Microstructural analysis of deformation-induced hypoxic damage in skeletal muscle

Deep pressure ulcers are caused by sustained mechanical loading and involve skeletal muscle tissue injury. The exact underlying mechanisms are unclear, and the prevalence is high. Our hypothesis is that the aetiology is dominated by cellular deformation (Bouten et al. in Ann Biomed Eng 29:153–63, 2001; Breuls et al. in Ann Biomed Eng 31:1357–364, 2003; Stekelenburg et al. in J App Physiol 100(6):1946–954, 2006) and deformation-induced ischaemia. The experimental observation that mechanical compression induced a pattern of interspersed healthy and dead cells in skeletal muscle (Stekelenburg et al. in J App Physiol 100(6):1946–954, 2006) strongly suggests to take into account the muscle microstructure in studying damage development. The present paper describes a computational model for deformation-induced hypoxic damage in skeletal muscle tissue. Dead cells stop consuming oxygen and are assumed to decrease in stiffness due to loss of structure. The questions addressed are if these two consequences of cell death influence the development of cell injury in the remaining cells. The results show that weakening of dead cells indeed affects the damage accumulation in other cells. Further, the fact that cells stop consuming oxygen after they have died, delays cell death of other cells

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Neoplastic myelopathies and traumatic spinal cord lesions: an Italian comparison of functional and neurological outcomes

BACKGROUND: Although neoplastic spinal cord injuries (NSCIs) constitute ∼25% of all non-traumatic spinal cord lesions, patients with such pathologies are seldom, if ever, admitted to specialized centers; further, their rehabilitation typically is short because of the perception that rehabilitation prolongs hospital stays unnecessarily and is reserved only for patients with very good prognoses. STUDY DESIGN: This study is a retrospective analysis. OBJECTIVE: The objective of this study is to evaluate the neurological and functional outcomes of patients with NSCIs compared with those of patients with traumatic spinal cord injury (TSCI). METHODS: We evaluated 208 patients with TSCIs and 63 with NSCIs; using a matching cohorts procedure, 43 comparable couples were selected from each group. The measures used to assess these patients were the American Spinal Injury Association standards, the Barthel Index (BI), the Rivermead Mobility Index and the Walking Index for Spinal Cord Injury. RESULTS: In the general population, NSCI patients are older and have longer lesion-to-admission times and more incomplete lesions than TSCI patients. Therefore, the functional status at admission and outcomes differed between the groups. In the matching cohorts, TSCI patients had lower BI scores at admission than NSCI subjects. At discharge, the two groups had comparable functional outcomes. Neurological status was similar at admission and at discharge. CONCLUSIONS: Although they had slightly disparate functional levels at admission, NSCI and TSCI patients had the same outcomes at discharge. Our data suggest that in a selected cohort of NSCI patients, rehabilitation is as successful as that in TSCI subjects and allows most patients to be discharged instead of being institutionalized

Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study

Alan J Bank,1 Christopher Obetz,2 Ann Konrardy,2 Akbar Khan,1 Kamalesh M Pillai,1 Benjamin J McKinley,1 Ryan M Gage,1 Mark A Turnbull,1 William O Kenney1 1United Heart and Vascular Clinic, St Paul, MN, USA; 2Abbott Northwestern Hospital, Minneapolis, MN, USA Objective: Scribes have been used in the emergency department to improve physician productivity and patient interaction. There are no controlled, prospective studies of scribe use in the clinic setting. Methods: A prospective controlled study compared standard visits (20 minute follow-up and 40 minute new patient) to a scribe system (15 minute follow-up and 30 minute new patient) in a cardiology clinic. Physician productivity, patient satisfaction, physician&ndash;patient interaction, and revenue were measured. Results: Four physicians saw 129 patients using standard care and 210 patients with scribes during 65 clinic hours each. Patients seen per hour increased (P < 0.001) from 2.2 &plusmn; 0.3 to 3.5 &plusmn; 0.4 (59% increase) and work relative value units (wRVU) per hour increased (P < 0.001) from 3.5 &plusmn; 1.3 to 5.5 &plusmn; 1.3 (57% increase). Patient satisfaction was high at baseline and unchanged with scribes. In a substudy, direct patient contact time was lower (9.1 &plusmn; 2.0 versus 12.9 &plusmn; 3.4 minutes; P < 0.01) for scribe visits, but time of patient interaction (without computer) was greater (6.7 &plusmn; 2.1 versus 1.5 &plusmn; 1.9 minutes; P < 0.01). Subjective assessment of physician&ndash;patient interaction (1&ndash;10) was higher (P < 0.01) on scribe visits (9.1 &plusmn; 0.9 versus 7.9 &plusmn; 1.1). Direct and indirect (downstream) revenue per patient seen was $142 and$2,398, with $205,740 additional revenue generated from the 81 additional patients seen with scribes. Conclusion: Using scribes in a cardiology clinic is feasible, produces improvements in physician&ndash;patient interaction, and results in large increases in physician productivity and system cardiovascular revenue. Keywords: physician productivity, medical economics, patient satisfaction, physician&ndash;patient interaction, scrib