each one-half unit increase in dose (p<0.001). Furthermore, there was an inverse relationship between dose and the ratio of osteocalcin to CTX, such that the mean ratio decreased by 0.9 (0.3, 1.5) for each one-half unit increase in dose (p=0.01). In summary, male cynomolgus macaques had decreased blood osteocalcin and CTX, and osteocalcin to CTX ratio during the 90-day interval of graded increases in ethanol consumption, indicative of reduced bone turnover and negative turnover balance, respectively. These findings suggest that over the range ingested, ethanol resulted in a linear decrease in bone turnover. Furthermore, the negative bone turnover balance observed is consistent with reported effects of chronic alcohol intake on the skeleton.

Treatment Response in Dogs with Naturally Occurring Grade 3 Elbow Osteoarthritis Following Intra-Articular Injection of 117mSn (Tin) Colloid: ARevie

The radionuclide 117mSn (tin-117m) embedded in a homogeneous colloid is a novel Radio Synovi Orthesis (RSO) device for Intra-Articular (IA) administration to treat synovial inflammation and mitigate Osteo Arthritis (OA) in dogs. A study to evaluate tin-117m colloid treatment response in dogs with OA was conducted at two centers, the School of Veterinary Medicine at Louisiana State University, and at a referral practice in Houston, Texas. The tin-117m colloid was administered per-protocol to 14 client-owned dogs with radio graphically confirmed grade 3 OA in one or both elbow joints. Dog owners and attending clinicians assessed the level of pain at Base Line (BL) and the posttreatment pain response at 90-day intervals for one year. Owners assessed treatment response according to a Pain Severity Score (PSS) and a Pain Interference Score (PIS) as defined by the Canine Brief Pain Inventory. Clinicians reported a lameness score using a 0-5 scale, from no lameness to continuous non-weight bearing lameness, when observing dogs at a walk and a trot. The rate of treatment success as determined by improved mean PSS and PIS scores reported by dog owners was >70% at all-time points. Clinicians reported an improved mean pain score from BL at post-treatment Days 90 (p<0.05), 180, and 270. The dog owner and clinician assessments of treatment success were significantly correlated (p>0.05) at Day 90 and Day 180 time points. Results indicated that a single IA dose of tin-117m colloid provided a significant reduction in pain and lameness and improved functionality for up to a full year, with no adverse treatment related effects, in a high percentage of dogs with advanced, clinical OA of the elbow joint.

Nutrition Care for Poorly Nourished Outpatients Reduces Resource Use and Lowers Costs.

Background and Objectives:Over 25% of United States (US) community-dwelling, older adults are at nutritional risk. Health and cost burdens of poor nutrition can be lowered by nutrition programs for hospital inpatients, but few studies have looked at the impact on outpatients. The objective of our study was to assess outcomes of a nutrition focused quality improvement program (QIP) on healthcare resource use and costs in poorly nourished outpatients.Methods:This pre-post QIP study was implemented at 3 US healthcare system clinics. Included patients (n = 600) were ≥45 years old, had ≥2 chronic conditions, and were enrolled over a 15-month interval. For comparison, historical (n = 600) and concurrent control (n = 600) groups were used. Assessment of poor nutritional status was performed during each patient’s baseline visit. Healthcare resource use (hospitalizations, emergency department visits, and outpatient clinic visits), medication use, and costs were determined for a 90-day interval.Results:QIP patients (mean age 61.6 years) were predominantly female (62.5%) and overweight/obese (81.7%). The proportion of QIP outpatients presenting for healthcare services was significantly reduced compared to both historical and concurrent controls—relative risk reduction (RRR) versus historical (11.6%, P < .001) and versus concurrent (8.9%, P = .003). Of those who presented, RRR for healthcare resource use by QIP was significant in comparison with historical (12.9%, P = .022) but not concurrent controls. No significant differences were observed for medication usage. Lower resource use among QIP patients yielded total cost savings of $290 923 or per-patient savings of $485.Conclusions:Nutrition QIPs in outpatient clinics are feasible and can reduce healthcare resource use and cut costs. Such findings underscore benefits of nutritional interventions for community-dwelling outpatients with poor nutritional status.

Reverse Cardiac Remodeling Following Initiation of Sacubitril/Valsartan in Patients With Heart Failure With and Without Diabetes

ObjectiveThis study sought to determine whether patients with heart failure and reduced ejection fraction (HFrEF) with type 2 diabetes mellitus (T2DM) have similar reverse cardiac remodeling with sacubitril/valsartan as patients without T2DM. BackgroundSacubitril/valsartan promotes reverse cardiac remodeling and improves outcomes in patients with HFrEF. Patients with HFrEF with T2DM have worse prognosis than those without T2DM. MethodsIn this post hoc analysis of PROVE-HF (Prospective Study of Biomarkers, Symptom Improvement, and Ventricular Remodeling During Sacubitril/Valsartan Therapy for Heart Failure), we examined changes in N-terminal pro–b-type natriuretic peptide (NT-proBNP), measures of cardiac remodeling, and Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) scores from baseline to 12 months following initiation of sacubitril/valsartan between patients with HFrEF with and without T2DM. Using latent growth curve modeling, we evaluated the longitudinal association between changes in NT-proBNP, left ventricular ejection fraction, and KCCQ-OS. ResultsAmong 794 patients enrolled, 361 (45.5%) had T2DM. NT-proBNP concentrations were modestly higher at baseline among patients with T2DM but were reduced after initiation of sacubitril/valsartan. Cross-sectional improvement was observed in left ventricular ejection fraction (T2DM: 28.3% at baseline and 37% at 12 months vs. non-T2DM: 28.1% at baseline and 38.3% at 12 months) and KCCQ-OS (T2DM: 71 at baseline and 83 at 12 months vs. non-T2DM: 76 at baseline and 88 at 12 months). Similar changes were also observed for other echocardiographic measures. In longitudinal analyses, the average NT-proBNP change was similar in patients with T2DM (–5.6% vs. –7.1% per 90-day interval; p = 0.64), whereas improvements in KCCQ-OS scores were slightly smaller (2.1 vs. 3.46 per 90-day interval; p = 0.07). ConclusionsSacubitril/valsartan favorably affects natriuretic peptide levels, reverse cardiac remodeling, and health status in patients with HFrEF with and without T2DM. (Effects of Sacubitril/Valsartan Therapy on Biomarkers, Myocardial Remodeling and Outcomes [PROVE-HF]; NCT02887183)

Smartphone-Delivered Progressive Muscle Relaxation for the Treatment of Migraine in Primary Care: A Randomized Controlled Trial.

Scalable, accessible forms of behavioral therapy for migraine prevention are needed. We assessed the feasibility and acceptability of progressive muscle relaxation (PMR) delivered by a smartphone application (app) in the Primary Care setting. This pilot study was a non-blinded, randomized, parallel-arm controlled trial of adults with migraine and 4+ headache days/month. Eligible participants spoke English and owned a smartphone. All participants were given the RELAXaHEAD app which includes an electronic headache diary. Participants were randomized to receive 1 of the 2 versions of the app-one with PMR and the other without PMR. The primary outcomes were measures of feasibility (adherence to the intervention and diary entries during the 90-day interval) and acceptability (satisfaction levels). We conducted exploratory analyses to determine whether there was achangein Migraine Disability Assessment Scale (MIDAS) scores or a changein headache days. Of 139 participants (77 PMR, 62 control), 116 (83%) were female, mean age was 41.7±12.8 years. Most patients 108/139 (78%) had moderate-severe disability. Using a 1-5 Likert scale, participants found the app easy to use (mean 4.2±0.7) and stated that they would be happy to engage in the PMR intervention again (mean 4.3±0.6). For the first 6weeks, participants practiced PMR 2-4days/week. Mean per session duration was 11.1±8.3minutes. Relative to the diary-only group, the PMR group showed a greater non-significant decline in mean MIDAS scores (-8.7 vs -22.7, P=.100) corresponding to a small-moderate mean effect size (Cohen's d=0.38). Smartphone-delivered PMR may be an acceptable, accessible form of therapy for migraine. Mean effects show a small-moderate mean effect size in disability scores.

Impact of the timing of coronary revascularization relative to the transcatheter aortic valve implantation procedure: insights from a propensity score analysis based on a nationwide analysis

Abstract Background The significance and the management of coronary artery disease (CAD) are disputed in patients treated by transcatheter aortic valve implantation (TAVI). In the presence of a significant CAD eligible for percutaneous coronary intervention (PCI), the issue of the timing of PCI relative to TAVI is unsettled. To answer this question, the present study aimed at comparing the short-term and long-term outcome in patients treated by staged PCI within a 90-day time interval before or after TAVI. Methods Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with TAVI between 2014 and 2018. Patients treated with PCI in the preceding 90 days before the TAVI procedure (pre-TAVI PCI) or subsequent 90 days after the TAVI procedure (post-TAVI PCI) were included. All-cause mortality, cardiovascular mortality, stroke, myocardial infarction and a combined cardiovascular endpoint were assessed at 30 days after the last procedure (short-term) and during the whole follow-up (long-term). Propensity score matching was used for the analysis of outcomes. Results 8613 patients met the inclusion criteria with a vast majority of pre-TAVI PCI patients (N=8324) as opposed to post-TAVI PCI (N=229). After propensity score matching, 2 groups of 227 patients with comparable characteristics were obtained. At 30 days, no significant difference was observed for any of the outcome tested with the exception of myocardial infarction more frequent in post-TAVI PCI (OR 2.43 [1.17–5.07]). After a mean [SD] follow-up of 459 [569] days, all outcomes were identical between subgroups. The figure below illustrates the Kaplan Meier curve for all-cause mortality. Conclusions Our study based on a French nationwide database shows that PCI is performed pre-TAVI in a majority of cases, with no significant impact on outcome. Deferring PCI after TAVI seems safe and may provide an opportunity to make the decision on more objective parameters while the stenosis has been removed (such as FFR or IFR). In any case, the timing of PCI relative to TAVI does not seem to represent a concern and should be decided on an individual basis. Figure 1 Funding Acknowledgement Type of funding source: None

When less is more: Can reduced health monitoring improve medication adherence?

As the prevalence of chronic diseases rises, improving self-management has become an important determinant of the productivity of healthcare delivery. Recently, Mexico's largest healthcare provider began issuing automatic-refill prescriptions to stable hypertensive patients, thus reducing the frequency of health monitoring from 30- to 90-day intervals. Exploiting this change, I find that less monitoring implies no drawbacks in health outcomes and actually improves self-management of disease by increasing medication adherence when baseline monitoring is relatively frequent. The number of days when patients are out of medication between fillings falls by 2.2 days—an improvement in adherence of 6.4%. Furthermore, patients appear to value being on a low-frequency regime as they improve adherence in order to remain on it, suggesting that lower monitoring could be used as a “reward” to promote medication adherence or, potentially, other health behaviors. Finally, I find evidence of positive spillovers on adherence, as clinic congestion falls.

CORR Synthesis: When Should We Be Skeptical of Clinical Prediction Models?

CORR Synthesis: When Should We Be Skeptical of Clinical Prediction Models?