IN HOSPITAL Research Articles

Use of a Stroke Alert Protocol and Outcomes at a Quaternary Children’s Hospital

To assess for improvement in diagnostic efficiency following implementation of an institutional pediatric stroke alert protocol at a quaternary children's hospital, and to compare characteristics of in-hospital (IH) and out-of-hospital (OH) stroke alert activations. We retrospectively reviewed data from pediatric stroke alerts called for children between age 1 month to 21 years of age at our quaternary children's hospital between October 2016 and October 2022 after implementation of an institutional stroke alert protocol. Generalized linear models assessed code-to-image (CTI) time over the study period, with and without interaction terms for alert location. Demographic, clinical, and imaging characteristics between IH and OH alerts were compared using Fisher's exact test or Mann-Whitney U test. Of 206 total stroke activations, 129 (62.6%) occurred IH and 77 (37.4%) occurred OH. Overall mean CTI time decreased by 4.56 minutes per year (p = 0.007) after adjusting for confounders. The association between year and mean CTI time was significantly stronger for IH alerts (decrease of 8.33 minutes/year) compared with OH alerts (increase of 1.90 minutes/year). Subgroup analyses showed that CTI for computed tomography (CT) ± CT angiography and magnetic resonance imaging (MRI) without sedation improved, although CTI time for MRI with sedation did not change over time. IH/OH divergent trends were consistent for CT ± CTA and non-sedated MRI. After implementation of a pediatric stroke alert protocol, we observed a steady and significant improvement in CTI times for IH, but not OH alerts.

A STUDY ON PATIENT SAFETY IN HOSPITAL

Patient safety is a fundamental aspect of healthcare quality, aiming to prevent and reduce risks, errors, and harm to patients during the provision of healthcare. This dissertation investigates the multifaceted nature of patient safety, examining its determinants, impacts, and strategies for improvement. The study employs a mixed-methods approach, combining quantitative data analysis from patient safety incident reports and qualitative insights from healthcare professionals through interviews and focus groups. Key findings highlight the prevalence of medication errors, surgical complications, and healthcare-associated infections as primary concerns. Contributing factors include inadequate staffing, insufficient training, and poor communication among healthcare teams. The dissertation emphasizes the critical role of a robust safety culture, where open communication and continuous learning are prioritized. Recommendations for enhancing patient safety include the implementation of standardized protocols, advanced training programs, and the integration of health information technologies such as electronic health records (EHRs) and computerized physician order entry (CPOE) systems. Additionally, fostering a non-punitive environment encourages reporting and addressing errors without fear of retribution. This study underscores the importance of interdisciplinary collaboration and the continuous evaluation of safety practices to adapt to the evolving healthcare landscape. By identifying key areas for intervention and providing actionable strategies, this dissertation contributes to the ongoing efforts to safeguard patient well-being and improve healthcare outcomes. This abstract encapsulates the main elements typically addressed in a comprehensive study on patient safety, focusing on the causes, consequences, and potential solutions to enhance safety in healthcare settings.

Outcomes of atherectomy in patients undergoing lower extremity revascularisation.

There is a paucity of real-world data on the in-hospital (IH) and post-discharge outcomes in patients undergoing lower extremity peripheral vascular intervention (PVI) with adjunctive atherectomy. In this retrospective, registry-based study, we evaluated IH and post-discharge outcomes among patients undergoing PVI, treated with or without atherectomy, in the National Cardiovascular Data Registry PVI Registry. The IH composite endpoint included procedural complications, bleeding or thrombosis. The primary out-of-hospital endpoint was major amputation at 1 year. Secondary endpoints included repeat endovascular or surgical revascularisation and death. Multivariable regression was used to identify predictors of atherectomy use and its association with clinical endpoints. A total of 30,847 patients underwent PVI from 2014 to 2019, including 10,971 (35.6%) treated with atherectomy. The unadjusted rate of the IH endpoint occurred in 524 (4.8%) of the procedures involving atherectomy and 1,041 (5.3%) of non-atherectomy procedures (p=0.07). After adjustment, the use of atherectomy was not associated with an increased risk of the combined IH endpoint (p=0.68). In the 6,889 (22.4%) patients with out-of-hospital data, atherectomy was associated with a reduced risk of amputation (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI]: 0.51-0.85; p<0.01) and surgical revascularisation (aHR 0.63, 95% CI: 0.44-0.89; p=0.017), no difference in death rates (p=0.10), but an increased risk of endovascular revascularisation (aHR 1.21, 95% CI: 1.06-1.39; p<0.01) at 1 year. The use of atherectomy during PVI is common and is not associated with an increase in IH adverse events. Longitudinally, patients treated with atherectomy undergo repeat endovascular reintervention more frequently but experience a reduced risk of amputation and surgical revascularisation.

THE RELATIONSHIP BETWEEN E-HEALTH LITERACY AND SOCIAL MEDIA USE IN HOSPITAL PREFERENCE

Amaç: Bu çalışma katılımcıların, e-sağlık okuryazarlık düzeyi ile hastane tercihinde sosyal medya kullanım algısı arasındaki ilişkinin incelenmesi amacıyla yapılmıştır. Yöntem: Çalışmanın evrenini Mersin ve Adana ilinde ikamet eden ve sosyal medya kullanıcısı olan 18 yaş ve üzeri bireyler oluşturmaktadır. Araştırmada örnekleme yöntemi olarak kararsal (kasti) ve kartopu yöntemleri kullanılmıştır. Araştırma sonucunda elde edilen veriler, tanımlayıcı istatistikler, korelasyon ve regresyon analizleri yapılarak raporlanmıştır. Bulgular: E-sağlık okuryazarlık düzeyi ile hastane tercihinde sosyal medya kullanımı arasındaarasında orta düzeyde pozitif yönlü bir ilişki tespit edilmiştir (p&amp;lt;0.001). E-sağlık okuryazarlık düzeyinin, hastane tercihinde sosyal medya kullanımı düzeyindeki varyansın %18’ini (R2) açıkladığı görülmüştür. Sonuç: Sosyal medya araçlarının, toplumu yönlendirme özelliği ve sağlıkla ilgili hususlarda duyarlılığını arttırma potansiyeli bulunmaktadır. Çalışma sonucunda bu potansiyelin doğru kullanılabilmesi için e-sağlık okuryazarlık düzeyinin arttırılması gerektiği ortaya konulmuştur.

Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN)

BackgroundCardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. MethodsThe Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. ResultsWe analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). ConclusionDespite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.

Percutaneous coronary intervention in elderly patients with chronic kidney disease and non-ST segment elevation acute coronary syndrome – is it worth it?

Abstract ESC guidelines recommend revascularization in patients (pts) with chronic kidney disease (CKD) irrespective of age. However, elderly pts are usually underrepresented in the available data on percutaneous coronary intervention (PCI). Thus, the decision on whether to perform PCI in these pts is usually at the discretion of the cardiology team. Aim To evaluate the impact of PCI vs conservative approach (CA) in elderly pts (&amp;gt;80 years) with CKD and unstable angina (UA)/non-ST segment elevation myocardial infarction (NSTEMI) who were enrolled in the Portuguese National Registry of Acute Coronary Syndromes. To determine impact of CKD in in-hospital (IH) and long-term outcomes, including MACE (myocardial infarction, stroke and death) and death at 1 year. Study population Elderly pts admitted with UA and NSTEMI, from 2010 until 2021. There were three different groups: Group 1 – eGFR ≥60 ml/min/1.73 m2; Group 2 – eGFR between 30 and 59 ml/min/1.73 m2 and Group 3 – eGFR &amp;lt;30 ml/min/1.73 m2. Pts with ST-segment elevation myocardial infarction and cardiogenic shock were excluded. Results A total of 2443 pts, of which 921 (37,7%) were submitted to PCI. 50,2% (n=1126,) were from the group 1, 38,5% (n=941) from group 2 and 11.3% (n=276) from group 3. Regarding overall population, pts submitted to PCI were mainly male (60,4%) with a mean age of 84±3 years old. They had previous history of PCI (21,6% vs 15,1% p&amp;lt;0.001), less history of heart failure (HF), stroke or dementia (8,5% vs 16,5%; 8,1 vs 13.3% and 2,1 vs 5,9%, p&amp;lt;0.001). At presentation they had more angina (88,8% vs 81,2% p&amp;lt;0.001), less NT-proBNP levels (387 vs 561 p&amp;lt;0.001) and were more frequently in KK class I (75,6% vs 70,2% p=0.004). They developed less HF (21% vs 27%, p&amp;lt;0.001) and MACE (5,7% vs 9,1% p=0.003). Pts in the group 3 were less submitted to PCI (27,5% vs 38,2% vs 39,6% p&amp;lt;0.001) and had more MACE and cardiovascular death when comparing to group 2 and 1 (16,1% vs 8,7% vs 5,3% and 10,5% vs 5,5% vs 2,6% p&amp;lt;0.001 respectively). Comparing PCI vs CA in each group, there was no difference in IH outcomes between both strategies in group 3. The same was not true for groups 1 and 2, in which PCI seemed to favor overall outcomes (p=0.001 and p=0.015 respectively). The predictors of IH death and MACE were: age (OR 1.068 p=0.010), dementia (OR 2,376 p=0.015), KK class &amp;gt;1 (OR 2,243, p&amp;lt;0.001), atrial fibrilhation (OR 1.605, p=0.046), not having PCI (OR 0.309, p&amp;lt;0.001), eGFR &amp;lt;30 (OR 3.51, p&amp;lt;0.001) and PCI in pts with eGFR &amp;lt;30 (OR 2.923, p=0.019). Interestingly, survival analysis showed that pts submitted to PCI in all 3 groups (including group 3) had a longer 1-year survival (p&amp;lt;0.001, p&amp;lt;0.001 and p&amp;lt;0.004). Conclusions PCI performance in elderly pts with CKD should be individualized. In our population, especially in group 3, the performance of PCI is associated with a higher IH mortality, however, after surviving hospitalization, these pts seem to have a benefit in 1 year survival. Funding Acknowledgement Type of funding sources: None.

Left atrial strain analysis improves non-invasive estimation of left ventricular filling pressures in takotsubo syndrome

Abstract Background Takotsubo syndrome (TTS) is associated with a non-negligible risk of in-hospital (IH) complications. Elevated left ventricular filling pressures (LVFP), measured invasively as LV end-diastolic pressure (LVEDP), showed to predict adverse IH outcomes in this population. Recently, novel indexes of left atrial (LA) function, including LA reservoir and LA pump strain, demonstrated a close correlation with increased LVFP in unselected patients. Purpose To assess the ability of LA reservoir and LA pump strain to improve non-invasive estimation of LVFP and to predict IH complications in TTS patients. Methods We retrospectively enrolled patients with confirmed TTS diagnosis at invasive left heart catheterization and coronary angiography. LVEDP was assessed invasively at the time of catheterization. Transthoracic echocardiography was performed with 48 hours from hospital admission. IH complications were collected, including occurrence of acute heart failure (pulmonary oedema/cardiogenic shock; Killip class III/IV), death from any cause and life-threatening arrhythmias. Results A total of 62 patients were analysed (72.2±10.1 years, female 80%). IH complications occurred in 25 (40.3%). Patients who experienced IH complications had higher LVEDP and lower LVEF, LA reservoir strain and LA pump strain values compared to patients without IH complications (all P≤0.001). At multivariate analysis, EF and LVEDP were independent predictors of worse IH outcomes (P≤0.001 and P=0.004 respectively). Correlation analysis proved that lower values of both LA reservoir and pump strain were associated with increasingly higher LVEDP (r −0.859, P≤0.001 and r −0.848, P≤0.001 respectively). Receiving operating characteristic (ROC) curve analysis showed that the AUC for LVEDP to predict IH complications was 0.814 (95% CI 0.679–0.949, P≤0.001) with an optimal cut-off value of 24.5 mmHg (sensitivity 77%, specificity 53%). Therefore, we performed ROC curve analysis to compare the ability of LA strain values and standard echocardiographic parameters currently used for non-invasive LVFP assessment to predict LVEDP ≥24.5 mmHg. As a result, we obtained higher AUC for LA reservoir and pump strain [0.909 (95% CI 0.818–0.999, P≤0.001) and 0.889 (95% CI 0.789–0.988, P≤0.001), respectively] vs E/e' 0.800 (95% CI 0.663–0.937, P≤0.001), LAVi 0.666 (P=0.092) and tricuspid regurgitation (TR) peak velocity 0.582 (P=0.596). The incorporation of LA strain values in a multivariable model including E/e' ratio, LAVi and TR peak velocity to predict a LVEDP ≥24.5 mmHg led to a significant incremental predictive value (changes in χ2=11.99; P=0.002). Conclusion In patients with TTS, lower LA reservoir and pump strain values correlate with increased LVEDP and improve non-invasive estimation of LVFP. LA strain analysis may be an easy tool to individuate subjects at higher risk of IH complications. Funding Acknowledgement Type of funding sources: None.

EXAMPLE OF USING 3D PRINTERS IN HOSPITAL BIOMEDICAL UNITS

Along with the developments in the industry, the Three-Dimensional (3D) printer technology, which came to the fore at the end of the 1980s, has started to be used in many areas and has taken an important place in our lives. The prototype of the final version of a product designed with the help of Computer Aided Design (CAD) programs can be easily produced. 3D printers; They are involved in areas such as automotive and machine production in order to develop prototypes in the industry, developing course materials in education, planning of surgical operations in the field of health, production of artificial organs and orthotic prosthesis applications in biomedicine. In this study, 3D printers in the biomedical units in hospitals, the production of new ones instead of the broken parts, and their usage areas are included. In this context, the static analysis of the broken keypad of the ultrasound device was made. Accordingly, the model was created using computer software and the production was carried out with a 3D printer. An example of the usage areas of 3D printers is presented. In addition, the cost of the keypad is reduced by manufacturing it one by one instead of replacing it as a whole.

Breaking a cycle of stigma: An interprofessional team approach to building trust for hospitalized patients with substance use disorder.

Journal of Hospital MedicineEarly View PERSPECTIVES IN HOSPITAL MEDICINE Breaking a cycle of stigma: An interprofessional team approach to building trust for hospitalized patients with substance use disorder Richard Bottner DHA, PA-C, Corresponding Author Richard Bottner DHA, PA-C richard.bottner@austin.utexas.edu orcid.org/0000-0003-4110-1628 @RichBottner Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA Correspondence Richard Bottner, DHA, PA-C, Dell Medical School, The University of Texas at Austin, 1601 Trinity Street, Bldg. B, Stop Z0900, Austin, TX 78712, USA. Email: richard.bottner@austin.utexas.edu; Twitter: @RichBottnerSearch for more papers by this authorAlanna Boulton MSHA, Alanna Boulton MSHA alanna.boulton@austin.utexas.edu Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorBlair Walker MD, Blair Walker MD Department of Psychiatry, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorJananie Ramesh MD, Jananie Ramesh MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorHemali Patel MD, Hemali Patel MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorEvan Solice BCC, Evan Solice BCC Department of Chaplain Services, Ascension Texas, Austin, Texas, USASearch for more papers by this authorSlade Skaggs RSPS, Slade Skaggs RSPS Communities for Recovery, Austin, Texas, USASearch for more papers by this authorChristopher Moriates MD, Christopher Moriates MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this author Richard Bottner DHA, PA-C, Corresponding Author Richard Bottner DHA, PA-C richard.bottner@austin.utexas.edu orcid.org/0000-0003-4110-1628 @RichBottner Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA Correspondence Richard Bottner, DHA, PA-C, Dell Medical School, The University of Texas at Austin, 1601 Trinity Street, Bldg. B, Stop Z0900, Austin, TX 78712, USA. Email: richard.bottner@austin.utexas.edu; Twitter: @RichBottnerSearch for more papers by this authorAlanna Boulton MSHA, Alanna Boulton MSHA alanna.boulton@austin.utexas.edu Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorBlair Walker MD, Blair Walker MD Department of Psychiatry, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorJananie Ramesh MD, Jananie Ramesh MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorHemali Patel MD, Hemali Patel MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorEvan Solice BCC, Evan Solice BCC Department of Chaplain Services, Ascension Texas, Austin, Texas, USASearch for more papers by this authorSlade Skaggs RSPS, Slade Skaggs RSPS Communities for Recovery, Austin, Texas, USASearch for more papers by this authorChristopher Moriates MD, Christopher Moriates MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this author First published: 27 March 2022 https://doi.org/10.1002/jhm.12814Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Building trust in medicine through physician mass media presence.

Journal of Hospital MedicineEarly View PERSPECTIVES IN HOSPITAL MEDICINE Building trust in medicine through physician mass media presence Chloë E. Nunneley MD, Corresponding Author Chloë E. Nunneley MD chloe.nunneley@childrens.harvard.edu @DrChloeNunneley Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA Correspondence Chloë E. Nunneley, MD, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Email: chloe.nunneley@childrens.harvard.edu; Twitter: @DrChloeNunneleySearch for more papers by this author Chloë E. Nunneley MD, Corresponding Author Chloë E. Nunneley MD chloe.nunneley@childrens.harvard.edu @DrChloeNunneley Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA Correspondence Chloë E. Nunneley, MD, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Email: chloe.nunneley@childrens.harvard.edu; Twitter: @DrChloeNunneleySearch for more papers by this author First published: 19 January 2022 https://doi.org/10.1002/jhm.2767Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue This article also appears in:Trust Series RelatedInformation

When silence is not golden: Crying and other responses to microaggressions and implicit bias in academic medicine.

Journal of Hospital MedicineEarly View PERSPECTIVES IN HOSPITAL MEDICINE When silence is not golden: Crying and other responses to microaggressions and implicit bias in academic medicine Himali Weerahandi MD, MPH, Corresponding Author Himali Weerahandi MD, MPH Himali.Weerahandi@nyulangone.org orcid.org/0000-0001-9614-345X Division of Hospitalist Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA Correspondence: Himali Weerahandi, MD, MPH, Department of Medicine, NYU Grossman School of Medicine, 227 E 30th St., New York, NY 10016, USA. Email: Himali.Weerahandi@nyulangone.orgSearch for more papers by this author Himali Weerahandi MD, MPH, Corresponding Author Himali Weerahandi MD, MPH Himali.Weerahandi@nyulangone.org orcid.org/0000-0001-9614-345X Division of Hospitalist Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA Correspondence: Himali Weerahandi, MD, MPH, Department of Medicine, NYU Grossman School of Medicine, 227 E 30th St., New York, NY 10016, USA. Email: Himali.Weerahandi@nyulangone.orgSearch for more papers by this author First published: 04 January 2022 https://doi.org/10.1002/jhm.2740Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

The No Judgment Zone: Building trust through trustworthiness.

Journal of Hospital MedicineVolume 17, Issue 6 p. 491-495 PERSPECTIVES IN HOSPITAL MEDICINE The No Judgment Zone: Building trust through trustworthiness Kimberly D. Manning MD, Corresponding Author Kimberly D. Manning MD [email protected] @gradydoctor Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Correspondence Kimberly D. Manning, MD, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Email: [email protected]; Twitter: @gradydoctorSearch for more papers by this authorMaya Isaacsohn MD, Maya Isaacsohn MD Department of Medicine, Emory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this authorShub Agrawal MD, MBA, Shub Agrawal MD, MBA Department of Medicine, Emory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this authorYolanda H. Wimberly MD, MSc, Yolanda H. Wimberly MD, MSc Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia Chief Health Equity Officer, Grady Health System, Atlanta, GeorgiaSearch for more papers by this author Kimberly D. Manning MD, Corresponding Author Kimberly D. Manning MD [email protected] @gradydoctor Department of Medicine, Emory University School of Medicine, Atlanta, Georgia Correspondence Kimberly D. Manning, MD, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia. Email: [email protected]; Twitter: @gradydoctorSearch for more papers by this authorMaya Isaacsohn MD, Maya Isaacsohn MD Department of Medicine, Emory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this authorShub Agrawal MD, MBA, Shub Agrawal MD, MBA Department of Medicine, Emory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this authorYolanda H. Wimberly MD, MSc, Yolanda H. Wimberly MD, MSc Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia Chief Health Equity Officer, Grady Health System, Atlanta, GeorgiaSearch for more papers by this author First published: 08 November 2021 https://doi.org/10.12788/jhm.3730Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume17, Issue6June 2022Pages 491-495 This article also appears in:Trust Series RelatedInformation

Non-ST Elevation Myocardial Infarction With Occluded Culprit Artery: A Continuum of Mortality Risk Across the Spectrum of Acute Myocardial Infarction.

Non-ST segment elevation myocardial infarction (NSTEMI) patients presenting with occluded culprit artery (OCA) may be at higher risk for worse outcomes. We sought to compare in-hospital (IH) mortality between patients presenting with NSTEMI with and without OCA, and ST-segment elevation myocardial infarction (STEMI). This retrospective analysis studied 14,037 patients enrolled in the Portuguese National Registry of Acute Coronary Syndromes. Three groups were defined: (A) STEMI (n = 8616); (B) OCA-NSTEMI (n = 1309); and (C) non-OCA NSTEMI (n = 4112). Baseline characteristics, therapeutic strategies, and outcomes were compared. Multivariate analysis was performed to assess the risk of IH all-cause mortality across the prespecified groups. Twenty-four percent of NSTEMI patients presented with OCA. The left circumflex artery was more frequently the culprit artery in group B (12.4% A vs 34.5% B vs 26.0% C; P<.001) and this group was also less likely to receive percutaneous revascularization (95.2% A vs 69.7% B vs 83.2% C; P<.001). The incidence of left ventricular systolic dysfunction was higher in group A and lower in group C (19.9% A vs 12.2% B vs 8.1% C; P<.001). The adjusted risk of IH mortality was significantly higher in group A when compared with group B (3.9% A vs 1.8% B; odds ratio, 2.34; 95% confidence interval, 1.34-4.07; P<.01) and in group B when compared with group C (1.8% B vs 0.9% C; odds ratio, 2.25; 95% confidence interval, 1.17-4.35; P=.02). OCA-NSTEMI patients had worse IH outcomes than non-OCA NSTEMI patients and better IH outcomes than STEMI patients, suggesting the existence of a continuum of increased risk of IH mortality across these groups.

LABOUR ANALGESIA BY NEUROAXIAL BLOCKADE TECHNIQUE AND ITS LABOUR OUTCOME

BACKGROUND:Pain relief during labour is an important component of modern obstetric care and can be produced by neuraxial, systemic or inhalational analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique.A good labour analgesia should aim at good pain relief during delivery process,at the same time not causing foetal acidosis,ensures safe for both mother and the baby. AIM OF THE STUDY:To study the influence of epidural analgesia on maternal and neonatal outcome MATERIALS AND METHODS:The study was conducted in the depar tment of Obstet r ics and Gynecology,GOVT.Stanley Medical College,Govt.RSRM LYING IN HOSPITAL,CHENNAI over a period of eight months from July 2019 to February 2021. The study was performed in 120 selected subjects. The study subjects were divided based on intervention – labour analgesia into 2 study groups. In this study,change in vital parameters,fetal heart rate,assessment of pain score,Duration of first and second stage of labour,mode of delivery,APGAR score and the need for NICU admission were noted and recorded.Any complications during the course of labour were also recorded. RESULTS:In this study,there was no significant difference in the mean duration of first and second stage of labour in both the study and control groups.The mean Apgar score of babies at one minute was 7.02 and at 5 minutes was 8.07 in the labour analgesia group and showed no significance.Maternal satisfaction for the effect of epidural analgesia,60.00% of the patients of epidural analgesia, the incidence of satisfactory/very satisfactory experience was meaningfully and significantly more in labour analgesia group subjects compared to control group subjects by 30 % with a 2 fold increase. CONCLUSION: As per this study labour analgesia using neuroaxial blockade technique are more likely to encounter increasing maternal satisfaction and good quality labour pain reduction.

Factors associated with non-survival from in-hospital maternal cardiac arrest: An analysis of Get With The Guidelines® (GWTG) data

IntroductionMaternal mortality has risen in the United States during the 21st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. ObjectiveWe sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. MethodsOur query of the American Heart Association’s GWTG®-Resuscitation voluntary registry from 2000–2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval. ResultsAmong 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16–2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00–5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15–3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20–0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673–0.757). ConclusionsOur study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.

Predictors of early and late re-hospitalization and mortality in non-ST elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Regarding prognosis, acute coronary syndromes (ACS) are heterogeneous. Non-ST elevation myocardial infarction (NSTEMI) is a subtype of ACS. In-hospital (IH) and post-hospitalization (PH) risk stratification is crucial. Objective To identify predictors of IH and PH mortality (early and late), as well as predictors of early and late re-admission (RA) in our center population suffering NSTEMI, using real-life data. Methods Based on a single-center retrospective study, data collected from admissions between 1/01/2018 and 11/12/2019. Patients (pts) who survived the ACS and were discharged from the hospital were included. Concerning prognosis, we assessed 1-month M and RA (1mM and 1mRA), 6-month M and RA (6mM and 6mRA), 1-year M and RA (1yM and 1yRA). Results 268 pts with ACS, 59.7% were males and mean age was 66.4 ± 12.5 years old. NSTEMI was the diagnosis in 66.4% and ST elevation myocardial infarction (STEMI) in 31%. Mean creatinine was 1.2 ± 1ml/min, mean sodium was 138 ± 3mmol/L, mean blood urea nitrogen (BUN) was 21 ± 12mg/dL and mean haemoglobin (Hb) was 13.6 ± 1.9g/dL. 88.2% of the pts presented in Killip-Kimball class (KKC) 1, 5.7% in KKC 2, 5.7% in KKC 3 and 0.4% in KKC IV; furthermore, 4.1% of the pts presented de novo AF. Concerning coronary artery disease, 250 were submitted to coronary angiography – 18.8% had no lesions or non-significant lesions (stenosis &amp;lt;50%), 34.8% had one significant lesion, 23.2% had 2 significant lesions and 23.2% had 3 or more. Regarding left ventricle (LV) function, 70.5% of the pts had no LV dysfunction, 15.7% had mild LV impairment (LVI), 9.3% moderate LVI and 4.5% had severe LVI. 8.4% of the patients experienced IH complications, such as auriculoventricular block, heart failure, ventricular tachycardia, stroke, cardiorespiratory arrest and major haemorrhage, during hospitalization. 1mM rate was 1.9% and 1yM rate was 7.8%. KKC (p = 0.001), BUN (p = 0.007), LV function (p= 0.001) and de novo AF (p = 0.46) were predictors of 1mM. Age (p = 0.004), KKC (p = 0.031), BUN (p = 0.002), sodium (p = 0.037), creatinine (p = 0.001), Hb (p = 0.003), LV function (p &amp;lt; 0.001), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p &amp;lt; 0.001) were predictors of 1yM. Age (p = 0.010), male gender (p = 0.19), Hb (p = 0.031), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p = 0.001) were predictors of 1mRA. Age (p = 0.004), smoking (p = 0.040), hypertension (p = 0.040), glycemia at admission (p = 0.031), Hb (p = 0.004), LV function (p = 0.019), de novo AF (p &amp;lt; 0.001) and occurrence of IH complications (p &amp;lt; 0.001) were predictors of 1yRA. Conclusion This study suggests that de novo AF and occurrence of IH complications are very important prognosis factors regarding early and late mortality and readmission rates.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Pediatric Extracorporeal Cardiopulmonary Resuscitation ELSO Guidelines.

Abstract 13466: Gender and Racial Disparities in Clinical Outcomes Among Patients With Preserved Ejection Fraction Heart Failure

Background: Heart failure is a chronic cardiovascular condition with associated high morbidity, mortality and health-related costs. The disparities of varying sociodemographic factors associated with clinical outcomes in patients with preserved ejection fraction heart failure (HFpEF) is yet to be extensively studied. Aim: To evaluate gender and racial disparities in length of hospital stay (LOS), cost of hospitalization, and in-hospital (IH) mortality in patients with HFpEF. Method: Adults (&gt;18 years) with a primary diagnosis of Acute on Chronic Diastolic dysfunction were identified from the 2016 and 2017 National Inpatient Sample using ICD 10 codes. The relationship between gender or racial groups (Non-Hispanic Whites (NHW)-Ref, Non-Hispanic Blacks (NHB), Hispanics, Asian/Pacific Islanders and Native Americans and study clinical outcomes were assessed using weighted multivariable logistic and linear regression models as appropriate. Results: Among patients with HFpEF (n=595,936), 59.8% were females; 73.4%, 15.6%, 6.6%, 1.9%, and 2.5% were NHW, NHB, Hispanics, Native Americans, and Asians/Pacific Islanders respectively. Females had lower IH mortality [adjusted OR (aOR) 0.9; 95% CI: 0.87 - 0.92) compared to males. Compared to NHW, NHB (aOR 0.81; 95%CI: 0.77 - 0.84) and Hispanics (aOR 0.91; 95%CI: 0.86 - 0.96) had lower odds of IH mortality, while IH mortality in Asian/Pacific Islander and Native American was not significantly different from NHW. Females had lower LOS (mean difference(mD) -0.34 days; 95%CI -0.38 to -0.30) and lower hospital cost (mD -$1967; 95%CI: -2097 to -1838) than males. NHB had similar rates of LOS (mD 0.04days; 95%CI: -0.02 - 0.11) and hospital cost (mD -$176; 95%CI: -412 - 60) compared to NHW. Hispanics had similar rates of LOS but higher hospital cost (mD 0.07 days; 95%CI -0.04 - 0.18; mD $1182; 95%CI: 754 - 1609), Asians/Pacific Islander (mD 0.32 days; 95%CI: 0.14 - 0.49, mD $2846; 95%CI 2173 - 3519) and Native American had a higher LOS and hospital cost compared to NHW (mD 0.49 days; 95%CI: 0.33 - 0.64, mD $2793; 95%CI: 2048 - 3539). Conclusion: Our study highlights racial and gender disparities in important clinical outcomes among patients with HFpEF, buttressing the need to tailor intervention to higher risk groups.

Abstract 286: Factors Associated with Non-survival From In-hospital Maternal Cardiac Arrest: An Analysis of Get with the Guidelines (gwtg) Data

Introduction: Maternal mortality has risen in the United States during the 21 st century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. Hypothesis: We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. Methods: Our query of the American Heart Association’s GWTG ® -Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of in IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm, and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Results: Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. In-hospital death was not associated with maternal age, race and year of event. In the final model (see table), IH death was significantly associated with prearrest hypotension/hypoperfusion (p=0.009). While MCA cases with a shockable vs non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (p=0.014). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Recovery Room (p=0.001) and ER/other (p= 0.012). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673-0.757). Conclusions: Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IHCA in this unique population.

Abstract 15559: In-hospital versus Out-of-hospital Cardiac Arrest in Patients Presenting to Cardiac Intensive Care Units: From the Critical Care Cardiology Trials Network (CCCTN) Registry

Background: Cardiac arrest (CA) is a common reason for cardiac intensive care unit (CICU) admission and is associated with considerable morbidity, mortality, and resource use. Aim: To describe characteristics and outcomes of pts presenting to contemporary CICUs with in-hospital (IH) or out-of-hospital (OH) CA. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter network of tertiary CICUs in North America (n=25). Participating centers contributed data from consecutive admissions during 2-month annual snapshots between 9/2017 and 8/2019 (n=8240). We analyzed characteristics and outcomes of pts with CA by IHCA vs OHCA. Results: Of 975 admissions with CA (48.9% OHCA), most were male (64.7%), Caucasian (63.4%) and smokers (60.6%). Acute coronary syndrome (ACS) was present in 30.6% and cardiomyopathy in 21.8%. Shockable rhythm was present in 54.1%, more commonly among those with reduced ejection fraction, ischemic cardiomyopathy, or ACS (p&lt;0.01 for all). Compared with IHCA, patients with OHCA were younger (median age 62 vs 66 years) and had fewer comorbidities including heart failure, atrial fibrillation, valvular disease, pulmonary HTN, and CKD (p&lt;0.01 for all). Pts with OHCA more commonly had shockable rhythms (58.3% vs 50.0%) and were more likely to be comatose at initial assessment (75.7% vs 40.4%); p&lt;0.01 for both. Resource use varied significantly between OHCA and IHCA [ Fig ] and CICU length of stay was longer for pts with OHCA (median 3.4 vs 3.1 days; p=0.049). In-hospital mortality was 41.2% and was higher in OHCA (44.7%) compared with IHCA (38.0%), p=0.03 [ Fig ]. Eventual discharge home or to rehab was more common among pts with IHCA (51.6% vs 49.1% for OHCA; p&lt;0.01). Conclusion: Despite advances in pre- and in-hospital care, pts presenting to contemporary CICUs with CA have high in-hospital mortality, with IHCA mortality only modestly lower than in OHCA. A better understanding of patterns may guide new approaches to improve patient outcomes.