Repeat Hospitalization Research Articles

Validating the Brain Injury Guidelines in a Pediatric Population with Mild Traumatic Brain Injury and Intracranial Injury at a Level I Trauma Center.

Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017-2023) using an institutional registry. Patients included (0-17 years) had an initial head computerized tomography scan with ICI and a GCS of 14-15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome.

Analysis of emergency centre recidivism for interpersonal violence in a district-level hospital in Cape Town, South Africa.

Interpersonal violence is a major cause of morbidity and mortality in low- and upper-middle-income countries. It is postulated that a significant portion of these patients have repeated presentations to an already overburdened healthcare system. Data describing the burden of interpersonal violence recidivism are poor. To determine and describe the burden of emergency centre recidivism for interpersonal violent injury presenting to Khayelitsha Hospital, Cape Town, over a 2-year period. An analysis of a prospectively collected observational database combined with a retrospective chart review was conducted of all trauma patients who presented to Khayelitsha Hospital from 1 October 2020 to 30 September 2022. All patients (aged ≥14 years) with ≥2 presentations for interpersonal violence-related injuries were included. Cases were limited to the inclusion of mechanisms of injury attributable to stab wounds, blunt assault, firearm injury and gender-based violence. Recidivist cases were identified by repeat hospital number on the electronic hospital patient system. Repeat cases were manually reviewed for inclusion. Summary statistics are used to describe all variables. In total, 10 218 interpersonal violence presentations were identified over the study period, and 1 125 (11.0%) were attributed to recidivists (522 patients). The mean (standard deviation) age was 30 (7.7) years, and most were male (n=463, 88.7%). Stab wounds (n=583, 51.8%) and blunt assault injuries (n=456, 40.5%) were the main mechanisms of injury. Repeat presentation occurred within a median of 198 (25th - 75th percentile, 81.5 - 373.9) days. A total of 337 (64.6%) patients presented with higher acuity at one of their subsequent visits. Recidivist presentations represent a significant proportion of interpersonally violently injured patients, and are likely to be under-documented. Recidivism poses a measurable burden, and further research is needed to facilitate the identification of at-risk individuals, and specific secondary prevention strategies should be developed to prevent or reduce escalating patterns of injury associated with interpersonal violence.

Safe transition home after transcatheter aortic valve implantation feasibility (START-F) study: Very early self-reported function and recovery status after early discharge

Abstract Background Despite significant excellent outcomes and significant improvements in rapid recovery protocols and early discharge, rates of 30-day readmission after transcatheter aortic valve implantation (TAVI) remain stubbornly high. There can be numerous drivers for readmission in older people with valvular heart disease; the time of transition home is the period of greatest risk when patients are most vulnerable to repeat hospitalization. We sought to assess patients’ early recovery (&amp;lt; post-procedure day 3) to inform the evaluation of a nurse-led telephone intervention to mitigate the risks of 30-day readmission after early (1 day) discharge TAVI. Methods We conducted a prospective observational cohort feasibility study in five Canadian TAVI programs to ascertain acceptability, compliance, delivery of the intervention, recruitment and retention. In this preliminary report, we assessed key indicators of patients’ status at the time of discharge and functional status in their early recovery. Results We recruited 188 participants, mean age 81.6 years (SD=7.0), 41.5% women with baseline mean KKCQ 53.4 (SD=20.1). Patients were admitted on the day of the procedure, and underwent TAVI with a balloon-expandable (n=146, 77.6%) or self-expanding (n=30, 16.0%) device, with local anaesthesia +/- light sedation (n=171, 90.1%) or general anaesthesia (n=17, 9.0%). There was 1 in-hospital death (0.5%) and 182 (97.4%) were discharged home. At the time of the 3-day telephone follow-up, 168 (95.5%) reported that an individual had stayed with them during the first 24 hours [spouse: 85 (48.9%); friend: 77 (44.3%)], and 165 (93.3%; missing: 11) were able to complete all activities of daily living, including cooking their own meals (n=80, 45.5%). Self-reported energy was low/very low for 49 participants (26.1%), moderate for 93 (52.8%), and high/very high for 34 (18.1%), with 104 (55.3%) describing feeling somewhat or quite a bit better than before TAVI, and 24 (12.8%) somewhat or quite a bit worse. Bruising was present in 120 participants (68.6%) and 137 (78.8%) had removed their bandage as instructed. 18 participants were readmitted within 30 days, including 14 cardiac-related events. Conclusion This is one of the first reports of TAVI patients’ self-reported function following next-day discharge, providing novel evidence that most patients describe safe self-care and very early improved functional status. Research is needed to identify and support patients who are at higher risk of poorer trajectories of recovery and readmission, and report the feasibility of a nurse-led intervention to mitigate these risks.

Right atrial and ventricular function in risk stratification of patients with pulmonary artery hypertension

Abstract Background Right atrial (RA) phasic function was proved to be impaired in individuals with pulmonary arterial hypertension (PAH), the awareness of the nonnegligible involvement of RA in the clinical course of PAH was raised. However, evidence for the clinical significance of the RA strain in prognostication and risk stratification for PAH patients was limited. Method Participants diagnosed with PAH from June 2013 to December 2022 in West China Hospital were prospectively and continuously recruited. The primary endpoint was all-cause mortality, and the second endpoint was a combination of all-cause mortality and heart failure-related repeat hospitalization. Cox regression analysis and Kaplan Meier survival analysis were performed to identify the association between variables and outcomes. C-index, 1-year mortality, and annual event rate were performed to confirm the value of RA strain in PAH patients’ risk stratification. Result A total of 283 participants (mean age, 38 ± 14 years, 84 male) were finally included, following a median follow-up duration of 31.5 months (interquartile range: 15.1-53.9 months). Significant decreases in RA reservoir (p&amp;lt;.001), conduit (p&amp;lt;.001), booster pump function (p&amp;lt;.001), right ventricular global longitudinal strain (RVGLS, p&amp;lt;.001), and free-wall longitudinal strain (RV-FWLS, p&amp;lt;.001) were observed in participants with all-cause mortality than those who survived. Using 16.1% and 23.6% as thresholds for RA reservoir strain, PAH patients could be divided into low-, intermediate, and high-risk groups well, with calculated 1-year mortality of 1.8%, 6.9%, and 21.4%. Moreover, RA reservoir strain presented with better 1-year mortality predictive performance than RV-FWLS (C-index, 0.82 [0.72-0.92] vs 0.72 [0.62-0.82], p&amp;lt;.001). The addition of RA reservoir strain had significantly increased the power of both REVEAL Lite2 and Comparative, Prospective Registry of Newly initiated Therapies for Pulmonary Hypertension (COMPERA) models (both p&amp;lt;.001). Conclusion RA reservoir strain was an independent predictor of all-cause mortality in individuals with pulmonary arterial hypertension and could be used to stratify participants into different risk stratification stratum.

Post Artesunate Delayed Hemolysis in Pediatric Patients in the United States

Abstract Background Malaria continues to pose a major threat to global public health, causing millions of infections and hundreds of thousands of deaths each year. Intravenous artesunate is the current first line therapy for severe malaria and has substantially reduced its mortality. Some patients develop severe delayed hemolysis after artesunate therapy, a phenomenon termed post artesunate delayed hemolysis (PADH). A recent study of U.S. adults treated with artesunate found that 2.7% of patients experienced PADH and 56% of those patients required blood transfusion. Thus, the U.S. Food and Drug Administration recommends that patients treated with artesunate receive weekly post-treatment monitoring of hemoglobin and hemolytic markers for four weeks after therapy. While PADH in adults frequently requires blood transfusion, the frequency and severity of PADH in pediatric patients in non-endemic countries is not known. Understanding the risk of PADH in pediatric patients is essential to determine appropriate monitoring for this condition. Methods Multicenter Retrospective Chart Review To estimate rates of PADH in pediatric patients (0-18 years of age), we used ICD-10 diagnosis codes to identify patients treated for malaria at seven hospitals (The Children’s Hospital of Philadelphia, Riley Hospital for Children, Texas Children’s Hospital, Seattle Children’s Hospital, UCSF Benioff Children’s Hospital, NYU Langone Medical Center, and Bellevue Hospital), between April 2017 and July 2022. We reviewed post-discharge laboratory values and clinic visits to identify patients with laboratory findings of PADH and determine clinical outcomes. Pediatric Health Information System (PHIS) Database Review To estimate rates of severe PADH requiring repeat emergency room visit or hospitalization, we used ICD-10 diagnosis codes to identify patients who were treated for malaria with artesunate between January 2019 and July 2023 in a database of 49 children’s hospitals (PHIS). We reviewed patient visits within eight weeks of treatment to identify patients with repeat presentations related to anemia or hemolysis. Results In our retrospective chart review, four of seventeen patients (25%) treated with artesunate had laboratory evidence of PADH. None of these patients were symptomatic and none required readmission or medical intervention. Haptoglobin levels remained low in most patients up to four weeks after treatment, regardless of the presence of PADH, and lactate dehydrogenase (LDH) levels slowly declined over this period. We identified 92 patients in the PHIS database who were treated with artesunate. Of these, three patients (3.3%) had a repeat presentation within four weeks with one or more diagnosis suggestive of new onset anemia. Repeat presentations occurred 5-13 days after initial admission for malaria. Conclusion PADH is common in US pediatric patients treated with artesunate for severe malaria. However, severe hemolysis requiring repeat emergency room visit or readmission is rare. We find that haptoglobin and LDH levels were not useful as initial screening labs for PADH in pediatric patients. Together, our findings call into question the utility of weekly laboratory monitoring, as opposed to symptom-based monitoring, to identify pediatric patients at risk of readmission for PADH. Additional studies are necessary to determine which patients would benefit from weekly laboratory monitoring and which can be monitored clinically.

Person-centred crisis support services as alternatives to emergency departments: a systematic scoping review.

To identify, critically appraise, and synthesise the published and grey literature on person-centred crisis support services as an alternative to support in emergency departments (EDs) for people experiencing mental health crises. This scoping review explores the characteristics and outcomes of these services. A systematic scoping review was undertaken to identify publications describing person-centred crisis support services and their outcomes. Search strings were applied to multiple databases, and publications were subjected to quality appraisal. The review process was informed by The Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Thirteen publications were included in the narrative synthesis, and these considered eight separate crisis support services. The methodological quality of the publications included was limited. Key findings were positive visitors' experiences, high rates of ED deflection, and overlaps between repeat visits, crises prevention, and hospital avoidance. Key recommendations included increasing opening hours and capacity and improving service awareness and accessibility. The available evidence suggests that person-centred crisis support services are perceived by stakeholders as safe and effective alternatives to EDs for people experiencing mental health crises, providing more timely and appropriate care while reducing ED mental health presentations. Due to the limited quality of the publications included, high-quality research is needed to better understand the model and confirm the findings reported in this review.

Behavioral, Cognitive, and Functional Risk Factors for Repeat Hospital Episodes Among Medicare-Medicaid Dually Eligible Adults Receiving Long-Term Services and Supports.

Repeat hospitalizations adversely impact the well-being of adults dually eligible for Medicare and Medicaid in the United States. This study aimed to identify behavioral, cognitive, and functional characteristics associated with the risk of a repeat hospital episode (HE) among the statewide population of dually eligible adults in Maryland receiving long-term services and supports prior to an HE between July 2018 and May 2020. The odds of experiencing a repeat HE within 30 days after an initial HE were positively associated with reporting difficulty with hearing (adjusted odds ratio, AOR: 1.10 [95% confidence interval: 1.02-1.19]), being easily distractible (AOR: 1.09 [1.00-1.18]), being self-injurious (AOR: 1.33 [1.09-1.63]), and exhibiting verbal abuse (AOR: 1.15 [1.02-1.30]). Conversely, displaying inappropriate public behavior (AOR: 0.62 [0.42-0.92]) and being dependent for eating (AOR: 0.91 [0.83-0.99]) or bathing (AOR: 0.79 [0.67-0.92]) were associated with reduced odds of a repeat HE. We also observed differences in the magnitude and direction of these associations among adults 65 years of age or older relative to younger counterparts.

Assessing the implementation of a tertiary care comprehensive pediatric asthma education program using electronic medical records and decision support tools

Background Self-management education is integral for proper asthma management. However, there is an accessibility gap to self-management education following asthma hospitalizations. Most pediatric patients and their families receive suboptimal or no education. Objective To implement a comprehensive pediatric asthma education program and evaluate subsequent self-management knowledge in patients as well as behavior change outcomes reflected in the frequency of asthma related repeat emergency department visits and hospitalization. The program implementation was informed by the Knowledge to Translation Action Framework and the i-PARIHS model for quality improvement and involved several iterative stages. Methods We implemented a comprehensive asthma education program for the families of all children 0-18 years old who had been admitted for an asthma exacerbation to the Children’s Hospital of Eastern Ontario (CHEO), beginning on April 1, 2018. The program was adapted to the stages of the Knowledge Translation to Action Framework including undertaking an environmental scan, expert stakeholder feedback, reviews, addressing barriers, and tailoring the intervention, along with evaluating knowledge and health outcomes. Education was delivered over 1-2 h in personalized individual or small group settings, within 4 wk of hospital discharge. All education was provided by registered nurses or respiratory therapists who were also certified asthma educators. The EPIC electronic medical record was used to facilitate referral and scheduling of asthma education sessions, and to track subsequent acute asthma visits. We compared the frequency of a repeat asthma emergency department (ED) visit or hospitalization within 1-year following an initial asthma hospitalization for children who would have received comprehensive asthma education, to a historical cohort of children who were hospitalized between April 9, 2017 – Apr 8, 2018, and did not receive asthma education. Results The program had a high enrollment, capturing nearly 75% of the target population. Most families found the program to be acceptable and reported increased knowledge of how to manage asthma. We identified a crude overall 54% reduction in repeat hospitalizations among children 1 year after implementation of the asthma education program (i.e. 10.2% (23/225) repeat hospitalization rate pre- implementation versus 4.8% (11/227) post-implementation). In adjusted time-to event analysis, this reduction was prominent at 3 months among those who received comprehensive asthma education, relative to those who did not, but this improvement was not sustained by 1 year (HR =1.1, 95% CI =0.55- 2.05; p-value = 0.6). Discussion Although we did not find long-term improvements in ED visits, or hospitalizations, in children of caregivers who participated in comprehensive asthma education, the asthma education program holds potential given that most patients found it to be acceptable and that it increased asthma management knowledge. A future asthma education program should include multiple sessions to ensure that the knowledge and behavior change will be sustained, leading ultimately to long-term reductions in repeat ED visits and hospitalizations.

813. SELF-DILATATION FOR THE MANAGEMENT OF REFRACTORY BENIGN OESOPHAGEAL STRICTURES: OUTCOMES FROM THE LARGEST EUROPEAN TERTIARY CENTRE EXPERIENCE TO DATE

Abstract Background Benign oesophageal strictures are commonly encountered in endoscopy and are often effectively managed with endoscopic dilatation. However, up to 40% of patients may develop refractory benign oesophageal strictures (RBES), necessitating frequent endoscopic interventions that are often challenging, pose a greater risk of complications, and negatively impact quality of life. Oesophageal self-dilatation (SD) offers an alternative treatment that potentially reduces the need for repeat hospital visits while allowing patients greater autonomy in managing their condition. We describe the efficacy and safety of oesophageal SD at a tertiary referral centre. Methods We retrospectively reviewed the electronic records of patients with RBES (n=43) who were referred for SD to our centre between 2013 and 2024. The primary outcomes were the endoscopic dilatation-free interval (EDFI; longest period of time patients did not require endoscopic dilatation) and the number of endoscopic procedures performed within 12 months of starting SD. Secondary outcomes included the technical success rate of learning SD, improvement in the Dakkak and Bennett dysphagia score, and complications. Results are reported as median (interquartile range). Results 41/43 patients (median age 57 years) with various RBES aetiologies (32% peptic, 19.5% post-radiation, 12% post-surgical, 11.6% post-endoscopic resection, 24.9% other) and locations (24.4% proximal, 29.3% middle, 34.1% lower, 12.2% multi-segment) successfully learned SD. Median follow-up was 23.2 months. The EDFI increased from 68.5 (41-106) to 161 (121-279) days (P&amp;lt;0.001) while endoscopic interventions decreased from 7 (4.7-10) to 1 (0.75-3) (P&amp;lt;0.001) within 12 months before and after SD. The all-time EDFI was 405 days (130-705) and dysphagia score improved from 2 at baseline to 0 after SD. One patient experienced clinically significant haematemesis and one presumed SD-related oesophageal perforation. Conclusion To our knowledge, we have described the largest European case series of oesophageal SD that has been published to date. Oesophageal SD appears to be an effective, well-tolerated, and safe approach in managing often complex patients with RBES providing a viable alternative to conventional endoscopic interventions. However, the occurrence of adverse events highlights the importance of careful patient selection and ongoing monitoring. Further research is warranted to validate these findings and identify predictive factors for treatment success.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow Up Study to Evaluate Acute Safety and Device Procedural Success of ADVAMRYL (Poliglecaprone 25) Surgical Suture. (ADVAMRYL PMCF Study)

In this real-world experience Post-Marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 70 subjects from &gt;60 surgical centers across various surgical specialties, ADVAMRYL (Poliglecaprone 25) monofilament, synthetic absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVAMRYL (Poliglecaprone 25) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow up Study to Evaluate Acute Safety and Device Procedural Success of ADVACRYL RAPID (Braided Coated Polyglactin 910) Surgical Suture. (ADVACRYL RAPID PMCF Study)

In this real-world experience Post-Marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 70 subjects from &gt;50 surgical centers across various surgical specialties, ADVACRYL RAPID (Polyglactin 910) braided, synthetic absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVACRYL RAPID (Braided coated Polyglactin 910) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow Up Study to Evaluate Acute Safety and Device Procedural Success of ADVALENE (Polypropylene) Surgical Suture. (ADVALENE PMCF Study)

In this real-world experience Post-marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 80 subjects from &gt;65 surgical centers across various surgical specialties, ADVALENE (Polypropylene) monofilament, synthetic, non-absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVALENE (Polypropylene) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow Up Study to Evaluate Acute Safety and Device Procedural Success of ADVALON (Polyamide) Surgical Suture. (ADVALON PMCF Study)

In this real-world experience Post-Marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 80 subjects from &gt;70 surgical centers across various surgical specialties, ADVALON (Polyamide) monofilament, synthetic, non-absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVALON (Polyamide) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow Up Study to Evaluate Acute Safety and Device Procedural Success of ADVAPD (Polydioxanone) Surgical Suture. (ADVAPD PMCF Study)

In this real-world experience Post-marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 70 subjects from &gt;55 surgical centers across various surgical specialties, ADVAPD (Polydioxanone) monofilament, synthetic absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVAPD (Polydioxanone) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population.

A Retrospective, Multicenter, Observational Real World Post Market Clinical Follow Up Study to Evaluate Acute Safety and Device Procedural Success of ADVACRYL PLUS (Triclosan Coated Triclosan Coated Polyglactin 910) Surgical Suture. (ADVACRYL PLUS PMCF Study)

In this real-world experience Post-Marketing Clinical Follow-up study conducted in accordance with EU MDR 2017/745 in 103 subjects from &gt;80 surgical centers across various surgical specialties, ADVACRYL PLUS (Triclosan Coated Polyglactin 910) braided, synthetic absorbable sterile surgical sutures demonstrated excellent suture, needle, and overall performance. No wound complications or adverse events were reported in this study during the follow-up period of 3 months, and there were no reports of prolonged or repeat hospitalization. ADVACRYL PLUS (Triclosan Coated Polyglactin 910) sutures are a safe and effective option for a very wide variety of surgical procedures in a diverse population

The impact of elevated C-reactive protein levels on long-term outcomes of patients undergoing transcatheter aortic valve replacement

BackgroundIn patients undergoing transcatheter aortic valve replacement (TAVR), elevated pre-procedural C-reactive protein (CRP) levels are frequently observed. Its impact on long-term results of TAVR is unclear. The aim of the study was to investigate the long-term (up to six years) clinical outcomes of TAVR patients with normal compared to elevated CRP levels before TAVR. MethodsConsecutive patients undergoing TAVR between August 2012 and January 2023 at a tertiary cardiology facility were included. Patients were divided into two cohorts based on the baseline CRP levels: normal CRP (≤ 5 mg/l) and elevated CRP (>5 mg/l). The cohorts were followed clinically for up to six years after TAVR. ResultsFrom a total of 1000 TAVR patients (mean age 81 ± 6 years), 268 patients (27 %) were found to have elevated baseline CRP (>5 mg/l). Such patients had significantly more co-morbidities (e.g. chronic obstructive pulmonary disease, atrial fibrillation, heart failure, concomitant valvopathies). They also developed periprocedural infections more frequently (3 % vs. 1 %, p = 0.007) and required more commonly repeat hospitalizations for infections during follow-up (HR 1.97, CI 1.47–2.64, p < 0.001). All-cause mortality and development of valve dysfunction did not significantly differ between patients with elevated and normal baseline CRP levels. ConclusionAlbeit long-term results of TAVR patients with elevated pre-procedural CRP levels seem favorable in terms of survival and development of valve dysfunction, they have an increased risk for periprocedural infections and re-admissions due to infections of any type during the follow-up period.

Five-year outcomes of transcarotid transcatheter aortic valve replacement

BackgroundTranscarotid transcatheter aortic valve replacement (TC-TAVR) has emerged as an alternative access route for transcatheter aortic valve replacement (TAVR). However, scarce data exist on long-term outcomes following TC-TAVR. This study aimed to evaluate clinical outcomes at 5 years after TC-TAVR. MethodsA total of 110 consecutive patients who underwent TC-TAVR were included. Baseline, procedural, and follow-up data were collected prospectively in a dedicated database. The primary endpoint was the incidence of a composite outcome of all-cause mortality, stroke, and repeat hospitalization at 5-year follow-up. Echocardiography results, New York Heart Association (NYHA) class, and quality of life (QoL) as assessed with the EuroQol visual analog scale (EQ-VAS) were examined over the 5-year follow-up. ResultsThe median patient age was 77 years (interquartile range [IQR], 72-82.2 years), 42.3% were women, and the median Society of Thoracic Surgeons (STS) risk score was 5.02% (IQR, 3.4%-7.5%). The incidence of the composite primary endpoint was 54.5%. Death from any cause occurred in 45.6% of patients (11.9 per 100 patient-years); stroke in 8.2% (1.9 per 100 patient-years); disabling stroke in 2.7% (0.7 per 100 patient-years); and rehospitalization in 27.2%. The improvements in valve hemodynamics, NYHA class, and EQ-VAS following the procedure persisted at 5-year follow-up (P < .001). The incidence of bioprosthetic valve failure was 0.9%. ConclusionsAbout half of the moderate-to high-risk patients undergoing TC-TAVR survived with no major cardiovascular events at the 5-year follow-up. The yearly incidence of stroke events was low, and early improvements in valve hemodynamics, functional status, and QoL persisted at 5 years. These results suggest the long-term safety and efficacy of TC-TAVR and would support this approach as an alternative to surgery in non-transfemoral candidates.

Long-term Stroke and Mortality Risk in Nonagenarians After Transcatheter Aortic Valve Insertion

BackgroundLimited data exist on the long-term outcomes of transcatheter aortic valve insertion (TAVI) in nonagenarian patients. This study investigated the relationship between patient baseline comorbidity and frailty on the long-term outcome of the nonagenarian population. MethodsA retrospective analysis was conducted of 187 consecutive nonagenarian patients who underwent TAVI from 2009 to 2020. Multivariable models were used to analyze the association between baseline patient and frailty variables and mortality, stroke, and repeat hospitalization. Long-term survival was compared with an age- and sex-matched United States population. ResultsThe median Society of Thoracic Surgeons predicted risk of mortality was 10% (interquartile range, 7%-17%). Frailty was met in 72% of patients based on the 5-meter walk test, 13% based on the Kansas City Cardiomyopathy Questionnaire 12-item instrument score, 12% based on Katz Index of Independence in Activities of Daily Living, and 8% based on serum albumin levels. Procedure-related death occurred in 3 patients (2%) and stroke in 8 (4%). The median duration of follow-up was 3.4 years. Outcomes included death in 150 patients (80%), stroke in 15, and repeat hospitalization in 114. Multivariable analysis identified no association between any of the baseline patient variables with mortality, stroke, repeat hospitalization, or the combined outcomes (all P > .05). The 1- and 5-year survival rates in TAVI-treated nonagenarians were similar to age- and sex-matched controls (P = .27). ConclusionsLong-term death or stroke is independent of The Society of Thoracic Surgeons predicted risk of mortality and frailty risk variables in this nonagenarian patient population who received TAVI. Furthermore, survival is similar to age- and sex-matched controls.

Prognostic Role of Ultrasound Diagnostic Methods in Patients with Acute Decompensated Heart Failure.

To evaluate the prognostic value (total mortality + repeated hospitalization for heart failure (HF)) of ultrasound diagnostic methods in patients with acute decompensated HF (ADHF). The subjects were patients with chronic HF, who were hospitalized for ADHF. Using ultrasound methods-lung ultrasound, ultrasound assessment of hepatic venous congestion as per the venous excess ultrasound (VExUS) protocol, and indirect elastometry-we assessed the number of B-lines, hepatic venous congestion, and liver density of the patients. Clinical outcomes were assessed using a structured telephone survey method at 1, 3, 6, and 12 months after discharge. Combined overall mortality and readmission rates associated with HF were assessed. Threshold values for different methods for detecting congestion were set as follows: the number of B-lines in ultrasound data > 5; liver density > 6.2 kPa. The subjects were 207 patients (54.1% male; mean age = 70.7 ± 12.8 years). A total of 63 (30.4%) endpoints and 23 (11.1%) deaths were detected within 364 days (IQR = 197-365). Liver density > 6.2 kPa had a hazard ratio (HR) of 1.9 (95% CI: 1.0-3.3; p = 0.029). Hepatic venous congestion (VExUS protocol) had HR of 2.8 (95% CI: 1.3-5.7; p = 0.004). There was a significant increase in the risk of overall prognostic value in the presence of congestion, identified by liver fibroelastometry + lung ultrasound (HR = 10.5, 95% CI: 2.3-46.2; p = 0.002). The ultrasound assessment of hepatic venous congestion (VExUS + lung ultrasound protocol) yielded HR of 16.7 (95% CI: 3.9-70.7; p < 0.001). For all three methods combined, the overall HR was 40.1 (95% CI: 6.6-243.1; p < 0.001). A combination of ultrasound diagnostic methods that include the number of B-lines, presence of hepatic venous congestion according to the VExUS protocol, and liver density according to indirect elastometry at discharge may have an independent prognostic value for patients with ADHF.

Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial

BackgroundIndividuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU).MethodsThis secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively.ResultsConsistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention.ConclusionsPrevious findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions.Trial RegistrationNIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic.clinicaltrials.gov/ct2/show/NCT02599818.