Development of a Semiautomated Database for Patients With Adult Congenital Heart Disease

BackgroundDatabases for Congenital Heart Disease (CHD) are effective in delivering accessible datasets ready for statistical inference. Data collection hitherto has, however, been labour and time intensive and has required substantial financial support to ensure sustainability. We propose here creation and piloting of a semiautomated technique for data extraction from clinic letters to populate a clinical database.MethodsPDF formatted clinic letters stored in a local folder, through a series of algorithms, underwent data extraction, preprocessing, and analysis. Specific patient information (diagnoses, diagnostic complexity, interventions, arrhythmia, medications, and demographic data) was processed into text files and structured data tables, used to populate a database. A specific data validation schema was predefined to verify and accommodate the information populating the database. Unsupervised learning in the form of a dimensionality reduction technique was used to project data into 2 dimensions and visualize their intrinsic structure in relation to the diagnosis, medication, intervention, and European Society of Cardiology classification lists of disease complexity. Ninety-three randomly selected letters were reviewed manually for accuracy.ResultsThere were 1409 consecutive outpatient clinic letters used to populate the Scottish Adult Congenital Cardiac Database. Mean patient age was 35.4 years; 47.6% female; with 698 (49.5%) having moderately complex, 369 (26.1%) greatly complex, and 284 (20.1%) mildly complex lesions. Individual diagnoses were successfully extracted in 96.95%, and demographic data were extracted in 100% of letters. Data extraction, database upload, data analysis and visualization took 571 seconds (9.51 minutes). Manual data extraction in the categories of diagnoses, intervention, and medications yielded accuracy of the computer algorithm in 94%, 93%, and 93%, respectively.ConclusionsSemiautomated data extraction from clinic letters into a database can be achieved successfully with a high degree of accuracy and efficiency.     

Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study

PurposeVasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response.MethodsThis retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%.ResultsOf 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference  −16%; 95% CI −30%,−2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04–1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e^{[0.81–0.1*t]}; at t = 0, HR 2.24; 95% CI 1.08–4.64).ConclusionsPre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.     

Therapeutic plasma exchange in pediatric patients with acute demyelinating syndromes of the central nervous system: A single-center experience

BackgroundTherapeutic plasma exchange (TPE) is an extracorporeal treatment that can be used in adult and pediatric patients with acute demyelinating syndromes of the central nervous system. In this study, the efficacy and safety of TPE was evaluated in 10 pediatric patients who underwent TPE that were unresponsive to corticosteroid treatment.MethodsRecords of 10 pediatric patients who underwent TPE in our pediatric intensive care unit (PICU) between May 2017 and June 2020 were used. Expanded Disability Status Scale (EDSS), Gait Scale (GS), and Visual Outcome Scale (VOS) were applied to the patients before and after TPE.ResultsOf the 10 patients who underwent TPE, five were diagnosed with multiple sclerosis (MS), three with transverse myelitis (TM), and two with acute disseminated encephalomyelitis (ADEM). The median age of the patients was 13.3 years (IQR 8-15), and the median day from symptom onset to onset of TPE was 12.5 days (IQR 7-28). A total of 104 TPE sessions were performed successfully. While no complications were encountered in three patients during the sessions, the most common complication was hypofibrinogenemia. The decrease in EDSS and GS scores was found to be consistent with the clinical response of the patients. There was no statistically significant decrease in the VOS.ConclusionsWith this study, we can say that TPE is a feasible, effective, and safe treatment modality in children with acute demyelinating syndromes of the central nervous system.     

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

ObjectiveThis article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.Data SourcesThese are electronic databases including PubMed and CINAHL.ConclusionFuture efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.Implications for Nursing PracticeIn the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients’ outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.     

Redefining “low risk”: Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era

ObjectivesGuidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.MethodsFrom January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.ResultsWith 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex–matched population.ConclusionsSTS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.