Very interesting!
With 3D printing physicians can make exact replica of a particular patient’s left atrial appendage to obtain a better fit during the appendage closure procedure. Left atrial appendage is the most common site of thrombus (or clot) formation in patients with atrial fibrillation. These clots can dislodge and go into circulation, blocking blood flow, and causing damage to the affected organs. The biggest concern (and the biggest risk) is of strokes.
It is commonly believed that the decline in lung function may be greater in people with already poor lung function than those with normal lung function. Now a study with a relatively large sample size shows that the decline in lung function varies among people and perhaps doesn’t depend on the baseline lung function.
Peter Lange and colleagues used three independent cohorts (Framingham, Copenhagen Heart, Lovelace Smokers) and showed that low FEV1 in early adulthood is important in the genesis of COPD and that accelerated decline in FEV1 is not an obligate feature of COPD.
Since the start of pneumococcal conjugate vaccine use for routine childhood immunization, the overall rate of invasive disease and pneumonia among adults has decreased, likely due to herd immunity. We also now have have more sensitive laboratory tests to detect pathogens responsible for pneumonia in adults. This requires an updated assessment of the incidence of pneumonia and causative pathogens.
The study enrolled adults 18 years of age or older were enrolled at three hospitals in Chicago (John H. Stroger, Jr., Hospital of Cook County, Northwestern Memorial Hospital, and Rush University Medical Center) and at two in Nashville (University of Tennessee Health Science Center–Saint Thomas Health and Vanderbilt University Medical Center) from January 1, 2010, to June 30, 2012.
There were 2320 cases of pneumonia confirmed with radiographs. Quite interestingly, and in contrast to what would one expect to see, pneumonia were distributed about evenly between younger (18-49) middle (50-64) and older (>64) age groups, roughly one third in each category. Most (78%) had some underlying condition predisposing to pneumonia. Surprisingly, less than half were vaccinated with influenza or pneumococcal vaccine. Only in 38% of patients, a pathogen was detected despite using an extensive battery of laboratory diagnostics. Pathogens detected were as follows: one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%). The most common pathogens were human rhinovirus (in 9% of patients), influenza virus (in 6%), and pneumococcus (in 5%).
At a population level, the annual incidence of pneumonia was 24.8 cases (95% confidence interval, 23.5 to 26.1) per 10,000 adults, with the highest rates among adults 65 to 79 years of age (63.0 cases per 10,000 adults) and those 80 years of age or older (164.3 cases per 10,000 adults).
The results overall reaffirm the common observation that pneumonia incidence is highest in the elderly population. Results further show that despite current diagnostic tests, no pathogen was detected in the majority of patients. The overall pathogens for pneumonia are changing with respiratory viruses being detected more frequently than bacteria.
Oral anticoagulants such as warfarin, factor Xa inhibitors, and direct thrombin inhibitors are the current standard of care in high-risk patients with atrial fibrillation to reduce the risk of stroke in patients with risk factors, albeit at the expense of an increase in bleed. However, the benefit of oral anticoagulation needs to be weighed against an increased risk of bleeding.
Left atrial appendage occlusion devices have the potential to change the therapy for stroke prevention in atrial fibrillation patients. ACC/HRS/SCAI have just published an overview of the literature on this topic. The overview reviews several questions related to the use of these occlusion devices. The overview starts with literature review of currently available devices (WATCHMAN, Amplatzer Cardiac Plug, LARIAT, and others) and then delves into the question of the need and requirements for care team and facilities needed for the use of such devices. This is followed by training requirement for the operator, standardization of protocols, and selection of patients for occlusion device placement. The overview is an interesting read and is available here.
There are always a small number of patients frequently visit Emergency Department (ED) and are frequently admitted to the hospital. The underlying reasons are sometimes medical conditions and sometimes are complex psychological and social issues. Formulating a care plan that is individualized for a patient with appropriate support from healthcare professionals may help to decrease utilization of healthcare services and resources by such patients.
A study published in this month’s Journal of Hospital Medicine examined the same question. Investigators formed a multidisciplinary team that developed individualized care plans integrated into electronic medical record (EMR) that summarized patient histories, utilization patterns, and management strategies. They enrolled twenty-four medically and psychosocially complex patients with the highest rates of inpatient admissions and ED visits from August 1, 2012 to August 31, 2013.
Investigators found that hospital admissions decreased by 56% (P < 0.001) and 50.5% (P = 0.003), 6 and 12 months after care-plan implementation. Thirty-day readmissions decreased by 66% (P < 0.001) and 51.5% (P = 0.002), 6 and 12 months after care-plan implementation. ED visits, ED costs, and inpatient LOS did not significantly change. Inpatient variable direct costs were reduced by 47.7% (P = 0.001) and 35.8% (P = 0.052), 6 and 12 months after care-plan implementation.
At least this one study found that individualized care plans developed by a multidisciplinary team and integrated with the existing healthcare workforce and EMR reduce hospital admissions, 30-day readmissions, and hospital costs for complex, high-utilizing patients.
