Heart Failure with Preserved Ejection Fraction and 30-Day Readmission.

OBJECTIVE: Several studies identify heart failure (HF) as a potential risk for hospital readmission; however, studies on predictability of heart failure readmission is limited. The objective of this work was to investigate whether a specific type of heart failure (HFpEF or HFrEF) has a higher association to the rate of 30-day hospital readmission and compare their predictability with the two risk scores: HOSPITAL score and LACE index. DESIGN: Retrospective study from single academic center. METHODS: Sample size included adult patients from an academic hospital in a two-year period (2015 - 2017). Exclusion criteria included death, transfer to another hospital, and unadvised leave from hospital. Baseline characteristics, diagnosis-related group, and ICD diagnosis codes were obtained. Variables affecting HOSPITAL score and LACE index and types of heart failure present were also extracted. Qualitative variables were compared using Pearson chi2 or Fisher's exact test (reported as frequency) and quantitative variables using non-parametric Mann-Whitney U test (reported as mean ± standard deviation). Variables from univariate analysis with P values of 0.05 or less were further analyzed using multivariate logistic regression. Odds ratio was used to measure potential risk. RESULTS: The sample size of adult patients in the study period was 1,916. All eligible cohort of patients who were readmitted were analyzed. Cumulative score indicators of HOSPITAL Score, LACE index (including the Charlson Comorbidity Index) predicted 30-day readmissions with P values of <0.001. The P value of HFpEF was found to be significant in the readmitted group (P < 0.001) compared to HFrEF (P = 0.141). Multivariate logistic regression further demonstrated the association of HFpEF with higher risk of readmission with odds ratio of 1.77 (95% CI: 1.25 - 2.50) and P value of 0.001. CONCLUSIONS: Our data from an academic tertiary care center supports HFpEF as an independent risk factor for readmission. Multidisciplinary management of HFpEF may be an important target for interventions to reduce hospital readmissions.

Dual 8-plate technique is not as effective as ablation for epiphysiodesis about the knee.

BACKGROUND: Lower extremity length inequality can be problematic in children and is often addressed surgically. Several techniques have traditionally been utilized for epiphysiodesis, the goal being physeal ablation. Recently, 8-plates, initially developed for hemiepiphysiodesis, have been extended to epiphysiodesis by placing the plates on both medial and lateral sides of the physis. No prior studies have compared 8-plates with physeal ablation techniques. METHODS: Between January 2003 and August 2009, 27 patients underwent epiphysiodesis surgery using either physeal ablation or 8-plate technique. Sixteen patients had physeal ablation and 11 had dual 8-plates. A retrospective chart review sought demographic data, outcomes, and complications. Radiographs were reviewed to measure pretreatment and posttreatment limb lengths. RESULTS: The median improvement in limb length discrepancy was 15.5 mm in the physeal ablation group and 4 mm in the 8-plate group (P<0.001). This difference was maintained following linear regression factoring out the effect of time (10.78 mm for ablation vs. 5.62 mm for 8-plates; P=0.016). There was no statistically significant difference in complication rate between the groups (P=0.112). CONCLUSIONS: Our study demonstrated physeal ablation to be a significantly superior treatment compared with dual 8-plates for epiphysiodesis. Despite theoretical advantages of 8-plates to perform epiphysiodesis about the knee, this study does not recommend the use of medial and lateral 8-plates to effect epiphysiodesis. LEVEL OF EVIDENCE: Therapeutic III.

Efficacy of alendronate in the treatment of low bone density in the pediatric and young adult population.

BACKGROUND: Pediatric osteoporosis is uncommon but can result in painful and debilitating insufficiency fractures. Treatment options for osteoporosis in children are few. Bisphosphonate therapy for children has not been approved by the Food and Drug Administration (FDA) in the United States, but its use in that population has been increasing. Randomized controlled studies have not been done because of the small subject pool and the difficulty in randomizing a child with an insufficiency fracture to a placebo arm of a study. This retrospective case-control study of a population of children with primarily neuromuscular disease was done to review changes in bone mineral density as reflected by dual x-ray absorptiometry (DXA) scanning. METHODS: Medical records and DXA scans were screened to identify children with low bone density who had been treated with alendronate as well as similar control subjects with low bone density for their age who had not received alendronate. Medication acquisition was confirmed by refill records, and cumulative exposure was calculated. Interval DXA scans were reviewed to correlate bone mineral density change in grams per square centimeter as well as the percent change and percent change over time for both alendronate-treated and control subjects. RESULTS: Twenty-eight alendronate-treated subjects and thirty control subjects met the inclusion criteria. No significant improvement in bone mineral density was seen in the alendronate-treated subjects as compared with the control subjects. Some patients in both groups exhibited marked improvement, with improvement of >31% seen only in the alendronate-treated subjects. CONCLUSIONS: Alendronate does not reliably improve bone density in children and young adults with primarily neuromuscular disease and without osteogenesis imperfecta. Individual patients treated with bisphosphonates must be carefully followed to ensure medication compliance and appropriate response.

Children with spina bifida are at risk for low bone density.

BACKGROUND: Patients with spina bifida frequently sustain lower extremity fractures which may be difficult to diagnose because they feel little or no pain, although the relative contributions of low bone density to pain insensitivity are unclear. Routine dual-energy xray absorptiometry (DXA) scanning is unreliable because these patients lack bony elements in the spine, and many have joint contractures and/or implanted hardware. QUESTIONS/PURPOSES: We asked (1) if the lateral distal femoral scan is useful in spina bifida; (2) whether nonambulatory children with spina bifida exhibit differences in bone mineral density (BMD) compared with an age-and-sex-matched population; and (3) whether Z-scores were related to extremity fracture incidence. METHODS: We retrospectively reviewed 37 patients with spina bifida who had DXA scans and sufficient data. Z-scores were correlated with functional level, ambulatory status, body mass index, and fracture history. RESULTS: The distal femoral scan could be performed in subjects for whom total body and/or lumbar scans could not be performed accurately. Twenty-four of 37 had Z-scores below -2 SD, defined as "low bone density for age." Ten of 35 patients (29%) with fracture information had experienced one or more fractures. Our sample size was too small to correlate Z-score with fracture. CONCLUSION: We believe BMD should be monitored in patients with spina bifida; nonambulatory patients with spina bifida and those with other risk factors are more likely to have low bone density for age than unaffected individuals. The LDF scan was useful in this population in whom lumbar and total body scans are often invalidated by contracture or artifact. Although lower extremity fractures occur regardless of ambulation or bone density, knowing an individual's bone health status may lead to interventions to improve bone health.

An alternate site for pacemaker placement when standard locations are not available.

In patients with no standard sites available for venous access and pulse generator location, the authors found that tunneling the leads from the jugular vein under the clavicle and placing this pulse generator beneath the latissimus dorsi muscle was a satisfactory alternative.

The nature and frequency of postimplant surgical interventions: a realistic appraisal.

The purpose of this retrospective study was to investigate the nature and frequency of surgical reinterventions after primary pacemaker implantation in patients who survived at least 20-30 years. Eighty-five such patients were identified, 32 of whom had radioisotopic (nuclear) implants, and 53 lithium battery powered lithium units. Excluding reoperations within the first 3 months, patients with nuclear implants experienced about two reoperations in 25 years, while those with lithium experienced one every 8 years. The most frequent reasons for surgery were pulse generator replacements, lead revisions, and mode changes, particularly in the nuclear group. There were no premature device failures. This study allows us to make reasonable predictions to patients about the experience a pacemaker implantation, and reassures us about the reliability of the devices that were implanted in the past.