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To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ≥67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per “eligible day alive” over the 3-year period. Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.

A 25-year-old man with a medical history of propionic acidemia was brought to hospital after he collapsed while jogging. He was unresponsive, received immediate bystander cardiopulmonary resuscitation and was defibrillated by paramedics from an initial rhythm of ventricular fibrillation with successful return of spontaneous circulation. He had been diagnosed with propionic acidemia at two years of age when he presented with developmental delay, and metabolic work-up showed the classic profile of 3-OH-propionic and methylcitric acids on analysis of organic acids in urine, low carnitine with increased propionylcarnitine on acylcarnitine profile and increased glycine on quantitative amino acid analysis of plasma. At the time of the patient's witnessed cardiac arrest, initial laboratory investigations showed an anion gap metabolic acidosis and lactic acidemia (lactate level 7.9 mM). Although the patient's ventricular arrhythmia may have been due to a reversible cause, we decided to proceed with insertion of an implantable cardioverter-defibrillator. We based this on

The early diagnosis of acute coronary syndrome (ACS) remains challenging, and a considerable proportion of patients are diagnosed with “possible” ACS on admission. The Global Registry of Acute Coronary Events (GRACE/GRACE2) and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 16,618 Canadian patients with suspected ACS in 1999 to 2008. We compared the demographic and clinical characteristics, use of cardiac procedures, prognostic accuracy of the GRACE risk score, and in-hospital outcomes between patients given an admission diagnosis of “definite” versus “possible” ACS by the treating physician. Overall, 11,152 and 5,466 patients were given an initial diagnosis of “definite” ACS and “possible” ACS, respectively. Patients with a “possible” ACS had higher GRACE risk score (median 130 vs 125) and less frequently received aspirin, clopidogrel, heparin, or β blockers within the first 24 hours of presentation and assessment of left ventricular function, stress testing, cardiac catheterization, and percutaneous coronary intervention (all p <0.05). Patients with “possible” ACS had greater rates of in-hospital myocardial infarction (9.0% vs 2.0%, p <0.05) and heart failure (12% vs 8.9%, p <0.05). The GRACE risk score demonstrated excellent discrimination for in-hospital mortality in both groups and for the entire study population. In conclusion, compared to patients with “definite” ACS on presentation, those with “possible” ACS had higher baseline GRACE risk scores but less frequently received evidence-based medical therapies within 24 hours of admission or underwent cardiac procedures during hospitalization. The GRACE risk score provided accurate risk assessment, regardless of the initial diagnostic impression.

Background Hepatic encephalopathy (HE) is considered reversible regarding mental status but may not be cognitively in single-center studies. Aim To evaluate persistence of learning impairment in prior HE compared to those who never experienced HE (no-HE) in a multicenter study. Methods A total of 174 outpatient cirrhotics from three centers (94 Virginia, 30 Ohio, and 50 Rome; 36 prior HE) underwent psychometric hepatic encephalopathy score (PHES) and inhibitory control (ICT) testing at baseline and then at least 7 days apart. ICT learning (change in 2nd half lures compared to 1st half) was compared between patient groups at both visits. Change in the PHES individual sub-tests and total score between visits was compared in both groups. US versus Italian trends were also analyzed. Results HE patients had worse PHES and ICT results compared to no-HE patients at baseline. Significant improvement (1st half 7.1 vs. 2nd half 6.2, p  < 0.0001) was observed in no-HE, but not in HE (1st half 7.9 vs. 2nd half 7.8, p  = 0.1) at baseline. At retesting (median 20 days later), no-HE patients continued with significant learning (1st half 6.0 vs. 2nd half 5.4, p  < 0.0001), while HE patients again did not improve (1st half 7.8 vs. 2nd half 6.9, p  = 0.37). Between visits, no-HE patients improved significantly on four PHES sub-tests and overall score, while HE patients only improved on two sub-tests with similar overall PHES score. Trends were similar between US and Italian subjects. Conclusion In this multicenter study, prior HE patients showed persistent significant learning impairment compared to those without prior HE, despite adequate medical therapy. This persistent change should increase efforts to reduce the first HE episode.

A 16-year-old male presented to the emergency department with chest pain after smoking a synthetic cannabinoid from a vape pen. He had rising troponin I levels, and his exercise stress echocardiogram showed distal apical and septal hypokinesis that resolved at six-month follow-up. This case report raises concern about cardiac ischemia related to synthetic cannabinoid abuse in the pediatric population in the current era of cannabis legalization.