Updated Meta-Analysis of Randomized Trials Comparing Safety and Efficacy of Intraoperative Defibrillation Testing with No Defibrillation Testing On Implantable Cardioverter-Defibrillator Implantation

Introduction: There is an ongoing debate regarding the need to conduct intraoperative defibrillation testing (DFT) at the time of implantable cardioverter-defibrillator (ICD) implantation. To provide sufficiently strong evidence for the feasibility of omitting intraoperative DFT in clinical practice, we conducted a meta-analysis of randomized controlled trials (RCT) comparing patients with DFT and no-DFT.Methods: We systematically searched Medline (via PubMed), ClinicalTrial.gov, the Cochrane Central Register of Controlled Trials, and Embase for studies evaluating DFT vs. no-DFT on ICD implantation with regard to total mortality and arrhythmic death, efficacy of first and any appropriate shock in interrupting ventricular tachycardia (VT)/ventricular fibrillation (VF), and procedural adverse events. Effect estimates [risk ratio (RR) with 95% confidence intervals (CI)] were pooled using the random-effects model.Results: Our meta-analysis included 4 RCTs comprising 3770 patients (1896 with DFT and 1874 without DFT). Total mortality (RR = 1.00, 95% CI 0.86–1.17; P = 0.98) and arrhythmic death (RR = 1.60, 95% CI 0.46-5.59: P = 0.46) were not statistically different. Both first (RR = 0.94, 95% CI 0.89–0.98; P = 0.004) and any appropriate ICD shock (RR = 0.97, 95% CI 0.95–1.00; P = 0.02) significantly increased the rate of VT/VF interruption in the group with no-DFT in comparison with DFT. Finally, the incidence of adverse events was lower in no-DFT patients (RR = 1.23; 95% CI 1.00–1.51; P = 0.05).Conclusions: The practice of DFT (as opposed to no-DFT) did not yield benefits in mortality or the overall rate of conversion of VT/VT. Moreover, a slightly higher incidence of perioperative adverse events was observed in the DFT group

Deriving a Model for Predicting Hospital Falls

Background: In the United States 700,000 to 1,000,000 people fall in the hospital annually, 1/3 result in injury. One single fall averages $14,000, resulting in an increase in hospital length of stay and burden on hospital budget. In St. Joseph Hospital of Orange, from calendar year 2019 to 2020, there was an increase in falls from 178 to 185 falls, despite the use of a telesitter. At time of data collection, 12 telesitter cameras were initiated after a fall. An investigation was deemed necessary to determine the cause of the increase and the factors related to patient falls. Purpose: The purpose is to derive and validate predictors of falls by identifying criteria responsible for falls in a population of in-patients in an acute care setting. Compare research findings responsible for falls with current fall scales. Lastly, increase awareness with bedside nurses of patients most at risk for falls. Methods: The study utilized a retrospective cross-sectional design with a review of the electronic health records from calendar years of 2018 and 2019. Patients included are over the age of 18 and who were admitted to inpatient units in the hospital. A comprehensive literature review and comparison of current fall scales provided for identification of similarities, differences, and gaps among fall scales and identified common fall factors. Findings from the literature review were used to select variables for this study. The statistical methods and modeling used were descriptive statistics, continuous variables, categorical variables and bivariate analysis. Results: A total of 1,247 patient records, 929 records were randomized, while the other 318 records represented patients who fell during the hospital stay. Patient demographics shown to be statistically significant were age, gender, length of stay, and diagnosis. Identified patient behavior at most risk for falls are withdrawn, restless, anxious, and agitated. Lastly, if patient takes sedatives, anti-convulsants, anti-psychotics, and anticoagulants put a patient at risk for falls. Statistical analysis identified the factors posing the greatest risk. The strongest individual predictor was dizziness and vertigo; individuals were 7.2 times more likely to fall than those without dizziness/vertigo. Results also demonstrated a two-level “high” Morse Fall Risk with those with a 65 or greater score having double the risk of falling than those scoring 45-64. The fall predictor model derived from this study predicted 82% of the falls. This was especially significant when compared to the Morse Fall Scale which only predicted 62% of the falls. Conclusions: Results of the study will contribute to changes in policy and procedure on fall interventions for low, moderate, and high fall risk patients. Learning which variables are most likely to be present in a patient who could fall, can increase a bedside nurse awareness, and improve patient safety. Implications for practice: For future research, we would like to utilize the data and create a new model for predicting patient falls. Partner with other ministries to replicate study to see if results are similar. Incorporate the developed model to classify patient\u27s at risk for falls or early visual camera implementation

Role of transoesophageal echocardiography in evaluating the effect of catheter ablation of atrial fibrillation on anatomy and function of the pulmonary veins

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Genética y genómica médica en el Perú

Genética y genómica médica en el Per

Improving Discharge Times and Patient Flow

Background: Delays in discharging patients can impact hospital and emergency department (ED) throughput. The complex discharge process makes it difficult to ensure that patients are set up for successful post-hospital care regimens. The focus of this project was to improve discharge times and flow throughout the hospital to align with national standards of providing the right care, in the right place, at the right time. To improve access to beds, The Joint Commission stipulates that hospitals have processes in place to support patient flow throughout the hospital and to use data to drive improvements in patient flow. Failure to regulate flow puts patients at risk for harm and less than optimal care. It also increases clinician burden which may accelerate burnout. A lack of optimal patient flow results in ED boarding and diversions, long waits, and boarding in post-anesthesia care units. Purpose: The purpose of this project was to improve overall patient throughput within one large acute care hospital by improving discharge times. Baseline discharge times averaged over 4 hours with less than 15% of patients being discharged in less than 2 hours. Methods: A multidisciplinary patient flow team was charged with improving discharge times and removing barriers to timely discharges. The team consisted of representation from executive leadership, nursing management, pharmacy, physician staff, case management, and frontline staff. Meeting weekly, the team rapidly instituted small tests of change to address the barriers to timely discharges. The Admission Discharge Team facilitated education. Discharge accountability teams on nightshift assisted with preparing patients for discharge. Case Manager/charge nurse rounds were instituted to identify patients ready for discharge and anticipated barriers. Electronic whiteboards were utilized for interdisciplinary communication. Discharge times were reported weekly in a public area on units. Results: The program resulted in an increase in caregiver engagement in discharges and discharge times. Readmission rates decreased for heart failure patients to below national benchmark. Discharges completed in less than 2 hours improved to almost 30%. Average discharge times decreased from 4 hours to 2 hours and 30 minutes. Also, responses improved to the patient satisfaction question When I left the hospital, I had a good understanding of the things I was responsible for in managing my heath: by 25%. Conclusions: Discharge planning that is initiated on the day of admission and addressed ongoing in a uniform fashion by both nursing shifts and ancillary caregivers can alleviate delays on discharge day. An improvement in discharge times improved hospital flow. A focused approach on education throughout the patients stay improved their ability to manage their health at home and reduced readmits. Implication for Practice: The discharge protocol and procedures will continue to be implemented and evaluated for improvement needs and barriers and expanded to include skilled nursing facility transfers. The discharge process has been implemented in several inpatient units. Discharge times/barriers will be re-evaluated quarterly and the focused patient flow team will make additional adjustments to make the discharge process more efficient.https://digitalcommons.psjhealth.org/prov_rn_conf_all/1034/thumbnail.jp

In Heart Failure Patients with Left Bundle Branch Block Single Lead MultiSpot Left Ventricular Pacing Does Not Improve Acute Hemodynamic Response To Conventional Biventricular Pacing. A Multicenter Prospective, Interventional, Non-Randomized Study.

Introduction Recent efforts to increase CRT response by multiSPOT pacing (MSP) from multiple bipols on the same left ventricular lead are still inconclusive. Aim The Left Ventricular (LV) MultiSPOTpacing for CRT (iSPOT) study compared the acute hemodynamic response of MSP pacing by using 3 electrodes on a quadripolar lead compared with conventional biventricular pacing (BiV). Methods Patients with left bundle branch block (LBBB) underwent an acute hemodynamic study to determine the %change in LV+dP/dtmax from baseline atrial pacing compared to the following configurations: BiV pacing with the LV lead in a one of lateral veins, while pacing from the distal, mid, or proximal electrode and all 3 electrodes together (i.e. MSP). All measurements were repeated 4 times at 5 different atrioventricular delays. We also measured QRS-width and individual Q-LV durations. Results Protocol was completed in 24 patients, all with LBBB (QRS width 171±20 ms) and 58% ischemic aetiology. The percentage change in LV+dP/dtmax for MSP pacing was 31.0±3.3% (Mean±SE), which was not significantly superior to any BiV pacing configuration: 28.9±3.2% (LV-distal), 28.3±2.7% (LV-mid), and 29.5±3.0% (LV-prox), respectively. Correlation between LV+dP/dtmax and either QRS-width or Q-LV ratio was poor. Conclusions In patients with LBBB MultiSPOT LV pacing demonstrated comparable improvement in contractility to best conventional BiV pacing. Optimization of atrioventricular delay is important for the best performance for both BiV and MultiSPOT pacing configurations. Trial Registration ClinicalTrials.gov NTC0188314

Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. A Simulation Study

[EN] Patients suffering from heart failure and left bundle branch block show electrical ventricular dyssynchrony causing an abnormal blood pumping. Cardiac resynchronization therapy (CRT) is recommended for these patients. Patients with positive therapy response normally present QRS shortening and an increased left ventricle (LV) ejection fraction. However, around one third do not respond favorably. Therefore, optimal location of pacing leads, timing delays between leads and/or choosing related biomarkers is crucial to achieve the best possible degree of ventricular synchrony during CRT application. In this study, computational modeling is used to predict the optimal location and delay of pacing leads to improve CRT response. We use a 3D electrophysiological computational model of the heart and torso to get insight into the changes in the activation patterns obtained when the heart is paced from different regions and for different atrioventricular and interventricular delays. The model represents a heart with left bundle branch block and heart failure, and allows a detailed and accurate analysis of the electrical changes observed simultaneously in the myocardium and in the QRS complex computed in the precordial leads. Computational simulations were performed using a modified version of the O'Hara et al. action potential model, the most recent mathematical model developed for human ventricular electrophysiology. The optimal location for the pacing leads was determined by QRS maximal reduction. Additionally, the influence of Purkinje system on CRT response was assessed and correlation analysis between several parameters of the QRS was made. Simulation results showed that the right ventricle (RV) upper septum near the outflow tract is an alternative location to the RV apical lead. Furthermore, LV endocardial pacing provided better results as compared to epicardial stimulation. Finally, the time to reach the 90% of the QRS area was a good predictor of the instant at which 90% of the ventricular tissue was activated. Thus, the time to reach the 90% of the QRS area is suggested as an additional index to assess CRT effectiveness to improve biventricular synchrony.This work was supported by the Secretaría de Educación Superior, Ciencia, Tecnología e Innovación (SENESCYT) of Ecuador CIBAE-023-2014, the Plan Estatal de Investigación Científica y Técnica y de Innovación 2013 2016 from the Ministerio de Economía, Industria y Competitividad of Spain and Fondo Europeo de Desarrollo Regional (FEDER) DPI2016-75799-R (AEI/FEDER, UE), and by Dirección General de Política Científica de la Generalitat Valenciana (PROMETEU 2016/088).Carpio-Garay, EF.; Gómez García, JF.; Sebastian, R.; López-Pérez, AD.; Castellanos, E.; Almendral, J.; Ferrero De Loma-Osorio, JM.... (2019). Optimization of Lead Placement in the Right Ventricle During Cardiac Resynchronization Therapy. 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