Ascertainment of aortic valve disease using administrative claims

Background

Administrative claims may be useful for characterizing patients with aortic stenosis (AS) and aortic regurgitation (AR) and estimating disease prevalence. However, the accuracy of diagnostic codes for aortic valve disease has not been well studied.

Purpose

To evaluate the validity of International Classification of Diseases, 10th Revision (ICD-10) codes for identification of AS and AR.

Methods

Using a large, transthoracic echocardiographic (TTE) report dataset linked to Medicare Fee-for-service (FFS) claims, 2017–2018, the performance of candidate claims to ascertain AS/AR status using standard TTE definitions was evaluated. Recursive partitioning with 10-fold cross validation was used to build the optimal prediction tree for AS/AR status using all ICD-10 codes as candidate predictors. The optimal performing claims algorithm was tested against patient outcomes in a separate 100% sample of Medicare FFS inpatient and outpatient claims, 2017–2019.

Results

Of those included in the derivation dataset (N=5497, mean age 74.4±11.0 years, 49.7% female), any AS or AR was present in 24% and 38.8%, respectively. The code I35.0 was optimal for identification of any AS with a sensitivity and specificity for any AS of 53.1% and 94.8%, respectively (Table 1). Amongst those with an I35.0 code, 40.3% had severe AS. Claims were unable to distinguish disease severity (i.e. severe vs. non-severe) or subtypes (e.g. bicuspid or rheumatic AS), and were insensitive and nonspecific for AR of any severity. Among all Medicare beneficiaries who received an TTE (N=3,783,249), those with an I35.0 code, compared to those without, had a higher risk of all-cause mortality (HR 1.65, 95% CI 1.63–1.67), heart failure hospitalization (HR 2.17, 95% CI 2.11–2.24), and aortic valve replacement (HR 32.35, 95% CI 31.46–33.27) (Table 2).

Conclusions

Amongst those receiving TTE, the ICD-10 code I35.0 in any position was optimal for identification of AS and identified a population at significant greater risk of all-cause mortality, heart failure hospitalization, and receipt of aortic valve replacement. Though 40.3% of those with I35.0 had severe AS, claims were unable to distinguish disease severity of subtype. Claims may be feasibly used to identify those with AS who may be at risk for adverse valve-related cardiovascular events and require future treatment.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National, Heart, Lung, and Blood Institute

Stellate ganglion blockade-techniques and modalities

Stellate ganglion block (SGB) is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in upper extremity, head and neck. The stellate ganglion lies medial to the scalene muscles, lateral to longus coli muscle, esophagus, trachea and recurrent laryngeal nerve, anterior to C7 transverse process and prevertebral fascia, superior to the subclavian artery and posterior to vertebral vessels. Consequently, inadvertent placement of the needle tip into these soft tissues and vessels occur with blind technique. Henceforth, various interventional modalities are being used for SGB, these have been reviewed in this paper. Various techniques of SGB have been described, and vary from the use of standard blind technique to the use of fluoroscopy, computerized tomography, magnetic resonance imaging, and radio nucleotide tracers. However, these techniques may not be practical in a clinical setting, insofar as they are time consuming, costly, and may involve radiation exposure. The use of fluoroscopy does not visualize the blood vessels close to the stellate ganglion. Ultrasounds are the alternative. They help in visualization of soft tissues to prevent complications and help in deposition of drug subfascially, under direct visual control.

Denture mimicking vocal cords--a rare entity. A case report

Laryngeal foreign bodies are not uncommon. A common difficulty encountered is a delay in diagnosis. The clinical features of a laryngeal foreign body may simulate asthma in an adult. The differentiation is necessary in the initial stages as the laryngeal foreign body can lead to sudden death due to airway obstruction. Sudden onset of wheeze in a non-asthmatic patient should arouse its suspicion. A case is reported where patient was transferred to respiratory intensive care unit for respiratory distress with wheeze which was later diagnosed as foreign body larynx.

The Impact of Protocolized Communication during Cardiac Surgery

Background: Communication breakdowns are a common cause of adverse events in high consequence industries. It has become increasingly evident that within healthcare systems that poor communication is the causal factor of a large percentage of sentinel events. Methods: All communication exchanges between surgeon and perfusionist were monitored via observation for 18 cardiovascular surgery cases. Breakdowns were analyzed by stage and type of breakdown and a communication protocol designed based on the breakdowns. The protocol was then implemented, and use of the protocol was then monitored for 16 cardiovascular surgery cases. Results: Breakdowns decreased at each stage of cardiovascular surgery. Specific types of breakdowns decreased dramatically, most by more than half. Conclusions: This study shows that protocolizing communication can have a profound impact on communication breakdowns in the cardiovascular surgery operating theatre.

Branchio-oto-renal syndrome

Branchio-oto-renal syndrome (Melnick-Fraser syndrome) is a rare autosomal dominant disorder characterized by syndromic association of branchial cysts or fistulae along with external, middle & inner ear malformations and renal anomalies. Authors are reporting a 19 year male patient, who presented with profound deafness & low set "lop-ear" with right sided preauricular pit. USG abdomen revealed agenesis of the left kidney.