Predicting unplanned readmissions to a pediatric cardiac intensive care unit using predischarge Pediatric Early Warning Scores

Objective

Unplanned readmission to the pediatric cardiac intensive care unit (CICU) is associated with significant morbidity and mortality. The Pediatric Early Warning Score (PEWS) predicts ward patients at risk for decompensation but has not been previously reported to identify at‐risk patients with cardiac disease prior to ward transfer. This study aimed to determine whether PEWS prior to transfer may serve as a predictor of unplanned readmission to the CICU.

Design

All patients discharged from a tertiary children's hospital CICU from September 2012 through August 2015 were included for analysis. PEWS assessment was performed following transfer to the cardiac ward, and starting in January 2014, PEWS scores were also assigned by bedside CICU nurse prior to transfer from the CICU. Scores exceeding a predetermined threshold prompted further stability assessment by provider team prior to transfer.

Results

Among 1320 discharges of 1082 patients during the study period, there were 130 unplanned readmissions during their hospitalization. Following implementation of pretransfer PEWS scoring, there was no significant reduction in unplanned readmission frequency (10.2% vs 9.2%, P = .39). A secondary analysis of PEWS scores revealed cardiac scoring as a strong discriminator of those likely to experience an unplanned readmission, independent of other significant clinical predictors of readmission (OR 1.78, 95% CI 1.17–2.71, P = .007). The resultant multivariate model was a good predictor of unplanned readmission (AUC 0.77, 95% CI 0.71‐0.83, P < .001).

Conclusion

While implementation of a pretransfer PEWS assessment did not reduce the frequency of unplanned readmissions in this small single‐center cohort, a multivariate model including pretransfer elements of an early warning scoring system, along with other patient characteristics serves as a good discriminator of patients likely to experience an unplanned readmission following CICU discharge. Further prospective investigation is needed to define objective measures of pretransfer discharge readiness to potentially reduce the likelihood of unplanned readmissions.     

The influence of immunosuppressants on direct‐acting antiviral therapy is dependent on the hepatitis C virus genotype

Background

Direct‐acting antivirals (DAAs) have substantially increased sustained virological response rates after liver transplantation, with improved tolerance compared to interferon‐based therapy. The influence of immunosuppressive agents on the efficacy of DAAs has not been clarified.

Methods

Subgenomic hepatitis C virus (HCV) replicons for genotype (GT) 1b, 2b, 3a, and 4a were treated with the mammalian target of rapamycin (mTOR) inhibitors everolimus and sirolimus or with the calcineurin inhibitors (CNIs) cyclosporine or tacrolimus, either alone or in combination with selected DAAs. Cell proliferation‐related effects were excluded with MTT assays. HCV replication activity was quantified by quantitative real‐time polymerase chain reaction or luciferase assay.

Results

Addition of either mTOR inhibitor to the DAA daclatasvir (DAC) resulted in a 30% increase in antiviral activity compared to DAC alone for HCV GT2a, GT3a, and GT4a (all P ≤ .01). Similar results were obtained using sofosbuvir and ledipasvir. In contrast, addition of either mTOR inhibitor to DAC induced a 30% reduction in antiviral activity in GT1b cells (P ≤ .01 vs DAC alone). Neither CNI affects the antiviral activity of the DAAs in any HCV GT.

Conclusion

For patients with HCV GT2a, GT3a, or GT4a infection, mTOR‐based immunosuppressive therapy may be beneficial. CNI‐based therapy may be more efficacious in GT1b patients, as mTOR inhibitors seem to impair antiviral efficacy of DAAs in HCV GT1b infection.     

Do we still need to restrict preoperative fluid administration in ambulatory anorectal surgery under spinal anaesthesia?

Background  

This study was undertaken to determine the effect of a restricted versus a standard intravenous fluid regimen on urinary retention and readiness for discharge after surgery for benign anorectal disease.     

Wearable cardioverter defibrillator after cardiac surgery: Analysis of real-life data from patients at transient risk of sudden cardiac death

Background

Especially in the first 3 months after cardiac surgery, patients are at transient risk of sudden cardiac death (SCD). To close the gap between hospital discharge and the final implantable cardioverter-defibrillator (ICD) decision, guidelines recommend temporarily using a wearable cardioverter-defibrillator (WCD) to protect these patients from SCD. We investigated real-life data on the safety, effectiveness, and compliance of the WCD in this population.

Methods

Data for analysis were collected via the Zoll Patient Management Network (ZPM) from patients who underwent cardiac surgery and who were discharged with a WCD between 2018 and 2021 at the Cardiac Surgery Center of the University of Erlangen in Germany.

Results

The majority of the 55 patients were male (90.9%) and underwent a coronary artery bypass graft (80.0%). The number of patients with left ventricular ejection fraction (LVEF) >35% increased from 9.1% at the beginning of WCD use to 58.2% at the end of WCD use. Six ventricular tachycardia (VT) episodes occurred in four patients. The WCD appropriately defibrillated two patients with VT episodes. There were no inadequate shocks and no fatalities during the observation time. WCD wearing compliance was high, with a median wear time of 23.3 h/day.

Conclusion

This retrospective analysis in a single cardiac surgery center confirms prior data on the safety and effectiveness of the WCD in patients in post-surgery care in a real-life setting. The WCD successfully protected patients from SCD during life-threatening VT episodes. WCD wearing compliance was high.     

Resource utilization and cost of influenza requiring hospitalization in Canadian adults: A study from the serious outcomes surveillance network of the Canadian Immunization Research Network

Background

Consideration of cost determinants is crucial to inform delivery of public vaccination programs.

Objectives

To estimate the average total cost of laboratory‐confirmed influenza requiring hospitalization in Canadians prior to, during, and 30 days following discharge. To analyze effects of patient/disease characteristics, treatment, and regional differences in costs.

Methods

Study utilized previously recorded clinical characteristics, resource use, and outcomes of laboratory‐confirmed influenza patients admitted to hospitals in the Serious Outcomes Surveillance (SOS), Canadian Immunization Research Network (CIRN), from 2010/11 to 2012/13. Unit costs including hospital overheads were linked to inpatient/outpatient resource utilization before and after admissions.

Results

Dataset included 2943 adult admissions to 17 SOS Network hospitals and 24 Toronto Invasive Bacterial Disease Network hospitals. Mean age was 69.5 years. Average hospital stay was 10.8 days (95% CI: 10.3, 11.3), general ward stays were 9.4 days (95% CI: 9.0, 9.8), and ICU stays were 9.8 days (95% CI: 8.6, 11.1) for the 14% of patients admitted to the ICU. Average cost per case was $14 612 CAD (95% CI: $13 852, $15 372) including $133 (95% CI: $116, $150) for medical care prior to admission, $14 031 (95% CI: $13 295, $14 768) during initial hospital stay, $447 (95% CI: $271, $624) post‐discharge, including readmission within 30 days.

Conclusion

The cost of laboratory‐confirmed influenza was higher than previous estimates, driven mostly by length of stay and analyzing only laboratory‐confirmed influenza cases. The true per‐patient cost of influenza‐related hospitalization has been underestimated, and prevention programs should be evaluated in this context.     

New Institutionalization in Long‐Term Care After Hospital Discharge to Skilled Nursing Facility

Background/Objectives

Approximately half of individuals newly admitted to long‐term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.

Design

Retrospective cohort study.

Setting

SNFs and LTC NHs.

Patients

Medicare fee‐for‐service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).

Measurements

We used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined “new institutionalization” as LTC NH residence for longer than 90 non‐SNF days, starting within 6 months of hospital discharge.

Results

For individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89–0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27–1.55) and Hispanics (OR = 1.44, 95% CI = 1.25–1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.

Conclusion

Associations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.     

A phase 3 trial of mometasone furoate sinus implants for chronic sinusitis with recurrent nasal polyps

Background

Topical intranasal corticosteroid sprays (INCSs) are standard treatment for nasal polyps (NPs), but their efficacy is reduced by poor patient compliance and impaired access of drug to the sinus mucosa. A corticosteroid‐eluting sinus implant was designed to address these limitations in patients with recurrent polyposis after sinus surgery by delivering 1350 μg of mometasone furoate (MF) directly to the ethmoid sinus mucosa over approximately 90 days.

Methods

A randomized, sham‐controlled, double‐blind trial was undertaken in 300 adults with refractory chronic rhinosinusitis with NPs (CRSwNP), who were candidates for repeat surgery. Eligible patients were randomized (2:1) and underwent in‐office bilateral placement of 2 implants or a sham procedure. All patients used the MF INCS 200 μg once daily. Co‐primary efficacy endpoints were the change from baseline in nasal obstruction/congestion score and bilateral polyp grade, as determined by an independent panel based on centralized, blinded videoendoscopy review.

Results

Patients treated with implants experienced significant reductions in both nasal obstruction/congestion score (p = 0.0074) and bilateral polyp grade (p = 0.0073) compared to controls. At day 90, implants were also associated with significant reductions in 4 of 5 prespecified secondary endpoints compared to control: proportion of patients still indicated for repeat sinus surgery (p = 0.0004), percent ethmoid sinus obstruction (p = 0.0007), nasal obstruction/congestion (p = 0.0248), and decreased sense of smell (p = 0.0470), but not facial pain/pressure (p = 0.9130). One patient experienced an implant‐related serious adverse event (epistaxis).

Conclusion

Significant improvements over a range of subjective and objective endpoints, including a reduction in the need for sinus surgery by 61%, suggest that MF sinus implants may play an important role in management of recurrent NP.     

Arrhythmia after cone repair for Ebstein anomaly: The Mayo Clinic experience in 143 young patients

Background

The increased incidence of preoperative and postoperative arrhythmia in Ebstein anomaly (EA) prompted some clinicians to perform an electrophysiology study (EPS) in all patients prior to surgery for EA. The cone repair (CR) is the current surgical option of choice for most young patients with EA but the effect of the CR on arrhythmia is not well established.

Objectives

To assess the burden of arrhythmia in young patients after CR and to assess the utility of selective preoperative EPS.

Materials and Methods

A retrospective review of all patients <21 years of age with EA who had a CR at Mayo Clinic from June 2007 to December 2015 was performed. Surveys were mailed and telephone calls were made to all individuals to assess antiarrhythmic medication use and EP/device procedures performed after CR.

Results

There were 143 patients; median age, 10 years (0.1–20.9 years). Thirty‐five (24%) patients had a preoperative EPS of which 26 (18%) had a preoperative ablation. Indications for EPS were Wolff–Parkinson–White (WPW), documented arrhythmia, or suspected arrhythmia. Posthospital discharge data were available for 140 (98%) patients. Mean follow‐up was 2.9 years (0.1–9.2 years). At follow‐up, 7 (5%) patients were receiving antiarrhythmic medications. After CR, only 3 (2%) patients who did not have a preoperative EPS have required an ablation.

Conclusions

The risk of arrhythmia after CR for EA in young patients is very low when a preoperative EPS is limited to those with WPW, known arrhythmia, or suspected arrhythmia. In smaller patients, it may be reasonable to defer the EPS.     

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Objectives

To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia.

Design

Multicenter, mixed‐mode, anonymous questionnaire.

Setting

Three tertiary and four community hospitals in New York.

Participants

Internal medicine physicians (N = 168).

Measurements

Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia.

Results

Ninety‐nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision‐making process; 38% were unsure whether the ABIM/AGSChoosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGSChoosing Wisely recommendations (71% vs 28%, P < .001). Fifty‐two percent felt in control of the PEG placement decision, and 27% expressed concerns about potential litigation. The most common factor influencing physicians was patient or decision‐maker request (70%); 63% stated that families request PEG placement even when physician would not recommend it. Only 4% of the physicians would choose to have a PEG tube if they had advanced dementia.

Conclusion

Despite the scientific evidence supporting the ABIM/AGSChoosing Wisely recommendations against the use of PEG tubes in individuals with advanced dementia, numerous incentives for placement complicate the decision for PEG placement. In today's healthcare environment, it is incumbent upon healthcare practitioners to be aware of the available evidence and to provide leadership to guide this complex decision‐making process to promote true person‐centered care.     

Enteral Access by Double-Balloon Enteroscopy: An Alternative Method of Direct Percutaneous Endoscopic Jejunostomy Placement

Background  

Although direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement.     

Compression Test (Gaenslen's Squeeze Test) Positivity,Joint Tenderness,and Disease Activity in Patients With Rheumatoid Arthritis

Objective

Gaenslen's test (GT) positivity is characterized by tenderness upon lateral compression (squeezing) of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints. We aimed to assess the factors related to a positive GT and to explore differences in disease activity between GT‐positive and ‐negative patients.

Methods

The GT was performed routinely in outpatients with rheumatoid arthritis (RA). In total, 229 patients had a positive GT (GT‐positive group). To this group, we matched a GT‐negative group (n = 222) comparable in sex, age, disease duration, and rheumatoid factor (RF) positivity. Disease activity scores, swollen and tender joint counts, patient pain and global assessments, evaluator's global assessment, morning stiffness, disability assessments, acute phase reactants, RF, and anti–citrullinated protein antibody levels were assessed and used for correlation analyses. A comparison between the GT‐positive and ‐negative groups was performed and a regression model was calculated.

Results

All clinical variables, including disease activity scores, joint counts, and disability assessments, were significantly higher in the GT‐positive group than the GT‐negative group. Also, there were significantly fewer patients in remission or with low disease activity in the GT‐positive group. GT positivity correlated most strongly (r > 0.5) with joint tenderness (32‐ and 28‐joint counts). Tender proximal interphalangeal, MCP, and MTP joints appeared mostly responsible for a positive GT, but more than 1 MCP/MTP joint had to be tender to explain a positive GT.

Conclusion

The GT is related primarily to tenderness in MCP and MTP joints and signifies a moderate to high disease activity among patients with RA.     

Efficacy and safety of Extrapleural block in patients with coronary artery disease after thoracoscopic surgery

Objective

This study aimed to investigate the efficacy and safety of extrapleural block (EPB) application in patients with coronary artery disease after thoracoscopic surgery.

Methods

Patients with typical symptoms of angina and myocardial ischemia who underwent thoracoscopic surgery at our institution between December 2018 and December 2020 were screened for eligibility and they received paravertebral blocking (PVB), EPB, and patient-controlled intravenous analgesia (PCIA). Visual analog scale (VAS) scores were used to assess the analgesic effect and safety outcomes included heart rate, incidence of postoperative rescue analgesics, cardiac complications, and adverse reactions such as nausea and vomiting.

Results

In total, 76 patients (age: 66.5 [61.3, 71] years; male: 63.2%) were eligible, including the PVB group (n = 22), EPB group (n = 25), and PVIA group (n = 29) with comparable baseline characteristics. There was a significantly higher proportion of patients with a VAS score of 1 in the EPB group compared with the other groups at 4 h (88.0% vs. 10.3% for PCIA and 45.5% for PVB; p < .001) and 6 h after the surgery (32.0% vs. 3.4% for PCIA and 13.6% for PVB; p = .012). The preoperative heart rate in the EPB group (81 [71, 94] beats/min) was slightly higher than those in the PVB (76 [70, 85] beats/min) and PCIA groups (76 [69, 84 beats/min]) but without significant difference (p = .193). There was no significant difference in the incidence of rescue analgesia, adverse events, and cardiac complications among the three groups (p = .296, .808, and .669, respectively.)

Conclusion

Compared with PVB and PCIA, the EPB could more effectively relieve acute pain after thoracoscopic surgery in patients with coronary artery disease and offer comparable safety benefits in the management of postoperative heart rate, adverse events, and cardiac complications.     

The effect of cardiac genetic testing on psychological well-being and illness perceptions

Objective

To assess the effects of positive cardiac genetic diagnoses, ICD discharges, and arrhythmias on measures of psychological well-being.

Methods

Fifty-eight adults with prior cardiac genetic testing were enrolled. Patient well-being was determined using the SF-36 (QoL), HADS-A and HADS-D (anxiety/depression), and IPQ-R (patients' perceptions of illness). Patients with positive and negative cardiac genetic test results were compared using non-parametric statistics.

Results

Genetic testing yielded 76% with a positive diagnosis and 29% reported an ICD shock. QoL assessments (n = 33) were within normal ranges (mean of 50) with the exceptions of general health (44.1 ± 12.2, p < 0.01) and bodily pain (55.1 ± 9.1, p < 0.01) domains, but only the bodily pain domain showed differences between those with positive and negative cardiac genetic test results. Subjects with ICD discharges had higher scores than those without shocks in consequential and emotional IPQR subscales as well as greater perceived risks of experiencing a serious cardiac event, developing additional symptoms, or limitations in daily activities.

Conclusion

Positive genetic results did not negatively impact patient well-being with the exception of the bodily pain domain of the SF-36.     

Zero‐fluoroscopy cryothermal ablation of atrioventricular nodal re‐entry tachycardia guided by endovascular and endocardial catheter visualization using intracardiac echocardiography (Ice&ICE Trial)

1 Introduction

Stochastic damage of the ionizing radiation to both patients and medical staff is a drawback of fluoroscopic guidance during catheter ablation of cardiac arrhythmias. Therefore, emerging zero‐fluoroscopy catheter‐guidance techniques are of great interest.

2 Methods and results

We investigated, in a prospective pilot study, the feasibility and safety of the cryothermal (CA) slow‐pathway ablation in patients with symptomatic atrioventricular‐nodal‐re‐entry‐tachycardia (AVNRT) using solely intracardiac echocardiography (ICE) for endovascular and endocardial catheter visualization. Twenty‐five consecutive patients (mean age 55.6 ± 12.0 years, 17 female) with ECG‐documentation or symptoms suggesting AVNRT underwent an electrophysiology study (EPS) in our laboratory utilizing ICE for catheter navigation. Supraventricular tachycardia was inducible in 23 (92%) patients; AVNRT was confirmed by appropriate stimulation maneuvers in 20 (80%) patients. All EPS in the AVNRT subgroup could be accomplished without need for fluoroscopy, relying solely on ICE‐guidance. CA guided by anatomical location and slow‐pathway potentials was successful in all patients, median cryo‐mappings = 6 (IQR:3–10), median cryo‐ablations = 2 (IQR:1–3). Fluoroscopy was used to facilitate the trans‐septal puncture and localization of the ablation substrate in the remaining 3 patients (one focal atrial tachycardia and two atrioventricular‐re‐entry‐tachycardias). Mean EPS duration in the AVNRT subgroup was 99.8 ± 39.6 minutes, ICE guided catheter placement 11.9 ± 5.8 minutes, time needed for diagnostic evaluation 27.1 ± 10.8 minutes, and cryo‐application duration 26.3 ± 30.8 minutes.

3 Conclusions

ICE‐guided zero‐fluoroscopy CA in AVNRT patients is feasible and safe. Real‐time visualization of the true endovascular borders and cardiac structures allow for safe catheter navigation during the ICE‐guided EPS and might be an alternative to visualization technologies using geometry reconstructions.     

Safety profiles of percutaneous left atrial appendage closure devices: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016

1 Background

Percutaneous left atrial appendage closure (LAAC) is a viable option for AF patients who are unable to tolerate long‐term oral anticoagulation (OAC).

2 Objective

We sought to assess the safety of two commonly used percutaneous devices for LAA closure in the United States by analysis of surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database.

3 Methods

The MAUDE database was queried between May 1, 2006 and May 1, 2016 for LARIAT^® (SentreHEART Inc., Redwood City, CA, USA) and WATCHMAN? (Boston Scientific Corp., Marlborough, MA, USA) devices. Among 622 retrieved medical device reports, 356 unique and relevant reports were analyzed. The cumulative incidence of safety events was calculated over the study period and compared between the two devices.

4 Results

LAAC was performed with LARIAT in 4,889 cases. WATCHMAN was implanted in 2,027 patients prior to FDA approval in March 2015 and 3,822 patients postapproval. The composite outcome of stroke/TIA, pericardiocentesis, cardiac surgery, and death occurred more frequently with WATCHMAN (cumulative incidence, 1.93% vs. 1.15%; P = 0.001). The same phenomenon was observed when comparing the WATCHMAN pre‐ and postapproval experiences for the composite outcome, as well as device embolization, cardiac surgery, and myocardial infarction.

5 Conclusions

MAUDE‐reported data show that postapproval, new technology adoption is fraught with increased complications. Improved collaboration between operators, device manufacturers, and regulators can better serve patients through increased transparency and practical postmarket training and monitoring mechanisms.     

Early Repair of Congenital Heart Disease Associated With Increased Rate of Attention Deficit Hyperactivity Disorder Symptoms

Background

As more children survive with congenital heart disease, their neurodevelopmental outcomes (including attention deficit hyperactivity disorder [ADHD]) are becoming increasingly important. The objective of our study was to determine if school-aged children who underwent early cardiac surgery for congenital heart disease are more likely than healthy control subjects to have screening scores on the Swanson, Nolan, and Pelham IV (SNAP-IV) questionnaire suggestive of ADHD.

Methods

Children aged 7-15 years who underwent open-heart surgery before 1 year of age were identified from the Izaak Walton Killam (IWK) Children's Heart Centre Database. Control subjects were recruited from healthy volunteers. The SNAP-IV questionnaire was administered to all participants and a chart review was performed on all eligible children in the cardiac surgery group. Case and control subjects were compared using Fisher's exact test, linear, and logistic regression analyses. Potential predictors of a positive screening score were sought.

Results

A positive screening score was found in 29% (16/56) of the surgical group compared with 3% (2/60) of the control group (P < 0.001). Surgical and control subjects differed in average overall scores (0.93 vs 0.30; P < 0.001) and in scores for hyperactivity (0.83 vs 0.24; P < 0.001) and inattention (1.04 vs 0.37; P < 0.001). No other significant predictors of a positive screening score were identified. The early open-heart surgery participants who responded to the questionnaire did not differ in baseline characteristics compared with nonresponders.

Conclusions

Children who have open-heart surgery at younger than 1 year of age are more likely than healthy control subjects to have a SNAP-IV score suggestive of ADHD when they reach school age.     

Fragmented QRS complex as a predictor of exercise‐related sudden cardiac death

1 Introduction

Little is known about the association between electrocardiographic abnormalities and exercise‐related sudden cardiac death. Therefore, our aim was to identify possible electrocardiographic findings related to exercise‐induced sudden cardiac death.

2 Methods and results

The FinGesture study includes 3,989 consecutive sudden cardiac deaths in northern Finland between 1998 and 2012, out of whom a total of 647 subjects had a previously recorded electrocardiography acquired from the archives of Oulu University Hospital. In 276 of these cases the death was witnessed, and the activity at the time of death was either rest or physical exercise (PE); in 40 (14%) cases sudden cardiac death was exercise‐related and in 236 (86%) cases death took place at rest. Fragmented QRS complex in at least two consecutive leads within anterior leads (V1‐V3) was more common in the exercise‐group compared to rest‐group (17 of 40, 43% vs. 51 of 236, 22%, P  =  0.005). Pathologic Q wave in anterior leads was more common in the PE group (9 of 40, 23% vs. 26 of 236, 11%; P  =  0.044). Median QRS duration was prolonged in the exercise‐group compared to the rest‐group (100 milliseconds vs. 94 milliseconds, P = 0.047). QTc interval, the prevalence of inverted T‐waves, or other electrocardiographic abnormalities did not differ significantly between the two groups.

3 Conclusions

As a conclusion, fragmented QRS complex in the anterior leads is associated with an increased risk of sudden cardiac death during PE.     

Interpreting the Chinese version of quality of life questionnaire for functional digestive disorders

Background and Aim

The Chinese version quality of life questionnaire for functional digestive disorders (Chin‐FDDQL) is a useful health assessment instrument for functional dyspepsia. This study aims to identify its score interpretation for clinical practice.

Methods

Data of Chin‐FDDQL from the functional dyspepsia patients (≥ 18 years) between November 2009 and April 2013 were enrolled in the 1st and 14th day. After baseline and responsiveness analysis, the single score interpretation and percentile ranks were established. The statistically reliable change was defined with effect size, standardized response mean, minimal detectable change, and others. Then the receiver operating characteristic curve analysis for health improvement was performed to define the clinically important change.

Results

Two hundred two functional dyspepsia patients, 150 healthy participants, and 25 missing data were enrolled for analysis. Compared with the intake patients, the discharged and healthy persons have significant better health status in all domains (P < 0.001, expect discomfort in discharged people, P = 0.142), totally contrast to missing data. The reliability for single total intake and discharge were both ± 1. Based on score distribution, the 25th, 50th, and 75th percentile ranks were 49, 58, and 66 for intake scores and 59, 65, and 72 for discharge scores, respectively. The minimal detectable change and Reliable Change Index were 6 and 11 for total score. Receiver operating characteristic analyses supported that total score changes 4 or more represented minimal clinically important improvement.

Conclusions

The score interpretation system of the Chin‐FDDQL could assist clinician's decision making during the therapy practice.     

Peptic ulcer bleeding patients with Rockall scores ≥6 are at risk of long‐term ulcer rebleeding: A 3.5‐year prospective longitudinal study

Background and Aim

Patients with high Rockall scores have increased risk of rebleeding and mortality within 30 days after peptic ulcer bleeding, but long‐term outcomes deserve follow‐up after cessation of proton pump inhibitors. The paper aimed to validate whether patients with high Rockall scores have more recurrent ulcer bleeding in a 3.5‐year longitudinal cohort.

Methods

Between August 2011 and July 2014, 368 patients with peptic ulcer bleeding were prospectively enrolled after endoscopic hemostasis to receive proton pump inhibitors for at least 8 to 16 weeks. These subjects were categorized into either a Rockall scores ≥6 group (n = 257) or a Rockall scores <6 group (n = 111) and followed up until July of 2015 to assess recurrent ulcer bleeding.

Results

The proportion of patients with rebleeding during the 3.5‐year follow‐up was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 vs. 3.63 per 100 person‐year, P = 0.004, log–rank test). Among patients with Rockall scores ≥6, activated partial thromboplastin time prolonged ≥1.5‐fold (P = 0.045), American Society of Anesthesiologists physical status class ≥III (P = 0.02), and gastric ulcer (P = 0.04) were three additional independent factors found to increase rebleeding risk. The cumulative rebleeding rate was higher in patients with Rockall scores ≥6 with more than or equal to any two additional factors than in those with fewer than two additional factors (15.69 vs. 7.63 per 100 person‐year, P = 0.012, log–rank test).

Conclusions

Patients with Rockall scores ≥6 are at risk of long‐term recurrent peptic ulcer bleeding. The risk can be independently increased by the presence of activated partial thromboplastin time prolonged ≥1.5‐fold, American Society of Anesthesiologists class ≥III, and gastric ulcer in patients with Rockall scores ≥6.     

Percutaneous Mitral Valve Repair for Mitral Regurgitation in High-Risk Patients : Results of the EVEREST II Study

Background

The EVEREST II (Endovascular Valve Edge-to-Edge REpair STudy) High-Risk registry and REALISM Continued Access Study High-Risk Arm are prospective registries of patients who received the MitraClip device (Abbott Vascular, Santa Clara, California) for mitral regurgitation (MR) in the United States.

Objectives

The purpose of this study was to report 12-month outcomes in high-risk patients treated with the percutaneous mitral valve edge-to-edge repair.

Methods

Patients with grades 3 to 4+ MR and a surgical mortality risk of ≥12%, based on the Society of Thoracic Surgeons risk calculator or the estimate of a surgeon coinvestigator following pre-specified protocol criteria, were enrolled.

Results

In the studies, 327 of 351 patients completed 12 months of follow-up. Patients were elderly (76 ± 11 years of age), with 70% having functional MR and 60% having prior cardiac surgery. The mitral valve device reduced MR to ≤2+ in 86% of patients at discharge (n = 325; p < 0.0001). Major adverse events at 30 days included death in 4.8%, myocardial infarction in 1.1%, and stroke in 2.6%. At 12 months, MR was ≤2+ in 84% of patients (n = 225; p < 0.0001). From baseline to 12 months, left ventricular (LV) end-diastolic volume improved from 161 ± 56 ml to 143 ± 53 ml (n = 203; p < 0.0001) and LV end-systolic volume improved from 87 ± 47 ml to 79 ± 44 ml (n = 202; p < 0.0001). New York Heart Association functional class improved from 82% in class III/IV at baseline to 83% in class I/II at 12 months (n = 234; p < 0.0001). The 36-item Short Form Health Survey physical and mental quality-of-life scores improved from baseline to 12 months (n = 191; p < 0.0001). Annual hospitalization rate for heart failure fell from 0.79% pre-procedure to 0.41% post-procedure (n = 338; p < 0.0001). Kaplan-Meier survival estimate at 12 months was 77.2%.

Conclusions

The percutaneous mitral valve device significantly reduced MR, improved clinical symptoms, and decreased LV dimensions at 12 months in this high-surgical-risk cohort. (Endovascular Valve Edge-to-Edge REpair STudy [EVERESTIIRCT]; NCT00209274)