Cardiac device therapy in patients with left ventricular dysfunction and heart failure: ‘real‐world’ data on long‐term outcomes (mortality, hospitalizations, days alive and out of hospital)
Giuseppe BorianiElena BertiLaura Maria Beatrice BelottiMauro BiffiRossana De PalmaVincenzo Livio MalavasiNicola BottoniLuca RossiElia De MariaRoberto MantovanMarco ZardiniEdoardo CasaliM. MarconiAlberto BandiniCorrado TomasiGiulio BoggianG BarbatoTiziano ToselliMauro ZennaroBiagio Sassone
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Charlson comorbidity index
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Abstract Although pituitary adenomas (PAs) are common intracranial tumors, literature evaluating the utility of comorbidity indices for predicting perioperative complications in patients undergoing pituitary surgery remains limited, thereby hindering the development of complex models that aim to identify high-risk patient populations. Accordingly, we utilized comparative modeling strategies to evaluate the predictive validity of various comorbidity indices and combinations thereof in predicting key pituitary surgery outcomes. The Nationwide Readmissions Database was used to identify patients who underwent transsphenoidal pituitary tumor operations (n=19,653) in 2016-2017. Patient frailty was assessed using the Johns Hopkins Adjusted Clinical Groups (JHACG). Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were calculated for each patient. Five sets of generalized linear mixed-effects models were developed, using 1) Frailty, 2) CCI, 3) ECI, 4) Frailty+CCI, or 5) Frailty+ECI as the primary predictor. Complications investigated included inpatient mortality, non-routine discharge (e.g., to locations other than home) , length of stay (LOS) within the top quartile, cost within the top quartile, and one-year readmission rates. Postoperative mortality occurred in 73 patients (0.4%), one year readmission was reported in 2,994 patients (15.2%),and non-routine discharge occurred in 2,176 (11.1%) patients. The mean adjusted all-payer cost for the procedure was $25,553.85±$26,518.91 (Top Quartile: $28,261.20) and mean LOS was 4.8 days±7.4 days (Top Quartile: 5.0 days). The model using frailty+ECI as the primary predictor consistently outperformed other models, with statistically significant p-values as determined by comparing their AUCs, for most complications. For prediction of mortality, however the Frailty+ECI model (AUC:0.831) was not better than the ECI model alone (AUC:0.831;p=0.95). For prediction of readmission the Frailty+ECI model (AUC:0.617) was not better than the frailty model alone (AUC:0.606;p=0.10) or the Frailty+CCI model (AUC:0.610;p=0.29). Knowledge gained from these models may help neurosurgeons identify high-risk patients requiring additional clinical attention or specific resource utilization prior to surgical planning.
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Learning curve
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Background— Recent studies have demonstrated that a positive response to cardiac resynchronization therapy (CRT) is related to the presence of preimplantation left ventricular (LV) dyssynchrony. The time course and the extent of LV resynchronization after CRT implantation and their relationship to response are currently unknown. Methods and Results— One hundred consecutive patients scheduled for implantation of a CRT device were prospectively included if they met the following criteria: New York Heart Association class III to IV, LV ejection fraction ≤35%, QRS duration >120 ms, and LV dyssynchrony (≥65 ms) on color-coded tissue Doppler imaging. Immediately after CRT implantation, LV dyssynchrony was reduced from 114±36 to 40±33 ms ( P <0.001), which persisted at the 6-month follow-up (35±31 ms; P <0.001 versus baseline; P =0.14 versus immediately after implantation). At the 6-month follow-up, 85% of patients were classified as responders to CRT (defined as >10% reduction in LV end-systolic volume). Immediately after implantation, the responders to CRT demonstrated a significant reduction in LV dyssynchrony from 115±37 to 32±23 ms ( P <0.001). The nonresponders, however, did not show a significant reduction in LV dyssynchrony (106±29 versus 79±44 ms; P =0.08). If the extent of acute LV resynchronization was <20%, response to CRT at the 6-month follow-up was never observed. Conversely, 93% of patients with LV resynchronization ≥20% responded to CRT. Conclusions— LV resynchronization after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up in patients with echocardiographic evidence of LV dyssynchrony at baseline.
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Extravascular cardiac resynchronization therapy (CRT) defibrillators (CRT-Ds) are ideal for recurrent blood stream infections. Furthermore, CRT is useful for patients intolerant to right ventricular (RV) pacing. The case was a 65-year-old man with a CRT-D who presented with a blood stream infection. Because he was hemodynamically unstable with temporary RV pacing, an epicardial CRT device was re-implanted concomitantly through a surgical procedure. After the operation, a subcutaneous implantable cardioverter defibrillator (S-ICD) was placed. However, not all pacing is eligible for S-ICD screening. Combination therapy with an epicardial CRT device and S-ICD might be an alternate option for cardiac surgery cases.
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Although cardiac resynchronization therapy is currently used for treatment of refractory heart failure in patients with low ejection fraction and cardiac dyssynchrony, there is a substantial number of non-responders. This indicates that, in addition to cardiac dyssynchrony, there are other factors affecting response to cardiac resynchronization therapy. Pre-implant identification of these factors appears of crucial importance in order to finalize the resynchronization treatment to those patients who have the highest probability of a positive response. In this review the main non-dyssynchrony determinants of response to cardiac resynchronization therapy are presented and discussed.
Ventricular dyssynchrony
Refractory (planetary science)
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The purpose of this paper is to propose setting guidance levels on entrance surface dose for radiographic examinations on children in Japan. This proposal is based on the results of surveys conducted broadly on Japanese institutes. Each value of the entrance doses (the 1st quartile, median, the 3rd quartile, and mean) was calculated with the Numerical Dose Determination method (NDD). The difference between the values of the 1st quartile and the 3rd quartile for each part of all 7 subject parts of examination ranges from 2.7 times to 3.7 times among institutions. In some institutions, the values of the 3rd quartile appeared over ten times as many as the 1st quartile. We propose the guidance levels on entrance surface doses for the children's radiographic examinations to be the value of the 3rd quartile, which was calculated from the result of the surveys.
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Background We sought to analyze the impact of socioeconomic status ( SES ) on in‐hospital outcomes, cost of hospitalization, and resource use after acute ischemic stroke. Methods and Results We used the 2003–2011 Nationwide Inpatient Sample database for this analysis. All admissions with a principal diagnosis of acute ischemic stroke were identified by using International Classification of Diseases, Ninth Revision codes. SES was assessed by using median household income of the residential ZIP code for each patient. Quartile 1 and quartile 4 reflect the lowest‐income and highest‐income SES quartile, respectively. During a 9‐year period, 775 905 discharges with acute ischemic stroke were analyzed. There was a progressive increase in the incidence of reperfusion on the first admission day across the SES quartiles (P‐trend<0.001). In addition, we observed a significant reduction in discharge to nursing facility, across the SES quartiles (P‐trend<0.001). Although we did not observe a significant difference in in‐hospital mortality across the SES quartiles in the overall cohort (P‐trend=0.22), there was a significant trend toward reduced in‐hospital mortality across the SES quartiles in younger patients (<75 years) (P‐trend<0.001). The mean length of stay in the lowest‐income quartile was 5.75 days, which was significantly higher compared with other SES quartiles. Furthermore, the mean adjusted cost of hospitalization among quartiles 2, 3, and 4, compared with quartile 1, was significantly higher by $621, $1238, and $2577, respectively. Compared with the lowest‐income quartile, there was a significantly higher use of echocardiography, invasive angiography, and operative procedures, including carotid endarterectomy, in the highest‐income quartile. Conclusions Patients from lower‐income quartiles had decreased reperfusion on the first admission day, compared with patients from higher‐income quartiles. The cost of hospitalization of patients from higher‐income quartiles was significantly higher than that of patients from lowest‐income quartiles, despite longer hospital stays in the latter group. This might be partially attributable to a lower use of key procedures among patients from lowest‐income quartile.
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Household income
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