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Cureus May 2024Introduction The coronavirus disease 2019 (COVID-19) pandemic has impacted the lives of thousands of patients worldwide with many patients having residual symptoms...
Introduction The coronavirus disease 2019 (COVID-19) pandemic has impacted the lives of thousands of patients worldwide with many patients having residual symptoms months after the acute infection. The severity of lung involvement ranges from mild asymptomatic to severe acute respiratory distress syndrome (ARDS), which may lead to pulmonary fibrosis. Pulmonary fibrosis increases the long-term morbidity of post-COVID-19 patients in the form of restrictive lung disease. The six-minute walk test (6MWT), Borg scale, and spirometry are simple and low-cost tests used to evaluate a patient's exercise capacity and functional status. This study was conducted to assess the residual symptoms and functional status using spirometry and 6MWT in COVID-19 patients of moderate to severe category after three months of discharge. Methods This was an observational, prospective, and cross-sectional study conducted at a tertiary care center in North India, aiming to enroll a minimum of 50 patients who recovered from COVID-19 pneumonia. These patients were previously hospitalized with moderate to severe disease severity as defined by the Indian Council of Medical Research (ICMR) criteria, and the assessment occurred at least three months after their discharge. Individuals who were under 18 years of age or pregnant or had any respiratory or cardiac illness in the past were excluded from the study. Results A total of 50 patients were included in the study for final analysis. After a three-month follow-up, 40 (80%) patients were still symptomatic. The most commonly reported symptom was exertional dyspnea in 21 (42%), dyspnea at rest in 16 (32%), and fatigue in three (6%) patients. Of the total patients, 37 (74%) covered a distance less than expected in the six-minute walk test. The mean distance covered by patients was 426.1 ± 115.01 m, in contrast to the expected mean distance of 537.22 ± 37.61 m according to standard equations for Indian males and females. A fall in oxygen saturation by more than or equal to 3% was observed in approximately 24 (48%) patients after the six-minute walk test. The mean value of fatigue and dyspnea score was 3.2 ± 1.7 (moderate score). Among patients with moderate disease during their hospital stay, a higher proportion exhibited a normal pattern on pulmonary function tests (PFT) compared to those severely affected, 23 (69.70%) versus two (11.76%), respectively. Conclusion The persistence of symptoms and functional limitation of activities should be anticipated in patients with COVID-19. Spirometry and 6MWT can be a valuable tool in determining the prevalence of functional limitation in recovered patients of COVID-19. It can potentially help in determining and further planning the rehabilitative measures in the management of COVID-19 survivors. It can also be concluded that it is important to have a long-term follow-up in patients with moderate to severe COVID-19.
PubMed: 38939290
DOI: 10.7759/cureus.61221 -
Cureus May 2024Prolonged hospital stays can significantly impede patients' recovery, negatively affecting anything from physical health via issues like hospital-acquired infections and... (Review)
Review
Prolonged hospital stays can significantly impede patients' recovery, negatively affecting anything from physical health via issues like hospital-acquired infections and increased complications due to immobility to psychological health. Several studies investigated the psychosocial impact of prolonged hospital stays, revealing a variety of patient perspectives, such as feeling uncertain and frustrated about their conditions, which can erode their trust in healthcare providers. Delayed discharges not only affect patients but also have multifaceted effects on healthcare providers, potentially reducing physician efficiency and contributing to higher rates of burnout among healthcare professionals. This article investigates the consequences of delayed versus early discharge on physicians, patients, and the overall hospital system. We conducted an extensive search through PubMed and Google Scholar using the keywords "delayed discharge," "hospital discharge," and "bed blocking" to identify all the recent studies highlighting the dynamics of patient discharge. Our results support the hypothesis that reducing delayed discharge rates will not only improve patient outcomes but also have widespread fiscal impacts. This review also outlines measures to reduce delayed discharges, ultimately leading to a significant enhancement in the healthcare system.
PubMed: 38939266
DOI: 10.7759/cureus.61249 -
JACC. Advances Jun 2024Cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is associated with high morbidity and mortality. Frailty is a common comorbidity in patients...
BACKGROUND
Cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is associated with high morbidity and mortality. Frailty is a common comorbidity in patients with cardiovascular disease and is also associated with adverse outcomes. The impact of preexisting frailty at the time of CS diagnosis following AMI has not been studied.
OBJECTIVES
The purpose of this study was to examine the prevalence of frailty in patients admitted with AMI complicated by CS (AMI-CS) hospitalizations and its associations with in-hospital outcomes.
METHODS
We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for AMI-CS. We classified them into frail and nonfrail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes.
RESULTS
A total of 283,700 hospitalizations for AMI-CS were identified. Most (70.8%) occurred in the frail. Those with frailty had higher odds of in-hospital mortality (adjusted OR [aOR]: 2.17, 95% CI: 2.07 to 2.26, < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, including intracranial hemorrhage, gastrointestinal hemorrhage, acute kidney injury, and delirium. Importantly, AMI-CS hospitalizations in the frail had lower odds of coronary revascularization (aOR: 0.55, 95% CI: 0.53-0.58, < 0.001) or mechanical circulatory support (aOR: 0.89, 95% CI: 0.85-0.93, < 0.001). Lastly, hospitalizations for AMI-CS showed an overall increase from 53,210 in 2016 to 57,065 in 2020 ( trend <0.001), with this trend driven by a rise in the frail.
CONCLUSIONS
A high proportion of hospitalizations for AMI-CS had concomitant frailty. Hospitalizations with AMI-CS and frailty had higher rates of in-hospital morbidity and mortality compared to those without frailty.
PubMed: 38938859
DOI: 10.1016/j.jacadv.2024.100949 -
CHEST Critical Care Jun 2024A 48-year-old man with history of recent travel to central Mexico and immunosuppression sought treatment with a 1-month-long history of progressive headache, fatigue,...
A 48-year-old man with history of recent travel to central Mexico and immunosuppression sought treatment with a 1-month-long history of progressive headache, fatigue, word-finding difficulties, and night sweats. The patient had a history of end-stage renal disease; he had undergone a kidney transplantation 7 years prior with good graft function with immunosuppression with tacrolimus, everolimus, and low-dose prednisone. At an outside hospital, he recently had been treated with empiric antibiotics for meningitis, but these were discontinued given the low suspicion for a bacterial cause. After discharge, he continued to have headaches, limited oral intake, persistent nausea, urinary frequency, and falls, prompting him to seek treatment at the ED. Physical examination findings were benign aside from disorientation. Laboratory workup was significant for hyponatremia of 122 mM, creatinine of 1.4 mg/dL (baseline, 1.4-1.5 mg/dL), WBC count of 7.2 10/L, hemoglobin of 13 g/dL, and platelet count of 349 10/L. Neither tacrolimus nor everolimus levels were supratherapeutic.
PubMed: 38938509
DOI: 10.1016/j.chstcc.2024.100064 -
JACC. Advances Oct 2023Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.
BACKGROUND
Cardiac rehabilitation (CR) is strongly recommended for a spectrum of cardiovascular conditions and procedures including aortic valve replacement.
OBJECTIVES
The purpose of this study was to characterize patient and hospital factors associated with CR participation after transcatheter aortic valve replacement (TAVR) and determine which factors explain hospital-level variation in CR participation.
METHODS
We linked clinical and administrative claims data from patients who underwent TAVR at 24 Michigan hospitals between January 1, 2016 and June 30, 2020 and obtained rates of CR enrollment within 90 days of discharge. Sequential mixed models were fit to evaluate hospital variation in 90-day post-TAVR CR participation.
RESULTS
Among 3,372 patients, 30.6% participated in CR within 90-days after discharge. Several patient factors were negatively associated with CR participation after TAVR including older age, Medicaid insurance, atrial fibrillation/flutter, dialysis use, and slower baseline 5-m walk times. There was substantial hospital variation in CR participation after TAVR ranging from 5% to 60% across 24 hospitals. Patient case mix did not explain hospital variation in CR across hospitals with median OR numerically increasing from 2.11 (95% CI: 1.62-2.67) to 2.13 (95% CI: 1.61-2.68) after accounting for patient-level factors.
CONCLUSIONS
Less than 1 in 3 patients who underwent TAVR in Michigan participated in CR within 90-days of discharge. Although several patient factors are associated with CR participation, hospital-level variation in CR participation after TAVR is not explained by patient case mix. Identifying hospital processes of care that promote CR participation after TAVR will be critical to improving CR participation after TAVR.
PubMed: 38938330
DOI: 10.1016/j.jacadv.2023.100581 -
Case Reports in Obstetrics and... 2024Primary extragonadal germ cell tumors (EGCTs) are a very rare clinical encounter most commonly reported in males. Among females, the placenta, pelvis, uterus, brain, and...
INTRODUCTION
Primary extragonadal germ cell tumors (EGCTs) are a very rare clinical encounter most commonly reported in males. Among females, the placenta, pelvis, uterus, brain, and mediastinum are the most common extragonadal sites and predominantly display nondysgerminoma histology. In this report, we present a case of a primary cervical dysgerminoma in a young female patient. . An 18-year-old nulligravid woman presented with a 12-month history of vaginal bleeding and discharge. Routine blood tests and serum levels of tumor markers were within normal limits. The chest X-ray was normal. A high-resolution pelvic MRI showed a well-defined lobulated cervicovaginal mass measuring 8 × 6 × 5 cm expanding into the vaginal canal with mild homogenous contrast enhancement. An incisional biopsy was performed vaginally under anesthesia, and histologic findings were consistent with dysgerminoma. A repeat follow-up pelvic MRI was done and showed a reduction in the size of the mass by more than 70%. The patient was treated with 4 cycles of bleomycin, etoposide, and cisplatin chemotherapy. Additional external pelvic beam radiation treatment was administered for a partial response. After 3 months of radiotherapy, a contrast abdominopelvic CT scan showed a recurrent cervicovaginal mass with extension to the pelvic sidewalls. The patient was initiated with ifosfamide, paclitaxel, and cisplatin (ITP) as second-line chemotherapy for a recurrent germ cell tumor but later died from hydronephrosis, chronic anemia, and sepsis.
CONCLUSION
The uterine cervix is a very unusual site for primary dysgerminoma and can have a very aggressive clinical course. A high index of suspicion and an exhaustive workup are necessary to reach a diagnosis, particularly in a young patient presenting with a cervical lesion.
PubMed: 38938322
DOI: 10.1155/2024/6465387 -
JACC. Advances Jun 2023Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain...
BACKGROUND
Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied.
OBJECTIVES
The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined.
METHODS
All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization.
RESULTS
Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs.
CONCLUSIONS
CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.
PubMed: 38938260
DOI: 10.1016/j.jacadv.2023.100375 -
Journal of Cardiothoracic Surgery Jun 2024Symptom assessment based on patient-reported outcome (PRO) can correlate with disease severity, making it a potential tool for threshold alerts of postoperative...
PURPOSE
Symptom assessment based on patient-reported outcome (PRO) can correlate with disease severity, making it a potential tool for threshold alerts of postoperative complications. This study aimed to determine whether shortness of breath (SOB) scores on the day of discharge could predict the development of post-discharge complications in patients who underwent lung cancer surgery.
METHODS
Patients were from a study of a dynamic perioperative rehabilitation cohort of lung cancer patients focusing on patient-reported outcomes. Patients were assessed using the Perioperative Symptom Assessment Scale for Lung surgery (PSA-Lung). Logistic regression model was used to examine the potential association between SOB on the day of discharge and complications within 3 months after discharge. The post-discharge complications were taken as the anchor variable to determine the optimal cutpoint for SOB on the day of discharge.
RESULTS
Complications within 3 months post-discharge occurred in 71 (10.84%) of 655 patients. Logistic regression analysis revealed that being female (OR 1.764, 95% CI 1.006-3.092, P < 0.05) and having two chest tubes (OR 2.026, 95% CI 1.107-3.710, P < 0.05) were significantly associated with post-discharge complications. Additionally, the SOB score on the day of discharge (OR 1.125, 95% CI 1.012-1.250, P < 0.05) was a significant predictor. The optimal SOB cutpoint was 5 (on a scale of 0-10). Patients with an SOB score ≥ 5 at discharge experienced a lower quality of life 1 month later compared to those with SOB score<5 at discharge (73 [50-86] vs. 81 [65-91], P < 0.05).
CONCLUSION
SOB on the day of discharge may serve as an early warning sign for the timely detection of 3 month post-discharge complications.
Topics: Humans; Female; Male; Patient Discharge; Lung Neoplasms; Dyspnea; Postoperative Complications; Aged; Middle Aged; Pneumonectomy
PubMed: 38937786
DOI: 10.1186/s13019-024-02845-1 -
Epicardial and Endocardial Surgical Ablation of Atrial Fibrillation: Outcomes from CASE-AF Registry.Interdisciplinary Cardiovascular and... Jun 2024The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analyzing outcomes of patients undergoing surgical ablation for atrial...
OBJECTIVES
The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analyzing outcomes of patients undergoing surgical ablation for atrial fibrillation as concomitant or stand-alone procedures. This data sub-analysis of the German CArdioSurgEry Atrial Fibrillation Registry aims to describe the in-hospital and one-year outcomes after concomitant surgical ablation, based on two different ablation approaches, epicardial and endocardial surgical ablation.
MATERIALS AND METHODS
Between January 2017 and April 2020 seventeen German cardiosurgical units enrolled 763 consecutive patients after concomitant surgical ablation. In the epicardial group, 413 patients (54.1%), 95.6% underwent radiofrequency ablation. In the endocardial group, 350 patients (45.9%), 97.7% underwent cryoablation. 61.5% of patients in the epicardial- and 49.4% of patients in the endocardial group presenting with paroxysmal atrial fibrillation. Pre-, intra-, and post-operative data were gathered.
RESULTS
Upon discharge, 32.3% (n = 109) of patients after epicardial- and 24.0% (n = 72) of patients after endocardial surgical ablation showed recurrence of AF. The in-hospital mortality rate was low, 2.2% (n = 9) in the epi- and 2.9% (n = 10) in the endocardial group. The overall one-year procedural success rate was 58.4% in the epi- and 62.2% in the endocardial group, with significant symptom improvement in both groups. The one-year mortality rate was 7.7% (n = 30) in epi- and 5.0% (n = 17) in the endocardial group.
CONCLUSIONS
Concomitant surgical ablation is safe and effective with significant improvement in patient symptoms and freedom from atrial fibrillation. Adequate cardiac rhythm monitoring should be prioritized for higher-quality data acquisition.
PubMed: 38937269
DOI: 10.1093/icvts/ivae123 -
Journal of Pediatric and Adolescent... Jun 2024Prepubertal vaginal bleeding is a common presentation for pediatric adolescent gynecologists with a broad differential diagnosis that historically may not have included...
BACKGROUND
Prepubertal vaginal bleeding is a common presentation for pediatric adolescent gynecologists with a broad differential diagnosis that historically may not have included complex lymphatic anomalies. However, given recent consensus criteria and imaging capabilities, this may be a condition that pediatric adolescent gynecologists see more frequently in the future.
CASE
We present a case of a 5-year-old pre-pubertal girl whose only presenting symptoms of a rare complex lymphatic anomaly was copious vaginal bleeding. After three vaginoscopies, two hysteroscopies, two pelvic MRIs, and a percutaneous ultrasound guided core needle biopsy, this patient was eventually diagnosed with Kaposiform lymphangiomatosis at age 9 years-old, and she is now being treated medically with sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, with improvement in her symptoms.
SUMMARY AND CONCLUSION
Complex lymphatic anomalies should be considered after initial and secondary workups for pre-pubertal vaginal bleeding or copious vaginal discharge are negative. Furthermore, this case illustrates the value of pelvic MRI in the setting of unknown cause of vaginal bleeding when typical workup is negative.
PubMed: 38936506
DOI: 10.1016/j.jpag.2024.06.005