Outpatient Follow-up Research Articles

From Acute Pancreatitis to Diabetes: Risk Factors and Timeline Analysis in a Pediatric Population Study

Abstract Objectives Identify the risk profile for post-pancreatitis diabetes mellitus (PPDM) in children after a single acute pancreatitis (AP) episode, investigate episode severity's association with complications, length of stay (LOS), and intensive care unit (ICU) needs. Methods This cross-sectional study used the Pediatric Health Information System database for patients ≤19 years old with index AP admissions (2011-2020). A query (2012-2021) was performed for diabetes mellitus (DM). Patients were excluded if they had prior DM or pancreatic surgery on or before AP or DM diagnoses. Results Out of 12,822 patients with index AP admissions (median age: 13.4 years, 54% female), 686 (5.4%) developed PPDM, 320 (2.5%) during and 366 (2.9%) at a later admission. The median collective time to PPDM during and after index AP admission was 1.9 months (IQR: 0-20.8). Patients with PPDM experienced extended LOS, heightened ICU needs, and increased complications such as sepsis, pancreatic necrosis, cyst formation, along with higher rates of organ dysfunction and comorbidities. Conclusions Children face DM risks during or following AP episodes. Enhanced DM screening is crucial for patients with existing comorbidities, local or systemic complications or organ dysfunction. Close outpatient follow-up within 3-6 months of discharge from an index AP episode is recommended.

Missing appointments in Parkinson´s Disease: A longitudinal study on the pattern of attendance and its effects on motor and non-motor symptoms, quality of life and disability progression

Background and purposeParkinson's Disease (PD) requires regular therapeutic adjustments and ongoing outpatient clinic follow-up. Nevertheless, the impact of appointment non-attendance on PD patients concerning the different symptomatic dimensions of the condition remains uncertain. We compared the level of attendance of PD and Essential Tremor (ET) patients and assessed the value of attendance variables as predictors of progression in cognition, motor dysfunction, affect, disability and health-related quality of life in PD. MethodsThe number of attended, no-shows and cancelled appointments of PD and ET patients were collected over 4 years. PD patients were assessed at baseline and 4 years later with the Non-Motor Symptoms Scale (NMSS), cognition (MoCA), disability (Schwab and England [S&E]), motor dysfunction (UPDRS-III), health-related quality of life measured with EQ-5D and hospital anxiety and depression scale (HADS). Linear regression (univariate) was used to test the correlation between the number of appointments (predictors) and absolute change in the NMSS, MoCA, S&E, UPDRS-III, EQ-5D and HADS. Results62 PD and 35 ET patients were assessed. PD patients attended more appointments (8,08 ± 3,13 vs 5,43 ± 2,09) and had a similar number of no-shows (0,39 ± 0,66 vs 0,46 ± 0,70) and cancelled (0,74 ± 0,88 vs 0,54 ±0,65) appointments than ET patients. In the univariate analysis there was a significant relation between the number of cancelled appointments and change in the S&E score (B=6375; p=0022). ConclusionOur findings suggest the number of cancelled appointments, but not no-shows, could be considered a predictor of disability progression in PD.

Abstract 4137919: Electrical Storm Caused by Chagasic Cardiomyopathy Successfully Treated with Ventricular Aneurysmectomy

Introduction: Chronic Chagasic cardiomyopathy (CCC) is a serious complication of Chagas disease that can manifest as LV dysfunction, ventricular aneurysms, and ventricular arrhythmias. Management of the electrical storm in CCC is challenging, especially when it is refractory to catheter ablation. Case Presentation: A 59-year-old woman from southern Peru presented to the ED with palpitations and dyspnea for 1 week. Physical exam was normal. ECG showed Q waves in III and AVF leads. TTE revealed an LVEF of 45% with an inferolateral LV aneurysm. Coronary angiography showed no lesions. CCC was suspected and serology was ordered, which was positive for T. cruzi . Cardiac MRI confirmed the presence of a 32x22mm basal inferolateral LV aneurysm. During hospitalization, she experienced 4 episodes of unstable monomorphic ventricular tachycardia (VT) within 24 hours, requiring defibrillation with 200J, vasopressor support, and invasive mechanical ventilation. The diagnosis of electrical storm secondary to CCC was proposed, for which amiodarone infusion was started until complete impregnation was achieved. Additionally, support was provided with IABP and specific antiparasitic treatment with benznidazole. Electrophysiology determined that the probable focus of the VT was situated at the level of the LV aneurysm. Therefore, ablation with endocardial-epicardial mapping was performed. However, the patient continued to experience recurrent episodes of VT. Consequently, in a multidisciplinary discussion, it was decided to perform a ventricular aneurysmectomy, which was successful. The patient's clinical progress was favorable, with initiation of GDMT and placement of a single-chamber ICD for secondary prevention. After one year of outpatient follow-up, the patient remains free of VT recurrences. Conclusion: Ventricular aneurysmectomy is a successful management approach for patients with CCC who present with electrical storm refractory to antiarrhythmic drugs and catheter ablation, and whose VT is believed to originate from the aneurysm. The diagnosis of CCC is highly arrhythmogenic and should be suspected at an early stage, given the patient's demographics and the presence of LV aneurysm in the absence of coronary artery disease.

ASSESSMENT OF NITRIC OXIDE METABOLISM, MALONDIALDEHYDE, SIALIC ACIDS , AND ENOS GENE VARIANTS (RS1799983) IN NEWBORNS WITH HYPOXIC-ISCHEMIC ENCEPHALOPATHY FOLLOWING L-CARNITINE ADMINISTRATION

In Ukraine, conditions arising during the perinatal period accounted for 57.9% of infant mortality under 1 year of age in 2021, compared to 55.6% in 2017. Hypoxic-ischemic encephalopathy (HIE) remains a leading cause of neurological complications and disability, particularly in low-income countries, where its incidence reaches 10-20 cases per 1,000 newborns. Despite advances in medical care, the risk of irreversible brain damage from HIE remains high. The processes associated with HIE are marked by oxidative stress and disrupted ionic homeostasis, leading to neuroapoptosis and necrosis of brain cells. Objective: to investigate metabolic changes in newborns with HIE by assessing nitric oxide, malondialdehyde, sialic acids, eNOS gene variants, and the impact of L-carnitine on metabolite concentrations. Materials and Methods. The study included 30 neonates. The main group consisted of 16 children with HIE, monitored in an outpatient follow-up clinic and receiving levocarnitine. The comparison group included 14 randomly selected relatively healthy neonates without HIE. Levels of nitrites, nitrates, malondialdehyde, and sialic acids in urine were assessed during the early neonatal period and at 6-9 months of age in children with HIE. In the comparison group, metabolite levels were measured at 6-9 months of age. Results. The study revealed increased nitrite (1.71 vs. 2.7; p=0.003) and nitrate (3.72 vs. 5.42; p=0.010) levels in newborns with HIE, indicating activation of nitric oxide metabolism. Malondialdehyde levels decreased following L-carnitine treatment, suggesting reduced oxidative stress. Genetic analysis showed a higher frequency of the 894GT genotype in the eNOS gene among newborns with reduced sialic acid concentrations (0.2 vs. 0.59; p=0.008). Conclusion. L-carnitine shows potential neuroprotective effects in the treatment of HIE by stabilizing mitochondrial function and reducing oxidative stress. Further studies are needed to optimize therapeutic strategies.

Atomized inhalation of indocyanine green in thoracoscopic surgery for intralobar pulmonary sequestration: a multicenter study

BackgroundInvestigate the safety and efficacy of preoperative atomization inhalation of indocyanine green (ICG) solution in precise lesion resection of pediatric thoracoscopic intralobar pulmonary sequestration.MethodsA multicenter 1:1 matched case-control study was adopted, to compare the safety and efficacy of the ICG group (preoperative atomization inhalation of 0.5 mg/kg ICG solution) with traditional group (no preoperative atomization inhalation of ICG solution). The baseline, intraoperative, and postoperative recovery conditions of the two groups were observed. Outpatient follow-up visits were conducted 3 to 6 months after surgery, including lung CT scans and pulmonary ventilation function tests.Results134 patients were included in the study. The ICG group included 67 patients, and the traditional surgery group included 67 patients matched at a ratio of 1:1 according to age and lesion location. There were no reports of deaths or adverse reactions. The postoperative chest drainage tube indwelling time [(53.19 ± 8.15) hours vs. (73.25 ± 15.51) hours, P < 0.001] and postoperative hospital stay [(4.81 ± 1.84) days vs. (6.72 ± 1.31) days, P < 0.001] were shorter in the ICG group than in the traditional group. More importantly, the postoperative pulmonary function in the ICG group was better than that in the traditional group. No residual lesions were found in the postoperative CT examination of both groups.ConclusionsThe innovative application of atomization inhalation of ICG provides the possibility for precise localization and lesion resection of pediatric thoracoscopic intralobar pulmonary sequestration. This maximizes the preservation of normal lung parenchyma, better improves postoperative pulmonary function, and shortens postoperative recovery time.

Cardiovascular sequelae in symptomatic SARS-CoV-2 infection survivors.

SARS-CoV-2 infection may lead to myocardial and endothelial damage. The present study sought to characterize the cardiovascular sequel in a large group of consecutive patients admitted for out-patient cardiovascular follow-up after a symptomatic COVID-19 infection. The aims of this study were as follows: to evaluate the presence of post-covid cardiovascular symptoms in an unselected population of outpatients referred to a post-COVID outpatient cardiology clinic and to characterize the long-term abnormalities associated with a more severe COVID-19 infection clinical course. A total of 914 patients were included in this single-center, observational, cross-sectional study, of which 163 were hospitalized and 149 required mechanical ventilation for COVID-19 pneumonia. Patients were analyzed at follow-up according to the care setting during the initial presentation. The median time to follow-up was 126 days. At that time, only 3.5% of patients reported no persistent dyspnea, chest pain, or fatigue on exertion. In a follow-up echocardiographic assessment, patients who required hospitalization showed slight alterations in the pulmonary acceleration time and the tricuspid regurgitation pressure gradient, as well as reduced exercise tolerance during treadmill exercise testing when compared to patients with a benign clinical course. 24-hour Holter EKG monitoring or 24-hour blood pressure monitoring did not identify significant differences between the analyzed subgroups. The current study reports on an association between COVID-19 severity and the presence of cardiovascular alterations at follow-up. A simple diagnostic protocol, comprising an exercise treadmill test and transthoracic echocardiography is useful in identifying patients who may benefit from regular, structured cardiovascular medical care.

The roles and patterns of critical care pharmacists: a literature review and practical operation model in China.

Drug-related problems (DRPs) are prevalent in critically ill patients and may significantly increase mortality risks. The participation of critical care pharmacists (CCPs) in the medical team has demonstrated a benefit to healthcare quality. Research indicates that CCP medication order evaluations can reduce DRPs, while their participation in rounds can reduce adverse drug events and shorten hospital stays. Pharmacist medication reconciliation often proves more effective than physicians, and CCPs play a crucial role in antimicrobial management and reducing treatment costs. Despite these benefits, there is a noticeable lack of practical guidance for implementing CCP roles effectively. Their workflow heavily influences the efficiency of CCPs. Integrating results from the literature with our practical experience, we have detailed workflows and critical entry points that CCPs can refer to. Pharmacists should be proactive rather than passive consultants. Pre-round medication order evaluations are crucial for determining the depth of a pharmacist's involvement in patient care. These evaluations should cover the following aspects: medication indication, dosage, treatment duration, detection of DRPs, implementation of therapeutic drug monitoring, dosing of sedatives and analgesics, and pharmaceutical cost containment. Beyond identifying medication issues, a primary task during rounds is gathering additional information and building trust with the medical team. Post-round responsibilities for CCPs include patient and caregiver education on medication, medication reconciliation for transitioning patients, and follow-up care for post-ICU patients. Establishing a rationalized and standardized workflow is essential to minimize daily work omissions and maximize the pharmacist's value. A multidisciplinary pharmacist-led team can significantly promote the rational use of antibiotics. Participation in post-ICU outpatient follow-ups can reduce drug-induced injuries after discharge. This review provides a detailed overview of the tasks performed by CCPs before, during, and after medical rounds, serving as a valuable reference for establishing an efficient workflow for CCPs.

Validation of British Society of Gastroenterology guidelines for acute lower gastrointestinal bleeding from 8,956 cases in Japan

Background and aimsWe sought to validate the British Society of Gastroenterology (BSG) guidelines for acute lower gastrointestinal bleeding (ALGIB). MethodsWe analyzed 8,956 patients with ALGIB in CODE BLUE-J study and categorized them into four groups based on BSG guidelines. Outcomes included 30-day rebleeding, 30-day mortality, blood transfusion, therapeutic intervention, and severe bleeding. ResultsThe severe bleeding rates significantly decreased from Group I to IV: 92.1%, 70.1%, 58.7%, and 38.4%. The rate of the need for blood transfusion and 30-day mortality also decreased from I to IV. Although outpatient follow-up was recommended in Group IV, it had high rates of severe bleeding (38%) and 30-day rebleeding (11%). Notably, for colonic diverticular bleeding, the rate of 30-day rebleeding was 25.5%, even with an Oakland score ≤ 8. We identified abdominal pain, diarrhea, and a high white blood cell count as independent factors that differentiate between non-severe and severe bleeding cases in Group IV. Using these factors, the 30-day rebleeding rate in the non-severe group was 3.6%, suggesting the feasibility of outpatient follow-up in this group. Furthermore, a novel, Group X, which deviated from the existing four groups, had a high severe bleeding rate (70.9%) comparable to that of Group II. ConclusionsThe BSG guidelines suggest a management approach that can clearly differentiate severity. However, caution is advised when using the Oakland score to triage patients for outpatient follow-up. Additionally, prompt intervention may be necessary for groups not covered by the guidelines.

Healthcare utilization among COVID-19 mRNA vaccine-associated myocarditis cases: a matched retrospective cohort study

ObjectivesWe evaluated all-cause healthcare utilization among those with vaccine-associated myocarditis, compared to vaccinees without postvaccination myocarditis. MethodsWe conducted a retrospective cohort study in individuals aged 12 and older who received COVID-19 mRNA vaccination in British Columbia. Exposure was defined as an ED visit or hospitalization for myocarditis within 21 days postvaccination. The primary outcome was healthcare utilization. Ratios of rate ratios (RRRs) for exposure-associated healthcare utilization were calculated using a difference-in-differences (DiD) analysis. ResultsIn the postindex period, the exposed and unexposed groups showed substantial utilization rate difference (RD = 15.30 [95% CI, 14.47-16.13). A 51% overall increase in healthcare utilization was observed over 18 months among exposed individuals (RRR, 1.51 [95%CI, 1.08-2.11]). In the initial six months, healthcare utilization surpassed the 18-month estimate, exhibiting a 125% increase (RRR, 2.25 [95%CI, 1.43-3.52]), while the last 12 months showed no statistically significant change (RRR, 1.03 [95%CI, 0.72-1.47]). An additional 9.1 (95%CI, 8.53-9.71) visits per person were attributed to vaccine-associated myocarditis over 18 months (total excess = 938.26 healthcare visits). ConclusionThe initial surge in healthcare visits postexposure, mainly outpatient follow-ups, followed by a return to baseline rates, indicates a positive prognosis and supports the vaccine's safety profile.

Cost Analysis of Oncological Outpatient Neurosurgery Under General Anesthesia with Hospital-At-Home-Based Postoperative Care

ObjectiveThis study evaluates the efficiency and cost-effectiveness of an oncological outpatient neurosurgery (OON) protocol using Enhanced Recovery After Surgery (ERAS) principles in a European healthcare setting. Additionally, it assesses the impact of incorporating Hospital at Home (HaH) for perioperative follow-up on program efficiency and costs. MethodsWe analyzed a case cohort of patients who underwent OON with HaH-based postoperative follow-up for tumor removal or biopsy at a tertiary care center since 2019. A control cohort treated under standard inpatient care was also examined. Costs associated with surgery and postoperative care were meticulously calculated for both groups. ResultsThe case (n=17) and control (n=38) cohorts had comparable demographics and clinical profiles. Surgical costs, including operating room, anesthesia, and surgeon fees, were similar across groups. However, post-operative monitoring was significantly shorter for the outpatient cohort, leading to reduced observation costs (p<0.001). While the duration of follow-up care was similar, outpatient follow-up via HaH was more cost-effective, reducing overall surgery costs by approximately €2958 per patient (p<0.001) compared to inpatient care. No significant differences were observed in costs related to treatment, radiology, or lab tests between groups. ConclusionsOutpatient neurosurgery with HaH follow-up offers substantial cost savings without compromising care quality in a public health setting. Inpatient care's higher costs are largely due to bed utilization, while the integration of HaH does not add significant costs, making it a viable alternative for postoperative management.

Patient-initiated follow-up supported by asynchronous telemedicine versus usual care in spondyloarthritis (TeleSpA-study): a randomised controlled trial of clinical and cost-effectiveness

With rising health-care expenditures and workforce shortages, sustainable alternatives to traditional outpatient follow-up strategies are required to optimise care efficiency. We aimed to investigate the cost-effectiveness and clinical effectiveness of patient-initiated follow-up (PIFU) supported by asynchronous telemedicine for patients with spondyloarthritis compared with usual care in daily practice. TeleSpA was a multicentre, pragmatic, open-label, randomised controlled trial. Patients with spondyloarthritis and stable disease were randomly assigned (1:1) to either the PIFU and asynchronous telemedicine group or usual care group. All patients received a scheduled outpatient visit at baseline and after 1 year. Patients were monitored remotely at 6 months (PIFU and asynchronous telemedicine) or at the discretion of the treating rheumatologist (usual care). The primary outcome was the number of rheumatology visits within a 1-year period. A trial-based 1-year health-economic evaluation from a Dutch health-care perspective (only including health-care costs) and societal perspective (also including travel costs and work productivity losses), per the Dutch guidelines was used to estimate cost-effectiveness. The safety analysis was done in the intention-to-treat population and was based on spontaneous reports of adverse events and serious adverse events or as observed by the research team. The primary analysis was in the intention-to-treat population. Individuals with relevant lived experience were involved in the study design. This trial was registered with the Dutch National Trial Register (NL71041.068.19) and ClinicalTrials.gov (NCT04673825) and is completed. Between Dec 2, 2020, and June 20, 2022, 200 patients were randomly assigned to PIFU and asynchronous telemedicine (n=100) or usual care (n=100). 79 (40%) of 200 participants were women, 121 (60%) were men, and the mean age was 55·0 years (SD 11·9). After 1 year, the mean number of rheumatology visits was 1·9 (SD 1·5) for the PIFU and asynchronous telemedicine group and 2·6 (1·3) in the usual care group (mean difference -0·7 [95% CI -1·0 to -0·3]; 25·4% reduction; p<0·0001). PIFU and asynchronous telemedicine was cost-effective from a health-care perspective, saving health-care costs (-€180 [95% CI -921 to 560]) without a loss in quality-adjusted life-years (0·004 [95 % CI -0·022 to 0·030]). Seven non-trial-related adverse events occurred in the PIFU and asynchronous telemedicine group and eight in usual care group (including one death). PIFU and asynchronous telemedicine resulted in significant and clinically meaningful reductions in rheumatology visits. This was not at the expense of health outcomes and saved health-care costs. Dutch Arthritis Society.

Synovial Chondromatosis of the Shoulder: Report of Two Cases.

Synovial chondromatosis is an uncommon, progressive, benign condition favoring synovial metaplasia resulting from the production of cartilaginous tissue as loose bodies within the joints. In rare cases, it can affect the interior of the shoulder joint and present with pain, edema, and impaired mobility. The diagnosis is challenging, requiring imaging techniques. Its confirmation often occurs only after surgical treatment and anatomopathological examination. The authors report two cases of patients with similar clinical presentations of pain, edema, and mobility loss in the shoulder joint. The investigation included imaging exams, such as radiographs and magnetic resonance imaging, and an anatomopathological examination confirming the diagnostic hypothesis. Arthroscopic surgical treatment with synovectomy and removal of loose bodies followed by physical therapy rehabilitation resulted in clinical improvement in both patients. This report emphasizes the importance of investigating suspected synovial chondromatosis due to its nonspecific clinical presentation. Comparing our outcomes with the literature, we concluded that surgical treatment with synovectomy, loose body removal, and physical therapy is effective, and that long-term outpatient follow-up is necessary to detect recurrence.

Portosinusoidální vaskulární choroba s portální hypertenzí – popis případu

Portosinusoidal vascular disease (PSVD) is a rarely recognized liver condition caused by the involvement of small hepatic vessels. The diagnosis is established based on a set of clinical and/or histopathological criteria, with the absolute requirement of excluding liver cirrhosis through biopsy. Clinically, PSVD often presents with complications related to portal hypertension, although not all patients exhibit these signs. This article discusses the case of a 71-year-old patient with known splenomegaly, which had not been fully investigated and lacked a hematological explanation. The patient was evaluated for severe symptomatic microcytic anemia, likely secondary to portal hypertension, despite the absence of overt bleeding symptoms. During hospitalization, ligation of large, high-risk esophageal varices was performed, and no other sources of anemia were identified. Pre- or post-hepatic causes of portal hypertension were ruled out. Liver elastography results were within normal ranges, and liver function tests were normal except for a marginal isolated elevation of gamma-glutamyltransferase. Liver function remained intact. Liver biopsy findings were consistent with a diagnosis of PSVD. The patient did not have any identifiable associated conditions and was not taking any medications known to pose a risk. Therefore, treatment was focused solely on managing the complications of portal hypertension. Outpatient follow-up included the eradication of esophageal varices. Treatment with oral iron supplements led to the normalization of hemoglobin levels, which remained stable for months after the discontinuation of therapy, and liver function tests continued to be normal.

Epilepsy in Loeys-Dietz Syndrome: The Rare Concurrence of a Connective Tissue and Neuronal Migration Disorder

We present a 7-year-old girl who presented to our emergency department in active status epilepticus. Seizures responded to standard antiepileptic medications; however, baseline work-up for seizure etiology remained unremarkable. Her new-onset seizures were further investigated via EEG and MRI brain, which revealed focal epileptiform discharges and periventricular nodular heterotopia, respectively. Concurrently, the clinical evaluation revealed extensive marfanoid features, and a personal history of eczema and asthma. Her family history was pertinent for aortic valve disease, asthma, and tall stature. Given the peculiar skeletal features, allergic propensities and coexistent weighty family history, a molecular genetic panel analysis for Marfan Syndrome and Loeys-Dietz Syndrome (LDS) were sought. Genetic testing revealed an underlying heterozygous variant in the TGFBR-1 gene; thereby confirming the presence of LDS. The child had responded well to single antiepileptic agent therapy and was discharged in good condition with regular outpatient cardiac and neurology follow-up. This is a unique case reported of a child with genetically diagnosed LDS concurring with an underlying neuronal migration disorder, manifesting in an acute, severe, and lifethreatening fashion.

MÚLTIPLOS ABSCESSOS ESPLÊNICOS EM PACIENTE COM CIRROSE HEPÁTICA NO AMAZONAS

A 38-year-old male patient with a diagnosis of liver cirrhosis for 5 years, irregularly treated with lactulose and furosemide, presented with fever, confusion, fatigue, jaundice, and ventilator-dependent pleuritic pain when seeking medical attention. Upon examination, he was lucid but exhibited slowed thinking, a sleep-wake cycle inversion, and flapping. The physical examination revealed edema in the lower limbs, jaundice, and pain in the left subcostal region. Due to the presence of decompensated cirrhosis, monitoring and diagnostic investigation for possible etiologies were initiated. Laboratory tests, ECG, chest X-ray, and echocardiogram were performed. A computed tomography (CT) scan revealed splenomegaly with regular contours and heterogeneous attenuation coefficients, showing hypodense, non-enhancing collections occupying the entire upper half, as well as a left pleural effusion and signs of chronic liver disease and portal hypertension. A transverse incision was made, revealing splenomegaly with the presence of thick fluid collections in the upper pole of the spleen, consistent with a diagnosis of splenic abscess. The patient progressed to hypovolemic shock and underwent reoperation after 72 hours for active bleeding control. Ciprofloxacin and clindamycin were administered for 28 days. The patient improved well after discharge from the ICU, with clinical and laboratory improvement. Follow-up was conducted with amoxicillin 250 mg for two years, and he continues outpatient follow-up with a gastroenterologist. Splenic abscess (SA) usually arises from endocarditis or other forms of hematogenous transmission, such as pneumonias, gastrointestinal perforations, or arteriovenous malformations. Although not always present, risk factors for the development of endocarditis include immunosuppression, diabetes mellitus, trauma, or microorganisms. Diagnosis is based on clinical findings and imaging studies (ultrasound and CT). Treatment depends on the number, size, and location of the abscesses. Antibiotic therapy can drastically reduce mortality associated with this condition, and percutaneous drainage has been successful. However, in some cases, splenectomy is necessary. Splenic abscess is a rare condition, and its early diagnosis requires a high degree of suspicion, and there is still no best approach for treatment.

Assessing one-year risk of heart failure following first time myocardial infarction and subsequent five-year mortality risk: a nationwide study of 34,401 patients

Abstract Introduction A comprehensive understanding of the post-myocardial infarction (MI) trajectory leading to heart failure (HF) and its profound impact on long-term mortality is imperative for effective secondary prevention and risk assessment. Methods We conducted a registry-based nationwide cohort study of all Danish patients with a first MI during 2014 to 2020. Excluding patients with prior HF, individuals were followed for one year post-MI, assessing HF incidence through hospital admissions and visits to elective HF ambulatory clinics. Among those who survived one year, long-term mortality 1-6 years post-index MI was assessed using landmark analysis and Cox proportional hazards models adjusting for age, gender and comorbidities and hazard. Patients were categorized into three groups: not HF, referred for elective HF outpatient follow-up, and acute admission for HF. Results Among 34,301 individuals with a first MI and surviving the first year (median age 67.5, and 66.9 % male), 3.3 % were admitted acute for HF while 11.2 % had an elective HF outpatient follow-up within one year of the MI event (see Figure 1a). We observed a significant association between acute HF admissions post-MI and increased five-year mortality risk (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.40-1.90, p-value &amp;lt;0.001, see Figure 1b) (absolute 5-year risk: 18.4 %). In contrast, the five-year mortality risk for patients with elective outpatient HF follow-up was comparable to that of individuals without HF (HR 1.06 [0.94-1.19], p-value 0.34) (absolute 5-year risk: 9.6 vs 8.5 %). Conclusion Our findings suggest that acute admission for HF after a first time MI occur in 3.3 % of the patients with a subsequent significantly increased mortality risk compared to patients that do not develop clinical HF. Admission for HF in patients with a first time MI should be considered as a relatively rare but fatal complication.

Direct annual healthcare costs in survivors of acute pulmonary embolism: estimates based on a prospective multicentre cohort study

Abstract Background Patients surviving acute pulmonary embolism (PE) necessitate long-term care and follow-up. However, the economic impact of PE on healthcare systems after the acute event remains largely unknown. Purpose To estimate the direct cost of PE during the first year after discharge from hospital for the index event, focusing on rehospitalizations, anticoagulant medication, and outpatient follow-up. Methods We analyzed the data from a multicentre cohort study of 1017 unselected patients with confirmed acute symptomatic PE in Germany. After the index episode, the costs of which were not considered, patients prospectively followed an outpatient visit plan at 3, 12 and 24 months. All rehospitalisations were documented with the main and accompanying diagnoses; hospital costs were calculated based on current reimbursement in the German Diagnosis Research Groups (G-DRG) system. The duration and type (central unique drug identifier) of anticoagulant treatment was documented at each visit. Per-patient costs of ambulatory follow-up visits and tests were calculated by multiplying (i) the costs of each visit/test (German ambulatory healthcare services reimbursement catalogue) by (ii) the probability π (0.0≤π≤1.0) of needing that specific service, based on the PE follow-up algorithm of the ESC Guidelines which we populated with the actual results per step in the present study (Figure). The primary analysis was conducted in all patients with ≥3-month follow-up. An additional sensitivity analysis included only the patients completing ≥12-month follow-up. We additionally identified the baseline predictors for the number of rehospitalizations and costs using multivariable zero-inflated Poisson and hurdle regression and accounting for censored data. Results Of 1017 enrolled patients, 958 (94%) were included in the primary analysis. Of them, 24% were rehospitalized, for a marginal mean of 0.34 (bootstrapped 95% CI: 0.30-0.39) readmissions per PE survivor. Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis) cancer, emerged as independent cost predictors by multivariable hurdle gamma regression (Table). Estimated overall rehospitalisation costs were €1138 (95% CI 896-1420) per patient (€1171 [908-1479] in the sensitivity analysis). Mean anticoagulation duration was 330 days, with estimated per-patient costs of €1050 (€1190 in the sensitivity analysis). Per-patient costs of ambulatory follow-up visits and tests were estimated at €182, yielding a total cost of illness per PE survivor of €2370-2543. For the entire country, the annual direct costs after acute PE would thus amount to €202-217 million. Conclusions By estimating per-patient costs and identifying major cost drivers of post-PE care, the present study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved overall cardiovascular prevention.TableFigure

Basal natriuresis as a predictor of diuretic resistance and clinical evolution in acute heart failure

Abstract Introduction Current clinical guidelines recommend serial measurement of natriuresis to detect diuretic resistance (DR) and to adjust the dose of furosemide in patients with acute heart failure (AHF) (1-5). However, multiple natriuretic dosages could make more complex the AHF management. Our objective was to correlate a single measurement of basal natriuresis (BN) on admission with the development of DR and cardiovascular (CV) events in patients hospitalized for AHF and during early outpatient follow-up (6-11). Methodology Prospective, multicenter study that included patients admitted to the coronary care unit (CCU) for AHF. Patients in shock or with creatinine &amp;gt;2.5 mg% at admission were excluded. Patients included received 40 mg of intravenous furosemide on admission, BN was measured in the first urination (the result was blinded to the treating physician), and subsequent diuretic treatment was guided by a pre-established protocol. The BN was considered low if it was &amp;lt;70 meq/L. The DR was defined as a combined endpoint composed of the requirement for intravenous furosemide ≥240 mg/day, tubular diuretic blockade (TB), hypertonic saline solution (HSS) or renal replacement therapy (RRT). In-hospital CV mortality was evaluated, as well as CV mortality and AHF readmissions at 60-day post-discharge follow-up. Results 157 patients were included, 56% men, with a median age of 74 years. The median BN was 103 meq/L (IQR 74-122), and BN was low in 22% of the cohort (N=34). DR was presented in 19% (N=30), 12.7% (N=20) required furosemide ≥240 mg/day, 8% (N=13) TB, 1 patient HSS and 4% (N=6) RRT. In-hospital CV mortality was 5.7%, CV mortality at 60-day follow-up 6.8%, and AHF readmissions at 60-day follow-up 12.2%. The group with low BN presented more DR (44% vs 12%; p 0.0001; RR 0.27; 95% CI 0.15-0.5), persistence of congestion at 48 hs (26.5% vs 11.4%; p 0.05; RR 0.48; IC 95% 0.22-1), administration of furosemide ≥240 mg/day (29% vs 8%; RR 0.27; 95% CI 0.12-0.61; p 0.003), more cumulative dose of furosemide at 72 hours (220mg [IQR 180-440] vs 160mg [IQR 100-180]; p 0.0001), use of TB (20.6 vs 4.9%; p 0.008; RR 0.23; 95%CI 0.08-0.65) and RRT (11.8 vs 1.6%; p 0.02; RR 0.14; 95%CI 0.02-0.72). Low BN was associated with in-hospital worsening of AHF (26.5% vs 9%; p 0.016; RR 0.34; 95%CI 0.15-0.74), inotropics use (21% vs 7%; p 0.048; RR 0.36; 95%CI 0.14 -0.88) or mechanical respiratory assistance (12% vs 2%; p 0.02; RR 0.14; 95%CI 0.02-0.72). Low BN presented higher in-hospital CV mortality (12% vs 4%; p 0.1), without association with endpoints in outpatient 60-day follow-up. Conclusions In patients hospitalized for AHF, low BN was associated with DR, persistence of congestion, need for more aggressive decongestion strategies, and a worse in-hospital clinical outcome

Effects of deferment of clinic visit on cardiovascular outcomes during COVID-19 outbreak: a prospective cohort study

Abstract Background Current guidelines recommend 3-6 months interval outpatient follow-up for patients with cardiovascular (CV) diseases and risk factors such as hypertension, diabetes mellitus (DM) and dyslipidemia. The impact of longer follow-up intervals is unclear. From 2020 to 2022, due to the infection control measures for COVID-19 pandemic, many patients voluntarily deferred their scheduled clinic visits. This provided us with an opportunity to study the impact of prolonged visit intervals on management CV risk factors. Purpose We aimed to investigate the impact of prolonged clinic visit intervals on CV outcomes and CV risk factor management among patients with CV diseases. Methods Patients with at least 1 CV risk factor (DM, hypertension, dyslipidemia, or a history of CV disease) were recruited from cardiology outpatient clinics from a tertiary teaching hospital from 2020-2022. Patients who opted to defer their appointment (Deferred group) were compared to those who attended their scheduled appointment (Normal group). The primary outcomes were composite major adverse cardiovascular events (MACE) of myocardial infarction, stroke, or CV-related death. The secondary outcomes were any unscheduled hospitalizations, suboptimal DM control (haemoglobin A1C &amp;gt;7%) or hyperlipidemia (LDL &amp;gt; 1.4 mmol/L). Results Out of the 455 patients recruited from outpatient clinics, 162 patients (35.6%) opted to defer their scheduled clinic visit (mean age 64.7 ± 12, 37.7% female), and 293 patients (mean age 64.5 ± 10, 36.2% female) continued to attend their appointments. The mean appointment interval was 226 days for the normal group and 582 days for the deferred group (p&amp;lt; 0.001). There was no significant difference in the primary outcome of MACE between the ‘Normal’ group and the ‘Deferred’ group (2.5% vs 0.6%, p=NS). The number of patients with suboptimal DM control (11.4% vs 21.9%, p = 0.029) was higher in the deferred group, whereas suboptimal hyperlipidemia (73.1% vs 77.1%, p=NS) was not statistically different. There were a total of 27 of unscheduled hospitalizations, among which the majority was for CV-related events (63.0%). Patients in the ‘Deferred’ group had higher rates of unscheduled hospitalization (12.3% vs 2.4%, p &amp;lt; 0.001) and higher rate of CV-related hospitalization compared to the ‘Normal’ group (6.2% vs 2.4%, p=0.041). Conclusion Our prospective data demonstrates that a prolonged clinic visit interval of more than 365 days was not associated with significant increase in adverse CV event or worsening of lipid control. However, prolonged clinic visit interval was associated with worse DM control and more frequent unscheduled hospitalization. More frequent medical contact might allow timely management of medical emergency at the outpatient setting and contribute to the lower rate of hospitalization in the routine follow-up group.

Influence of process-focused patient care on clinical outcomes among hospitalized heart failure patients in the cardiology ward

Abstract Background The implementation of a process-oriented organizational structure in patient care allows for a comprehensive and optimized approach. In the context of heart failure (HF), it remains uncertain whether the establishment of a specialized hospitalisation team can contribute to improved major clinical outcomes. Purpose To analyse the rates of all-cause hospitalisation, cardiovascular hospitalization, HF hospitalization and overall mortality at 180 days among patients admitted to the Cardiology ward for HF, both prior to and after the implementation of a specialized HF hospitalisation team. Methods The study included all patients discharged from the Cardiology department with HF as the primary diagnosis and subsequent outpatient follow-up by the Community HF Unit in both 2019 and 2022. Clinical outcomes were compared between two distinct periods: the pre-implementation year of 2019 and the subsequent year of 2022, characterized by process-oriented HF care. Statistical analyses were performed using Kaplan-Meier and adjusted Cox proportional-hazards models. Results A total of 140 patients were enrolled in the study, comprising 55 individuals receiving care from a conventional ward team in 2019 and 85 under the specialized HF team in 2022. The mean age of the cohort was 69.4 years (+/-11.8), with a mean LVEF of 40.6%. The pre-implementation group showed a higher percentage of male patients (73% vs. 47%; p=0.003) and LVEF was lower in the HF team period (38.9% vs. 43.4%; p=0.045), with no statistically significant differences in other baseline variables. As shown in figure 1, over 180 days of follow-up, 15 patients (27.6%) were admitted to hospital in the conventional ward team period and 13 (15.3%) in the HF team period (hazard ratio [HR] 0.44; 95% confidence interval [CI] 0.19 to 0.99; P=0.047). Of these hospitalisations, 13 patients (23.6%) in pre-implementation period and 10 (11.8%) in post-implementation period were attributed to cardiovascular events (HR 0.40; 95% CI 0.16 to 0.99; P=0.049). Additionally, there was a reduction in the rate of heart failure admissions in the post-implementation period compared to the pre-implementation time (HR 0.30; 95% CI 0.09 to 0.94; P=0.039). Furthermore, a significant decline in all-cause of death was observed in patients treated by HF-team in 2022 compared to patients receiving care from the conventional ward team (log-rank test, p=0.015). Conclusions The implementation of a process-oriented organizational model within the Cardiology unit consisting in the provision of patient care by a team specialized in HF management, is associated with a statistically significant reduction in major clinical outcomes such as all-cause hospitalization, cardiovascular hospitalization and HF readmission, alongside a reduction in overall mortality rates at 180 days.