Association between measures of and prognostic significance of cardiorespiratory fitness in community-dwelling older adults

The age structure of the U.S. population is expected to change with the segment of the population aged over 65 years experiencing the largest increase in size. Given the expected change in the U.S. population, efforts aimed at screening and diagnosis, in addition to the prevention and treatment of diseases with a significant burden in older adults should be at the forefront of public health efforts. Accordingly, in order to obtain an appreciation of the significance of cardiovascular diseases in older adults we initially performed a literature review of the burden and prevention of cardiovascular diseases, the leading cause of morbidity and mortality in older adults. Subsequently, we focused our research efforts on cardiorespiratory fitness in older adults. Cardiorespiratory fitness is a determinant of morbidity and mortality in middle-aged and older adults which can be measured objectively by either exercise testing or walk-based tests. Few studies of community-dwelling older adults have characterized the relationship between fitness as assessed by exercise testing versus walk-based testing, with subclinical cardiovascular, or the prognostic significance of walk-based test performance. We sought to characterize these relationships among community-dwelling adults participating in the Cardiovascular Health Study (CHS). In an analysis of the Arterial Calcification in the Elderly (ACE-CHS), 6 Minute Walk test (6 MWT) performance was a useful measure of treadmill test capability and performance. A second analysis of ACE-CHS failed to identify subclinical cardiovascular disease as quantified by the coronary artery calcification score as a significant determinant of exercise duration in exercise treadmill testing. However, the coronary artery calcification score was associated with ischemia as detected by electrocardiographic changes during exercise testing. Finally, in the full CHS cohort, the 6 MWT performance was independently associated with all-cause mortality, demonstrating a prognostic value for submaximal fitness assessment using the 6 MWT across a wide range of function present in community-dwelling older adults. The public health relevance of these finding is the potential clinical utility of the 6 MWT, a quick, safe and inexpensive alternative to exercise treadmill testing, in the assessment of cardiorespiratory fitness and the prediction of mortality in community-dwelling older adults

Plagiocephaly Perception and Prevention: A Need to Intervene Early to Educate Parents

Background: Plagiocephaly is a condition where the cranium has been malformed because of external forces or premature cranial suture fusion. This study’s objective was to gather and examine data regarding parent and caregiver awareness of plagiocephaly and its potential impact on development as well as to determine their rate of concern for positional flattening. Method: A cross-sectional survey study was conducted. Categorical variables were described by frequency and proportions. The study was conducted across eight outpatient pediatric sites. Approximately 1,100 parents and caregivers were targeted. Inclusion criteria required participants to be willing to answer the questionnaire, to be 18 years of age or older, and to have an infant 12 months of age or younger. Results: There were 404 participants, most of whom were female (89.8%) and 30–39 years of age (61.1%). Nineteen children (4.7%) were reported to have plagiocephaly, torticollis, and/or muscle weakness (PTM). A greater percentage of the participants with a child with PTM knew of positional flattening or plagiocephaly (73.3%) compared to those without (53.8%). The respondents with a child with PTM had a greater concern about plagiocephaly than those without (p = .03). Many of the respondents (65.3%) would use a device designed to prevent plagiocephaly. Conclusion: Many parents and caregivers were unaware of plagiocephaly and its potential impact on facial symmetry. A greater percentage of the participants with a child with PTM knew of positional flattening and also had a greater concern about plagiocephaly than those without

Clinical outcomes in patients with heart failure with and without cirrhosis: an analysis from the national inpatient sample.

Outcomes of heart failure (HF) hospitalization are driven by the presence or absence of comorbid conditions. Cirrhosis is associated with worse outcomes in patients with HF, and both HF and cirrhosis are associated with worse renal outcomes. Using a nationally representative sample we describe inpatient outcomes of all-cause mortality and length of stay (LOS) among patients with and without cirrhosis hospitalized for decompensated with HF. We conducted a cross sectional analysis using Nationwide Inpatient Sample (2010-2014) data including patients hospitalized for decompensated HF, with or without cirrhosis. We calculated the adjusted odds of all-cause mortality, acute kidney injury (AKI), and target LOS after adjusting for potential confounders. Out of the 2,487,445 hospitalized for decompensated HF 39,950 had cirrhosis of which majority (75.1%) were non-alcoholic cirrhosis. Patients with comorbid cirrhosis were more likely to die (OR, 1.26; 95% CI, 1.11 to 1.43) and develop AKI (OR, 1.26; 95% CI, 1.16 to 1.36) as compared to those without cirrhosis. Underlying CKD was associated with a greater odds of AKI (OR, 4.99; 95% CI, 4.90 to 5.08), and the presence of cirrhosis amplified this risk (OR, 6.03; 95% CI, 5.59 to 6.51). There was approximately a 40% decrease in the relative odds of lower HF hospitalization length of stay among those with both CKD and cirrhosis, relative to those without either comorbidities. Cirrhosis in patients with hospitalizations for decompensated HF is associated with higher odds of mortality, decreased likelihood of discharge by the targeted LOS, and AKI. Among patients with HF the presence of cirrhosis increases the risk of AKI, which in turn is associated with poor clinical outcomes

Association Between Cirrhosis and 30-Day Rehospitalization After Index Hospitalization for Heart Failure.

There are limited data on clinical outcomes in patients re-admitted with decompensated heart failure (HF) with concomitant liver cirrhosis. We conducted a cross sectional analysis of the Nationwide Readmissions Database (NRD) years 2010 thru 2012. An Index admission was defined as a hospitalization for decompensated heart failure among persons aged ≥ 18 years with an alive discharge status. The main outcome was 30 - day all-cause rehospitalization. Survey logistic regression provided the unadjusted and adjusted odds of 30 - day rehospitalization among persons with and without cirrhosis, accounting for age, gender, kidney dysfunction and other comorbidities. There were 2,147,363 heart failure (HF) hospitalizations among which 26,156 (1.2%) had comorbid cirrhosis. Patients with cirrhosis were more likely to have a diagnosis of acute kidney injury (AKI) during their index hospitalization (18.4% vs 15.2%). There were 469,111 (21.9%) patients with readmission within 30 - days. The adjusted odds of a 30 - day readmission was significantly higher among patients with cirrhosis compared to without after adjusting for comorbid conditions (adjusted Odds Ratio [aOR], 1.3; 95% Confidence Interval [CI}: 1.2 to 1.4). The relative risk of 30 - day readmission among those with cirrhosis but without renal disease (aOR, 1.3; 95% CI: 1.3 to 1.3) was lower than those with both cirrhosis and renal disease (aOR, 1.8; 95% CI: 1.6 to 2.0) when compared to persons without either comorbidities. Risk of 30 - day rehospitalization was significantly higher among patients with heart failure and underlying cirrhosis. Concurrent renal dysfunction among patients with cirrhosis hospitalized for decompensated HF was associated with a greater odds of rehospitalization

A customized early warning score enhanced emergency department patient flow process and clinical outcomes in a COVID-19 pandemic.

Objective: Patient crowding and boarding in the emergency department (ED) is associated with adverse outcomes and has become increasingly problematic in recent years. We investigated the impact of an ED patient flow countermeasure using an early warning score. Methods: We conducted a cross-sectional analysis of observational data from patients who presented to the ED of a Level 1 Trauma Center in Pennsylvania. We implemented a modified version of the Modified Early Warning Score (MEWS), called mMEWS, to address patient flow. Patients aged ≥18 years old admitted to the adult hospital medicine service were included in the study. We compared the pre-mMEWS (February 19, 2017-February 18, 2019) to the post-mMEWS implementation period (February 19, 2019-June 30, 2020). During the intervention, low MEWS (0-1) scoring admissions went directly to the inpatient floor with expedited orders, the remainder waited in the ED until the hospital medicine admitting team evaluated the patient and then placed orders. We investigated the association between mMEWS, ED length of stay (LOS), and 24-hour rapid response team (24 hour-RRT) activation. RRT activation rates were used as a measure of adverse outcome for the new process and are a network team response for admitted patients who are rapidly decompensating. The association between mMEWS and the outcomes of ED length of stay in minutes and 24 hour-RRT activation was assessed using linear and logistic regression adjusting for a priori selected confounders, respectively. Results: Of the total 43,892 patients admitted, 19,962 (45.5%) were in the pre-mMEWS and 23,930 (54.5%) in the post-mMEWS implementation period. The median post-mMEWS ED LOS was shorter than the pre-mMEWS (376 vs 415 minutes; Conclusion: The use of a modified MEWS enhanced admission process to the hospital medicine service, even during the COVID-19 pandemic, was associated with a significant decrease in ED LOS without a significant increase in 24 hour-RRT activation

Influence of Pennsylvania liquor store closures during the COVID-19 pandemic on alcohol withdrawal consultations.

INTRODUCTION: Alcohol withdrawal syndrome (AWS) is a serious consequence of alcohol use disorder (AUD). Due to the current COVID-19 pandemic there was a closure of Pennsylvania (PA) liquor stores on March 17, 2020. METHODS: This is a retrospective, observational study of AWS patients presenting to a tertiary care hospital. We used descriptive statistics for continuous and categorical variables and compared AWS consults placed to the medical toxicology service for six months preceding liquor store closure to those placed between March 17, 2020 and August 31, 2020. We compared this to consults placed to the medical toxicology service placed from October 1, 2019 through March 16, 2020. Charts were identified based on consults placed to the medical toxicology service, and alcohol withdrawal was determined via chart review by a medical toxicologist. This study did not require IRB approval. We evaluated Emergency Department (ED) length of stay (LOS), weekly and monthly consultation rate, rate of admission and ED recidivism, both pre- and post-liquor store closure. RESULTS: A total of 324 AWS consults were placed during the ten month period. 142 (43.8%) and 182 (56.2%) consults were pre- and post-liquor store closure. The number of consults was not statistically significant comparing these two time frames. There was no significant difference by patient age, gender, or race or by weekly or monthly consultation rate when comparing pre- and post-liquor store periods. The median ED LOS was 7 h (95% Confidence Interval (CI) Larson et al. (2012), Pollard et al. (2020) [5, 11]) and did not significantly differ between pre- and post-liquor store periods (p = 0.78). 92.9% of AWS patients required admission without significant difference between the pre- and post-liquor store closure periods (94.4% vs. 91.8%, p = 0.36). There was a significant increase in the number of AWS patients requiring a return ED visit (Odds Ratio 2.49; 95% CI [1.38, 4.49]) post closure. CONCLUSION: There were nearly 2.5 times greater odds of ED recidivism among post-liquor store closure AWS patients compared with pre-closure AWS patients

Invasive hemodynamic parameters in patients with hepatorenal syndrome.

Background: Hepatorenal syndrome (HRS), a form of kidney dysfunction frequent in cirrhotic patients, is characterized by low filling pressures and impaired kidney perfusion due to peripheral vasodilation and reduced effective circulatory volume. Cardiorenal syndrome (CRS), driven by renal venous hypertension and elevated filling pressures, is a separate cause of kidney dysfunction in cirrhotic patients. The two entities, however, have similar clinical phenotypes. To date, limited invasive hemodynamic data are available to help distinguish the primary forces behind worsened kidney function in cirrhotic patients. Objective: Our aim was to analyze invasive hemodynamic profiles and kidney outcomes in patients with cirrhosis who met criteria for HRS. Methods: We conducted a single center retrospective study among cirrhotic patients with worsening kidney function admitted for liver transplant evaluation between 2010 and 2020. All met accepted criteria for HRS and underwent concurrent right heart catheterization (RHC). Results: 127 subjects were included. 79 had right atrial pressure \u3e10 mmHg, 79 had wedge pressure \u3e15 mmHg, and 68 had both. All patients with elevated wedge pressure were switched from volume loading to diuretics resulting in significant reductions between admission and post diuresis creatinine values (2.0 [IQR 1.5-2.8] vs 1.5 [IQR 1.2-2.2]; p = 0.003). Conclusion: 62% of patients diagnosed with HRS by clinical criteria have elevated filling pressures. Improvement of renal function after diuresis suggests the presence of CRS physiology in these patients. Invasive hemodynamic data profiling can lead to meaningful change in management of cirrhotic patients with worsened kidney function, guiding appropriate therapies based on filling pressures