Time Series Cohort Study Research Articles

Impact of the COVID-19 Pandemic on Elective and Emergency Surgeries, and Postoperative Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study.

The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in surgical services. The primary objective of the study was to assess the impact of COVID-19 on elective and emergency surgeries in a Brazilian metropolitan area. The secondary objective was to compare the postoperative hospital mortality before and during the pandemic. Time-series cohort study including data of all patients admitted for elective or emergency surgery at the hospitals in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. A causal impact analysis was used to evaluate the impact of COVID-19 on elective and emergency surgeries and hospital mortality. There were 174,473 surgeries during the study period. There was a reduction in overall (absolute effect per week: -227.5; 95% CI: -307.0 to -149.0), elective (absolute effect per week: -170.9; 95% CI: -232.8 to -112.0), and emergency (absolute effect per week: -57.7; 95% CI: -87.5 to -27.7) surgeries during the COVID-19 period. Comparing the surgeries performed before and after the COVID-19 onset, there was an increase in emergency surgeries (53.0% vs 68.8%, P < 0.001) and no significant hospital length of stay (P = 0.112). The effect of the COVID-19 pandemic on postoperative hospital mortality was not statistically significant (absolute effect per week: 2.1, 95% CI: -0.01 to 4.2). Our study showed a reduction in elective and emergency surgeries during the COVID-19 pandemic, possibly due to disruptions in surgical services. These findings highlight that it is crucial to implement effective strategies to prevent the accumulation of surgical waiting lists in times of crisis and improve outcomes for surgical patients.

Impact of the COVID-19 Pandemic on Births, Vaginal Deliveries, Cesarian Sections, and Maternal Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study.

The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in healthcare. The primary objective of the study was to assess the impact of the COVID-19 pandemic on birth, vaginal delivery, and cesarian section (c-section) rates. The secondary objective was to compare the maternal mortality before and after the pandemic. Time-series cohort study including data of all women admitted for childbirth (vaginal delivery or c-section) at the maternities in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. Causal impact analysis was used to evaluate the impact of COVID-19 on birth, vaginal delivery, and c-section using the CausalImpact R package, and a propensity score matching was used to evaluate the effect on maternal mortality rate using the Easy R (EZR) software. There were 150,617 births, and considering total births, the effect of the COVID-19 pandemic was not statistically significant (absolute effect per week: 5.5, 95% CI: -24.0-33.4). However, there was an increase in c-sections after COVID-19 (absolute effect per week: 18.1; 95% CI: 11.9-23.9). After propensity score matching, the COVID-19 period was associated with increased maternal mortality (OR: 3.22, 95% CI: 1.53-6.81). The e-value of the adjusted OR for the association between the post-COVID-19 period and maternal mortality was 5.89, with a 95% CI: 2.43, suggesting that unmeasured confounders were unlikely to explain the entirety of the effect. Our study revealed a rise in c-sections and maternal mortality during the COVID-19 pandemic, possibly due to disruptions in maternal care. These findings highlight that implementing effective strategies to protect maternal health in times of crisis and improve outcomes for mothers and newborns is crucial.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India.

IntroductionPediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings.Materials and MethodsWe conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room.ResultsThere was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05).ConclusionTelesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

Time-series cohort study to forecast emergency department visits in the city of Milan and predict high demand: a 2-day warning system

ObjectivesThe emergency department (ED) is one of the most critical areas in any hospital. Recently, many countries have seen a rise in the number of ED visits, with an increase...

Test-Retest Reliability of Postural Control Assessment on Biodex BioSway™.

Background Recent protocols for posturographic assessment of postural control and balance have included head shake test conditions to challenge the vestibular contributions of postural control in an effort to increase the diagnostic accuracy of identifying individuals with impaired balance. However, evidence is limited regarding the test-retest reliability of such assessment protocols. Purpose The purpose of this study was twofold: to determine the test-retest reliability of postural control assessment on the Biodex Biosway™, an accessible and field expedient tool for posturographic assessment, and to determine the test-retest reliability of the Head Shake Sensory Interaction and Balance Test (HS-SIB), an adaptation of the modified Clinical Test of Sensory Interaction and Balance (mCTSIB) which adds two head shake conditions to challenge the vestibular contributions to postural control. Study Design. This was a correlational time series cohort study completed in a biomechanics laboratory. Methods The sample consisted of nineteen healthy adults (10 females, 9 males). Sway Index, Equilibrium Score, and the area of the ellipse enclosing 95% of the anterior-posterior (AP) and medial-lateral (ML) center of gravity (COG) displacement (AREA95) are the 3 summary variables. Standard Error of Measurement (SEM) and Minimum Detectable Change (MDC) are also reported. Results Test-retest reliability was generally poor with limited exceptions. Moderate to good reliability was observed for the more challenging stance conditions (ICC range 0.58-0.81), including those with head shake. Conclusions Field-expedient systems, such as the Biodex BioSway™, may offer reliable posturographic testing where gold-standard methods are not available. Clinicians should be aware that less demanding test conditions have limited reliability; however, test-retest reliability of this assessment tool is improved with more challenged stance conditions and the inclusion of a head shake task.

Cohort study of use of the hands-and knees-position as the first approach to resolving shoulder dystocia and preventing neonatal birth trauma

BackgroundMcRoberts' maneuver, turning the woman's thighs up in the supine position, has become the dominant method for resolving shoulder dystocia (defined as failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery). Another method that is less commonly used is the Gaskin maneuver, which was first described by the midwife Ina May Gaskin, who learned of it from traditional midwives in Central America, and involves turning women to the hands-and-knees position. One retrospective observational study reported an 84% higher resolution of shoulder dystocia and less injury to the baby with the use of the hands-and-knees position as the first approach to resolving shoulder dystocia. The hands-and-knees position was reported to result in a wider pelvic diameter than the supine position and hence facilitate rotation of the baby and delivery, so it is possibly to resolving shoulder dystocia. The purpose of this study is to explore whether applying the Gaskin maneuver as the first approach for resolving cases of shoulder dystocia is a safer and better method than applying the McRoberts' maneuver first. MethodsA time series cohort study was conducted in Laiwu Maternal and Child Health Hospital in Shandong, China over a seven -year period. Between January 2011 and July 2013 all women receiving traditional support at delivery were enrolled as a control group. During this time period, when shoulder dystocia was suspected, McRoberts’ maneuver (MR) was the most commonly employed first maneuver as described in the HELPERR mnemonics. Between October 2013 and December 2017, a change of practice was implemented for all vaginal births at the site, whereby midwives were instructed to use the Gaskin maneuver (i.e., moving the mother onto hands-and-knees position) as the first protocol if shoulder dystocia was suspected. Patients in this group were assigned to the experimental group. The neonatal outcomes including birth asphyxia and baby injury in both groups were recorded and analyzed. ResultsThe injuries in the control group included 14 clavicular fractures, and one permanent brachial plexus injury, three temporary arm movement disorders that resolved within 7 days and those cases were not calculated as baby injury cases (the same in experimental group). In the experimental group, 58 cases of shoulder dystocia were reported, with one case of clavicular fracture, three temporary arm movement disorders that resolved within 3 days, and no permanent brachial plexus injuries. The rate of baby injury in the control group [14.6% (15/103)] was higher than that in the experimental group [1.7% (1/58)], and this difference was statistically significant [ χ2 ​= ​6.834, P ​= ​0.009; OR ​= ​1.150 (1.055–1.254)]. Multiple logistic regression analysis showed that using the McRoberts' maneuver as the first approach in cases of shoulder dystocia [OR ​= ​19.609 (1.620–273.430)], the mother's employment status [OR ​= ​1.909 (1.118–3.262)], and intravenous dripping of oxytocin [OR ​= ​5.969 (1.391–25.605)] are risk factors for baby injury. There was no difference in neonate Apgar score between the two groups, and no baby died in either group. ConclusionsResolving shoulder dystocia by turning to the Gaskin maneuver as the first approach reduces the incidence of baby injury. This method should be recommended in clinical practice for better neonate outcomes.

Effects of Decompressive Cervical Surgery on Blood Pressure in Cervical Spondylosis Patients With Hypertension: A Time Series Cohort Study

The blood pressure of cervical spondylosis (CS) patients with hypertension often returns to normal after decompressive cervical surgery (DCS). However, the effect of DCS on the blood pressure of patients with CS has not been rigorously studied. We recruited 50 consecutive CS patients with hypertension from 2014-2017 and investigated the changes in blood pressure after DCS using a time series design. Ambulatory blood pressure monitoring (ABPM) was performed at 3 and 0 days before DCS and at 30 and 90 days after DCS. The primary outcome was mean 24-hour systolic blood pressure (SBP). Secondary outcomes included mean 24-hour diastolic blood pressure (DBP), office blood pressure, and the percentage of patients on antihypertensive medication. Paired t test was used for assessing the changes in blood pressure over time and a McNemar test was used for comparison among different medication groups. The mean 24-hour SBP did not vary significantly among 4 time points (134.5 ± 14.7, 132.8 ± 14.7, 131.5 ± 13.3, and 133.2 ± 14.6, respectively; P = .42). The mean 24-hour DBP showed a similar trend. However, mean office SBP/DBP decreased significantly from 142.5/82.0 mm Hg before surgery to 127.3/76.6 mm Hg after surgery (both P < .01). The corresponding percentage of patients on antihypertensive medication decreased significantly, from 84% to 54% (P < .01). This study confirmed previous findings of reduction in office blood pressure associated with DCS among CS patients with hypertension. However, this was not confirmed by multiple-time series of 24-hour ABPM. 3.

Epidemiology and outcome of older patients presenting with dyspnoea to emergency departments.

To describe the epidemiology and outcomes of non-traumatic dyspnoea in patients aged 75years or older presenting to emergency departments (EDs) in the Asia-Pacific region. A substudy of a prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia of patients presenting to the ED with dyspnoea as a main symptom. Data were collected over three 72-h periods and included demographics, co-morbidities, mode of arrival, usual medications, ED investigations and treatment, ED diagnosis and disposition, and outcome. The primary outcomes of interest are the epidemiology and outcome of patients aged 75years or older presenting to the ED with dyspnoea. 1097 patients were included. Older patients with dyspnoea made up 1.8% [95% confidence interval (CI) 1.7-1.9%] of ED presentations. The most common diagnoses were heart failure (25.3%), lower respiratory tract infection (25.2%) and chronic obstructive pulmonary disease (17.6%). Hospital ward admission was required for 82.6% (95% CI 80.2-84.7%), with 2.5% (95% CI 1.7-3.6%) requiring intensive care unit (ICU) admission. In-hospital mortality was 7.9% (95% CI 6.3-9.7%). Median length of stay was 5days (interquartile range 2-8days). Older patients with dyspnoea make up a significant proportion of ED case load, and have a high admission rate and significant mortality. Exacerbations or worsening of pre-existing chronic disease account for a large proportion of cases which may be amenable to improved chronic disease management.

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. Standard- or low-dose WBCT. The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, -2.0% [95% CI, -7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

Assessment of Unintentional Duplicate Orders by Emergency Department Clinicians Before and After Implementation of a Visual Aid in the Electronic Health Record Ordering System

Electronic health records allow teams of clinicians to simultaneously care for patients, but an unintended consequence is the potential for duplicate orders of tests and medications. To determine whether a simple visual aid is associated with a reduction in duplicate ordering of tests and medications. This cohort study used an interrupted time series model to analyze 184 694 consecutive patients who visited the emergency department (ED) of an academic hospital with 55 000 ED visits annually. Patient visits occurred 1 year before and after each intervention, as follows: for laboratory orders, from August 13, 2012, to August 13, 2014; for medication orders, from February 3, 2013, to February 3, 2015; and for radiology orders, from December 12, 2013, to December 12, 2015. Data were analyzed from April to September 2019. If an order had previously been placed during the ED visit, a red highlight appeared around the checkbox of that order in the computerized provider order entry system. Number of unintentional duplicate laboratory, medication, and radiology orders. A total of 184 694 patients (mean [SD] age, 51.6 [20.8] years; age range, 0-113.0 years; 99 735 [54.0%] women) who visited the ED were analyzed over the 3 overlapping study periods. After deployment of a noninterruptive nudge in electronic health records, there was an associated 49% decrease in the rate of unintentional duplicate orders for laboratory tests (incidence rate ratio, 0.51; 95% CI, 0.45-0.59), from 4485 to 2731 orders, and an associated 40% decrease in unintentional duplicate orders of radiology tests (incidence rate ratio, 0.60; 95% CI, 0.44-0.82), from 956 to 782 orders. There was not a statistically significant change in unintentional duplicate orders of medications (incidence rate ratio, 1.17; 95% CI, 0.52-2.61), which increased from 225 to 287 orders. The nudge eliminated an estimated 17 936 clicks in our electronic health record. In this interrupted time series cohort study, passive visual cues that provided just-in-time decision support were associated with reductions in unintentional duplicate orders for laboratory and radiology tests but not in unintentional duplicate medication orders.

Nation-Wide Use of Periprocedural Bridging Anticoagulation in Patients With Atrial Fibrillation

The randomized, controlled BRIDGE trial established a lack of efficacy for use of bridging anticoagulation in warfarin-treated patients who underwent surgical procedures. A large nation-wide insurance claims database was used to perform a retrospective interrupted time series cohort study of adult patients with atrial fibrillation treated with warfarin who underwent surgical procedures. Patients were assessed for the use of low-molecular-weight heparin (LMWH) use as a periprocedural bridging anticoagulant between July 2015 and November 2017. The interrupted time series regression model was used to estimate the reduction in use of bridging LMWH following the publication of the BRIDGE trial in July 2015. The cohort consisted of 9,278 warfarin-treated patients with atrial fibrillation. Use of bridging LMWH declined by an estimated 6.7% (95% confidence interval [CI] 2.1% to 11.3%) to 13.0% following publication of the BRIDGE trial. The decline in bridging LMWH use was numerically larger for patients with a moderate- or high risk of stroke (8.9% decline, 95% CI 0.4% to 17.4%) than for patients at low risk for stroke (6.2% decline, 95% CI 0.7% to 11.5%). Significant predictors of bridging LMWH use include younger age and no co-morbid diabetes. In conclusion, this nation-wide, claims-based study identified a significant reduction in the use of bridging LMWH following the publication of the BRIDGE trial for warfarin-treated patients with AF.

Implementation of a Multidisciplinary Inpatient Cardiology Service to Improve Heart Failure Outcomes in Guyana

Guyana is a small developing country with a high burden of cardiovascular disease and extensive barriers to optimal care delivery. We investigated the effectiveness of a newly established multidisciplinary inpatient cardiology service in this setting. We performed an interrupted time-series cohort study of heart failure (HF) patients admitted to the Georgetown Public Hospital Corporation from January to December 2015 and July 2016 to December 2017. The primary outcome was discharge on guideline-directed medical therapy (GDMT). Secondary outcomes included length of hospitalization and all-cause mortality. We identified 740 patients, 347 (46.9%) of whom were admitted after service implementation. The postimplementation cohort was more likely to be discharged on a beta-blocker (66.6% vs 41.7%; P < .01) and mineralocorticoid receptor antagonist (31.7% vs 15.3%; P = .01). They were also more likely to undergo echocardiography (60.8% vs 40.5%; P < .01) and chest x-rays (70.6% vs 46.6%; P < .01). Hospitalization length (10.0 ± 13.1 vs 9.8 ± 10.1 days) and readmissions within 90 days (19.0% vs 19.1%) were not significantly different. There were fewer deaths in the postimplementation cohort compared with the preimplementation cohort (12/347 vs 28/393). Establishment of a multidisciplinary inpatient cardiology service demonstrated increased adherence to GDMT without extending length of hospitalization.

Falls and long-term care: a report from the care by design observational cohort study

BackgroundFalls and the resulting complications are common among frail older adults. We aimed to explore risk factors and potential prevention strategies for falls in elderly residents of Long-Term Care Facilities (LTCF).MethodsThis was a cross sectional study design using data from the Care by Design (CBD) study, within Nova Scotia’s Capital District Health Authority. This observational time series cohort study collected data before, during and after the implementation of CBD, a new model of coordinated primary care in LTCF. Here, we analyzed data collected after the implementation of CBD (September 1, 2011- February 28, 2012).ResultsFalls were frequent; 56.2% of our sample of 395 residents fell at least once. In univariate analyses, male gender (p = 0.009), dementia (p = 0.005), and use of Selective Serotonin Reuptake Inhibitors or Selective Serotonin-Norepinepherine Reuptake Inhibitors (SSRI/SNRI) (p = 0.084) showed statistically significant associations with having fallen. Benzodiazepine use appeared to be protective for falls (p = 0.058). In a fully adjusted multivariable linear regression model, dementia (β coefficient 0.96, 95% CI: 0.83,1.84; p = 0.032), visual impairment (β 0.84, 95% CI: 0.13,1.56; p = 0.021), and use of any PIMs (β 0.34, 95% CI: 0.037,0.65; p = 0.028) were associated with increased risk of having fallen. Benzodiazepine use remained associated with reduced numbers of falls (p = 0.009), and SSRI/SNRI use was associated with increased numbers of falls (p = 0.007). Male gender was associated with increased falls in the model which excluded frailty (p = 0.022), though gender lost statistical significance once frailty was added to the model (p = 0.06).ConclusionsIn our sample of LTCF residents, falls were common. Cognitive impairment, male gender, visual impairment, PIM use and use of SSRI/SNRI medications were associated with increased risk of falls, while benzodiazepine use appeared to be associated with a decreased risk of having fallen. Falls remain an important problem among LTC residents. Screening for falls during patient encounters is recommended, along with further research to identify risk factors and target interventions.

Epidemiology, treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED. This was a planned sub-study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72-h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality). Forty-six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort; 95% CI: 12.5-14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety-one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non-invasive ventilation (NIV). Seventy-eight percent of patients were admitted to hospital, 7% to an intensive care unit. In-hospital mortality was 4% and median LOS was 4 days (95% CI: 2-7). Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in-hospital mortality. Compliance with evidence-based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes.

IMPLEMENTATION OF AN INPATIENT CARDIOLOGY SERVICE IN GUYANA TO IMPROVE HEART FAILURE OUTCOMES: PRELIMINARY ANALYSIS

Improved control of communicable diseases and longer life expectancy in low and middle income countries (LMICs) has resulted in an increased prevalence of cardiovascular disease. Heart failure (HF) represents a significant proportion of this growing burden but there remain significant limitations in both resources and capacity for treating HF in LMICs. Guyana is a small nation of 771 000 people that illustrates the growing need for organized cardiovascular care in these settings. In partnership with the Libin Cardiovascular Institute, a multi-disciplinary inpatient cardiology service and cardiac intensive care unit was implemented at the Georgetown Public Hospital (GPH) in January 2016 to improve cardiovascular outcomes. We conducted an interrupted time-series cohort study of patients admitted with a primary diagnosis of HF. Our two cohorts included patients admitted between January 1, 2015 and December 31, 2015 (before implementation) and those admitted between July 1, 2016 until April 26, 2017 (after implementation) with a period to account for service implementation. Manual chart review was performed in the pre-implementation cohort to confirm the primary diagnosis and establish presence of outcomes. Outcomes of interest included length of hospitalization, medication at discharge, readmission rates, in-hospital mortality and 90 day mortality. An online database was designed to summarize hospital stays for both cohorts and capture post-implementation outcomes. We identified 405 patients admitted with a primary diagnosis of HF with mean age 59.4± 15.8 and 56% being female. There were 201 (49.6%) patients admitted in the pre-implementation period. Patients admitted post-implementation were hospitalized for a similar duration (8.2 days vs 9.2 days, p=0.36) and had similar in-hospital mortality (2.9% vs 5.5%, p=0.15) and 90-day readmission rates (16.7% vs 11.0%, p=0.11) compared to patients admitted before service implementation. However, they were more likely to be discharged on a beta-blocker (66% vs 38%, p < 0.01) or mineralocorticoid receptor antagonist (32% vs 13%, p < 0.01) and less likely to die within 90 days (3.4% vs 8.0%, p=0.04). Implementation of a multi-disciplinary cardiology service in Guyana reduced the incidence of death at 90 days as well as other key performance indicators. While readmission rates were not affected, this may be related to improved follow-up after hospital discharge. This preliminary data suggests that building capacity in chronic disease care, in this case a dedicated inpatient heart failure service, has the potential to significantly bridge care gaps and encourage use of guideline-directed medical therapy in LMICs.

Effects of physical activity calorie expenditure (PACE) labeling: study design and baseline sample characteristics

BackgroundObesity and physical inactivity are responsible for more than 365,000 deaths per year and contribute substantially to rising healthcare costs in the US, making clear the need for effective public health interventions. Calorie labeling on menus has been implemented to guide consumer ordering behaviors, but effects on calories purchased has been minimal.MethodsIn this project, we tested the effect of physical activity calorie expenditure (PACE) food labels on actual point-of-decision food purchasing behavior as well as physical activity. Using a two-group interrupted time series cohort study design in three worksite cafeterias, one cafeteria was assigned to the intervention condition, and the other two served as controls. Calories from food purchased in the cafeteria were assessed by photographs of meals (accompanied by notes made on-site) using a standardized calorie database and portion size-estimation protocol. Primary outcomes will be average calories purchased and minutes of moderate to vigorous physical activity (MVPA) by individuals in the cohorts. We will compare pre-post changes in study outcomes between study groups using piecewise generalized linear mixed model regressions (segmented regressions) with a single change point in our interrupted time-series study. The results of this project will provide evidence of the effectiveness of worksite cafeteria menu labeling, which could potentially inform policy intervention approaches.DiscussionLabels that convey information in a more readily understandable manner may be more effective at motivating behavior change. Strengths of this study include its cohort design and its robust data capture methods using food photographs and accelerometry.

An Observational Study of Dyspnea in Emergency Departments: The Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM).

The objective was to describe the epidemiology of dyspnea presenting to emergency departments (EDs) in the Asia-Pacific region, to understand how it is investigated and treated and its outcome. Prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong, and Malaysia of adult patients presenting to the ED with dyspnea as a main symptom. Data were collected over three 72-hour periods and included demographics, comorbidities, mode of arrival, usual medications, prehospital treatment, initial assessment, ED investigations, treatment in the ED, ED diagnosis, disposition from ED, in-hospital outcome, and final hospital diagnosis. The primary outcomes of interest are the epidemiology, investigation, treatment, and outcome of patients presenting to ED with dyspnea. A total of 3,044 patients were studied. Patients with dyspnea made up 5.2% (3,105/60,059, 95% confidence interval [CI]= 5.0% to 5.4%) of ED presentations, 11.4% of ward admissions (1,956/17,184, 95% CI= 10.9% to 11.9%), and 19.9% of intensive care unit (ICU) admissions (104/523, 95% CI= 16.7% to 23.5%). The most common diagnoses were lower respiratory tract infection (20.2%), heart failure (14.9%), chronic obstructive pulmonary disease (13.6%), and asthma (12.7%). Hospital ward admission was required for 64% of patients (95% CI= 62% to 66%) with 3.3% (95% CI= 2.8% to 4.1%) requiring ICU admission. In-hospital mortality was 6% (95% CI= 5.0% to 7.2%). Dyspnea is a common symptom in ED patients contributing substantially to ED, hospital, and ICU workload. It is also associated with significant mortality. There are a wide variety of causes however chronic disease accounts for a large proportion.

Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: an observational study.

BackgroundThis study aimed to determine epidemiology and outcome for patients presenting to emergency departments (ED) with shortness of breath who were transported by ambulance.MethodsThis was a planned sub-study of a prospective, interrupted time series cohort study conducted at three time points in 2014 and which included consecutive adult patients presenting to the ED with dyspnoea as a main symptom. For this sub-study, additional inclusion criteria were presentation to an ED in Australia or New Zealand and transport by ambulance. The primary outcomes of interest are the epidemiology and outcome of these patients. Analysis was by descriptive statistics and comparisons of proportions.ResultsOne thousand seven patients met inclusion criteria. Median age was 74 years (IQR 61-68) and 46.1 % were male. There was a high rate of co-morbidity and chronic medication use. The most common ED diagnoses were lower respiratory tract infection (including pneumonia, 22.7 %), cardiac failure (20.5%) and exacerbation of chronic obstructive pulmonary disease (19.7 %). ED disposition was hospital admission (including ICU) for 76.4 %, ICU admission for 5.6 % and death in ED in 0.9 %. Overall in-hospital mortality among admitted patients was 6.5 %.DiscussionPatients transported by ambulance with shortness of breath make up a significant proportion of ambulance caseload and have high comorbidity and high hospital admission rate. In this study, >60 % were accounted for by patients with heart failure, lower respiratory tract infection or COPD, but there were a wide range of diagnoses. This has implications for service planning, models of care and paramedic training.ConclusionThis study shows that patients transported to hospital by ambulance with shortness of breath are a complex and seriously ill group with a broad range of diagnoses. Understanding the characteristics of these patients, the range of diagnoses and their outcome can help inform training and planning of services.

Effects of decompressive cervical surgery on blood pressure in cervical spondylosis patients with hypertension: a time series cohort study.

BackgroundPatients with cervical spondylosis myelopathy (CSM) and complicated with hypertension are often experiencing a blood pressure decrease after taking cervical decompressive surgery in clinical observations, but how this blood pressure reduction is associated with the surgery, which cut cervical sympathetic nervous, has never been rigorously assessed. Thus, the purpose of this study is to investigate the effect of cervical decompressive surgery on blood pressure among CSM patients with hypertension.Methods/DesignThe study will be a time series cohort study. Fifty eligible patients will be selected consecutively from the Peking University First Hospital. Two 24-h ambulatory blood pressure measurement (ABPM) will be taken before the surgery, apart by at least 3 days. The patients will be followed up for another two ABPMs at 1 and 3 months after the surgery.We will recruit subjects with cervical spondylosis myelopathy meeting operation indications and scheduled for receiving cervical decompressive surgery, aged 18–84 years, have a history of hypertension or office systolic blood pressure ≥140 mmHg on initial screening, and willing to participate in the study and provide informed consent. Exclusion criteria includes a history of known secondary hypertension, visual analogue scale (VAS) score ≥4, and unable to comply with study due to severe psychosis.The change in systolic ABPs over the four times will be analyzed to observe the overall pattern of the blood pressure change in relation to the surgery, but the primary analysis will be the comparison of systolic ABP between the 2nd and 3rd , 4th measurements (before and after the surgery). We will also calculate the regression-to-the-mean adjusted changes in systolic ABP as sensitivity analysis. Secondary endpoints are the changes in 24 h ABPM diastolic blood pressure, blood pressure control status, the use and dose adjustment of antihypertensive medication, and the incidence of operative complications. Primary outcome analyses will be carried out using analysis of covariance, as well as the first secondary endpoint.DiscussionThis study will inform us the important knowledge about cervical sympathetic nervous system (SNS) and blood pressure. Once confirmed, it may help to produce new method for control of hypertension, which is the leading cause of death in the world.Trial registrationThe study is registered to Clinical Trials.gov (NCT02016768).

Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study: Rationale, design and analysis.

Shortness of breath is a common reason for ED attendance. This international study aims to describe the epidemiology of dyspnoea presenting to EDs in the South East Asia-Pacific region, to compare disease patterns across regions, to understand how conditions are investigated and treated, and to assess quality of care. This is a prospective, interrupted time series cohort study conducted in EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia of consecutive adult patients presenting to the ED with dyspnoea as a main symptom. Data were collected over three 72 h periods in May, August and October 2014 (autumn, winter and spring), and included demographics, comorbidities, mode of arrival, usual medications, pre-hospital treatment, initial assessment, ED investigations, treatment in the ED, ED diagnosis, disposition from ED, in-hospital outcome and final hospital diagnosis. The primary outcomes of interest are the epidemiology and outcome of patients presenting to ED with dyspnoea. Secondary outcomes of interest are seasonal and geographic comparisons of diagnoses and outcomes, disease-specific descriptions of epidemiology, investigation, treatment and disposition, and compliance with treatment guidelines. This novel study will explore dyspnoea from the viewpoint of the patient's symptom (shortness of breath) rather than that of a single disease. The results will provide robust data about the epidemiology, investigation, treatment and disposition of this diverse patient group. The obtained data also have the potential to inform service planning and to quantify the proportion of patients with mixed cardiac and respiratory disease.