Outpatient Setting Research Articles

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

Abstract Background Acute chest pain in primary care often results in defensive and unnecessary hospital referrals due to the limited ability to rule out an acute myocardial infarction (AMI) outside of hospital. In a previous prospective observational study (OUT-ACS; One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome), we demonstrated that the ESC 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) would be safe and cost-effective if implemented to assess low-risk patients with chest pain in emergency primary care. Purpose We evaluated the real-world applicability, personnel adherence, and disposition of low-risk patients with chest pain following the implementation of the ESC 0/1-hour algorithm in emergency primary care. Methods In April 2023, the ESC 0/1-hour algorithm for hs-cTnT was implemented at a large emergency primary care clinic in Norway. The clinic is located close to a hospital, enabling the patient to wait at the clinic while blood samples are analysed for hs-cTnT at the hospital laboratory. For the following six months, all patients ≥18 years with acute non-traumatic chest discomfort, offered hs-cTnT measurements at the clinic, were anonymously registered, including their discharge diagnoses and disposition from the clinic. By applying the ESC 0/1-hour algorithm, patients were assigned to rule-out, rule-in or further observation. Patients in the observation group were offered a 4-hour hs-cTnT measurement before a final decision. Results During the six-month period, 10.3% (n=3,053/29,631) of the clinic's consultations involved chest complaints. Hs-cTnT measurements were conducted in 32.6% (n=995/3,053) with a median age of 58 years (IQR 45-68), 50.6% being female. A single hs-cTnT <5 ng/L, sampled ≥3 hours since symptom onset, triaged 24.1% (n=240/995) of the patients towards the rule-out group, increasing to 63.8% after adding a 1-hour measurement. In the rule-in group (n=42/995, 4.2%), 16 patients were diagnosed with an AMI. The intermediate observation group (n=318/995, 32.0%, 4 AMIs) was reduced to 23.0 % after a 4-hour hs-cTnT measurement. Healthcare personnel adhered well to the algorithm, with a median sampling interval of 63 minutes (IQR 60-66) and 4.5 hours (IQR 4.1-5.5) for the 1- and 4-hour measurements, respectively. The algorithm was misinterpreted or overruled in 8.8% of the cases. Ultimately, only 14.8% required hospital transfer following troponin assessment at the clinic. The remaining patients were sent home or managed in the outpatient setting. Conclusions The OUT-ACS strategy, utilizing a 0/1/4-hour algorithm for hs-cTnT measurements in emergency primary care, is safe, effective and applicable, and the strategy contributes to reduced hospital referrals for low-risk patients with chest pain.0/1/4-hour algorithm for hs-cTnTDisposition

BE-SAFE: Intervention to reduce benzodiazepine and sedative hypnotics in elderly with sleep problems

Abstract Introduction Benzodiazepine and sedative hypnotics (BSH) may have significant adverse effects and associated costs, especially in older adults: increased risk of falls, fractures, hospitalisations, impaired functioning, delirium, cognitive impairment and mortality. Addressing BSH overuse is therefore an urgent priority to improve patient safety in Europe. Objectives To present the 5-year research project BE-SAFE, funded by the European Commission (HORIZON Europe) and by the Swiss State Secretariat for Education, Research, and Innovation. BE-SAFE aims to improve patient safety by addressing knowledge and practice gaps related to the reduction of BSH used by older adults for sleep problems. Methods BE-SAFE involves seven inter-related work packages and six European countries (Belgium, Greece, Norway, Poland, Spain and Switzerland) as well as experts from Canada; it proposes an interdisciplinary and inter-sectorial approach with experts in guidelines, implementation, dissemination, case studies, geriatrics and sleep. BE-SAFE will develop an intervention comprising trustworthy clinical guidelines, implementation recommendations and patient-centred material. This intervention will be tested in a cluster randomized controlled trial; 470 patients (65 years old and above) and 62 prescribing physicians in hospital and outpatient settings. Results BE-SAFE is expected to result in reduction of BSH use. Its toolkit, encompassing setting-specific implementation recommendations, will enable healthcare professionals (HCPs) to identify, evaluate and prevent risks of BSH use. The BE-SAFE approach could also be expanded to cover reduction of use of other medications. Conclusions Through BE-SAFE, patient safety is expected to improve; BE-SAFE project will reach a wide-ranging audience, including general population, informal carers, older adults, HCPs, healthcare system leaders and decision makers. Authors acknowledge the significant input of J. Grimshaw and W. Levinson, Canada. Key messages • Deprescription of benzodiazepine and sedative hypnotics, especially in older adults, is a priority due to their side effects, particularly in this age group. • The European project BE-SAFE aspires to create easy-to-use guidelines to this aim, improving thus patient safety and healthcare.

Preliminary findings of the TB-HEART Study: prevalence of cardiac pathology among newly diagnosed patients with tuberculosis with and without HIV in Zambia

Abstract Background Cardiovascular diseases (CVD) burden is rapidly increasing in sub-Saharan Africa (SSA) where tuberculosis and HIV prevalence remain high.(1-3) Recent data suggest pulmonary tuberculosis (PTB) is associated with increased CVD morbidity.(4) However, the mechanisms of cardiac injury remain poorly understood. Purpose The TB-HEART study is a cross-sectional and natural history study consecutively recruiting participants with newly-diagnosed PTB, living with and without HIV in Zambia. The primary outcome is the burden of cardiac pathology in PTB patients with and without HIV. Methods Participants with bacteriologically-proven PTB, consecutively recruited from an outpatient settings in Zambia, undergo detailed clinical and functional assessments including point-of-care and standard two-dimensional (2D) echocardiography. Participants are reviewed at completion of TB treatment when all assessments are repeated. The target sample size is 250 participants with PTB, with and without HIV, matched 2: 1 to participants without PTB, stratified by HIV. Results Since 1 November 2023, we have recruited 73 participants with a mean age of 35.3±10.9 years of whom 51/73 (69.9%) are male and 19/73 (23.5%) are living with HIV. Baseline characteristics including cardiovascular risk factors, TB symptoms, anthropometry and clinical and functional observations at presentation, stratified by HIV status, are summarised in Table 1. We detected significant cardiac pathology (defined as left ventricular ejection fraction (LVEF) <51% and/or pericardial effusion >2cm in depth) in 8/65 (12.3%) participants for whom 2D-echocardiography had been completed. Median LVEF was 61.2% (IQR 57.7-67.8). LVEF was normal in 59/65 (91%); mildly abnormal in 5/65 (7.7%); and moderately abnormal in 1/65 (1.5%) participants, respectively. Pericardial effusion >0.5cm was detected in 16/65 (24.6% ) participants and maximum effusion depth was >2cm in 2/16 (3.1%), 1-2cm in 12/16 (75%) and <1cm in 2/16 (12.5%). 2D-echocardiography findings, stratified by HIV-status, are described in Table 2 alongside two echocardiography stills of typical pericardial effusion findings in one participant. Conclusions Our preliminary results demonstrate a higher than expected prevalence of cardiac pathology among participants with PTB with and without HIV, which ranges from 1-7% in autopsy studies and case series.(5-7) The most common cardiac pathology was pericardial effusion. Further analyses will include cardiac biomarkers; repeat clinical and echocardiographic assessments at TB treatment completion; and comparator data, to determine associations between prevalent cardiac pathology and PTB controlling for HIV and TB status, respectively. This may have important implications for clinical practice to prevent complications such as constrictive pericarditis; and policy design to better integrate TB and HIV patient services with preventative care to reduce future CVD risk.Table 1 - Baseline characteristicsFigure 1 and Table 2

Return to work after hip and knee arthroplasty: qualitative outcome from the Netherlands

Abstract Background Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) are performed daily worldwide. More younger working-age patients are receiving a THA and/or TKA. Outcomes, including Quality-of-Life (QOL), patient satisfaction and Return-to-Work (RTW) are becoming more important and have implications for healthcare budget and health workforce. Clinical recovery pathways should improve patient outcomes and cost-effective care. Insight in patient experiences and expectations regarding RTW remains behind. This study aims to gain insight into influenceable factors in the recovery pathway after THA or TKA that could lead to improved care and enhanced patient participation. Methods In this single-center qualitative study, performed at Zuyderland Medical Center (Sittard-Geleen, the Netherlands), 12 patients (n = 6 THA; n = 6 TKA) aged under 65 years were approached to participate. During interviews 6-weeks after arthroplasty, this research explored their RTW experiences in both pre-, and postoperative, in- and outpatient settings. Results In total, 12 employed patients who received a THA (n = 6, mean age 56 ± 7.4 years; female: n = 4, 66%) or a TKA (n = 6, mean age 61 ± 2.6 years; female n = 3, 50%) participated. Own control regarding RTW and a minimal recovery time after the operation was necessary for all patients. During this time, focus on physical therapy and strengthening was most important. RTW was not expected to be the primary goal during the clinical recovery pathway. The RTW topic was said to belong to the occupational physician (OP) and employer. Patients however knowledge that the type of work should gain importance in the consultation room. Patients missed accessible communication between the orthopedic surgeon and OP. Conclusions Overall, patients are satisfied with the current clinical recovery pathway. Intercollegiate communication should be made more accessible. Own control and strengthening self-management in the RTW remain important for all patients. Key messages • Own control and strengthening self-management should have importance in the guidance of working-age patients after THA or TKA. • Intercollegiate communication should be made more accessible.

Multidisciplinary strategies for cardiotoxicity management in ambulatory care: exploring practices, insights, and prospects for advancement

Abstract Background The management of cardiotoxicity, a significant concern in chemotherapy patients, necessitates a multidisciplinary approach. This study investigates the variability in cardiotoxicity management in outpatient settings across different medical specialties, which may lead to inconsistencies in patient care. Methods An extensive questionnaire-based study was conducted to assess the current practices and viewpoints of cardiologists, oncologists, and gynecologists in the management of cardiotoxicity among patients receiving outpatient chemotherapy in Germany. The survey engaged 1,329 medical professionals through an online platform, with a participation rate of 9.9%, amounting to 132 respondents. Results Respondents reported managing a combined total of 1,905 chemotherapy patients monthly, with individual patient loads ranging from 1 to 200. Notably, only a fraction of these patients – 37% under oncologist care and 48% under gynecologist care – underwent routine cardiological examinations. As shown in Figure 1, the three most common causes of cardiological presentations in patients undergoing chemotherapy were due to acute patient complaints (65.2%), before the start of chemotherapy (91.3%), and after the end of chemotherapy (78.3%). Furthermore, 37% of healthcare providers reported incorporating chemotherapy-induced cardiovascular toxicity risk assessments in their clinical routines. Medical history, ECG, and echocardiography were the most frequent examinations. Notably, 91.3% did not include cardiac biomarker measurements in their follow-up procedures (Figure 2). More than half of the participants (56%) expressed a need for simplified cardio-oncology guidelines. The majority of participants (84% and 83%, respectively) requested tools to assist in cardiovascular toxicity risk assessment and the implementation of appropriate therapeutic measures for patients undergoing chemotherapy. Conclusions The study draws attention to significant interdisciplinary care gaps in managing cardiotoxicity, which may contribute to an increased risk of undiagnosed cardiovascular complications in chemotherapy patients. The evident variability in cardiotoxicity management practices among different medical specialties underscores the critical need for heightened awareness and enhanced collaborative efforts. The implementation of comprehensive interdisciplinary clinical pathways and the establishment of a dedicated cardio-oncology network could potentially address these challenges, particularly in supporting primary care physicians.Figure 1Figure 2

An observational study on the efficacy of intralesional steroids in patients with idiopathic granulomatous lobular mastitis in a tertiary care centre

Background: Granulomatous lobular mastitis (GLM) is a rare benign disease of the breast which usually affects young women of childbearing age. The patients usually present with a painful breast mass or with multiple discharging sinuses of breast. Diagnosis is usually established by means of clinical examination followed by radiological, microbiological and histopathological evaluation. The ideal management of patients with GLM is still a matter of debate and treatment modalities such as surgery, systemic and intra-lesional steroids, as well as immunosuppressive agents are being used in clinical practice. In our study, we assessed the clinical response of patients with GLM, treated with intra-lesional steroid injection. Methods: In this prospective observational study, from December 2021 to December 2023, a total of 29 patients who were diagnosed as having GLM and who opted for intra-lesional steroid therapy as the solo treatment, were enrolled. After obtaining informed consent, intra-lesional steroid injection was administered in all the 29 patients. The treatment response was assessed after a period of 3 months from the date of injection. Results: A complete resolution of symptoms and signs was found in majority of the patients (75.9%), 4 (13.8%) had a partial resolution and 2 (6.9%) had persistence of symptoms. One patient (3.4%) was lost to follow up. None had any worsening of symptoms. Conclusions: Intra-lesional steroid can be effectively used in the treatment of GLM and this modality can be completed in a few minutes in an Outpatient setting and is extremely cost effective.

Factors impacting time to genetic diagnosis for children with epilepsy.

Molecular diagnosis for pediatric epilepsy patients can impact treatment and health supervision recommendations. However, there is little known about factors affecting the time to receive a diagnosis. Our objective was to characterize factors affecting the time from first seizure to molecular diagnosis in children with epilepsy. A retrospective, population-based review was used to analyze data from pediatric patients with a genetic etiology for epilepsy over a 5 year period. A subgroup of patients with seizure onset after 2016 was evaluated for recent trends. We identified 119 patients in the main cohort and 62 in a more recent (contemporaneous) subgroup. Sex, race, and ethnicity were not significantly associated with time to molecular diagnosis. A greater number of hospitalizations was associated with a shorter time to diagnosis (p < 0.001). Developmental delay was associated with a longer time to diagnosis (p = 0.002). We found no association for time to diagnosis with a diagnosis of autism, utilization of free genetic testing, or epilepsy type. In the recent subgroup analysis, commercial insurance was associated with decreased time to diagnosis (p = 0.02). Developmental delay, public insurance, or patients in the outpatient setting had longer times to molecular diagnosis. These findings suggest that there may be opportunities to implement interventions aimed at accelerating the provision of genetic testing in pediatric epilepsy. PLAIN LANGUAGE SUMMARY: Genetic diagnosis for pediatric epilepsy patients can impact treatment and care. This study looked at factors that affect how long it takes a pediatric epilepsy patient to receive a genetic diagnosis. We found that sex, race and ethnicity, epilepsy type, and whether the patient had autism did not affect how long it took the patient to receive a diagnosis. However, we found that patients with developmental delay, fewer hospitalizations, and public insurance took a longer time to receive a diagnosis. Our findings suggest potential strategies for reducing the time to receive a genetic diagnosis.

Health impact of the Serious Accidents Punishment Act in Korean occupational settings

Abstract Background Interrupted time series analysis serves as a valuable study design for assessing the efficacy of public health interventions implemented at a specific moment in time at the population level. We aim to elucidate the effects of the Serious Accidents Punishment Act implemented in February 2021 in Korea by analyzing changes in the incidence rates of occupational diseases. Methods The monthly data from patients with occupational diseases was extracted from the National Health Insurance Service Cohort database from 2011 to 2023. An Interrupted time series analysis with Poisson segmented regression was used to compare the rates before and after the Serious Accidents Punishment Act introduction in both outpatients and inpatients. Adjustments or stratification variables included sex, age, company size, and injury-related international classification of diseases codes (Injury, poisoning, and certain other consequences of external causes, S00-T88). Results Based on injury rates, men’s inpatient injury rates remained stable, but outpatient rates decreased after the act implementation, while women’s injury rates consistently declined in both inpatient and outpatient settings. The Interrupted time series regression analysis indicates that the Serious Accidents Punishment Act led to a significant reduction in both outpatient and inpatient injury rates for men and women, with a marked decline in outpatient rates and hospital admissions among women post-intervention. Conclusions The Interrupted time series regression results suggest that the Serious Accidents Punishment Act has been effective in reducing injury-related healthcare usage, highlighting the necessity of gender-specific interventions and the potential impact on lowering inpatient visits, although causality remains uncertain without further analysis. Key messages • The Serious Accidents Punishment Act significantly reduced occupational injury rates in Korea, especially among women, demonstrating effective public health intervention. • Interrupted time series analysis reveals Serious Accidents Punishment Act’s impact on reducing healthcare usage for occupational injuries, highlighting the need for gender-specific approaches.

Associations between general practice and outpatient care continuity in people with multimorbidity

Abstract Background Relational continuity in primary and secondary care is linked to better health outcomes for patients, but it is unclear whether metrics of continuity in each setting are associated. Our study examined the association between relational continuity in general practice (GP) and continuity of hospital outpatient specialties in people with clusters of multimorbidity. Methods We used GP records from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics outpatient records. Included were patients ≥18 years, with two or more of 212 Long-Term Conditions (LTCs), registered throughout 2019 and with at least three GP and three outpatient appointments. The Continuity of Care Index (COCI) was calculated separately for visits to the same i) GP and ii) hospital specialty, where 0 represents no continuity and 1 represents all visits to the same GP or specialty. We assessed the association between the indices using univariable and multivariable fractional logit regression. We calculated expected COCI scores for each LTC and assessed variation in the COCI between LTCs assigned to one of 15 clusters of co-occurring diseases derived previously. A sensitivity analysis repeated analysis using the Sequential Continuity (SECON) score, which captures longitudinal continuity. Results Of 1,135,903 patients, 56.2% were ≥60 years. The median (IQR) COCI in GP was 0.22 (0.11-0.40) and in outpatients was 0.33 (0.20-0.52). Although statistically significant (p &amp;lt; 0.001) the relationship between the two measures was clinically insignificant in both univariable and multivariable models. No strong relationships were found between COCI scores and LTC clusters. Similar patterns were found using the SECON score. Conclusions We found no strong association between continuity of care in GP and outpatient settings, and no clear patterns with LTC clusters. This suggests that lack of continuity in secondary care is not compensated for by increased continuity of care in primary care. Key messages • We found no meaningful association between measures of continuity of care in general practice and hospital outpatient settings. • Our findings suggest that lack of continuity of outpatient care is not compensated for by increased continuity in primary care.

Value-based versus usual care for heart failure patients leads to reduction in cost, hospital admissions and improved survival

Abstract Background OptumCare (OC) in our city, Nevada established a heart failure (HF) program comprised of a team of outpatient cardiologists including two who are board certified in advanced heart failure. Referred patients are enrolled in the HF program once HF is diagnosed by a cardiologist. Patients are managed by an interdisciplinary team of cardiologists, advanced practice clinicians (APC), registered nurse case managers (RNCM), and a social worker. Patients at higher risk for HF admissions are enrolled in remote patient telemonitoring. In contrast, OC in Arizona utilizes a "usual" care approach of fee-for-service contracted cardiology groups to manage HF patients in outpatient and in-patient settings. Purpose A head-to-head comparison was performed between the cohort of patients enrolled in HF program in OC Nevada (treatment group) and patients with HF diagnosis in OC Arizona (control group). The groups were compared on the following measures: medical cost, hospital admissions, and survival rates. Methods In this retrospective study, a 1:1 iterative propensity score (PS) matching was performed to closely approximate patient demographics and comorbidities, which resulted in 818 matched pairs (total n=1,636) of the patients with program enrollment or 1st HF diagnosis between March 1, 2019 and June 30, 2022. For Difference-in-Difference Analysis (Diff-in-Diff), generalized linear models were used on PS matched data to test the difference in difference in medical cost and utilizations changes between control and treatment group over a six month period. Log-Binomial regression was used to estimate the relative risk of post period 30-day readmission and hospice enrollment. Kaplan Meier Estimator was used to test the difference in survival rates over time. Results Average age of patients was 77.6 years old, and 49% were female. The treatment group resulted in significantly lower overall medical costs per member per month (PMPM), significantly less emergency room (ER) visits, less acute hospital and skilled nursing facility (SNF) admissions, and shorter overall hospital length of stays. The control group was twice as likely to be readmitted to the hospital. Lastly, the treatment group had a significantly better survival rate than the control group. 19% of the patients in the control group expired within 12 months of enrollment vs. 10% of the patients in the treatment group expired during the same time period. Average survival was 142 days in the control group vs. 200 days in the treatment group. Conclusions A value-based care approach involving a multidisciplinary team in an outpatient-based cardiology HF program resulted in statistically significant improvement in medical costs, acute care visits/admissions, and survival rates compared to "usual" care approach for HF patients.

Exploring vocal biomarkers as non-invasive fine-tuning assays of cardiovascular health: heart failure model

Abstract Background Mobile health (mHealth) technologies offer a promising avenue for non-invasive heart failure monitoring through vocal biomarkers. The relationship between feature changes in anonymous and standardized voice recordings of heart failure patients and the NYHA scores of the same patients is assessed, aiming to identify vocal biomarkers as delicate indicators of chronic noncommunicable disease progression and/ or fluctuation. Methods In a cardiology outpatient setting, 55 chronic heart failure patients provided voice recordings via a mobile app, performing specific vocal tasks prospectively. We analyzed waveforms visually via Mel spectrograms and extracting features by audio processing, focusing on chroma centroids and tonnetz measurements across 147 clinical and laboratory parameters (Mean NYHA: 2.62, SD: 0.56). Applying Ordinary Least Squares (OLS) test, we assessed the relevance of spectral bandwidth mean (0.04), spectral bandwidth std (0.00), spectral roll-off std (0.011) between NYHA scores, given each p-score &amp;lt; 0.05. Results 147 voice recordings taken from 55 patients were analyzed to examine whether there were any correlations between changes in the voice recordings and NYHA scores. OLS test underscored the significance of spectral bandwidth mean (0.04), spectral bandwidth std (0.00), spectral roll-off std (0.011) between NYHA scores with p-value &amp;lt; 0.05. These findings show the potential role of multiple vocal features in reflecting heart failure progression and/or fluctuation. Analysis based on the clinical status progression from NYHA 2 to NYHA 3 over time showed notable changes in chroma centroids (mean = 0.006, std = 0.174, skew = 0.179, kurtosis = 0.205) and tonnetz (mean = 0.023, std = 0.131, skew = 0.023, kurtosis = 4.247). Conclusion This investigation highlights vocal biomarkers' potential in heart failure management, offering insights into non-invasive monitoring techniques and shows the importance of standardised recording procedures and patient engagement for data integrity. Future directions include quantifying vocal changes' correlation with clinical status and integrating additional parameters (e.g., edema, weight) to enhance predictive models for personalised care.Vocal features according to NYHA scores

Analyzing the economic ramifications of the broad implementation of generic prasugrel

Abstract Introduction The 2023 European Acute Coronary Syndrome (ACS) guidelines state that prasugrel (PRG) should be considered in preference to ticagrelor (TCG) in patients (pts) who proceed to percutaneous coronary angioplasty (PCI). In Portugal, PRG is less available due to earlier evidence considering pretreatment and contraindications for each drug. PRG (10mg) is currently a generic drug, while TCG is not. We aimed to evaluate the proportion of pts that could be switched from TCG to PRG, and the economic impact of a widespread national adoption. Methods To determine eligibility for generic PRG 10mg, we examined a single center prospective database of consecutive ACS pts undergoing PCI in a full year. Eligibility for TCG and PRG was based on drug specific contraindications, previous stroke for PRG and chronic liver disease (CLD) for TCG, and indication for PRG dose reduction (≤60 kg and ≥75 years). To estimate hospital costs we used the price per pill indicated by the pharmacy (0.98€ TCG, 0.67€ PRG). To obtain post-discharge and NHS savings we used the INFARMED public information. We estimated 3500 PCIs per year on a national level, based on published data. Results A total of 780 pts were included, median age 68±10.4years, 523 (67.1%) were male, 51.9% (n=406) had non-ST elevation ACS. Mean admission time was 8.36 days. Considering PRG and TCG contraindications, 157 pts (20.3%) had a previous history of stroke and 20pts (2.6%) had CLD. 150 pts (19.2%) had PRG dose reduction criteria. Eligible for PRG 10mg and TCG 90mg were 434 pts (57.8% of total PCI pts). Cost per admission would be 33 697.35€ for TCG and 17 617.28€ for PRG. At a national level, hospital costs can be reduced by 16080.07€. Considering the 1-year outpatient setting and a widespread generic PRG 10mg adoption, NHS savings are estimated in 898 323.59€, and patient savings in 401248.25€ (198.38€ per patient). Conclusions ACS pts in real-world scenarios exhibit both eligibility for PRG and TCG. Considering the lower cost, the NHS can potentially save 914 403,66€ (figure 1) annually through the widespread adoption of generic PRG 10mg.

Long-term outcomes in women diagnosed with heart failure in connection to delivery

Abstract Background Heart failure (HF) among young patients may be from various causes, often triggered by heightened physical demands like pregnancy. Data regarding outcomes of women diagnosed with HF in conjunction to pregnancy and delivery are varied. There remains a notable gap in understanding the outcomes observed in women diagnosed with heart failure in conjunction with delivery. Also, long-term follow-up studies are crucial to elucidate the impact of pregnancy-associated HF on future cardiovascular. Purpose To study the interplay between pregnancy, HF, and subsequent cardiovascular risk. Method Using the personal identification numbers (PINs) that all individuals in Sweden have enables linkage of data between different registers. Data from the National Patient Register (NPR), Swedish Medical Birth Register (MBR) and the Cause of Death Register were also used. All women 18 to 50 years of age registered in the in MBR in the period 1st January 1997 to 31st December 2019 were included. Women with first-time HF in relation to delivery were identified using the international classification code for diseases (ICD-10) I50, I42, I43 and 090.3 together with co-morbidities. Every patient was compared with 5 controls without HF from the Total Population Register matched on age at delivery and calendar year of delivery. Outcomes: all-cause mortality, and any cardiovascular disease (CVD) diagnosed during the observation time. Results A total of 286 cases and 1,430 controls were included. The prevalence of comorbidities at baseline for both patients and controls was low; congenital heart disease (1.4%, vs. 0%), pulmonary hypertension (1.0% vs. 0%), valvular heart disease (5.9% vs. 0%), myocardial infarction 0.7% vs. 0%), arrhythmia (5.9% vs. 0%), hypertension (6.3 % vs. 0.1%), (all p&amp;lt;0.05). Preeclampsia prior to HF diagnosis had 31% of patients vs. 0.2% of controls (p&amp;lt;0.001). Patients exhibited higher mortality rates at 4.9% during median follow up 9.0 (IQR 5.6-13.0) years vs. 0.3%, median follow up 9.4 (6.2-13.5) years and hazard ratios (HR) for all-cause mortality HR (95% CI) of 18.20 (5.99 - 55.31) (p&amp;lt;0.001) compared to controls. During median follow up of 3.2 (0.0-9.2) years 60.1% of patients were diagnosed with CVD both at in-/out-patient settings compared with 4.1% in controls during 9.4 (5.8-13.5) years of follow up. Comparing patients with controls the HR (95% CI) was 22.24 (16.50 - 29.96) p&amp;lt;0.0001 for CVD diagnosis during follow-up, see Figure 1. Conclusion In conjunction with delivery, and in the years thereafter, women with heart failure diagnosis had more than eighteen times higher risk of mortality than women without heart failure. The risk of CVD event in the heart failure group is highest in conjunction with delivery. Figure 1. Cumulative incidence functions for all-cause mortality, CVD in- or out-patient visit adjusted for death as competing risk, comparing cases with controls.

Desmopressin dosing in children using real-world data and pharmacokinetic/pharmacodynamic model simulations.

Variability in pediatric dosing of desmopressin (ddAVP) in AVP-deficiency (AVP-D) is well-documented but dosing recommendations are limited. This study evaluates and optimizes ddAVP dosing regimens in children with AVP-D using pharmacokinetic and pharmacodynamic (PK/PD) simulations. Retrospective electronic health record review was done to identify children (<18 years) with AVP-D on ddAVP evaluated in the outpatient setting using ICD 9 and 10 codes. A previously developed PK/PD model from Michelet et al was used to simulate ddAVP concentrations and urine rates based on a child's age and ddAVP dose. The effects of demographic characteristics (age, weight, etc.) on dose and urine rate were investigated through simulations to optimize doses of ddAVP for children who were wet overnight. A total of 276 dosing records were identified among 53 children with AVP-D. Simulations indicated that in children under 5 years of age who were wet overnight, increasing the outpatient dose to 50 mcg was predicted to decrease urine rate to a pattern similar to those who remained dry. An initial outpatient dose of at least 50 mcg for children between 1 and 5 years of age would improve efficacy of ddAVP. 50 mcg is likely a safe initial outpatient dose of oral desmopressin tablet for young children 1-5 yrs of age with central Diabetes Insipidus/AVP-Deficiency. We confirmed that desmopressin doses vary greatly in children with central Diabetes Insipidus/AVP-deficiency. Real-world clinical data can be leveraged to improve medication dosing in rare diseases.

Improving Laryngeal Procedure Workflow: Moving From the Operating Room to the Outpatient Setting.

Laryngology disease burden is growing while theater capacity is falling. Over half a million patients are waiting for ENT care in England alone (1). The demand for laryngology services has continued to grow significantly, particularly post-COVID (2). Meanwhile, the number and efficiency of ENT theater lists are reduced (3). To tackle the growing backlog, NHS England has emphasized the need for innovative strategies by separating elective from emergency services and by increasing the resilience of elective delivery (4). The establishment of an office-based laryngology procedure clinic is a potential solution. We offer a narrative review and audit of our experience in founding an in-office laryngology procedure service within a tertiary NHS center with the aim of streamlining this setup process for other interested ENT units. We outline an in-depth exploration of the personnel, equipment, and processes necessary to establish an in-office procedure clinic. Our experience showed that the procedure clinic functions well when implemented within the framework of existing ENT elective and emergency services. Although there is initial investment required in terms of money, effort, and time, our outcomes show that the clinical and economic benefits of the clinic outweigh the costs, also allowing for patients to access investigations and treatments reliably and efficiently. Setting up a laryngology in-office procedure clinic within the NHS confers patient, organizational, and economic benefits. It provides a novel and resilient approach in addressing the growing backlog of patients awaiting laryngology care and should be popularized in the current health care environment. Level 4 Laryngoscope, 2024.

Specialty-Based Ambulatory Quality Improvement Program: A Specialty-Specific Ambulatory Metric Project.

Healthcare is increasingly being delivered in the outpatient setting, but robust quality improvement programs and performance metrics are lacking in ambulatory care, particularly specialty-based ambulatory care. To promote quality improvement in ambulatory care, we developed an infrastructure to create specialty-specific quality measures and dashboards that could be used to display providers' performance across relevant measures to individual providers and institutional leaders. The products of this program include a governance and infrastructure for specialty-specific ambulatory quality metrics as well as two distinct dashboards for data display. One dashboard is provider-facing, displaying provider's performance on specialty-specific measures as compared to institutional standards. The second dashboard is a leadership dashboard that provides overall and provider-level information on performance across measures. The Specialty-based Ambulatory Quality program reflects a systematic, institutionally-supported quality improvement framework that can be applied across diverse ambulatory specialties. As next steps, we plan to evaluate the program's impact on provider performance across measures and expand this program to other specialties practicing in the outpatient setting.

A Case of Tracheogastric Puncture Using Transnasal Esophagoscopy After Total Laryngopharyngoesophagectomy and Gastric Pull-Up Reconstruction

Voice rehabilitation after total laryngopharyngoesophagectomy is a significant challenge, especially when accompanied by gastric pull-up reconstruction. In 2021, a study revealed that tracheoesophageal puncture is also safe and feasible option for voice rehabilitation in patients who underwent gastric pull-up surgery. Here, we report for the first time in South Korea a case that represents an instance of voice prosthesis insertion after gastric pull-up surgery. The case demonstrates the feasibility and safety of voice prosthesis insertion in patients who undergo total laryngopharyngoesophagectomy and gastric pull-up surgery, providing evidence that voice prosthesis insertion is achievable and can be performed in the outpatient setting using transnasal esophagoscopy.

Reimagining Cryptogenic Stroke Care: Collaborative Care and Inpatient Insertable Cardiac Monitors for Detection of Atrial Fibrillation

BACKGROUND Atrial fibrillation (AF) is a known risk factor of ischemic stroke, and AF‐related stroke is twice more likely to be fatal. Long‐term cardiac rhythm monitoring using insertable cardiac monitors (ICMs) has greater diagnostic yield compared with conventional monitoring in detecting AF, and the clinical utility of ICMs is established in cryptogenic stroke, strokes attributable to large‐artery atherosclerosis, and strokes attributable to small‐vessel disease. A registry‐based study was conducted to evaluate the inpatient implantation of ICMs and the feasibility of vascular and interventional neurologists as implanters using novel collaborative clinical care pathway for cryptogenic stroke. METHODS Multiyear data from a hospital‐based registry at a comprehensive stroke center were reviewed to evaluate inpatient ICM implantation and test feasibility of vascular and interventional neurologists as implanters of ICMs together with cardiology using a novel collaborative care pathway. Reviewed data included the number of ICMs, implantation trend, inpatient versus outpatient setting, time to ICM implantation, inpatient workflow, including defined roles of team members, and AF detection rate. RESULTS A total of 290 ICMs for cryptogenic stroke were implanted when patients were in the hospital and 78 as outpatients after discharge during the study period of 3 years. Most inpatient ICM implants were performed by vascular and interventional neurology (n = 181), and ICM use for cryptogenic stroke increased by 130%. The average time to inpatient ICM implant was 4.1 days, with 77% in 5 days and 95.5% within 10 days poststroke. The average time to out‐patient ICM placement was 57 days. AF detection rate of 36.5% was noted at 24 months with a collaborative care pathway. CONCLUSION Inpatient implantation of ICMs is feasible and was performed safely and efficiently by vascular and interventional neurology together with cardiology using a collaborative care pathway. An increase in use of ICMs and higher AF detection rates were noted. Findings support innovative efforts to improve access and close the gaps in the delivery of cryptogenic stroke care to ultimately reduce the secondary stroke burden.

Is Outpatient Supraglottoplasty Possible? Examination of Perioperative Comorbidities and Outcomes.

Supraglottoplasty (SGP) is necessary in approximately 10% to 15% of infants with congenital laryngomalacia (LM). Postoperative management strategies vary and this study examines outcomes and readmission rates. This is a retrospective chart review. A single tertiary care institution's patients undergoing SGP from 2012 to May 2022. Patients were assigned to 1 of 3 groups based on length of stay (LOS) including 0, 1, or 2+ days. Preoperative data included age, prevailing symptoms, and comorbidities at the time of surgery. Postoperative data included level of care, perioperative complications, readmission rates, and SGP failure. Descriptive statistics were used to evaluate differences between the 3 groups. Following SGP in 975 patients, 23.8% were discharged the same day (Group 0), 63.2% were observed overnight (Group 1), and 13.0% required 2+ days (Group 2). Four of the 616 patients in Group 1 were admitted to an intensive care unit (ICU) setting, and 11 patients in Group 2. The patients in Group 2 had a higher incidence of Pepcid use, previous intubation, cardiac anomalies, prior gastrostomy tube (G tube), subglottic stenosis, cyanosis, failure to thrive, and prematurity. The significant differences in the group admitted to the ICU were those admitted for airway, cerebral palsy, prior G tube, PSG, prior intubation, or cardiac anomaly (P = <.05). Readmission rates from Group 0 versus 1 were 1.3% and 2.9%, respectively, though this was not statistically significant. SGP is a safe procedure that can be performed in the outpatient setting in select patients.

P-55719761-1353 - Advanced non-melanocytic skin cancer in the facial region: versatility of local reconstructive flaps in the outpatient setting

P-55719761-1353 - Advanced non-melanocytic skin cancer in the facial region: versatility of local reconstructive flaps in the outpatient setting