Day Hospital Regimen Research Articles

524 SAFETY OF HAND-HELD ULTRASOUND GUIDANCE FOR JUGULAR RIGHT HEART CATHETERIZATION IN ANTICOAGULATED PATIENTS: A TERTIARY CARE CENTER RETROSPECTIVE STUDY

Abstract Background RHC is currently the gold standard in the assessment of diagnosis, prognostic evaluation, and decision-making of pulmonary hypertension patients. Internal jugular vein (IJV) access is the preferred option among the available vascular access routes in most of pulmonary hypertension centers; furthermore, ultrasound (US) guidance is strongly recommended for the IJV access (IA) since it reduces the number of access complications. Many patients requiring RHC are on long-term oral anticoagulant therapy. Continuation of direct oral anticoagulant (DOAC) has been shown to be safe in patients undergoing percutaneous coronary intervention (PCI) and cardiac implantable electronic device implantation (CIED). However only few data in the literature are available in the setting of RHC. Objectives To compare the feasibility and safety of ultrasound (US)-guided IJV access for RHC procedure in pulmonary hypertension's patients anticoagulated vs non-anticoagulated. Methods This is a retrospective observational single–center study, including a cohort of 114 consecutive patients undergoing RHC via IJV assess by US guidance RHC at our tertiary care center between February 2018 and February 2022. The primary outcome was a composite of general (defined as overall success rate, patient discomfort, syncope, mortality) and access site complications (defined as significant hematoma formation greater than 5 cm in diameter, thrombosis, embolism, arterial puncture, pneumothorax, haemotomediastinum and hydro mediastinum, subcutaneous emphysema and nerve injury) after adequate hemostasis, at the access site at 6-hour post procedure. Results Of the 114 patients, 50 (44%) were on anticoagulation and 64 (56%) were not. Mean age was 71 ± 13 and 59 ± 16 years, respectively. The main indication for anticoagulation was atrial fibrillation in 40 (80%) patients. 43 (86%) patients were on DOAC, only 7 (14%) on Warfarin. 13 patients were on single antiplatelet therapy and 8 were on double antiplatelet therapy. Mean INR value was 1.25 ± 0.33 in the anticoagulated population and 1.08 ± 0.11 in the non-anticoagulated one. HAS-BLED score was equal or greater than 3 in 29 (25%) patients. Indication for RHC was mainly confirmation of PH class I diagnosis (54% of patients). None of the patients enrolled developed general or access site complications, except for 1 (2%) non-anticoagulated patient who develop a significant hematoma (defined as >5 cm in diameter) at the puncture site. All patients underwent day-hospital regimen, were able to mobilize immediately following the procedure, and were discharged as planned at 6 hours. Conclusions To the best of our knowledge this is the first study in the literature supporting the feasibility and safety of US guided IJV approach to RHC in anticoagulated patients when compared to non-anticoagulated patients affected by pulmonary hypertension. Keywords: Right heart catheterization, catheterization, anticoagulation, internal jugular vein, US-guidance, access site complications

The subcutaneous ICD replacement in the clinical practice: preliminary observations from the multicentre RHYTHM DETECT

Abstract Funding Acknowledgements Type of funding sources: None. Background Experience with the subcutaneous implantable cardioverter-defibrillator (S-ICD) is expanding rapidly. However, few data on generator replacement exist. Purpose The aim of this analysis was to describe the procedural characteristics of the pulse generator replacement in the current Italian practice and to provide a preliminary insight in the possible acute complications associated with first elective S-ICD generator replacements. Methods We analyzed 106 consecutive patients enrolled in the Rhythm Detect registry who underwent elective replacement of the S-ICD generator from September 2019 to July 2021. Procedures were accomplished according to the local clinical practice. A chest X-ray was performed, and the PRAETORIAN score was assessed and compared with the one measured after the first implantation. Results All replacements were performed in electrophysiology laboratories, 50% in day-hospital regimen, by 1 or 2 expert operators. Procedures were performed using local (87%) or general anaesthesia (13%). The median procedure duration was 40 (30-45) min. The previous S-ICD generator was in a subcutaneous pocket in 58 (55%) patients, and in an intermuscular pocket in the remaining patients. The PRAETORIAN score of the previous system was low (<90) in 93% of patients and intermediate in 7% of patients. In all patients with the device in an intermuscular pocket, the PRAETORIAN score was <90. During the replacement procedure, 22 S-ICD (3 with PRAETORIAN ≥90 before replacement) were removed from the initial subcutaneous position and placed in an intermuscular pocket. After replacement all patients with intermuscular devices had a score <90, and the overall proportion of patients with low-risk PRAETORIAN score raised to 97%. Defibrillation testing was performed only in 10% of patients, while testing was performed in 77% of patients at the first implantation procedure. No procedure-related complications occurred. Conclusions S-ICD replacements seem easy to perform with no peri-procedural complications. The adoption of an intermuscular pocket is associated with optimal positioning according to the PREATORIAN score, and seems preferred also in many cases of generators previously placed subcutaneously. In the Italian clinical practice conversion testing is rarely performed at device replacement.

New Perspective to Improve Care of Patients with Infected Diabetic Foot Ulcer: Early Economic Impact of the Use of Photodynamic Therapy with RLP068 (Based) System.

ObjectiveTo perform an early economic evaluation of a system based on photodynamic advanced adjuvant therapy with photosensitizer RLP068/CI to facilitate the healing process of foot/leg skin lesions/ulcers with an excellent safety profile.DesignAn early short-term (10 weeks) cost-effectiveness and a budget impact analysis (over 5 years) comparing photodynamic therapy with photosensitizer RLP068/CI based (PDT-RLP068) system added to Standard of Care (SoC) vs SoC alone.SettingThe Italian National Healthcare System perspective considering both the outpatient and the day-hospital regimen.ParticipantsHypothetical patients with diabetic foot infection (DFI) grades I/IIB.InterventionsThe PDT-RLP068 system as an add-on to Standard of Care (SoC) vs SoC alone as the first-line treatment for the management of DFIs.Main OutcomesDays within which the clinical target was achieved and direct health costs for patients’ management.ResultsAdditional costs generated by the use of the PDT-RLP068 system progressively decreased as time to reach the target induced by the novel system decreased. In the outpatient regimen, when time to reach clinical target decreased in the range 7–28 days, ICERs varied from about 1€ to 70€ for each additional day gained with clinical target achieved. The system was dominant when halving time to reach the target in the outpatient regimen and even for modest reduction of time in day-hospital regimen. In terms of budget impact, when considering day-hospital regimen, if the PDT-RLP068 based system allowed a shortened duration to reach the clinical target of between 7–28 days, BI was 8,100,000€ to 700,000€, with saving less than 2,000,000€ with 50% reduction of time. Considering the inpatient setting, the use of the PDT-RLP068 system would result in saving even with the modest impact on the time needed to activate the healing process.ConclusionThe early economic evaluation performed suggested that, if the claimed effectiveness of the technology demonstrated in case reports and in preliminary clinical studies can be confirmed in larger population studies, and allowing for shortening of the time needed to activate the healing process, the PDT-RLP068 system could offer the chance to improve care for DFI patients without compromising the sustainability of the system.

CT-guided percutaneous drilling is a safe and reliable method of treating osteoid osteomas

Computed tomography (CT)-guided percutaneous drilling is an alternative for osteoid osteoma treatment. This study aims to evaluate the remodeling of the drill orifice. The success rate and complications were also recorded and compared with other treatment methods.Fifteen patients with an average age of fourteen years (ranging from 4 to 25) submitted to CT-guided percutaneous drilling between 2003 and 2009 were retrospectively analyzed according to clinical and radiological criteria.Fourteen cases showed complete alleviation of pain one week after surgery. No relapse was detected even in the subject who continued complaining of pain. All patients were treated with a day-hospital regimen and were discharged with partial weight bearing. Total weight bearing was allowed after one month, and sports were allowed after consolidation, which occurred in all but one case after the third month. One patient, who did not follow our medical advice, returned to sports activities after two weeks and experienced a fracture as a result. Atrophy of the vastus lateralis muscle developed after the procedure in another patient.Our case series suggests that this method is reliable and safe. The level of complexity is comparable with other minimally invasive percutaneous procedures. The cost is low because there is no need to buy probes or other equipment. The negative points include weakening of the bone and the logistical problem of assembling the orthopedic surgeon, radiologist, and anesthesiologist in the tomography room.

The Growing Importance of Socioeconomic Aspects in Cardiovascular Disease

Objective: Disparities in mortality between socioeconomic groups have widened during the last decades in Europe, and socioeconomic inequalities in health have been marked as one of the most important issues to be tackled by public health policy. Previous studies have shown an inverse relationship between socioeconomic status (SES) defined by education, income, occupation, social status and neighbourhood environment, and the occurrence of cardiovascular risk factors and disease (CVD). In Italy, poor evidence exists about the relative burden of every single component of SES leading to a higher prevalence of CVD. The aim of this study was to investigate the relationship between SES and CVD in a cohort of patients admitted to our institution over a period of 9 months. Methods: We retrospectively studied 656 patients admitted to our institution over a period of 9 months, performing a correlation between individual SES and the prevalence of CVD. Admissions included day-hospital and ordinary regimens. Occupation was defined by different categories: employed, unemployed, student, housewife, retired/unable, whereas educational level was classified as no qualification, primary school certificate, secondary school certificate, school-leaving certificate, degree or other academic qualifications. A high educational level was defined as school-leaving certificate, degree or other academic certificate, while primary school certificate or no qualification corresponded to a low educational level. Concerning the causes of disease related to admission, we considered all registered diagnoses according to the WHO classification of disease (ICD-9). Results: Educational level and heart disease appeared to be inversely related, showing that people with hypertensive disease and coronary artery disease (CAD) belonged mainly to the low educational group (r = −0.13, p = 0.001). Gender did not alter such findings significantly: the higher the educational level, the lower the prevalence of hypertensive disease and CAD in women (r = −0.17, p = 0.001) and men (r = −0.18, p = 0.001). Occupational status seemed to mainly influence the prevalence of CAD (r = −0.24; p < 0.001). In addition, an association between educational level and the choice of admission regimen has been observed (r = −0.27; p < 0.001). In the examined population, a more frequent rate of the day-hospital regimen was recorded among high-level qualification subjects compared with ordinary admissions (7.1% vs 6.6%, p < 0.001). Conclusions: In this retrospective analysis from an Italian registry, we observed a decrease in the prevalence of CVD with increasing educational status. However, the mechanism underlying this relationship remains uncertain and needs to be addressed in further studies.

The Use of Intravenous Methotrexate in the Treatment of Ectopic Pregnancy

Between January 1996 and December 2001, at the Department of Gynecology, Perinatology and Human Reproduction of the University of Florence, 49 ectopic pregnancies were submitted to medical treatment. The treatment schedule consisted of the administration of 100 mg of intravenous methotrexate (MTX). The patients included in this study fulfilled the following requisites: gestational period <8 weeks; diameter of the ectopic gestational sac <4 cm; serum level of human chorionic beta-gonadotropin (β-hCG)<5000 IU/ml; absence of clinical and ultrasound signs of tube rupture with initial hemoperitoneum; hematochemical tests compatible with chemotherapic treatment.All patients were followed with a dosage of serum β-hCG repeated every 2-3 days after chemotherapy and with an ultrasound every 3-4 days. In case of docu-mented success of treatment the patient was hospitalized for no more than 3 days after administration of the drug. In 1 case therapy took place in a day-hospital reg-imen.Medical treatment was effective in 35 patients out of 49 (71.4%) and led to negative ?-hCG in a median time of 11 days, with a range between 2 and 48 days. In the 14 non-responsive cases (28.6%), after a mean time of 6 days we proceeded to a traditional surgical approach or laparoscopy. In none of the cases did we find significant pharmacological toxicity, while in 9 patients (18.3%), severe painful symptoms appeared immediately after treatment, but resolved within 24 hours.Our results are interesting and in agreement with other experiences found in the literature. In our opinion, the advisability of a second administration in case of slow response, the comparison with an analogous intramuscular treatment, a more pre-cise definition of the eligibility criteria, long-term follow-up of the patients, espe-cially in case of subsequent pregnancies should all be further considered.

Nurse's activities and infusional protocols in a day-hospital regimen

Nurse's activities and infusional protocols in a day-hospital regimen

A rapid blood lactate assay using a centrifugal analyser and 3-acetylpyridine-adenine dinucleotide.

The COVID-19 pandemic brought the outpatient management to the spotlight, especially in what home mechanical ventilation (HMV) is regarded. Our goal was to assess the main complaints/problems and the adjustments made in the appointment. We performed a transversal retrospective analysis of patients on HMV for at least a month, followed in the outpatient clinic of a tertiary hospital, in 2019’s 2nd semester. The HMV outpatient clinic consists of a pulmonologist, a nurse and a technician from the home respiratory care company (provider of HMV in Portugal). In a day-hospital regimen, patients are monitored on HMV with their equipment for at least 30 minutes with blood gas analysis and/or capnography. Ventilator data is observed in real time and also collected from the previous 3 months. A total of 301 patients were analyzed. No changes were made in 138 cases (45.8%). A total of 212 changes were made in the remainder 163 patients. Most detected problems were found in HMV software data (33.5%), such as usage, leakage and volumes. HMV parameters suffered the most adjustments (36.3%). Only 5 problems (2.4%) lead to stop HMV. All results are shown in this table: Almost half of the patients needed no changes. On the other hand, our results show how an outpatient approach to HMV follow-up allows clinicians to detect a diverse amount of patients’ complaints or problems regarding the treatment itself and, at the same time, address changes to try to fix them.