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Background Heart failure and sleep-disordered breathing have been increasingly recognized as co-occurring conditions. Their bidirectional relationship warrants investigation into whether heart failure therapy improves sleep and sleep-disordered breathing. We sought to explore the effect of treatment with sacubitril/valsartan on sleep-related endpoints from the AWAKE-HF study. Methods and Results AWAKE-HF was a randomized, double-blind study conducted in 23 centers in the United States. Study participants with heart failure with reduced rejection fraction and New York Heart Association class II or III symptoms were randomly assigned to receive treatment with either sacubitril/valsartan or enalapril. All endpoints were assessed at baseline and after 8 weeks of treatment. Portable sleep-monitoring equipment was used to measure the apnea-hypopnea index, including obstructive and central events. Total sleep time, wake after sleep onset and sleep efficiency were exploratory measures assessed using wrist actigraphy. The results were as follows 140 patients received treatment in the double-blind phase (sacubitril/valsartan, n = 70; enalapril, n = 70). At baseline, 39% and 40% of patients randomly assigned to receive sacubitril/valsartan or enalapril, respectively, presented with undiagnosed, untreated, moderate-to-severe sleep-disordered breathing (≥ 15 events/h), and nearly all had obstructive sleep apnea. After 8 weeks of treatment, the mean 4% apnea-hypopnea index changed minimally from 16.3/h to 15.2/h in the sacubitril/valsartan group and from 16.8/h to 17.6/h in the enalapril group. Mean total sleep time was long at baseline and decreased only slightly in both treatment groups at week 8 (–14 and –11 minutes for sacubitril/valsartan and enalapril, respectively), with small changes in wake after sleep onset and sleep efficiency in both groups. Conclusions In a cohort of patients with heart failure with reduced rejection fraction who met prescribing guidelines for sacubitril/valsartan, one-third had undiagnosed moderate-to-severe obstructive sleep apnea. The addition of sacubitril/valsartan therapy did not significantly improve sleep-disordered breathing or sleep duration or efficiency. Patients who meet indications for treatment with sacubitril/valsartan should be evaluated for sleep-disordered breathing.

Background Telemedicine is uniquely positioned to address challenges posed to emergency departments (EDs) by the COVID-19 pandemic. By reducing in-person contact, it should decrease provider risk of infection and preserve personal protective equipment (PPE). Objectives To describe and assess the early results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. Methods Retrospective chart review was completed three weeks after implementation. Metrics include the number of patients evaluated, number of patients discharged without in-person contact, telehealth wait time and duration, collection of testing, ED length of stay (ED-LOS), 72-hour return, number of in-person healthcare provider contacts, and associated PPE use. Results Among 302 patients evaluated by telehealth, 153 patients were evaluated and discharged by a telehealth provider with reductions in ED-LOS, PPE use, and close contact with healthcare personnel. These patients had a 62.5% shorter ED-LOS compared to other ESI Level 4 patients seen over the same time period. Telehealth use for these 153 patients saved 413 sets of PPE. We observed a 3.9% 72-hour revisit rate. One patient discharged after telehealth evaluation was hospitalized on a return visit 9 days later. Conclusion Telehealth can be safely and efficiently used to evaluate, treat, test, and discharge ED patients suspected to have COVID-19. This workflow reduces infection risks to healthcare providers, PPE use, and ED-LOS. Additionally, it allows quarantined but otherwise well clinicians to continue working., Article Summary: Why is this topic important? ● Telemedicine is uniquely positioned to address many of the challenges posed to emergency departments (EDs) by the COVID-19 pandemic. Using telehealth to evaluate and potentially discharge low-risk, well-appearing patients with suspected COVID-19 infection should decrease infection risk to providers, preserve personal protective equipment (PPE), and potentially mitigate surge. What does this study attempt to show? ● This study describes and assesses the preliminary results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. What are the key findings? ● One hundred fifty-three patients were evaluated and discharged by a telehealth provider, with reductions in length of stay, PPE use, and close contact with healthcare personnel. The practice appears safe, with a 3.9% 72-hour revisit rate. How is patient care impacted? ● Patients discharged by a telehealth provider had a 62.5% shorter length of stay compared to other ESI Level 4 patients seen over the same time period. Using telehealth to discharge these well-appearing patients can help unload a busy ED, mitigating surge. Reducing PPE usage and decreasing provider infection risk supports a sustained ED response to the continuing pandemic.

Background Previous studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission. Results A total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P Conclusion Patients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA. Level of evidence : Level III

There is sparsity of data on outcomes following joint arthroplasty among polycythemia vera (PV) patients. The aim of this study is to evaluate postoperative outcomes following primary total knee (TKA) and hip (THA) arthroplasty among PV patients.A retrospective Medicare database review identified 6932 PV patients who underwent a primary total joint arthroplasty (4643 TKAs and 2289 THAs) from 2006 to 2013. A comparison of hospital length of stay, mortality, and the diagnosis of surgical site infections (SSIs), stroke, myocardial infarction, acute pulmonary embolism (PE), deep vein thrombosis (DVT), and other postoperative complications was made between PV patients undergoing TKA and THA and their respective matched control groups.PV was significantly associated with increased rates of acute PE (2.3% vs 1.6%; odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.75), DVT (4.2% vs 3.6%; OR 1.40, 95% CI 1.20-1.61, P.001), postoperative hematoma (0.6% vs 0.4%; OR 1.57, 95% CI 1.03-2.28), and SSI (4.5% vs 3.6%; OR 1.25, 95% CI 1.08-1.44, P = .002) following TKA. Among PV patients who underwent a primary THA, PV was significantly associated with increased rate of acute PE (1.9% vs 1.4%; OR 1.40, 95% CI 1.01-1.88, P = .035), DVT (3.5% vs 2.6%; OR 1.32, 95% CI 1.04-1.66, P = .035), postoperative hematoma (1.1% vs 0.6%; OR 1.86, 95% CI 1.22-2.80), and 1-year mortality (2.2% vs 1.6%; OR 1.43, 95% CI 1.06-1.89, P = .016).PV was significantly associated with increased risk for DVT, PE, postoperative hematoma, SSI (TKA only), and 1-year mortality (THA only) following primary total joint arthroplasty.

In many low- and middle-income countries, the quality of public goods available to the poor is inadequate. We report findings from a unique combination of a village-randomized controlled trial and a lab-in-the-field behavioral experiment involving the establishment of “self-help” groups in one of the poorest districts in India. The presence of these groups improved villagers' access to and quality of certain critical local public goods, in particular, water. Our evidence suggests that the underlying mechanisms responsible were better information provision through the groups, stronger engagement by members in village governance, and lower coordination costs. Public goods games played in a subset of control and treatment villages four years following the start of the intervention, additionally, indicate that cooperative norms are stronger in villages where self-help groups were present. We find little evidence that membership leads to a convergence of tastes among group members. These results suggest that, in contrast to traditional participatory development programs, self-help groups can build durable social capital that can improve government performance in poor communities.

Opioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS).We used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05.All cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p 0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3-6) than for the NORCS group (median, 3; IQR 2-4) (p = 0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16-38) compared with the NORCS group (median, 9 days; IQR: 5-13) (p 0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p 0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p 0.001). All ORCS patients presented8 h after immobilization in a dependent position.Patients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.

Introduction: Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to 1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and 2) assess the difference in adjusted mortality risk between the two groups. Hypothesis: We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables. Methods: We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity. Results: There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p = 0.290), length of stay (p = 0.282), or discharge disposition (p = 0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1-5.6). Discussion: Operative treatment of acute compartment syndrome for patients on ECMO therapy is associated with significantly increased mortality and morbidity. Whether fasciotomy is a marker of sickness or represents a cause-and-effect relationship is unknown and future should investigate the role of non-operative treatment of compartment syndrome on mortality in this population. Level of Evidence: III; Prognostic

Surgery for adult spinal deformity (ASD) is increasingly common. Although outcomes of ASD surgery have been studied extensively, to our knowledge, no data exist regarding factors predicting nonroutine discharge in this population. Nonroutine discharge is defined as discharge to a health care facility after surgery rather than to home.To determine which patient and surgical factors predict nonroutine discharge after ASD surgery.This is a retrospective study.We conducted a retrospective single-center study of 303 patients who underwent arthrodesis of five or more spinal levels to treat ASD between 2009 and 2014.Patients were stratified into two groups according to discharge disposition: home or nonroutine.Objective preoperative characteristics, intraoperative course, and postoperative recovery were analyzed to identify pre- and perioperative factors associated with nonroutine discharge. Univariate analysis was performed first. All factors with P values.2 on univariate analysis were included in a logistic regression model. Additionally, to understand the relationship between subjective patient-reported outcome measures and nonroutine discharge, we compared the two groups with respect to mean Oswestry Disability Index and Scoliosis Research Society-22r domains using Student t-tests.On univariate analysis, objective measures that differed significantly (P.05) between the two cohorts were age (≥65 years), osteoporosis, Charlson Comorbidity Index score of ≥2, prolonged hospital stay (8 days), and blood transfusion. Given the above logistic regression inclusion criteria, we controlled for the performance, and type, of osteotomy (P = .055). On multivariate analysis, older age, osteoporosis, prolonged hospital stay, blood transfusion, and 3-column osteotomy were independently associated with nonroutine discharge. Subjective patient-reported outcome measures, including Oswestry Disability Index and Scoliosis Research Society-22r physical function and pain domain scores, were significantly worse in the nonroutine discharge cohort (P.05).To our knowledge, this is the first study to evaluate pre- and perioperative factors associated with nonroutine discharge after ASD surgery. Elderly patients who undergo complex surgery and receive blood transfusions are at particularly high risk of nonroutine discharge. Surgeons should consider these factors during surgical planning and preoperative patient counseling.