1
|
Gard EK, Noaman S, Stub D, Vriesendorp P, Htun N, Johnston R, Gartner E, Dick R, Walton A, Kaye D, Nanayakkara S. The Role of Comorbidities in Predicting Functional Improvement After Transcatheter Aortic Valve Implantation. Heart Lung Circ 2024:S1443-9506(24)00078-7. [PMID: 38582702 DOI: 10.1016/j.hlc.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/05/2024] [Accepted: 02/04/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Patients undergoing transcatheter aortic valve implantation (TAVI) have a high comorbidity burden. We sought to stratify patients into functional outcomes using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), a patient-reported outcome with benefits over both the New York Heart Association (NYHA) classification and the original 23-item KCCQ, and to evaluate the importance of comorbidities in predicting failure of functional improvement post-TAVI in a contemporary cohort. METHODS In total, 366 patients with severe aortic stenosis undergoing TAVI with baseline KCCQ-12 were retrospectively analysed and divided into two groups. Failure to improve was defined as a score <60 and a change in score <10 at 1 year in either overall score (KCCQ-OS) or clinical summary score (KCCQ-CSS). RESULTS Failure to improve was noted in 13% of patients, who were more likely to have lower KCCQ-OS at baseline (47 [35-59] vs 56 [42-74]), chronic obstructive pulmonary disease (COPD) (19% vs 8%), severe chronic kidney disease (CKD) (13% vs 2%), a clinical frailty score (CFS) ≥5 (41% vs 14%), and lower serum albumin (36 g/L [34-38] vs 38 g/L [35-40]). On multivariate analysis, with an area under the curve of 0.71 (0.63-0.78), baseline KCCQ-OS (adjusted odds ratio [aOR] 0.3 [0.1-0.6], p=0.04), COPD (aOR 2.8 [1.2-6.5], p=0.02), and severe CKD (aOR 5.7 [1.7-18.5], p=0.004) remained independent predictors. CFS alone had a similar predictive value as the multivariable model (OR 2.0 [1.3-3.4], area under the curve 0.69 [0.59-0.80], p<0.001). CONCLUSIONS KCCQ scores were effective in delineating functional outcomes, with most patients in our relatively lower surgical risk cohort showing significant functional improvements post-TAVI. Low baseline KCCQ, moderate or worse COPD, and severe CKD were associated with failure of improvement post-TAVI. Baseline CFS appears to be a good screening tool to predict poor improvement. These factors should be evaluated and weighted accordingly in pre-TAVI assessments and decision-making.
Collapse
Affiliation(s)
- Emma K Gard
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Vic, Australia; School of Public Health and Preventative Medicine, Monash University, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia
| | - Pieter Vriesendorp
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Vic, Australia
| | - Nay Htun
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Vic, Australia
| | - Rozanne Johnston
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Elisha Gartner
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Ronald Dick
- Department of Cardiology, Epworth Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Vic, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia; Baker Heart & Diabetes Institute, Melbourne, Vic, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Vic, Australia; Baker Heart & Diabetes Institute, Melbourne, Vic, Australia.
| |
Collapse
|
2
|
Zhou J, Nehme E, Dawson L, Bloom J, Smallwood N, Okyere D, Cox S, Anderson D, Smith K, Stub D, Nehme Z, Kaye D. Impact of socioeconomic status on presentation, care quality and outcomes of patients attended by emergency medical services for dyspnoea: a population-based cohort study. J Epidemiol Community Health 2024; 78:255-262. [PMID: 38228390 DOI: 10.1136/jech-2023-220737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024]
Abstract
BACKGROUND Low socioeconomic status (SES) has been linked to poor outcomes in many conditions. It is unknown whether these disparities extend to individuals presenting with dyspnoea. We aimed to evaluate the relationship between SES and incidence, care quality and outcomes among patients attended by emergency medical services (EMS) for dyspnoea. METHODS This population-based cohort study included consecutive patients attended by EMS for dyspnoea between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital and mortality datasets. Patients were stratified into SES quintiles using a composite census-derived index. RESULTS A total of 262 412 patients were included. There was a stepwise increase in the age-adjusted incidence of EMS attendance for dyspnoea with increasing socioeconomic disadvantage (lowest SES quintile 2269 versus highest quintile 889 per 100 000 person years, ptrend<0.001). Patients of lower SES were younger and more comorbid, more likely to be from regional Victoria or of Aboriginal or Torres Strait Islander heritage and had higher rates of respiratory distress. Despite this, lower SES groups were less frequently assigned a high acuity EMS transport or emergency department (ED) triage category and less frequently transported to tertiary centres or hospitals with intensive care unit facilities. In multivariable models, lower SES was independently associated with lower acuity EMS and ED triage, ED length of stay>4 hours and increased 30-day EMS reattendance and mortality. CONCLUSION Lower SES was associated with a higher incidence of EMS attendances for dyspnoea and disparities in several metrics of care and clinical outcomes.
Collapse
Affiliation(s)
- Jennifer Zhou
- Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Emily Nehme
- Centre for Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Luke Dawson
- Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natasha Smallwood
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Daniel Okyere
- Centre for Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - David Anderson
- Centre for Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Silverchain Group, Melbourne, Victoria, Australia
| | - Dion Stub
- Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Centre for Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Kaye
- Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Marasco SF, McLean J, Kure CE, Rix J, Lake T, Linton A, Farag J, Zhu MZL, Doi A, Bergin PJ, Leet AS, Taylor AJ, Hare JL, Patel HC, Kaye D, McGiffin DC. HeartMate 3 implantation with an emphasis on the biventricular configuration. Artif Organs 2024. [PMID: 38459775 DOI: 10.1111/aor.14741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/21/2024] [Accepted: 02/26/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES Right ventricular failure following implantation of a durable left ventricular assist device (LVAD) is a major driver of mortality. Reported survival following biventricular (BiVAD) or total artificial heart (TAH) implantation remains substantially inferior to LVAD alone. We report our outcomes with LVAD and BiVAD HeartMate 3 (HM3). METHODS Consecutive patients undergoing implantation of an HM3 LVAD between November 2014 and December 2021, at The Alfred, Australia were included in the study. Comparison was made between the BiVAD and LVAD alone groups. RESULTS A total of 86 patients, 65 patients with LVAD alone and 21 in a BiVAD configuration underwent implantation. The median age of the LVAD and BiVAD groups was 56 years (Interquartile range 46-62) and 49 years (Interquartile range 37-55), respectively. By 4 years after implantation, 54% of LVAD patients and 43% of BiVAD patients had undergone cardiac transplantation. The incidence of stroke in the entire experience was 3.5% and pump thrombosis 5% (all in the RVAD). There were 14 deaths in the LVAD group and 1 in the BiVAD group. The actuarial survival for LVAD patients at 1 year was 85% and BiVAD patients at 1 year was 95%. CONCLUSIONS The application of HM 3 BiVAD support in selected patients appears to offer a satisfactory solution to patients requiring biventricular support.
Collapse
Affiliation(s)
- Silvana F Marasco
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Janelle McLean
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - Christina E Kure
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julia Rix
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - Tanieka Lake
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - Ashlee Linton
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - James Farag
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
| | - Michael Z L Zhu
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
| | - Atsuo Doi
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
| | - Peter J Bergin
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - Angeline S Leet
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - James L Hare
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Heart Failure Research Laboratory, The Baker Institute, Melbourne, Victoria, Australia
| | - Hitesh C Patel
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, The Alfred, Melbourne, Victoria, Australia
- Heart Failure Research Laboratory, The Baker Institute, Melbourne, Victoria, Australia
| | - David C McGiffin
- Department of Cardiothoracic Surgery and Transplantation, The Alfred, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Doi A, Batchelor R, Demase KC, Manfield JC, Burrell A, Paul E, Marasco SF, Kaye D, McGiffin DC. Impact of postoperative hyperlactatemia in orthotopic heart transplantation. J Cardiol 2024:S0914-5087(24)00012-1. [PMID: 38354768 DOI: 10.1016/j.jjcc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Hyperlactatemia (HL) is a common phenomenon after cardiac surgery which is related to tissue hypoperfusion and hypoxia and associated with poor outcomes. It is also often seen in the postoperative period after orthotopic heart transplantation (OHTx), but the association between HL and outcomes after OHTx is not well known. We evaluated the incidence and outcome of HL after OHTx. METHODS This was a retrospective study of 209 patients who underwent OHTx between January 2011 and December 2020. Patients were classified into 3 groups according to their peak lactate levels within the first 72 h postoperatively: group 1, normal to mild hyperlactatemia (<5 mmol/L, n = 42); group 2, moderate hyperlactatemia (5-10 mmol/L, n = 110); and group 3, severe hyperlactatemia (>10 mmol/L, n = 57). The primary composite endpoint was all-cause mortality or postoperative initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) within 30 days. Secondary endpoints included duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay. RESULTS Patients with higher postoperative peak lactate levels were more commonly transplanted from left ventricular assist device support (33.3 % vs 50.9 % vs 64.9, p < 0.01) and had longer cardiopulmonary bypass time [127 min (109-148) vs 141 min (116-186) vs 153 min (127-182), p = 0.02]. Composite primary endpoint was met in 18 patients (8.6 %) and was significantly more common in patients with higher postoperative peak lactate levels (0.0 % vs 6.4 % vs 19.3 %, p < 0.01). CONCLUSIONS Severe hyperlactatemia following orthotopic heart transplant was associated with an increased risk of post-transplant VA ECMO initiation and mortality at 30 days.
Collapse
Affiliation(s)
- Atsuo Doi
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia.
| | - Riley Batchelor
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Kathryn C Demase
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Jaimi C Manfield
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia
| | - Aidan Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Silvana F Marasco
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - David C McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Australia
| |
Collapse
|
5
|
Dawson LP, Ball J, Wilson A, Voskoboinik A, Nehme Z, Horrigan M, Emerson L, Kaye D, Stub D. Population trends in the incidence and outcomes of atrial fibrillation presentations to emergency departments in Victoria, Australia. Heart Rhythm 2024:S1547-5271(24)00021-3. [PMID: 38219891 DOI: 10.1016/j.hrthm.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Luke P Dawson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Wilson
- Department of Health Services, Safer Care Victoria, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Mark Horrigan
- St Vincent's Health, Melbourne, Victoria, Australia; Austin Health, Melbourne, Victoria, Australia
| | - Lance Emerson
- Department of Health Services, Safer Care Victoria, Melbourne, Victoria, Australia
| | - David Kaye
- The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Markowitz M, Woods B, Schroeder G, Kepler C, Kaye D, Kurd M, Armstrong J, Vaccaro A, Radcliff K. A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study. Int J Spine Surg 2023; 17:828-834. [PMID: 37673683 PMCID: PMC10753327 DOI: 10.14444/8484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. METHODS The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. RESULTS There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). CONCLUSION Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. CLINICAL RELEVANCE In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- Michael Markowitz
- Rowan University School of Osteopathic Medicine Orthopedic Surgery, Stratford, NJ, USA
| | - Barrett Woods
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory Schroeder
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Kepler
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David Kaye
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Kurd
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joshua Armstrong
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Vaccaro
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kris Radcliff
- The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| |
Collapse
|
7
|
Dawson LP, Carrington MJ, Haregu T, Nanayakkara S, Jennings G, Dart A, Stub D, Kaye D. Differences in predictors of incident heart failure according to atherosclerotic cardiovascular disease status. ESC Heart Fail 2023; 10:3398-3409. [PMID: 37688465 PMCID: PMC10682860 DOI: 10.1002/ehf2.14521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/09/2023] [Accepted: 08/18/2023] [Indexed: 09/11/2023] Open
Abstract
AIMS Heart failure (HF) is a common cause of morbidity and mortality, related to a broad range of sociodemographic, lifestyle, cardiometabolic, and comorbidity risk factors, which may differ according to the presence of atherosclerotic cardiovascular disease (ASCVD). We assessed the association between incident HF with baseline status across these domains, overall and separated according to ASCVD status. METHODS AND RESULTS We included 5758 participants from the Baker Biobank cohort without HF at baseline enrolled between January 2000 and December 2011. The primary endpoint was incident HF, defined as hospital admission or HF-related death, determined through linkage with state-wide administrative databases (median follow-up 12.2 years). Regression models were fitted adjusted for sociodemographic variables, alcohol intake, smoking status, measures of adiposity, cardiometabolic profile measures, and individual comorbidities. During 65 987 person-years (median age 59 years, 38% women), incident HF occurred among 784 participants (13.6%) overall. Rates of incident HF were higher among patients with ASCVD (624/1929, 32.4%) compared with those without ASCVD (160/3829, 4.2%). Incident HF was associated with age, socio-economic status, alcohol intake, smoking status, body mass index (BMI), waist circumference, waist-hip ratio, systolic blood pressure (SBP), and low- and high-density lipoprotein cholesterol (LDL-C and HDL-C), with non-linear relationships observed for age, alcohol intake, BMI, waist circumference, waist-hip ratio, SBP, LDL-C, and HDL-C. Risk factors for incident HF were largely consistent regardless of ASCVD status, although diabetes status had a greater association with incident HF among patients without ASCVD. CONCLUSIONS Incident HF is associated with a broad range of baseline sociodemographic, lifestyle, cardiometabolic, and comorbidity factors, which are mostly consistent regardless of ASCVD status. These data could be useful in efforts towards developing risk prediction models that can be used in patients with ASCVD.
Collapse
Affiliation(s)
- Luke P. Dawson
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Melinda J. Carrington
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - Tilahun Haregu
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - Shane Nanayakkara
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - Garry Jennings
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - Anthony Dart
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - Dion Stub
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| | - David Kaye
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
- Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Baker Heart and Diabetes Institute55 Commercial Rd, PrahranMelbourneVictoriaAustralia
| |
Collapse
|
8
|
Trenchfield D, Lee Y, Lambrechts M, D'Antonio N, Heard J, Paulik J, Somers S, Rihn J, Kurd M, Kaye D, Canseco J, Hilibrand A, Vaccaro A, Kepler C, Schroeder G. Correction of Spinal Sagittal Alignment after Posterior Lumbar Decompression: Does Severity of Central Canal Stenosis Matter? Asian Spine J 2023; 17:1089-1097. [PMID: 38050360 PMCID: PMC10764140 DOI: 10.31616/asj.2023.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 12/06/2023] Open
Abstract
STUDY DESIGN This study adopted a retrospective study design. PURPOSE Our study aimed to investigate the impact of central canal stenosis severity on surgical outcomes and lumbar sagittal correction after lumbar decompression. OVERVIEW OF LITERATURE Studies have evaluated sagittal correction in patients with central canal stenosis after lumbar decompression and the association of stenosis severity with worse preoperative sagittal alignment. However, none have evaluated the impact of spinal stenosis severity on sagittal correction. METHODS Patients undergoing posterior lumbar decompression (PLD) of ≤4 levels were divided into severe and non-severe central canal stenosis groups based on the Lee magnetic resonance imaging (MRI) grading system. Patients without preoperative MRI or inadequate visualization on radiographs were excluded. Surgical characteristics, clinical outcomes, and sagittal measurements were compared. Multivariate logistic regression was performed to determine the predictors of pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI-LL). RESULTS Of the 142 patients included, 39 had severe stenosis, and 103 had non-severe stenosis. The mean follow-up duration for the cohort was 4.72 months. Patients with severe stenosis were older, had higher comorbidity indices and levels decompressed, and longer lengths of stay and operative times (p <0.001). Although those with severe stenosis had lower lordosis, lower SS, and higher PI-LL mismatch preoperatively, no differences in Delta LL, SS, PT, or PI-LL were observed between the two groups (p >0.05). On multivariate regression, severe stenosis was a significant predictor of a lower preoperative LL (estimate=-5.243, p =0.045) and a higher preoperative PI-LL mismatch (estimate=6.192, p =0.039). No differences in surgical or clinical outcomes were observed (p >0.05). CONCLUSION Severe central lumbar stenosis was associated with greater spinopelvic mismatch preoperatively. Sagittal balance improved in both patients with severe and non-severe stenosis after PLD to a similar degree, with differences in sagittal parameters remaining after surgery. We also found no differences in postoperative outcomes associated with stenosis severity.
Collapse
Affiliation(s)
- Delano Trenchfield
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Yunsoo Lee
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas D'Antonio
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremy Heard
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sydney Somers
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeffrey Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
9
|
Emmanuel S, Muthiah K, Tardo D, MacDonald P, Hayward C, McGiffin D, Kaye D, Fraser J, Jansz P. Advances in cardiac machine perfusion: Exceeding 8 hours from procurement to implant without requiring extracorporeal membrane oxygenation. J Heart Lung Transplant 2023; 42:1766-1767. [PMID: 37557939 DOI: 10.1016/j.healun.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Sam Emmanuel
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia.
| | - Kavitha Muthiah
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Daniel Tardo
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Peter MacDonald
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Christopher Hayward
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| | - David McGiffin
- The Alfred Hospital, Melbourne, Australia; Critical Care Research Group, Brisbane, Australia
| | - David Kaye
- The Alfred Hospital, Melbourne, Australia
| | - John Fraser
- Critical Care Research Group, Brisbane, Australia
| | - Paul Jansz
- St Vincent's Hospital, Sydney, Australia; School of Medicine, University of New South Wales, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia; Victor Chang Cardiac Research Institute, Sydney, Australia
| |
Collapse
|
10
|
Karamian BA, Canseco JA, Kanhere AP, Minetos PD, Lambrechts MJ, Lee Y, Trenchfield D, Pohl N, Kothari P, Conaway W, Jeyamohan H, Endersby K, Kaye D, Woods BI, Rihn JA, Kurd MF, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Reimbursement of Lumbar Fusion at an Orthopaedic Specialty Hospital Versus Tertiary Referral Center. Clin Spine Surg 2023:01933606-990000000-00237. [PMID: 38031293 DOI: 10.1097/bsd.0000000000001554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/01/2023]
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE To explore the differences in Medicare reimbursement for lumbar fusion performed at an orthopaedic specialty hospital (OSH) and a tertiary referral center and to elucidate drivers of Medicare reimbursement differences. SUMMARY OF BACKGROUND DATA To provide more cost-efficient care, appropriately selected patients are increasingly being transitioned to OSHs for lumbar fusion procedures. There are no studies directly comparing reimbursement of lumbar fusion between tertiary referral centers (TRC) and OSHs. METHODS Reimbursement data for a tertiary referral center and an orthopaedic specialty hospital were compiled through the Centers for Medicare and Medicaid Services. Any patient with lumbar fusions between January 2014 and December 2018 were identified. OSH patients were matched to TRC patients by demographic and surgical variables. Outcomes analyzed were reimbursement data, procedure data, 90-day complications and readmissions, operating room times, and length of stay (LOS). RESULTS A total of 114 patients were included in the final cohort. The tertiary referral center had higher post-trigger ($13,554 vs. $8,541, P<0.001) and total episode ($49,973 vs. $43,512, P<0.010) reimbursements. Lumbar fusion performed at an OSH was predictive of shorter OR time (β=0.77, P<0.001), shorter procedure time (β=0.71, P<0.001), and shorter LOS (β=0.53, P<0.001). There were no significant differences in complications (9.21% vs. 15.8%, P=0.353) or readmission rates (3.95% vs. 7.89%, P=0.374) between the 2 hospitals; however, our study is underpowered for complications and readmissions. CONCLUSION Lumbar fusion performed at an OSH, compared with a tertiary referral center, is associated with significant Medicare cost savings, shorter perioperative times, decreased LOS, and decreased utilization of post-acute resources. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Khoury NM, Cogswell A, Arthur M, Ryan M, MacMaster E, Kaye D. Towards practice change: a qualitative study examining the impact of a Child Psychiatric Access Program (Project TEACH) on Primary Care Provider practices in New York State during pandemic times. BMC Health Serv Res 2023; 23:985. [PMID: 37704980 PMCID: PMC10500716 DOI: 10.1186/s12913-023-09999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND This study aims to explore the perceived impact of Project TEACH (Training and Education for the Advancement of Children's Health), a New York State Office of Mental Health funded Child Psychiatric Access Program (CPAP), on pediatric Primary Care Providers (PCPs) and their practice. Practice change over time was assessed in the context of rising mental health needs and in the context of COVID19 pandemic. METHODS Focus groups utilizing a semi-structured format were conducted with pediatric PCPs who have been high utilizers of Project TEACH over the past 5-10 years and PCPs in similar regions who have been low or non-utilizers of the program. The semi-structured interview focused on practice change, asking about pediatric mental health, practice setting and flow, professional development, and changes over time in the context of COVID-19 pandemic and Project TEACH. RESULTS Themes identified include increasing confidence of PCPs, particularly those who are high utilizers of the phone consultation line, increased routine use of screening and comfort bridging pediatric patients with mental health needs. Challenges include rising mental health needs, inadequate mental health services, difficulties with family follow through and high emotional burden on PCPs caring for these patients. In this context, participants noted that collaboration with Project TEACH provided needed emotional support. CONCLUSIONS Integrated care and CPAPs such as Project TEACH are vital to helping PCPs handle rising mental health needs particularly in current crisis times. Ongoing systemic challenges accessing care remain and contribute to emotional burden placed on pediatric PCPs.
Collapse
Affiliation(s)
- Nayla M Khoury
- Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, 13210, USA.
| | - Alex Cogswell
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo SUNY, Buffalo, USA
| | - Melissa Arthur
- Family Medicine Residency Program, St. Joseph's Hospital Health Center, Trinity Health, Syracuse, USA
| | - Maureen Ryan
- Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Eric MacMaster
- Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - David Kaye
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo SUNY, Buffalo, USA
| |
Collapse
|
12
|
Dawson LP, Andrew E, Nehme Z, Bloom J, Okyere D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Risk-standardized mortality metric to monitor hospital performance for chest pain presentations. Eur Heart J Qual Care Clin Outcomes 2023; 9:583-591. [PMID: 36195327 DOI: 10.1093/ehjqcco/qcac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/10/2022] [Accepted: 09/29/2022] [Indexed: 09/13/2023]
Abstract
AIMS Risk-standardized mortality rates (RSMR) have been used to monitor hospital performance in procedural and disease-based registries, but limitations include the potential to promote risk-averse clinician decisions and a lack of assessment of the whole patient journey. We aimed to determine whether it is feasible to use RSMR at the symptom-level to monitor hospital performance using routinely collected, linked, clinical and administrative data of chest pain presentations. METHODS AND RESULTS We included 192 978 consecutive adult patients (mean age 62 years; 51% female) with acute chest pain without ST-elevation brought via emergency medical services (EMS) to 53 emergency departments in Victoria, Australia (1/1/2015-30/6/2019). From 32 candidate variables, a risk-adjusted logistic regression model for 30-day mortality (C-statistic 0.899) was developed, with excellent calibration in the full cohort and with optimism-adjusted bootstrap internal validation. Annual 30-day RSMR was calculated by dividing each hospital's observed mortality by the expected mortality rate and multiplying it by the annual mean 30-day mortality rate. Hospital performance according to annual 30-day RSMR was lower for outer regional or remote locations and at hospitals without revascularisation capabilities. Hospital rates of angiography or transfer for patients diagnosed with non-ST elevation myocardial infarction (NSTEMI) correlated with annual 30-day RSMR, but no correlations were observed with other existing key performance indicators. CONCLUSION Annual hospital 30-day RSMR can be feasibly calculated at the symptom-level using routinely collected, linked clinical, and administrative data. This outcome-based metric appears to provide additional information for monitoring hospital performance in comparison with existing process of care key performance measures.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Emily Andrew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
| | - Daniel Okyere
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
| | - David Anderson
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Medicine, Monash University, Melbourne, VIC 3800, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Centre for Research & Evaluation, Ambulance Victoria, Melbourne, VIC 3130, Australia
- Department of Paramedicine, Monash University, Melbourne, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3004, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
- Heart Failure Research Group, The Baker Institute, Melbourne, VIC 3004, Australia
| |
Collapse
|
13
|
Dawson LP, Nehme E, Burchill LJ, Nehme Z, O’Brien J, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Chest pain epidemiology and care quality for Aboriginal and Torres Strait Islander peoples in Victoria, Australia: a population-based cohort study from 2015 to 2019. Lancet Reg Health West Pac 2023; 38:100839. [PMID: 37790074 PMCID: PMC10544300 DOI: 10.1016/j.lanwpc.2023.100839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/28/2023] [Accepted: 06/20/2023] [Indexed: 10/05/2023]
Abstract
Background This study examined chest pain epidemiology and care quality for Aboriginal and Torres Strait Islander ('Indigenous') patients presenting to hospital via emergency medical services (EMS) with chest pain. Methods State-wide population-based cohort study of consecutive patients attended by ambulance for acute chest pain with individual linkage to emergency, hospital admission and mortality data in the state of Victoria, Australia from January 2015 to June 2019. Multivariable models were used to assess for differences in pre-hospital and hospital adherence to care quality, process measures and clinical outcomes. Findings From 204,969 EMS attendances for chest pain, 3890 attendances (1.9%) identified as Aboriginal or Torres Strait Islander. Age-standardized incidence rates were higher overall for Indigenous people (3128 vs. 1147 per 100,000 person-years, incidence rate ratio 2.73, 95% CI 2.72-2.74), this difference being particularly striking for younger patients, women, and those residing in outer regional areas. In multivariable models, adherence to care quality and process measures was lower for attendances involving Indigenous people. In the pre-hospital setting, Indigenous people were less likely to be provided intravenous access or analgesia. In the hospital setting, Indigenous people were less likely to be seen by emergency clinicians within target time and less likely to transferred following myocardial infarction to a revascularization capable centre. Interpretation Incidence of acute chest pain presentations is high among Indigenous people in Victoria, Australia. Opportunities to improve the quality of care for Indigenous Australians presenting with acute chest pain are identified. Funding National Health and Medical Research Council, National Heart Foundation.
Collapse
Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Luke J. Burchill
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Aboriginal Cardiovascular Health Equity Research Group, Department of Medicine, The University of Melbourne, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jessica O’Brien
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Shelley Cox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew J. Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| |
Collapse
|
14
|
Ebrahimi BS, Khwaounjoo P, Argus F, Chan HF, Nash MP, McGiffin D, Kaye D, Doi A, Joseph T, Whitford H, Tawhai MH. Predicting Patient Status in Chronic Thromboembolic Pulmonary Hypertension Using a Biophysical Model. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38083065 DOI: 10.1109/embc40787.2023.10340433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) involves abnormally high blood pressure in the pulmonary vessels and is associated with small vessel vasculopathy and pre-capillary proximal occlusions. Management of CTEPH disease is challenging, therefore accurate diagnosis is crucial in ensuring effective treatment and improved patient outcomes. The treatment of choice for CTEPH is pulmonary endarterectomy, which is an invasive surgical intervention to remove thrombi. Following PEA, a number of patients experience poor outcomes or worse-than-expected improvements, which may indicate that they have significant small vessel disease. A method that can predict the extent of distal remodelling may provide useful clinical information to plan appropriate CTEPH patient treatment. Here, a novel biophysical modelling approach has been developed to estimate and quantify the extent of distal remodelling. This method includes a combination of mathematical modelling and computed tomography pulmonary angiography to first model the geometry of the pulmonary arteries and to identify the under-perfused regions in CTEPH. The geometric model is then used alongside haemodynamic measurements from right heart catheterisation to predict distal remodelling. In this study, the method is tested and validated using synthetically generated remodelling data. Then, a preliminary application of this technique to patient data is shown to demonstrate the potential of the approach for use in the clinical setting.Clinical relevance- Patient-specific modelling can help provide useful information regarding the extent of distal vasculopathy on a per-patient basis, which remains challenging. Physicians can be unsure of outcomes following pulmonary endarterectomy. Therefore, the predictive aspect of the patient's response to surgery can help with clinical decision-making.
Collapse
|
15
|
Siegel N, Lambrechts MJ, Karamian BA, Carter M, Magnuson JA, Toci GR, Krueger CA, Canseco JA, Woods BI, Kaye D, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion. Clin Spine Surg 2023; 36:E123-E130. [PMID: 36127771 DOI: 10.1097/bsd.0000000000001386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress. SUMMARY OF BACKGROUND DATA Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs. METHODS A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05. RESULTS A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228). CONCLUSION Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Navani RV, Dawson LP, Nehme E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Variation in Health Care Processes, Quality and Outcomes According to Day and Time of Chest Pain Presentation via Ambulance. Heart Lung Circ 2023:S1443-9506(23)00150-6. [PMID: 37100698 DOI: 10.1016/j.hlc.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous studies examining temporal variations in cardiovascular care have largely been limited to assessing weekend and after-hours effects. We aimed to determine whether more complex temporal variation patterns might exist in chest pain care. METHODS This was a population-based study of consecutive adult patients attended by emergency medical services (EMS) for non-traumatic chest pain without ST elevation in Victoria, Australia between 1 January 2015 and 30 June 2019. Multivariable models were used to assess whether time of day and week stratified into 168 hourly time periods was associated with care processes and outcomes. RESULTS There were 196,365 EMS chest pain attendances; mean age 62.4 years (standard deviation [SD] 18.3) and 51% females. Presentations demonstrated a diurnal pattern, a Monday-Sunday gradient (Monday peak) and a reverse weekend effect (lower rates on weekends). Five temporal patterns were observed for care quality and process measures, including a diurnal pattern (longer emergency department [ED] length of stay), an after-hours pattern (lower angiography or transfer for myocardial infarction, pre-hospital aspirin administration), a weekend effect (shorter ED clinician review, shorter EMS off-load time), an afternoon/evening peak period pattern (longer ED clinician review, longer EMS off-load time) and a Monday-Sunday gradient (ED clinician review, EMS offload time). Risk of 30-day mortality was associated with weekend presentation (Odds ratio [OR] 1.15, p=0.001) and morning presentation (OR 1.17, p<0.001) while risk of 30-day EMS reattendance was associated with peak period (OR 1.16, p<0.001) and weekend presentation (OR 1.07, p<0.001). CONCLUSIONS Chest pain care demonstrates complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs to improve care across all days and times of the week.
Collapse
Affiliation(s)
- Rohan V Navani
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/RohanNavani
| | - Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Emily Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Vic, Australia; Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Vic, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; Department of Paramedicine, Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Ambulance Victoria, Melbourne, Vic, Australia; The Baker Institute, Melbourne, Vic, Australia.
| |
Collapse
|
17
|
Kaye D, Fraser J, Jansz P, MacDonald P, Marasco S, Doi A, Merry C, Emmanuel S, Larbalestier R, Shah A, Geldenhuys A, Sibal A, Wasywich C, Kure C, McGiffin D. Favorable Impact of Hypothermic Machine Perfusion (HMP) on Early Renal Outcomes in Patients Undergoing Heart Transplantation Using Prolonged (6-8 Hour) Donor Hearts. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
18
|
Emmanuel S, MacDonald P, Hayward C, Watson A, Iyer A, Connellan M, Granger E, Herrera C, Kure C, Fraser J, Kaye D, McGiffin D, Jansz P. Initial Australian Experience with the Xvivo Non-Ischaemic Hypothermic Perfusion Device for Heart Preservation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
19
|
Kaye D, Fraser J, Jansz P, MacDonald P, Marasco S, Doi A, Merry C, Emmanuel S, Leet A, Hare J, Cheshire C, Larbalestier R, Shah A, Wasywich C, Mathew J, Sibal A, Kure C, McGiffin D. Influence of Hypothermic Machine Perfusion (HMP) on Donor Heart Function Following an Ischemic Time of 6-8 Hours. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
|
20
|
Ho FC, Zheng WC, Noaman S, Batchelor RJ, Wexler N, Hanson L, Bloom JE, Al-Mukhtar O, Haji K, D'Elia N, Kaye D, Shaw J, Yang Y, French C, Stub D, Cox N, Chan W. Sex differences among patients presenting to hospital with out-of-hospital cardiac arrest and shockable rhythm. Emerg Med Australas 2023; 35:297-305. [PMID: 36344254 DOI: 10.1111/1742-6723.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/29/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Sex differences in patients presenting with out-of-hospital cardiac arrest (OHCA) and shockable rhythm might be associated with disparities in clinical outcomes. METHODS We conducted a retrospective cohort study and compared characteristics and short-term outcomes between male and female adult patients who presented with OHCA and shockable rhythm at two large metropolitan health services in Melbourne, Australia between the period of 2014-2018. Logistic regression was used to assess the effect of sex on clinical outcomes. RESULTS Of 212 patients, 166 (78%) were males and 46 (22%) were females. Both males and females presented with similar rates of ST-elevation myocardial infarction (44% vs 36%, P = 0.29), although males were more likely to have a history of coronary artery disease (32% vs 13%) and a final diagnosis of a cardiac cause for their OHCA (89% vs 72%), both P = 0.01. Rates of coronary angiography (81% vs 71%, P = 0.23) and percutaneous coronary intervention (51% vs 42%, P = 0.37) were comparable among males and females. No differences in rates of in-hospital mortality (38% vs 37%, P = 0.90) and 30-day major adverse cardiac and cerebrovascular events (composite of all-cause mortality, myocardial infarction, coronary revascularization and nonfatal stroke) (39% vs 41%, P = 0.79) were observed between males and females, respectively. Female sex was not associated with worse in-hospital mortality when adjusted for other variables (odds ratio 0.66, 95% confidence interval 0.28-1.60, P = 0.36). CONCLUSION Among patients presenting with OHCA and a shockable rhythm, baseline sex and sex differences were not associated with disparities in short-term outcomes in contemporary systems of care.
Collapse
Affiliation(s)
- Felicia Cs Ho
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Noah Wexler
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Laura Hanson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Nicholas D'Elia
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yang Yang
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Craig French
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
21
|
Dawson L, Nehme E, Nehme Z, Zomer E, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor A, Kaye D, Cullen L, Smith K, Stub D. Healthcare cost burden of acute chest pain presentations. Emerg Med J 2023; 40:437-443. [PMID: 36918268 DOI: 10.1136/emermed-2022-212674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/19/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND This study aimed to estimate the direct healthcare cost burden of acute chest pain attendances presenting to ambulance in Victoria, Australia, and to identify key cost drivers especially among low-risk patients. METHODS State-wide population-based cohort study of consecutive adult patients attended by ambulance for acute chest pain with individual linkage to emergency and hospital admission data in Victoria, Australia (1 January 2015-30 June 2019). Direct healthcare costs, adjusted for inflation to 2020-2021 ($A), were estimated for each component of care using a casemix funding method. RESULTS From 241 627 ambulance attendances for chest pain during the study period, mean chest pain episode cost was $6284, and total annual costs were estimated at $337.4 million ($68 per capita per annum). Total annual costs increased across the period ($310.5 million in 2015 vs $384.5 million in 2019), while mean episode costs remained stable. Cardiovascular conditions (25% of presentations) were the most expensive (mean $11 523, total annual $148.7 million), while a non-specific pain diagnosis (49% of presentations) was the least expensive (mean $3836, total annual $93.4 million). Patients classified as being at low risk of myocardial infarction, mortality or hospital admission (Early Chest pain Admission, Myocardial infarction, and Mortality (ECAMM) score) represented 31%-57% of the cohort, with total annual costs estimated at $60.6 million-$135.4 million, depending on the score cut-off used. CONCLUSIONS Total annual costs for acute chest pain presentations are increasing, and a significant proportion of the cost burden relates to low-risk patients and non-specific pain. These data highlight the need to improve the cost-efficiency of chest pain care pathways.
Collapse
Affiliation(s)
- Luke Dawson
- Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia .,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emily Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Ella Zomer
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - David Anderson
- Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia.,Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, Melbourne Health, Parkville, Victoria, Australia
| | - Andrew Taylor
- Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Dawson LP, Nehme E, Nehme Z, Zomer E, Bloom J, Cox S, Anderson D, Stephenson M, Ball J, Zhou J, Lefkovits J, Taylor AJ, Horrigan M, Chew DP, Kaye D, Cullen L, Mihalopoulos C, Smith K, Stub D. Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment. JAMA Intern Med 2023; 183:203-211. [PMID: 36715993 PMCID: PMC9887542 DOI: 10.1001/jamainternmed.2022.6409] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/28/2022] [Indexed: 01/31/2023]
Abstract
Importance Prehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear. Objective To analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways. Design, Setting, and Participants In this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019. Interventions Paramedic risk stratification and point-of-care troponin testing. Main Outcomes and Measures The outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways. Results A total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations). Conclusions and Relevance Prehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.
Collapse
Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Victoria, Australia
| | - Emily Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Shelley Cox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Zhou
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Victoria, Australia
| | - Andrew J. Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
- Safer Care Victoria, Melbourne, Australia
| | - Derek P. Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Queensland, Australia
| | - Cathrine Mihalopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| |
Collapse
|
23
|
Gustafsson F, Damman K, Nalbantgil S, Van Laake LW, Tops LF, Thum T, Adamopoulos S, Bonios M, Coats AJ, Crespo-Leiro MG, Mehra MR, Filippatos G, Hill L, Metra M, Jankowska E, de Jonge N, Kaye D, Masetti M, Parissis J, Milicic D, Seferovic P, Rosano G, Ben Gal T. Inotropic therapy in patients with advanced heart failure. A clinical consensus statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2023; 25:457-468. [PMID: 36847113 DOI: 10.1002/ejhf.2814] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/01/2023] Open
Abstract
This clinical consensus statement reviews the use of inotropic support in patients with advanced heart failure. The current guidelines only support use of inotropes in the setting of acute decompensated heart failure with evidence of organ malperfusion or shock. However, inotropic support may be reasonable in other patients with advanced heart failure without acute severe decompensation. The clinical evidence supporting use of inotropes in these situations is reviewed. Particularly, patients with persistent congestion, systemic hypoperfusion, or advanced heart failure with need for palliation, and specific situations relevant to implantation of left ventricular assist devices or heart transplantation are discussed. Traditional and novel drugs with inotropic effects are discussed and use of guideline-directed therapy during inotropic support is reviewed. Finally, home inotropic therapy is described, and palliative care and end-of-life aspects are reviewed in relation to management of ongoing inotropic support (including guidance for maintenance and weaning of chronic inotropic therapy support).
Collapse
Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, København, Denmark
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Sanem Nalbantgil
- Cardiology Department, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Linda W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas Thum
- Institute of Molecular and Therapeutic Strategies (IMTTS), Hannover Medical School, and Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | | | | | | | - Maria G Crespo-Leiro
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, Athens University Hospital, Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Ewa Jankowska
- Institute of Heart Diseases, Wroclaw Medical University and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David Kaye
- The Alfred Hospital, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - John Parissis
- Heart Failure Unit and University Clinic of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | | | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
24
|
Defilippi CR, Alemayehu WG, Voors AA, Kaye D, Blaustein RO, Butler J, Ezekowitz JA, Hernandez AF, Lam CSP, Roessig L, Seliger S, Shah P, Westerhout CM, Armstrong PW, O'Connor CM. Assessment of Biomarkers of Myocardial injury, Inflammation, and Renal Function in Heart Failure With Reduced Ejection Fraction: The VICTORIA Biomarker Substudy. J Card Fail 2023; 29:448-458. [PMID: 36634811 DOI: 10.1016/j.cardfail.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Circulating biomarkers may be useful in understanding prognosis and treatment efficacy in heart failure with reduced ejection fraction. In the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial, vericiguat, a soluble guanylate cyclase stimulator, decreased the primary outcome of cardiovascular death or heart failure hospitalization in heart failure with reduced ejection fraction. We evaluated biomarkers of cardiac injury, inflammation, and renal function for associations with outcomes and vericiguat treatment effect. METHODS AND RESULTS High-sensitivity cardiac troponin T (hs-cTnT), growth differentiation factor-15 (GDF-15), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), and cystatin C were measured at baseline and 16 weeks. Associations of biomarkers with the primary outcome and its components were estimated. Interaction with study treatment was tested. Changes in biomarkers over time were examined by study treatment. One or more biomarkers were measured in 4652 (92%) of 5050 participants at baseline and 4063 (81%) at 16 weeks. After adjustment, higher values of hs-cTnT, growth differentiation factor-15, and interleukin-6 were associated with the primary outcome, independent of N-terminal pro-B-type natriuretic peptide. Higher hs-cTnT values were associated with a hazard ratio per log standard deviation of 1.21 (95% confidence interval 1.14-1.27). A treatment interaction with vericiguat was evident with hs-cTnT and cardiovascular death (P = .04), but not HF hospitalization (P = .38). All biomarkers except cystatin C decreased over 16 weeks and no relationship between treatment assignment and changes in biomarker levels was observed. CONCLUSIONS hs-cTnT, growth differentiation factor-15, and interleukin-6 levels were associated with risk of the primary outcome in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction). Uniquely, lower hs-cTnT was associated with a lower rate of cardiovascular death but not HF hospitalization after treatment with vericiguat.
Collapse
Affiliation(s)
| | | | - Adriaan A Voors
- University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - David Kaye
- Baker Heart & Diabetes Institute, Melbourne, Australia
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | - Stephen Seliger
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | |
Collapse
|
25
|
Zheng WC, Noaman S, Batchelor RJ, Hanson L, Bloom JE, Al-Mukhtar O, Haji K, D'Elia N, Ho FCS, Kaye D, Shaw J, Yang Y, French C, Stub D, Cox N, Chan W. Evaluation of factors associated with selection for coronary angiography and in-hospital mortality among patients presenting with out-of-hospital cardiac arrest without ST-segment elevation. Catheter Cardiovasc Interv 2022; 100:1159-1170. [PMID: 36273421 PMCID: PMC10092555 DOI: 10.1002/ccd.30442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/02/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical factors favouring coronary angiography (CA) selection and variables associated with in-hospital mortality among patients presenting with out-of-hospital cardiac arrest (OHCA) without ST-segment elevation (STE) remain unclear. METHODS We evaluated clinical characteristics associated with CA selection and in-hospital mortality in patients with OHCA, shockable rhythm and no STE. RESULTS Between 2014 and 2018, 118 patients with OHCA and shockable rhythm without STE (mean age 59; males 75%) were stratified by whether CA was performed. Of 86 (73%) patients undergoing CA, 30 (35%) received percutaneous coronary intervention (PCI). CA patients had shorter return of spontaneous circulation (ROSC) time (17 vs. 25 min) and were more frequently between 50 and 60 years (29% vs. 6.5%), with initial Glasgow Coma Scale (GCS) score >8 (24% vs. 6%) (all p < 0.05). In-hospital mortality was 33% (n = 39) for overall cohort (CA 27% vs. no-CA 50%, p = 0.02). Compared to late CA, early CA ( ≤ 2 h) was not associated with lower in-hospital mortality (32% vs. 34%, p = 0.82). Predictors of in-hospital mortality included longer defibrillation time (odds ratio 3.07, 95% confidence interval 1.44-6.53 per 5-min increase), lower pH (2.02, 1.33-3.09 per 0.1 decrease), hypoalbuminemia (2.02, 1.03-3.95 per 5 g/L decrease), and baseline renal dysfunction (1.33, 1.02-1.72 per 10 ml/min/1.73 m2 decrease), while PCI to lesion (0.11, 0.01-0.79) and bystander defibrillation (0.06, 0.004-0.80) were protective factors (all p < 0.05). CONCLUSIONS Among patients with OHCA and shockable rhythm without STE, younger age, shorter time to ROSC and GCS >8 were associated with CA selection, while less effective resuscitation, greater burden of comorbidities and absence of treatable coronary lesion were key adverse prognostic predictors.
Collapse
Affiliation(s)
- Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Laura Hanson
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Nicholas D'Elia
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Felicia C S Ho
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yang Yang
- Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Craig French
- Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Research Domain, The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Brown A, Kiriazis H, Tai TY, Parslow A, Johnson C, Jansen S, Tham YK, Cohen C, Vais A, Krippner G, Wang B, Kaye D, Donner D. CD14 inhibition mitigates left ventricular damage and dysfunction following myocardial infarction. J Mol Cell Cardiol 2022. [DOI: 10.1016/j.yjmcc.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
27
|
Lambrechts MJ, Siegel N, Karamian BA, Fredericks DJ, Curran J, Safran J, Canseco JA, Woods BI, Kaye D, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. A Short-Term Assessment of Lumbar Sagittal Alignment Parameters in Patients Undergoing Anterior Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2022; 47:1620-1626. [PMID: 35867592 DOI: 10.1097/brs.0000000000004430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/04/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To determine if intraoperative on-table lumbar lordosis (LL) and segmental lordosis (SL) coincide with perioperative change in lordosis. SUMMARY OF BACKGROUND DATA Improvements in sagittal alignment are believed to correlate with improvements in clinical outcomes. Thus, it is important to establish whether intraoperative radiographs predict postoperative improvements in LL or SL. MATERIALS AND METHODS Electronic medical records were reviewed for patients ≥18 years old who underwent single-level and two-level anterior lumbar interbody fusion with posterior instrumentation between 2016 and 2020. LL, SL, and the lordosis distribution index were compared between preoperative, intraoperative, and postoperative radiographs using paired t tests. A linear regression determined the effect of subsidence on SL and LL. RESULTS A total of 118 patients met inclusion criteria. Of those, 75 patients had one-level fusions and 43 had a two-level fusion. LL significantly increased following on-table positioning [delta (Δ): 5.7°, P <0.001]. However, LL significantly decreased between the intraoperative to postoperative radiographs at two to six weeks (Δ: -3.4°, P =0.001), while no change was identified between the intraoperative and more than three-month postoperative radiographs (Δ: -1.6°, P =0.143). SL was found to significantly increase from the preoperative to intraoperative radiographs (Δ: 10.9°, P <0.001), but it subsequently decreased at the two to six weeks follow up (Δ: -2.7, P <0.001) and at the final follow up (Δ: -4.1, P <0.001). On linear regression, cage subsidence/allograft resorption was predictive of the Δ SL (β=0.55; 95% confidence interval: 0.16-0.94; P =0.006), but not LL (β=0.10; 95% confidence interval: -0.44 to 0.65; P =0.708). CONCLUSION Early postoperative radiographs may not accurately reflect the improvement in LL seen on intraoperative radiographic imaging, but they are predictive of long-term lumbar sagittal alignment. Each millimeter of cage subsidence or allograft resorption reduces SL by 0.55°, but subsidence does not significantly affect LL. LEVELS OF EVIDENCE 4.
Collapse
Affiliation(s)
- Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Dawson LP, Andrew E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Guo Y, Smith K, Stub D. Temperature-related chest pain presentations and future projections with climate change. Sci Total Environ 2022; 848:157716. [PMID: 35914598 DOI: 10.1016/j.scitotenv.2022.157716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/13/2022] [Accepted: 07/26/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Climate change has led to increased interest in studying adverse health effects relating to ambient temperatures. It is unclear whether incident chest pain is associated with non-optimal temperatures and how chest pain presentation rates might be affected by climate change. METHODS The study included ambulance data of chest pain presentations in Melbourne, Australia from 1/1/2015 to 30/6/2019 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the temperature-chest pain presentation associations overall and according to age, sex, socioeconomic status, and event location subgroups, with adjustment for season, day of the week and long-term trend. Future excess chest pain presentations associated with cold and heat were projected under six general circulation models under medium and high emission scenarios. RESULTS In 206,789 chest pain presentations, mean (SD) age was 61.2 (18.9) years and 50.3 % were female. Significant heat- and cold-related increased risk of chest pain presentations were observed for mean air temperatures above and below 20.8 °C, respectively. Excess chest pain presentations related to heat were observed in all subgroups, but appeared to be attenuated for older patients (≥70 years), patients of higher socioeconomic status (SES), and patients developing chest pain at home. We projected increases in heat-related chest pain presentations with climate change under both medium- and high-emission scenarios, which are offset by decreases in chest pain presentations related to cold temperatures. CONCLUSIONS Heat- and cold- exposure appear to increase the risk of chest pain presentations, especially among younger patients and patients of lower SES. This will have important implications with climate change modelling of chest pain, in particular highlighting the importance of risk mitigation strategies to minimise adverse health impacts on hotter days.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Institute, Melbourne, Victoria, Australia
| | - Shelley Cox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Victoria, Australia; Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; The Baker Institute, Melbourne, Victoria, Australia
| | - Yuming Guo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Baker Institute, Melbourne, Victoria, Australia.
| |
Collapse
|
29
|
Dawson L, Andrew E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Guo Y, Smith K, Stub D. Temperature-related chest pain presentations and future projections with climate change. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Climate change has led to increased interest in studying adverse health effects relating to ambient temperatures. It is unclear whether incident chest pain is associated with non-optimal temperatures and how chest pain presentation rates might be affected by climate change.
Methods
The study included ambulance data of chest pain presentations in Melbourne, Australia from 1/1/2015 to 30/6/2019 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the temperature-chest pain presentation associations, after adjusting for season, day of the week and long-term trend. Future excess chest pain presentations associated with cold and heat were projected under six general circulation models under medium and high emission scenarios.
Results
In 206,789 chest pain presentations, mean (SD) age was 61.2 (18.9) years and 50.3% were female. Significant heat- and cold-related increased risk of chest pain presentations were observed for mean air temperatures above and below 20.8°C, respectively (Figure 1). Excess chest pain presentations related to heat were observed in all subgroups, but appeared to be attenuated for older patients (≥70 years) and patients of higher socioeconomic status (SES). We projected no significant change in net temperature-related chest pain presentations with climate change under medium- and high-emission scenarios, with increases in heat-related chest pain presentations offset by decreases in chest pain presentations related to cold temperatures.
Conclusions
Heat- and cold-exposure appear to increase risk of chest pain presentations, especially among younger patients and patients of lower SES. In Melbourne, Australia, chest pain presentations overall were not projected to increase with climate change, but increases in heat-related chest pain presentations highlight the importance of risk mitigation strategies to minimise adverse health impacts on hotter days.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Alfred Health.
Collapse
Affiliation(s)
- L Dawson
- Royal Melbourne Hospital , Melbourne , Australia
| | - E Andrew
- Monash University , Melbourne , Australia
| | - Z Nehme
- Monash University , Melbourne , Australia
| | - J Bloom
- The Alfred Hospital , Melbourne , Australia
| | - S Cox
- Monash University , Melbourne , Australia
| | - D Anderson
- The Alfred Hospital , Melbourne , Australia
| | | | - J Lefkovits
- Royal Melbourne Hospital , Melbourne , Australia
| | - A J Taylor
- The Alfred Hospital , Melbourne , Australia
| | - D Kaye
- The Alfred Hospital , Melbourne , Australia
| | - Y Guo
- Monash University , Melbourne , Australia
| | - K Smith
- Monash University , Melbourne , Australia
| | - D Stub
- The Alfred Hospital , Melbourne , Australia
| |
Collapse
|
30
|
Dawson L, Andrew E, Stephenson M, Nehme Z, Bloom J, Cox S, Anderson D, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Impact of ambulance off-load delays on mortality in patients with chest pain. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Ambulance off-load delays in transferring patient care to emergency departments (EDs) are increasingly common, but it is unclear whether clinical outcomes are impacted.
Methods
Population-based cohort study of ambulance attendances for non-traumatic chest pain transported to ED in Victoria, Australia (1/1/2015–30/6/2019) excluding patients transported to hospital with “lights and sirens” or triaged as ED category 1. Multivariable models were used to assess the relationship between ambulance off-load times and 30-day mortality and ambulance re-attendance for chest pain.
Results
The study included 213,544 ambulance attendances for chest pain (mean age 62 [SD 18] years; 51% female). Median ambulance off-load times increased across the study period from 21 minutes (interquartile range [IQR] 15–30) in 2015 to 24 minutes (IQR 17–37) in 2019. Patients were divided into tertiles according to off-load times with 69,247 patients included in tertile 1 (0–17 minutes), 73,109 patients in tertile 2 (18–28 minutes), and 71,188 patients in tertile 3 (>28 minutes). In multivariable models, ambulance off-load delays were associated with higher unadjusted and adjusted rates of 30-day mortality (1.57% tertile 3 vs. 1.29% tertile 1, adjusted risk difference 0.28% [95% CI 0.16% - 0.42%], p<0.001) and ambulance re-attendance for chest pain (9.89% tertile 3 vs. 8.59% tertile 1, adjusted risk difference 1.30% [95% CI 1.00% - 1.61%], p<0.001). Similarly, in analysis using off-load times as a continuous variable with restricted cubic splines, a non-linear increase in adjusted odds ratio for mortality was observed (Figure 1).
Conclusions
Delays in ambulance off-load times appear to be associated with increased mortality and ambulance re-attendance risk among chest pain cohorts. This study has important policy implications given the increasing frequency of off-load delays in many healthcare settings.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Alfred health
Collapse
Affiliation(s)
- L Dawson
- Royal Melbourne Hospital , Melbourne , Australia
| | - E Andrew
- Monash University , Melbourne , Australia
| | | | - Z Nehme
- Monash University , Melbourne , Australia
| | - J Bloom
- The Alfred Hospital , Melbourne , Australia
| | - S Cox
- Monash University , Melbourne , Australia
| | - D Anderson
- The Alfred Hospital , Melbourne , Australia
| | - J Lefkovits
- Royal Melbourne Hospital , Melbourne , Australia
| | - A J Taylor
- The Alfred Hospital , Melbourne , Australia
| | - D Kaye
- The Alfred Hospital , Melbourne , Australia
| | - K Smith
- Monash University , Melbourne , Australia
| | - D Stub
- The Alfred Hospital , Melbourne , Australia
| |
Collapse
|
31
|
Navani RV, Dawson L, Andrew E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor A, Kaye D, Smith K, Stub D. Variation in health-care quality and outcomes according to time of chest pain presentation: a state-wide prospective cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist.
Purpose
We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes.
Methods
This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality.
Results
The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p<0.001) (Figure 2).
Conclusion
Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- R V Navani
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| | - L Dawson
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| | - E Andrew
- Ambulance Victoria , Melbourne , Australia
| | - Z Nehme
- Ambulance Victoria , Melbourne , Australia
| | - J Bloom
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| | - S Cox
- Ambulance Victoria , Melbourne , Australia
| | - D Anderson
- Ambulance Victoria , Melbourne , Australia
| | | | - J Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University , Melbourne , Australia
| | - A Taylor
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| | - D Kaye
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| | - K Smith
- Ambulance Victoria , Melbourne , Australia
| | - D Stub
- The Alfred Hospital, Department of Cardiology , Melbourne , Australia
| |
Collapse
|
32
|
Dawson LP, Andrew E, Stephenson M, Nehme Z, Bloom J, Cox S, Anderson D, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. The influence of ambulance offload time on 30-day risks of death and re-presentation for patients with chest pain. Med J Aust 2022; 217:253-259. [PMID: 35738570 PMCID: PMC9545565 DOI: 10.5694/mja2.51613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess whether ambulance offload time influences the risks of death or ambulance re-attendance within 30 days of initial emergency department (ED) presentations by adults with non-traumatic chest pain. DESIGN, SETTING Population-based observational cohort study of consecutive presentations by adults with non-traumatic chest pain transported by ambulance to Victorian EDs, 1 January 2015 - 30 June 2019. PARTICIPANTS Adults (18 years or older) with non-traumatic chest pain, excluding patients with ST elevation myocardial infarction (pre-hospital electrocardiography) and those who were transferred between hospitals or not transported to hospital (eg, cardiac arrest or death prior to transport). MAIN OUTCOME MEASURES Primary outcome: 30-day all-cause mortality (Victorian Death Index data). SECONDARY OUTCOME Transport by ambulance with chest pain to ED within 30 days of initial ED presentation. RESULTS We included 213 544 people with chest pain transported by ambulance to EDs (mean age, 62 [SD, 18] years; 109 027 women [51%]). The median offload time increased from 21 (IQR, 15-30) minutes in 2015 to 24 (IQR, 17-37) minutes during the first half of 2019. Three offload time tertiles were defined to include approximately equal patient numbers: tertile 1 (0-17 minutes), tertile 2 (18-28 minutes), and tertile 3 (more than 28 minutes). In multivariable models, 30-day risk of death was greater for patients in tertile 3 than those in tertile 1 (adjusted rates, 1.57% v 1.29%; adjusted risk difference, 0.28 [95% CI, 0.16-0.42] percentage points), as was that of a second ambulance attendance with chest pain (adjusted rates, 9.03% v 8.15%; adjusted risk difference, 0.87 [95% CI, 0.57-1.18] percentage points). CONCLUSIONS Longer ambulance offload times are associated with greater 30-day risks of death and ambulance re-attendance for people presenting to EDs with chest pain. Improving the speed of ambulance-to-ED transfers is urgently required.
Collapse
Affiliation(s)
- Luke P Dawson
- Royal Melbourne HospitalMelbourneVIC
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Ambulance VictoriaMelbourneVIC
| | - Michael Stephenson
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Jason Bloom
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | | | | | - Jeffrey Lefkovits
- Royal Melbourne HospitalMelbourneVIC
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
| | - Andrew J Taylor
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| | - David Kaye
- Monash UniversityMelbourneVIC
- Baker Heart Research Institute (BHRI)MelbourneVIC
| | - Karen Smith
- Ambulance VictoriaMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Dion Stub
- Centre for Research and Evaluation, Ambulance VictoriaMelbourneVIC
- Monash UniversityMelbourneVIC
| |
Collapse
|
33
|
Brennan A, Dinh D, Lefkovits J, Reid C, Stub D, Bloom J, Haji K, Noaman S, Kaye D, Cox N, Nicholas d’Elia. TCT-89 Presenting Electrocardiographic Patterns and Outcomes in Acute Coronary Syndrome–related Cardiogenic Shock—A Propensity Score Analysis. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
34
|
Warren J, Cheshire C, Gutman S, Hare J, Taylor A, Patel H, Bergin P, Zimmet A, Marasco S, Kaye D, Leet A. Spontaneous Coronary Artery Dissection in an Orthotopic Heart Transplant Recipient. JACC Case Rep 2022; 4:977-981. [PMID: 35935148 PMCID: PMC9350898 DOI: 10.1016/j.jaccas.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/18/2022]
Abstract
We present the case of acute myocardial infarction secondary to spontaneous coronary artery dissection in a patient 2 weeks post orthotopic heart transplantation. (Level of Difficulty: Advanced.)
Collapse
Affiliation(s)
| | | | - Sarah Gutman
- Department of Cardiology Alfred Hospital, Melbourne, Australia
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - James Hare
- Department of Cardiology Alfred Hospital, Melbourne, Australia
| | - Andrew Taylor
- Department of Cardiology Alfred Hospital, Melbourne, Australia
| | - Hitesh Patel
- Department of Cardiology Alfred Hospital, Melbourne, Australia
| | - Peter Bergin
- Department of Cardiology Alfred Hospital, Melbourne, Australia
| | - Adam Zimmet
- Department of Cardiothoracic Surgery Alfred Hospital, Melbourne, Australia
| | - Silvana Marasco
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
- Department of Cardiothoracic Surgery Alfred Hospital, Melbourne, Australia
| | - David Kaye
- Department of Cardiology Alfred Hospital, Melbourne, Australia
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Angeline Leet
- Department of Cardiology Alfred Hospital, Melbourne, Australia
- Address for correspondence: Dr Angeline Leet, Heart Centre, Alfred Hospital, Melbourne, Victoria 3004, Australia. @drjosiewarren
| |
Collapse
|
35
|
Dawson LP, Andrew E, Nehme Z, Bloom J, Liew D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Cullen L, Smith K, Stub D. Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain. Int J Cardiol Heart Vasc 2022; 40:101043. [PMID: 35514876 PMCID: PMC9062672 DOI: 10.1016/j.ijcha.2022.101043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 11/22/2022]
Abstract
Aims Existing risk scores for undifferentiated chest pain focus on excluding coronary events and do not represent a comprehensive risk assessment if an alternate serious diagnosis is present. This study aimed to develop and validate an all-inclusive risk prediction model among patients with undifferentiated chest pain. Methods We developed and validated a multivariable logistic regression model for a composite measure of early all-inclusive risk (defined as hospital admission excluding a discharge diagnosis of non-specific pain, 30-day all-cause mortality, or 30-day myocardial infarction [MI]) among adults assessed by emergency medical services (EMS) for non-traumatic chest pain using a large population-based cohort (January 2015 to June 2019). The cohort was randomly divided into development (146,507 patients [70%]) and validation (62,788 patients [30%]) cohorts. Results The composite outcome occurred in 28.4%, comprising hospital admission in 27.7%, mortality within 30-days in 1.8%, and MI within 30-days in 0.4%. The Early Chest pain Admission, MI, and Mortality (ECAMM) risk model was developed, demonstrating good discrimination in the development (C-statistic 0.775, 95% CI 0.772-0.777) and validation cohorts (C-statistic 0.765, 95% CI 0.761-0.769) with excellent calibration. Discriminatory performance for the composite outcome and individual components was higher than existing scores commonly used in undifferentiated chest pain risk stratification. Conclusions The ECAMM risk score model can be used as an all-inclusive risk stratification assessment of patients with non-traumatic chest pain without the limitation of a single diagnostic outcome. This model could be clinically useful to help guide decisions surrounding the need for non-coronary investigations and safety of early discharge.
Collapse
Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Andrew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - David Anderson
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew J. Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Victoria, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| |
Collapse
|
36
|
Zheng WC, Noaman S, Batchelor RJ, Hanson L, Bloom J, Kaye D, Duffy SJ, Walton A, Pellegrino V, Shaw J, Yang Y, French C, Stub D, Cox N, Chan W. Determinants of Undertaking Coronary Angiography and Adverse Prognostic Predictors Among Patients Presenting With Out-of-Hospital Cardiac Arrest and a Shockable Rhythm. Am J Cardiol 2022; 171:75-83. [PMID: 35296378 DOI: 10.1016/j.amjcard.2022.01.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/22/2022]
Abstract
Characteristics of patients presenting with out-of-hospital cardiac arrest (OHCA) selected for coronary angiography (CA) and factors predicting in-hospital mortality remain unclear. We assessed clinical characteristics associated with undertaking CA in patients presenting with OHCA and shockable rhythm (CA group). Predictors of in-hospital mortality were evaluated with multivariable analysis. Of 1,552 patients presenting with cardiac arrest between 2014 and 2018 to 2 health services in Victoria, Australia, 213 patients with OHCA and shockable rhythm were stratified according to CA status. The CA group had shorter cardiopulmonary resuscitation duration (17 vs 25 minutes) and time to return of spontaneous circulation (17 vs 26 minutes) but higher proportion of ST-elevation on electrocardiogram (48% vs 24%) (all p <0.01). In-hospital mortality was 38% (n = 81) for the overall cohort, 32% (n = 54) in the CA group, and 61% (n = 27) in the no-CA group. Predictors of in-hospital mortality included non-selection for CA (odds ratio 4.5, 95% confidence interval 1.5 to 14), adrenaline support (3.9, 1.3 to 12), arrest at home (2.7, 1.1 to 6.6), longer time to defibrillation (2.5, 1.5 to 4.2 per 5-minute increase), lower blood pH (2.1, 1.4 to 3.2 per 0.1 decrease), lower albumin (2.0, 1.2 to 3.3 per 5 g/L decrease), higher Acute Physiology and Chronic Health Evaluation II score (1.7, 1.0 to 3.0 per 5-point increase), and advanced age (1.4, 1.0 to 2.0 per 10-year increase) (all p ≤0.05). In conclusion, non-selection for CA, concomitant cardiogenic shock requiring inotropic support, poor initial resuscitation (arrest at home, longer time to defibrillation and lower pH), greater burden of co-morbidities (higher Acute Physiology and Chronic Health Evaluation II score and lower albumin), and advanced age were key adverse prognostic indicators among patients with OHCA and shockable rhythm.
Collapse
|
37
|
Dawson LP, Andrew E, Nehme Z, Bloom J, Okyere D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Incidence, diagnoses and outcomes of ambulance attendances for chest pain: A population-based cohort study. Ann Epidemiol 2022; 72:32-39. [PMID: 35513303 DOI: 10.1016/j.annepidem.2022.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 01/09/2023]
Abstract
AIMS Non-traumatic chest pain is one of the most common reasons for calls for emergency assistance and places a significant burden on health services. This study aimed to determine age- and sex-specific incidences, diagnoses, and outcomes of patients with chest pain attended by paramedics using a large population-based sample. METHODS Consecutive emergency medical services (EMS) attendances for non-traumatic chest pain in Victoria, Australia from January 2015 to June 2019 were included. Data were individually linked to emergency, hospital admission and mortality records. RESULTS During the study period (representing 22,186,930 person-years), chest pain was the reason for contacting EMS in 257,017 of 2,736,570 attendances (9.4%). Overall incidence of chest pain attendances was 1,158 (per 100,000 person-years) with a higher incidence observed with increasing age, among females, among Aboriginal and Torres Strait Islanders, in regional settings, and in socially disadvantaged areas. The most common diagnoses were non-specific pain (46%; 30-day mortality 0.5%), non-ST elevation myocardial infarction (5.3%; mortality 1.3%), pneumonia (3.8%; mortality 3.9%), stable coronary syndromes (3.5%; mortality 0.8%), unstable angina (3.3%; mortality 1.3%), and ST-elevation myocardial infarction (2.8%; mortality 7.0%), while pulmonary embolism (0.7%; mortality 3.2%) and aortic pathologies (0.2%; mortality 22.2%) were rare. CONCLUSIONS Chest pain accounts for one in ten ambulance calls, and underlying causes are diverse, with substantial differences according to age and sex. Almost half of patients are discharged from hospital with a diagnosis of non-specific pain and low rates of mortality.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Andrew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Cardiology and Therapeutics Division, The Baker Institute, Melbourne, Victoria, Australia
| | - Daniel Okyere
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - David Anderson
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Cardiology and Therapeutics Division, The Baker Institute, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Cardiology and Therapeutics Division, The Baker Institute, Melbourne, Victoria, Australia.
| |
Collapse
|
38
|
Karamian BA, Mangan J, Siegel N, Lambrechts MJ, Sirch F, Trivedi A, Toci G, D'Antonio ND, Canseco JA, Kaye D, Woods B, Radcliff K, Kurd M, Rihn J, Hilibrand A, Kepler CK, Vaccaro AR, Schroeder G. Workers' Compensation Status and Outcomes Following Lumbar Surgery. World Neurosurg 2022; 161:e730-e739. [PMID: 35231623 DOI: 10.1016/j.wneu.2022.02.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the influence of preoperative workers' compensation (WC) status on patient-reported outcome measures following lumbar decompression with or without fusion. METHODS All patients undergoing lumbar decompression with or without fusion at a single academic institution between 2013 and 2017 were identified. Patients were split into groups based on WC status: no workers' compensation (NWC), WC), or retired. Intragroup analysis used paired t tests. Outcomes between groups were compared using Kruskal-Wallis H test. Multiple linear regression analysis determined if WC status was a predictor of change in patient-reported outcome measures. Subgroup analysis was conducted for WC patients who returned to work. RESULTS Of 571 included patients, 242 (43.4%) had NWC, 83 (14.5%) had WC, and 246 (43.1%) were retired. Comparing within groups, WC patients showed significant improvement in Short Form-12 Health Survey Physical Component Score, Oswestry Disability Index, visual analog scale (VAS) back pain, and VAS leg pain (all P < 0.001) after surgery. However, WC patients improved less than NWC or retired patients in Short Form-12 Health Survey Physical Component Score (P = 0.010), VAS back pain (P = 0.028), and VAS leg pain (P = 0.015). WC was an independent predictor of decreased improvement in Short Form-12 Health Survey Physical Component Score (β = -4.31, P = 0.001), VAS back pain (β = 0.90, P = 0.034), and VAS leg pain (β = 1.50, P = 0.002) on multivariate analysis. WC patients who did not return to work was an independent predictor of decreased improvement in VAS back pain (β = 1.39, P = 0.016) and VAS leg pain (β = 2.11, P = 0.001). CONCLUSIONS WC patients improve less than NWC patients. However, WC patients who return to work have similar VAS back and neck pain improvements as NWC patients.
Collapse
Affiliation(s)
- Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - John Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Francis Sirch
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amol Trivedi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory Toci
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Kaye
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Barrett Woods
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kris Radcliff
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mark Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jeffrey Rihn
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
39
|
Noaman S, Vogrin S, Dinh D, Lefkovits J, Brennan AL, Reid CM, Walton A, Kaye D, Bloom JE, Stub D, Yang Y, French C, Duffy SJ, Cox N, Chan W. Percutaneous Coronary Intervention Volume and Cardiac Surgery Availability Effect on Acute Coronary Syndrome-Related Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:876-886. [PMID: 35450687 DOI: 10.1016/j.jcin.2022.01.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study sought to assess the association between cardiac surgery availability and percutaneous coronary intervention (PCI) volume with clinical outcomes of cardiogenic shock (CS) complicating acute coronary syndrome (ACS). BACKGROUND CS remains a grave complication of ACS with high mortality rates despite timely reperfusion and improved heart failure therapies. METHODS The study analyzed data from consecutive patients with CS complicating ACS who underwent PCI and were prospectively enrolled in the VCOR (Victorian Cardiac Outcomes Registry) from 26 hospitals in Victoria. We compared patients treated at cardiac surgical centers (CSCs) versus non-CSCs as well as the annual CS PCI volume (stratified into tiers of <10, 10-25, and >25 cases) for in-hospital major adverse cardiac and cerebrovascular events (MACCE) and long-term mortality. RESULTS Of 1,179 patients with CS, the mean age of patients was 65 years; males comprised 74%, and 22% had diabetes mellitus. Cardiac arrest occurred in 38% of patients, while 90% presented with ST-segment elevation myocardial infarction and 26% received intra-aortic balloon pump support. Overall, in-hospital and long-term mortality were 42% and 51%, respectively. There was no difference among patients treated non-CSCs compared with a CSCs for in-hospital MACCE and mortality (both P > 0.05). Similarly, there was no association between tiers of annual CS PCI volume with in-hospital MACCE and mortality (both P > 0.05). CONCLUSIONS Comparable short- and long-term mortality rates among patients with ACS complicated by CS treated by PCI irrespective of cardiac surgery availability and CS PCI volume support the emergent treatment of these gravely ill patients at their presenting PCI-capable hospital.
Collapse
Affiliation(s)
- Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yang Yang
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
| | | |
Collapse
|
40
|
Dawson LP, Andrew E, Nehme Z, Bloom J, Biswas S, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Association of Socioeconomic Status With Outcomes and Care Quality in Patients Presenting With Undifferentiated Chest Pain in the Setting of Universal Health Care Coverage. J Am Heart Assoc 2022; 11:e024923. [PMID: 35322681 PMCID: PMC9075482 DOI: 10.1161/jaha.121.024923] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study aimed to assess whether there are disparities in incidence rates, care, and outcomes for patients with chest pain attended by emergency medical services according to socioeconomic status (SES) in a universal health coverage setting. METHODS AND RESULTS This was a population‐based cohort study of individually linked ambulance, emergency, hospital admission, and mortality data in the state of Victoria, Australia, from January 2015 to June 2019 that included 183 232 consecutive emergency medical services attendances for adults with nontraumatic chest pain (mean age 62 [SD 18] years; 51% women) and excluded out‐of‐hospital cardiac arrest and ST‐segment–elevation myocardial infarction. Age‐standardized incidence of chest pain was higher for patients residing in lower SES areas (lowest SES quintile 1595 versus highest SES quintile 760 per 100 000 person‐years; P<0.001). Patients of lower SES were less likely to attend metropolitan, private, or revascularization‐capable hospitals and had greater comorbidities. In multivariable models adjusted for clinical characteristics and final diagnosis, lower SES quintiles were associated with increased risks of 30‐day and long‐term mortality, readmission for chest pain and acute coronary syndrome, lower acuity emergency department triage categorization, emergency department length of stay >4 hours, and emergency department or emergency medical services discharge without hospital admission and were inversely associated with use of prehospital ECGs and transfer to a revascularization‐capable hospital for patients presenting to non‐percutaneous coronary intervention centers. CONCLUSIONS In this study, lower SES was associated with a higher incidence of chest pain presentations to emergency medical services and differences in care and outcomes. These findings suggest that substantial disparities for socioeconomically disadvantaged chest pain cohorts exist, even in the setting of universal health care access.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology The Alfred Hospital Melbourne Victoria Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Department of Cardiology The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Emily Andrew
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Ambulance Victoria Melbourne Victoria Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Ambulance Victoria Melbourne Victoria Australia.,Department of Paramedicine Monash University Melbourne Victoria Australia
| | - Jason Bloom
- Department of Cardiology The Alfred Hospital Melbourne Victoria Australia.,The Baker Institute Melbourne Victoria Australia
| | - Sinjini Biswas
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Shelley Cox
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Ambulance Victoria Melbourne Victoria Australia
| | - David Anderson
- Ambulance Victoria Melbourne Victoria Australia.,Department of Intensive Care Medicine The Alfred Hospital Melbourne Victoria Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Ambulance Victoria Melbourne Victoria Australia.,Department of Paramedicine Monash University Melbourne Victoria Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Department of Cardiology The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Andrew J Taylor
- Department of Cardiology The Alfred Hospital Melbourne Victoria Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Department of Medicine Monash University Melbourne Victoria Australia
| | - David Kaye
- Department of Cardiology The Alfred Hospital Melbourne Victoria Australia.,The Baker Institute Melbourne Victoria Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,Ambulance Victoria Melbourne Victoria Australia.,Department of Paramedicine Monash University Melbourne Victoria Australia
| | - Dion Stub
- Department of Cardiology The Alfred Hospital Melbourne Victoria Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia.,The Baker Institute Melbourne Victoria Australia
| |
Collapse
|
41
|
Vatani A, Liao S, Burrell AJC, Carberry J, Azimi M, Steinseifer U, Arens J, Soria J, Pellegrino V, Kaye D, Gregory SD. Improved Drainage Cannula Design to Reduce Thrombosis in Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:205-213. [PMID: 33883503 DOI: 10.1097/mat.0000000000001440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Thrombosis is a potentially life-threatening complication in veno-arterial extracorporeal membrane oxygenation (ECMO) circuits, which may originate from the drainage cannula due to unfavorable blood flow dynamics. This study aims to numerically investigate the effect of cannula design parameters on local fluid dynamics, and thus thrombosis potential, within ECMO drainage cannulas. A control cannula based on the geometry of a 17 Fr Medtronic drainage cannula concentrically placed in an idealized, rigid-walled geometry of the right atrium and superior and inferior vena cava was numerically modeled. Simulated flow dynamics in the control cannula were systematically compared with 10 unique cannula designs which incorporated changes to side hole diameter, the spacing between side holes, and side hole angles. Local blood velocities, maximum wall shear stress (WSS), and blood residence time were used to predict the risk of thrombosis. Numerical results were experimentally validated using particle image velocimetry. The control cannula exhibited low blood velocities (59 mm/s) at the cannula tip, which may promote thrombosis. Through a reduction in the side hole diameter (2 mm), the spacing between the side holes (3 mm) and alteration in the side hole angle (30° relative to the flow direction), WSS was reduced by 52%, and cannula tip blood velocity was increased by 560% compared to the control cannula. This study suggests that simple geometrical changes can significantly alter the risk of thrombosis in ECMO drainage cannulas.
Collapse
Affiliation(s)
- Ashkan Vatani
- From the Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Cardio-Respiratory Engineering and Technology Laboratory (CREATELab), Monash University, Clayton, VIC, Australia
| | - Sam Liao
- From the Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Cardio-Respiratory Engineering and Technology Laboratory (CREATELab), Monash University, Clayton, VIC, Australia
| | - Aidan J C Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Josie Carberry
- From the Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
| | - Marjan Azimi
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Cardio-Respiratory Engineering and Technology Laboratory (CREATELab), Monash University, Clayton, VIC, Australia
| | - Ulrich Steinseifer
- From the Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Germany
- Chair of Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, The Netherlands
| | - Julio Soria
- Laboratory for Turbulence Research in Aerospace and Combustion ( LTRAC ), Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - David Kaye
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- The Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Shaun D Gregory
- From the Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Cardio-Respiratory Engineering and Technology Laboratory (CREATELab), Monash University, Clayton, VIC, Australia
| |
Collapse
|
42
|
Doi A, Gajera J, Niewodowski D, Gangahanumaiah S, Whitford H, Snell G, Kaye D, Joseph T, McGiffin D. Surgical management of giant pulmonary artery aneurysms in patients with severe pulmonary arterial hypertension. J Card Surg 2022; 37:1019-1025. [PMID: 35040512 DOI: 10.1111/jocs.16235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/23/2021] [Accepted: 12/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIM Giant aneurysm of the pulmonary artery (PAA) is an extremely rare condition that may develop in patients with pulmonary arterial hypertension (PAH) which may be complicated by rupture, dissection or intravascular thrombus formation. The aim of this study was to examine available literature with regard to surgical strategies in patients undergoing transplantation for PAH with PAA. RESULTS These patients were traditionally considered for heart-lung transplantation but more recently, there have been reports of successful lung transplantation with reconstruction of the pulmonary artery. CONCLUSIONS Unless there is a mandatory indication for heart-lung transplantation, patients with PAH and PAA can undergo lung transplantation and reconstruction of the pulmonary artery without compromising the outcome.
Collapse
Affiliation(s)
- Atsuo Doi
- Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Australia
| | - Jay Gajera
- Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Australia
| | | | | | - Helen Whitford
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
| | - Greg Snell
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, Alfred Health, Melbourne, Australia
| |
Collapse
|
43
|
Zheng W, Dinh D, Noaman S, Bloom J, Lefkovits J, Brennan A, Reid C, Al-Mukhtar O, Shaw J, Yang Y, Stub D, Kaye D, Cox N, Chan W. Effect of Concomitant Cardiac Arrest on Outcomes in Patients With Cardiogenic Shock Secondary to Acute Coronary Syndrome (ACS). Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
44
|
Noaman S, Kaye D, Nanayakkara S, Dart A, Yong A, Ng M, Vizi D, Duffy S, Cox N, Chan W. Haemodynamic and Metabolic Adaptations in Coronary Microvascular Disease (CMD). Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
45
|
Nan Tie E, Batchelor R, Romero L, Hopper I, Kaye D. Futility or Utility? Medical Management of NYHA IV Class Heart Failure With Reduced Ejection Fraction – A Systematic Review and Meta-Analysis. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Al-Mukhtar O, Peter K, Gooley R, Farouque O, Van Gaal W, Hiew C, Layland J, Oqueli E, Lefkovits J, Brennan A, Reid C, Walton A, Stub D, Kaye D, Lo S, Cox N, Chan W. Contemporary Practice of Heparin Prescription and Its Monitoring via Activated Clotting Time in Percutaneous Coronary Intervention in Victoria, Australia. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
47
|
Jumaah H, Kistler P, Mariani J, Patel H, Hare J, Kaye D, Taylor A, Voskoboinik A. Cardiac MRI Findings in Patients presenting With Advanced Conduction System Disease. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
48
|
Navani R, Dawson L, Andrew E, Nehme Z, Bloom J, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor A, Kaye D, Smith K, Stub D. Variation in Health-Care Quality and Outcomes According to Time of Chest Pain Presentation: A State-Wide Prospective Cohort Study. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Chieng D, Canovas R, Segan L, Sugumar H, Voskoboinik A, Prabhu S, Ling L, Lee G, Morton J, Kaye D, Kalman J, Kistler P. Effects of Habitual Coffee Consumption on Incident Cardiovascular Disease, Arrhythmia, and Mortality: Long Term Outcomes From the UK Biobank. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
50
|
Liu R, Koay Y, Kaye D, O’Sullivan J, Lal S. Male and Female Heart Failure With Preserved Ejection Fraction (HFpEF): An Insight Into the Differential Metabolic, Hypertensive, Exercise and Ketone Parameters. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|