Citations

Background: Activity aprons are commercially available products used to occupy patients with dementia at home or in long-term care facilities. We hypothesized that inpatient use of activity aprons could potentially reduce or eliminate behaviors that result in self-harm, increased nursing supervision, and restraint use in an inpatient hospital setting. Methods: A single-center prospective randomized controlled pilot study was performed from July 2015 to November 2016 comparing activity apron plus standard care versus standard care alone. Consecutively enrolled patients were randomized by stratified randomization using age (cutoff: 80 years) and preexisting diagnosis of dementia or cognitive impairment. Primary outcomes were safety and feasibility of apron use. Secondary outcomes included duration of hospitalization postrandomization and individual nursing assignment (IA), time in restraints, nonphysical restraints use, falls, apron-related complications, dismissal destination, and 30-day hospital readmission. Results: Thirty patients were enrolled, with 13 randomized to apron and 17 randomized to the control group. There was no statistically significant reduction in mean length of hospital stay (15.8 vs 21.5 day; P = .40), duration of IA compared to non-apron control group (6.4 vs 9.1, respectively; P = .39), or antipsychotic medication use (61.5% vs 70.6% in control group; P = .60). No complications secondary to apron use were seen. Conclusions: Activity aprons are a safe addition to the standard of care when managing encephalopathic patients in the inpatient setting. These aprons may have a role as part of a comprehensive complement of interventions to address delirium and encephalopathy in hospitalized patients.

Background and Aims: Clostridium difficile infection (CDI) has been associated with an increased mortality risk among patients with inflammatory bowel disease (IBD) in multiple observational studies. We performed a systematic review and meta-analysis to help clearly define the magnitude of risk in IBD patients with and without CDI, and to assess the risk in individual IBD subtypes. Methods: A systematic search of multiple electronic databases was conducted for observational studies reporting the risk of mortality in IBD, stratified by the presence of CDI. Weighted summary estimates were calculated using generalized inverse variance with random-effects model. Study quality was assessed using the Newcastle-Ottawa scale. Results: Ten observational studies were identified (8 from North America and 2 from Europe) and included 40,700 IBD patients with CDI and 1,320,764 IBD controls without CDI. Overall, IBD patients with CDI had a higher risk of mortality compared with IBD patients without CDI [odds ratios (OR), 4.39; 95% confidence interval (CI), 3.56-5.42; I 2=93%]. The results were stable in high-quality studies and in hospitalized patients. When patients were stratified by IBD type, CDI was associated with increased mortality in patients with ulcerative colitis (7 studies) (OR, 4.39; 95% CI, 3.44-5.61; I 2), but not in patients with Crohn’s disease (4 studies) (OR, 2.21; 95% CI, 0.84-5.77; I 2). Individual studies were limited by an inability to control for IBD disease activity and therapeutic interventions. Conclusions: On the basis of 10 observational studies with at least moderate quality, CDI seems to increase mortality risk in IBD, particularly in ulcerative colitis. These findings are a cause for concern and suggest that CDI should be managed aggressively in patients with IBD.

AbstractObjectivesTo assess the in‐hospital mortality and complications in female between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).BackgroundFemale is one of the risk factors for increased adverse events in cardiac surgery.Methods and resultsNationwide Inpatient Sample database was queried from 2011 to 2014 for patients who underwent TAVR or SAVR in female patients. The primary endpoint was in‐hospital all‐cause mortality and second endpoints were perioperative complications. We performed a propensity score analysis to calculate the adjusted odds ratio (OR) for each outcome. Patients who had concomitant cardiac surgery and those who had TAVR or SAVR mainly for aortic regurgitation were excluded. Our query from 2011 to 2014 resulted in a total of 3,067 TAVR and 18,594 SAVR in female patients. TAVR patients were in general elder and had a higher burden of comorbidities. The primary endpoint was similar between TAVR and SAVR (4.2% vs. 3.9%, OR 1.0, P = 0.89). Compared to SAVR, female TAVR patients had less hemorrhage requiring transfusion (12% vs. 21%, OR 0.41, P < 0.001), perioperative cardiac arrest and nonfatal myocardial infarction (9.8% vs. 17%, OR 0.38, P < 0.001), respiratory complication (1.6% vs. 4.4%, OR 0.28, P < 0.001), post‐op sepsis (1.7% vs. 2.9%, OR 0.65, P = 0.03), acute myocardial infarction (3.0% vs. 4.9%, OR 0.60, P < 0.001), and acute kidney injury (15% vs. 18%, OR 0.62, P < 0.001). Conversely, female TAVR patients had significantly increased risk of new pacemaker implantation (11% vs. 5.9%, OR 1.7, P < 0.001) and use of extracorporeal membrane oxygenation (0.66% vs. 0.24%, OR 2.8, P < 0.001). TAVR patients had less nonroutine discharge. The median hospital cost was significantly higher in TAVR than SAVR (median $51,274 vs. $43,677, P < 0.001) but the length of stay was shorter (mean 7.8 days vs. 10.5 days).ConclusionsTAVR may be a better option for those patients with underlying comorbidities that predispose them at higher risk for complications that was less observed in TAVR group. However, higher cost and increased risk of need for extracorporeal membrane oxygenation, although rare, should be taken into consideration upon deciding the optimal mode for aortic valve replacement.

AbstractBackgroundTo assess the impact of post transcatheter aortic valve implantation (TAVI) mild paravalvular regurgitation (PVR) on mortality. More than moderate PVR after TAVI has decreased with the advent of new‐generation prosthetic valves. However, mild PVR remains common and its clinical impact has been inconsistent. We aimed to assess the impact of mild PVR through meta‐analysis.Methods and ResultsA systematic literature search was conducted through PUBMED and EMBSE. Manuscripts that reported hazard ratio (HR) with 95% confidence interval (CI) for clinical outcome of interest (all‐cause and cardiac mortality) has been included. Random‐effects model was used for calculation of HR. A total of 25 articles including total of 21,018 patients were finally included for quantitative synthesis (meta‐analysis). Our pooled analysis demonstrated higher all‐cause mortality in patients with mild PVR compared to none/trivial PVR (HR 1.26, 95%CI 1.11–1.43, I2=45%, p < 0.001) (follow up duration range 6 months to 5 years). Significant heterogeneity among studies was observed (p for heterogeneity = 0.005). Egger's test showed no evidence of publication bias. Cardiovascular mortality was increased in patients with mild PVR compared with none/trivial PVR (HR 1.28, 95%CI 1.05–1.57, I2=8%, p = 0.02) (follow up duration range 1–3 years).ConclusionsMild PVR was associated with increased all‐cause and cardiovascular mortality after TAVI. Whether further interventions in mild PVR is of benefit, has yet to be determined.

AbstractObjectivesTo summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).BackgroundCTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve‐in‐valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve‐in‐valve/valve‐in‐ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high‐surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described.MethodsWe performed a systematic review of all the published articles from PUBMED and EMBASE.ResultsA total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6–365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post‐procedure was rare.ConclusionsCTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.

VA Cooperative Studies Program #571 (DIVA) was designed to evaluate the efficacy of drug‐eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure when compared with bare‐metal stents (BMS) in participants undergoing stenting of de novo SVG lesions. Participants undergoing clinically indicated stenting of de novo SVG lesions were randomized in a 1:1 ratio to DES or BMS. Randomization was stratified by presence/absence of diabetes mellitus and the number of target SVG lesions (1 vs ≥2) within each participating site. At sites that did not routinely administer 12‐months of dual antiplatelet therapy after SVG stenting participants without acute coronary syndromes received 1 month of open‐label clopidogrel, followed by 11 months of clopidogrel for those assigned to DES and 11 months of placebo for those assigned to BMS. The primary endpoint was the 12‐month incidence of target‐vessel failure (defined as the composite of cardiac death, target‐vessel myocardial infarction, or target‐vessel revascularization). Secondary endpoints included the incidence of other clinical endpoints and the incremental cost‐effectiveness of DES relative to BMS. Due to lower‐than‐anticipated target‐vessel failure rates, target enrollment was increased from 519 to 762. The study had randomized 599 participants when recruitment ended in December 2015. The DIVA trial will provide clarity on the appropriate stent type for de novo SVG lesions.

AbstractBackgroundEvidence suggests that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing Transcatheter aortic valve replacement (TAVR) in the United States.MethodsThis study was conducted using the National Inpatient Sample (NIS) in the United States from 2011 to 2014. Teaching status was classified, as teaching vs. nonteaching and endpoints were clinical outcomes, length of stay and cost. Procedure‐related complications were identified via ICD‐9 coding and analysis was performed via mixed effect model.ResultsAn estimated 33,790 TAVR procedures were performed in the U.S between 2011 and 2014, out of which 89.3% were in teaching hospitals. Mean (SD) age was 81.4 (8.5) and 47% were females. There was no significant difference between teaching versus nonteaching hospitals in regards to the primary outcome of in‐hospital mortality and secondary outcomes of several cardiovascular and other end points except for a high rates of acute kidney injury (AKI) (OR: 1.34 [95% CI, 1.04–1.72]) and lower rate for use of mechanical circulatory support devices in teaching vs. nonteaching centers. The mean length of stay was significantly higher in teaching hospitals (7.7 days) vs. nonteaching hospitals (6.8 days) (P = 0.002) and so was the median cost of hospitalization (USD 50,814 vs. USD 48, 787, P = 0.02) for teaching vs. nonteaching centers.ConclusionMost TAVR related short‐term outcomes including all cause in‐hospital mortality are about the same in teaching and nonteaching hospitals. However, AKI, length of hospital stay and TAVR related cost were significantly higher in teaching than nonteaching hospitals. There was more use of mechanical circulatory support in nonteaching than teaching hospitals.