Home Heart Hospital Associated With Reduced Hospitalizations and Costs Among High-Cost Patients With Cardiovascular Disease.

BACKGROUND: There is no widely accepted care model for managing high-need, high-cost (HNHC) patients. We hypothesized that a Home Heart Hospital (H3), which provides longitudinal, hospital-level at-home care, would improve care quality and reduce costs for HNHC patients with cardiovascular disease (CVD). OBJECTIVE: To evaluate associations between enrollment in H3, which provides longitudinal, hospital-level at-home care, care quality, and costs for HNHC patients with CVD. METHODS: This retrospective within-subject cohort study used insurance claims and electronic health records data to evaluate unadjusted and adjusted annualized hospitalization rates, total costs of care, part A costs, and mortality rates before, during, and following H3. RESULTS: Ninety-four patients were enrolled in H3 between February 2019 and October 2021. Patients' mean age was 75 years and 50% were female. Common comorbidities included congestive heart failure (50%), atrial fibrillation (37%), coronary artery disease (44%). Relative to pre-enrollment, enrollment in H3 was associated with significant reductions in annualized hospitalization rates (absolute reduction (AR): 2.4 hospitalizations/year, 95% confidence interval [95% CI]: -0.8, -4.0; p < 0.001; total costs of care (AR: -$56 990, 95% CI: -$105 170, -$8810; p < 0.05; and part A costs (AR: -$78 210, 95% CI: -$114 770, -$41 640; p < 0.001). Annualized post-H3 total costs and part A costs were significantly lower than pre-enrollment costs (total costs of care: -$113 510, 95% CI: -$151 340, -$65 320; p < 0.001; part A costs: -$84 480, 95% CI: -$121 040, -$47 920; p < 0.001). CONCLUSIONS: Longitudinal home-based care models hold promise for improving quality and reducing healthcare spending for HNHC patients with CVD.

Improving Specialty Care Access via Telemedicine.

Introduction: Telehealth is a potential solution to persistent disparities in health and health care access by eliminating structural barriers to care. However, its adoption in urban underserved settings has been limited and remains poorly characterized. Methods: This is a prospective cohort study of patients receiving telemedicine (TM) consultation for specialty care of diabetes, hypertension, and/or kidney disease with a Federally Qualified Health Center (FQHC) as the originating site and an academic medical center (AMC) multispecialty group practice as the distant site in an urban setting. Primary data were collected onsite at a local FQHC and an urban AMC between March 2017 and March 2020, before the COVID-19 pandemic. Clinical outcomes of study participants were compared with matched controls (CON) from a sister FQHC site who were referred for traditional in-person specialty visits at the AMC. No-show rates for study participants were calculated and compared to their no-show rates for standard (STD) in-person specialty visits at the AMC during the study period. A patient satisfaction questionnaire was administered at the end of each TM visit. Results: Visit attendance data were analyzed for 104 patients (834 visits). The no-show rate was 15%. The adjusted odds ratio for no-show for TM versus STD visits was 1.03 [0.66-1.63], p = 0.87. There were no significant differences between TM and CON groups in the change from pre- to intervention periods for mean arterial pressure (p = 0.26), serum creatinine (p = 0.90), or estimated glomerular filtration rate (p = 0.56). The reduction in hemoglobin A1c was significant at a trend level (p = 0.053). Patients indicated high overall satisfaction with TM. Discussion: The study demonstrated improved glycemic control and equivalent outcomes in TM management of hypertension and kidney disease with excellent patient satisfaction. This supports ongoing efforts to increase the availability of TM to improve access to care for urban underserved populations.

Popliteal Artery Occlusion in a Sole Sciatic Arterial System Requiring Complex Repair.

Objective: Persistence of the sciatic artery is a rare phenomenon in vascular surgery. It results from abnormal embryologic development, and where present in the absence of a femoral arterial system, it can have significant clinical implications for patients and can even be limb threatening. We present the case of a 69-year-old man with left-sided, short-distance claudication and rest pain, which caused concern for critical limb ischaemia. Methods: Computed tomography angiography revealed a persistent sciatic artery arising from the common iliac artery and resulting in an occluded popliteal artery. The patient underwent a double-bypass procedure to restore the arterial supply to the symptomatic limb. A left iliopopliteal Dacron graft bypass was performed, followed by a left iliopopliteal Dacron to posterior tibial bypass using the patient's great saphenous vein. The left sciatic artery was ligated proximally. Results:This allowed for restoration of arterial supply to the patient's left lower limb, relieving his claudication and rest pain. Conclusion: The key finding was the aneurysmal nature of the sciatic artery, reflecting the likely thromboembolic nature of the distal popliteal disease. Thus, our patient required not only a bypass procedure but also ligation of the native sciatic artery. Timely management is critical due to severity of consequences.

Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease.

OBJECTIVE: Diabetic foot disease poses a significant and rising financial burden on health care systems worldwide. This study investigated the effect of a new multidisciplinary diabetic foot clinic (MDDFC) in a large tertiary hospital on patient outcomes and treatment cost. METHODS: Patients' records were retrospectively reviewed to identify all patients who had been managed in a new MDDFC between July 2014 and July 2017. The wound episode-the period from initial presentation to the achievement of a final wound outcome-was identified, and all relevant inpatient and outpatient costs were extracted using a fully absorbed activity-based costing methodology. Risk factor, treatment, outcome, and costing data for this cohort were compared with a group of patients with diabetic foot wounds who had been managed in the same hospital before the advent of the MDDFC using a generalized linear mixed model. RESULTS: The MDDFC and pre-MDDFC cohorts included 73 patients with 80 wound episodes and 225 patients with 265 wound episodes, respectively. Compared with the pre-MDDFC cohort, the MDDFC group had fewer inpatient admissions (1.56 vs 2.64; P ≤ .001). MDDFC patients had a lower major amputation rate (3.8% vs 27.5%; P ≤ .001), a lower mortality rate (7.5% vs 19.2%; P ≤ .05), and a higher rate of minor amputation (53.8% vs 31.7%; P ≤ .01). No statistically significant difference was noted in the rate of excisional débridement, skin graft, and open or endovascular revascularization. In the MDDFC cohort, the median total cost, inpatient cost, and outpatient cost per wound episode was New Zealand dollars (NZD) 22,407.465 (U.S. dollars [USD] 17,253.74), NZD 21,638.93 (USD 16,661.97), and NZD 691.915 (USD 532.77), respectively. The MDDFC to pre-MDDFC wound episode total cost ratio was 0.7586 (P < .001). CONCLUSIONS: This study is the first to compare the cost and treatment outcomes of diabetic foot patients treated in a large tertiary hospital before and after the introduction of an MDDFC. The results show that an MDDFC improves patient outcomes and reduces the cost of treatment. MDDFCs should be adopted as the standard of care for diabetic foot patients.

Liver abscess: contemporary presentation and management in a Western population.

AIM: Historically, liver abscesses (LA) affected elderly, immunocompromised patients and were characterised by high morbidity and mortality, however there are no data pertaining to a New Zealand population with little information surrounding recent management trends. METHODS: A retrospective review of demographic characteristics, clinical management and microbiological data on patients presenting with liver abscess between 2005-2014 was conducted. RESULTS: Fifty-seven patients [37 males, median age 64 (range 15-87)] presented with LA and most patients were not comorbid. Ethnicity included European (47%), Chinese (16%) and Pacific Island (11%). Twenty-six patients had primary abscesses, 31 patients had secondary abscesses [biliary disease, appendicitis, diverticular disease]. Presenting symptoms were non-specific. Admission white cell count was raised in 50 (88%) of patients and 43 (75%) had a CRP≥200mg/L. All patients were investigated with CT scan with 34 LA located in the right lobe, 14 in the left and eight bi-lobar. Klebsiella pneumoniae was the commonest pathogen (26% of aspirates). Percutaneous drainage (PD) was used to treat 36 of 37 patients, 17 patients were treated with intravenous antibiotics alone and three patients required open drainage for loculated collections despite PD (n=1), intra-peritoneal rupture or sepsis (n=2). Thirteen patients were readmitted within 30 days for ongoing symptoms requiring intravenous antibiotics/further PD (9) or further investigations (4). The median PD duration was 10 days (range 3-53). Twenty-six patients required follow-up imaging over one month with 16 requiring follow-up over six weeks. CONCLUSION: In a New Zealand setting, LA affect fit patients, and primary abscesses account for almost half of all presentation. PD is effective treatment in most LA although prolonged drainage and treatment with antibiotics may be necessary.

Dissipation and heating in solar wind turbulence: from the macro to the micro and back again.

The past decade has seen a flurry of research activity focused on discerning the physics of kinetic scale turbulence in high-speed astrophysical plasma flows. By 'kinetic' we mean spatial scales on the order of or, in particular, smaller than the ion inertial length or the ion gyro-radius--the spatial scales at which the ion and electron bulk velocities decouple and considerable change can be seen in the ion distribution functions. The motivation behind most of these studies is to find the ultimate fate of the energy cascade of plasma turbulence, and thereby the channels by which the energy in the system is dissipated. This brief Introduction motivates the case for a themed issue on this topic and introduces the topic of turbulent dissipation and heating in the solar wind. The theme issue covers the full breadth of studies: from theory and models, massive simulations of these models and observational studies from the highly rich and vast amount of data collected from scores of heliospheric space missions since the dawn of the space age. A synopsis of the theme issue is provided, where a brief description of all the contributions is discussed and how they fit together to provide an over-arching picture on the highly topical subject of dissipation and heating in turbulent collisionless plasmas in general and in the solar wind in particular.

Single cell adhesion measuring apparatus (SCAMA): application to cancer cell lines of different metastatic potential and voltage-gated Na+ channel expression.

We have developed a simple yet effective apparatus, based upon negative pressure directed to the tip of a micro-pipette, to measure the adhesiveness of single cells. The "single cell adhesion measuring apparatus" (SCAMA) could differentiate between the adhesion of strongly versus weakly metastatic cancer cells as well as normal cells. Adhesion was quantified as "detachment negative pressure" (DNP) or "DNP relative to cell size" (DNPR) where a noticeable difference in cell size was apparent. Thus, for rat and human prostate and human breast cancer cell lines, adhesiveness (DNPR values) decreased in line with increased metastatic potential. Using the SCAMA, we investigated the effect of tetrodotoxin (TTX), a specific blocker of voltage-gated Na(+) channels (VGSCs), on the adhesion of rat and human prostate cancer cell lines of markedly different metastatic potential. Following pretreatment with TTX (48 h with 1 microM), the adhesion values for the Mat-LyLu cells increased significantly 4.3-fold; there was no effect on the AT-2 cells. For the strongly metastatic PC-3M cells, TTX treatment caused a significant (approximately 30%) increase in adhesion. The adhesion of PNT2-C2 ("normal") cells was not affected by the TTX pretreatment. The TTX-induced increase in the adhesiveness of the strongly metastatic cells was consistent with the functional VGSC expression in these cells and the proposed role of VGSC activity in metastatic cell behaviour. In conclusion, the SCAMA, which can be constructed easily and cheaply, offers a simple and effective method to characterise single-cell adhesion and its modulation.