Quantification of the left atrium applying cardiovascular magnetic resonance in clinical routine

Objectives. In recent years the impact of the left atrium (LA) has become more evident in different cardiovascular pathologies. We aim to provide LA parameters in healthy volunteers for cardiovascular magnetic resonance (CMR) using a fast approach. Design. We analyzed 203 healthy volunteers (mean age 44.6 years (y), range 19y–76y) at 1.5 and 3.0 Tesla (T) using steady-state free precession (SSFP) cine in routine long axis view. Left atrial enddiastolic volume (LA-EDV), endsystolic volume (LA-ESV), stroke volume (LA-SV) and ejection fraction (LA-EF) were quantified and indexed to body-surface-area (BSA). Dependency on age and sex was analyzed. Results. 21 subjects had to be excluded. In the remaining, there was no significant difference between 1.5 T and 3.0 T. Absolut LA-EDV and LA-ESV were larger in men than in women (LA-EDV: male 70?±?19?ml vs. female 61?±?16?ml (p?=?.001); LA-ESV: male 24?±?9?ml vs. female 21?±?8?ml (p?=?.01)). These differences disappeared after indexing to BSA (LA-EDV/BSA: male 34?±?10?ml/m² vs. female 33?±?9?ml/m² (p?=?.65) and LA-ESV/BSA: male 12?±?4?ml/m² vs. female 11?±?4?ml/m² (p?=?.71)). LA-EDV/BSA decreased with older age. Conclusions. Reference values for LA size and function based on a fast approach are provided. LA size decreases with older age. Normalization to body size overcomes sex-dependency. Reports should be related to body size.     

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution

Background

The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution.

Methods

Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann–Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost.

Results

There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost.

Conclusions

Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.     

Orthogeriatric model for hip fracture patients in Singapore: our early experience and initial outcomes

Introduction

The aging population is growing rapidly in Asia resulting in an increased number of fragility fractures. Studies have shown that an integrated model of care for the elderly can improve the quality of patient care and outcomes. This report describes our concept, initial experience and short-term outcomes of the integrated model of care that was established in managing geriatric hip fractures in Tan Tock Seng Hospital, Singapore.

Patient and methods

An integrated care pathway model was implemented. The principle of the model is based on (a) timely admission, review, surgery, rehabilitation, transfer, (b) multidisciplinary approach and (c) integration of a care manager. Hip fracture patients (>60 years) were included in our study and were followed up for 1 year. Demographic data, Charlson comorbidity index (CCI), time to surgery, length of stay and modified Barthel index (MBI) scores were recorded.

Results

The mean age was 82 years (62–108) with a female predominance (75 %). The mean CCI was 1.8. Time to admission was 3.7 h and mean time taken to be reviewed by an integrated care manager was 21.7 h. Close to 40 % of patients were operated within 48 h with a median time to surgery of 36.7 h. Mean length of stay was 10 days with an inpatient and 1-year mortality rate of 2.3 and 5.9 %, respectively. Complication rate was 5.1 % (urinary tract infection and wound infection) and MBI scores at 1 year revealed significant functional improvement of 95 % (p < 0.01).

Conclusion

Our integrated model of care for hip fractures can lead to satisfactory outcomes. Though the time to surgery and length of stay can be improved further, our initial results have shown a reasonable time to admission and review by a care manager. Besides a low complication and mortality rate, functional improvement was significant post-operatively.     

Understanding Disposition After Referral for Bariatric Surgery: When and Why Patients Referred Do Not Undergo Surgery

Background

Bariatric surgery is an effective long-term solution for weight loss in the severely obese. Prevalence of bariatric surgery has increased over the recent years; however, the attrition rate of those referred who actually undergo surgery is high. The purpose of this study was to examine patients' attrition rates after referral for bariatric surgery at an academic tertiary care institution. When and why patients who were referred for bariatric surgery did not ultimately undergo surgical treatment was examined.

Methods

Charts of 1,237 patients referred to the Toronto Western Hospital Bariatric Program from program inception to February 2011 were retrospectively reviewed. Patient demographics, appointment dates, no shows and cancellations, and when and why patients did not undergo surgery were summarized.

Results

Patients' mean age was 47. Most patients were female, and the mean body mass index was 47. Half (50.6 %) of the total persons referred left the program prior to being seen by a health-care professional, and only 36.2 % underwent surgical treatment. Only 2.75 % of persons were ineligible for surgery. A total of 60.6 % of persons self-removed from our program. Reasons for self-removal varied, with the most common reason for leaving the program recorded as “unknown.”

Conclusions

Our multidisciplinary program with in-hospital psychosocial resources resulted in very few persons being excluded from receiving surgical treatment. However, less than half of those referred underwent surgery as most persons self-removed from our program for unknown reasons. Further investigation is required to determine which patient, administrative, and system factors play a role in the patients' decision to not undergo bariatric surgical treatment.     

Brain Atrophy in Type 2 Diabetes: Regional distribution and influence on cognition

OBJECTIVE

Type 2 diabetes (T2DM) is associated with brain atrophy and cerebrovascular disease. We aimed to define the regional distribution of brain atrophy in T2DM and to examine whether atrophy or cerebrovascular lesions are feasible links between T2DM and cognitive function.

RESEARCH DESIGN AND METHODS

This cross-sectional study used magnetic resonance imaging (MRI) scans and cognitive tests in 350 participants with T2DM and 363 participants without T2DM. With voxel-based morphometry, we studied the regional distribution of atrophy in T2DM. We measured cerebrovascular lesions (infarcts, microbleeds, and white matter hyperintensity [WMH] volume) and atrophy (gray matter, white matter, and hippocampal volumes) while blinded to T2DM status. With use of multivariable regression, we examined for mediation or effect modification of the association between T2DM and cognitive measures by MRI measures.

RESULTS

T2DM was associated with more cerebral infarcts and lower total gray, white, and hippocampal volumes (all P < 0.05) but not with microbleeds or WMH. T2DM-related gray matter loss was distributed mainly in medial temporal, anterior cingulate, and medial frontal lobes, and white matter loss was distributed in frontal and temporal regions. T2DM was associated with poorer visuospatial construction, planning, visual memory, and speed (P ≤ 0.05) independent of age, sex, education, and vascular risk factors. The strength of these associations was attenuated by almost one-half when adjusted for hippocampal and total gray volumes but was unchanged by adjustment for cerebrovascular lesions or white matter volume.

CONCLUSIONS

Cortical atrophy in T2DM resembles patterns seen in preclinical Alzheimer disease. Neurodegeneration rather than cerebrovascular lesions may play a key role in T2DM-related cognitive impairment.Type 2 diabetes (T2DM) is associated with an increased risk of incident cognitive impairment, dementia, and Alzheimer disease as a possible result of cerebrovascular and/or neurodegenerative disease (1–3). T2DM is associated with brain infarcts (4,5) on magnetic resonance imaging (MRI) and less consistently with cerebral white matter hyperintensities (WMHs) (6,7) and cerebral microbleeds (8,9). Lower hippocampal volume (10–12) and total brain volume (13), which are features of Alzheimer disease, are also more likely to occur in T2DM. However, few studies have clarified the regional distribution of brain atrophy attributable to T2DM (14–16). These studies were small, and only one compared people with and without T2DM, with the results suggesting that temporal lobe gray matter may be affected in T2DM (15). Understanding the pattern of brain atrophy in T2DM may provide clues toward the underlying neurodegenerative process. For example, gray matter atrophy occurs early in the temporal, parietal, and limbic cortices before spreading to involve frontal and occipital regions in Alzheimer disease (17). Moreover, although some studies demonstrated associations of T2DM with brain atrophy or cerebrovascular disease, no data describe how MRI measures of atrophy and cerebrovascular disease mediate the difference in cognitive function between those with and without T2DM. Manschot et al. (18) found an association between T2DM and more deep white matter lesions, cortical and subcortical atrophy, and infarcts as well as impaired cognitive performance. In subgroup analysis of only those with T2DM, they found that cognitive performance was inversely associated with deep white matter lesion volume, atrophy, and infarcts. In the current study, we examined the distribution of brain atrophy in older people with T2DM, predicting that MRI measures of brain atrophy and cerebrovascular disease would mediate or modify the association between T2DM and cognitive function.     

Old ideals and new realities: the changing context of young people's partnerships in Cebu,Philippines

The Philippines has experienced rapid sociodemographic changes in recent years, with implications for young people. This study combines quantitative and qualitative data from Metro Cebu to assess the timing and predictors of young people's partnerships, as well as the context in which these partnerships are occurring. The majority of young people (54%) had premarital sex, though this pattern varied by gender. Wealthier, urban young men, and women with less education and lower reported religiosity, were more likely to have premarital sex. Engagement in risk behaviours was predictive of premarital sex for both males and females. The qualitative data contextualise the circumstances under which young people engage in sex and form partnerships and illustrate how sociocultural norms contribute to gender differences in partnership patterns. Given the ‘new’ realities of young Filipinos' lives, targeted efforts to support the transition to adulthood are needed to avert potentially adverse life events.     

Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement

Economic evaluations of health interventions pose a particular challenge for reporting. There is also a need to consolidate and update existing guidelines and promote their use in a user friendly manner. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update previous health economic evaluation guidelines efforts into one current, useful reporting guidance. The primary audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication. The need for new reporting guidance was identified by a survey of medical editors. A list of possible items based on a systematic review was created. A two round, modified Delphi panel consisting of representatives from academia, clinical practice, industry, government, and the editorial community was conducted. Out of 44 candidate items, 24 items and accompanying recommendations were developed. The recommendations are contained in a user friendly, 24 item checklist. A copy of the statement, accompanying checklist, and this report can be found on the ISPOR Health Economic Evaluations Publication Guidelines Task Force website (www.ispor.org/TaskForces/EconomicPubGuidelines.asp). We hope CHEERS will lead to better reporting, and ultimately, better health decisions. To facilitate dissemination and uptake, the CHEERS statement is being co-published across 10 health economics and medical journals. We encourage other journals and groups, to endorse CHEERS. The author team plans to review the checklist for an update in five years.