Trends and Predictors of Palliative Care Referrals in Patients With Acute Heart Failure.

OBJECTIVE:: To determine the rate and predictors of palliative care referral (PCR) in hospitalized patients with acute heart failure (AHF). INTRODUCTION:: The PCR is commonly utilized in terminal conditions such as metastatic cancers. There is no data on trends and predictors from large-scale registry of general population regarding PCR in patients with AHF. METHODS:: For this retrospective study, data were obtained from National Inpatient Sample Database from 2010 to 2014. We used International Classification of Diseases, Ninth Revision diagnosis codes to identify cases with a principle diagnosis of AHF. These patients were divided into 2 groups: (1) PCR, (2) no PCR groups. We performed multivariate analysis to identify predictors of PCRs, as well as reported PCR trends from 2010 to 2014. RESULTS:: From the database, out of 37 312 324 hospitalizations, 621 947 unweighted cases with primary diagnosis of AHF were selected for further analysis. About 2.8% received PCR. From 2010 to 2014, there was an uptrend from 2.0% to 3.6% for PCR. Metastatic cancer, ventilator-dependent respiratory failure, and cardiogenic shock were strongly associated with PCR. Those who underwent percutaneous coronary intervention and African American or other races were negative predictors for PCR. In the PCR group, 31.4% of patients died during hospitalization. CONCLUSION:: Palliative care referrals were made in a very small proportion of patients with AHF. We observed steady rise in the PCR utilization. Chronic conditions, advancing age, and high-risk patients were major predictors of PCR.

His Bundle Pacing: Hemodynamics and Clinical Outcomes.

From 1993 to 2009, nearly 2.9 million pacemakers were implanted in the United States; the majority of which were dual-chamber pacemakers. One of the major physiologic advantages of dual-chamber pacing over single-chamber ventricular pacing is atrioventricular synchrony, which prevents the pacemaker syndrome. However, patients who are pacemaker dependent or use right ventricle (RV) apical pacing more than 40% of the time are at a risk of developing heart failure from electromechanical dyssynchrony. Studies have also shown that RV pacing results in nonphysiological activation of the left ventricle, leading to adverse clinical outcomes. Hence, alternative pacing sites, including the RV outflow tract, the high-RV septal region, bi-ventricular pacing, or His bundle pacing, have been explored for a better physiological electromechanical coupling of the ventricles. Although His bundle pacing has gained attention due to favorable data and clinical outcomes, it has not gained widespread acceptance into clinical practice. Hence, we aim to review the current experience with His bundle pacing and its clinical implications in this article.

Delayed neurological deficits after endovascular placement of a pipeline embolisation device: clinical manifestation and treatment.

Endovascular treatment has been the mainstay of therapy for repair of both ruptured and unruptured cerebral aneurysms. Flow diverter devices offer a new option for the treatment of complex aneurysms that were previously not amenable to coiling. Procedural adverse effects include intracranial haemorrhage and ischaemic stroke, which usually occur on the same day. Delayed complications are rare. We report a case of a patient who underwent placement of a pipeline embolisation device and developed delayed neurological deficits, which were thought to be an inflammatory reaction to the hydrophilic coating used in guidewires and microcatheters. Our patient was treated with a course of steroids, with improvement of her neurological deficits and resolution of MRI findings. As the use of flow diverter devices has increased, variable and delayed complications of such therapy are increasingly being reported in the literature.

Thirty-day readmissions after cardiac implantable electronic devices in the United States: Insights from the Nationwide Readmissions Database.

BACKGROUND: Limited data are available regarding true estimates of individual complications contributing to readmissions after cardiac implantable electronic device (CIED) implantation. OBJECTIVE: The purpose of this study was to identify predictors of 30-day readmission in patients admitted for CIED implantation. METHODS: The study cohort consisted of patients who underwent CIED implantation in 2014, identified from the National Readmission Database. Readmission was defined as a subsequent hospital admission within 30 days after the discharge day of index admission. If patients had more than 1 readmission within 30 days, only the first readmission was included. RESULTS: Our final cohort consisted of 70,223 cases, 61,738 (88%) in the no-readmission group and 8485 patients (12%) in the readmission group. Female gender (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.04-1.14; P = .001), atrial fibrillation/flutter (OR 1.23; 95% CI 1.17-1.29, P <.001), acute renal failure (OR 1.65; 95% CI 1.56-1.74; P <.001), coronary artery disease (OR 1.09; 95% CI 1.03-1.14; P = .002), length of stay (OR 1.70; 95% CI 1.51-1.89; P <.001), device placement on the day of admission (OR 0.87; 95% CI 0.80-0.95, P = .001), and fourth quartile of hospital procedure volume (OR 0.91; 95% CI 0.84-0.99; P = .03; first quartile of hospital procedure volume as reference) were independent predictors of 30-day readmissions. The 30-day readmission resulted in additional median charges of $30,692 per patient. Device-related complications were seen in 10.7% of readmitted patients. The most common complications were mechanical (2.8%) and infectious (2.6%). CONCLUSION: Several patient and hospital-related factors were identified to be independent predictors of 30-day readmission, accounting for increased health care cost.

Evaluating safety of thrombolysis in chronic kidney disease patients presenting with pulmonary embolism using propensity score matching.

To assess the safety of thrombolytic therapy in chronic kidney disease (CKD) patients who present with pulmonary embolism (PE). We used the Nationwide Inpatient Sample Database to identify patients who underwent thrombolysis for PE between 2010 and 2014. The patients were divided into two groups: (1) No CKD and (2) CKD. Patients with and without CKD were matched using 1:1 propensity score matching and a caliper width of 0.01. The primary outcomes were in-hospital mortality and hemorrhagic events. The secondary outcomes were blood transfusions, length of stay and total hospitalization charge. Two separate, multivariate analyses were also performed to determine the predictors for primary outcomes. The No CKD group had 16,238 and CKD group had 1341 patients prior to matching. Patients with CKD were older (Median age 67 vs. 57 years; p < 0.01), male (60.6 vs. 51.8%) and had a higher prevalence of coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, hypertension, and prior stroke among other comorbidities. They also had significantly higher rate of in-hospital mortality (OR 1.66) and hemorrhagic events (OR 1.47) prior to matching. Post-matching, there was no difference in hospital mortality (22.9 vs. 21.8%; p = 0.51) or hemorrhagic events (3.8 vs. 3.0%; p = 0.27) between CKD and No CKD groups. Patients with CKD had a longer length of stay, but no difference in proportion of patients receiving a blood transfusion and total hospitalization charges post-matching. Multivariate analysis showed that CKD did not predict mortality (OR 0.88, 0.75-1.02; p = 0.09) or hemorrhagic events (OR 0.89, 95% CI 0.76-1.04; 0.13). There was no increase in rate of hospital mortality or hemorrhagic events among CKD patients who underwent thrombolysis for PE.

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

A novel approach to the management of carotid blowout syndrome: the use of thrombin in a case of failed covered stenting.

Acute hemorrhage relating to an expanding pseudoaneurysm of the carotid artery is referred to as carotid blowout syndrome (CBS). CBS is associated with a high morbidity and mortality. We describe the case of a patient who presented with dysphagia and a pulsatile mass in the neck. Imaging revealed a pseudoaneurysm originating from the bifurcation of the distal right common carotid artery. On neuroangiography the patient lacked sufficient collaterals to allow for vessel sacrifice. A decision was made to use covered stents to prevent flow into the pseudoaneurysm while maintaining vessel patency. Despite placement of multiple covered stents there was residual slow filling of the pseudoaneurysm. We augmented this therapy with direct percutaneous thrombin injection into the pseudoaneurysm. This resulted in complete thrombosis of the pseudoaneurysm. For recalcitrant lesions in which the usual methods of stopping blood flow to the pseudoaneurysmal sac fail, an adjuvant approach with thrombin should be considered.

A qualitative evaluation of racial disparities in glucose control.

OBJECTIVE: Type 2 diabetes is more prevalent and severe among African Americans than among Whites. To elucidate barriers to glucose control that are unique to African Americans with poor glucose control we conducted a qualitative study among veterans with diabetes in an academic Veterans Affairs medical center. METHODS: We enrolled African American and White veterans with diabetes; participants' glucose control was described as well controlled or poorly controlled, and groups were organized on the basis of ethnicity and glucose control. Discussions were conducted by using modified nominal group technique to define factors that aided or hindered glucose control. RESULTS: Well-controlled groups similarly reported that self-care, health care, and psychosocial factors were important in controlling glucose. Although poorly controlled African Americans cited self-care as important, they also noted difficulty following self-care practices and the interference of psychosocial factors with glucose control. Poorly controlled Whites were similar. Uniquely, poorly controlled African Americans were less likely to report positive healthcare experiences; their barriers were related to poor access and poor relationships with providers. CONCLUSIONS: Poorly controlled African Americans endorsed healthy self-care behaviors but found it difficult to follow through. Interventions targeting the management of stress, depression, mood, and temptation, as well as improved access to and communication with providers may help these patients better manage their glucose and minimize disparities in diabetes outcomes. (Ethn Dis. 2009; 19:121-127)