3-month Outcome Research Articles

Can ischemic stroke patients with mTICI of 2b achieve similar outcomes compared to those with complete recanalization following endovascular therapy?

Endovascular therapy (EVT) has been used as a standard treatment method for patients with large vessel ischemic stroke within 24 h of the onset. The extent of recanalization after EVT can be assessed using the modified thrombolysis in cerebral infarction (mTICI) scale as an accepted angiographic grading system. In this study, we aimed to investigate whether patients with a mTICI grade of 2b achieve similar outcomes compared to those with complete recanalization (mTICI of 3) following EVT for acute ischemic stroke. A retrospective analysis was conducted on 196 consecutive patients who underwent EVT in a comprehensive stroke center. In the final study, 176 patients were included based on the inclusion criteria. The primary outcome was the 3-month modified Rankin Scale (mRS) of 0-2 considered as a favorable outcome, while excellent outcomes were defined as mRS scores of 0-1. Our data showed that 59.46% of patients in the mTICI 2b group achieved a favorable outcome, comparable to 58.99% observed in the mTICI 3 group (p = 0.959). Additionally, 54.05% (n = 37) of patients with mTICI 2b achieved an excellent outcome, compared to 51.80% (n = 139) in the mTICI 3 group (p = 0.807). The case fatality rates were also comparable between the groups, with 8.11% in the mTICI 2b group and 10.79% in the mTICI 3 group (p = 0.632). Overall, there were no statistically significant differences between the two groups in terms of 3-month favorable outcomes, excellent outcomes, or mortality. Similar 3-month outcomes can be achieved for ischemic stroke patients undergoing EVT with a mTICI grade of 2b compared to those with a mTICI grade of 3. These data can help clinicians in setting realistic expectations and making informed decisions during EVT procedures.

12-month Safety and Efficacy Outcomes of a Standalone Trabecular Bypass Device

12-month Safety and Efficacy Outcomes of a Standalone Trabecular Bypass Device

BRIVA-ONE study: 12-month outcomes of brivaracetam monotherapy in clinical practice.

This study investigated the effectiveness and tolerability of brivaracetam (BRV) monotherapy in a large series of patients with epilepsy. This was a multicenter, retrospective, observational, non-interventional study in 24 hospitals across Spain. Patients aged ≥18 years who started on BRV monotherapy, either as first-line or following conversion, at least 1 year before database closure were included. Patients were evaluated at baseline and at 3, 6 and 12 months after initiation of BRV monotherapy, in accordance with usual clinical practice at these centers. Data were collected retrospectively from patients' individual charts by participating physicians. The primary effectiveness and safety endpoints were the percentage of seizure-free patients 1 year after initiation of BRV monotherapy and the proportion of patients reporting adverse events (AEs) over the complete follow-up period. Retention rates and subpopulation analysis (levetiracetam switchers, elderly and different etiologies) were also investigated. A total of 276 patients were included (48 with BRV as first-line monotherapy and 228 who converted to BRV monotherapy). The overall retention rate in monotherapy at 12 months was 89.9% (87.5% for first-line monotherapy group; 90.4% for conversion-to-monotherapy group). Seizure-freedom rates at 12 months were 77.8% (75% for first-line monotherapy group; 78.4% for conversion-to-monotherapy group). AEs occurred in 39.5% of patients at 12 months (35.4% for first-line monotherapy group; 40.4% for conversion-to-monotherapy group). Most AEs were mild-to-moderate. The most frequent AEs were irritability (12.3%) and dizziness (10.1%). The most frequent AEs leading to BRV withdrawal were dizziness (1.8%) and memory problems (1.4%). Similar outcomes in terms of effectiveness and tolerability of BRV monotherapy were observed in patients switching from levetiracetam, those with different epilepsy etiologies, and elderly patients. BRV was effective and well tolerated both as first-line monotherapy and following conversion to monotherapy in a real-world setting of patients with epilepsy. The goal of the medical treatment of epilepsy is to ensure best possible patient quality of life, by maximizing seizure control and minimizing medication toxicity. Brivaracetam (BRV) is a new-generation epilepsy treatment that is well tolerated by patients. In our study, monotherapy with BRV reduced seizures in patients who had not received other treatments and in patients who switched from a previous treatment to BRV monotherapy. BRV was well tolerated and also effective in sensitive patients (i.e., the elderly and those who had epilepsy caused by a brain tumor or a brain injury).

Random Forest Prognostication of Survival and 6-Month Outcome In Pediatric Patients Following Decompressive Craniectomy For Traumatic Brain Injury

There is a dearth of literature regarding prognostic and predictive factors for outcome following pediatric decompressive craniectomy (DC) following traumatic brain injury (TBI). The aim of this study was to develop a random forest machine learning algorithm to predict outcomes following DC in pediatrics. This is a multi-institutional retrospective study assessing the 6-month postoperative outcome in pediatric patients that underwent DC. We developed a machine learning model using classification and survival random forest algorithms (CRF and SRF respectively) for the prediction of outcomes. Data was collected on clinical signs, radiographic studies, and laboratory studies. The outcome measures for the CRF were mortality and good or bad outcome based on Glasgow Outcome Scale (GOS) at 6-months. A GOS score of 4 or higher indicated a good outcome. The outcomes for the SRF model assessed mortality at during the follow-up period. A total of 40 pediatric patients were included. There was a hospital mortality rate of 27.5%, and 75.8% of survivors had a good outcome at 6-month follow up. The CRF for 6-month mortality had a ROC AUC of 0.984; whereas, the 6-month good/bad outcome had a ROC AUC of 0.873. The SRF was trained at the 6-month timepoint with a ROC AUC of 0.921. CRF and SRF models successfully predicted 6-month outcomes and mortality following DC in pediatric TBI patients. These results suggest random forest models may be efficacious for predicting outcome in this patient population.

Cardiovascular disease history as a predictor for adverse outcomes in frail older adults admitted to acute geriatric settings: 12-month outcomes from an Australian frailty registry

Abstract Introduction Frailty is common in older adults with cardiovascular disease (CVD), with prevalence between 25-62% (1). The incidence of CVD increases with age, yet the outcomes of frail older adults with a history of CVD who present to acute geriatric settings, is not well understood. Purpose To report the association of CVD and rehospitalisation and/or mortality at 12 months in a cohort of frail older adults enrolled in an Australian frailty registry. Methods A convenience sample of participants enrolled in the frailty registry, with 12-month follow-up completed. The frailty registry is a prospective cohort study of adults admitted to the rehabilitation and aged care departments at two Australian hospitals. Frailty was assessed using the Clinical Frailty Scale (CFS), a score of 1-4 is ‘non-frail’, 5-6 is ‘mild-moderately frail’ and 7-9 is ‘severely frail’ (2). For this study, ‘CVD’ was defined as having a history of either heart failure, stroke, or atrial fibrillation. The cumulative incidence of first rehospitalisation and/or death during the first 12 months post discharge was estimated using one minus the Kaplan-Meier estimate of the survival function. Association between CVD (history of CVD, and type of CVD condition) and the composite endpoint were analysed. Adjusted Hazard Ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox models incorporating variables of interest and potential confounders. Results A total of 592 participants were included, median age was 82 years, 59% (n= 349) were female. The majority were frail with 50% (n= 295) classified as mild-moderately frail and 21% (n= 123) classified as severely frail. Almost half (45%, n= 265) had a history of CVD. The incidence of frailty (CFS score ≥5, mild-severely frail) was higher in those with CVD compared to those without CVD (76% vs 66%). A history of CVD was significantly associated with higher rate of first readmission or death within 12 months, compared to no history of CVD (p=0.017) (Figure 1). Of the three CVD conditions, heart failure was the only independent predictor of the composite endpoint (HR 1.60 [CI 1.14 -2.24], p=0.007). A CFS score of mild-moderately frail (HR 1.51 [CI 1.18 - 1.93, p=0.001) and severely frail were also independent predictors of the composite endpoint (HR 1.83 [CI 1.35- 2.48], p=<0.001) (Table 1). Conclusions A history of CVD has a significant impact on adverse outcomes in frail older adults admitted to acute geriatric settings. Frailty according to the CFS was independently predictive of rehospitalisation and mortality in this cohort. Heart failure was the only independent predictor of the composite endpoint. These findings underscore the importance of identifying and addressing CVD and in the context of frailty, emphasising the need for targeted interventions to improve outcomes in this vulnerable population.Figure 1.Table 1.

Atrial fibrillation ablation with temperature-controlled very high-power short-duration, with conventional-power, or with combined modes in clinical practice: 12-month outcomes from SECURE

Abstract Background/Introduction QDM is a contact force-sensing catheter optimized for temperature-controlled radiofrequency ablation in very high-power short-duration (vHPSD; 90 W/4 s), conventional-power (CP; ≤50 W), or vHPSD/CP combined modes. Purpose Evaluate 12-month (M) safety and effectiveness of atrial fibrillation (AF) ablations performed with 3 different ablation modes using the QDM catheter, a frequently used single tip catheter in Europe. Methods SECURE is an observational, prospective, post-market study collecting data on procedures performed per standard-of-care with up to 12M follow-up, in 16 enrolling sites in 8 countries across Europe and Israel. Index pulmonary vein (PV) isolation procedures are reported here. The primary safety endpoint is the incidence of primary adverse events (PAEs); the primary effectiveness endpoint is PV isolation (entrance block) of targeted PVs. Additional endpoints include acute reconnections, incidence of char and steam pop, 12M recurrence, repeat ablation, and healthcare utilization (HCU). Ablation strategy, impedance drop, and catheter stability were analysed with a cloud-based data management and artificial intelligence-powered algorithm. Results Since Feb 2021, 291 patients (70% male, 61±11 yrs, CHA2DS2-VASc 1.9±1.5) completed 12M follow-up in 11 sites. Most patients (175 [60.1%]) were treated for paroxysmal (PAF), 85 (29.2%) for persistent (PsAF), and 31 (10.7%) for long-standing persistent (LsPsAF) AF, under general anaesthesia (44.0%) or sedation (55.7%). A combined workflow was used in 66.0% of ablations, while vHPSD-only and CP-only were used in 13.4% and 20.6% of cases, respectively. Four (1.4%) patients reported a PAE; all resolved, and none were catheter related. Acute effectiveness was achieved in all targeted veins; 5.0% of PVs had acute reconnections, with the most common being the left superior PV. No steam pops were reported; 2 counts of char were noted in PsAF ablations with combined modes. Freedom from documented recurrence were 95.8% for PAF, 88.1% for PsAF, and 73.5% for LsPsAF (Fig 1). Freedom from repeat ablation post-blanking and freedom from cardioversion were both 96.8%. Cardiovascular hospitalization and emergency room visits decreased by 65.3% and 76.5% from 12M pre- to 12M post-procedure, respectively. Application-level analyses showed larger impedance drop and greater catheter stability with vHPSD. In procedures using a combined workflow, vHPSD was used preferentially for most PV segments, except anteriorly on the left wide area circumferential ablation (Fig 2). Conclusions Real-world data demonstrates that AF ablation with the QDM catheter is safe and effective with a low PAE rate, high 12M effectiveness, and reduced HCU. Most procedures were done with combined modes, where vHPSD was used preferentially, except at left anterior thicker regions. Larger impedance drop and greater catheter stability were observed with vHPSD applications.

Lower early mortality after acute pulmonary embolism in patients with WHO-defined obesity: results from a post-hoc cohort analysis with external validation

Abstract Background The relationship between obesity, defined as a Body Mass Index (BMI) ≥ 30 kg/m2, and mortality in venous thrombo-embolism remains controversial. Objectives To compare early outcomes after pulmonary embolism (PE) between obese patients, and non-obese, non-underweight patients. Methods We performed a post-hoc analysis based on prospectively recorded individual patient data from the multicenter BFC-FRANCE registry. We compared rates of outcomes using multivariable logistic regression or a Cox model for 30-day and 6-month outcomes respectively. We assessed the incremental value of adding BMI information on top of the 30-day European Society of Cardiology (ESC) prognostic algorithm. Results A total of 2,390 patients with a BMI ≥ 18.5 kg/m2 (mean age, 66.9±16.8 years; 1,188 men [49.7%]) were included, 686 patients [28.7%] in the obese group, and 1,704 patients [71.3%] in the non-obese group. Mortality rates were significantly lower in obese patients versus non-obese patients at 30 days (OR, 0.59; 95% CI, 0.35-0.98), and 6 months. Cox-model-derived adjusted curves for all-cause death at 6 months, with hazard ratios (HRs) between obese and non-obese patients, after acute PE, are shown in the Figure. Rates of secondary non-fatal outcomes (including recurrent VTE) did not differ between groups. The addition of the obesity information on top of the ESC prognostic model improved global model fit, and discriminatory and calibration capacities, yielding significant reclassification based on the observed mortality rates with the ESC model as reference. Findings were confirmed in an external validation using 35,796 PE patients from the RIETE registry. Conclusion We present evidence indicating lower early and mid-term mortality after PE in patients classified as obese based on BMI, compared with non-obese, non-underweight patients. BMI should likely be incorporated into algorithms or scoring systems for predicting early mortality following PE.

Clinical presentation, risk factors and six-month outcomes in Ugandan women with peripartum cardiomyopathy: prospective case-control study

Abstract Background Peripartum Cardiomyopathy (PPCM) frequently affects women of African descent. There is scarcity of data pertaining to the clinical presentation and outcomes of PPCM patients in Uganda, particularly when employing modern diagnostic tools and adhering to guideline-directed medical therapy (GDMT). Purpose We aimed to delineate the clinical characteristics, echocardiographic findings, and 6-month outcomes among women in Uganda diagnosed with PPCM. Methods Prospective case-control design conducted from June 2022 to August 2023. We enrolled 80 PPCM cases and 80 matched controls. Inclusion criteria comprised: (i) peripartum state, (ii) signs and symptoms of HF, (iii) left ventricular (LV) ejection fraction ≤ 45%, and (iv) exclusion of alternative causes of HF. Controls were healthy women matched for age and parity. Over a 6-month period, enrolled PPCM cases were diligently monitored while on GDMT. All participants underwent a physical examination, 12-lead electrocardiography, and a detailed echocardiography incorporating global longitudinal strain measurements at both baseline and the 6-month follow-up. Results At baseline, amongst the cases, the mean age was 33.6 ± 6.6 years, mean parity was 3±2.1 pregnancies. HF onset occurred within 9.5±6.5 weeks post-delivery. A total of 20 (25.0%) cases presented in NYHA Class 4 with dyspnea as the predominant symptom in 79.95% of cases. Atrial fibrillation (AF) was observed in 2(2.5%) patients. In comparison with healthy controls, high gravidity (0.2±1.0; p<0.001) was identified as the only predictor of PPCM in this study. (Table 1) At 6-months follow up, the mean LV ejection fraction (LVEF) showed improvement from 35.7±-11.0% to 45.9 ± 15.7% (p<0.001) accompanied by a reduction in left ventricular diameter (LVD) from 6.1±0.7 cm to 5.5±1cm(p<0.001). At the 6-month follow-up, recovery (LVEF ≥ 50%) occurred in 37 cases (55%), and 52 (65%)patients were asymptomatic (NYHA Class 1) at the 6-month follow-up. Six-month mortality data were available for 5(6.3%) women, and one patient successfully underwent the insertion of an Implantable Cardioverter-defibrillator for recurrent Ventricular Tachycardia. Regarding GDMT, 55 participants received Bromocriptine as part of their medication. Twenty(25%) patients received anticoagulation for AF(n=2) or intracardiac thrombus (n=6, 1.67%) (Figure 1) resulting in 2(2.5%) strokes within the 6-month follow-up. Conclusion The current study demonstrated a comparable mortality rate on GDMT, aligning with contemporary global studies at 7.5%. The observed high thrombus burden in patients may indicate suboptimal adherence to anticoagulation therapy. While the incidence of PPCM remains undefined in Uganda, the primary predisposing factor identified was high gravidity. A noteworthy proportion of patients exhibited incomplete LV recovery, suggesting the need for larger studies to comprehensively define the maternal and fetal outcomes in Uganda.Figure 1Table 1

Clinical impact of performing esophagogastroduodenoscopy before percutaneous coronary intervention in patients with acute coronary syndrome patients and anaemia

Abstract Background In patients presenting with acute coronary syndrome (ACS) and anaemia, esophagogastroduodenoscopy (EGD) is commonly performed to exclude an upper gastrointestinal source of bleeding prior to perform percutaneous coronary intervention (PCI). However, the diagnostic yield and clinical impact of EGD in this setting is uncertain. Purpose We aimed to investigate the clinical yield and impacts of EGD on the 1-year clinical outcomes in ACS patients with concomitant anaemia who underwent PCI. Methods We retrospectively analysed electronic health records of ACS patients who underwent PCI at 16 public hospitals from 2014-2018. Patients with anaemia (defined as haemoglobin (Hb) <11dl/L) and EGD before PCI during the same admission were identified. The primary outcomes were bleeding events including clinical GIB (as diagnosed by EGD), need for urgent EGD, need for transfusion, Hb drop of >3 dl/L and Hb <8 dl/L. Secondary outcomes were 12-month 4-point MACE including myocardial infarction (MI), stroke, subsequent PCI or CABG, or cardiovascular-related death. Propensity-score models with inverse probability of treatment weighting (IPTW) against EGD were developed for the comparisons. A weighted Cox Proportional Hazard Model was performed to estimate adjusted hazards ratio (aHR) with corresponding 95% confidence intervals (CI). Results Of 13,793 patients, 3625 (25%) had anaemia on admission and 12.8% (n=466/3625) underwent EGD. Most EGD findings were not accountable for overt GIB, with gastritis, gastric polyps and gastric erosion being the 3 most common EGD diagnoses. After IPTW, clinical outcomes of 466 patients with EGD were compared with 3159 patients without EGD. 12-month bleeding event rates were higher among EGD patients compared to non-EGD patients (59.7% vs. 27.6%, p< 0.01; aHR = 3.01, 95% CI 2.58-3.52, p<0.005). Overall, 12-month GIB rate was low 1.0%, with 4.1% in EGD patients and 0.57% in non-EGD patients (aHR=7.99, 95% CI 4.13-15.45, p<0.005). The 12-month cumulative MACE rate overall was 39.9% and no significant difference between EGD and non-EGD patients. Conclusion Our real-world data demonstrated that the presence of anaemia is common among ACS patients. The yield of EGD in identifying sources of upper GI bleeding was low and there was no difference in 12-month clinical outcome among EGD patients. Although EGD was associated with higher rates of 12-month bleeding events, the cause was unclear with very low incidence of upper GI bleeding events. Therefore, the benefits of routine EGD prior to PCI in ACS patients with anaemic is unclear.

Thirty days clinical outcomes following stent implantation with aspirin-free prasugrel monotherapy in non-ST segment elevation myocardial infarction. Interim report from ASET-Japan pilot study

Abstract Background Dual antiplatelet therapy with a P2Y12 inhibitor, in addition to aspirin, is the standard therapy after percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) to prevent ischemic cardiovascular events. The Acetyl-Salicylic Elimination Trial (ASET) pilot studies conducted in Japan in patients with NSTE-ACS investigated the safety and feasibility of a low-dose prasugrel monotherapy after PCI. Purpose To ensure the safety of the patients, enrolment in the study was implemented only after confirmation of a successful procedure. The abstract reports our interim analysis, aimed at evaluating preliminary safety and feasibility. Methods The ASET-Japan pilot study was designed to explore the feasibility and safety of a low dose of prasugrel monotherapy (3.75mg/day), without adjunctive aspirin, after optimal PCI using Everolimus eluting stent (EES) in Japanese patients with non-ST-segment elevation acute coronary syndromes. The primary endpoint in the ASET-Japan NSTE-ACS (Phase 2) is a 12-month clinical outcome. The study is currently in the follow-up phase. All the target lesions were treated with a platinum-chromium everolimus-eluting stent. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis, and the primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding up to 12-month. If more than 3 events occurred, trial enrollment would have to be terminated by the data and safety monitoring board. Results One hundred one patients were enrolled after successful index PCI and completed a 30 days follow-up. The mean age was 69.1±12.3 years and 75.2% was male. The mean anatomical SYNTAX score was 7.9±4.7. Unstable angina (UAP) and NSTEMI were seen in 24.8% (25/101) and 75.2% (75/101) patients, respectively. According to the Braunwald classification, 8 percent of the patients were categorised as Class IA UAP, 48% as Class IB, 20% as Class IIB, 4% as Class IIIA and 20% as Class IIIB. In NSTEMI patients, the median (IQR) pre-procedural troponin value (cardiac Troponin T or I) was 2.79 (1.12 – 22.27) times the Upper Limit of Normal. According to the PRECISE DAPT score, 36.6% of patients were categorised as High Bleeding Risk (HBR) with scores above 25. At one month, the primary ischemic endpoints of cardiac death, target-vessel spontaneous MI or definite Stent thrombosis did not occur. Two patients (2.0%) had BARC type 3a bleeding. Conclusion Prasugrel monotherapy in the first 30 days following platinum-chromium everolimus-eluting stent deployment is a feasible and safe strategy in NSTE-ACS patients with simple anatomy and successful PCI.

A retrospective study on real world, 2-stent left main bifurcation PCI using DK crush technique with IVUS guidance - a single center experience

Abstract Objectives The aim of this study is to investigate clinical outcome of the IVUS guided 2-stent bifurcation strategy using DK crush technique performed in a complex Left Main (LM) bifurcation lesions defined according to DEFINITION study in our local setting. We seek to assess the composite endpoint of target vessel failure (TVF) at 9-12 months. Methods All patients underwent IVUS guided 2-stent Bifurcation PCI with DK crush technique for complex LM bifurcation lesions defined by the DEFINITION criteria performed in a heart institute from 1.1.2019 to 31.7.2023 were included..Patient baseline characteristics, post-procedural and 12-months follow-up outcomes including cardiac death,myocardial infarction (MI),rate of target vessel failure (TVF),rate of stent thrombosis (ST) and major adverse coronary event (MACE) were analysed.Exclusion criteria are patients age <18 years and previous stenting in the target vessel Results A total of 50 patients were included in this analysis. Mean age was 64.3±9.1 years with predominant males (n= 38, 76%).Majority were hypertensive (n=37, 74%) and diabetes mellitus accounted for 32 (64%) cases.Patients with pre-existing coronary artery disease were 39 (78%) cases. 40% presented with history of recent myocardial infarction (MI), 12% had new onset angina and 6% had heart failure. Pre-existing chronic renal failure (18%) and history of CVA (2%). Among chronic renal failure cases, 50% had eGFR <50 during index procedure.Additionally, previous PCI was performed in 22 cases (44%) and 2 previous CABG cases included (4%).Majority of the cases were performed as staged elective procedure ( n=45, 90%) and others were indicated for ACS ( n=5, 10%). Radial approach was predominantly preferred with 25 cases (50%), where additional 5 cases (10%) were converted to femoral approach due to severe radial spasm. Among these 50 cases, 1 case required additional PCI to CTO LAD and mid LCX, while 7 cases (14%) had calcified lesions requiring scoring / cutting balloons and atherectomy device utilization for adequate lesion preparation prior to bifurcation stenting.All 50 patients received combination of both aspirin and a P2Y12 inhibitors for 12 months. Follow up done at at 30-day, 60-days and 1 year after the index procedure.Clinical follow-up were available in 46 (92%) patients only.4 cases were lost to follow up due to logistic reasons. At 1 year follow-up, cardiac death occurred in 5 (10.9%) patients, out of which 3 (6.5%) cases were cardiac related and 2 (4.4%) are non-cardiac. Major adverse cardiac events (MACE) and target vessel failure (TVF) occurred in total 4 (8.7%) cases, where 3 (6.5%) cases resulted in cardiac death and 1 (2.2%) case had MI and clinically driven target lesion revascularization. Conclusion Our experience demonstrates that IVUS guided, upfront 2-stent Bifurcation PCI using DK crush technique for complex bifurcation lesions is effective and safe with a low MACE and TLR rate at 1 year follow-up.

Telehealth-aided outpatient management of acute heart failure in a specialist virtual ward compared to standard care

Abstract Background/Introduction Acute decompensated heart failure (ADHF) leads to hospitalisations, frequent re-hospitalisations and mortality. The safety and efficacy of telehealth-guided outpatient ADHF management (virtual ward-VW) as an alternative to hospitalisation has not been assessed previously. Aim The aim of this study was to assess the safety and outcomes of our acute heart failure virtual ward (HFVW) pathway (Figure 1) when compared to hospitalised ADHF patients. Methods This cohort study (May 2022-October 2023) assessed the outcomes of telehealth-guided outpatient ADHF management using bolus intravenous furosemide in a HF-specialist VW. We compared baseline patient characteristics, NTproBNP, ejection fraction, NYHA Class, clinical risk score (Get With the Guidelines-Heart Failure-GWTG-HF), comorbidities (Charlson Co-morbidity Index-CCI), frailty (Rockwood Clinical Frailty Score-CFS), HF therapies and measured clinical outcomes at 1, 3, 6 and 12 months (re-hospitalisations, mortality) in the HFVW cohort versus standard care (ADHF patients managed without telehealth in 2021). Results 554 HFVW ADHF patients (age 73.1±10.9 years; 46% female) were compared with 402 ADHF patients (74.2±11.8; p=0.15 and 49% female) in the standard care cohort (SC). Despite similar baseline patient characteristics, GWTG-HF score, CCI and CFS, re-hospitalisations were significantly lower in the HFVW compared to standard care (1 month - 11.6% vs. 21%, p=0.002; 3 months - 20.4% vs. 30%, p=0.001; 6 months -29.3% vs 41%, p=0.02 and 12 months-48% vs. 57%,p=0.03) whereas mortality was lower at 1 month (6% vs. 14%; p<0.001), 3 months (10.5% vs. 15%; p=0.02) and 6 months (15.5% vs. 21%; p=0.04) (Figure 2). Multivariate logistic regression analysis showed that an increased daily step count whilst on HFVW independently predicted reduced odds of re-hospitalisations at 1 month (OR 0.85; 95% CI 0.7-0.9; p=0.005), 3 months [OR 0.95 (0.93-0.98); p=0.003] and 1 month mortality [OR 0.85 (0.7-0.95), p=0.01]. Whereas CCI predicted adverse 12-month outcomes [OR 1.2 (1.1-1.4), p=0.03]. Higher GWTG-HF score independently predicted increased odds of re-hospitalisation [1-month OR 1.2 (1.1-1.3), p=0.01; 12-month OR 1.1, 1.05-1.2, p=0.03) as well as mortality [1-month OR 1.2 (1.1-1.4), p=0.01; 12-month OR 1.3 (1.1-1.7), p=0.02]. Similarly higher CFS also independently predicted increased odds of re-hospitalisations [1-month OR 1.5 (1.1-2.2), p=0.03; 12-month OR 1.9 (1.2-3, p=0.01] and mortality [1-month OR 2 (1.1-3.5), p=0.02; 12-month OR 2.6 (1.6-10); p=0.02] throughout the follow-up period. Conclusions A telehealth-guided specialist HFVW management strategy for ADHF may offer a safe and efficacious alternative to hospitalisation in suitable patients. Daily step count, GWTG, CCI and CFS can play a vital role in assessing suitability for VW and in predicting risk of adverse clinical outcomes.Heart Failure Virtual Ward PathwayMortality & Re-hospitalisations outcomes

Identifying Patients at Increased Risk for Poor Outcomes Among Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients: The IPOGRO Risk Model

Background: A subarachnoid hemorrhage due to an aneurysmal rupture (aSAH) is a serious condition with severe neurological consequences. The World Federation of Neurosurgical Societies (WFNS) classification is a reliable predictor of death and long-term disability in patients with aSAH. Poor-grade neurological conditions on admission in aSAH (PG-aSAH) are often linked to high mortality rates and unfavorable outcomes. However, more than one-third of patients with PG-aSAH may recover and have good functional outcomes if aggressive treatment is provided. We developed a risk model called Identifying POor GRade Outcomes (IPOGRO) to predict 6-month mRS outcomes in PG-aSAH patients as a secondary analysis of a previously published study. Methods: All consecutive patients in poor-grade neurological conditions (WFNS IV-V) admitted to our institute from 2010 to 2020 due to aSAH were considered. Clinical and neuroradiological parameters were employed in the univariable analysis to evaluate the relationship with a 6-month modified Rankin Scale (mRS). Then, a multivariable multinomial regression model was performed to predict 6-month outcomes. Results: 149 patients with PG-aSAH were included. Most patients were surgically treated, with only 33.6% being endovascularly treated. The 6-month mRS score was significantly associated with clinical parameters on admission, such as lowered Glasgow Coma Scale (GCS), leukocytosis, hyperglycemia, raised Systolic Blood Pressure (SBP), greater Simplified Acute Physiology Score (SAPS II score), increased initial serum Lactic Acid (LA) levels, and the need for Norepinephrine (NE) administration. Neuroradiological parameters on the initial CT scan showed a significant association with a worsening 6-month mRS. The IPOGRO risk model analysis showed an association between a WFNS V on admission and a poor outcome (mRS 4-5), while raised SBP was associated with mortality. Conclusions: Our IPOGRO risk model indicates that PG-aSAH patients with higher SBP at admission had an increased risk of death at 6-month follow-up, whereas patients with WFNS grade V at admission had an increased risk of poor outcome but not mortality.

Hyperbaric Oxygen Therapy (HBOT) in Moderate Traumatic Brain Injury (TBI): A Randomized Controlled Trial

Abstract Introduction Hyperbaric oxygen therapy (HBOT) is a novel technique recently under investigation with intention to improve outcomes in traumatic brain injury (TBI). It increases the partial pressure of oxygen in the blood and tissues by inhaling pure oxygen in an environment pressurized to at least 1.4 times normal atmospheric pressure (ATM) at sea level. The rationale behind the use of HBOT in TBI is its potential to mitigate the secondary brain injury cascade initiated by the primary mechanical trauma. Tissue damage and neuroinflammation secondary to intricate and complex cellular biochemical processes are expected to be counteracted by increased oxygen availability during HBOT, which reduces oxidative stress and improves neuroplasticity. Materials and Methods All patients, except whose legal guardians denied informed consent, with moderate TBI presenting to the neurotrauma center, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India, were included within the study period of June 2022 to July 2023. Patient allocation was randomized into two arms: namely, treatment and control arm. Simple randomization was done using randomization mobile app, RRApp. Each patient received standard of care per the Brain Trauma Foundation guidelines. Patients randomized under the treatment arm additionally received adjuvant HBOT sessions. One session daily for 10 consecutive days. Session duration was for 60 minutes each at 1.4 ATM. The primary objective of the study was to compare the Glasgow Coma Score (GCS) at discharge and 3-month post-TBI Glasgow Outcome Scale-Extended (GOS-E) among patients in the treatment arm (those who received adjuvant HBOT) with those in the control arm (those who received only standard of care). Results The mean GCS (±standard deviation [SD]) at discharge in the treatment arm was 14.37 (±00.51) with a median of 14 and a range of 14 to 15. Comparatively, the mean GCS (±SD) at discharge in the control arm was 13.40 (±00.84) with a median of 13 and a range of 12 to 15. The difference between the two arms was statistically significant (p < 0.001). GOS-E at 3 months postinjury for the treatment arm was 7.62 ± 00.51 (mean ± SD) with a median of 8 (range: 7–8). For the control arm, GOS-E at 3 months postinjury was 6.40 ± 1.50 (mean ± SD) with a median of 7 (range: 4–8). The difference between the two arms was statistically significant (p < 0.001). Conclusion The current study concludes that early adjuvant HBOT using 1.4 ATM with one session of one-hour daily for 10 days among adults sustaining moderate TBI significantly improves GCS at 10 days. Early adjuvant HBOT is also associated with significantly improved GOS-E at 3 months postinjury compared to standard of care alone.

Factors Influencing Surgical Outcome of Patients with Traumatic Acute Subdural Hematoma

Background: Traumatic acute subdural hematoma (ASDH) is a catastrophic devastating component of brain injury in neurosurgical arena. Due to its significant mortality rate, potential for functional disability and disastrous consequence of complications, it is considered as a challenge for neurosurgeons worldwide. Consequently, precise recognition of predictive outcome factors is crucial for appropriate neurosurgical management and prognostication for patients with traumatic ASDH. Aims: The study aimed to determine the demographic, clinical, radiological and therapeutic factors associated with the surgical outcomes in patients with traumatic acute subdural hematoma (ASDH) who managed surgically in the Neurosurgery Department at a tertiary level hospital in Bangladesh. Materials and Methods: This prospective observational study included 40 radiologically diagnosed cases of traumatic ASDH age more than 18 years who were admitted and operated in the Department of Neurosurgery of Chittagong Medical College Hospital from May 2022 to April 2023. Data regarding demographic, clinical, radiographic, surgical procedure and findings were recorded. Three months mortality rate with clinical outcome was assessed by Glasgow Outcome Scale (GOS) score and analyzed. The outcome was divided into favorable outcomes (GOS score >3) and unfavorable outcomes (GOS score d”3). Results: The median age of the patients was 45 years (range: 19-82 years), and there was a male predominance (82.5%) with a male to female ratio of 4.7:1. Road traffic accident (RTA) was the most common cause of trauma (65%), followed by fall from height (15%), and physical assault (12.5%). Craniotomy was done in 16 (40%) patients and other 24 (60%) patients had decompressive craniectomy. Overall, 21 (52.5%) patients had good outcome and other 19 (47.5%) had poor outcome, and three months mortality rate was 42.5%. Regression analysis revealed that, increasing age [Odds ratio (OR): 1.12, 95% Confidence interval CI: 1.02-1.22. p=0.014], preoperative GCS of d”8 (OR: 13.98, 95% CI:1.22-160.00, p=0.034), and presence of Anisocoria with non-reacting pupil (OR; 17.99, 95% CI: 1.32-244.08, p=0.030) were independently associated with poor outcome. Conclusions: This study identified higher age, preoperative low GCS score and pupillary abnormality as the independent predictors for 3-months poor outcome in patients who underwent surgical treatment for traumatic ASDH Bang. J Neurosurgery 2024; 13(2): 140-148

77 Antenatal MgS04 in very preterm babies is not related to improved 36 month neurodevelopmental outcomes once accounting for neonatal interventions

Abstract Background Magnesium Sulphate (MgSO4) has become a standard practice for fetal neuroprotection prior to delivery of very-preterm babies due to an association with MgSO4 and reduction of cerebral palsy at 2 years of age in randomized clinical trials. Objectives In a prospective cohort of very preterm babies, we aimed to define the association between antenatal MgSO4 administration and neurodevelopmental outcome. Design/Methods We included a prospective cohort of 265 infants born ≤ 32 weeks’ gestation recruited at three tertiary neonatal intensive care units (NICU). Infants underwent two brain MRIs, one in the initial weeks after birth and one at term-equivalent age. Neurodevelopmental follow-up assessments were completed using the Bayley-3 at 3 years. Univariate analysis was undertaken to determine whether MgSO4 was associated with outcome. Multiple maternal and neonatal factors were analyzed according to their relationship with outcome. Gestational age was accounted for in all models. Maternal factors associated with MgSO4 administration were hypertension, multiple births and antenatal corticosteroid administration. Neonatal factors were sex, neonatal resuscitation, major surgery, and moderate-severe white matter injury (volume >40mm3). Multivariable linear regression models of maternal and neonatal risk factors were used to account for potential confounders based on those factors that were significantly (p<0.05) associated in univariate analysis. Results On univariate analysis, MgSO4 administration was inversely associated with 36-month motor scores (p<0.05). On the multivariable analysis, no maternal confounders had an impact on the relationship between MgSO4 and outcome (Table 2). MgS04 was no longer statistically related to any Bayley outcomes after adjusting for confounders at 36 months (Table 2). Neonatal surgery was related to poorer 36-month motor and cognitive outcomes. Conclusion Antenatal MgSO4 exposure was not associated with improved measures on the Bayley scales at 3 years after adjusting for potential confounders. However, neonatal interventions remained significant risk factors for poorer neurodevelopmental outcome.

The impact of sex differences on stroke risk factors and 3-month outcomes in patients receiving thrombolytic therapy for acute ischemic stroke

BackgroundAcute ischemic stroke (AIS) is a major public health issue, and women have a disproportionate share of stroke-related disability and mortality, which is poorly understood. This study aimed to determine the effect of sex differences on AIS treated by thrombolysis using recombinant tissue plasminogen activator (rTPA). The study included 134 AIS patients eligible for rTPA. Risk factors, clinical presentation, thrombolysis response, complications, and outcomes were recorded. The outcomes were measured using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) 3 months after stroke. The incidence of intracranial haemorrhage was also determined.ResultsAmong 134 AIS patients treated with rTPA (59% male, 41% female), females had higher rates of hypertension (67.3% versus 49.4%, p = 0.040) and atrial fibrillation (AF) (12.7% versus 2.5%, p = 0.020), while smoking was more prevalent in males (31.6% versus 0%, p < 0.0001). Cardioembolism was more frequent in females than in males (23.6% versus 6.3%, p = 0.004). Females also had shorter onset-to-door (110.7 ± 63 versus 131.1 ± 50.2 min, p = 0.035) and onset-to-needle times (151.6 ± 66.5 versus 173.7 ± 50.6 min, p = 0.046). Both sexes showed significant improvements in NIHSS (males: 11.58 ± 3.7 to 6.05 ± 5.6; females: 11.64 ± 4.7 to 6.9 ± 5.9; p < 0.0001) and mRS scores (males: 3.34 ± 1.05 to 2.03 ± 2; females: 3.53 ± 1 to 2.02 ± 2; p < 0.0001) over 3 months, with no significant differences between sexes. Predictors of poor outcome (mRS 3–6) differed: diabetes mellitus (DM) (OR 7.79, p = 0.002) and longer door-to-needle time (OR 1.04, p = 0.008) for males, and hemorrhage (OR 9.41, p = 0.048) for females. Hemorrhage predicted mortality in males (OR 27.08, p < 0.0001), while AF was associated with increased mortality in females (OR 8.06, p = 0.024).ConclusionsThis study revealed sex-specific differences in AIS risk factors, aetiology, and rTPA treatment timelines, although post-treatment improvements were comparable between sexes. Notably, outcome predictors and mortality factors differed by sex. These findings emphasize the need for sex-specific considerations in AIS management and risk assessment.

Behavioral and Cognitive Consequences of Spreading Depolarizations: A Translational Scoping Review.

Spreading depolarizations (SDs) are self-propagating waves of mass depolarization that cause silencing of brain activity and have the potential to impact brain function and behavior. In the eight decades following their initial discovery in 1944, numerous publications have studied the cellular and molecular underpinning of SDs, but fewer have focused on the impact of SDs on behavior and cognition. It is now known that SDs occur in more than 60% of patients with moderate-to-severe traumatic brain injury (TBI), and their presence is associated with poor 6-month outcomes. Since cognitive dysfunction is a key component of TBI pathology and recovery, understanding the impact of SDs on behavior and cognition is an important step in developing diagnostic and therapeutic approaches. This study summarizes the known behavioral and cognitive consequences of SDs based on historical studies on awake animals, recent experimental paradigms, and modern clinical examples. This scoping review showcases our current understanding of the impact of SDs on cognition and behavior and highlights the need for continued research on the consequences of SDs.

Short-term functional outcome of total hip arthroplasty for avascular necrosis of femoral head and influence of patient-related factors

Introduction Avascular necrosis of the femoral head (ANFH) is a phenomenon vascular supply disruption lead to death of bone cells around the femoral head. The disease is a severe health issue all over the world. Within 2 years about 80 % to 85 % of symptomatic cases will result in collapse of the femoral head. Recovery of hip function after total hip arthroplasty (THA) may be influenced by many factors that vary among different racial/ethnic groups. Most findings in this field have been from Western developed nations, and not much information from developing Asian countries is available.This study aimed to determine the six-month functional outcome and patient–related factors that predict functional recovery in patients with avascular necrosis of the femoral head (ANFH) undertaking total hip arthroplasty (THA).Methods Between January 2022 and December 2023 there were 143 patients participating in this prospective study. Demographic, medical history and clinical findings were collected from their medical records. The six-month functional outcome was evaluated using the Harris hip score (HHS). The mean age of the participants was 55.90 ± 11.49 years, and the majority (86.7 %) were male. Most patients had excellent (43.4 %) or good outcome (51.7 %).Discussion Our study had some limitations: the length of the follow-up after surgery is short (6 months), that hospital-related factors like the type and volume of the hospital have not been analyzed. Nonetheless, previous observations suggest that most of the improvement in physical function occurs during the first six months following surgery and remains the same for a long time. However, our sample has typical demographic and clinical characteristics of patients with THA for ANFH, suggesting that determinants of the 6-month functional outcome in the current study could apply to other patients undergoing this surgery.Results The determinants of excellent outcome were a higher preoperative HHS (odds ratio (OR): 4.369, 95 % confidence interval (CI) =1.854 – 10.299; p &lt; 0.001) and absence of comorbidity (OR: 2.440, 95 % CI = 1.071 – 5.557, p = 0.034). No demographic (age, gender, body mass index), medical history (using of steroids, alcohol consumption or smoking), or any other clinical parameter (stage or side of the affected hip, time until surgery) had a significant influence on functional outcome.Conclusion Earlier surgery during functional decline and better management of comorbidity may help improve THA outcomes for patients with avascular necrosis of the femoral head.

Ischemic Stroke in Young Adults in India: Predictors of Recurrence and Functional Outcome.

Ischemic stroke (IS) in young is increasingly recognized as an important health problem in low- and middle-income countries (LMICs). Limited data is available from LMICs about the predictors of outcome and recurrence of IS in young. The study aims to assess the predictors of short-term and long-term functional outcome and the recurrence of the first-ever IS and transient ischemic attack in young. The clinical, radiological data, functional outcome, and recurrence of 569 IS patients aged 18-50 years were recorded. The etiological classification was done. The functional outcome was assessed using the modified Rankin scale (mRS), with a good outcome being mRS 0-2. Logistic regression was used to analyze the predictors of recurrence and outcome. The most common risk factors were hypertension (40.3%) and diabetes mellitus (34.3%). Stroke of undetermined etiology (33.6%) was the most common etiological subtype. Among the cardioembolic subtypes, rheumatic heart disease constituted 47.4%. A good functional outcome at 1 year was seen in 76.3%. While baseline stroke severity predicted both the 3-month and 1-year functional outcome, age ≥40 years and male gender predicted poor outcome at 1 year. The risk of recurrent strokes at 1 year was 2.5%. On multiple logistic regression analysis, diabetes mellitus independently predicted recurrent vascular events at 1 year (odds ratio = 2.43, 95% confidence interval 1.07-5.50). We found a good functional outcome with a relatively low recurrence at 1 year among young IS patients. Baseline stroke severity, age, and male gender predicted a poor 1-year functional outcome.