Post-discharge Follow-up Period Research Articles

A standard experiment with emergency endovascular interventions on the descending thoracic aorta

Background: Using emergency endovascular aortic repair to treat severe acute aortic disorders affecting the descending aorta is an appealing prospect. Aim: This study's objective was to evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in the management of acute surgical emergencies involving the descending thoracic aorta. Methods: The medical records of every patient who underwent TEVAR in a single centre since 2007 were retrospectively evaluated. Emergency criteria for inclusion were used to treat patients with aortic disease who had complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other symptoms calling for urgent treatment. The Society for Vascular Surgery reporting guidelines for thoracic endovascular aortic repair were used to evaluate the technical and clinical success with regard to patient mortality, survival, and re-operation rate (TEVAR). Results: In 74 cases (51.0%), emergency procedures were required, including those involving patients with traumatic aortic acute injuries (TAIs) (31.1%) and complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48). Aortic iatrogenic dissection (AID) in one case and two other fistulas following the prior stent graft were also identified as implantation's. While 2 hybrid operations required extra approaches, all procedures were performed through surgically exposed femoral arteries. The main technical success rate was 95.9%; endoleak was recorded in 3 instances. In 94.5% of cases, the main clinical success was achieved. All of the patients made it through the endovascular procedures, however one of them passed away in the hospital as a result of multi-organ failure (early mortality: 1.3%). 11 patients passed away throughout the follow-up period, which lasted 6 to 164 months (median 67). The probability of survival over one year, five years, and 10 years was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, following TAI (95.2%) compared to scAAS (63.4%), the rate of 5-year survival was significantly greater (p=0.008). One person experienced temporary para-paresis right after the operation (1.3%). Throughout the post-discharge follow-up period, no more severe stent-graft-related adverse events were reported. Conclusion: The probability of survival over one year, five years, and 10 years was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, following TAI (95.2%) compared to scAAS (63.4%), the rate of 5-year survival was significantly greater (p=0.008). One person experienced temporary para-paresis right after the operation (1.3%). Throughout the post-discharge follow-up period, no more severe stent-graft-related adverse events were reported.

Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience.

Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta. The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta. A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR). The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period. Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.

Cardiovascular Biomarkers for Prediction of in-hospital and 1-Year Post-discharge Mortality in Patients With COVID-19 Pneumonia.

AimsWhile COVID-19 affects the cardiovascular system, the potential clinical impact of cardiovascular biomarkers on predicting outcomes in COVID-19 patients is still unknown. Therefore, to investigate this issue we analyzed the prognostic potential of cardiac biomarkers on in-hospital and long-term post-discharge mortality of patients with COVID-19 pneumonia.MethodsSerum soluble ST2, VCAM-1, and hs-TnI were evaluated upon admission in 280 consecutive patients hospitalized with COVID-19-associated pneumonia in a single, tertiary care center. Patient clinical and laboratory characteristics and the concentration of biomarkers were correlated with in-hospital [Hospital stay: 11 days (10; 14)] and post-discharge all-cause mortality at 1 year follow-up [FU: 354 days (342; 361)].Results11 patients died while hospitalized for COVID-19 (3.9%), and 11 patients died during the 1-year post-discharge follow-up period (n = 11, 4.1%). Using multivariate analysis, VCAM-1 was shown to predict mortality during the hospital period (HR 1.081, CI 95% 1.035;1.129, p = 0.017), but not ST2 or hs-TnI. In contrast, during one-year FU post hospital discharge, ST2 (HR 1.006, 95% CI 1.002;1.009, p < 0.001) and hs-TnI (HR 1.362, 95% CI 1.050;1.766, p = 0.024) predicted mortality, although not VCAM-1.ConclusionIn patients hospitalized with Covid-19 pneumonia, elevated levels of VCAM-1 at admission were associated with in-hospital mortality, while ST2 and hs-TnI might predict post-discharge mortality in long term follow-up.

Nonadherence after hospital discharge in patients with schizophrenia or schizoaffective disorder: A six-month naturalistic follow-up study

BackgroundDespite a wealth of studies seeking to identify factors associated with nonadherence few consistent predictors have been determined, and several gaps still exist in the literature. MethodWe assessed 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder according to ICD-10 criteria. Assessments were performed during hospitalization and at six-months follow-up. Evaluation included sociodemographic, clinical, psychopathologic and treatment-related variables. Prevalence of nonadherence, associated variables, reasons for nonadherence and possible subtypes were explored. Adherence was defined as the concurrence of adherence to antipsychotic treatment and adherence to outpatient follow-up, during the six-month period. ResultsNonadherence was detected in 58.2% of patients. An identifiable profile was found in nonadherent patients. After multivariate logistic regression analysis, low socio-economic level (OR = 3.68; 95% CI = 1.42–9.53), current cannabis use or abuse (OR = 2.79; 95% CI = 1.07–7.28), nonadherence as a reason for relapse and admission (OR = 5.46; 95% CI = 2.00–14.90), and greater overall severity of symptoms at six months follow-up (OR = 2.00; 95% CI = 1.02–3.95) remained independently associated with nonadherence. Believing that medication is unnecessary was the most reported reason for nonadherence. For nonadherent patients (N = 64), two distinguishable subtypes were found: intentional nonadherence (N = 32; 50%), and unintentional nonadherence (N = 32; 50%). ConclusionsA large percentage of patients with schizophrenia or schizoaffective disorder did not adhere to their treatment in the post-discharge follow-up period. The profile identified may enable better prevention of this problem. Specific reasons for nonadherence should also be explored to provide individualized strategies.

Extended-release naltrexone for youth with opioid use disorder

BackgroundFew published research studies have examined the effectiveness of extended-release naltrexone (XR-NTX) for the treatment of opioid use disorder (OUD) among adolescents and young adults. MethodsThis two-group randomized controlled trial recruited 288 youth, ages 15–21, with moderate/severe OUD from a residential addiction treatment program in Baltimore, Maryland. The study randomized the youth within the first week of treatment entry to receive either XR-NTX or treatment-as-usual (TAU; either buprenorphine maintenance treatment or treatment without OUD medication following medically managed withdrawal) prior to discharge, with continued treatment in the community for 6 months. However, due to various reasons spanning patients' and caregivers' preferences and constraints, considerable participant nonadherence to randomized condition occurred (i.e., only 30% of the participants randomized to XR-NTX received an initial injection, while 27% of participants randomized to TAU received an XR-NTX injection at treatment discharge, instead of their assigned treatment). The study used generalized linear mixed modeling (GLiMM) to examine self-reported 90-day opioid, cocaine, marijuana, and alcohol use as well as DSM-5 OUD criteria on “intention-to-treat” (as randomized), “as-received” (XR-NTX vs. not XR-NTX), and “as-medicated” (XR-NTX vs. buprenorphine vs. no medication) bases. ResultsThe condition x time interactions in the intention-to-treat analyses failed to reach significance for past-90-day self-reported use of illicit opioids, cocaine, marijuana, or alcohol, or in meeting DSM-5 OUD criteria at 3 or 6 months [all ps > 0.05]. However, these findings are of limited interpretive value due to participant nonadherence to their randomized condition. When the study analyzed results by the treatment received at discharge, the “as-received” group x time interaction for illicit opioid use was significant [p = .003], with the XR-NTX group reporting less opioid use in the past 90 days at 3 and 6 months. Participants who received their first XR-NTX dose at inpatient discharge (n = 82) received, on average, 1.3 subsequent injections in the community over the 6-month study follow-up period. Only 2 of the 82 study participants received XR-NTX continuously through the 6-month postdischarge follow-up period. Twelve serious adverse events (SAEs) occurred during the study, but the study determined that only 1 was possibly study related (hepatitis C/elevated liver function test results). ConclusionNone of the condition x time interactions in the intention-to-treat analyses reached significance. Participants' nonadherence may have contributed to the failure to reject the null hypothesis. Irrespective of randomized condition, participants who received XR-NTX for OUD demonstrated low retention in treatment, receiving an average of only 1.3 subsequent injections, yet reported less opioid use at follow-up than participants who did not received XR-NTX. Treatment programs should consider XR-NTX as a treatment option for youth motivated to receive it. Future research should focus on building developmentally informed strategies to improve uptake of and adherence to relapse prevention medication in this population.

Cardio-Ankle Vascular Index Reflects Impaired Exercise Capacity and Predicts Adverse Prognosis in Patients With Heart Failure.

Aims: We aimed to assess the associations of CAVI with exercise capacity in heart failure (HF) patients. In addition, we further examined their prognosis.Methods: We collected the clinical data of 223 patients who had been hospitalized for decompensated HF and had undergone both CAVI and cardiopulmonary exercise testing.Results: For the prediction of an impaired peak oxygen uptake (VO2) of < 14 mL/kg/min, receiver-operating characteristic curve demonstrated that the cutoff value of CAVI was 8.9. In the multivariate logistic regression analysis for predicting impaired peak VO2, high CAVI was found to be an independent factor (odds ratio 2.343, P = 0.045). We divided these patients based on CAVI: the low-CAVI group (CAVI < 8.9, n = 145) and the high-CAVI group (CAVI ≥ 8.9, n = 78). Patient characteristics and post-discharge cardiac events were compared between the two groups. The high-CAVI group was older (69.0 vs. 58.0 years old, P < 0.001) and had lower body mass index (23.0 vs. 24.1 kg/m2, P = 0.013). During the post-discharge follow-up period of median 1,623 days, 58 cardiac events occurred. The Kaplan–Meier analysis demonstrated that the cardiac event rate was higher in the high-CAVI group than in the low-CAVI group (log–rank P = 0.004). The multivariate Cox proportional hazard analysis revealed that high CAVI was an independent predictor of cardiac events (hazard ratio 1.845, P = 0.035).Conclusion: High CAVI is independently associated with impaired exercise capacity and a high cardiac event rate in HF patients.

Risk Factors Associated with Ninety Day Readmission in Chronic Obstructive Pulmonary Disease Exacerbation at a Tertiary Care Hospital: A retrospective cohort study

Background Chronic obstructive pulmonary disease (COPD) exacerbation is a leading cause of frequent hospital admission. Globally, several studies have reported potential risk factors associated with COPD exacerbations which are largely unknown in Nepalese health care setting. Objective To identify the risk factors associated with hospital readmission within ninety days of discharge in acute COPD exacerbation. Method This is a hospital based retrospective cohort study conducted at Tribhuvan University Teaching Hospital. COPD patients admitted in respiratory ward from August 2019 to November 2019 were followed up till 90 days after discharge. Logistic regression analysis was performed at 95% Confidence Interval (CI) to identify risk factors for readmission in COPD exacerbation. Statistical analysis was performed using SPSS version 20.0. Result Of total 86 patients hospitalized for COPD, 42 (48.8%) had at least one subsequent readmission during post-discharge follow-up period of 90 days. Mean age of patients was 70.55±10.98 years. There were 45 (52.3%) males. Logistic regression analysis revealed preadmission domiciliary oxygen use (Odds Ratio (OR) 2.93; 95% CI 1.195- 7.202; p=0.019), admission in intensive care unit (ICU) (OR 3.060; 95% CI 1.145- 8.179; p=0.026), previous hospital admission for COPD exacerbation (OR 3.230; 95% CI 1.219-8.556; p=0.018), age (OR 0.946; 95% CI 0.905-0.988; p=0.012) and duration of hospital stay (OR 0.901; 95% CI 0.819-0.992; p=0.034) were independently associated with ninety day readmission in COPD patients. Conclusion Five clinical factors were found to be independently associated with COPD readmission in this study. Large multi-centre study at various health care levels is recommended to validate the potential risk factors in different populations and health care settings in Nepal.

Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure.

Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.

Abstract 13334: Cardio-ankle Vascular Index Reflects Impaired Exercise Capacity and Predicts Adverse Prognosis in Patients With Heart Failure

Aims: We aimed to clarify the associations of cardio-ankle vascular index (CAVI) with exercise capacity and prognosis in patients with heart failure (HF). Methods and Results: We recruited clinical data of total of 273 patients hospitalized for treatment of decompensated HF, and underwent both CAVI and cardiopulmonary exercise testing at stable condition in prior to hospital discharge. For the prediction of impaired peak oxygen uptake (VO 2 ) of &lt; 14 mL/kg/min, receiver-operating characteristic curve demonstrated that the cutoff value of CAVI was 8.9. According to the multiple logistic regression analysis, high CAVI was independently associated with impaired peak VO 2 (odds ratio 2.055, 95% confidence interval 1.015-3.960, P = 0.045). We divided these patients based on CAVI: the low CAVI group (CAVI &lt; 8.9, n = 178, 65.2%) and the high CAVI group (CAVI ≥ 8.9, n = 95, 34.8%). We compared the patients’ characteristics and cardiac events such as cardiac death and re-hospitalization due to worsening HF between the two groups. The high CAVI group was older (69.0 vs. 58.0 years old, P &lt; 0.001) and showed lower body mass index (22.9 vs. 23.8 kg/m 2 , P = 0.018). With respect to laboratory data, levels of estimated glomerular filtration rate were lower in the high CAVI group than in the low CAVI group (56.1 vs. 64.2 mL/min/1.73 m 2 , P = 0.001). During the post-discharge follow-up period of median 1,544 days, 76 cardiac events occurred. The Kaplan-Meier analysis showed that cardiac event rates was higher in the high CAVI group than in the low CAVI group ( Figure , Log-rank P = 0.021). In the multivariable Cox proportional hazard analysis, high CAVI was found to be an independent predictor of cardiac events (hazard ratio 1.765, 95% confidence interval 1.123-2.773, P = 0.014). Conclusions: High CAVI independently associated with impaired exercise capacity accompanied by a high cardiac event rate in HF patients.

Mental Health Status of Survivors Following COVID-19 in Wuhan, China: A Descriptive Study

Background: Inpatients with coronavirus disease 2019 (COVID-19) have been well depicted in clinical characteristics. However, few studies reported post-discharge conditions, especially mental health status, for survivors following COVID-19. In this study, we aimed to first report mental health status in COVID-19 survivors and explore relevant influence factors. Methods: In this descriptive case series, we enrolled a population of 370 COVID-19 survivors in Wuhan Jinyintan Hospital, China. Survivors were discharged during Jan 4 and Feb 12, 2020. Telephone follow-up was conducted. Readmission status and post-discharge symptoms and signs were inquired. Mental health conditions of anxiety and depression were assessed using The Generalized Anxiety Disorder Screener (GAD-7) and Patient Health Questionnaire-9 (PHQ-9), respectively. Results: The median post-discharge follow-up period was 22 days (interquartile range 20~30 days). Of the 370 COVID-19 survivors, no survivors were readmitted due to recurrence of SARS-CoV-2-positive pneumonia. Sixty (16.2%) survivors had post-discharge cough and 45 (12.2%) had breathlessness after activity. One hundred and seventy-three (46.8%) survivors worried about recurrence and 174 (47.0%) worried about infection to others such as their family. Two hundred and ninety-three (79.2%) survivors took a home quarantine lifestyle. Fifty (13.5%) survivors occurred anxiety and 40 (10.8%) survivors occurred depression. Survivors were most bothered by sleeping disorders (29.5%). Four survivors (1.1%) once had thoughts of suicide in several days. Three hundred and fifty-six (96.2%) survivors were willing to return to hospital for health examination. Anxiety was significantly associated with post-discharge respiratory symptoms, worry about recurrence and worry about infection to others (P<0.05). Depression was significantly associated with gender of female, post-discharge respiratory symptoms, worry about recurrence, worry about infection to others and home quarantine lifestyle (P<0.05). Interpretation: About 10 percent of COVID-19 survivors would develop anxiety or depression, because of post-discharge residual respiratory symptoms, worry about recurrence and infection to others. We clinicians and psychiatrists must pay attention to mental health care for these survivors. We need to explain to COVID-19 survivors that they should not be overly worried about residual respiratory symptoms and a rare event of recurrence. In addition, depression caused by home quarantine lifestyle should also be noted and relieved. Funding Statement: This study was supported by The National Natural Science Foundation of China (NSFC) (81972393, 81772705, 31570775), NSFC (81630001, 81770075), Shanghai Municipal Key Clinical Specialty (shslczdzk02201) and Shanghai Top-Priority Clinical Key Disciplines Construction Project (2017ZZ02013), Sub-specialist project of Qingpu Branch of Zhongshan Hospital, Fudan university (YZK 2019-04), 2019 Hospital-level National Natural Science Foundation Incubation Project (QYP 2019-03), Science and technology development fund of Qingpu district science and technology commission in 2018 (QKY 2018-01), Academic Leader of Shanghai Qingpu District Healthcare Commission (WD2019-36), Shanghai key discipline of medicine (ZK2019B07 SZ2019- 1), NSFC(81870035), Project of Shanghai municipal commission of health and family planning (201740210). Declaration of Interests: All authors declared that they have no Conflicts of Interest. Ethics Approval Statement: This study was approved by the Ethics Committee of Jinyintan Hospital in Wuhan, China.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-componentdifferences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. Level II, economic analysis.

Impact of symptom onset to first medical contact time on the prognosis of patients with acute ST-segment elevation myocardial infarction

Objective: To investigate the impact of symptom onset to first medical contact (SO-to-FMC)time on the prognosis of patients with acute ST-segment elevation myocardial infarction(STEMI). Methods: The clinical data of 341 consecutive STEMI patients, who were hospitalized to our hospital and received primary percutaneous coronary intervention(PCI) from August 2011 to April 2016, were retrospectively analyzed. The patients were divided into ≤90 min group (201 cases) and >90 min group (140 cases) according to the SO-to-FMC time. The treatment time, mortality and incidence of major adverse cardiac and cerebro-vascular events(MACCE) were analyzed. The risk factor of 1-year mortality after PCI and 1-year incidence of MACCE during the post-discharge follow-up period were analyzed by binary logistic regression analysis. The predictor of 4.5-year mortality after PCI was analyzed by multivariate Cox regression analysis. Methods The door to balloon time (104(88, 125) min vs. 111(92, 144)min, P=0.023), first medical contact to balloon time(146(119, 197) min vs. 177(125, 237)min, P=0.005), and symptom onset-to-balloon time(200(170, 257) min vs. 338(270, 474)min, P<0.001)were all significantly shorter in the ≤90 min group than in>90 min group. The 30-day mortality (2.99% (6/201) vs. 7.86%(11/140), P=0.042), 1-year mortality (2.89 (5/173) vs. 9.57(11/115), P=0.015), 1-year incidence of MACCE during the post-discharge follow-up period(1.16%(2/173) vs. 6.96%(8/115), P=0.021), and 4.5-year cumulative mortality(3.00% vs. 11.20%, P=0.007) after PCI were significantly lower in the ≤90 min group than in the >90 min group. Moreover, the 4.5-year incidence with free of MACCE (97.20% vs. 88.80%, P=0.025) during the post-discharge follow-up period was significantly higher in the ≤90 min group than in the >90 min group. In-hospital mortality was similar between the two groups (2.49%(5/201) vs. 6.43%(9/140), P=0.071). Results: The door to balloon time (104(88, 125) min vs. 111(92, 144)min, P=0.023) , first medical contact to balloon time(146(119, 197) min vs. 177(125, 237)min, P=0.005), and symptom onset-to-balloon time(200(170, 257) min vs. 338(270, 474)min, P<0.001) were all significantly shorter in the ≤90 min group than in >90 min group. The 30-day mortality(2.99% (6/201) vs. 7.86%(11/140), P=0.042), 1-year mortality (2.89(5/173) vs. 9.57(11/115), P=0.015), 1-year incidence of MACCE during the post-discharge follow-up period (1.16%(2/173) vs. 6.96%(8/115), P=0.021), and 4.5-year cumulative mortality (3.00% vs. 11.20%, P=0.007) after PCI were significantly lower in the ≤90 min group than in the >90 min group. Moreover, the 4.5-year incidence with free of MACCE (97.20% vs. 88.80%, P=0.025) during the post-discharge follow-up period was significantly higher in the ≤90 min group than in the >90 min group. In-hospital mortality was similar between the two groups (2.49%(5/201) vs. 6.43%(9/140), P=0.071). Results of binary logistic regression analysis showed that the SO-to-FMC time >90 min was the risk factor of 1-year mortality(OR=2.90, 95%CI 1.22-6.92, P=0.016) and 1-year incidence of MACCE (OR=5.19, 95%CI 1.21-22.20, P=0.026) during the post-discharge follow-up period. Multivariate Cox regression analysis demonstrated that the SO-to-FMC time >90 min was the risk factor of 4.5-year mortality after PCI in patients with STEMI (HR=2.88, 95%CI 1.10-7.53, P=0.031). Conclusion: Shorting the SO-to-FMC time can significantly reduce the treatment time of STEMI patients, short and long-term mortalities and the incidence of MACCE, and improve the prognosis of patients with STEMI.

Predictors of short-term outcome variables in hospitalised female adolescents with eating disorders

Objective: Research in eating disorders (EDs) suggests that outcome variables other than that of the ED per se, such as the presence of comorbid disorders and overall functioning at follow-up, may influence the ED condition at that time. We sought to assess the factors potentially predicting these different outcome variables.Methods: Eighty-eight female adolescent in-patients with an ED were assessed on admission, discharge, and around one-year post-discharge using clinical interviews and self-rating questionnaires assessing ED and other relevant symptoms.Results: The mean body mass index (BMI) of patients with anorexia nervosa increased from admission to discharge and was maintained at follow-up. Twenty-eight patients were remitted at follow-up, whereas 48 and 12 patients had intermediate and poor ED-related outcome, respectively. Follow-up BMI was correlated with baseline BMI. Good ED-related outcome at follow-up according to accepted criteria was associated with more lifetime suicide attempts and more severe baseline ED symptomatology. Elevated psychiatric comorbidity at follow-up was associated with elevated baseline anxiety and with re-hospitalisation during the post-discharge follow-up period. Better academic/occupational functioning and social functioning at follow-up were associated with less lifetime suicide attempts, less re-hospitalisation and lower baseline anxiety.Conclusions: In EDs, diverse factors may predict different outcome variables.

Ultrasound-Assisted Catheter-Directed Thrombolysis in High-Risk and Intermediate-High-Risk Pulmonary Embolism: Results From a Single-Center Cohort.

We present our single-center results on ultrasound-assisted thrombolysis (USAT) in patients with pulmonary embolism (PE) at intermediate high risk (IHR) and high risk (HR). Our study consisted of 75 patients with PE who underwent USAT (60 at IHR and 15 at HR). The median time delay from symptoms to USAT was 5 days. Ultrasound-assisted thrombolysis resulted in improvements in tricuspid annular plane systolic excursion; pulmonary artery (PA) systolic and mean pressures; Qanadli score; right to left ventricle diameter ratio and right to left atrial diameter ratio; and diameters of main, right, and left PA regardless of the baseline risk status ( P < .0001 for all). Death was documented in 4 patients, and major and minor bleeding were noted in 2 and 5 of the patients, respectively. No PE-related event was noted during postdischarge follow-up period of median 310 days. Our study revealed that USAT facilitates the resolution of PA thrombotic burden, recovery of pulmonary hemodynamics, and right heart functions with acceptable rates of procedure-related complications in patients with PE, irrespective of the IHR or HR status.

Extracranial Internal Carotid Artery Dissection Treated with Self-expandable Stents: A Single-Centre Experience.

Treatment of choice for the internal carotid artery dissection (ICAD) is anticoagulation for three to 6 months. Endovascular procedures may be a promising alternative for patients (pts) with haemodynamic impairment, recurrent ischaemic symptoms or symptomatic pseudoaneurysms. Thus, the purpose of this study was to evaluate the efficacy and safety of carotid artery stenting in treatment of selected pts with extracranial ICAD. This study involved 18 symptomatic pts with the mean age of 44.6 ± 10.4 years with ICAD treated with the use of self-expandable stents. Six months after primary procedures, pts were readmitted to hospital and physical examination followed by cerebral angiography was performed. In the late follow-up period, clinical evaluations completed by duplex Doppler ultrasonography were carried out every 6 months and at the end of the follow-up period. Nobody died and no life-threatening adverse events were observed during either the in-hospital stay or post-discharge follow-up period (median 21 months). Stent deployment immediately restored flow in the true lumen of ICA in all cases. However, residual blood flow through the false lumen was observed in one pt. Complete resolution of clinical symptoms was observed in 14 pts (78%), partial improvement in 2 (11%) and persistence of neurological deficit in 2 (11%). Implantation of self-expandable stents in treatment of selected extracranial ICAD cases is safe. This method may enable us to restore immediately and usually permanently proper arterial blood flow in the ICA and in consequence lead to significant clinical improvement in the late follow-up period.

Patterns and predictors of sleep quality before, during, and after hospitalization in older adults.

The impact of hospitalization on sleep in late-life is underexplored. The current study examined patterns of sleep quality before, during, and following hospitalization, investigated predictors of sleep quality patterns, and examined predictors of classification discordance between two suggested clinical cutoffs used to demarcate poor/good sleep. This study included older adults (n = 163; mean age 79.7 ± 6.9 years, 31% female) undergoing inpatient post-acute rehabilitation. Upon admission to inpatient post-acute rehabilitation, patients completed the Pittsburgh Sleep Quality Index (PSQI) retrospectively regarding their sleep prior to hospitalization. They subsequently completed the PSQI at discharge, and 3 months, 6 months, 9 months, and 1 year post discharge. Patient demographic and clinical characteristics (pain, depression, cognition, comorbidity) were collected upon admission. Using latent class analysis methods, older adults could be classified into (1) Consistently Good Sleepers and (2) Chronically Poor Sleepers based on patterns of self-reported sleep quality pre-illness, during, and up to 1 year following inpatient rehabilitation. This pattern was maintained regardless of the clinical cutoff employed (> 5 or > 8). Logistic regression analyses indicated that higher pain and depressive symptoms were consistently associated with an increased likelihood of being classified as a chronic poor sleeper. While there was substantial classification discordance based on clinical cutoff employed, no significant predictors of this discordance emerged. Clinicians should exercise caution in assessing sleep quality in inpatient settings. Alterations in the cutoffs employed may result in discordant clinical classifications of older adults. Pain and depression warrant detailed considerations when working with older adults on inpatient units when poor sleep is a concern.

Early and long-term outcomes of pericardiotomy in the treatment of primary cardiac tamponade.

IntroductionCardiac tamponade is a life-threatening clinical entity that requires emergent treatment. A variety of therapeutic methods have been applied. The purpose of this retrospective analysis was to study the efficacy of emergent surgical pericardiotomy in both the relief of cardiac tamponade and in the prevention of recurrence of pericardial effusion.Material and methodsThis study involved 90 consecutive patients (58 males and 32 females) with a mean age of 57.4 ± 14.1 years, who underwent emergent pericardiotomy in the years 2006 to 2011 due to symptomatic primary cardiac tamponade. At the end of the follow-up period all living subjects had control echocardiographic examination. Survival analysis was performed with the use of the Kaplan-Meier method.ResultsThe mean duration time of surgery was 14.2 ± 4.5 minutes. All patients survived surgery but one died during in-hospital stay. During the post-discharge follow-up period (median 49 months) 32 patients died for any reason. One-year and four-year probability of survival was 0.68 ± 0.05 and 0.64 ± 0.05, respectively. Malignancy diagnosis was associated with significant negative impact on survival. One-year and four-year probability of survival was 0.56 ± 0.06 and 0.53 ± 0.06 for cancer patients while it was 0.93 ± 0.05 and 0.89 ± 0.06 for the others, respectively. In two cases, only cancer patients, re-intervention due to effusion recurrence was necessary.ConclusionsPericardiotomy, although invasive, is a safe method to relieve cardiac tamponade. It is also very efficient in the prevention of recurrence of pericardial effusion, even in cancer patients.

Early and long-term results of cardiosurgical treatment of coronary artery disease and aortic stenosis in patients over 80 years old.

BackgroundIn recent years, patients over 80 years of age have been a growing group of individuals referred to cardiac surgeons. They pose a serious challenge and usually require a multidisciplinary approach.AimThe aim of this study was to evaluate the early and late outcomes of cardiosurgical treatment of patients over 80 years of age suffering from coronary artery disease and aortic stenosis.Material and methodsThe study involved 96 patients aged over 80 years treated between January, 2004 and December, 2012. The mortality and morbidity in the early postoperative period, as well as throughout the follow-up period, were analyzed.ResultsThe majority of patients underwent isolated coronary artery bypass grafting (CABG) (58.3%; Group I), while 29.2% of them underwent an isolated aortic valve replacement (AVR) (Group II). Combined procedures (CABG + AVR) were carried out in 12.5% of patients (Group III). The mean operational risk calculated according to the logistic EuroSCORE was 11.6%, 11.9%, and 9.5%, respectively in Group I, Group II and in Group III. In the early postoperative period, 4 patients died (all from Group I). The 30-day mortality rate was 4.2% and the morbidity rate was 56.3%. During the post-discharge follow-up period that lasted from 1 to 100 months, 4 patients died (2 from Group I and 2 from Group III). The 2-year probability of survival was 91.9 ± 3.0%. During the last follow-up clinical assessment, half of the patients were asymptomatic.ConclusionsThe perioperative mortality of the patients is acceptably and markedly lower than that predicted by the logistic EuroSCORE calculator. However, the complication rate, particularly in the early postoperative period, is relatively high.

U-Health: an example of a high-quality individualized healthcare service.

National Taiwan University Hospital (Taipei, Taiwan), which is one of the largest hospitals in Taiwan, is undergoing healthcare service reforms: it is combining the home healthcare service network and sensors network into a new service known as the Ubiquitous Healthcare (U-Health) service system in order to continually provide a personalized healthcare service to patients who live in remote areas. The U-Health service system is comprised of six service components that are introduced in an integrated manner: tele-education, telediagnosis, telemonitoring, teleconsultation, teletherapy and lifetime health. The target patient segments are postdischarge patients, patients suffering from cardiovascular diseases, patients suffering from chronic diseases and patients in hospice care. Since its launch in October 2009, the U-Health service system has effectively reduced the rehospitalization rate from 12% in October 2009 to 6% in May 2010 and the rate of visiting the emergency room from 21% in October 2009 to 9% in May 2010, during the 14-day postdischarge follow-up period.

Successful Treatment of Paraquat Poisoning by Xuebijing, an Injection Concocted from Multiple Chinese Medicinal Herbs: A Case Report

1,1'-Dimethyl-4,4'-bipyridinium dichloride (Paraquat) poisoning remains a significant global health problem. Despite noteworthy research and clinical efforts worldwide in the last few decades, little improvement has been made in reducing fatality from Paraquat poisoning with conventional treatment strategies. We herein report a case of successful management of Paraquat poisoning by Xuebijing, a newly developed injection concocted from multiple traditional Chinese medicinal herbs. A 25-year-old male patient was brought to the Emergency Department at the First Affiliated Hospital of Jilin University in Changchun, China approximately 23 hours after ingestion of approximately 50 mL of 20% (w/v) Paraquat in a suicide attempt. On admission, the patient presented with clinical symptoms as well as significantly abnormal results in the liver and kidney function tests that were typical of severe Paraquat poisoning. Following the routine emergency procedures for pesticide poisoning to minimize the poison exposure and relieve the poisoning symptoms, an intravenous drip of Xuebijing together with dexamethasone was given daily to the patient until discharge 10 days after admission. The patient was followed up for 15 months after discharge, during which monthly chest radiography was performed. Treatment outcomes: At the time of discharge, the patient had recovered well: His symptoms of poisoning in the mouth and gastrointestinal tract were all diminishing; his liver and kidney functions were recovering with the major test parameters improving; his chest radiograph was clear, showing no signs of pulmonary fibrosis. During the postdischarge follow-up period, the monthly chest radiographs were all normal. This case report suggests that Xuebijing has great potential as a novel effective alternative to the conventional management of Paraquat poisoning. This potential needs to be further evaluated in a substantially larger number of clinical cases in the future.