Association Between Serum Albumin and the Length of Hospital Stay Among Patients With Acute Heart Failure.

Introduction: Albumin plays a vital role in improving osmotic pressure and hemodynamics. A lower serum albumin level may cause pulmonary congestion and edema and contribute to myocardial dysfunction, diuresis resistance, and fluid retention in acute heart failure. Hypothesis: We hypothesized that AHF patients with normal serum albumin have shorter hospital stays. Methods: Using Electronic Medical Records, patients admitted from May 2020 through May 2021 aged >18, ICD-10, and positive Framingham Heart Failure Diagnostic Criteria were included. We excluded patients without albumin records and eGFRs less than 30 mL/min/1.73 m2. Prolonged hospitalization was defined as >8 days of hospitalization. Results: During index emergency department visits, patients were symptomatic (New York Heart Association), aged median of 70 years (Interquartile range (IQR) 18), 59% (n = 103) were male, predominantly White (73%, n = 128), and had a high Charleston Comorbidity index score [5, IQR (4-7)]. Nearly one-fourth (23%, n = 41) of the patients had <3.5 g/dL albumin levels. The median length of hospital stay was eight days (IQR of 11). Comparing differences between lengths of hospital stays (<8 vs. >8 days), there was different serum albumin (3.9 + 0.48 vs. 3.6 + 0.53, p < .001) and left ventricular ejection fraction (45% (range 26-63) versus 30% (range 24-48), p = .004). An increased serum albumin decreased prolonged hospitalization (odds ratio (OR), 0.28; 95% confidence interval (CI), 0.14-0.55, p = <0.001). Patients in the lower albumin group had higher NT-proBNP (median: 8521 (range 2025-9134) versus 5147 (range 2966-14,795) pg/ml, p = .007) and delay in administering intravenous diuretics (391 (167-964) minutes versus 271 (range 157-533) minutes, p = .02). Conclusion: Hypoalbuminemia is strongly associated with prolonged hospitalization. Timely and effective diuretic therapy may reduce hospital stay durations, particularly with albumin supplementation.

Estimating Ejection Fraction from the 12 Lead ECG among Patients with Acute Heart Failure.

Background: Identifying patients with low left ventricular ejection fraction (LVEF) in the emergency department using an electrocardiogram (ECG) may optimize acute heart failure (AHF) management. We aimed to assess the efficacy of 527 automated 12-lead ECG features for estimating LVEF among patients with AHF. Method: Medical records of patients >18 years old and AHF-related ICD codes, demographics, LVEF %, comorbidities, and medication were analyzed. Least Absolute Shrinkage and Selection Operator (LASSO) identified important ECG features and evaluated performance. Results: Among 851 patients, the mean age was 74 years (IQR:11), male 56% (n=478), and the median body mass index was 29 kg/m2 (IQR:1.8). A total of 914 echocardiograms and ECGs were matched; the time between ECG-Echocardiogram was 9 hours (IQR of 9 hours); ≤30% LVEF (16.45%, n=140). Lasso demonstrated 42 ECG features important for estimating LVEF ≤30%. The predictive model of LVEF ≤30% demonstrated an area under the curve (AUC) of 0.86, a 95% confidence interval (CI) of 0.83 to 0.89, a specificity of 54% (50% to 57%), and a sensitivity of 91 (95% CI: 88% to 96%), accuracy 60% (95% CI:60 % to 63%) and, negative predictive value of 95%. Conclusions: An explainable machine learning model with physiologically feasible predictors may be useful in screening patients with low LVEF in AHF.

Signs and Symptoms Clusters Among Patients With Acute Heart Failure: A Correlational Study.

BACKGROUND: Patients with acute heart failure present to the emergency department with a myriad of signs and symptoms. Symptoms evaluated in clusters may be more meaningful than those evaluated individually by clinicians. OBJECTIVE: Among emergency department patients, we aimed to identify signs and symptoms correlations, clusters, and differences in clinical variables between clusters. METHODS: Medical record data included adults older than 18 years, International Classification of Diseases, Tenth Revisions codes , and positive Framingham Heart Failure Diagnostic Criteria. Exclusion criteria included medical records with a ventricular assist device and dialysis. For analysis, correlation, and the Gower distance, the independent t test, Mann-Whitney U test, χ 2 test, and regression were performed. RESULTS: A secondary analysis was conducted from the data set to evaluate door-to-diuretic time among patients with acute heart failure in the emergency department. A total of 218 patients were included, with an average age of 69 ± 15 years and predominantly White (74%, n = 161). Two distinct symptom clusters were identified: severe and mild congestion. The severe congestion cluster had a more comorbidity burden compared with the mild congestion cluster, as measured by the Charlson Comorbidity index (cluster 1 vs cluster 2, 6 [5-7] vs 5 [4-6]; P = .0019). Heart failure with preserved ejection fraction was associated with the severe congestion symptom cluster ( P = .009), and heart failure with mildly reduced ejection fraction was associated with the mild congestion cluster ( P = .019). CONCLUSIONS: In conclusion, 2 distinct symptom clusters were identified among patients with acute heart failure. Symptom clusters may be related to ejection fraction or overall cardiac output and comorbidity burden.

Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure.

INTRODUCTION: Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation. METHODS: We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported. RESULTS: Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG. CONCLUSIONS: ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.

Management of COVID-19 and vaccination in Nepal: A qualitative study.

OBJECTIVE: The aim of this research is to investigate the perspective of citizens of Nepal on the management COVID-19, the roll-out of the vaccine, and to gain an understanding of attitudes towards the governments' handling of the COVID-19 pandemic. METHOD: A qualitative methodology was used. In-depth interviews were conducted with 18 males and 23 females aged between 20 and 86 years old from one remote and one urban district of Nepal. Interviews were conducted in November and December 2021. A thematic approach was used to analyse the data, utilising NVivo 12 data management software. RESULT: Three major themes were identified: (1) Peoples' perspective on the management of COVID-19, (2) people's perception of the management of COVID-19 vaccination and (3) management and dissemination of information. It was found that most participants had heard of COVID-19 and its mitigation measures, however, the majority had limited understanding and knowledge about the disease. Most participants expressed their disappointment concerning poor testing, quarantine, vaccination campaigns and poor accountability from the government towards the management of COVID-19. Misinformation and stigma were reported as the major factors contributing to the spread of COVID-19. People's knowledge and understanding were mainly shaped by the quality of the information they received from various sources of communication and social media. This heavily influenced their response to the pandemic, the preventive measures they followed and their attitude towards vaccination. CONCLUSION: Our study concludes that the study participants' perception was that testing, quarantine centres and vaccination campaigns were poorly managed in both urban and rural settings in Nepal. Since people's knowledge and understanding of COVID-19 are heavily influenced by the quality of information they receive, we suggest providing contextualised correct information through a trusted channel regarding the pandemic, its preventive measures and vaccination. This study recommends that the government proactively involve grassroots-level volunteers like Female Community Health Volunteers to effectively prepare for future pandemics. PATIENT AND PUBLIC CONTRIBUTION: This study was based on in-depth interviews with 41 people from diverse socioeconomic backgrounds. This study would not have been possible without their participation.

Access to assistive technology for persons with disabilities: a critical review from Nepal, India and Bangladesh.

PURPOSE: The purpose of this paper is to analyse and critically reflect on access to Assistive Technology (AT) for persons with disabilities (PWD) in Nepal, India and Bangladesh. This analysis aims to guide the development of a contextualised generic AT service delivery model suitable for these countries, based on the best practices identified. MATERIALS AND METHODS: This paper is based on a comprehensive study conducted in Nepal, India and Bangladesh, observing mobility and hearing-related AT service delivery centres run by the government, as well as private and nongovernmental organisations, and interviews with key informants: policymakers (5), AT service providers (20) and AT service users (20) between December 2019 to February 2020. A descriptive, qualitative exploratory study design was followed. A quality assessment framework was used to structure the analysis and interpret the findings. RESULTS: AT service provisions are poorly developed in all three countries. On all quality indicators assessed, the systems show major weaknesses. AT users have very limited awareness about their rights to these services and the availability of AT services, the range of services available is very limited, and eligibility is dependent on medical criteria related to visible and severe disabilities. CONCLUSIONS: Lack of accessibility, eligibility, reachability and affordability are the main barriers to access AT services for PWD in Nepal, India and Bangladesh. Increased community level awareness, increased Government funding and a community based, medically informed flexible social model of AT services is a way forward to ensure access to AT services for PWD in these countries.IMPLICATIONS FOR REHABILITATIONIncreased community awareness is necessary to increase access to Assistive Technology Services for Persons with Disabilities.Increased and flexible funding from the Government and philanthropists will improve rehabilitation.Establishment of community based Assistive Technology Services centres will increase access and improve rehabilitation.

Dalit's livelihoods in Nepal: income sources and determinants.

This paper focuses on the lack of income opportunities for Dalits in Nepal, as they are the most affected group in any disaster. The presence of vulnerable family members in Dalit households may further increase their income deprivation. We therefore studied Dalit households' income sources and identified income determinants in Gandaki Rural Municipality in Gorkha District-the epicentre of the 2015 earthquake. We observed a higher dependency of Dalit households on daily wages, livestock sales, social security allowances, and vegetables sales; however, remittance and seasonal job earnings represented the largest share of household incomes. We observed a significant difference in per capita income between farm (US$46) and non-farm (US$273) income sources, with the difference smallest in the lowest income quantile and the largest in the highest quantile. When the household head was a single woman, we observed a reduction in non-farm (by 29%) and total incomes (by 23%). Likewise, when the household head had a chronic health problem, or the household included an elderly family member, there was a reduction in the household's income. We suggest economic interventions for Dalit households to prevent increased social exclusion in the development process, specifically focusing on vulnerable individuals and households in the lowest income quantile.

Processes of assistive technology service delivery in Bangladesh, India and Nepal: a critical reflection.

PURPOSE: This paper critically reviews and reflects on the processes for providing Assistive Technology (AT) services to Persons with Disabilities (PWD) in Bangladesh, India and Nepal. The aim is to investigate the AT service delivery systems in these countries and suggest improvements where weaknesses are identified. MATERIALS AND METHODS: We carried out a descriptive qualitative exploratory study in Bangladesh, India and Nepal by conducting key informant interviews with policymakers (5), AT service providers (22) and mobility and hearing related AT service users (21). We used a directed content analysis approach guided by a seven-point AT service delivery process model to thematically analyse the existing processes for AT service delivery, from first contact through to follow-up and maintenance. RESULTS: AT service delivery processes are sub-optimal in all three countries, and improvements are needed. No common AT service delivery process was found, although there are common features. In general, it is easier for PWDs in India and Nepal to access AT than for those in Bangladesh, but all three countries are failing to live up to their commitments to uphold the human rights of PWDs. CONCLUSIONS: Although good elements of AT service delivery processes can be identified, the systems in all three countries are fragmented and generally weak. A more holistic approach of looking at the process of AT service delivery, from first contact right through to follow-up and device maintenance, with a single door service delivery system, free of cost at the point of service is recommended in these countries. IMPLICATIONS FOR REHABILITATIONAlthough we found significant weaknesses in AT delivery in all three countries, there are some good AT service delivery practices and opportunities for these countries to learn from one another.A systematic and stepwise approach to assessing current AT service delivery processes in the three countries - examining the delivery system as a whole, from initiation to repair and management - can help identify opportunities to improve the process for (prospective) AT users.A more coherent single door system of AT service delivery will increase the quality and efficiency of the fragmented AT service delivery practices in Bangladesh, India and Nepal.

Delays in Door-to-Diuretic Time and 1-Year Mortality Among Patients With Heart Failure.

BACKGROUND: Achieving prompt euvolemic state in heart failure (HF) is associated with reduced mortality. Time-sensitive metrics such as door-to-diuretic time , or the time between presentation and administration of intravenous diuretics, may be an important facilitator of achieving a faster euvolemic state and reducing mortality. OBJECTIVE: The aim of this study was to investigate whether reduced door-to-diuretic time was associated with lower odds of death among hospitalized patients with HF. METHODS: A retrospective chart review of patients with HF admitted to a medical center was performed between 2020 and 2021. Inclusion criteria were an International Classification of Diseases, 10th Revision code for HF with positive Framingham Criteria and the use of intravenous bolus furosemide. Exclusion criteria included ventricular assist devices, dialysis, and ultrafiltration therapy. Data collected from the medical records included demographics, echocardiography, staff notes, and medications. The end point was 1-year all-cause mortality. Descriptive statistics, t tests or median test, and multivariate logistic regression were used to describe the sample, evaluate group differences, and determine odds of mortality, respectively. RESULTS: Among 160 charts from patients with HF (age, 70 ± 14.4 years; 52%, n = 83, male; 53%, n = 85, ischemic cardiomyopathy; 83%, n = 134, New York Heart Association classes III-IV), 30% (n = 48) died within 1 year. The median diuretic dose was 40 mg (interquartile range, 20 mg), with a median time of administration of 247 minutes (4.12 hours) (interquartile range, 294 minutes to 4.9 hours). After covariate adjustment, prolonged door-to-diuretic time more than doubled (2.22; 95% confidence interval, 1.03-4.8; P = .04) the odds of 1-year mortality. CONCLUSIONS: On the basis of this sample of charts from older highly symptomatic patients with HF, delayed door-to-diuretic time was associated with significantly greater odds of 1-year all-cause mortality.