Clinical and Economic Outcomes Associated With Remote Monitoring for Cardiac Implantable Electronic Devices: A Population-Based Analysis.

BACKGROUND: Despite expert recommendations advocating use of remote monitoring (RM) of cardiac implantable electronic devices, implementation in routine clinical practice remains modest due to inconsistent funding policies across health systems and uncertainty regarding the efficacy of RM to reduce adverse cardiovascular outcomes. METHODS: We conducted a population-based cohort study of patients with de novo implantable cardioverter-defibrillators (ICDs) with or without cardiac resynchronization therapy (CRT-D), using administrative health data in Alberta, Canada, from 2010 to 2016. We assessed RM status as a predictor of all-cause mortality and cardiovascular (CV) hospitalization using Cox proportional hazards modelling, and direct health costs by generalized linear models. From this real-world data, we then constructed a decision-analytic Markov model to estimate the projected costs and benefits associated with RM compared with in-clinic visit follow-up alone. RESULTS: Among 2799 ICD and CRT-D patients, 1830 (63.4%) were followed by RM for a mean follow-up of 50.3 months. After adjustment for age, sex, and comorbidities, RM was associated with a lower risk of death (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.36-0.52; P < 0.001) and CV hospitalization (HR 0.76, 95% CI 0.64-0.91; P = 0.002). In the economic model, cost savings were observed over 5 years with an estimated savings of $12,195 per person (95% CI -$21,818 to -$4,790). The model estimated a cost-savings associated with RM strategy in 99% of simulations. CONCLUSIONS: These population data support more widespread implementation of RM technology to facilitate better patient outcomes and improve health system efficiency.

Seroprevalencia de la infección por el virus SARS-CoV-2 en estudiantes de pregado de ciencias de la salud de una universidad pública / Seroprevalence of SARS-CoV-2 virus infection in undergraduate health sciences students from a public university

RESUMEN Introducción. El primer caso de COVID-19 en el Perú fue reportado el 5 de marzo del 2020 y se declaró el aislamiento social el 16 de marzo, quedando con ello interrumpida la actividad académica en las instituciones educativas. Objetivo. Determinar la seroprevalencia y los factores de riesgo asociados a la infección por SARS-CoV-2 en estudiantes de pregrado de una facultad de medicina en una universidad pública. Métodos. Estudio descriptivo, transversal mediante una encuesta serológica a una muestra aleatoria representativa de la población de estudiantes de pregrado de ciencias de la salud, utilizando una prueba rápida para la detección de anticuerpos IgG, IgM, o ambos, mediante la toma de muestra de sangre total del pulpejo de dedo. Resultados. Para el mes de agosto del 2021, el 24,92% (IC95% 18,2-33,0) de los estudiantes de ciencias de la salud presentaron anticuerpos contra el SARS-CoV-2, de ellos el 21,2% a IgG, 2,3% a IgM y 0,8% a ambos, el 75,08% (IC95% 66,9-82,0) no presentaron anticuerpos. Conclusiones. La seroprevalencia en estudiantes no muestra diferencia con la seroprevalencia de la enfermedad en la población general. Por lo tanto, para reiniciar las actividades académicas presenciales, esta población debe ser vacunada y debe cumplir además con las medidas no farmacológicas para la prevención y el control de la pandemia como son la ventilación natural de los ambientes, el uso de medidas de protección personal- mascarillas, lavado de manos y el distanciamiento físico.

ABSTRACT Introduction. On March 5 2020, the first case of COVID-19 was reported and on March 16, order of quarantine was issued which resulted in interruption of academic activities. Objective. Determine the seroprevalence and risk factors associated to SARS-CoV-2 infection in undergraduate students of the school of medicine in a public university. Methods. Descriptive cross-sectional study by means of a serology survey to a representative sample of the population of undergraduate students of a health sciences school using a rapid test to detect antibodies IgG, IGM or both in a total blood sample by digital punction. Results. On August 2021, 24,92% (IC95% 18,2-33,0) of students of health sciences tested positive for antibodies anti SARS-CoV-2, 21,2% for IgG, 2,3% for IGM and 0,8% for both; 75,08% (IC95% 66,9-82,0) tested negative antibodies. Conclusions. The seroprevalence in students was not different from the seroprevalence in general population. Therefore, in order to restart presential academic activities this population must be vaccinated and other nonpharmacological requirements should be accomplished for prevention and control of the pandemics such as natural ventilation of classrooms, use of personal protection equipment - masks, hand washing and keeping physical distancing.

Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial.

Importance: The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown. Objective: To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days. Design, Setting, and Participants: Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018. Interventions: Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months. Main Outcomes and Measures: The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months. Results: Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events. Conclusions and Relevance: Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT02428140.

Age, Sex, and Remote Monitoring Differences in Device Acceptance for Patients With Implanted Cardioverter Defibrillators in Canada.

BACKGROUND: Implantable cardioverter defibrillator (ICD) acceptance and shock anxiety are issues that clinicians should address to improve quality of life among device recipients. Previous findings have indicated that younger patients experience poorer device adjustment. The purpose of this study was to examine age and ICD-specific quality-of-life outcomes in a large sample of Canadian ICD patients. We tested the hypothesis that patient age is related to device acceptance and shock anxiety in an Alberta (Canada) ICD population. METHODS: The Florida Patient Acceptance Survey (FPAS) and Florida Shock Acceptance Survey (FSAS) were completed by ICD patients attending the Cardiac Implantable Electrical Device Clinics in Alberta. The population was dichotomized into those aged ≤ 65 years (younger) and those aged > 65 years (older). Sex, ICD shock history, and remote monitoring use were also examined. RESULTS: Surveys were completed by 126 younger (53 ± 11 years; 79% male) and 216 older (74 ± 6 years; 85% male) patients. Younger, compared with older, patients had greater device-related distress (P < 0.001) and more body-image concerns (P < 0.001), but no differences in return to function or positive appraisal. Younger patients reported lower total device acceptance (P = 0.001) and greater total shock anxiety (P < 0.001) compared with older patients. CONCLUSIONS: ICD patients aged ≤ 65 years reported poorer device acceptance and greater shock anxiety than older patients. Younger patients may require targeted interventions addressing adjustment to the ICD, and impact of the ICD on body image. Moreover, education about the relatively low probability of shocks may alleviate shock anxiety in younger patients.

CONTEXTE: L'acceptation d'un défibrillateur cardioverteur implantable (DCI) et la crainte des chocs de DCI sont des problèmes auxquels les cliniciens devraient s'attaquer pour améliorer la qualité de vie des patients qui sont porteurs d'un DCI. Selon des observations antérieures, les plus jeunes patients ont davantage de mal à s'adapter au dispositif. L'étude avait pour objet l'examen des paramètres de la qualité de vie particuliers à l'âge et au port d'un DCI dans un vaste échantillon de patients canadiens porteurs de ce dispositif. Nous avons testé l'hypothèse voulant que l'âge du patient soit lié à l'acceptation du dispositif et à la crainte des chocs chez des Albertains porteurs d'un DCI. MÉTHODOLOGIE: Les patients des cliniques de l'Alberta (Canada) des dispositifs cardiaques électroniques implantables qui étaient porteurs d'un DCI ont rempli les questionnaires FPAS (Florida Patient Acceptance Survey) et FSAS (Florida Shock Acceptance Survey). Les patients ont été partagés en deux groupes selon leur âge, soit ceux de 65 ans et moins (plus jeunes patients) et ceux de plus de 65 ans (patients âgés). Nous avons aussi examiné les facteurs suivants : sexe, chocs de DCI antérieurs et utilisation d'une télésurveillance. RÉSULTATS: Les questionnaires ont été remplis par 126 plus jeunes patients (53 ± 11 ans; 79 % d'hommes) et 216 patients âgés (74 ± 6 ans; 85 % d'hommes). Chez les plus jeunes patients, par rapport aux patients âgés, la détresse causée par le dispositif était plus grande (p < 0,001) et il y avait davantage de préoccupations liées à l'image corporelle (p < 0001), mais il n'y avait pas de différences pour ce qui est de la reprise des activités ou de l'évaluation positive du dispositif. Chez les plus jeunes patients, l'acceptation totale du dispositif était moindre (p = 0,001) et la crainte des chocs était plus grande (p < 0,001) que chez les patients âgés. CONCLUSIONS: Chez les porteurs d'un DCI de 65 ans et moins, le dispositif était moins bien accepté, et la crainte des chocs était plus grande que chez les patients âgés. Chez les plus jeunes patients, des interventions ciblées axées sur l'adaptation au DCI et les répercussions du DCI sur l'image corporelle pourraient être nécessaires. De plus, l'éducation à propos de la probabilité relativement faible de subir des chocs pourrait réduire cette crainte chez les plus jeunes patients.

A Population-Based Study of Device Eligibility, Use, and Reasons for Nonimplantation in Patients at Heart Function Clinics.

BACKGROUND: Implantable cardioverter defibrillator (ICD) therapy is lifesaving; however, real-world data regarding the proportion of patients eligible for a primary prevention ICD and subsequent use remain sparse. This study evaluated rates of primary prevention ICD eligibility and use among patients in heart function clinics (HFCs) and to identify reasons for nonimplantation. METHODS: A retrospective study was performed of patients seen at HFCs in Alberta, Canada, from 2013 to 2015. Demographics, comorbidities, clinical indications, and reasons for nonimplantation were abstracted. Eligibility was defined according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society ICD, 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society Focused Update, and 2013 Canadian Cardiovascular Society Cardiac Resynchronization Therapy guidelines. Logistic regression was used to calculate an odds ratio (OR) and 95% confidence interval (CI) for predictors of nonimplantation. RESULTS: Among 1239 patients in HFCs, the median age was 70 years (interquartile range, 59-80), 67% were male, and the median left ventricular ejection fraction was 0.40 (interquartile range, 0.28-0.53). Overall, 45% of patients (n = 553) met guideline criteria for an ICD, and of those, 36% (n = 198) received a device. Among device nonrecipients, 52% (n = 185) had no documented reason for nonimplantation. The most common reason for nonimplantation among nonrecipients was patient preference (48%). Predictors associated with nonimplantation were age more than 75 years (OR, 1.92; 95% CI, 1.31-2.82) and history of cancer (OR, 2.26; 95% CI, 1.07-4.78). At 3 years follow-up, 27% of nonrecipients were deceased. CONCLUSIONS: We found that one-third of patients who met guideline criteria received an ICD and that documentation for nonimplantation was poor.

CONTEXTE: Le défibrillateur cardioverteur implantable (DCI) sauve des vies. Or, les données recueillies dans la pratique réelle concernant le pourcentage de patients admissibles à l'implantation d'un tel dispositif en prévention primaire et l'utilisation subséquente de ce dispositif sont très limitées. Cette étude a évalué le taux de patients admissibles à la pose d'un DCI en prévention primaire et le taux d'utilisation de ce dispositif chez des patients traités en clinique de cardiologie. Elle a également recensé les motifs de non-implantation. MÉTHODOLOGIE: Une étude rétrospective a été réalisée chez des patients traités de 2013 à 2015 dans plusieurs cliniques de cardiologie de l'Alberta, au Canada. Les données relatives aux caractéristiques démographiques, aux comorbidités, aux indications cliniques et aux motifs de la non-implantation ont été extraites. L'admissibilité était définie en fonction des lignes directrices de 2008 de l'American College of Cardiology, de l'American Heart Association et de la Heart Rhythm Society sur le DCI, de leur mise à jour ciblée en 2012 et des lignes directrices de 2013 de la Société canadienne de cardiologie sur la thérapie de resynchronisation cardiaque. Une régression logistique a été utilisée pour calculer le risque relatif approché (RRA) et l'intervalle de confiance (IC) à 95 % associés aux facteurs de prédiction de la non-implantation. RÉSULTATS: L'âge médian des 1 239 patients traités en clinique de cardiologie était de 70 ans (plage interquartile : 59 ­ 80 ans); 67 % d'entre eux étaient des hommes, et la fraction d'éjection ventriculaire gauche médiane était de 0,40 (plage interquartile : 0,28 ­ 0,53). D'une manière générale, 45 % des patients (n = 553) répondaient aux critères énoncés dans les lignes directrices pour la pose d'un DCI, et 36 % d'entre eux (n = 198) ont reçu un dispositif. Parmi les patients qui n'ont pas reçu de dispositif, aucun motif justifiant la non-implantation n'a été documenté chez 52 % des patients (n = 185); chez les 48 % des patients restants, le motif le plus courant pour justifier la non-implantation a été la préférence du patient. Les facteurs de prédiction associés à la non-implantation ont été l'âge (plus de 75 ans; RRA : 1,92; IC à 95 % : 1,31 ­ 2,82) et les antécédents de cancer (RRA : 2,26; IC à 95 % : 1,07 ­ 4,78). Après 3 ans de suivi, 27 % des patients qui n'avaient pas reçu de dispositif étaient décédés. CONCLUSIONS: Nous avons constaté que le tiers des patients qui répondaient aux critères énoncés dans les lignes directrices ont reçu un DCI et que les motifs justifiant la non-implantation étaient mal documentés.

A Population-Based Study of Adherence to Guideline Recommendations and Appropriate-Use Criteria for Implantable Cardioverter Defibrillators.

Studies evaluating physician adherence to guideline recommendations for implantable cardioverter defibrillator (ICD) therapy are sparse, and none exist for the application of appropriate-use criteria (AUC) in clinical practice. As part of a quality improvement initiative, a review of all ICD procedures was performed from January 1, 2015 to December 31, 2016 in Alberta, Canada, to evaluate the proportion of patients receiving appropriate ICD therapy and to identify reasons for nonadherence. Our device-implant process involves an electrophysiologist or implanting cardiologist evaluation, reminders of ICD eligibility criteria on the device requisition, and peer-review consensus. Implants were classified according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) ICD guidelines, 2013 Canadian Cardiovascular Society (CCS) Cardiac Resynchronization Therapy (CRT) guidelines, and 2013 AUC. There were 1,300 ICD procedures performed, and the mean age was 63.8 ± 12.9 years; 79% were male; the mean ejection fraction was 0.32 ± 0.13, and 69% were for primary prevention. Among all implants, < 1% were discordant with American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) recommendations. Among CRT implants, 10% were inconsistent with Canadian Cardiovascular Society (CCS) recommendations. According to AUC, 92% of implants were appropriate. Reasons for nonadherence to ACC/AHA/HRS recommendations included QRS width < 120 msec (n = 3), LVEF > 0.35 (n = 2) and recent myocardial infarction (MI) (n = 1). The most common reason for nonadherence to AUC was the absence of criteria for classification (n = 57, 4%). In this population-based study, we found that a process of specialist evaluation, eligibility reminders on device forms, and peer-review consensus may improve adherence to guideline recommendations and AUC for ICD therapy.

Assessing physician knowledge regarding indications for a primary prevention implantable defibrillator and potential barriers for referral.

BACKGROUND: Although there is clear evidence to demonstrate that primary prevention implantable defibrillators (ICDs) reduce mortality in high-risk patients, ICDs are underutilized. Limited data exist assessing referring physicians' knowledge about guideline indications and attitudes towards ICDs, which may influence decision for referral. METHODS AND RESULTS: The Arrhythmia Working Group from the Alberta Cardiovascular and Stroke Strategic Clinical Network developed a web-based survey consisting of case scenarios regarding primary prevention ICD indications and a list of barriers for referral to aid in the design of a complex device care pathway. We invited referring physicians to participate in the survey including internists and cardiologists and cardiology residents. The survey was completed by 109 of 799 (response rate = 14%) of physicians. Of those, 55% were internists, 32% cardiologists, and 13% cardiology residents. The majority of physicians were male (62%), practicing in a university hospital (66%). Overall, complete guideline-concordant answers were provided by 34% of physicians. In multivariable analysis, predictors of complete guideline concordance were being a cardiologist (odd ratio [OR] 5.9, confidence interval [CI] 2.1-16.4, P = 0.001) and cardiology resident (OR 6.7, CI 1.7-27.3, P = 0.007). The most common barrier for referral for internists was lack of confidence in knowledge of guideline recommendations; while cardiologists reported concerns about cost-effectiveness and cardiology residents were most concerned with inappropriate shocks. CONCLUSION: Knowledge regarding indications for primary prevention ICD is limited and varies significantly among referring physicians. The barriers for referral differ among physician groups and addressing these identified barriers may help to improve appropriate ICD utilization.

Abdomen abierto con fístula gástrica y colón transverso / Open abdomen with gastric fistula and tranverse colon fistula

El abdomen abierto es una técnica quirúrgica para el tratamiento de la sepsis abdominal(peritonitis) realizada bajo anestesia, mediante la cual se hace lavado amplio de la cavidad abdominal y se deja protector de asas intestinales con bolsa de Bogotá (de polivinilcloruro, viaflex) u otros contenedores abdominales con la intención de realizar lavados repetidos según la evolución del paciente. Una de las complicaciones más graves en este tipo de pacientes es la fístula entero cutánea de tipo IV según la clasificación de SCHEIM. El manejo de estos pacientes exige una estrecha relación interdisciplinaria; de ello dependerá el pronóstico. Se presenta el caso clínico de un paciente de género masculino de 56 años con antecedentes patológicos crónicos, quien por su obesidad severa (índice de masa corporal mayor de 45), se sometió a derivación bilio-pancreática y switch duodenal; en el mismo tiempo quirúrgico se realizó colecistectomía y eventrorrafia con malla. Por sus antecedentes quirúrgicos, como parte del tratamiento de su obesidad mórbida, presentó como complicación fístulas entero cutáneas y falla multisistémica. El paciente requirió larga estancia hospitalaria, manejo de terapia enterostomal. Su evolución, esquema de tratamiento y la intervención de enfermería se presentan a continuación. También se adiciona revisión de literatura