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BACKGROUND: Same day discharge (SDD) following atrial fibrillation (AF) ablation procedure has emerged as routine practice, and primarily driven by operator discretion. However, the impacts of SDD on clinical outcomes, healthcare system costs, and patient reported outcomes (PROs) have not been systematically studied. METHODS: We retrospectively analyzed patients undergoing routine AF ablation procedures with SDD versus overnight observation (NSDD). After propensity adjustment we compared postprocedure adverse events (AEs), healthcare system costs, and changes in PROs. RESULTS: We identified 310 cases, with 159 undergoing SDD and 151 staying at least one midnight in the hospital (NSDD). Compared with NSDD, SDD patients were similar age (mean 64 vs. 66, p = 0.3), sex (26% female vs. 27%, p = 0.8), and with lower mean CHADS2-VA2Sc scores (2.0 vs. 2.7; p < 0.011). The primary outcome of AEs was noninferior in SDD versus NSDD patients (odds ratio 0.45, 95% confidence interval 0.21-0.99; noninferiority margin of 10%). There were also no differences in overall cost to the healthcare system between SDD and NSDD (p = 0.11). PROs numerically favored SDD (p = NS for all scores). CONCLUSIONS: Physician selection for SDD appears at least as safe as NSDD with respect to clinical outcomes and SDD is not significantly less costly to the health system. There is a trend towards more favorable, general PROs among SDD patients. Routine SDD should be strongly considered for patients undergoing routine AF ablation procedures.
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Fibrilación Atrial , Ablación por Catéter , Alta del Paciente , Medición de Resultados Informados por el Paciente , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/economía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Femenino , Masculino , Estudios Retrospectivos , Ablación por Catéter/economía , Ablación por Catéter/efectos adversos , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Factores de Tiempo , Alta del Paciente/economía , Costos de Hospital , Factores de Riesgo , Análisis Costo-Beneficio , Tiempo de Internación/economía , Procedimientos Quirúrgicos Ambulatorios/economía , Procedimientos Quirúrgicos Ambulatorios/efectos adversosRESUMEN
The Veterans Health Administration (VA) increasingly purchases community-based care (CC) to improve healthcare access, including behavioral health. In 2018, VA introduced standardized episodes of care (SEOCs) to guide authorization and purchase of CC services for specific indications in a defined timeframe without bundling payment. In this retrospective cross-sectional study, we describe trends in VA and CC behavioral healthcare utilization using the VA Outpatient Psychiatry SEOC definition. Counts of Outpatient Psychiatry SEOC-allowable service and procedure codes during fiscal years 2016-2019 were organized according to four SEOC-defined service types (evaluation and management, laboratory services, psychiatry services, transitional care) and measured as percentages of all included codes. Trends comparing behavioral healthcare utilization between Veterans using any CC versus VA only were analyzed using a linear mixed effects model. We identified nearly 3 million Veterans who registered 60 million qualifying service and procedure codes, with overall utilization increasing 77.8% in CC versus 5.2% in VA. Veterans receiving any CC comprised 3.9% of the cohort and 4.7% of all utilization. When examining service type as a percent of all Outpatient Psychiatry SEOC-allowable care among Veterans using CC, psychiatry services increased 12.2%, while transitional care decreased 8.8%. In regression analysis, shifts in service type utilization reflected descriptive results but with attenuated effect sizes. In sum, Outpatient Psychiatry SEOC-allowable service utilization grew, and service type composition changed, significantly more in CC than in VA. The role of SEOCs and their incentives may be important when evaluating future behavioral healthcare quality and value in bundled services.
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Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.
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Técnicas de Laboratorio Clínico , Infecciones por Coronavirus/prevención & control , Casas de Salud , Pandemias/prevención & control , Neumonía Viral/prevención & control , Anciano , COVID-19 , Prueba de COVID-19 , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/transmisión , Personal de Salud , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Transmisión de Enfermedad Infecciosa de Profesional a Paciente/prevención & control , Neumonía Viral/epidemiología , Neumonía Viral/transmisión , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: A large body of epidemiological and experimental evidence suggests that vitamin D deficiency may promote hypertension. This raises the possibility that vitamin D supplementation could be a simple intervention to reduce blood pressure, but data from prospective, randomized trials are limited. METHODS AND RESULTS: A double-blind, randomized, controlled trial was conducted at 4 sites in the United States. We enrolled 534 individuals 18 to 50 years of age with low vitamin D status (25-hydroxyvitamin D levels ≤25 ng/mL) and systolic blood pressure of 120 to 159 mm Hg. Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D3 for 6 months. The primary end point was change in mean 24-hour systolic blood pressure. Secondary end points included change in ambulatory diastolic blood pressure and clinic systolic and diastolic blood pressures. The median age was 38 years, and 62% of participants were men. Forty-six percent of participants were white, and 48% were black. The median 25-hydroxyvitamin D level at baseline was 15.3 ng/mL. Four-hundred fifty-five participants (85%) had at least 1 follow-up blood pressure measurement; 383 participants (72%) completed the full 6-month study. At the end of the study, there was no significant difference in the primary end point (change in mean 24-hour systolic blood pressure, -0.8 versus -1.6 mm Hg in the high-dose and low-dose arms; P=0.71) or in any of the secondary end points. Furthermore, there was no evidence of association between change in 25-hydroxyvitamin D and change in 24-hour systolic blood pressure at 6 months (Spearman correlation coefficient, -0.05, P=0.34). Results were consistent across prespecified subgroups. CONCLUSIONS: Vitamin D supplementation did not reduce blood pressure in individuals with prehypertension or stage I hypertension and vitamin D deficiency. Our findings suggest that the association between vitamin D status and elevated blood pressure noted in observational studies is not causal. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240512.
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Colecalciferol/uso terapéutico , Hipertensión/tratamiento farmacológico , Prehipertensión/tratamiento farmacológico , Deficiencia de Vitamina D/tratamiento farmacológico , Adulto , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Colecalciferol/sangre , Colecalciferol/farmacología , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Hipertensión/sangre , Hipertensión/diagnóstico , Masculino , Persona de Mediana Edad , Prehipertensión/sangre , Prehipertensión/diagnóstico , Deficiencia de Vitamina D/sangre , Deficiencia de Vitamina D/diagnósticoRESUMEN
BACKGROUND: Management of atrial fibrillation is frequently geared toward improving symptoms. Yet, the magnitude of symptom-rhythm discordance is not well known in the setting of monitoring by ambulatory electrocardiography (AECG). OBJECTIVE: We aimed to quantify the symptom-rhythm correlation (SRC) for atrial arrhythmia (atrial tachycardia/atrial fibrillation [AT/AF]) events. METHODS: This was a retrospective cohort analysis of AECG data at a tertiary care center. All AECGs of ≥7 days with at least 1 AT/AF were included. Patient-triggered symptoms included shortness of breath, tiredness, palpitations, dizziness, or passing out with or without concurrent AT/AF. SRC was calculated for each patient. In addition, AT/AF-symptom association was evaluated at the event level by multivariable mixed effects logistic regression. RESULTS: We identified 742 patients with qualifying AECG data; mean age was 64 years, 50% were female, and 22% had heart failure. The mean CHA2DS2-VASc score was 2.5. There were 6289 symptomatic events and 6900 AT/AF episodes. Of symptomatic events, 1013 (16%) had shortness of breath, 839 (13%) tiredness, 2640 (42%) palpitations, 783 (12%) dizziness, and 93 (1%) passing out. Overall SRC was 0.39 (range, 0-1.0), but presence of AT/AF increased odds of symptoms by â¼8.3 times in adjusted analyses (P < .01). In multivariable analysis, prior AF rhythm control treatment and lower heart rate were associated with worse SRC (P < .01). CONCLUSION: Whereas AT/AF events increase the chances of symptoms, there is poor overall correlation between symptomatic events and documented AT/AF. Patient factors and prior treatments influence SRC. An improved understanding of this relationship correlation is needed to optimize clinical outcomes and to improve the rigor of AF research.
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BACKGROUND: Oral sotalol is a class III antiarrhythmic commonly used for the maintenance of sinus rhythm in patients with atrial fibrillation (AF). Recently, the Food and Drug Administration (FDA) approved the use of IV sotalol loading, based primarily on modeling data for the infusion. We aimed to describe a protocol and experience with IV sotalol loading for elective treatment of adult patients with AF and atrial flutter (AFL). METHODS: We present our institutional protocol and retrospective review of initial patients treated with IV sotalol for AF/AFL at the University of Utah Hospital between September 2020 and April 2021. RESULTS: Eleven patients received IV sotalol for initial loading or dose escalation. All patients were male, aged 56-88 years (median 69). Mean QT interval (QTc) intervals increased from baseline (mean 384 ms) immediately after infusion of IV sotalol (mean change 42ms), but no patient required discontinuation of the medication. Six patients were discharged after 1 night; 4 patients were discharged after 2 nights; and 1 patient was discharged after 4 nights. Nine patients underwent electrical cardioversion prior to discharge (2 prior to load; 7 post-load on the day of discharge). There were no adverse events during the infusion or within 6 months of discharge. Persistence of therapy was 73% (8 of 11) at mean 9.9 weeks to follow up, with no discontinuations for adverse effects. CONCLUSIONS: We employed a streamlined protocol that was successfully implemented to facilitate the use of IV sotalol loading for atrial arrhythmias. Our initial experience suggests feasibility, safety, and tolerability while reducing hospitalization duration. Additional data are needed to augment this experience as IV sotalol use is broadened across different patient populations.
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Fibrilación Atrial , Aleteo Atrial , Adulto , Humanos , Masculino , Femenino , Sotalol/efectos adversos , Fibrilación Atrial/terapia , Antiarrítmicos/uso terapéutico , Cardioversión EléctricaRESUMEN
OBJECTIVE: To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids. DATA SOURCES AND STUDY SETTING: We collected patient surveys and electronic medical record data at an academic health system. STUDY DESIGN: We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias. DATA COLLECTION/EXTRACTION METHODS: From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy. PRINCIPAL FINDINGS: We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up. CONCLUSIONS: A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.
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Analgésicos Opioides , Trastornos Relacionados con Opioides , Humanos , Analgésicos Opioides/uso terapéutico , Hospitalización , Trastornos Relacionados con Opioides/tratamiento farmacológico , Alta del Paciente , Estudios Prospectivos , Adolescente , AdultoRESUMEN
OBJECTIVE: To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF). BACKGROUND: CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT. METHODS: We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant ( > 20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL. RESULTS: The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups). CONCLUSION: CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.
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Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca , Humanos , Femenino , Anciano , Masculino , Terapia de Resincronización Cardíaca/métodos , Volumen Sistólico/fisiología , Función Ventricular Izquierda , Calidad de Vida , Insuficiencia Cardíaca/terapiaRESUMEN
Adeno-associated virus (AAV) recombination can result in chimeric capsid protein subunits whose ability to assemble into an oligomeric capsid, package a genome, and transduce cells depends on the inheritance of sequence from different AAV parents. To develop quantitative design principles for guiding site-directed recombination of AAV capsids, we have examined how capsid structural perturbations predicted by the SCHEMA algorithm correlate with experimental measurements of disruption in seventeen chimeric capsid proteins. In our small chimera population, created by recombining AAV serotypes 2 and 4, we found that protection of viral genomes and cellular transduction were inversely related to calculated disruption of the capsid structure. Interestingly, however, we did not observe a correlation between genome packaging and calculated structural disruption; a majority of the chimeric capsid proteins formed at least partially assembled capsids and more than half packaged genomes, including those with the highest SCHEMA disruption. These results suggest that the sequence space accessed by recombination of divergent AAV serotypes is rich in capsid chimeras that assemble into 60-mer capsids and package viral genomes. Overall, the SCHEMA algorithm may be useful for delineating quantitative design principles to guide the creation of libraries enriched in genome-protecting virus nanoparticles that can effectively transduce cells. Such improvements to the virus design process may help advance not only gene therapy applications but also other bionanotechnologies dependent upon the development of viruses with new sequences and functions.
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Cápside/química , Quimera/genética , Dependovirus/genética , Ingeniería de Proteínas/métodos , Recombinación Genética/genética , Algoritmos , Quimera/metabolismo , Biología Computacional , Dependovirus/química , Dependovirus/metabolismo , Genoma Viral , HeparinaAsunto(s)
Carcinoma de Células Renales/patología , Neoplasias Renales/patología , Carcinoma de Células Renales/diagnóstico , Femenino , Estado de Salud , Humanos , Neoplasias Renales/diagnóstico , Anamnesis , Persona de Mediana Edad , Metástasis de la Neoplasia , Tomografía Computarizada por Rayos X , Pérdida de PesoAsunto(s)
Adenocarcinoma/terapia , Terapias Complementarias , Neoplasias Pulmonares/terapia , Terapia Nutricional , Oncología por Radiación , Adenocarcinoma/diagnóstico , Adenocarcinoma/psicología , Prestación Integrada de Atención de Salud , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/psicología , Persona de Mediana Edad , Consejos de Especialidades , Estados UnidosAsunto(s)
Adenocarcinoma/secundario , Neoplasias del Colon/patología , Terapias Complementarias/métodos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/terapia , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biopsia con Aguja , Colectomía/métodos , Neoplasias del Colon/cirugía , Terapia Combinada , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Neoplasias Hepáticas/diagnóstico , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Medición de Riesgo , Resultado del TratamientoAsunto(s)
Adenocarcinoma/diagnóstico , Adenocarcinoma/terapia , Prestación Integrada de Atención de Salud , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/terapia , Consejos de Especialidades , Terapias Complementarias , Femenino , Humanos , Persona de Mediana Edad , Terapia Nutricional , Oncología por Radiación , Estados UnidosRESUMEN
Practical circadian therapy for the cancer patient involves 3 spheres of intervention-improving lifestyle, optimizing internal biochemical milieu, and adjusting treatment times. The potential value of improving overall circadian functioning is shown in the work of Mormont et al in which pronounced rest-activity rhythms were associated with better survival in colorectal cancer patients receiving chronomodulated chemotherapy. Lifestyle interventions that may improve circadian functioning involve diet, physical activity, and mind-body therapies. A diet that is anti-inflammatory and has appropriate carbohydrate intake, as well as regular meal timing, encourages normal circadian cycles. Adequate daytime physical activity encourages restful sleep, and morning light exposure during exercise may entrain melatonin rhythms. Meditation and other mind-body therapies can reduce anxiety and depression that may disrupt sleep. Aspects of the biochemical milieu that specifically disrupt circadian functioning are inflammation and stress hormones. Inflammation and cytokine disruption can be addressed with diet, herbs, and other natural substances. Chronomodulation of chemotherapy in a US clinical setting will be discussed. A series of 12 cases will be presented of patients who experienced grade 3 to 4 toxicities with various chemotherapy regimens for colorectal cancer. When rechallenged with the same regimens administered chronotherapeutically, none of the patients experienced grade 3 to 4 toxicity. Integrating all the above treatment modalities has the potential to improve both the quality of life and disease outcomes in cancer patients.