Pediatric observation units in the United States: A systematic review

BACKGROUND: As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. PURPOSE: To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. DATA SOURCES: Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. STUDY SELECTION: English language peer-reviewed publications on pediatric OU care in the United States. DATA EXTRACTION: Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. DATA SYNTHESIS: A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. CONCLUSIONS: Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays. Journal of Hospital Medicine 2010;5:172–182. © 2010 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/69173/1/592_ftp.pd

Combination therapy with oral treprostinil for pulmonary arterial hypertension. A double-blind placebo-controlled clinical trial

Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown. Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy. Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response. Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting. Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening. Clinical trial registered with www.clinicaltrials.gov (NCT01560624)

Theoretische Ableitung und Bewertung unterschiedlicher quasi-eindimensionaler Modelle für die Eigenschwingungsanalyse dünnwandiger Konstruktionen

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Theoretische Ableitung und Bewertung unterschiedlicher quasi-eindimensionaler Modelle für die statische Strukturanalyse dünnwandiger komplexer Konstruktionen

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Risk stratification of patients undergoing major non-cardiac surgery and implications of preoperative echocardiography

Background: Preoperative risk assessment for major non-cardiac surgery focuses on ischemic heart disease, not heart failure. We examined whether transthoracic echo (TTE) parameters are associated with 6 month mortality. Methods: 1,770 patients who had TTE within 90 days prior to surgery (n=192 with LVEF≤40%) were retrospectively identified and followed for 6 months. Descriptive statistics were used to compare populations and Cox proportional hazards were used for univariate and multivariate models. Results: 6 month mortality was higher in patients with LVEF≤40% (Figure 1). In this group, univariate and multivariable models associated with mortality are shown in table 1. Conclusions: Preoperative LVE

The Association Between Doppler Measures of Cardiac Function and Outcomes in Patients With Left Ventricular Ejection Fraction ≤ 40% Undergoing Noncardiovascular Surgeries

Background: Preoperative risk assessments of individuals who undergo major noncardiac surgery have focused on ischemic heart disease. Information on how to assess the noncardiac surgical risks for patients with depressed cardiac function, as seen in heart failure, is sparse. Echocardiography is routinely performed in patients with depressed cardiac function and is an accepted standard cardiac assessment. Transthoracic echocardiography (TTE) provides strong independent prognostic implications in a wide range of cardiovascular conditions. Purpose: To identify the echocardiographic parameters associated with outcomes among patients undergoing major noncardiac surgery. Methods: A retrospective single-institution investigation identified 1,770 patients who underwent one or more major noncardiac procedures from Jan. 1, 2011, to June 30, 2014, and had at least one TTE performed within 90 days before surgery. Patients were stratified by presurgery left ventricular ejection fraction (LVEF) into LVEF ≤ 40% and LVEF \u3e 40% groups. The cohort was followed through June 12, 2015, with the outcome focused on all-cause mortality. Continuous and categorical variables were compared by Student’s t-test and chi-squared test, respectively. Kaplan-Meier method was used to calculate mortality estimates postsurgery. Cox proportional hazards model was used for univariate and multivariable models. Results: In patients with LVEF \u3e 40%, the 1-, 6- and 12-month mortality rates were 3.8%, 9.0% and 12.1%, respectively. In patients with LVEF ≤ 40%, 1-, 6- and 12-month mortality was 9.5%, 18.4% and 25.2%, significantly greater than patients with LVEF \u3e 40% at all time points (P \u3c 0.01). Univariate analysis of patients with LVEF ≤ 40% found the following echocardiographic parameters to be significant predictors of 6-month mortality: right atrial pressure, pulmonary artery systolic pressure, LVEF \u3c 25%, mitral A-wave velocity, mitral E-wave deceleration time, and left ventricular posterior wall diastolic thickness. Multivariate analysis identified mitral A-point velocity (hazard ratio [HR]: 0.98, P = 0.02), LVEF \u3c 25% (HR: 3.48, P \u3c 0.01), glomerular filtration rate (HR: 0.71 at 10-unit increments, P \u3c 0.01) and colectomy (HR: 5.47, P \u3c 0.01) as significant predictors of 6-month mortality. Conclusion: Preoperative LVEF \u3c 25%, lower mitral A velocity, colectomy, and lower glomerular filtration rate are associated with 6-month mortality postsurgery. Close preoperative cardiac assessment of patients with decreased LVEF prior to noncardiac surgery may prove beneficial in improving long-term outcomes

Echocardiographic Predictors of Admission Among Patients With Heart Failure With Reduced Ejection Fraction

Background: Congestive heart failure afflicts 5.7 million people in the United States with annual incidence of 600,000 and mortality of 280,000. Heart failure accounts for greater than 1 million hospitalizations annually and the single largest inpatient Medicare expense. As the U.S. population ages and greater emphasis is placed on population health as a means to bend projected health care expenditures, large health care organizations will need to develop algorithms to identify patients at high risk with heart failure and possibly preempt hospitalizations. Doppler echocardiography is routinely performed in clinical assessment of severe heart failure. Purpose: We sought to determine echocardiographic parameters that predict 1-year cardiac events among ambulatory patients diagnosed with heart failure with reduced ejection fraction. Methods: A retrospective single-institution investigation identified 485 patients aged \u3c 75 years with left ventricular ejection fraction \u3c 35%. Kaplan-Meier method was used to identify parameters that corresponded with primary endpoint of hospitalization, emergency room visit or death. Results: High risk of primary endpoint could be segregated into four groups by presence of one or more of the following parameters (0, 1, 2, 3): mitral inflow E/A ratio \u3e 1.5, mitral E-wave deceleration time \u3c 160 ms or peak tricuspid regurgitant (TR) velocity \u3e 3 m/s. Event-free survival was significantly lower in high-risk group compared to low-risk group (P = 0.002). The 30-day hospitalization rates among those with all three factors compared to those without was 37.5% and 17.3%, P = 0.018. Conclusion: Presence of routine echocardiographic parameters, including E/A ratio \u3e 1.5, E-wave deceleration time \u3c 160 ms and TR velocity \u3e 3 m/s, is associated with high cardiovascular event rates among nonhospitalized ambulatory patients with reduced ejection fraction heart failure