The association between urinary sodium concentration (UNa) and outcomes of acute heart failure: a systematic review and meta-analysis.

AIMS: Urinary sodium concentration (UNa) is a simple test advocated to assess diuretics efficacy and predict outcomes in acute heart failure (AHF). We performed a systematic review and meta-analysis to examine the association of UNa with outcomes of AHF. METHODS AND RESULTS: We searched Embase and Medline for eligible studies that reported the association between UNa and outcomes of urinary output, weight loss, worsening renal function, length of hospital stay, re-hospitalization, worsening heart failure, and all-cause mortality in AHF. Nineteen observational studies out of 1592 screened records were included. For meta-analyses of outcomes, we grouped patients into high vs. low UNa, with most studies defining high UNa as >48-65 mmol/L. In the high UNa group, pooled data showed a higher urinary output (mean difference 502 mL, 95% CI 323-681, P < 0.01), greater weight loss (mean difference 1.6 kg, 95% CI 0.3-2.9, P = 0.01), and a shorter length of stay (mean difference -1.4 days, 95% CI -2.8 to -0.1, P = 0.03). There was no significant difference in worsening kidney function (OR 0.54, 95% CI 0.25-1.16, P = 0.1). Due to the small number of studies, we did not report pooled estimates for re-hospitalization and worsening heart failure. High UNa was associated with lower odds of 30-day (OR 0.27; 95% CI 0.14-0.49, P < 0.01), 90-day (OR 0.39,95% CI 0.25-0.59, P < 0.01) and 12-month (OR 0.35; 95% CI 0.20-0.61, P < 0.01) mortality. CONCLUSION: High UNa after diuretic administration is associated with higher urinary output, greater weight loss, shorter length of stay, and lower odds of death. UNa is a promising marker of diuretic efficacy in AHF which should be confirmed in randomized trials.

Cardio-geriatric model of care in acute heart failure: initial experience of a multidisciplinary approach in complex elderly patients.

A 'cardio-geriatric' heart failure model of care was implemented to address the high rates of readmission in elderly acute decompensated heart failure patients. Despite demonstrably intensified management in both the cardiology and geriatric domains, this study did not demonstrate a positive effect on the primary outcome of all cause readmissions at 30 days.

Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE).

BACKGROUND: Handheld ultrasound could provide sufficient information to satisfy the clinical questions underlying 'rarely appropriate' echo requests, but there are limited data about its use as a gatekeeper to standard echocardiography. We sought to determine whether the use of handheld ultrasound could improve the appropriate use of echocardiography. METHOD: A prospective study comparing handheld ultrasound strategy to standard echocardiography for studies deemed rarely appropriate, using a questionnaire based on appropriate use criteria was conducted across two hospitals, from October 2017 to April 2018. RESULTS: Groups undergoing Handheld ultrasound (n = 76, 58 (46.5-72.5) years, 53 males, 78% outpatients) and standard echocardiography (n = 72, 61 (49.0-71.5) years, 42 males, 76% outpatients) were comparable. There was a significant decrease in the time to scan from just over 1 month in standard group to a median of 12 days in handheld ultrasound group (P < 0.001). This difference was small for inpatients (from 1 day to a median of 10 min in handheld ultrasound, P = 0.014), but prominent in outpatients (from 1.5 months in the standard group to median of 2 weeks in the handheld ultrasound group, P < 0.001). There was no increase in the need for follow-up scan within 6 months and no significant differences in length of hospital stay for inpatients. CONCLUSION: Handheld ultrasound can be an effective gatekeeper to standard echocardiography for requests deemed rarely appropriate, reducing time to echocardiography significantly and potentially decreasing the need for standard echocardiography by up to 20%.

The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program.

BACKGROUND: older people are high users of healthcare resources. The frailty index can predict negative health outcomes; however, the amount of extra resources required has not been quantified. OBJECTIVE: to quantify the impact of frailty on healthcare expenditure and resource utilisation in a patient cohort who entered a community-based post-acute program and compare this to a cohort entering residential care. METHODS: the interRAI home care assessment was used to construct a frailty index in three frailty levels. Costs and resource use were collected alongside a prospective observational cohort study of patients. A generalized linear model was constructed to estimate the additional cost of frailty and the cost of alternative residential care for those with high frailty. RESULTS: participants (n = 272) had an average age of 79, frailty levels were low in 20%, intermediate in 50% and high in 30% of the cohort. Having an intermediate or high level of frailty increased the likelihood of re-hospitalisation and was associated with 22 and 43% higher healthcare costs over 6 months compared with low frailty. It was less costly to remain living at home than enter residential care unless >62% of subsequent hospitalisations in 6 months could be prevented. CONCLUSIONS: the frailty index can potentially be used as a tool to estimate the increase in healthcare resources required for different levels of frailty. This information may be useful for quantifying the amount to invest in programs to reduce frailty in the community.

Lifting the mirror symmetry of metal surfaces: decoupling the electronic and physical manifestations of surface chirality.

Naturally occurring metal surfaces possess planes of mirror symmetry on the nanometer-length scale. This mirror symmetry can be lifted and chirality "physically" conveyed onto a surface by adsorbing a chiral molecule. Until now, it has not been known whether the conveying of chirality is limited to just the physical structure or whether it goes deeper and permeates the electronic structure of the underlying surface. By using optically active second harmonic generation (OA-SHG), it is demonstrated that the adsorption of some, but not all, chiral molecules can reversibly, and without significant structural rearrangement, measurably lift the mirror symmetry of the surface electronic structure of a metal. It is proposed that the ability of a chiral molecule to place a significant "chiral perturbation" on the electronic structure of a surface is correlated to its adsorption geometry. The microscopic origins of the observed optical activity are also discussed in terms of classical models of chirality. The results of the study challenge current models of how chiral adsorbates induce enantioselectivity in the chemical/physical behavior of heterogeneous systems, which are based on geometric/stereochemical arguments, by suggesting that chiral electronic perturbations could play a role.

A high-resolution photoemission study of nanoscale aluminum oxide films on NiAl(110).

Using high-resolution soft X-ray photoemission, Al 2p, we have been able to quantify the relative populations of tetrahedrally (Al(tet)) and octahedrally (Al(oct)) coordinated Al(3+) in three distinct phases of nanoscale aluminum oxide films on NiAl(110). We have hence determined the bulk alumina phases that the nanoscale films most resemble. Adsorption of oxygen at room temperature produces a layer which predominately (90%) contains Al(tet) and is analogous to the amorphous bulk phase of alumina. Annealing this layer results in an Al enrichment of the oxide layer, through the diffusion of metal from the substrate, and an increase in the relative amount of Al(oct), producing a gamma-alumina-like layer with a relative Al(oct)/Al(tet) occupancy of 28 +/- 3%/72 +/- 3%. Oxygen adsorption at 823 K also produces a gamma-like phase, with a relative Al(oct)/Al(tet) occupancy of 27 +/- 3%/73 +/- 3%, although this layer is thicker than that formed at room temperature. Both oxidation methods produce gamma-alumina layers that display poor translational order. However, these poorly ordered layers have a relative Al(oct)/Al(tet) occupation similar to that of well-ordered oxide films produced using different oxidation conditions in previous studies. Both gamma layers undergo partial decomposition upon annealing to 1273 K, producing an alpha-alumina-like oxide, which contains only Al(oct), and is highly deficient in Al. There are significant oxide-free areas within the alpha-alumina oxide layer, which is characteristic of crystallite formation. Repeated cycles of oxidation and annealing to 1273 K do not produce a homogeneous film, but they do make the alpha-like oxide more Al rich.

Chiral discrimination within disordered adlayers on metal surfaces.

Using a novel non-linear optical technique enantiomeric excess within a translationally disordered overlayer on a metal surface has been monitored for the first time.