Unplanned Visits Research Articles

Supporting older adults with cancer and their support person through geriatric assessment and remote exercise and education: The SOAR study protocol.

Frail older adults receiving cancer treatment are at heightened risk of adverse outcomes. Despite the known benefits of exercise during cancer treatment to improve well-being, few exercise studies focus on frail older adults receiving cancer treatment and their support person. Geriatric assessment (GA) is often recommended prior to the start of treatment for frail adults with cancer, but combining the GA with a planned exercise regimen remains unexplored. This study aims to determine the feasibility and acceptability of implementing geriatric assessment and management (GAM) in combination with virtual chair-based exercise (CBE) and health education for frail older adults with cancer and their support persons. This phase 2 randomized controlled trial will include patients aged 70years and above with a lung, gastrointestinal, or genitourinary cancer referred for first- or second-line chemotherapy, immunotherapy, or targeted therapy. Patients must be frail (≥3 on the Vulnerable Elders Survey), sedentary on the Godin Leisure Time Activity Questionnaire (<90min of moderate/intense activity per week), have English proficiency with ability to consent, a physician-estimated life expectancy of at least six months, and deemed safe to exercise. Each older adult will be invited to bring a support person to participate in the study. Patients will be randomized 1:1 to GAM combined with online CBE and health education for 12weeks or waitlist control. Participating support persons will follow the same intervention group. Primary endpoints for feasibility and acceptability will be recruitment rate, retention, adherence, and data collection. Outcome measures include physical activity, function, fatigability, quality of life, treatment toxicity, and unplanned hospital visits. Outcome measures will be used to obtain estimates of the effect size and feasibility analysis needed for designing a phase 3 study. The study will take place at two hospitals in Toronto, Canada. This study will investigate the feasibility, acceptability, and obtain preliminary estimates of the outcomes of GAM plus CBE and health education in preventing functional decline and improving quality of life in frail older adults receiving cancer treatment and their support persons. The results will help to design a definitive phase 3 randomized controlled trial. The trial is registered at ClinicalTrials.gov (Registration Number: NCT05509751).

Development and Validation of an Instrument to Assess Quality and Completeness of Medication-Related Discharge Documentation.

Transitions of care are periods of heightened risk of medication management errors. Poor-quality discharge documentation has been linked to incorrect or suboptimal medication use and unplanned hospital visits. Despite regulations defining essential components of medication-related discharge documentation, deficiencies persist, highlighting the need for a method to assess whether current clinical practice meets these standards. To conduct an initial validation of a newly developed instrument, the Complete Medication Documentation at Discharge - Measure (CMDD-M), assessing the quality and completeness of medication-related discharge documentation in a Swedish clinical setting. The instrument was developed and refined in multiple stages. In this study, two clinical pharmacists and one geriatrician independently applied the final instrument to discharge documentation from 50 patients. Inter-rater reliability (IRR) was evaluated using linear and quadratic weighted Cohen's κ (κW linear and κW quadratic). The average CMDD-M score, based on the consensus of the three raters, was 3.40 (SD ± 2.50) out of nine possible points across the patients' discharge documentation. The IRR between the pharmacists' individual assessments demonstrated almost perfect agreement, with κW linear and κW quadratic values of 0.92 (95% CI: 0.80-1.00) and 0.97 (95% CI: 0.85-1.00), respectively. Moreover, the IRR between the pharmacists' consolidated score and the geriatrician's assessment displayed a moderate to strong agreement, with κW linear and κW quadratic values of 0.64 (95% CI: 0.48-0.80) and 0.80 (95% CI: 0.64-0.97), respectively. The CMDD-M demonstrated robust IRR confirming its ability to consistently and accurately measure the quality and completeness of medication-related discharge documentation in an easy-to-use form. Further research is recommended to ensure validity, generalisability and association with clinically relevant outcomes supporting the instrument's potential usefulness for evaluating and improving clinical practice and research.

Cardiovascular Efficacy and Safety of Finerenone: A Meta-Analysis of Randomized Controlled Trials.

Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, has emerged as a novel therapeutic option for the management of patients with diabetes, chronic kidney disease, or heart failure. We seek to summarize the evidence on the drug's effectiveness regarding cardiovascular (CV) outcomes. We conducted a literature search of Pubmed, Cochrane CENTRAL, Embase, and ClinicalTrials.gov from inception to September 2024. Trials exploring the effects of finerenone on CV outcomes were extracted and analyzed. The results of pooled analyses were presented as risk ratios (RRs) with 95% confidence intervals (CIs). A total of eight trials, incorporating 21 200 patients, were included. The pooled analysis demonstrated a significant reduction in all-cause death (RR 0.92, 95% CI: 0.85-0.99), major adverse CV events (RR 0.85, 95% CI: 0.81-0.90), heart failure-related hospitalizations or unplanned hospital visits (RR 0.82, 95% CI: 0.76-0.87) with finerenone administration compared to control. Finerenone use was associated with a trend of reduced risk of CV death without reaching statistical significance (RR 0.90, 95% CI: 0.81-1.00). The risk of myocardial infarction (RR 0.91, 95% CI: 0.74-1.12), adverse events (RR 0.96, 95% CI: 0.89-1.03), adverse events leading to discontinuation (RR 1.06, 95% CI: 0.96-1.17) remained comparable across both groups. However, an increased risk of hyperkalemia (RR 2.07, 95% CI: 1.88-2.27) was observed with finerenone therapy compared to the control group. Finerenone administration was associated with improved CV outcomes in the CV-renmetabolic conditions compared to the control group.

Parents' perspective on unplanned return visits to the pediatric emergency department: A cross-sectional study.

The aim of this study was to investigate the factors leading to more than one time visit to the pediatric emergency department within 72h, parental wishes and experiences with emergency nurses from the parents' perspective. A cross-sectional study was conducted between April 15, 2023 and April 14, 2024 with 596 parents of children aged between 0 and 18years who had return visits to the pediatric emergency department of a gynaecology and pediatrics hospital in the Western Black Sea Region of Türkiye within 72h after the first visit. Following the acquisition of written informed consent from the parents, the data were collected using the Descriptive Characteristics of Children and Experiences of Parents Information Form. From the perspective of the parents, the most common reasons for an unplanned return visit to the pediatric emergency department were that the child's health had deteriorated (24.1%), the child required further tests (23.8%), and the child had developed a different health condition (18.7%). During the first visit to the pediatric emergency department, parents most frequently wished to be allowed to be with the child (24.2%), to touch the child during the procedures (20.5%), to receive up-to-date information about the child's condition (20.2%). In line with these results, it is thought that the frequency of unplanned return visits to pediatric emergency departments can be reduced by implementing adequate, accurate and effective planned discharge training in pediatric emergency departments. Pediatric emergency nurses can benefit from the perspectives of parents in their professional practices to improve the quality of care and reduce the number of unplanned return visits to the emergency department.

Telehealth vs Clinic Postoperative Visit After Hysterectomy: A Randomized Controlled Trial.

Telehealth is becoming more common, but there is a paucity of literature investigating the role of telehealth in perioperative gynecologic care. The authors hypothesized that patients evaluated via telehealth 4 weeks after minimally invasive hysterectomy would not have lower satisfaction than patients evaluated in clinic. This was a randomized controlled noninferiority trial of patients who underwent minimally invasive hysterectomy at a single academic medical center. Participants were randomized to postoperative clinic visit or telehealth visit 4 weeks after hysterectomy. After the 4-week postoperative visit, patients were sent a satisfaction questionnaire. The primary outcome was overall patient satisfaction on a 100mm visual analog scale. Secondary outcomes were 90-day postoperative complications and unplanned events. One hundred one patients who underwent minimally invasive hysterectomy were identified for inclusion. Complete data were collected for 47 in the clinic group and 45 in the telehealth group. Overall postoperative visit satisfaction did not differ between groups (94.3 clinic vs. 92.0 telehealth, p = 0.47). The clinic group was significantly more likely to contact the clinic two or more times (p = 0.02); both groups were similarly likely to contact the clinic at least once (57.4% vs. 51.1%). Postoperative complications did not differ between groups, nor did unplanned clinic visits or emergency department (ED) visits. Postoperative visit satisfaction of patients evaluated via telehealth was noninferior to the satisfaction of patients seen in the clinic 4 weeks after minimally invasive hysterectomy. Unplanned clinic visits and ED visits did not differ between groups, nor did 90-day postoperative complications.

P-1737. A pilot intervention trial to reduce the use of post-procedural antimicrobials after common endoscopic urologic surgeries

Abstract Background Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is still commonly prescribed and can lead to patient harm. The goal of this multicenter pilot intervention trial was to encourage less frequent use of post-procedural antimicrobials after common endoscopic urologic procedures.Table 1.Characteristics of patients across the 3 participating hospitals during both the baseline and intervention periods Methods We evaluated a bundled intervention using a pre-post, quasi-experimental design at three Veterans Affairs medical centers that performed common endoscopic urologic procedures: ureteroscopy and transurethral resection of a bladder tumor or prostate. There was a 2-year baseline, 1-month implementation, and 12-month intervention period. The intervention consisted of education, local champion(s), and audit-and-feedback of data, aggregated to the hospital-level, on the frequency of post-procedural antimicrobial use with comparisons to other facilities. The primary outcome was antimicrobial use on post-procedural day 1 and was evaluated using a logistic regression model for each site. Secondary outcomes were a) unplanned visits (i.e., Emergency Department visits and/or hospital readmissions within 30 days of the procedure) as well as b) late antimicrobial prescriptions (i.e., antimicrobials prescribed within 7-30 days after the procedure).Figure 1.Probability of post-procedural antimicrobial use after common urologic procedures across the 3 participating hospitals during the baseline and intervention periods Results There were 1,272 procedures performed across all sites at baseline compared to 525 during the intervention period (Table 1). During the baseline period, 644 (50.6%) patients received post-procedural antimicrobials compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the two periods (Figure 1). At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.089; 95% CI 0.016-0.445). There was no significant increase in unplanned visits or late antimicrobial prescriptions at any of the sites. Conclusion Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use after urologic procedures at 1 of the 3 participating sites. These mixed findings support the safety and also the difficulty of implementing guidelines on surgical antimicrobial prophylaxis. Disclosures Daniel J. Livorsi, MD, Merck: Grant/Research Support

CMR-derived left atrial strain predicts adverse events in dilated cardiomyopathy

Abstract Background Dilated cardiomyopathy (DCM) is associated with an increased risk of major adverse cardiovascular events (MACE). However, current risk stratification methods are imperfect. Left atrial global longitudinal strain (LA GLS) is an increasingly acknowledged predictive parameter, yet its potential role in DCM is not well defined. Purpose This study aims to investigate the prognostic role of cardiac magnetic resonance (CMR)-derived LA GLS for the occurrence of MACE in patients with DCM. Methods A retrospective, longitudinal, single-centre CMR study of DCM patients was conducted. DCM was defined according to current guidelines. Clinical data was collected from electronic medical records and a blinded CMR analysis was performed. LA GLS was derived from CMR two-chamber cine images by a semiautomatic method and was categorized according to its median value. A composite MACE endpoint was defined as: heart failure (HF) (including unplanned HF visit or hospitalization, CRT implant, LVAD implant, heart transplantation), ventricular arrhythmias (including sudden cardiac death, ventricular fibrillation, sustained and non-sustained ventricular tachycardias, appropriate ICD shocks), systemic embolisms and/or all-cause death. The HF endpoint was also independently analysed due to its prevalence. Cox regression analysis was performed. Results A total of 181 DCM patients were included. The mean age was 55±15 years, and 34% were female. The indexed left ventricular end diastolic volume was 126±43 mL/m2, left ventricular ejection fraction was 35±13% and 67 patients (37%) had late gadolinium enhancement. Mean LA GLS was 22.2±16.3%. After a median follow-up of 3,6 (IQR 2,1- 5,6) years, 52 patients (29%) experienced at least one MACE: 32 (18%) HF events, 9 (5%) ventricular arrhythmias, 2 (1%) embolic strokes and 11 (6%) deaths. LA GLS was significantly lower in patients with MACE (17.7±12.7% vs 24.0±17.2%, p=0.019) and HF events (14.6±9.7% vs 23.9±16.9%, p=0.004) compared to those without. Univariable and multivariable Cox regression analyses for MACE are shown in Table 1A. LA GLS was independently associated with MACE (HR 1.03; 95% CI: 1.01-1.05; p= 0.048; higher risk when lower LA GLS). Patients with a LA GLS below the median (18.7%) showed a 2-fold increased risk of MACE (Figure 1A). Univariable and multivariable Cox regression analyses for HF events are shown in Table 1B. LA GLS (HR 1.04; 95% CI: 1.01-1.08; p= 0.036) and LVESVi (HR 1.01; 95% CI: 1.01-1.03; p= 0.025) were independently associated with HF events. Patients with a LA GLS &amp;lt; 18.7% showed a 3-fold increased risk of HF (Figure 1B). Conclusions CMR-derived LA GLS is a predictor of outcomes in DCM beyond established prognostic variables. Patients with normal LA GLS show a better prognosis. If confirmed in larger studies, LA GLS could be used to enhance current risk stratification in DCM. Table 1A-B Figure 1A-B

Chest wall perforator flap reconstruction in breast conserving surgery: quality of life and limited complications in outpatient treatment

BackgroundBreast conserving surgery (BCS) with partial breast reconstruction (PBR) results in less morbidity, better cosmetic outcomes, and improved patient satisfaction compared to mastectomy. Perforator flap reconstruction can attenuate defects prone to breast deformity after BCS. Usually, postoperative drains and inpatient admission are part of this treatment. The main objective of this study is to report on postoperative complications and patient satisfaction after drainless perforator flap reconstruction by a dedicated breast surgeon.MethodsIn a retrospective case series, 42 patients were included. All patients underwent BCS with drainless perforator flap reconstruction, planned and performed by a single breast surgeon. Outcomes were complication incidence and patient satisfaction reported in the Breast-Q Breast Conserving Therapy (BCT) module.ResultsIn the study cohort, the median age was 59.5 (49.8–71.3) years. Tumour types were ductal carcinoma in situ (DCIS, four patients, 9.5%), invasive no special type (NST, 22 patients, 52.4%), invasive lobular (12 patients, 28.6%), and other invasive cancers (4 patients, 9.5%). Complication incidence was seven of 42 patients (16.7%), including hematoma, seroma, wound dehiscence, fat necrosis, and lymphedema, all Clavien Dindo grade 0–1, without readmission or reoperation. Reported Breast-Q scores (median of 17 months after surgery) were 87/100 for psychosocial well-being, 82/100 for breast satisfaction, and 71/100 for physical well-being. Outpatient treatment was successful in 38 patients (90.5%), and 13 patients (31.0%) had an unplanned visit to the outpatient clinic.ConclusionDrainless perforator flap reconstruction performed by the breast surgeon results in high patient satisfaction and limited complications, both in number and severity. The use of drains and hospital stays after perforator flap reconstruction must be discouraged.

Costs of Oral Corticosteroid Use in Patients with Severe Asthma With/Without Chronic Rhinosinusitis with Nasal Polyps: Data from the Italian SANI Registry.

The burden of severe asthma on patients, especially on those with concomitant chronic rhinosinusitis with nasal polyps (CRSwNP), is substantial. Treatment intensification with oral corticosteroids is a common strategy for managing severe asthma exacerbations; however, prolonged exposure to systemic corticosteroids is associated with multisystem toxicity. This study aimed to quantify the association between oral corticosteroid use and annual asthma-related costs in patients with severe asthma with or without CRSwNP. This pharmacoeconomic analysis was based on data from the Severe Asthma Network in Italy (SANI) registry. Asthma-related costs were estimated in the context of the Italian healthcare system and included exacerbations requiring treatment intensification, unplanned visits, admissions to hospital and emergency/intensive care units, and lost workdays. For each item, the mean annual cost per patient was estimated based on national tariffs and the frequency of the event. To quantify the association between oral corticosteroid treatment and costs, the study cohort was stratified according to oral corticosteroid use in the 1-year preceding inclusion in the SANI registry. A total of 669 patients from the SANI registry were included in the present analysis, 255 of whom had concomitant CRSwNP. Corticosteroid use was associated with significantly higher annual disease-related costs per patient compared with no corticosteroid use. Compared with the overall study cohort and patients without CRSwNP, patients with CRSwNP had higher disease-related costs (higher by €1307 and €1869, respectively). Use of corticosteroids, in particular systemic corticosteroids, is associated with an increase in asthma-related costs. The concomitant presence of CRSwNP impacts negatively on costs. This study suggests that a thorough analysis of costs, expected benefits, and occurrence of adverse events is required when selecting treatment intensification strategies for managing uncontrolled severe asthma.

Patient Race and Ethnicity are Associated with Higher Unplanned 90-Day Emergency Department Visits and Readmissions but not 10-year All-Cause Complications or Reoperations: A Matched Cohort Analysis of Primary Shoulder Arthroplasties

Patient Race and Ethnicity are Associated with Higher Unplanned 90-Day Emergency Department Visits and Readmissions but not 10-year All-Cause Complications or Reoperations: A Matched Cohort Analysis of Primary Shoulder Arthroplasties

Cost Analysis of Lymphadenectomy and Lymphedema One Year after Surgery for Endometrial Cancer: A Prospective Longitudinal Observational Multicenter Study

Background: Since the therapeutic effect of lymphadenectomy on long-term survival in endometrial cancer treatment is disputed, a health economic evaluation of lymphadenectomy is important. The primary aim was to evaluate the direct hospital-related and health care-related costs of lymphadenectomy one year after surgery for endometrial cancer. A secondary aim was to evaluate the costs for lymphedema. Methods: This was a prospective longitudinal observational multicenter study. Fifteen Swedish hospitals participated: four university, seven central and four county hospitals. Women with presumed early-stage endometrial cancer assigned for primary surgery were eligible for the study. Between June 2014 and January 2018, 116 women, categorized as having high-risk endometrial cancer, underwent surgery with lymphadenectomy, and 119 categorized as having low-risk endometrial cancer had surgery without lymphadenectomy. The calculations of costs followed the structure of a cost analysis. Results: Lymphadenectomy increased the total costs for surgery within one year after surgery compared with treatment without lymphadenectomy by 71%, (mean (standard deviation) 118,205 Swedish crowns (SEK) (43,116 SEK) vs. 70,451 SEK (31,138 SEK)). The total hospital costs for those who developed lymphedema were 25% higher than for those without lymphedema (115,099 SEK (44,593 SEK) vs. 91,793 SEK (44,062 SEK)). Conclusions: Lymphadenectomy in the treatment of endometrial cancer increased hospital costs significantly. The hospital costs for the primary treatment of endometrial cancer for those who developed lymphedema one year after surgery were moderately higher than for those who did not, mainly due to higher surgical costs for lymphadenectomy, more unplanned outpatient visits, and readmissions that required surgery. Clinical Trial registration: The study has been registered on https://classic.clinicaltrials.gov/ (registration number: NCT02115477).

Outpatient worsening of heart failure and mortality in transthyretin amyloid cardiomyopathy.

Transthyretin cardiomyopathy (ATTR-CM) is characterized by episodes of worsening heart failure (WHF) which can include heart failure (HF) hospitalizations or urgent unplanned visits for administration of intravenous diuretics. WHF characterized by outpatient intensification of oral loop diuretics is common yet its prognostic implications for ATTR-CM patients relative to other WHF events remains unclear. We assessed how WHF characterized by outpatient diuretic intensification (ODI) relates to mortality in this population. This was a retrospective study of ATTR-CM patients presenting to the Columbia University Irving Medical Center. Oral loop diuretic dose was recorded longitudinally. WHF characterized by ODI was defined as a persistent increase in oral loop diuretic dose lasting >1 month. We analysed the all-cause mortality rate after either WHF event (hospitalization or ODI) relative to subjects who had no WHF event. Overall, 303 patients highly treated with tafamidis were included: 152 (50.2%) patients had no WHF events, 35 (11.6%) experienced HF hospitalization, and 145 (47.9%) experienced ODI; 29 (9.6%) patients experienced both WHF events. Patients experiencing ODI had higher rates of subsequent mortality (17.7 per 100 person-years; 95% confidence interval [CI] 13.3-23.7) as did those with a HF hospitalization (29.8 per 100 person-years; 95% CI 17.7-50.3) than patients without WHF events (5.0 per 100 person-years; 95% CI 3.0-8.3) on log-rank test. WHF characterized by ODI was independently associated with mortality in a model adjusting for age, genotype, atrial fibrillation, disease duration, time-varying tafamidis use and National Amyloid Centre (NAC) or Columbia stages. In contemporary patients with ATTR-CM treated with tafamidis, WHF requiring ODI is prognostic of subsequent mortality and is a clinical marker of disease progression.

Blood Loss in Women of Childbearing Potential Taking Oral Anticoagulants for Venous Thromboembolism (The BLEED Study).

Oral anticoagulants (OAC) may exacerbate menstrual bleeding in women of childbearing age; however, the existing literature on this issue has several limitations. This study investigates abnormal uterine bleeding in women of childbearing age taking OAC-vitamin K antagonists or direct oral anticoagulants-for venous thromboembolism through a retrospective analysis of prospectively collected data. Uterine bleeding was assessed using the Pictorial Blood Assessment Chart (PBAC) and hemoglobin (Hb) values during anticoagulation compared with prior therapy. The number of unplanned medical visits for bleeding complications was also calculated. From June 2014 to November 2023, 110 women were recruited (median age, 36 years). PBAC scores correlated with Hb values at baseline and during therapy (analysis of variance [ANOVA], p < 0.01), with a significant difference in Hb values before and during anticoagulant therapy (delta Hb) among groups (ANOVA, p.0.034). Seventeen women (15.5%) reported uterine fibroids, experiencing a greater reduction in Hb values during anticoagulant administration than women without uterine fibroids (delta 0.3, interquartile range [IQR]: 0.8, 2.9 vs. 0.5, IQR 1.2, 0.3; p.0.012). Women with selfreported uterine fibroids required more frequent unplanned medical consultations for bleeding (mean visits 5 vs. 4, respectively; Poisson regression, p < 0.05). Among women with uterine fibroids, those taking apixaban showed smaller Hb changes than those on other oral anticoagulants (ANOVA, p.0.047). This difference persisted even after adjusting for potential confounders (multiple ANOVA, p.0.004). Women of childbearing age taking OAC frequently experience changes in Hb values and PBAC scores during treatment, with uterine fibroids playing a significant role.

Assessment of Continuous Pulse Oximetry Monitoring in Infants With Bronchiolitis in the Pediatric Emergency Department: A Cross-Sectional Study.

Purpose Bronchiolitis guidelines recommend intermittent pulse oximetry monitoring for stable infants. Continuous pulse oximetry can lead to harm for some infants with bronchiolitis but is still frequently used in emergency departments (EDs) for infants who do not require oxygen supplementation. Measuring continuous pulse oximetry use from medical charts can be challenging. This study aimed to (1) develop a feasible method for documenting the use of continuous pulse oximetry in infants with bronchiolitis and (2) explore factors influencing its use in this population. Methods We conducted a cross-sectional observational study in a tertiary pediatric ED. Infants 60 days and 12 months old with possible bronchiolitis and not requiring oxygen were included. The patients were recruited from January 11 to March 21, 2023. Research assistants directly observed the use of pulse oximetry monitors. The primary outcome was the proportion of infants placed on continuous pulse oximetry. The secondary outcomes included disease severity, admission, unplanned return visits, the use of supplemental oxygen, and the need for investigationsand interventions. Results Eighteen infants were included in this study, with six (33.3%) placed on continuous pulse oximetry. The median disease severity score was similar between infants who were continuously monitored (6.5 (IQR 5.3, 10.8)) and those in the intermittent pulse oximetry group (4.5 (IQR 2, 9)). Infants in the continuous pulse oximetry group underwent more investigations and interventions than those in the intermittent pulse oximetry group: chest radiograph and bloodwork in 50% versus 8.3%, antibiotics in 33.3% versus 8.3%, bronchodilators in 33.3% versus 16.7%, and steroids in 16.7% versus 0%. In the continuous pulse oximetry group, four infants (66.7%), all of whom were placed on supplemental oxygen, were admitted, compared to one infant (8.3%) in the intermittent pulse oximetry group. Conclusion The decision to use continuous pulse oximetry may be influenced by provider characteristics. Objectiveparameters should be developed to guide its applicationand minimize potential harms associated with it.

Validating the DIVERT scales, CARS, and EARLI for predicting emergency department visits in home health care in Japan: A retrospective cohort study.

The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) scale, the Community Assessment Risk Screen (CARS), and the Emergency Admission Risk Likelihood Index (EARLI) are scales that assess the risk of emergency department (ED) visits among home health care patients. This study validated these scales and explored factors that could improve their predictive accuracy among Japanese home health care patients. This was a single-center retrospective cohort study. The primary outcome of unplanned ED visits was used to assess the validity of the DIVERT scale, CARS, and EARLI. Additionally, we examined whether the addition of patient age and receipt of advance care planning as variables on these assessments could enhance their precision. Altogether, 40 (17.8%) had at least one ED visit during the 6 months study period. In these patients, the DIVERT scale, CARS, and EARLI of the patients with ≥1 ED visit was superior compared with no ED visit (both p < 0.05). The area under the curve (AUC) of the DIVERT scale, CARS, and EARLI were 0.62, 0.59, and 0.60, respectively. Adding patient age and receipt of advance care planning improved the AUC in all three scales. Our findings suggest that these assessment scales could be applicable to home health care patients in Japan. Furthermore, adding age and receipt of advance care planning as variables was found to enhance the predictive accuracy of the scales.

Cost-Effectiveness of Nonoperative Management vs Upfront Laparoscopic Appendectomy for Pediatric Uncomplicated Appendicitis Over 1 Year.

Non-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis. A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs). Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities. NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.

Risk Factors for Unplanned Emergency Department Visits in Patients with Nasopharyngeal Carcinoma During Radiotherapy.

Background/Objectives: Nasopharyngeal carcinoma (NPC) is commonly treated with radiotherapy (RT) or concurrent chemoradiotherapy (CCRT). However, unplanned emergency department (ED) visits during treatment can disrupt therapy and impact patient outcomes. This study aims to identify the risk factors associated with unplanned ED visits in patients with NPC receiving RT or CCRT. Methods: We retrospectively analyzed 2111 patients with NPC treated between 2001 and 2019 at Chang Gung Memorial Hospital. Patients were categorized based on whether they experienced an unplanned ED visit during or up to three months post-treatment. Demographic and clinical variables were compared using the Chi-squared test, and survival outcomes were assessed using Kaplan-Meier analysis. Results: Among the cohort, 573 patients (27.2%) experienced at least 1 unplanned ED visit. Risk factors for unplanned ED visits included older age (p < 0.001), hypertension (p < 0.001), higher Charlson Comorbidity Index (p = 0.001), and advanced clinical stage (T stage, p = 0.0046; N stage, p = 0.0034; M stage, p = 0.0008). No significant difference in ED visit rates was observed between RT alone and CCRT groups. Conclusions: Unplanned ED visits were common during NPC treatment, with risk factors primarily related to patient age, comorbidities, and disease stage. Identifying high-risk patients may enable interventions to reduce ED visits, improve survival outcomes, and alleviate healthcare costs.

A pilot intervention trial to reduce the use of post-procedural antimicrobials after common endourologic surgeries.

Post-procedural antimicrobial prophylaxis is not recommended by professional guidelines but is commonly prescribed. We sought to reduce use of post-procedural antimicrobials after common endoscopic urologic procedures. A before-after, quasi-experimental trial with a baseline (July 2020-June 2022), an implementation (July 2022), and an intervention period (August 2022-July 2023). Three participating medical centers. We assessed the effect of a bundled intervention on excess post-procedural antimicrobial use (ie, antimicrobial use on post-procedural day 1) after three types of endoscopic urologic procedures: ureteroscopy and transurethral resection of bladder tumor or prostate. The intervention consisted of education, local champion(s), and audit-and-feedback of data on the frequency of post-procedural antimicrobial-prescribing. 1,272 procedures were performed across all 3 sites at baseline compared to 525 during the intervention period; 644 (50.6%) patients received excess post-procedural antimicrobials during the baseline period compared to 216 (41.1%) during the intervention period. There was no change in the use of post-procedural antimicrobials at sites 1 and 2 between the baseline and intervention periods. At site 3, the odds of prescribing a post-procedural antimicrobial significantly decreased during the intervention period relative to the baseline time trend (0.09; 95% CI 0.02-0.45). There was no significant increase in post-procedural unplanned visits at any of the sites. Implementation of a bundled intervention was associated with reduced post-procedural antimicrobial use at one of three sites, with no increase in complications. These findings demonstrate both the safety and challenge of guideline implementation for optimal perioperative antimicrobial prophylaxis.This trial was registered on clinicaltrials.gov, NCT04196777.

Safety and effectiveness of sodium-glucose co-transporter 2 inhibitors in active cancer patients with heart failure: results of the observational TOSCA trial

Abstract Background Sodium-glucose co-transporter 2 inhibitors (SGLT2i) currently represent a pillar of heart failure (HF) treatment. However, cancer patients have not been included in landmark randomized controlled trials (RCTs), and data on safety and effectiveness in this population are lacking. Purpose Purpose of present study was to evaluate safety and effectiveness of SGLT2i in active cancer patients with HF. Methods TOSCA is a multi-centre observational trial including patients (≥ 18 years) with active cancer (diagnosis &amp;lt; 3 years) receiving SGLT2i for HF treatment. Patients were enrolled in two (prospective and retrospective) cohorts. The primary endpoint was safety (incidence of known and unexpected side effects). The secondary endpoint was effectiveness (ejection fraction (EF) increase, New York Heart Association (NYHA) class change, HF-related events). Exploratory endpoints included drug-drug interactions with anticancer and supportive care drugs, treatment of cancer therapy-related cardiac dysfunction (CTRCD), and changes in NT-proBNP. Results Eighty-three pts were enrolled (59 prospective - 24 retrospective). Median age was 71 (range 44-92) yrs, M/F 48/52%. The main cancer sites were breast, gastrointestinal tract, and hematological malignancies. Most cases (62%) received an active treatment (mainly chemotherapy) while on SGLT2i. Prevalent aetiology was drug-induced HF (37%) with reduced EF as the prevalent clinical presentation (39%). Prescribed agents were dapagliflozin in 60% and empagliflozin in 40% of cases on top of conventional guideline-directed medical therapy, with a median treatment duration of 3 (range 3-25) months. The incidence of urinary tract infection was 2.5%. No cases of genital infection, hypoglycemia, diabetic ketoacidosis, acute renal injury, thrombosis, and bone fractures were reported. Mean overall EF slightly increased (44.1% vs. 46.6%), and NYHA class improved (class improvement in 16%). Unplanned cardiology visits (1.2%), i.v. diuretics (1.2%), coronary angiography (5%), emergency access (2.5%), and new HF episodes (3.7%) rates were low. SGLT2i appeared effective in 31 cases of CTRCD. A relative reduction in mean NT-proBNP levels (2748 vs 1125pg/mL) was observed. No drug-drug interactions were reported. Conclusions SGLT2i appear to be safe and effective in active cancer patients with HF, with potential cardioprotective effect. No new safety warnings were recorded.

Clinical implications of atrial fibrillation recurrence vs. burden following catheter ablation: outcome data from 3 contemporary clinical trials using an insertable cardiac monitor

Abstract Background Recurrence of atrial fibrillation (AF) following catheter ablation is typically defined in clinical trials in a binary fashion, e.g. &amp;gt; 30 seconds or none. However, the clinical implications of this endpoint, adopted from formal guidelines, have been questioned. Purpose We hypothesized that assessment of AF burden can provide incremental clinical and management implications to the dichotomous definition of AF recurrence following ablation. Methods The study population comprised 147 patients enrolled in 3 ongoing multicenter randomized clinical trials (ICM REDUCE-AF [N=67]); HYBRID-AF (N=55] and DAPA-AF [N=25]), each employing an insertable cardiac monitor (ICM) to assess post-ablation AF recurrence and burden. The rate of cardiovascular (CV)-related healthcare utilization (CV-HCU, defined as the total number CV admissions, ED visits, cardioversions, procedures, and unplanned office visits) was compared based on AF recurrence (defined as &amp;gt;2 minutes of ICM-detected AF) vs. based on AF burden post-ablation (defined as time in AF divided by total monitoring time). Results Among the 147 study patients, mean age was 65 years; 53 (36%) were women; and 78 (53%) had persistent AF. At 12-months post-ablation (excluding blanking), the cumulative probability of AF recurrence was 60% (Figure 1A). However, 27% of AF recurrences were associated with a very low AF burden (≤0.1%) and low CV-HCU (10 events per 100 patient-months), similar to patients without AF recurrence (11 events per 100 patient-months). In contrast, recurrences with a higher AF burden (&amp;gt;0.1%; mean 17% ± 25%) were associated with a 3-fold higher rate of CV-HCU (31 events per 100 patient-months, p&amp;lt;0.001; Figure 1B). Findings were consistent regardless of AF-type, comorbidities or LVEF. Conclusions A substantial proportion of AF recurrences following contemporary AF ablation are associated with a very low AF burden without apparent effect on CV outcomes, whereas higher AF burden is associated with increased CV-HCU. These findings stress the need to move beyond a dichotomous definition of AF recurrence and to monitor AF burden post-ablation to guide management decisions in contemporary clinical practice.Figure 1