Dynamic assessment of surge capacity in a large hospital network during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has provided an unprecedented scenario to deepen knowledge of surge capacity (SC), assessment of which remains a challenge. This study reports a large-scale experience of a multi-hospital network, with the aim of evaluating the characteristics of different hospitals involved in the response and of measuring a real-time SC based on two complementary modalities (actual, base) referring to the intensive care units (ICU). METHODS: Data analysis referred to two consecutive pandemic waves (March-December 2020). Regarding SC, two different levels of analysis are considered: single hospital category (referring to a six-level categorization based on the number of hospital beds) and multi-hospital wide (referring to the response of the entire hospital network). RESULTS: During the period of 114 days, the analysis revealed a key role of the biggest hospitals (>Category-4) in terms of involvement in the pandemic response. In terms of SC, Category-4 hospitals showed the highest mean SC values, irrespective of the calculation method and level of analysis. At the multi-hospital level, the analysis revealed an overall ICU-SC (base) of 84.4% and an ICU-SC (actual) of 106.5%. CONCLUSIONS: The results provide benchmarks to better understand ICU hospital response capacity, highlighting the need for a more flexible approach to SC definition.

Long-term outcomes of robot-assisted radical thymectomy for large thymomas: A propensity matched analysis.

BACKGROUND: The aim of this study was to evaluate the long-term results of robot-assisted (RATS) thymectomy in the treatment of large thymomas, defined as larger than 5 cm. METHODS: We retrospectively reviewed 106 thymectomies from 2010 to 2020, creating two groups based on the surgical approach (open or RATS) and size. Kaplan-Meier and Cox-regression were used to estimate and identify risk factors of oncological outcomes. To perform a well-balanced analysis, a propensity score matched (PSM) analysis was conducted for large thymomas. RESULTS: From 2015, we performed 54 RATS thymectomies: 53.7% (n = 29) for small and 46.3% (n = 25) for large thymomas. Conversions were similar and all patients had a complete resection. The overall (82% vs. 92%, p = 0.57) and disease-free survival were comparable between RATS and open (92.5% vs. 93%, p = 0.67), outcomes confirmed after PSM for large thymomas. CONCLUSIONS: RATS thymectomy could be considered a valid option in selected patients with large thymomas.

Long-term results after surgical treatment of the dominant lung adenocarcinoma associated with ground-glass opacities.

BACKGROUND: To evaluate the effect of first-time and eventual reiterative surgery on overall survival (OS) and disease-free survival (DFS) in Caucasian patients affected by an invasive adenocarcinoma (ADC) with at least another ground-glass opacity (GGO). METHODS: We analysed 47 patients operated on for lung ADC, identified as main cancer (MC), with at least one synchronous GGO, from January 2003 to March 2017. Characteristics associated with the evolution of GGOs were investigated with logistic regression and overall and DFS were evaluated with Kaplan-Meier method. RESULTS: Forty-two (89%) patients received an anatomic resection of the MC, 5 patients were treated by a single or multiple wedge resections. In total, 9 (19.1%) patients had all the lesions resected undergoing simultaneous resection of ipsilateral GGOs at first surgery while the remaining 38 (80.9%) patients still had at least one GGO that was followed up by serial CT scan. At the median follow-up of 41 months, GGO evolved in 16 (42.1%) patients. The presence of solid component at the initial CT scan was the only risk factor for evolution of the GGO. Thirteen patients underwent surgical resection showing an invasive ADC in 9 patients, MIA in 3 and AIS in 1. New GGOs developed in 7 (14.9%) patients, in which three underwent surgery showing the presence of solid ADC, MIA and AAH. OS rate at 5 years was 97.4%. DFS at 3 years was 82% and was significantly influenced by the stage of MC. CONCLUSIONS: Patients affected by an invasive ADC with at least another GGO nodule enjoy good OS and DFS with a surgical reiterative approach. Part-solid GGO is associated with GGO progression requiring treatment, but OS is not influenced by the new onset or evolution of GGOs. DFS is affected by the stage of the MC which dictates the treatment strategy.

Using overbooking to manage no-shows in an Italian healthcare center.

BACKGROUND: In almost all healthcare systems, no-shows (scheduled appointments missed without any notice from patients) have a negative impact on waiting lists, costs and resource utilization, impairing the quality and quantity of cares that could be provided, as well as the revenues from the corresponding activity. Overbooking is a tool healthcare providers can resort to reduce the impact of no-shows. METHODS: We develop an overbooking algorithm, and we assess its effectiveness using two methods: an analysis of the data coming from a practical implementation in an healthcare center; a simulation experiment to check the robustness and the potential of the strategy under different conditions. The data of the study, which includes personal and administrative information of patients, together with their scheduled and attended examinations, was taken from the electronic database of a big outpatient center. The attention was focused on the Magnetic Resonance (MR) ward because it uses expensive equipment, its services need long execution times, and the center has actually used it to implement an overbooking strategy aimed at reducing the impact of no-shows. We propose a statistical model for the patient's show/no-show behavior and we evaluate the ensuing overbooking procedure implemented in the MR ward. Finally, a simulation study investigates the effects of the overbooking strategy under different scenarios. RESULTS: The first contribution is a list of variables to identify the factors performing the best to predict no-shows. We classified the variables in three groups: "Patient's intrinsic factors", "Exogenous factors" and "Factors associated with the examination". The second contribution is a predictive model of no-shows, which is estimated on context-specific data using the variables just discussed. Such a model represents a fundamental ingredient of the overbooking strategy we propose to reduce the negative effects of no-shows. The third contribution is the assessment of that strategy by means of a simulation study under different scenarios in terms of number of resources and no-show rates. The same overbooking strategy was also implemented in practice (giving the opportunity to consider it as a quasi-experiment) to reduce the negative impact caused by non attendance in the MR ward. Both the quasi-experiment and the simulation study demonstrated that the strategy improved the center's productivity and reduced idle time of resources, although it increased slightly the patient's waiting time and the staff's overtime. This represents an evidence that overbooking can be suitable to improve the management of healthcare centers without adversely affecting their costs and the quality of cares offered. CONCLUSIONS: We shown that a well designed overbooking procedure can improve the management of medical centers, in terms of a significant increase of revenue, while keeping patient's waiting time and overtime under control. This was demonstrated by the results of a quasi-experiment (practical implementation of the strategy in the MR ward) and a simulation study (under different scenarios). Such positive results took advantage from a predictive model of no-show carefully designed around the medical center data.

Myocardial blood flow and left ventricular functional reserve in hypertrophic cardiomyopathy: a 13NH3 gated PET study.

INTRODUCTION: Ischemia in hypertrophic cardiomyopathy (HCM) is caused by coronary microvascular dysfunction (CMD), which is detected by measuring myocardial blood flow (MBF) with PET. Whether CMD may be associated with ischemic left ventricular (LV) dysfunction is unclear. We therefore assessed LV ejection fraction (EF) reserve in HCM patients undergoing dipyridamole (Dip) PET. METHODS: Resting and stress 13NH3 dynamic as well as gated PET were performed in 34 HCM patients. Segmental MBF and transmural perfusion gradient (TPG = subendocardial / subepicardial MBF) were assessed. LVEF reserve was considered abnormal if Dip LVEF decreased more than 5 units as compared to rest. RESULTS: Eighteen patients had preserved (group A) and 16 abnormal LVEF reserve (group B; range -7 to -32). Group B patients had greater wall thickness than group A, but resting volumes, LVEF, resting and Dip MBF, and myocardial flow reserve were similar. Group B had slightly higher summed stress score and summed difference score in visual analysis than group A, and a significantly higher summed stress wall motion score. In group B, resting TPG was slightly lower (1.31 ± 0.29 vs. 1.37 ± 0.34, p <0.05), and further decreased after Dip, whilst in group A it increased (B = 1.20 ± 0.39, p < 0.0001 vs. rest and vs. A = 1.40 ± 0.43). The number of segments per patient with TPG <1 was higher than in group A (p < 0.001) and was a significant predictor of impaired LVEF reserve (OR 1.86, p < 0.02), together with wall thickness (OR 1.3, p < 0.02). CONCLUSION: Abnormal LVEF response is common in HCM patients following Dip, and is related to abnormal TPG, suggesting that subendocardial ischemia might occur under Dip and cause transient LV dysfunction. Although in vivo this effect may be hindered by the adrenergic drive associated with effort, these findings may have relevance in understanding exercise limitation and heart failure symptoms in HCM.

Validation of pixel-wise parametric mapping of myocardial blood flow with ¹³NH3 PET in patients with hypertrophic cardiomyopathy.

PURPOSE: Transmural abnormalities in myocardial blood flow (MBF) are important causes of ischaemia in patients with left ventricular (LV) hypertrophy. The study aimed to test whether pixel-wise parametric mapping of (13)NH3 MBF can reveal transmural abnormalities in patients with hypertrophic cardiomyopathy (HCM). METHODS: We submitted 11 HCM patients and 9 age-matched controls with physiological LV hypertrophy to rest and stress (dipyridamole) (13)NH3 PET. We measured MBF using a compartmental model, and obtained rest and stress parametric maps. Pixel MBF values were reorganized to obtain subendocardial and subepicardial MBF of LV segments. RESULTS: MBF at rest was higher in the subendocardial than in the subepicardial layer: 0.78 ± 0.19 vs. 0.60 ± 0.18 mL/min/g in HCM patients; 0.92 ± 0.24 vs. 0.75 ± 0.24 mL/min/g in controls (both p < 0.0001). Transmural perfusion gradient (TPG = subendocardial MBF/subepicardial MBF) at rest was similar: 1.35 ± 0.31 in HCM patients; 1.28 ± 0.27 in controls (NS). During stress, controls maintained higher subendocardial MBF: 2.44 ± 0.54 vs. 1.96 ± 0.67 mL/min/g tissue (p < 0.0001), with a TPG of 1.33 ± 0.35 (NS vs. rest). In HCM patients, the difference between subendocardial and subepicardial MBF was reduced (1.46 ± 0.48 vs. 1.36 ± 0.48 mL/min/g tissue, p < 0.01) and TPG decreased to 1.11 ± 0.34 (p < 0.0001 vs. rest and vs. controls). In HCM patients 8 of 176 segments had subendocardial MBF less than -2 × SD of the mean, versus none of 144 segments in controls (p < 0.01). CONCLUSION: Pixel-wise parametric mapping of (13)NH3 MBF enables the identification of transmural abnormalities in patients with HCM.

Detection of infarct size safety threshold for left ventricular ejection fraction impairment in acute myocardial infarction successfully treated with primary percutaneous coronary intervention.

PURPOSE: In acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention (PCI), there is a direct relationship between myocardial damage and consequent left ventricular (LV) functional impairment. It is however unclear whether there is a safety threshold below which infarct size does not significantly affect LV ejection fraction (EF). The aim of this study was to evaluate the relationship between infarct size and LVEF in AMI patients treated by successful PCI using a specific statistical approach to identify a possible safety threshold. METHODS: Among patients with recent AMI submitted to perfusion gated single photon emission computed tomography (SPECT) to define the infarct size, the data of 427 subjects with sizable infarct size were considered. The relationship between infarct size and LVEF was analysed using a simple segmented regression (SSR) model and an iterative algorithm based on robust least squares (RLS) for parameter estimation. RESULTS: The RLS algorithm detected two break points in the SSR model, set at infarct size values of 11.0 and 51.5 %. Because the slope coefficients of the two extreme segments of the regression line were not significant, by constraining such segments to zero slope in the SSR model, the lower break point was identified at infarct size = 8 % and the upper one at 45 %. CONCLUSION: Using a rigorous statistical approach, it is possible to demonstrate that below a threshold of 8 % the infarct size apparently does not affect the LVEF and therefore a safety threshold could be set at this value. Furthermore, the same analysis suggests that the relationship between infarct size and LVEF impairment is lost for an infarct size > 45 %.

Use, Attitudes and Knowledge of Complementary and Alternative Drugs (CADs) Among Pregnant Women: a Preliminary Survey in Tuscany.

To explore pregnant women's use, attitudes, knowledge and beliefs of complementary and alternative drugs (CADs) defined as products manufactured from herbs or with a natural origin. A preliminary survey was conducted among 172 pregnant women in their third trimester of pregnancy, consecutively recruited in two obstetrical settings; 15 women were randomly selected to compute a test-to-retest analysis. Response rate was 87.2%. Test-to-retest analysis showed a questionnaire's reproducibility exceeding a K-value of 0.7 for all items. Mean age was 32.4 ± 0.4 years; most women were nulliparae (62.7%). The majority of subjects (68%) declared to have used one or more CADs during their lifetime; 48% of pregnant women reported taking at least one CAD previously and during the current pregnancy. Women's habitual use of CADs meant they were at higher risk of taking CADs also during pregnancy (adjusted odds ratio = 10.8; 95% confidence interval: 4.7-25.0). Moreover, 59.1% of the subjects were unable to correctly identify the type of CADs they were using. The majority of women resorted to gynecologists as the primary information source for CADs during pregnancy, while they mainly referred to herbalists when not pregnant. Habitual use of CADs seems to be a strong predictor for their ingestion also during pregnancy; in addition most subjects were unable to correctly identify the products they were taking. In the light of the scanty data concerning the safety of CADs during pregnancy, these preliminary results confirm the need to investigate thoroughly the situation of pregnant women and CADs consumption.