Outpatient Program Research Articles

Buprenorphine/naloxone initiation in the emergency department: a series of vignettes

BackgroundOpioid drug overdose deaths are at an all-time high. Buprenorphine, a medication used to treat opioid use disorder, has dramatic effects on mortality after overdose as well as engagement with outpatient treatment programs. Recent regulatory changes have eased barriers to prescription, yet buprenorphine is infrequently prescribed from the emergency department. Objectives: Emergency physicians see patients who would benefit from this medication on a regular basis. We aim to illustrate how buprenorphine can be initiated from the emergency department. DiscussionUsing a series of six cases, the use of buprenorphine for common presentations of patients with opioid use disorder (OUD) is described. ConclusionsWe present a series of clinical vignettes in order to increase emergency physicians’ familiarity and comfort with the use of buprenorphine/naloxone in the treatment of OUD. Patients with OUD treated with buprenorphine/naloxone are less likely to die from overdose and more likely to engage in long-term treatment. Emergency departments are well suited to initiate buprenorphine/naloxone for patients who are ready for change and eligible for medications for OUD. Now that barriers to prescribing have been removed, emergency clinicians should seek out patients with opioid use disorder who may benefit from this life-saving treatment, initiated either in the ED or at home.

Changes in cognitive functional performance and basic activities of daily living in patients with traumatic brain injury after two methods of cognitive retraining

Introduction: Evidence supports a bottom-up approach to assist in addressing functional cognitive deficits in patients with traumatic brain injury (TBI). There is however, little evidence supporting the use of online programmes for this purpose. The aim of this research was to describe the outcomes for cognitive functional performance and basic activities of daily living (bADL) or self-care functioning after cognitive retraining using an online programme versus task-oriented intervention for patients with acute mild and moderate traumatic brain injury (TBIs). Methods: A quantitative, quasi experimental, longitudinal research design was used for determining within-group and between-groups changes for cognitive functional performance and bADL functioning in two sample groups with mild to moderate TBI. Intervention using an online programme (n=7) or task-oriented activities (n=15) was evaluated at three assessment intervals: on recruitment into the study (Assessment 1), on completion of inpatient hospital intervention (Assessment 2) and after four weeks of home programme intervention and fortnightly outpatient intervention (Assessment 3). Results: Results for both groups showed a statistically significant change for cognitive functional performance assessed on the Bay Area Functional Performance Evaluation (BaFPE) while the task-oriented cognitive training group also achieved a statistically significant change in bADL scores during the first inpatient assessment period. Only the online programme group had statistically significant improvement during the home programme in the third assessment period. Conclusion: Cognitive retraining using an online programme or task-oriented activities resulted in positive change in a therapist directed inpatient programme but a structured, graded, online programme was more effective in supporting significant improvement in cognitive functional performance when used with an outpatient home programme. Implications for practice Cognitive retraining using an online programme or task orientated activities have a positive outcome for cognitive functional performance in patients with mild or moderate TBI in a therapist directed inpatient intervention. A task orientated approach for cognitive retraining appears to have positive effect on bADL outcomes. Cognitive retraining using an online programme intervention should be considered as a home programme to improve cognitive functional performance in patients with mild or moderate TBI.

Comorbid treatment of traumatic brain injury and mental health disorders.

The Emory Healthcare Veterans Program (EHVP) is a multidisciplinary intensive outpatient treatment program for post-9/11 veterans and service members with invisible wounds, including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), substance use disorders (SUD), and other anxiety- and depression-related disorders. This article reviews the EHVP. The different treatment tracks that provide integrated and comprehensive treatment are highlighted along with a review of the standard, adjunctive, and auxiliary services that complement individualized treatment plans. This review particularly emphasizes the adjunctive neurorehabilitation service offered to veterans and service members with a TBI history and the EVHP data that indicate large reductions in PTSD and depression symptoms across treatment tracks that are maintained across 12 months follow up. Finally, there is a discussion of possible suboptimal treatment response and the pilot programs related to different treatment augmentation strategies being deploying to ensure optimal treatment response for all. Published data indicate that the two-week intensive outpatient program is an effective treatment program for a variety of complex presentations of PTSD, TBI, SUD, and other anxiety- and depression-related disorders in veterans and active duty service members.

Worsening sleep predicts next-week suicidal ideation in a high-risk adolescent outpatient treatment sample.

Suicidal thoughts and behaviors often onset during adolescence, constituting a major public health concern. Despite rising rates in youth, psychotherapeutic and pharmacological treatment outcomes remain meager, indicating a need to identify modifiable risk factors. Experts suggest sleep may serve as a promising clinical indicator of risk and treatment progress, yet few studies have examined acute temporal associations between sleep and suicidal ideation. Participants were depressed and suicidal adolescents (age 13-19, n = 311) attending an intensive outpatient program (IOP). Patients completed weekly self-report assessments of sleep, depression, and suicidal ideation throughout IOP, with an average of 5 assessments over 30 days. Greater overall sleep difficulties, as well as within-person increases in sleep difficulties, were predictive of greater depression severity and suicidal ideation at subsequent assessments, above and beyond previous levels of symptoms. The reverse associations were not found. Inclusion of within-person changes in sleep difficulties significantly improved model fit compared to inclusion of overall sleep difficulties alone. This study provides additional evidence for a prospective relationship between worsening sleep difficulties and suicidal ideation in an IOP youth sample. Worsening sleep may be an important clinical indicator of subsequent depression and suicide risk among adolescents in treatment.

Prehabilitative/rehabilitative exercise, nutrition, and psychological support for bladder cancer: A scoping review of randomized clinical trials.

The study of prehabilitation and rehabilitation ([p]rehabilitation) to alleviate the sequelae of bladder cancer and its treatment has generated numerous opportunities to improve the quality of life of bladder cancer survivors. The authors conducted a scoping review of randomized clinical trials (RCTs) to identify knowledge gaps in and research directions for (p)rehabilitative support for those affected by bladder cancer. The authors systematically searched six databases and synthesized key findings from RCTs conducted from January 1, 2004, through March 15, 2022, that enrolled participants with bladder cancer, survivors, or caregivers in outpatient (p)rehabilitative programs (e.g., exercise, nutrition, or psychological support). Outcomes were characterized according to eight prespecified, clinically relevant categories. The search retrieved 10,968 records, 27 of which met the inclusion criteria, and 24 described unique RCTs with 2471 enrolled participants. Of 24 interventions, 17 (71%) yielded statistically significant results for the outcome of interest. Only one RCT included a cost-effectiveness analysis, and only two characterized the efficacy of interventions for caregivers. Of 11 RCTs involving psychological support, eight yielded statistically significant results, as did nine of 11 RCTs with physical exercise interventions, three of four RCTs with educational interventions, three of four RCTs with nutritional support interventions, one of two RCTs with pharmacologic medications, and zero of one RCT with physical therapy. The most promising interventions for inclusion in multimodal, personalized (p)rehabilitation programs included exercise, stress management training, cognitive training, smoking and alcohol cessation counseling, immunonutrition, stoma education, and penile rehabilitation. Further studies of the cost effectiveness and efficacy for caregivers of such interventions are needed. PLAIN LANGUAGE SUMMARY: In a scoping review of all randomized clinical trials involving prehabilitative or rehabilitative diet, exercise, and psychological support interventions for patients with bladder cancer, survivors, and their caregivers, 17 of 24 (71%) interventions yielded statistically significant improvements in the outcome of interest. Clinicians should consider implementing such interventions for those affected by bladder cancer.

Outpatient management of patients conditioned with Fludarabine and Treosulfan prior to allogeneic hematopoietic cell transplantation

BackgroundAllogenic hematopoietic cell transplantation (allo-HCT) with myeloablative conditioning traditionally requires 30 days long hospitalizations after stem cell infusion. However, advancements in supportive and prophylactic care have allowed for a trend towards outpatient management of allo-HCT, potentially leading to improved patient quality of life and increased procedure cost-effectiveness. In 2014, Fludarabine and Treosulfan (FluTreo) conditioning was introduced as a myeloablative regimen with reduced toxicity at Copenhagen University Hospital, Rigshospitalet (CUH). After gaining experience with the regimen, an outpatient program was established. This study shares the outcome of outpatient conditioning with FluTreo allo-HCT at CUH. ObjectiveTo investigate safety and feasibility of outpatient FluTreo allo-HCT. Furthermore, to investigate the potentially enhanced cost-effectiveness of outpatient allo-HCT primarily through reduction in hospitalization days compared to the 30 days hospitalization associated with standard myeloablative conditioning. Study designThis retrospective study included all patients undergoing FluTreo allo-HCT due to malignant diseases (n = 124) at CUH from 2018 to 2022. Patients received outpatient treatment (n = 91) unless certain circumstances required planned hospitalization (n = 33). As conditioning, patients received intravenous Fludarabine 90 mg/m2 and Treosulfan either 30 or 42 g/m2. Statistical analyses included descriptive statistics and Kaplan Meier survival analysis. ResultsThe median duration of hospitalization in the outpatient group was 4 days (Q1-Q3 0-12.5) from day -6 to +28 compared to a median of 28 days (Q1-Q3 26-34) in the inpatient group. 32 (35%) in the outpatient group did not require hospitalization within day +28 after transplantation. The remaining 59 patients (65%) were hospitalized after 12 days (Q1-Q3 7-16 days) from start of conditioning, for a median of 10 days (Q1-Q3 5-18). The outpatient group required significantly less IV antibiotics, IV opioids and parenteral nutrition than the inpatient group, despite no difference in treatment toxicity, acute graft-versus-host disease, or relapse between the groups. The outpatient group experienced no early deaths during the first 3 months after transplantation and 1-year non-relapse mortality was 6%. ConclusionOutpatient allo-HCT with FluTreo conditioning is feasible and safe in a selected group of patients, significantly reducing hospitalization days without compromising patient outcomes. Outpatient FluTreo allo-HCT potentially stands as a more cost-effective and patient-friendly alternative compared to traditional in-patient management.

Effects of E-Cigarettes on Combustible Cigarette Smoking Among Adults with Opioid Use Disorder on Buprenorphine: Single Arm ERASER Pilot Trial.

People with opioid use disorder (OUD) on buprenorphine smoke at high rates and have low cessation rates, even with evidence-based medications. Electronic cigarettes (EC) are a promising harm reduction strategy for combusted cigarette (CC) smokers unable to quit. Unfortunately, people with OUD are underrepresented in EC research. A pilot study assessed the feasibility, acceptability, and preliminary effectiveness of EC as a harm reduction tool among CC smokers with OUD on buprenorphine (N=30). Participants were provided with an EC and freebase nicotine liquid (6mg/mL) with a choice of flavor, and a brief training session. Research visits were scheduled in-person at baseline, week 4, and week 8 (follow-up). Daily diary assessments were completed during the 4-week EC period. Most visits (>74%) and 61.4% of daily diary assessments were completed. During the 4-week study period, 90% of participants used the EC at least one day, 66.7% used the EC for at least 16 days, and 43.3% used the EC every day. Significant reductions were observed between baseline and both weeks 4 and 8 in cigarettes smoked per day (CPDbaseline=16.2(8.3), CPDweek4=9.6(9.3), CPDweek8=8.4(8.3)) carbon monoxide (CO) levels (CObaseline=21.5(15.0), COweek4=16.9(9.6), COweek8=15.7(10.0)), and nicotine dependence measured using the Fagerström Test for Nicotine Dependence (FTNDbaseline=5.4(2.5), FTNDweek4=4.2(2.6), FTNDweek8=4.4(2.6))), with all p-values<.05. Implementing an EC protocol in outpatient maintenance treatment programs is feasible and acceptable. Preliminary results suggest that ECs may facilitate reductions in CPD, CO levels, and nicotine dependence. Future research should explore the effect of prolonged EC use on harm reduction and cessation milestones. EC are a potentially promising harm reduction strategy for adult CC smokers with OUD on buprenorphine who are unable to quit using evidence-based medications. However, previous studies have largely overlooked people with OUD on buprenorphine with recent drug use. This study addresses this gap through a pilot trial investigating the feasibility, acceptability, and preliminary effects of EC on CC behavior. The brief and standardized nature of the protocol and its implementation in outpatient settings highlights its potential for widespread implementation in facilities providing care to people with OUD on buprenorphine.

The Effect of Outpatient Rehabilitation Program on the Quality of Life of Drug Abuse Patients in the National Narcotics Agency of North Sumatra Province in 2023

Improving outpatient rehabilitation enhances the lives of those battling substance abuse. This study evaluates its impact at the National Narcotics Agency, North Sumatra. The study aims to assess outpatient rehabilitation's effectiveness on individuals with substance abuse history, focusing on physical health, psychological well-being, social support, and the environment. Using quantitative methodology with pre-post design, the entire patient population (n=54) was included. Research findings reveal significant and positive impacts of the rehabilitation program on physical health, psychological well-being, social support, and patient environmental conditions. Statistical analysis, with a significance level of (p &lt; 0.001), confirms the remarkable success of the intervention, emphasizing the crucial role of the program in enhancing the overall quality of life for patients. This study delves into outpatient rehabilitation program effectiveness, highlighting the need for multidimensional support in the recovery journey.

CHARACTERIZATION OF BASELINE SYMPTOMS AND FUNCTIONAL IMPAIRMENTS IN A LARGE COHORT OF OUTPATIENTS ATTENDING A LONG COVID REHABILITATION CLINIC IN THE UNITED KINGDOM.

In response to the high prevalence and morbidity associated with long COVID (LC), outpatient rehabilitation programmes were created across jurisdictions. We aimed to characterize baseline symptoms and impairments of patients attending outpatient LC rehabilitation. This study was a retrospective quality-improvement analysis. Patients attending outpatient LC rehabilitation at the Oxfordshire Post-Covid Service. Data included age/sex and 6 questionnaires performed at baseline: Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Dyspnoea-12 (D12), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Assessment-7 (GAD-7), Visual Analogue Scale (VAS) of self-rated health, and the Work And Social Adjustment Scale (WSAS). All scores were dichotomized (indicating presence/absence of clinically significant pathology). Potential differences between age (</≥ 50 years) and sex were assessed using χ2 tests. A total of 422 patients were included (mean/standard deviation [SD] age = 47.1/13.2;132/31.3% male). A total of 76% had significant fatigue (FACIT-F), 69% had breathlessness (D12), 55% had depression (PHQ-9), 34% had anxiety (GAD-7), 41% self-reported poor health (VAS), and 57% had work/social life dysfunction (WSAS). D12 scores differed between age groups (older > younger, χ2 = 3.19/p = 0.048), with no differences observed on other scales. In this preliminary study, a high proportion of LC outpatients had significant impairments across domains. The findings of this study reaffirm the need for high-quality, multidisciplinary LC rehabilitation, and may be used to help build a standardized set of outcome measures moving forward.

Massed treatment of posttraumatic stress disorder, traumatic brain injury, and co-occurring conditions: the Home Base intensive outpatient program for military veterans and service members.

The two-week Home Base Intensive Clinical Program (ICP) provides treatment to veterans and active duty service members suffering from primary diagnoses of posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), anxiety, or depression. First launched in 2015, this paper provides a programmatic update, including new treatment components implemented since inception, and examines outcomes for all participants who entered the program from September 2015 to July 2024 (n = 2561). The Home Base ICP provides a massed care approach through daily individual Prolonged Exposure, Cognitive Processing Therapy, Unified Protocol, or cognitive rehabilitation, along with groups targeting coping skills. Participants entering the program are provided with core group programming, as well as individualized therapy sessions tailored to their unique needs and symptom presentation. Supplemental dual recovery support is also available for all participants with co-occurring substance use or behavioral addiction concerns. Participants' support people receive education, support, and case management services. Participants have a multidisciplinary team comprising therapists, psychopharmacology providers, case managers, nurses, and wellness providers. Results demonstrate that program participants exhibited statistically significant reductions in PTSD symptoms (Cohen's d = 0.80), depression (d = 0.68), post-concussion symptoms (d = 0.71), and increased satisfaction in social roles (d = -0.65). Completion rate was 94.60% (n = 2422), suggesting that the Home Base ICP is a well-received and effective model of care for veterans and service members.

Impact of a clinician-to-clinician electronic consultation program in heart failure patients with previous hospitalization. Implications for heart failure multidisciplinary management

Abstract Background A clinician-to-clinician electronic consultation (e-consultation) programme may not only improve the accessibility to care but may also impact patient outcomes, particularly in heart failure (HF) patients with a previous episode of hospitalization (HFH), group of patients associated with a worse outcome. Purpose To evaluate the impact of an outpatient care management programme that includes a clinician-to-clinician e-consultation on delay time in care, hospital admissions, and mortality in a high-risk group of patients with heart failure (HF) and previous episodes of HF hospitalization (HFH). Materials and methods We selected 6444 HF patients who visited the cardiology service at least once between 2010 and 2021. Of these, 4146 were attended in e-consultation, and 2230 had previous HFH (Fig 1a). Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the healthcare model in the group of patients with HFH and evaluated the elapsed time to cardiology care, HF, cardiovascular (CV), and all-cause hospital admissions and mortality, calculating the incidence relative risk (iRR). We performed a multivariate logistic regression for each of these outcomes in both groups. Results Patients with HFH had a higher prevalence of men (P &amp;lt; 0.001) but had a similar age (P = 0.267) compared to patients without HFH. Patients with HFH had a higher prevalence of diabetes (P &amp;lt; 0.001), ischaemic heart disease (P = 0.036), and peripheral arterial disease (P = 0.008) (Fig 1b). In the group of patients with HFH, the introduction of e-consult substantially decreased waiting times to cardiology care (8.6 [8.7] vs. 55.4 [79.9] days, P &amp;lt; 0.001) (Fig 2a). In that group of patients, after e-consult implantation, hospital admissions for HF were reduced (iRR [95%CI]: 0.837 [0.840–0.833]), 0.900 [0.862–0.949] for CV and 0.699 [0.678–0.726] for all-cause hospitalizations (Fig 2b). There was also lower mortality (iRR [95%CI]: 0.715 [0.657–0.798] due to HF, 0.737 [0.764–0.706] for CV and 0.687 [0.652–0.718] for all-cause) (Fig 2c). The improved outcomes after e-consultation implementation were significantly higher in the group of patients with previous HFH. The multivariate analyses showed a higher risk of hospitalizations in men, patients with HFH, and those who required more emergency department assistance (Fig 2d). Conclusions In patients with HFH, an outpatient care programme that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year. Our results may have implications for optimize the heart failure care organization.Figure 1Figure 2

A randomized controlled trial of an eight-week cardiac rehabilitation home verse hospital exercise programme for post coronary cardiac bypass patients

Abstract Background The prevalence and morbidity and mortality rates of coronary heart disease (CHD) continue to increase towards epidemic proportions in the Kingdom of Saudi Arabia (KSA). Despite the advances in Cardiac surgery, currently there are no established out-patient phase program of Cardiac Rehabilitation (CR) for CHD participants in KSA. Aim of the study To evaluate the effectiveness of a home-based CR (Home CR) program using individualized exercise (Physiotools-R) and out-patient phase of CR (Hospital CR) program compared to standard care of home instructions on physical function, physiological and psychological status, body composition and the quality of life of the CHD participants post Coronary Artery Bypass Graft (CABG) surgery. Methods 73 participants post-CABG surgery were randomly assigned to one of three groups: Hospital CR group (n=25), Home CR group (n=24) and Control group (n=24). Outcome measures include Incremental Shuttle Walk Test (ISWT), Metabolic Equivalent Tasks (METs), Psychosocial outcomes and body composition were recorded at baseline, eight weeks of CR intervention, and after four weeks of observation follow up. Intervention: Hospital CR program comprised of group based Aerobic Circuit Training, home based structured individualized exercise program. Each programme had 2 hours’ sessions, 3 times a week for 8 weeks, followed by four weeks of observation follow-up. The control group followed standard care comprised usual advice on post-operation precautions. Results Post intervention, there was an increase in mean ISWT score from baseline in both the home-based cardiac rehabilitation and outpatient-based cardiac rehabilitation groups (66 [0.58] m and 71 [9.19] m, respectively). No difference was observed in the control group. At the 4-week follow-up, both intervention groups showed statistically significant improvements in all outcome measures (ISWT, metabolic equivalence tasks, HADS-A, HADS-D, and Short Form-36) compared with baseline (all P &amp;lt; .001). The home-based cardiac rehabilitation group showed statistically continuous improvement compared with the outpatient-based cardiac rehabilitation group. The control group did not show any significant changes across time in outcome measures Conclusion Home-based CR is as effective as hospital-based CR at improving exercise capacity in patients following CABG surgery. Home-based CR appears to be more effective at maintaining these improvements with no further input in the longer term.

The impact of childhood abuse on future military sexual assault and PTSD symptomology in Australian veterans.

The trauma most commonly associated with the military is combat-related trauma. It is increasingly recognised that childhood sexual and physical abuse and military sexual assault may influence or exacerbate posttraumatic stress disorder (PTSD) when military members are exposed to combat. The study aimed to determine whether a history of childhood sexual and physical abuse would increase the likelihood of military sexual assault (MSA) and determine whether a history of sexual abuse (childhood or military) impacted the incidence and severity of post-trauma sequelae compared to veterans without this history. A retrospective correlational analysis was performed on baseline data collected from clinical case records of a cohort of 134 Australian veterans with PTSD who had attended an outpatient Military Service Trauma Recovery Day Programme between October 2020 and May 2022. Almost half (48.5%) of veterans reported a history of abuse. Prevalence rates of military sexual abuse, child sexual abuse and child physical abuse were 14.9%, 13.4% and 23.1% respectively. The relationship between those who experienced childhood abuse and those who experienced military sexual abuse was not significant. No significant differences were observed between those who experienced any sexual abuse and those who did not on intake scores of psychological symptoms. This is the first Australian study to investigate the prevalence of childhood abuse and military sexual abuse and its impact on PTSD and associated psychopathology in a sample of veterans seeking mental health treatment. No additional risks of experiencing military sexual assault were found for those who had survived childhood sexual abuse.

C-Reactive Protein-to-Serum Chloride Ratio: A Novel Marker of All-Cause Mortality in Maintenance Haemodialysis Patients

Background and Objectives: hypochloremia is an emerging risk factor for mortality in patients with chronic kidney disease. The pathophysiological mechanisms of this finding are not very clear. Some studies suggest the influence of inflammation as a synergistic factor, so we set out to analyse the association of a novel C-reactive protein-to-serum chloride ratio (CRP/Cl−) with the prognosis of maintenance haemodialysis patients and to assess its relationship with fluid status and body composition measured by bioimpedance. Materials and Methods: the present work is a retrospective cohort study of maintenance haemodialysis patients from our chronic outpatient haemodialysis programme between 1 January 2022 and 31 December 2022. (n = 281). Survival time was collected for all patients and analysed using the Kaplan–Meier method. A Cox proportional hazards regression model was used to evaluate survival probabilities. Variables included in the model were selected using a stepwise selection procedure based on the corrected Akaike information criterion (AICc), which balances model fit and complexity. Results: during a median follow-up of 306 days, 34 patients died. Patients in the fourth quartile of the CRP/Cl− (&gt;0.118 mg/mEq) had higher overall mortality (log-rank test, p = 0.0011). In the Cox multivariate analysis, the variables significantly associated with higher mortality were higher modified Charlson index (MCI), lower body surface area (BSA), lower interdialytic weight gain (IDWG), and higher CRP/Cl− ratio. The latter variable was independently associated with higher overall mortality (adjusted hazard ratio = 1.027; 95% confidence interval [CI], 1.000–1.055 p = 0.0469). Conclusions: Higher CRP/Cl− ratio values were associated with higher all-cause mortality in our maintenance haemodialysis patients.

Sex-specific guideline target value attainment and prognostic value of low-density lipoprotein cholesterol in tertiary care

Abstract Background Factors contributing to guideline-target-level-attainment of low-density lipoprotein cholesterol (LDL-C) in countries with high healthcare expenditure are incompletely understood. Purpose the primary aim of this study was to test two hypotheses: 1) LDL-C control may be inferior in women versus men; 2) within the secondary prevention group, presence of a previous acute atherothrombotic event (acute myocardial infarction and stroke) may result in superior LDL-C control. Methods LDL-C levels and guideline target level attainment were determined in 4090 consecutive patients referred for myocardial perfusion single photon emission tomography (MPI-SPECT) between 2010 and 2016. Findings were validated in an independent cohort (n=1228) of consecutively enrolled patients in an outpatient cardiac rehabilitation program, between 2016 and 2023. Results About one third of patients (33%) were women, median age was 68 years, 1439 patients had a history of atherothrombosis, 759 patients a history of atherosclerosis without atherothrombosis, and 1892 were in primary prevention. LDL-C levels were higher and guideline target level attainment worse in women than in men in all three strata: age-adjusted difference in atherothrombosis 0.19 mmol/L (95%CI 0.03,0.35 mmol), guideline-target-value-attainment 39.5 % versus 49.4%, p&amp;lt;0.01; in atherosclerosis 0.33 mmol/L (95%CI 0.10-0.57), guideline-target-value-attainment 27.3 % versus 42.2 %, p&amp;lt;0.01; and in primary prevention 0.24 mmol/L (95% CI 0.13-0.38). This was confirmed in the validation cohort. LDL-C levels were higher and guideline-target-value-attainment worse in women versus men: age-adjusted difference age-adjusted difference 0.17 mmol/L (95%CI 0.02-0.33) guideline-target-value-attainment 43.8% versus 49.5%, After multivariate adjustment, female sex remained an independent predictor for higher LDL-C levels. LDL-C concentrations with atherothrombosis was 1.93 mmol/L (IQR 1.48-2.47) versus 2.07 mmol/L (IQR 1.40-2.72, p=0.003) with atherosclerosis and guideline target value attainment 47.5% vs 38.6%, p&amp;lt;0.001, respectively. Conclusion Concerning age-adjusted sex-inequalities with higher LDL-C levels and lower guideline-target-value-attainment in women were found in both primary and secondary prevention. Within secondary prevention, a previous atherothrombotic event was associated with lower LDL-C levels and higher guideline-target-value-attainment.

The utility of cardiac rehabilitation in improving endothelium-dependent vascular function in very elderly patients

Abstract Background Endothelial function is crucial for cardiovascular health and diseases. Cardiac rehabilitation has been reported to be useful in enhancing physical performance, quality of life, and endothelial function. The aging of patients with cardiovascular diseases is further progressing, and it is unclear whether cardiac rehabilitation improves physical function and endothelial function in very elderly patients with cardiovascular diseases. Purpose The purpose of this study is to investigate whether outpatient cardiac rehabilitation for individuals aged 80 and above improves physical function, quality of life (QOL), and vascular endothelial function. Methods Forty nine patients aged over 80 years with cardiovascular diseases participated in an outpatient cardiac rehabilitation program. Cardiac rehabilitation was conducted for 1 hour per session, 1-2 times per week for 3-4 months. Cardiopulmonary exercise testing (CPX) was conducted for the evaluation of physical function. QOL was assessed with Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. The reactive hyperemia index (RHI) was measured using EndoPAT2000 in each patient to assess endothelial function. An RHI ≤ 1.67 was defined as endothelial dysfunction. Results The mean ± standard deviation of age was 84 ± 4 years, with 16 (33%) being male. Peak oxygen uptake improved significantly (from 14.1 ± 4.0 to 15.4 ± 3.9 mL/kg/min, P=0.002), as did short physical performance battery scores (from 10.1 ± 2.7 to 10.7 ± 2.0, P=0.004), mini-mental state examination scores (from 27.7 ± 2.2 to 28.2 ± 2.0, P=0.004), Japanese version of the Cardiovascular Health Study criteria (from 2.3 ± 1.3 to 1.5 ± 1.2, P&amp;lt;0.0001), and KCCQ scores (from 76.8 ± 18.4 to 81.4 ± 20.4, P=0.02) after the cardiac rehabilitation program. Endothelial function also improved (LogRHI 0.48 ± 0.39 to 0.57 ± 0.30, P=0.027), and the prevalence of endothelial dysfunction decreased from 54% to 36% after the cardiac rehabilitation program. Conclusion Even in the very elderly patients, outpatient cardiac rehabilitation is beneficial for improving physical function, quality of life, and endothelial function.

Undetected heart failure in tertiary care: prevalence, predictors and outcomes

Abstract Background Undetected heart failure (HF) seems to be unexpectedly common in primary care. We hypothesized that undetected HF may also be common in tertiary care, even in care pathways including cardiologists. Methods We assessed prevalence, predictors, and outcome of undetected HF in a large prospective cohort study enrolling patients referred for myocardial perfusion single photon emission tomography (MPI-SPECT) with central adjudication of HF according to guidelines. Findings were validated in two independent prospective cohorts (outpatient cardiac rehabilitation program, major noncardiac surgery). Prevalence of undetected HF, ratio of undetected HF to known HF and number needed to screen (NNS) were the primary endpoints. Results Among 3623 patients, median age 68 years, 31% women. 100 patients (3%) had known HF and 928 patients (25.6%) were adjudicated to have undetected HF, resulting in a ratio of undetected to known HF of 9.3-to-1 and a NNS of 2.8. Older age, atrial fibrillation, and previous pacemaker implantation were strong independent predictors of undetected HF. Patients with undetected HF were at significantly higher risk of cardiovascular death or HF hospitalization (adjusted HR 1.47 [95%CI, 1.17-1.85] versus no HF). These findings were confirmed in both validation cohorts: among 970 and 1563 patients the prevalence of undetected HF was 21.5% and 19%, ratio of undetected HF to known HF 0.7-to-1 and 2.8-to-1, NNS 2.2 and 3.7, respectively. Conclusion The prevalence of undetected HF is high also in tertiary care, even higher with older age, atrial fibrillation, and previous pacemaker implantation, and associated with increased risk of cardiovascular death or HF hospitalization.Prevalence of undetected HFKaplan-Meier cumulative incidence curves

Electronic consultation from primary care to a cardiology department improves outcomes in patients with cancer

Abstract Background The number of cancer patients with known cardiovascular (CV) disease is increasing due to improved cancer prognosis. Purpose The objective of this study is to assess the long-term results of cancer patients referred to a cardiology department by primary care using electronic consultation (e-consultation). Methods We analysed the patients with previous diagnosis of cancer referred to a cardiology department (CD) from 2010 to 2021 (n=6.889), selected from a total of 68.518 patients (61.629 without cancer), and compared two assistance models: in-person practice (from 2010 to 2012) and e-consultation (from 2013 to 2021). In the first period, all the patients referred by primary care physicians (PCPs) were seen in an in-person consultation and in the e-consultation model the cardiologist reviewed the electronic records (e-consultation) and decided to solve without any visit or, if it was necessary, with an in-person consultation. The outcomes between both periods were analysed using an interrupted time series regression model: 1) delay time to cardiology assistance; 2) all-cause and cardiovascular hospital admissions, and 3) all-cause and cardiovascular mortality during the first year after the initial consultation or e-consultation to the CD. Results Among cancer patients referred to cardiology consultation, the introduction of e-consultation decreased waiting times to cardiology care by 51,8% (95% CI: 51,7%-51,9%) (Fig 1). Over 60% of referrals were resolved in less than 8 days, with this proportion significantly higher after the e-consultation program was introduced (p&amp;lt;0,001). Furthermore, we observed a reduction in the one-year rate of outcomes, with an incidence rate ratio (iRR) [IC 95%] of 0,75 [0,73-0,77] for CV-related hospitalizations (Fig 2b), 0,43 [0,42-0,44] for all-cause hospitalization (Fig 2a), and 0,87 [0,86-0,88] for all-cause mortality. In the multivariate analysis, the delay in receiving cardiology care was significantly associated with an independent increase in 1-year mortality (OR [95% CI] 1,39 [1,06-1,83]) and hospital admission (OR [95% CI] 1,25 [1,02-1,52]). Furthermore, the implementation of the e-consult model was associated with a reduction in hospital admission rates (OR [95% CI] 0,19 [0,14-0,25]). Conclusions In comparison to the in-person consultation period, an outpatient care program that incorporates e-consultation for cancer patients significantly reduced waiting times for cardiology care and shown to be safe, associated with lower rates of hospital admissions.Figure 1Figure 2

Maternal childhood trauma, caregiving behavior, and child cognitive development in the context of drug addiction.

Exposure to childhood trauma confers intergenerational risk on child development. However, the mechanism linking a mother's childhood trauma with her child's cognitive development remains poorly understood. This study recruited 71 mother-child dyads affected by substance use disorder from local, community-based, outpatient substance use treatment programs. Maternal exposure to childhood trauma, caregiving behavior, and child cognitive development were assessed in each mother-child dyad. These were measured through a comprehensive biopsychosocial interview, an observed dyadic interaction coded using the Coding Interactive Behavior system, and the Bayley Scales of Infant and Toddler Development, Screening Test, respectively. We hypothesized that compromised caregiving behavior would mediate a negative relationship between maternal childhood trauma and child cognitive development. Analyses did not support this hypothesis. Specifically, maternal childhood trauma was not significantly associated with child cognitive development nor the four dimensions of maternal caregiving behavior. However, caregiving behavior (specifically maternal sensitivity and limit setting) was associated with child cognitive development, when controlling for maternal childhood trauma and child age. The lack of associations observed suggests that protective factors may buffer the intergenerational impact of childhood trauma. Furthermore, the relationship between quality of caregiving and child cognitive development highlights the importance of interventions which foster sensitive caregiving behaviors that may bolster child cognitive development in the context of maternal substance use disorder and maternal childhood trauma. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Transitioning to oral feeding: A retrospective cohort study of a family-centered, hunger-based tube weaning program.

We investigated the effectiveness of a novel, hunger-based outpatient tube weaning program for children with feeding-tube dependency. This interdisciplinary program induced hunger via rapid reduction in tube-fed calories, followed by 2 weeks of daily outpatient mealtime support and regular follow-up. Forty-one children (6.9 months to 12.8 years) participated in this retrospective cohort study. Before the program, children received a median of 90.0% (interquartile range [IQR]: 75.0%-100%) of caloric intake via tube feeds. At the end of the 2-week program, children received 16.0% (IQR: 0.0%-30.0%) of caloric intake via tube feeds, which further reduced to 1.5% (IQR: 0.0%-33.0%) at 6-months, and 0.0% (IQR: 0.0%-35.0%) at 1-year follow-up. The percentage of participants who ate >30 different foods increased from 4.9% at baseline to 81.5% at 1-year follow-up. The baseline median weight z score of -1.24 (IQR: -1.69 to -0.69) decreased to -1.81 (IQR: -2.77 to -1.02) at 1-year follow-up. A linear mixed-effects model demonstrated that weight z score was significantly higher at baseline and 2-weeks compared to the 1-year follow-up (P < 0.001 and P = 0.001, respectively), but was not significantly different between 6 months and 1 year (P = 0.44). Age was not associated with percentage of caloric intake via tube feeds or number of foods eaten. Children who participated in the hunger-based tube-weaning program had increased and more varied oral intake 1 year following the intervention. The median weight z score decreased over the year after intervention but did not significantly decrease between 6 and 12 months after the program.