Unexpected Hospital Research Articles

Initial Experience of Vericiguat Treatment in Patients with Heart Failure and Reduced Ejection Fraction.

Vericiguat, a novel oral soluble guanylate cyclase stimulator, decreased the incidence of cardiovascular death and heart failure hospitalization in the cohort receiving triple therapy for heart failure with reduced ejection fraction. However, efficacy and optimal patient selection in real-world practice in the era of "quadruple therapy" remains unknown. Consecutive patients who received vericiguat between September 2021 and December 2022 were retrospectively evaluated. A total of 28 patients (median age 66 years, median left ventricular ejection fraction 33%) were included. Of them, 21 patients (75%) received quadruple therapy, and the dose of sacubitril/valsartan was 100 mg in the median. Three patients receiving dobutamine infusion discontinued vericiguat due to symptomatic hypotension. One patient with a high N-terminal pro-B-type natriuretic peptide of 4848 pg/mL at the baseline underwent unexpected heart failure hospitalization. Efficacy was evaluated in 21 patients who continued vericiguat for more than 4 months. The plasma B-type natriuretic peptide concentration tended to increase during the six-month pre-treatment period from 104 pg/mL to 179 pg/mL on median (p = 0.665) but remained unchanged after six-month vericiguat treatment to 170 pg/mL on median (p = 0.188). Vericiguat therapy might be feasible and effective upon quadruple therapy for those with heart failure, although further investigation is warranted to validate our findings.

Decrease in maximum paced walking speed predicts hospitalization in community-dwelling older people with disabilities.

Walking speed is a useful predictor of hospitalization for community-dwelling older people. However, whether it is an effective predictor for disabled older people has not been clarified. This study aimed to investigate the association of walking speed with unexpected hospitalizations in community-dwelling, disabled, older people. The participants were ambulatory, community-dwelling older adults aged ≥ 65years with disabilities. Comfortable and maximum walking speeds were measured at two timepoints, baseline and 3months later. Furthermore, the change over time at 3months in walking speed was also calculated. If the change in walking speed decreased more than 0.1m/s, it was defined as walking speed decreased. The primary outcome was unexpected hospitalization during 4-year follow-up. The associations among baseline walking speed, walking speed decline, and hospitalization were analyzed using Cox regression analysis adjusted for potential confounding factors. A total of 93 people (age 81.8 ± 7.0years, 64 female) were included, and unexpected hospitalization occurred in 47 people during 4-year follow-up. On Cox regression analysis adjusted for potential confounding factors, only the maximum walking speed decrease was significantly associated with hospitalization (hazard ratio = 2.53, 95% confidence interval: 1.23-5.21), not baseline walking speed and comfortable walking speed decrease. As for the assessment of walking speed for the prediction of unexpected hospitalization in disabled people, measurement at a single timepoint is not useful, whereas change over time is. Monitoring of change over time in maximum walking speed appears to be one of the indicators for the health management of disabled people.

Risk Factors for Unexpected Hospital Admission Following Achilles Tendon Repair: A National Database Study

INTRODUCTION Achilles tendon rupture (ATR) repair is one of the most common orthopaedic surgeries performed in the United States, however there is a paucity of literature on predisposing risk factors for hospital readmissions. The purpose of this study is to identify risk factors for 30-day readmission in patients undergoing ATR repair with emphasis on procedures performed in the outpatient setting. Specifically, we examine: 1) 30-day post-operative hospital readmission rates; 2) the medical comorbidities and patient characteristics that predisposed this cohort to post-operative complications; and 3) the complications leading to readmission. METHODS The ACS-NSQIP was queried for patients who underwent ATR from 2015 to 2019 using CPT code 27650 in all fields yielding a sample size of 3,887 cases. The following demographic, lifestyle, and comorbidity variables were recorded: age, sex, race, BMI, morbid obesity (BMI ≥ 40.00 kg/m2), bleeding disorders, chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension, tobacco use, and chronic steroid use. The primary outcome of 30-day readmission was defined as unplanned hospital readmission likely related to the principal procedure. Independent samples Student’s t-tests, chi-squared, and, where appropriate, Fisher’s exact tests were used in univariate analyses to identify demographic, lifestyle, and peri-operative variables related to 30-day readmission following ATR. Multivariate logistic regression modeling was subsequently performed. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. RESULTS Of the 3,887 patients included in our sample, 28 were readmitted within the 30-day post-operative period, corresponding to a readmission rate of 0.73%. Significant relationships with univariate analyses between readmission status and the following patient variables included: mean patient age (p = 0.02); hypertension (p < 0.001); BMI (p = 0.01); morbid obesity (p = 0.002); ASA Classification (p = 0.006); and bleeding disorders (p = 0.03). Multivariate logistic regression modeling confirmed that the following patient variables were associated with statistically significantly increased odds of readmission: age, p = 0.02), OR = 1.03, 95% CI [1.01, 1.06]; hypertension, p < 0.001, OR = 3.82, 95% CI [1.81, 8.06]; BMI, p = 0.01, OR = 1.06, 95% CI [1.01, 1.11]; morbid obesity, p = 0.004, OR = 3.53, 95% CI [1.49, 8.36]. CONCLUSION Our study indicated that only 0.73% of patients were readmitted after their outpatient procedure. Patients who: 1) have BMIs greater than 40; 2) are older in age 3) have hypertension; and 4) a higher ASA Classification were at increased risk for readmission.

Readmission after orthognathic surgery

To evaluate the readmission rate after orthognathic surgery and identify associated risk factors. Retrospective analysis of patients who underwent orthognathic surgery and had an unexpected hospital admission, with or without return to the operating room (OR), within the first postoperative year. Study variables included sex, age, American Society of Anesthesiologists (ASA) status, type of surgery, concomitant third molar extraction, concomitant genioplasty, duration of surgery, first assistant experience, and duration of hospitalization. Bivariate associations were calculated between variables and readmission status. Chi-square and Fisher's Exact tests were used to compare categorical variables, and a 2-sample t test was used to compare continuous variables. There were 701 patients included in the study. The readmission rate was 9.70%. Twelve patients were managed non-surgically, and 56 patients required an OR procedure. The most common reason for readmission without return to the OR was an infection, and for reoperation was hardware removal. Age, sex, type of surgery, third molar extraction, genioplasty, duration of surgery, and experience of first assistant were not found to be predictors for readmission. Only ASA classification and duration of initial hospitalization were significant risk factors for readmission of patients within the first postoperative year after orthognathic surgery.

Transformation of chronic disease management: Before and after the COVID-19 outbreak.

Adults with chronic diseases often experience a decline in their quality of life along with frequent exacerbations. These diseases can cause anxiety and impose a significant economic burden. Self-management is a crucial aspect of treatment outside of the hospital and can improve quality of life and reduce the financial burden resulting from unexpected hospitalizations. With the COVID-19 pandemic, telehealth has become a vital tool for both medical professionals and patients; many in-person appointments have been canceled due to the pandemic, leading to increased reliance on online resources. This article aimed to discuss various methods of chronic disease management, both traditional self-management and modern telehealth strategies, comparing before and after the COVID-19 outbreak and highlighting challenges that have emerged.

Health and Socioeconomic Risk Factors for Unplanned Hospitalization Following Ambulatory Unicompartmental Knee Arthroplasty: Development of a Patient Selection Tool Using Machine Learning

BackgroundIdentifying ambulatory surgical candidates at risk for adverse surgical outcomes can optimize outcomes. The purpose of this study was to develop and internally validate a machine learning (ML) algorithm to predict contributors to unexpected hospitalizations after ambulatory unicompartmental knee arthroplasty (UKA). MethodsA total of 2,521 patients undergoing UKA from 2006 to 2018 were retrospectively evaluated. Patients admitted overnight postoperatively were identified as those who had a length of stay ≥ 1 day were analyzed with four individual ML models (ie, random forest, extreme gradient boosting, adaptive boosting, and elastic net penalized logistic regression). An additional model was produced as a weighted ensemble of the four individual algorithms. Area under the receiver operating characteristics (AUROC) compared predictive capacity of these models to conventional logistic regression techniques. ResultsOf the 2,521 patients identified, 103 (4.1%) required at least one overnight stay following ambulatory UKA. The ML ensemble model achieved the best performance based on discrimination assessed via internal validation (AUROC = 87.3), outperforming individual models and conventional logistic regression (AUROC = 81.9-85.7). The variables determined most important by the ensemble model were cumulative time in the operating room, utilization of general anesthesia, increasing age, and patient residency in more urban areas. The model was integrated into a web-based open-access application. ConclusionThe ensemble gradient–boosted ML algorithm demonstrated the highest performance in identifying factors contributing to unexpected hospitalizations in patients receiving UKA. This tool allows physicians and healthcare systems to identify patients at a higher risk of needing inpatient care after UKA.

Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage

BackgroundEarly unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated.ResultsThis was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression.After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) − 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23).ConclusionOur intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.

Impact of hospitalisation on behavioural and physiological stress responses associated with cardiovascular risk in visiting family members

BackgroundThe hospitalisation of a patient in intensive care impacts the psychological health of family members, with a high prevalence of anxiety, depression, and post-traumatic stress symptoms reported among families of critically ill patients. Understanding of the behavioural and physiological impact is limited and presents a new area of focus. ObjectivesThe objective of this study was to evaluate behavioural and physiological stress responses of visiting family members following hospitalisation of their adult relative. MethodsProspective longitudinal evaluation included 40 family members of adult patients with admission to intensive or coronary care in a large tertiary care metropolitan hospital. Assessments were conducted at three timepoints: in-hospital within 1 week of admission and 2 weeks and 3 months post discharge. Assessments included duration and quality of sleep (self-reported and actigraphy measured), physical activity, dietary and alcohol patterns, resting heart rate and blood pressure, and morning blood cortisol and lipid levels. Assessment of a reference group of 40 non-hospital-exposed control participants was also conducted. ResultsAt the in-hospital assessment, study participants reported lower sleep time, altered 24-h physical activity patterns, reduced dietary and alcohol intake, and higher systolic and diastolic blood pressure than a nonhospitalised reference group. Compared to in-hospital assessment, these altered behavioural and physiological responses improved over time except for systolic blood pressures which remained unchanged at 3 months post family member discharge. ConclusionHospitalisation is associated with altered behavioural and physiological responses in family members. These findings contribute to understanding of the impact of unexpected hospitalisation on family members’ cardiovascular risk factors and provide insights into potential mechanisms for the proposed increased risk during this time. Elevated systolic blood pressure at 3 months post discharge suggests a prolonged cardiovascular stress response in many family members of critical care patients that requires further study, with a focus on contributing and potential modifiable factors.

Potential Utility of the Mallampati Score for Prediction of Treatment Compliance and Safety Profiles of Patients With Head and Neck Cancer Undergoing Definitive Concurrent Chemoradiotherapy.

Restriction of mouth opening (RMO) is a common manifestation of head and neck cancer (HNC) and a poor prognostic factor following concurrent chemoradiotherapy (CCRT) of patients. This study aimed to explore whether the Mallampati score, a visual assessment of the distance from the tongue base to the roof of the mouth, can be used as a surrogate for RMO in predicting treatment outcomes in patients with HNC undergoing CCRT. A total of 461 consecutive patients who received definitive CCRT for the treatment of locally advanced HNC between August 2016 and December 2017 at Chang Gung Memorial Hospital in Taiwan (Linkou, Keelung, and Kaohsiung branches) were enrolled in this prospective study. Patients were allocated by the pre-treatment Mallampati score of 1 or 2 (n=24) vs. 3 or 4 (n=207) to compare treatment compliance and treatment-related complications. Patients in the Mallampati score of 3 or 4 group had a higher prevalence of betel quid chewing, oral cavity and oropharynx cancers, advanced tumor stage, poorer performance status, and were more likely to receive platinum monotherapy during CCRT. Patients in the Mallampati score of 3 or 4 group had a 2.08-fold (p=0.002) hazard ratio (HR) for overall survival compared to those in the score of 1 or 2 group in the univariate analysis, the difference remained significant in multivariate analysis (adjusted HR=1.61; 95% CI=1.02-2.61; p=0.047). Patients in the Mallampati score 3 or 4 group had a 2.36-fold (95% CI=1.07-5.19; p=0.033) increased likelihood of incomplete chemotherapy, 2.44-fold (95% CI=1.17-5.06; p=0.017) increased likelihood of incomplete radiotherapy, and 1.84-fold (95% CI=1.18-2.87; p=0.007) risk of unexpected hospitalization compared to those with a Mallampati score of 1 or 2 in multivariate analysis. Patients with HNC with higher pre-treatment Mallampati scores had poorer survival outcomes and were at a higher risk of treatment incompletion and treatment-related toxicities when undergoing CCRT. Our results support the utility of Mallampati score as a surrogate for measuring RMO to predict survival outcomes, treatment compliance, and safety profiles in patients with HNC undergoing CCRT.

OC-017 INTRAPERITONEAL ONLAY MESH (IPOM) TECHNIQUE FOR THE LAPAROSCOPIC TREATMENT OF PRIMARY AND INCISIONAL VENTRAL HERNIA IN DAY SURGERY REGIME

Abstract IPOM technique is a well-established technique for the repair of primary and incisional ventral hernia; and outpatient regime is considered a cost-effective strategy without compromising the quality of care. In this retrospective observational study, we evaluated the application of IPOM technique through outpatient setting, with the use of a non-absorbable, transparent, light prostheses in polypropylene, composed of a macroporous monofilament mesh and a transparent polypropylene film. 179 consecutive procedures of primary and incisional hernia repair from 2011 to 2022 have been included in this study (149 with the above-mentioned composite meshes and 30 with other meshes, semi-absorbable and non-absorbable). All the procedures were performed through 3 abdominal trocars executing cold adhesiolysis to release the contents of the hernial sac without dissecting the latter. The abdominal wall was then prepared by blunt dissection to create the space for the mesh and to favor a prompt cell colonization. Mesh fixation was achieved using transparietal points and resorbable tackers. The primary outcomes of the study were the evaluation of any risk factors for conversion from outpatient regime to standard hospitalisation, and the hernia recurrence, in two subgroups: primitive hernias (n=72) and incisional hernias (n=107). Our clinical experience showed that IPOM technique through outpatient setting is a safe and effective approach. No statistically significant difference in the recurrence rate between the primitive and incisional hernias groups (5.9% vs 5.0%, p=0.80) was found. Moreover, we found a relationship between the rate of unexpected hospitalization and age of the patients, number of defects and hernia dimension.

Association of Rapid Response Teams With Hospital Mortality in Medicare Patients.

Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends. Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix-adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index. The median annual number of Medicare admissions was 5214 (range, 408-18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94-1.02]; P=0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99-1.02]; P=0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals. Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes.

From “organs on a chip” to “patient on a chip”

The increasing cost of drug safety is attributed to the inappropriate pre-clinical models with unrepresentative pharmacokinetic and pharmacodynamic profiles that blur drug efficacy and toxicity. Moreover, the commercial drugs designed by impromper disease models could cause potential multi-organ side effects. Even worse, in some cases, unqualified drug screening is the cause of unexpected hospitalization in clinical. These urgent yet unsolved issues push scholars to reform monolayer cell culture and traditional animal models for drug validation.

Optimal Frailty Dimensions for Assessing Frailty and Predicting Chemotherapy Adverse Events in Older Taiwanese Cancer Patients

BackgroundThis study aimed to investigate the effects of different frailty dimensions on frailty prevalence in older Taiwanese cancer patients receiving chemotherapy, and to analyze the dimensions that should be included in frailty assessment for effectively predicting serious adverse events, unexpected hospitalizations, and emergency department visits.Materials and MethodsThis study prospectively enrolled 234 cancer patients with solid cancer or lymphoma and aged 65 years or older who later received chemotherapy at a medical center in Taiwan from September 2016 to November 2018. First, all patients were subjected to a frailty assessment on eight frailty dimensions within 1 week before their first chemotherapy treatment. The effects of different dimensions on frailty were analyzed using a Poisson regression model. Second, after sequentially excluding one, two, and three dimensions with the lowest effects, frailty was sequentially assessed in the remaining seven, six, and five dimensions for comparison of chemotherapy-related adverse events.ResultsNutritional status, comorbidity, history of falls, cognitive status, and polypharmacy were the top five important dimensions of frailty in older Taiwanese cancer patients. Regardless of the number (five to eight) of dimensions used for frailty assessment, frail patients had higher rates of serious adverse events, unexpected hospitalizations, and emergency room visits than non-frail patients during chemotherapy.ConclusionsFrailty assessment in older Taiwanese cancer patients should be based on at least five dimensions to accurately identify those at high risk of serious adverse events during chemotherapy. It is expected that the present findings may be used to design a frailty scale for older Taiwanese in the future.

Percutaneous radiofrequency ablation of hepatocellular carcinoma in a recent cohort at a tertiary cancer center: incidence and factors associated with major complications and unexpected hospitalization events.

This study aimed to assess the incidence of and factors associated with major complications, delayed discharge, and emergency room (ER) visits or readmission after percutaneous radiofrequency ablation (RFA) for single hepatocellular carcinoma (HCC) <3 cm in a recent cohort at a tertiary cancer center. A total of 188 patients with treatment-naïve single HCCs <3 cm who underwent RFA between January 2018 and April 2021 were included in the analysis. Univariable and multivariable logistic regression analyses were performed to identify the factors associated with major complications, delayed discharge, and ER visits or readmission. Local tumor progression (LTP) and overall survival were estimated using the Kaplan-Meier method and Cox proportional-hazards regression analysis. Major complications occurred in 3.2% (6/188) of the patients. The longest diameter of the ablation zone was significantly larger in patients with major complications (P=0.023). Delayed discharge occurred in 5.8% (9/188) of the patients, for which albumin-bilirubin grade 3 was identified as an important determinant. No variables other than major complications were significantly associated with ER visits or readmission, which occurred in 7.0% (13/188) of the patients. Major complications, delayed discharge, and ER visits or readmission were not substantially related to the post-treatment outcomes of LTP and overall survival. This study confirmed RFA as a highly safe procedure for single HCCs <3 cm, despite the rapidly changing RFA techniques in the most recent cohort. A large ablation zone and poor liver function were predictors of major complications and delayed discharge, respectively.

The association between cardiac involvement and long-term clinical outcomes in patients with Duchenne muscular dystrophy.

AimsDespite advances in contemporary cardiopulmonary therapies, cardiomyopathy remains the leading cause of death in patients with Duchenne muscular dystrophy (DMD). Also, the long‐term clinical outcomes of patients with DMD and cardiomyopathy is unknown. This study investigated long‐term clinical outcomes and their associated factors in patients with late‐stage DMD.Methods and resultsA total of 116 patients with late‐stage DMD (age > 15 years) were enrolled in this retrospective study. All enrolled patients were followed up at a single tertiary referral hospital. LV systolic dysfunction was dichotomously defined as reduced [left ventricular ejection fraction (LVEF) ≤ 40%] vs. preserved [>40%] based on the initial echocardiographic result. The primary endpoint was all‐cause death. The secondary endpoint was a composite event defined as death or unexpected hospitalization due to cardiovascular reasons including chest pain, dyspnoea, and generalized oedema. The patients were divided into preserved (n = 84, 72.4%) and reduced LVEF groups (n = 32, 27.6%). The mean age was 20.8 ± 5.9 years, the mean disease duration, 8.8 ± 3.7 years, and the mean follow‐up duration, 1708 ± 659 days. For primary endpoint, the reduced LVEF group showed a lower rate of overall survival (Reduced LVEF vs. Preserved LVEF; 81.3% vs. 98.8%, log‐rank P = 0.005). In the multivariable Cox regression analysis, brain‐natriuretic peptide (BNP) level (adjusted hazard ratio [HR] 1.088, 95% confidence interval [CI] 1.019–1.162, P = 0.011) and diuretic use (adjusted HR 9.279, 95%CI 1.651–52.148, P = 0.011) were significant predictors of all‐cause death in patients with DMD. For the secondary endpoint, the reduced LVEF group had a lower rate of freedom from composite events than the preserved LVEF group (65.6% vs. 86.9%, log‐rank P = 0.005). In the multivariable Cox regression analysis, BNP level (adjusted HR 1.057, 95%CI 1.005–1.112, P = 0.032) and diuretic use (adjusted HR 4.189, 95% CI 1.704–10.296, P = 0.002) were significant predictors of the composite event in patients with DMD.ConclusionsPatients with DMD and reduced LVEF had worse clinical outcomes than those with preserved LVEF. BNP level and diuretic use were associated with adverse clinical outcomes in patients with late‐stage DMD, irrespective of LVEF.

Experiences of parents and patients hospitalised in a child psychiatric unit for anorexia nervosa after reorganisation of care imposed by the COVID-19 Pandemic in France: a qualitative study\u2014The QUALICOVID study

BackgroundAnorexia nervosa is a serious, albeit common mental illness that generally occurs during adolescence. Although outpatient care is recommended, hospitalisation is sometimes required. There is a dedicated hospitalisation unit caring for children and adolescents presenting with anorexia nervosa in Nancy, France. However, on 16 March 2020, a national lockdown was declared by the French government as the COVID-19 pandemic escalated in France. This resulted in the adjustment of hospital admissions accompanied by premature discharge and an intensive outpatient care programme. In the light of such changes, consideration should be given to the potential impact of changes in the care pattern for anorexic patients and their parents. The purpose of our study was to explore the experiences of anorexia nervosa patients hospitalised in the unit, and their parents, following changes in the care strategy.MethodsThe study was conducted between weeks four and eight after lockdown was announced. The study cohort included all the patients treated for anorexia nervosa and hospitalised in the treatment unit before 16 March 2020 and their parents. A qualitative method was used and every subject was offered a semi-structured interview. Data were analysed by means of inductive thematic analysis.ResultsSeven superordinate themes were identified: positive aspects, concerns, preparation, loss of landmarks and hospital security, gradual return to a “normal” life, relational aspects and the likelihood of disease progression. Moreover, all the parents and patients were satisfied with the intensive outpatient care offered on discharge.ConclusionDespite initial ambivalence, all patients and their parents viewed this unexpected hospital discharge positively in these exceptional conditions. This suggests that restructuring the care programme could prove beneficial with increasing use of outpatient management, thereby reducing the length of the hospital stay and adjusting the return to school.Trial registration: ID-RCB 2020-A01101-38—This project was approved by the Comité de Protection des Personnes (CPP) Sud Méditerranée IV [South Mediterranean IV Ethics Committee (EC)] on 5 May 2020.

The risk of unexpected hospital admissions and primary care visits after an elective day-case gastroscopy: a cohort study within England.

SummaryAimTo determine the excess of acute medical contacts following a day‐case diagnostic gastroscopy.MethodsCohort study using English linked primary, secondary care and death registry electronic health data. We included 277,535 diagnostic day‐case gastroscopies in 225,304 people between 1998 and 2016 and followed up for 30 days. 1,383,535 30‐day periods without a gastroscopy within 991,249 people frequency matched on year, gender and decade of birth. Non‐cancer deaths, emergency non‐cancer admissions and cardio, vascular or respiratory (CVR) primary care consultations were identified and adjusted for each other as competing risks. Outcomes related to possible indications for gastroscopy were censored.Results5.1% of day‐case diagnostic gastroscopies were followed by emergency hospital admission, 0.4% for a CVR diagnosis. Adjusted for age, sex, morbidity, time trends, indications and competing risks, there was a 0.1% excess of CVR‐related hospital admissions compared to controls. This reduced to 0.05% (95% confidence interval 0.04–0.06%) in people under 40 years without morbidity and increased to 1.1% (0.6%–1.6%) in people over 90 years with high comorbidity. Similarly, by 30 days, 3.8% had a primary care consultation for a CVR problem, with an excess after adjustment ranging from 0.13% (0.11%–0.16%) to 0.31% (0.14%–0.50%). Overall numbers needed to harm ranged from 1 in 294 gastroscopies to 1 in 67 gastroscopies.ConclusionsThere was an excess of vascular and respiratory events associated with a diagnostic gastroscopy. In younger patients, this risk manifested as an increase in primary care consultations while in older patients there was an increase in emergency hospital admissions.

Prospective comparison of the value of CARG, G8, and VES-13 toxicity tools in predicting chemotherapy-related toxicity in older Turkish patients with cancer

BackgroundIn older patients with cancer, it is very important to choose the appropriate treatment because they are at high risk for chemotherapy toxicity. Our study investigated characteristics of Cancer and Aging Research Group (CARG), Geriatric 8 (G8), and Vulnerable Elders Survey (VES-13) screening tools for predicting chemotherapy-related toxicity (CRT) prospectively. Materials and methods208 patients aged ≥65 years old for whom chemotherapy was planned to treat non-haematological cancer between February 2021–September 2021 were included in the study. The CARG, G8, and VES-13 toxicity tools were completed by the oncologist through face-to-face interviews before starting the first chemotherapy treatment. CRTs during chemotherapy were evaluated according to the National Cancer Institute's Common Terminology Criteria for Adverse Events v4.03. Logistic regression models, the area under the receiver operating characteristic curve (ROC-AUC), and correlation analyses were used for comparing questionnaires. ResultsMedian age was 70.4 (range 65–86) years. Of the participants, 103 (49.5%) participants experienced grade 3–5 CRT (32.2% haematological, 28.4% non-haematological) during chemotherapy. ROC-AUC value of CARG was determined as 0.827 (95% CI [confidence interval]: 0.77–0.88, p < 0.001), it was determined as 0.744 (95% CI: 0.68–0.81, p < 0.001) for G8 and 0.726 (95% CI: 0.66–0.80, p < 0.001) for VES-13. In the univariate regression analysis, CARG (OR [odds ratio] = 13.57, 95% CI: 6.0–30.72, p < 0.001), G8 (OR = 3.19, 95% CI: 1.62–6.29, p = 0.001), and VES-13 (OR = 9.5, 95% CI: 5.01–17.89, p < 0.001) were found to be predictive for CRT. The multivariate analysis (included stage, Eastern Cooperative Oncology Group [ECOG] performance status, presence of comorbid disease, platinum-based treatment regimen, taxane-based treatment regimen, CARG, VES-13, G8) showed that CARG (OR = 12.08, 95% CI: 5.11–28.56, p < 0.001), VES-13 (OR = 10.06, 95% CI: 4.92–22.98, p < 0.001), and G8 (OR = 2.20, 95% CI: 1.04–4.69, p = 0.040) screening tools were strong predictors for CRT. The CARG and VES-13 questionnaires were predictive for reducing the initial treatment dose (p = 0.004, p = 0.004, respectively), interruption of treatment (p < 0.001, p < 0.001, respectively), discontinuing treatment (p = 0.002, p = 0.002, respectively), and unexpected hospitalisation (p = 0.012, p = 0.003, respectively). ConclusionsWe showed that all three CARG, G8, and VES-13 questionnaires are helpful tools in the decision-making process for ideal chemotherapy to predict severe CRT; however, CARG and VES-13 questionnaires appear more useful in daily oncology practice than the G8 questionnaire.

Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound.

BackgroundWhile coronary stent implantation in ST-elevation myocardial infarction (STEMI) can mechanically revascularize culprit epicardial vessels, it might also cause distal embolization. The relationship between geometrical and functional results of stent expansion during the primary percutaneous coronary intervention (pPCI) is unclear.ObjectiveWe sought to determine the optimal stent expansion strategy in pPCI using novel angiography-based approaches including angiography-derived quantitative flow ratio (QFR)/microcirculatory resistance (MR) and intravascular ultrasound (IVUS).MethodsPost-hoc analysis was performed in patients with acute STEMI and high thrombus burden from our prior multicenter, prospective cohort study (ChiCTR1800019923). Patients aged 18 years or older with STEMI were eligible. IVUS imaging, QFR, and MR were performed during pPCI, while stent expansion was quantified on IVUS images. The patients were divided into three subgroups depending on the degree of stent expansion as follows: overexpansion (>100%), optimal expansion (80%−100%), and underexpansion (<80%). The patients were followed up for 12 months after PCI. The primary endpoint included sudden cardiac death, myocardial infarction, stroke, unexpected hospitalization or unplanned revascularization, and all-cause death.ResultsA total of 87 patients were enrolled. The average stent expansion degree was 82% (in all patients), 117% (in overexpansion group), 88% (in optimal expansion), and 75% (in under-expansion). QFR, MR, and flow speed increased in all groups after stenting. The overall stent expansion did not affect the final QFR (p = 0.08) or MR (p = 0.09), but it reduced the final flow speed (−0.14 cm/s per 1%, p = 0.02). Under- and overexpansion did not affect final QFR (p = 0.17), MR (p = 0.16), and flow speed (p = 0.10). Multivariable Cox analysis showed that stent expansion was not the risk factor for MACE (hazard ratio, HR = 0.97, p = 0.13); however, stent expansion reduced the risk of MACE (HR = 0.95, p = 0.03) after excluding overexpansion patients. Overexpansion was an independent risk factor for no-reflow (HR = 1.27, p = 0.02) and MACE (HR = 1.45, p = 0.007). Subgroup analysis shows that mild underexpansion of 70%−80% was not a risk factor for MACE (HR = 1.11, p = 0.08) and no-reflow (HR = 1.4, p = 0.08); however, stent expansion <70% increased the risk of MACE (HR = 1.36, p = 0.04).ConclusionsStent expansion does not affect final QFR and MR, but it reduces flow speed in STEMI. Appropriate stent underexpansion of 70–80% does not seem to be associated with short-term prognosis, so it may be tolerable as noninferior compared with optimal expansion. Meanwhile, overexpansion and underexpansion of <70% should be avoided due to the independent risk of MACEs and no-reflow events.

Transition in cardiology 1: Pediatric patients with congenital heart disease to adulthood.

With advances in medical care, the majority of infants and children with chronic diseases are now able to reach adulthood. However, many of them still need special health care because of their original diseases, sequelae, and complications. The transition from the child health care system to the adult health care system is a crucial step for these patients. The goal of transitional care is to maximize the lifelong function and potential of these patients by uninterruptedly providing appropriate health-care services. To achieve this goal, we should (i) coordinate the transfer to adequate medical institutions and departments for adults, (ii) educate patients to improve self-management, and (iii) support the transition to social and welfare services for adults. Transitional care in pediatric cardiology has been a step ahead of such care in other diseases because of the relatively high incidence and the long history of adult congenital heart disease. Education of the patients to establish autonomy reduces dropping out and unexpected hospitalizations and it is the most important part of transitional care. To achieve this goal, we should provide explanations to pediatric patients according to their age and level of understanding from their first visit, rather than waiting until they reach a certain age. Tools for education and readiness checks are also being developed. To achieve a situation in which pediatric patients with chronic disease can take care of their own health and fully utilize their abilities at the growing step, transitional care plays a crucial role not only in pediatric cardiology but also in other subspecialties.