Early follow-up in the cardiological day hospital after heart surgery. Impact on hospital readmissions and emergency room visits

Introduction In the first few months after heart surgery, readmissions and emergency visits are common. In order to reduce these events, we developed an early follow-up protocol after discharge based on attention in our cardiological day hospital (CDH), which allows clinical and analytical assessment, monitoring and intravenous treatment at successive visits. The objective of the study is to assess the effectiveness of the protocol after its implementation. Methods Patients in our area discharged after heart surgery between 2013 and 2017 were included. They were divided into two groups, one with conventional follow-up and one with initial follow-up in CDH. Baseline clinical characteristics, type of surgery and surgical risk were compared. The primary endpoint was the time to the first readmission or emergency visit. The follow-up time was 200 days from discharge. Quantitative variables were compared using Student's t test and categorical variables using chi-square test. Cox proportional hazards model was used for multivariate analysis. Results 321 patients, 160 with conventional and 161 with CDH follow-up, were included. There were no differences in baseline characteristics (age, type of surgery, comorbidities, risk and hospital stay) except for sex (44.7% women in conventional group vs 33.8% in HDC, p=0.04). The results of readmissions and the composite endpoint (readmission or emergency visit) at 30, 90 and 200 days are shown in the table. We found a trend of decreasing events in the CDH group, although statistical significance was not achieved. In multivariate analysis, the variables independently associated (p<0.05) with an increase in the combined endpoint at 200 days were: female sex, prior atrial fibrillation, hypertension and an Euroscore surgical risk index greater than 3. The time to a first cardiological assessment after discharge decreased significantly in the CDH group (58 vs 18 days, p<0.001). Conclusions In patients followed in CDH after heart surgery, there is a trend towards less readmissions and emergency visits in the first six months after discharge. Some baseline characteristics have been shown to be independently associated with the risk of events, which will help us to identify the most at-risk patients, on which an intervention could have a greater magnitude of benefit. FUNDunding Acknowledgement Type of funding sources: None. Table 1. Results Figure 1. Hazard of composite end-point

Risk Factors Associated with Mortality among Chronic Kidney Disease Patients on Regular Hemodialysis Presenting in Emergency Services

Background: With the increasing number of Chronic Kidney Disease (CKD), emergency visit of these patients is also increasing. This study tried to find some of the reasons for which patients with CKD visit the emergency room and the reasons for their mortality. Method: A cross-sectional study was done in the emergency room of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. We conducted this study from 1 May 2018 to 31 October 2018 among the adult CKD patients under regular hemodialysis. We used a convenience sampling method. Three hundred patients were included. We studied the following variables: patient’s age, sex, risk factors, laboratory parameter during the emergency visit (viz. hemoglobin, pH, serum bicarbonate level, and potassium level), emergency hemodialysis, blood transfusion, and clinical outcome during emergency room stay. Result: We enrolled 300 patients in the study. The mean age was 45.04 years in the mortality group and 45.69 years in the survival group 152 (50.7%) of patients had hypertension. Mean hemoglobin was 6.52gm% (SD = 1.93). Mean hemoglobin in survivor and the non-survivor group was 6.59 gm% and 5.58 gm% respectively. Serum creatinine was 1220.87 micromol/l and 1064.01 micromol/l in mortality and survivor group respectively. Likewise, serum potassium was 6.13 mEq/l and 5.74 mEq/l among mortality and survivor groups respectively. Binary logistic regression showed significant association (p <0.05) of anemia, emergency dialysis and presence of sepsis with the mortality. There was significant correlation of presence of comorbidities, anemia, serum creatinine, serum potassium level, and sepsis with mortality. Area under the Receiver Operating Curve to predict mortality among CKD patients was 0.660 for potassium and 0.598 for serum creatinine. Conclusion: Anemia, increased serum creatinine, and hyperkalemia was significantly correlated with mortality in chronic kidney disease and were causes of frequent visits in the emergency room. Therefore, we should address these factors during the management of CKD patients.

A Parental Smoking Cessation Intervention in the Pediatric Emergency Setting: A Randomized Trial

We examined the efficacy of a pediatric emergency visit-based screening, brief intervention, and referral to treatment (SBIRT) condition compared to a control condition (Healthy Habits Control, HHC) to help parental smokers quit smoking. We enrolled 750 parental smokers who presented to the pediatric emergency setting with their child into a two-group randomized controlled clinical trial. SBIRT participants received brief cessation coaching, quitting resources, and up to 12-weeks of nicotine replacement therapy (NRT). HHC participants received healthy lifestyle coaching and resources. The primary outcome was point-prevalence tobacco abstinence at six weeks (T1) and six months (T2). The mean (SD) age of parents was 31.8 (7.7) years, and 86.8% were female, 52.7% were Black, and 64.6% had an income of ≤$15,000. Overall abstinence rates were not statistically significant with 4.2% in both groups at T1 and 12.9% and 8.3% in the SBIRT and HHC groups, respectively, at T2. There were statistically significant differences in SBIRT versus HHC participants on the median (IQR) reduction of daily cigarettes smoked at T1 from baseline (−2 [−5, 0] versus 0 [−4, 0], p = 0.0008),at T2 from baseline (−4 [−9, −1] vs. −2 [−5, 0], p = 0.0006), and on the mean (SD) number of quit attempts at T2 from baseline (1.25 (6.5) vs. 0.02 (4.71), p = 0.02). Self-reported quitting rates were higher in SBIRT parents who received NRT (83.3% vs. 50.9%, p = 0.04). The novel use of the pediatric emergency visit to conduct cessation interventions helped parents quit smoking. The near equivalent abstinence rates in both the SBIRT and HHC groups may be due to underlying parental concern about their child’s health. Cessation interventions in this setting may result in adult and pediatric public health benefits.

Emergency and Urgent Dental Visits Among Medicaid Enrollees from 2013 to 2017

Background: Efforts to combat the spread of COVID-19 have led to guidance to restrict dental practice to treating emergency and urgent dental visits and reduce or eliminate elective dental procedures. Better understanding of the frequency of dental emergencies and the procedures performed during those emergency visits can help providers, insurers, and policymakers understand workforce and care provision needs.Methods: Procedures performed at an emergency dental encounter and in the encounter following that encounter are assessed. Emergency dental encounters are those with a CDT code of D0140, D0160, or D0170. Data was analyzed from the IBM Watson Medicaid Marketscan data from 2013 to 2017, a nationally representative dental and medical claims database from 13 deidentified states.Result: Consistently over time, about 10% of all dental encounters are due to a dental emergency. 28% of emergency dental encounters had no other procedure performed during those encounters. When other procedures were performed during the encounter, the majority were diagnostic in nature, primarily radiographs. Among patients who returned to the dentists following an emergency visit, 43% returned for more definitive dental treatment, most within 30 days. Among patients who returned to the dentists following an emergency visit, 43% returned for more definitive dental treatment, with the majority returning within 30 days for that treatment.Conclusions: The majority of dental emergency encounters do not result in definitive treatment, rather patients often return to the dentist at a later date for that treatment. Where possible, dental providers could utilize teledental services to triage patients to appropriate care.

Exploring associations between oral health and frailty in community-dwelling older people

Background: In frail older people with natural teeth factors like polypharmacy, reduced salivary flow, a decrease of oral self-care, general healthcare issues, and a decrease in dental care utilization contribute to an increased risk for oral complications. On the other hand, oral morbidity may have a negative impact on frailty. Objective: This study explored associations between oral health and two frailty measures in community-dwelling older people. Design: A cross-sectional study. Setting: The study was carried out in a Primary Healthcare Center (PHC) in The Netherlands. Participants: Of the 5,816 persons registered in the PHC, 1,814 persons were eligible for participation at the start of the study. Measurements: Two frailty measures were used: 1. Being at risk for frailty, using Electronical Medical Record (EMR) data, and: 2. Survey-based frailty using ‘The Groningen Frailty Indicator’ (GFI). For oral health measures, dental-record data (dental care utilization, dental status, and oral health information) and self-reported oral problems were recorded. Univariate regression analyses were applied to determine the association between oral health and frailty, followed by age- and sex-adjusted multivariate logistic regressions. Results: In total 1,202 community-dwelling older people were included in the study, 45% were male and the mean age was 73 years (SD=8). Of all participants, 53% was at risk for frailty (638/1,202), and 19% was frail based on the GFI (222/1,202). A dental emergency visit (Odds Ratio (OR)= 2.0, 95% Confidence Interval (CI)=1.33;3.02 and OR=1.58, 95% CI=1.00;2.49), experiencing oral problems (OR=2.07, 95% CI=1.52;2.81 and OR=2.87, 95% CI= 2.07;3.99), and making dietary adaptations (OR=2.66, 95% CI=1.31;5.41 and OR=5.49, 95% CI= 3.01;10.01) were associated with being at risk for frailty and survey-based frailty respectively. Conclusions: A dental emergency visit and self-reported oral health problems are associated with frailty irrespective of the approach to its measurement. Healthcare professionals should be aware of the associations of oral health and frailty in daily practice.

Clinical Presentations of Chronic Kidney Disease Patients on Regular Haemodialysis Attending in Tribhuvan University Teaching Hospital Emergency Services

Background: Chronic kidney disease is increasing day by day and so is condition of renal replacement therapy mainly hemodialysis. Emergency visit of the patients under maintenance hemodialysis is frequent. The objective of the study is to study clinical parameters of these patients so that in future these deranged parameters can be focused during patient management and decrease their emergency visit. Methods: A prospective cross sectional study was conducted in emergency services of Tribhuvan University Teaching Hospital from 1st May 2018 to 31st October 2018 among the adult chronic kidney disease patients under maintenance hemodialysis. Ethical approval was taken from Institutional review board, Institute of Medicine, Tribhuvan University. Non-probability sampling method was used. Total of 300 patients were enrolled in the study. Patients’ age, sex, causes, laboratory parameter during emergency visit, need of emergency hemodialysis, and need of blood transfusion were studied. Results: Out of total 300 patients, mean age was 45.64 years (S.D =17.15). 190 (63.3 %) were male and 110(36.70%) were female. 152(50.70%) of patients had hypertension.Diabetes and Glomerulonephritis both had equal prevalence of 63(21%). Mean hemoglobin was 6.52gm% (S.D = 1.93). Mean pH was 7.17 (S.D =0.154). Mean serum potassium and creatinine level were 5.77 mEq/L (S.D =0.76) and 1076.03 mmol/l (S.D =367.25) respectively. Area under the Receiver Operating Curve was 0.660 for potassium and 0.598 for serum creatinine. Conclusion: Causes of chronic kidney disease, decreased hemoglobin level, increased serum creatinine and potassium level and metabolic acidosis are reasons of frequent emergency room visit among CKD patients. So these conditions need to be addressed to decrease emergency visit of these patients

Does the male gender govern conversion of laparoscopic cholecystectomy?

Introductions: Laparoscopic cholecystectomy (LC) occasionally demands conversion to open cholecystectomy (OC) because of multiple risk factors. This study was conducted to find out whether male gender is a stand-alone risk factors for conversion of LC to OC. Methods: This was a comparative analysis of conversion of LC to OC in patients operated for symptomatic cholelithiasis during June 2017 to May 2018 at Bir hospital, National Academy of Medical Sciences, Kathmandu, Nepal. The patients were divided into two groups: male (group 1) and female (group 2). Study variables included gender, America Society of Anesthesiologist class, history of upper abdominal pain within six weeks prior to surgery, upper abdominal surgery, emergency department visit due to upper abdominal pain, adhesion of gallbladder to adjacent structure and body mass index. Binominal logistic regression analysis of risk factors for conversion was conducted. Odds ratio (95% CI) was calculated. The p value ≤ 0.05 was considered statistically significant. Results: Among 151 patients (male 39, female 112), 7 (4.6%, male 3 and female 4) had conversion from LC to OC. Male gender itself as an isolated risk factor had no significant association to conversion (p=0.303). There was no significant difference found for age, operating time and hospital stay. Previous emergency visit (p=0.020) and adhesion (p<0.030) were associated with conversion. Conclusions: Male gender had no significant association for conversion of LC to open. Previous emergency visit due to upper abdominal pain and adhesion of gallbladder were associated risk factors for conversion.