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Medicine Jun 2024Cerebral embolism presents a significant challenge for recovery of motor and neurological function. Early integrated rehabilitation therapy (EIRT) has been proposed as a... (Observational Study)
Observational Study
Cerebral embolism presents a significant challenge for recovery of motor and neurological function. Early integrated rehabilitation therapy (EIRT) has been proposed as a beneficial approach, yet its efficacy requires thorough evaluation. This retrospective study, conducted from January 2020 to January 2023, involved 117 patient's post-cerebral embolism, divided into an EIRT group (n = 56) receiving EIRT and a control group (n = 61) receiving standard care. The Fugl-Meyer Assessment (FMA) and the National Institutes of Health Stroke Scale (NIHSS) were used to evaluate motor and neurological functions, while muscle strength was categorized from Level 0 (complete paralysis) to Level V (normal strength) to assess physical recovery. Eligibility centered on confirmed cerebral embolism diagnosis, timing of poststroke admission, and baseline functional status. The study adhered to strict ethical standards, with informed consent obtained from all participants. The EIRT group showed substantial improvements in both FMA and NIHSS scores compared to the control group, indicating better motor and neurological recovery. Significant differences were found in the posttreatment FMA (P < .01) and NIHSS scores (P < .01). Muscle strength analysis further confirmed the positive impact of EIRT with more patients in the EIRT group achieving higher levels of muscle strength at discharge. The study demonstrates the potential of EIRT to significantly improve motor and neurological outcomes for patient's post-cerebral embolism. The marked improvements in the observation group suggest that EIRT should be considered for broader application in stroke rehabilitation to enhance recovery and improve quality of life.
Topics: Humans; Male; Female; Retrospective Studies; Recovery of Function; Middle Aged; Aged; Stroke Rehabilitation; Intracranial Embolism; Treatment Outcome; Muscle Strength
PubMed: 38875419
DOI: 10.1097/MD.0000000000038436 -
JAMA Network Open Jun 2024Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and...
IMPORTANCE
Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid-related outcomes are unclear.
OBJECTIVE
To evaluate associations between an intravenous opioid dose received during mechanical ventilation and postdischarge opioid-related outcomes in medical (nonsurgical) patients.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study evaluated adults receiving mechanical ventilation lasting 24 hours or more for acute respiratory failure and surviving hospitalization. Participants from 21 Kaiser Permanente Northern California hospitals from January 1, 2012, to December 31, 2019, were included. Data were analyzed from October 1, 2020, to October 31, 2023.
EXPOSURES
Terciles of median daily intravenous fentanyl equivalents during mechanical ventilation.
MAIN OUTCOMES AND MEASURES
The primary outcome was the first filled opioid prescription in 1 year after discharge. Secondary outcomes included persistent opioid use and opioid-associated complications. Secondary analyses tested for interaction between opioid doses during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Estimates were based on multivariable-adjusted time-to-event analyses, with death as a competing risk, and censored for hospice or palliative care referral, rehospitalization with receipt of opioid, or loss of Kaiser Permanente plan membership.
RESULTS
The study included 6746 patients across 21 hospitals (median age, 67 years [IQR, 57-76 years]; 53.0% male). Of the participants, 3114 (46.2%) filled an opioid prescription in the year prior to admission. The median daily fentanyl equivalent during mechanical ventilation was 200 μg (IQR, 40-1000 μg), with terciles of 0 to 67 μg, more than 67 to 700 μg, and more than 700 μg. Compared with patients who did not receive opioids during mechanical ventilation (n = 1013), a higher daily opioid dose was associated with opioid prescriptions in the year after discharge (n = 2942 outcomes; tercile 1: adjusted hazard ratio [AHR], 1.00 [95% CI, 0.85-1.17], tercile 2: AHR, 1.20 [95% CI, 1.03-1.40], and tercile 3: AHR, 1.25 [95% CI, 1.07-1.47]). Higher doses of opioids during mechanical ventilation were also associated with persistent opioid use after hospitalization (n = 1410 outcomes; tercile 3 vs no opioids: odds ratio, 1.44 [95% CI, 1.14-1.83]). No interaction was observed between opioid dose during mechanical ventilation, prior opioid use, and posthospitalization opioid use.
CONCLUSIONS AND RELEVANCE
In this retrospective cohort study of patients receiving mechanical ventilation, opioids administered during mechanical ventilation were associated with opioid prescriptions following hospital discharge. Additional studies to evaluate risks and benefits of strategies using lower opioid doses are warranted.
Topics: Humans; Male; Female; Analgesics, Opioid; Respiration, Artificial; Retrospective Studies; Middle Aged; Patient Discharge; Aged; California; Respiratory Insufficiency; Administration, Intravenous
PubMed: 38874921
DOI: 10.1001/jamanetworkopen.2024.17292 -
EClinicalMedicine Jul 2024To assess the equivalence of tranexamic acid (TRAN) versus synthetic oxytocin (OXY) in reducing post-partum blood loss, in full-term patients (37-42 weeks), at low risk...
BACKGROUND
To assess the equivalence of tranexamic acid (TRAN) versus synthetic oxytocin (OXY) in reducing post-partum blood loss, in full-term patients (37-42 weeks), at low risk of post-partum hemorrhage, with vaginal childbirth.
METHODS
Phase III, randomized (1:1), open-label, longitudinal, multi-center, prospective clinical trial (Prot. n 63209, ClinicalTrials.gov Identifier: NCT02775773). From January 7, 2020, to June 30, 2023, a total of 256 women were enrolled at two general urban community hospitals in Italy, serving a multi-ethnic patient population with National Health Insurance. The primary outcome was to explore a potential equivalence between the two treatments (OXY and TRAN) in preventing total blood loss. Therefore, we randomized 231 women into two groups: Group A (OXY), 127 women who were administered 10UI intramuscularly within 5 min from childbirth; Group B (TRAN), 104 women to whom 1-g slow intravenous infusion was administered within 5 min from childbirth.
FINDINGS
At the time of delivery, mean blood loss for OXY group versus TRAN group was 269.12 mL versus 263.88 mL, respectively, with equivalence between the two groups. Similarly, there was equivalence in total blood loss between the OXY and the TRAN group (397.66 mL versus 405.64 mL, respectively. No statistical differences between Hb levels at admission and discharge in the two groups were reported. No difference was found in terms of additional uterotonic and surgical therapies between the two groups of patients. Neither group showed thrombotic complications at check-up performed after 7 days or after a questionnaire regarding adverse effects, subjected after 40 days.
INTERPRETATION
The study shows the equivalence of tranexamic acid versus synthetic oxytocin in post-partum blood loss prophylaxis in term patients at low risk of PPH with vaginal childbirth. The safety profiles of OXY and TRAN were similar.
FUNDING
None.
PubMed: 38873634
DOI: 10.1016/j.eclinm.2024.102665 -
BMC Cardiovascular Disorders Jun 2024Studies of transcatheter pulmonary valve replacement (TPVR) with the Melody valve have demonstrated good clinical and hemodynamic outcomes. Our study analyzes the...
BACKGROUND
Studies of transcatheter pulmonary valve replacement (TPVR) with the Melody valve have demonstrated good clinical and hemodynamic outcomes. Our study analyzes the midterm clinical and hemodynamic outcomes for patients who underwent Melody valve implantation in Southeast Asia.
METHODS
Patients with circumferential conduits or bioprosthetic valves and experiencing post-operative right ventricular outflow tract (RVOT) dysfunction were recruited for Melody TPVR.
RESULTS
Our cohort (n = 14) was evenly divided between pediatric and adult patients. The median age was 19 years (8-38 years), a male-to-female ratio of 6:1 with a median follow-up period of 48 months (16-79 months), and the smallest patient was an 8-year-old boy weighing 18 kg. All TPVR procedures were uneventful and successful with no immediate mortality or conduit rupture. The primary implant indication was combined stenosis and regurgitation. The average conduit diameter was 21 ± 2.3 mm. Concomitant pre-stenting was done in 71.4% of the patients without Melody valve stent fractures (MSFs). Implanted valve size included 22-mm (64.3%), 20-mm (14.3%), and 18-mm (21.4%). After TPVR, the mean gradient across the RVOT was significantly reduced from 41 mmHg (10-48 mmHg) to 16 mmHg (6-35 mmHg) at discharge, p < 0.01. Late follow-up infective endocarditis (IE) was diagnosed in 2 patients (14.3%). Overall freedom from IE was 86% at 79 months follow-up. Three patients (21.4%) developed progressive RVOT gradients.
CONCLUSION
For patients in Southeast Asia with RVOT dysfunction, Melody TPVR outcomes are similar to those reported for patients in the US in terms of hemodynamic and clinical improvements. A pre-stenting strategy was adopted and no MSFs were observed. Post-implantation residual stenosis and progressive stenosis of the RVOT require long term monitoring and reintervention. Lastly, IE remained a concern despite vigorous prevention and peri-procedural bacterial endocarditis prophylaxis.
Topics: Humans; Male; Child; Heart Valve Prosthesis; Female; Heart Valve Prosthesis Implantation; Adolescent; Pulmonary Valve; Treatment Outcome; Hemodynamics; Young Adult; Prosthesis Design; Cardiac Catheterization; Time Factors; Adult; Recovery of Function; Pulmonary Valve Insufficiency; Bioprosthesis; Pulmonary Valve Stenosis; Retrospective Studies; Risk Factors; Asia, Southeastern
PubMed: 38872098
DOI: 10.1186/s12872-024-03919-7 -
PloS One 2024Asthma is the leading source of unscheduled hospitalisation in Australian children, with a high burden placed upon children, their parents/families, and the healthcare...
BACKGROUND
Asthma is the leading source of unscheduled hospitalisation in Australian children, with a high burden placed upon children, their parents/families, and the healthcare system. In Australia, there are widening disparities in paediatric asthma care including inequitable access to comprehensive ongoing and planned asthma care for children.
METHODS
The Asthma Care from Home Project is a comprehensive virtually enabled asthma model of care that aims to a. supports families, communities and healthcare providers, b. flexible and locally acceptable, and c. allow for adoption of innovations such as digital technologies so that asthma care can be provided "from home", reduce potentially preventable asthma hospitalisation, and ensure satisfaction at a patient, family, and healthcare provider level. The model of care includes standardisation of discharge care through provision of an asthma discharge resource pack containing individual asthma action plan, follow-up letters for the child's general practitioner (GP) and school/child care, and access to online asthma educational sessions and resource; post-discharge care coordination through text message reminders for families for regular GP review, email correspondence with their child's GP and school/childcare; and virtual home visits to discuss home environmental triggers, provide personalised asthma education and respond to parental concerns relating to their child's asthma. This study is comprised of three components: 1) a quasi-experimental pre/post impact evaluation assessing the impact of the model on healthcare utilisation and asthma control measures; 2) a mixed-methods implementation evaluation to understand how and why our intervention was effective or ineffective in producing systems change; 3) an economic evaluation to assess the cost-effectiveness of the proposed model of care from a family and health services perspective.
DISCUSSION
This study aims to improve access to asthma care for children in rural and remote areas. Implementation evaluation and economic evaluation will provide insights into the sustainability and scalability of the asthma model of care.
Topics: Asthma; Humans; Child; New South Wales; Rural Population; Child, Preschool; Female; Male; Telemedicine; Adolescent
PubMed: 38870226
DOI: 10.1371/journal.pone.0304711 -
PloS One 2024Patient education at the time of discharge is one of the most important challenges in the emergency department. This study aimed to evaluate the Effect of implementing...
BACKGROUND
Patient education at the time of discharge is one of the most important challenges in the emergency department. This study aimed to evaluate the Effect of implementing the IDEAL, or integrated discharge model, on the satisfaction of patients referred to the trauma emergency department.
METHODS
This quasi-experimental study was conducted on the patients referred to the trauma emergency department of Imam Hossein Hospital in Tehran. Eighty-six patients were recruited from January 20, 2023, until July 30, 2023. In the intervention group, the educational content was taught using the IDEAL (Inclusion, Discussion, Education, Assessment, Listening) or integrated discharge model, and in the control group, it was taught using the emergency department routine method. The satisfaction questionnaire of the emergency department was completed before and after the education in both groups and compared between the two groups. The data were analyzed by using SPSS (version 20) software.
RESULTS
The results showed that out of the 86 participating patients, 52 (60.5%) were male and 34 (39.5%), with a mean (Standard Deviation) of 39.14 (10.89) years old. Demographic characteristics were homogeneous between the two groups (P > 0.05). The mean (standard deviation) of satisfaction of the participants after education, totally was 63.56 (16.21), in the intervention group it was 77.37 (7.95), and in the Control group it was 49.74 (8.84). The mean (SD) participants satisfaction on arrival at the emergency department in the intervention group was 19.16 (2.75) and in the control group was 13.51 (2.51), during hospitalization in the intervention group was 10.72 (1.77) and in the Control group 6.74 (1.81), discharge time in the intervention group 14.51 (2.93) and in the control group 2.93 (2.04), Overall satisfaction with nursing care in intervention group 13.85 (2.46) and in the control group 8.46 (2.41), Overall satisfaction with medical procedures in the intervention group 12.81 (2.73) and in the control group 8.58 (3.20) and Overall patient satisfaction in the intervention group 2.27 (1.81) and 41.4 (1.66) in the control group. An independent T-test was used to compare satisfaction and its dimensions in two groups, and there was a statistically significant difference between the two groups (P<0.01).
CONCLUSION
The study results showed a statistically significant difference in the satisfaction in the intervention and control groups, so it can be concluded that conducting the integrated discharge model is effective in increasing the satisfaction of trauma patients. Therefore, it is recommended to use this educational method to increase patient satisfaction and decrease readmission rates.
Topics: Humans; Male; Female; Patient Satisfaction; Patient Discharge; Adult; Emergency Service, Hospital; Middle Aged; Iran; Surveys and Questionnaires; Patient Education as Topic; Referral and Consultation
PubMed: 38870177
DOI: 10.1371/journal.pone.0304969 -
The Lancet Regional Health. Western... Jun 2024Carbapenem resistant organisms (CROs) such as (CR), (CR), (CR), and (CR) have been identified by the World Health Organization (WHO) as global priority pathogens....
BACKGROUND
Carbapenem resistant organisms (CROs) such as (CR), (CR), (CR), and (CR) have been identified by the World Health Organization (WHO) as global priority pathogens. The dissemination of these pathogens and clonal outbreaks within healthcare facilities are of serious concern, particularly in regions with limited resources. In Fiji, where healthcare services are primarily provided by public hospitals, understanding the extent and nature of this problem is essential for the development of effective patient management, prevention interventions and control strategies.
METHODS
CROs isolated from 211 (77.3%) non-sterile (urinary catheters, urine, sputum, wound swab, and endotracheal tube) and 62 (22.7%) normally sterile (blood, cerebrospinal fluid, intravascular catheter, and aspirates) body sites of 272 patients treated at the three major hospitals in Fiji, the Colonial War Memorial Hospital (CWMH), Lautoka Hospital (LTKH), and Labasa Hospital (LBSH), and outer peripheral health centres around Fiji, were analysed. Clinical and demographic patient data such as age, sex, admission diagnosis, admission and discharge dates, patient outcomes, date of death, start and end date of meropenem and colistin treatment were reviewed. These CRO isolates comprised , , , and , that were prospectively collected at the microbiology laboratory of CWMH and LBSH from January 2020 through August 2021 and at the LTKH from January 2020 to December 2021. In addition, 10 retrospectively stored CR isolates collected from patients at the CWMH from January through December 2019, were also included in the study. All isolates were characterised using mass spectrometry, antimicrobial susceptibility testing, and whole genome sequencing. Phylogenetic relationships among the CROs were assessed through core genome single nucleotide polymorphism (SNP) analysis. The CR isolates were also compared to the CR isolates from CWMH isolated in 2016/2017 and 2019, along with CR isolates obtained from Fijian patients admitted to New Zealand hospitals in 2020 and 2021 from our retrospective study.
FINDINGS
Of 272 patients, 140 (51.5%) were male, the median (range) age of patients was 45 (<1-89) years, 161 (59.2%) were I-Taukei, 104 (38.2%) Fijians of Indian descent, and 7 (2.6%) were from other ethnic backgrounds. 234 (86.0%) of these 272 patients, had their first positive CRO sample collected ≥72 h following admission and the remaining 38 (14.0%) were isolated within 72 h following admission. Of the 273 CROs, 146 (53.5%) were collected at the CWMH, 66 (24.2%) LTKH, and 61 (22.3%) LBSH, while 62 (22.7%) were isolated from normally sterile sites and 211 (77.3%) from sites that are not sterile. Of 273 isolates, 131 (48.0%) were CR, 90 (33.0%) CR, 46 (16.8%) CR, and 6 (2.2%) CR. Of 131 CR, 108 (82.4%) were ST2, with three distinct clones, all encoding and , while clone 3 also encoded ; was associated with two copies of IS insertion element, forming the composite transposon Tn. The first two CR ST2 clones were genetically linked to those isolated at CMWH 2016 through 2019, while the third was genetically linked to isolates from Fijian patients admitted to New Zealand hospitals in 2020 and 2021. Of CR, 65 (72.2%) were ST773 and carried β-lactamase genes , , and . Of 10 retrospective CR isolates, all belonged to CR ST773 and carried , , and . Of 46 CR, 44 (95.7%) were ST410 and encoded on an IncX3 plasmid. Of 6 CR, 4 (66.7%) were ST16 and carried on an IncX3 plasmid. Other sequence types of CR (ST9, ST357, ST654, ST664), CR (ST25, ST374, ST499), CR (ST167), and CR (ST45, ST336) were also detected. Of those receiving meropenem treatment in the prospective study, 30 (57.7%) received it inappropriately. Of 272 patients, 65 (23.9%) died within the 30 days after first positive CRO isolation.
INTERPRETATION
We identified nosocomial transmission of distinct clones of CR ST2, CR ST773, CR ST410, and CR ST16 within and between the three major hospitals in Fiji. Moreover, community onset infections associated with CR, CR, and CR were also detected. Of note, cross-border transmission of CR ST2 clone 3 strain between Fiji and New Zealand was also detected. These clones encoded an array of carbapenem resistance genes associated with mobile genetic elements, including plasmids, transposons, and integrative and conjugative elements, signifying their potential for increased mobility, further acquisition of resistance genes, and spread. Inappropriate use of meropenem was common. Of note, the majority of patients who died had acquired CRO during their hospital stay. These findings highlight the need for stringent IPC strategies focusing on catheter and ventilator management, meticulous wound care, rigorous sepsis control, consistent hand hygiene, effective use of disinfectants, and thorough sanitisation of both hospital environments and medical equipment in the three major hospitals in Fiji. Additionally, diligent surveillance of AMR and robust antimicrobial stewardship are crucial for effectively managing nosocomial infections.
FUNDING
This project was funded by the Otago Medical School Foundations Trust (Dean's Bequest Fund) and a Fiji National University seed grant. The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.
PubMed: 38867891
DOI: 10.1016/j.lanwpc.2024.101095 -
BMC Medicine Jun 2024Understanding the enduring respiratory consequences of severe COVID-19 is crucial for comprehensive patient care. This study aims to evaluate the impact of post-COVID...
BACKGROUND
Understanding the enduring respiratory consequences of severe COVID-19 is crucial for comprehensive patient care. This study aims to evaluate the impact of post-COVID conditions on respiratory sequelae of severe acute respiratory distress syndrome (ARDS).
METHODS
We examined 88 survivors of COVID-19-associated severe ARDS six months post-intensive care unit (ICU) discharge. Assessments included clinical and functional evaluation as well as plasma biomarkers of endothelial dysfunction, inflammation, and viral response. Additionally, an in vitro model using human umbilical vein endothelial cells (HUVECs) explored the direct impact of post-COVID plasma on endothelial function.
RESULTS
Post-COVID patients with impaired gas exchange demonstrated persistent endothelial inflammation marked by elevated ICAM-1, IL-8, CCL-2, and ET-1 plasma levels. Concurrently, systemic inflammation, evidenced by NLRP3 overexpression and elevated levels of IL-6, sCD40-L, and C-reactive protein, was associated with endothelial dysfunction biomarkers and increased in post-COVID patients with impaired gas exchange. T-cell activation, reflected in CD69 expression, and persistently elevated levels of interferon-β (IFN-β) further contributed to sustained inflammation. The in vitro model confirmed that patient plasma, with altered levels of sCD40-L and IFN-β proteins, has the capacity to alter endothelial function.
CONCLUSIONS
Six months post-ICU discharge, survivors of COVID-19-associated ARDS exhibited sustained elevation in endothelial dysfunction biomarkers, correlating with the severity of impaired gas exchange. NLRP3 inflammasome activity and persistent T-cell activation indicate on going inflammation contributing to persistent endothelial dysfunction, potentially intensified by sustained viral immune response.
Topics: Humans; COVID-19; Male; Female; Middle Aged; Inflammation; Aged; SARS-CoV-2; Biomarkers; Respiratory Distress Syndrome; Human Umbilical Vein Endothelial Cells; Pulmonary Gas Exchange; Endothelium, Vascular; NLR Family, Pyrin Domain-Containing 3 Protein; Adult
PubMed: 38867241
DOI: 10.1186/s12916-024-03461-5 -
Journal of Cardiothoracic Surgery Jun 2024Iatrogenic aortic regurgitation secondary to leaflet injury is a rare complication of mitral valve surgery. For the first time, we report a patient who had progressive...
Iatrogenic aortic regurgitation secondary to leaflet injury is a rare complication of mitral valve surgery. For the first time, we report a patient who had progressive aortic regurgitation due to non-coronary leaflet perforation after robotic mitral valve repair and required aortic valve repair 18 months after this initial surgery. As in our case, aortic regurgitation after mitral valve surgery may remain undiagnosed on intraoperative transesophageal echocardiography or undetected until the patient's discharge due to gradual enlargement of very small perforations over the postoperative course.
Topics: Humans; Iatrogenic Disease; Mitral Valve; Robotic Surgical Procedures; Mitral Valve Insufficiency; Aortic Valve Insufficiency; Echocardiography, Transesophageal; Male; Postoperative Complications; Heart Valve Prosthesis Implantation; Female
PubMed: 38867224
DOI: 10.1186/s13019-024-02753-4 -
BJGP Open Jun 2024Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide.
BACKGROUND
Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide.
AIM
To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition.
DESIGN & SETTING
A nested case-control study utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation and region with up to 20 living discharged people.
METHOD
We described patterns of consultation, prescription of psychotropic medication and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables.
RESULTS
Over 40% of patients who died within 2 weeks and 80% who died later had at least one primary care consultation. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within two weeks of discharge, AOR 0.61 (0.42-0.89), more likely to consult in the week before death, AOR 1.71 (1.36-2.15), to be prescribed multiple types of psychotropic medication, (AOR 1.73, 1.28-2.33), to experience readmission and have a diagnosis outside of the 'Severe Mental Illness' definition.
CONCLUSION
Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support.
PubMed: 38866405
DOI: 10.3399/BJGPO.2023.0165