Risultati per: Passo 12. Ripulire in modo mirato le cartelle cliniche degli assisiti

Objectives
To evaluate the impact of providing additional dementia caregiver support services on caregiver burden.

Design
Interrupted time-series analysis using territory-wide panel data.

Settings
All public-funded district elderly community centres in Hong Kong (HK).

Participants
Primary caregivers for older adults (age over 65 years) living with dementia assessed through International Residential Assessment in HK between 1 October 2004 and 31 September 2016. Paid caregivers were excluded.

Interventions
In April 2014, US$280 million was allocated to provide additional psychological support, education and respite care for dementia caregivers in HK.

Main outcome measures
Caregiver burden was measured by two age-standardised rates: (1) caregivers in emotional distress; and (2) caregivers with long care time in a week (more than 20 hours a week). We fitted the two time-series into Autoregressive Integrated Moving Average models to evaluate intervention impacts, with follow-up analyses to consider a 6-month transition period of policy implementation. Segmented linear regressions and Holt-Winter exponential smoothening models were used as sensitivity analyses.

Results
36 689 dementia caregivers were included in this study, of which 14.4% caregivers were distress and 31.9% were long-hours caregivers after the policy intervention in April 2014. Providing additional caregiver service significantly reduced standardised rates of caregivers in distress (β (95% CI)=–3.93 (–7.85 to –0.01), p

Effettuati 5.600 screening medici e 920 consulti psicologici

Objective
To assess the spatial distribution, trends and determinants of crude full vaccination coverage (FVC) in children aged 12–59 months between 2010 and 2019 in Peru.

Design, setting and analysis
A cross-sectional study based on the secondary data analysis of the 2010 and 2019 Peruvian Demographic and Health Surveys (DHSs) was conducted. Logit based multivariate decomposition analysis was employed to identify factors contributing to differences in FVC between 2010 and 2019. The spatial distribution of FVC in 2019 was evaluated through spatial autocorrelation (Global Moran’s I), ordinary kriging interpolation (Gaussian process regression) and Bernoulli-based purely spatial scan statistic.

Outcome measure
FVC, as crude coverage, was defined as having completely received BCG; three doses of diphtheria, pertussis, and tetanus, and polio vaccines; and measles vaccine by 12 months of age.

Participants
A total of 5 751 and 14 144 children aged 12–59 months from 2010 and 2019 DHSs, respectively, were included.

Results
FVC increased from 53.62% (95% CI 51.75% to 55.49%) in 2010 to 75.86% (95% CI 74.84% to 76.85%) in 2019. Most of the increase (70.39%) was attributable to differences in coefficients effects. Family size, visit of health workers in the last 12 months, age of the mother at first delivery, place of delivery and antenatal care follow-up were all significantly associated with the increase. The trend of FVC was non-linear and increased by 2.22% annually between 2010 and 2019. FVC distribution was heterogeneous at intradepartmental and interdepartmental level. Seven high-risk clusters of incomplete coverage were identified.

Conclusions
Although FVC has increased in Peru, it still remains below the recommended threshold. The increase of FVC was mainly attributed to the change in the effects of the characteristics of the population. There was high heterogeneity across Peruvian regions with the presence of high-risk clusters. Interventions must be redirected to reduce these geographical disparities.

Circulation, Volume 146, Issue Suppl_1, Page A13312-A13312, November 8, 2022. Background:In hypertrophic cardiomyopathy (HCM), late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is an in vivo marker of replacement fibrosis with a continuous relationship between amount of LGE and both risk for sudden death and development of endstage disease. Cost and accessibility can limit routine utilization of CMR. In contrast, electrocardiogram (ECG) is an inexpensive readily available test and identifies patients with myocardial scarring in ischemic heart disease. Its ability to identify presence and extent of LGE in HCM is unknown.Methods:1983 consecutive HCM patients were included; 62% male, average wall thickness 18 ± 3mm, and 36% with resting LV outflow tract obstruction ≥ 30mmHg. ECGs were analyzed for LV hypertrophy, T wave abnormalities, ST-segment depression or elevations, abnormal Q waves, conduction disease, atrial enlargement and QTc prolongation. Extent of LGE was quantified and expressed as a proportion of total LV myocardium.Results:822 (41%) had no LGE, while 1161 (59%) had LGE, including 687 (35%) with

Circulation, Volume 146, Issue Suppl_1, Page A15229-A15229, November 8, 2022. Introduction:Over 100 FDA-approved medications, electrolyte perturbations, and many disease states can prolong the QTc beyond its 99thpercentile value resulting in acquired QT prolongation. In contrast, approximately 1 in 2000 people have congenital long QT syndrome (LQTS) hallmarked by pathological QT prolongation secondary to genetic defects in the heart.Hypothesis:An artificial intelligence (AI) deep neural network (DNN) can distinguish patients with LQTS from those with acquired QT prolongation.Methods:The study cohort included all patients with LQTS evaluated in the Windland Smith Rice Genetic Heart Rhythm Clinic and controls from Mayo Clinic’s ECG data vault comprising over 2.5 million patients. For the AI-DNN model, every patient/control with ≥ 1 ECG above age- and sex- specific 99thpercentile values for QTc [ > 460 ms for all patients (male/female) < 13 years of age, or > 470 ms for men and > 480 ms for women above this age] was included. An AI-DNN involving a multi-layerconvolutionalneuralnetwork (CNN) was developed to classify patients. LQTS patients were age- and sex- matched to controls at 1:5 ratio.Results:Among the 1,599 patients with genetically confirmed LQTS, 808 had ≥ 1 ECG with QTc above the threshold (2,987 ECGs) compared to 361,069/2.5M controls (14% of Mayo Clinic patients getting an ECG, ‘presumed negative’; 989,313 ECGs). Following age- and sex- matching and splitting, 3,309 (training), 411 (validation) and 887 (testing) control ECGs were used. This model distinguished LQTS from those with acquired QT prolongation with an AUC of 0.896 (accuracy 85%, sensitivity 77%, specificity 88%, PPV 0.58, NPV 0.94). After exclusion of patients with a wide QRS ( >150 ms) or pacemaker, the model remained successful in distinguishing the two groups (AUC 0.85, accuracy 78%, sensitivity 78%, specificity 87%, PPV 59%, NPV 94%).Conclusions:For patients with a QTc exceeding its 99thpercentile values, this novel AI-DNN functions as a LQTS mutation detector being able to identify patients with abnormal QT prolongation secondary to a LQTS-causative mutation rather than acquired QT prolongation with a >50% positive predictive value. This algorithm may facilitate screening for this potentially lethal, yet highly treatable, genetic heart disease.

Circulation, Volume 146, Issue Suppl_1, Page A9374-A9374, November 8, 2022. Introduction:Prediction for appropriate shock in patients with implantable cardioverter defibrillator (ICD) is still challenging. We tried to predict the shock by machine learning (ML) model on automated microvolt-level measurement of 12-leads electrocardiography (ECG).Hypothesis:ML on 12-leads ECG can predict appropriate ICD shock.Methods:Consecutive 177 patients (61.5±14.4years, 141males, organic heart disease: 121cases) with ICD were enrolled. ECG was measured by ECAPs12c system (Nihon-Koden) at ICD implantation. Shock was defined as appropriate ICD shock and anti-tachycardia overdrive pacing. Statistic significant predictors were extracted by univariate Cox regression analysis. Because of many correlation/confounding/multicollinearity among the predictors, multivariate Cox was not performed, and machine learning (ML) predictive model was utilized to compare the importance of the predictors.Results:Fifty-six patients were treated by appropriate shock during the observation period (median during implantation to shock: 1.85years). Thirteen significant predictors were extracted, and T-axis showed the smallest P value of univariate Cox (P=0.0007). Random Forest Classifier model demonstrated high accuracy (0.740) and T-axis showed the most important role to build the model. Receiver operating characteristics (ROC) curve analysis indicated the cut-off value as 105 degree, and Kapan-Meier curve analysis demonstrated T-axis ≥105 degree group showed worse prognosis than T-axis >105 degree group.Conclusions:ML of microvolt-level measurement of 12-leads ECG potentially had high predictive value for appropriate shock of ICD, and T-axis played an essential role for the prediction.

Circulation, Volume 146, Issue Suppl_1, Page A14804-A14804, November 8, 2022. Introduction:Use of mobile cardiac outpatient monitor (MCOT) increased during the COVID-19 pandemic as a substitute for telemetry and monitoring of arrythmias during loading of antiarrhythmic drugs (AAD). However, data comparing difference of QTc interval between a MCOT, and 12 lead ECG is scare.Hypothesis:To assess the accuracy of mobile cardiac outpatient monitor in comparison to 12 lead ECG for QTc monitoringMethods:We prospectively evaluated 24 patients at our institution who received IV sotalol as single day loading dose for initiation of oral sotalol therapy for atrial fibrillation/atrial flutter (AF/AFL). All patients were discharged 6 hours after the IV loading dose with a MCOT for 3 days. All patients had a 12 lead ECG within 12-18 hours of the baseline line MCOT transmission. Variation in heart rate and QTc was assessed.Results:A total of 24 patients were included in the study. The mean age was 65+7.3 years, 80% of patients were men. The mean difference between the QTc interval measured on 12 lead ECG and MCOT was 5.1+6 milliseconds [450+33 (EKG) – 445+39 (MCOT)], p=0.92. The mean heart rate difference between the two modalities was also not significant, p=0.726 [ 70.4+19 (EKG) -72+11.8 (MCOT), ΔHR=1.6+7.2 beats per minute].Conclusions:MCOT can be considered as a reliable alternate to 12 lead ECG for monitoring of QTc in patients receiving AAD.

Circulation, Volume 146, Issue Suppl_1, Page A12463-A12463, November 8, 2022. Introduction:Clinical uncertainty remains about the relationship between cholesterol levels and risk of death in older persons.Hypothesis:Lower low-density lipoprotein (LDL) cholesterol level was associated with a decreased mortality risk from cardiovascular disease (CVD) and an increased mortality risk due to non-CVD causes in primary prevention older populations.Methods:We examined the relationship between LDL cholesterol levels and mortality outcomes in a cohort of older individuals aged ≥65 years enrolled into a clinical trial. At baseline, participants had no diagnosed dementia, physical disability or CVD events, and were not taking lipid-lowering agents. Multivariable Cox proportional-hazards models were used to examine associations of LDL cholesterol with all-cause, CVD, cancer, and combined non-CVD/non-cancer mortality. Restricted cubic splines were used to depict non-linear relationships.Results:Among 12,334 participants included in this analysis [mean (SD) age: 75.2 (4.6) years; 54% females], who were followed for a median of 6.9 (5.7-8.0) years, 1250 (10%) died (24% due to CVD, 43% cancer, and 33% non-CVD/non-cancer). There was a U-shaped relation linking LDL cholesterol and all-cause mortality (nadir: 3.3mmol/L) and a curvilinear relation for other mortality outcomes. Each 1-mmol/L higher LDL cholesterol was associated with a lower risk of all-cause mortality (HR=0.91, 95% CI 0.85-0.98), cancer mortality (0.83, 0.74-0.94) and non-CVD/non-cancer mortality (0.81, 0.71-0.93), but a higher risk of CVD mortality (1.19, 1.03-1.38). Reduced risks of all-cause and non-CVD/non-cancer mortality were only significant in males and but not females (P values for sex interaction 0.10).Conclusions:Higher LDL cholesterol is associated with a greater risk of CVD mortality in older adults. Reduced risks for non-CVD mortality were likely driven by reverse causality, evidenced by the absence of associations after excluding deaths that occurred within the initial five years of follow-up.

Circulation, Volume 146, Issue Suppl_1, Page A14935-A14935, November 8, 2022. Introduction:The electrocardiogram (ECG) contains information about age-related changes in cardiovascular physiology, which have been linked with the frailty syndrome.Hypothesis:We sought to develop and validate a predictive model leveraging the 12-lead ECG to screen for frailty as defined by a prospective reference standard.Methods:We conducted a population-based cohort study using data from the Canadian Longitudinal Study of Aging (CLSA). From 2010-2015, the CLSA enlisted a diverse and multi-ethnic sample of community-dwelling adults 45-85 years of age. Comprehensive phenotyping was performed through interviews at participants’ homes and assessments at data collection sites. Frailty was quantified by the 110-item Frailty Index (FI) Composite, consisting of self-reported comorbidities, blood tests, physical performance tests, body composition tests, cardiovascular and pulmonary tests, cognitive and sensory tests. After dividing our sample into training (80%) and test (20%) sets, we developed an end-to-end deep neural network to predict the FI score based on the 12-lead ECG time series.Results:A total of 26,700 ECGs with paired FI scores were evaluated. For classification of FI quintiles, a bidirectional long short-term memory (BiLSTM) neural network with a cross-entropy loss function achieved a 5-fold mean area under the receiver operating characteristics curve (AUROC) of 0.70 and area under the precision-recall curve (AUPRC) of 0.36. Predictive performance was superior for classification of the first (most robust) quintile that had AUROC 0.79 and AUPRC 0.46, and the fifth (most frail) quintile that had AUROC 0.79 and AUPRC 0.56, as compared to the middle quintiles that had AUROC 0.60-0.69 and AUPRC 0.27-0.29.Conclusions:Our deep learning model can be used to screen for high or low levels of frailty based on the readily available 12-lead ECG. Additional research is underway to gain insights into other representations of the ECG signal and relative importance of the ECG features.

Circulation, Volume 146, Issue Suppl_1, Page A14359-A14359, November 8, 2022. Background:Psychosocial stress is associated with worse cardiac outcomes, but little is known about the prognostic impact of marital stress in young adults (≤55 years) with acute myocardial infarction (AMI). We investigated the association between marital stress and 1-year health outcomes in young AMI survivors.Methods:We used data from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), which enrolled people aged 18-55 years with AMI (2008-2012). Marital stress was assessed among married/partnered participants at 1 month post-AMI using the Stockholm Marital Stress Scale, categorized as absent/mild, moderate, and severe. Main outcomes were physical/mental health status, generic/disease-specific quality of life, angina, depressive symptoms, and all-cause readmission at 1 year post-AMI. Linear and logistic regression models were sequentially adjusted for baseline health status, demographics, and socioeconomic factors (including education level, income level, employment status, and insurance status).Results:Among the 1593 married/partnered participants in our study, more women reported severe marital stress than men (39.4% vs 30.4%, p=0.001). Having severe marital stress was associated with worse physical and mental health, lower generic and cardiovascular-specific quality of life, more angina and depressive symptoms, and 1.48 times higher all-cause readmission at 1 year post-AMI. These associations remained significant after adjusting for baseline health score and patient demographics (Table Model 1), but they attenuated and became non-significant when further adjusting for socioeconomic factors (Model 2).Conclusion:Marital stress was associated with worse health outcomes in young AMI patients, which can be partially mediated by socioeconomic factors. Further research is needed to understand this complex relationship and potential causal pathway associated with these findings.

Circulation, Volume 146, Issue Suppl_1, Page A14313-A14313, November 8, 2022. Introduction:Patients with obstructive hypertrophic cardiomyopathy (oHCM) frequently present with heart failure symptoms refractory to medical therapy and require septal myectomy (SM). The magnitude of benefit from SM is thought to be better than the recently reported data from EXPLORER-HCM and REDWOOD-HCM trials. We prospectively investigated the association between SM, patient-reported 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) and physician-reported NYHA class in a community-based cohort of oHCM.Hypothesis:SM ± submitral valve repair is associated with improvement in NYHA class and KCCQ-12 but with a varying magnitude of benefit.Methods:We conducted a prospective cohort study of 108 patients with oHCM who underwent SM (48% women, age 59 (45, 67) years). KCCQ-12 and NYHA class were assessed prospectively prior to SM, at 1-3 months post-SM and at 4-12 months post-SM. KCCQ-12 is reported as an additive score. Data are reported as median values (IQR).Results:Pre-SM, LVEF was 70% (65, 75) while resting and Valsalva LVOT gradients were 42 (22, 90) and 87 (53, 119) mm Hg, respectively. Post-SM, median LVEF was 65% (60, 69) with respective resting and Valsalva LVOT gradients of 11 (8, 16) and 16 (11, 28) mm Hg (all p

Circulation, Volume 146, Issue Suppl_1, Page A13564-A13564, November 8, 2022. Introduction:Based on the development of AI (artificial intelligence) and big data, an emerging number of methods achieved outstanding performance in myocardial infarction (MI) diagnosis by an electrocardiogram (ECG). However, conventional interpretation methods have low reliability for detecting MI and are challenging to apply to 2 leads of wearable devices.Objectives:To evaluate whether the novel method can facilitate MI diagnosis by only 2-lead ECG.Methods:We propose T2T (from 2-lead to 12-lead), a deep generative model that simulates a standard 12-lead ECG from an input of two asynchronous leads by generating ten leads. (Figure a) We used and selected 15,012 ECGs (9,527 normal, 5,485 samples with any MI) from the Physikalisch-Technische Bundesanstalt dataset. This dataset was split into stratified training, validation, and test sets with a ratio of 7:1:2. Three models using 2-lead, T2T, and 12-lead ECG were developed and validated to predict a diagnosis of MI, and their accuracy was compared.Results:The area under the receiver operating characteristic curves of the 2-lead, T2T and 12-lead ECG were 0.937, 0.948, and 0.960, respectively.Figure bshows representative cases over a two-second window, where the green and pink lines are the signals from the original ECG and T2T. The generated signals have less noise (seen in aVR and aVL in 2a and V4, V5, and V6) and baseline wander. For the V1 and V5 leads generated by T2T, the differences in amplitude are 6.4% and 7.3%, respectively, and the missing positional errors are under 10 ms.Conclusions:Novel ECG T2T algorithm demonstrated favorable performance in detecting MI using 12-lead ECG.Figure a.ECGT2T model architecture. The model is comprised of style, mapping, generative, and discriminative networks. Each network is built with residual blocks.Figure b.Representative samples of ECG T2T. The green line denotes the original signal, while the pink line represents the signals generated by ECGT2T.

Circulation, Volume 146, Issue Suppl_1, Page A227-A227, November 8, 2022. Introduction:Cardiac arrest (CA) survivors have significant impairments and poor functional outcomes at hospital discharge. We assessed if discharge disposition to acute inpatient rehabilitation after CA-related hospitalization is associated with improved functional recovery at 12 months relative to alternative acute care hospital discharge dispositions.Methods:Adults with the return of spontaneous circulation after in-hospital or out-of-hospital CA between 2/1/2016- 1/31/2020 admitted to intensive care units in a single tertiary care center were enrolled in an observational, prospective cohort study. A series of logistic regressions were used to assess acute inpatient rehabilitation associations with good functional recovery patterns, defined as persistent Modified Rankin Score (mRS) 0-2, or absence of any worsening of mRS at 12 months relative to discharge mRS. The model included demographics, individual and structural-level Social Determinants of Health, and pertinent clinical characteristics.Results:Of 201 included patients (24% Hispanic and 19% Black; average age 56±16 years; 40% women), 63% (n=127) reported good functional recovery pattern. Patients who went to acute inpatient rehabilitation were significantly more likely to experience good recovery pattern (54.3% vs 37.8% with poor recovery pattern, p

Circulation, Volume 146, Issue Suppl_1, Page A12-A12, November 8, 2022. Background:Black and Hispanic individuals have lower survival rates for out-of-hospital cardiac arrest (OHCA). Whether there are Emergency Medical Service (EMS) agencies in Black and Hispanic communities with high survival rates for OHCA is unknown but critical to identifying strategies to reduce racial and ethnic disparities in OHCA survival.Methods:Within the Cardiac Arrest Registry to Enhance Survival, we identified adults with non-traumatic OHCA during 2015-2019. EMS agencies were categorized as working in Black/Hispanic communities if >50% of residents in their catchment area were Black or Hispanic. Using hierarchical logistic regression, we calculated risk-standardized survival rates (RSSR) to hospital admission for OHCA in each EMS agency, adjusted for patients’ age, sex, witnessed arrest status, presumed arrest etiology, initial cardiac arrest rhythm, and arrest location. We then examined the distribution of EMS agencies that work in Black/Hispanic communities across quartiles of OHCA survival.Results:Among 764 EMS agencies (258,342 OHCAs), the median RSSR was 27.4% with an absolute difference of >10% across quartiles (median 22.4% in the lowest vs. 32.9% in the highest quartile; 191 EMS agencies in each quartile). There were 82 EMS agencies working in Black/Hispanic communities overall, with 26 (31.7%) in the lowest RSSR quartile and 15 (18.3%) in the highest. After further adjustment for agency-level rates of bystander CPR, EMS response time and termination of resuscitation practices, there remained 29 (35.4%) EMS agencies in the lowest RSSR quartile and 16 (19.5%) in the highest.Conclusion:EMS agencies working in Black and Hispanic communities have lower prehospital survival for OHCA, although high-performing agencies exist. Identifying best practices at EMS agencies with the highest prehospital survival rates, particularly among agencies serving Black and Hispanic communities, has the potential to improve overall OHCA survival and reduce existing survival disparities.

Circulation, Volume 146, Issue Suppl_1, Page A12473-A12473, November 8, 2022. Introduction:Cardiac amyloidosis accounts for 13% of all patients with heart failure with preserved ejection fraction (HFpEF). The National Amyloidosis Centre (NAC) scoring system (Stage 1-3), utilising eGFR and NT-proBNP correlates well with overall prognosis.Hypothesis:We wished to explore the feasibility of diagnosing disease severity using 12-lead ECG alone, using our database of >6,000 ECGs from 292 ATTR patients.Methods:Triplicate 12-lead ECG parameters (PR interval, QRS width, QT-interval, QRS morphology, axis, rhythm and low amplitude presence or absence), baseline NT-proBNP and baseline eGFR were extracted. Patients with pacing were excluded. For numeric baseline parameters, the mean triplicate ECG value was used. NAC stage was then calculated from eGFR and NT-proBNP (Stage 1: NT-proBNP 45, Stage 3: NT-proBNP >3000 and eGFR

Circulation, Volume 146, Issue Suppl_1, Page A9814-A9814, November 8, 2022. Background:Low voltage ECG (LowV-ECG) pattern is defined as a peak-to-peak QRS amplitude of less than 5mm in the limb leads and/or less than 10mm in the pericardial leads. It can occur in many cardiac conditions associated with congestive heart failure (CHF), such as ischemic cardiomyopathy (ICM), cardiac amyloidosis (CA), hemochromatosis (HC), and hypothyroidism (HT). The clinical significance of LowV-ECG abnormalities in CHF patients has not been well investigated.Methods:Clinical, echocardiographic, and ECG data was collected in 460 consecutive CHF patients with non-V-paced rhythms enrolled over 2 years in the Get With the Guidelines Heart Failure (GWG-HF) registry at a single academic tertiary center. ECGs were reviewed for the presence of low QRS voltage and additional ECG features classically reported in ICM, CA, HC, and HT.Results:LowV-ECG was noted in 8.5% patients (39/460) of the study cohort, and was more common in females, 11.6% (25/216) vs. 5.7% (14/244) in males, p=0.025. LowV-ECG patients had increased BMI (34.9+/-12.8 vs. 31.1+/-9 kg/m2, p=0.016) and more commonly had a history of DM (12.2% vs.5.5%, p=0.01). There were no significant differences in age, GFR, or presence of CAD, hypertension or Afib. Prevalence of HFrEF, HFmrEF, and HFpEF in patients with LowV-ECG was 6.8, 10, and 9.8%, respectively, p=0.506. With regards to the ECG features typically associated with cardiac amyloidosis, poor R-wave progression was more common in LowV-ECG patients, 41% (16/39) vs.13.5% (57/421) in the rest of the cohort, p