Updated Meta-Analysis of Randomized Trials Comparing Safety and Efficacy of Intraoperative Defibrillation Testing with No Defibrillation Testing On Implantable Cardioverter-Defibrillator Implantation

Introduction: There is an ongoing debate regarding the need to conduct intraoperative defibrillation testing (DFT) at the time of implantable cardioverter-defibrillator (ICD) implantation. To provide sufficiently strong evidence for the feasibility of omitting intraoperative DFT in clinical practice, we conducted a meta-analysis of randomized controlled trials (RCT) comparing patients with DFT and no-DFT.Methods: We systematically searched Medline (via PubMed), ClinicalTrial.gov, the Cochrane Central Register of Controlled Trials, and Embase for studies evaluating DFT vs. no-DFT on ICD implantation with regard to total mortality and arrhythmic death, efficacy of first and any appropriate shock in interrupting ventricular tachycardia (VT)/ventricular fibrillation (VF), and procedural adverse events. Effect estimates [risk ratio (RR) with 95% confidence intervals (CI)] were pooled using the random-effects model.Results: Our meta-analysis included 4 RCTs comprising 3770 patients (1896 with DFT and 1874 without DFT). Total mortality (RR = 1.00, 95% CI 0.86–1.17; P = 0.98) and arrhythmic death (RR = 1.60, 95% CI 0.46-5.59: P = 0.46) were not statistically different. Both first (RR = 0.94, 95% CI 0.89–0.98; P = 0.004) and any appropriate ICD shock (RR = 0.97, 95% CI 0.95–1.00; P = 0.02) significantly increased the rate of VT/VF interruption in the group with no-DFT in comparison with DFT. Finally, the incidence of adverse events was lower in no-DFT patients (RR = 1.23; 95% CI 1.00–1.51; P = 0.05).Conclusions: The practice of DFT (as opposed to no-DFT) did not yield benefits in mortality or the overall rate of conversion of VT/VT. Moreover, a slightly higher incidence of perioperative adverse events was observed in the DFT group

Deriving a Model for Predicting Hospital Falls

Background: In the United States 700,000 to 1,000,000 people fall in the hospital annually, 1/3 result in injury. One single fall averages $14,000, resulting in an increase in hospital length of stay and burden on hospital budget. In St. Joseph Hospital of Orange, from calendar year 2019 to 2020, there was an increase in falls from 178 to 185 falls, despite the use of a telesitter. At time of data collection, 12 telesitter cameras were initiated after a fall. An investigation was deemed necessary to determine the cause of the increase and the factors related to patient falls. Purpose: The purpose is to derive and validate predictors of falls by identifying criteria responsible for falls in a population of in-patients in an acute care setting. Compare research findings responsible for falls with current fall scales. Lastly, increase awareness with bedside nurses of patients most at risk for falls. Methods: The study utilized a retrospective cross-sectional design with a review of the electronic health records from calendar years of 2018 and 2019. Patients included are over the age of 18 and who were admitted to inpatient units in the hospital. A comprehensive literature review and comparison of current fall scales provided for identification of similarities, differences, and gaps among fall scales and identified common fall factors. Findings from the literature review were used to select variables for this study. The statistical methods and modeling used were descriptive statistics, continuous variables, categorical variables and bivariate analysis. Results: A total of 1,247 patient records, 929 records were randomized, while the other 318 records represented patients who fell during the hospital stay. Patient demographics shown to be statistically significant were age, gender, length of stay, and diagnosis. Identified patient behavior at most risk for falls are withdrawn, restless, anxious, and agitated. Lastly, if patient takes sedatives, anti-convulsants, anti-psychotics, and anticoagulants put a patient at risk for falls. Statistical analysis identified the factors posing the greatest risk. The strongest individual predictor was dizziness and vertigo; individuals were 7.2 times more likely to fall than those without dizziness/vertigo. Results also demonstrated a two-level “high” Morse Fall Risk with those with a 65 or greater score having double the risk of falling than those scoring 45-64. The fall predictor model derived from this study predicted 82% of the falls. This was especially significant when compared to the Morse Fall Scale which only predicted 62% of the falls. Conclusions: Results of the study will contribute to changes in policy and procedure on fall interventions for low, moderate, and high fall risk patients. Learning which variables are most likely to be present in a patient who could fall, can increase a bedside nurse awareness, and improve patient safety. Implications for practice: For future research, we would like to utilize the data and create a new model for predicting patient falls. Partner with other ministries to replicate study to see if results are similar. Incorporate the developed model to classify patient\u27s at risk for falls or early visual camera implementation

Análisis sistémico de las externalidades del mercado de bioetanol

Trabajo de investigaciónEn Colombia a partir de la resolución 40108 de 2018, se aumentó el porcentaje de mezcla del combustibles llegando a un 10% (90% combustibles fósiles 10% biocombustibles), actualmente para suplir esta demanda, las productoras de bioetanol requieren emplear al 100% su capacidad instalada, mejorar sus prácticas de cultivo de caña de azúcar y hacer uso de nuevas hectáreas, por tanto, el presente trabajo de grado tiene como objetivo realizar un análisis sistémico de las externalidades del mercado de bioetanol.INTRODUCCIÓN 1. Formulación del trabajo 2. Marco referencial 3. Diagrama propuesto 4. Conclusiones generales BibliografiaPregradoEconomist

Genética y genómica médica en el Perú

Genética y genómica médica en el Per

Improving Discharge Times and Patient Flow

Background: Delays in discharging patients can impact hospital and emergency department (ED) throughput. The complex discharge process makes it difficult to ensure that patients are set up for successful post-hospital care regimens. The focus of this project was to improve discharge times and flow throughout the hospital to align with national standards of providing the right care, in the right place, at the right time. To improve access to beds, The Joint Commission stipulates that hospitals have processes in place to support patient flow throughout the hospital and to use data to drive improvements in patient flow. Failure to regulate flow puts patients at risk for harm and less than optimal care. It also increases clinician burden which may accelerate burnout. A lack of optimal patient flow results in ED boarding and diversions, long waits, and boarding in post-anesthesia care units. Purpose: The purpose of this project was to improve overall patient throughput within one large acute care hospital by improving discharge times. Baseline discharge times averaged over 4 hours with less than 15% of patients being discharged in less than 2 hours. Methods: A multidisciplinary patient flow team was charged with improving discharge times and removing barriers to timely discharges. The team consisted of representation from executive leadership, nursing management, pharmacy, physician staff, case management, and frontline staff. Meeting weekly, the team rapidly instituted small tests of change to address the barriers to timely discharges. The Admission Discharge Team facilitated education. Discharge accountability teams on nightshift assisted with preparing patients for discharge. Case Manager/charge nurse rounds were instituted to identify patients ready for discharge and anticipated barriers. Electronic whiteboards were utilized for interdisciplinary communication. Discharge times were reported weekly in a public area on units. Results: The program resulted in an increase in caregiver engagement in discharges and discharge times. Readmission rates decreased for heart failure patients to below national benchmark. Discharges completed in less than 2 hours improved to almost 30%. Average discharge times decreased from 4 hours to 2 hours and 30 minutes. Also, responses improved to the patient satisfaction question When I left the hospital, I had a good understanding of the things I was responsible for in managing my heath: by 25%. Conclusions: Discharge planning that is initiated on the day of admission and addressed ongoing in a uniform fashion by both nursing shifts and ancillary caregivers can alleviate delays on discharge day. An improvement in discharge times improved hospital flow. A focused approach on education throughout the patients stay improved their ability to manage their health at home and reduced readmits. Implication for Practice: The discharge protocol and procedures will continue to be implemented and evaluated for improvement needs and barriers and expanded to include skilled nursing facility transfers. The discharge process has been implemented in several inpatient units. Discharge times/barriers will be re-evaluated quarterly and the focused patient flow team will make additional adjustments to make the discharge process more efficient.https://digitalcommons.psjhealth.org/prov_rn_conf_all/1034/thumbnail.jp

Pulsed field ablation technology for pulmonary vein and left atrial posterior wall isolation in patients with persistent atrial fibrillation

Introduction: Limited data exist on pulsed-field ablation (PFA) in patients with persistent atrial fibrillation (PeAF) undergoing left atrial posterior wall isolation (LAPWI). Methods: The Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA) prospective registry included consecutive patients referred for PeAF catheter ablation at 9 Italian centers, treated with the FARAPULSETM-PFA system. The primary efficacy and safety study endpoints were the acute LAPWI rate, freedom from arrhythmic recurrences and the incidence of major periprocedural complications. Patients undergoing pulmonary vein isolation (PVI) alone, PWI + LAPWI and redo procedures were compared. Results: Among 249 patients, 21.7% had long-standing PeAF, 79.5% were male; mean age was 63 ± 9 years. LAPWI was performed in 57.6% of cases, with 15.3% being redo procedures. Median skin-to-skin times (PVI-only 68 [60−90] vs. PVI + LAPWI 70 [59−88] mins) did not differ between groups. 45.8% LAPWI cases were approached with a 3D-mapping system, and 37.3% with intracardiac echocardiography. LAPWI was achieved in all patients by means of PFA alone, in 88.8% cases at first pass. LAPWI was validated either by an Ultrahigh-density mapping system or by recording electrical activity + pacing maneuvers. No major complications occurred, while 2.4% minor complications were detected. During a median follow-up of 273 [191–379] days, 41 patients (16.5%) experienced an arrhythmic recurrence after the 90-day blanking period, with a mean time to recurrence of 223 ± 100 days and no differences among ablation strategies. Conclusion: LAPWI with PFA demonstrates feasibility, rapidity, and safety in real-world practice, offering a viable alternative for PeAF patients. LAPWI is achievable even with a fluoroscopy-only method and does not significantly extend overall procedural times