6-month Mortality Research Articles

Microvesicle Tissue Factor Procoagulant Activity Is Elevated and Correlated With Disease Severity in Patients With Cirrhosis.

Tissue factor-expressing microvesicles (MV-TF) have been found to correlate with thrombotic complications in various diseases. Simultaneously, there is expanding research regarding the effect of the coagulation cascade on liver fibrosis progression. The aim of our manuscript was to evaluate MV-TF activity in patients with cirrhosis and its correlation with disease severity. We prospectively enrolled 82 patients [11 with cirrhosis and hepatocellular cancer (Group 1), 50 with cirrhosis (Group 2) and 21 controls (Group 3)]. Extensive workup for disease staging and exclusion criteria was undertaken. Exclusion criteria included thrombophilia, history of thrombosis, recent hospitalisation, ongoing infection, alcohol dependence, cancer, haematological diseases and use of anticoagulant, antiplatelet or contraceptive drugs. Plasma tissue factor antigen concentration and MV-TF activity were assessed. MV-TF showed median values of 4.03 [1.57], 3.17 [1.59] and 2.26 [1.23] pg/mL in Groups 1, 2 and 3, respectively. There was a statistically significant difference between Groups 1 and 3 (p < 0.001) and Groups 2 and 3 (p = 0.003), while Group 1 had higher values than Group 2 without statistical significance (p = 0.088). In Group 2, the patients' Child-Pugh (CP) stage was A in 56%, B in 26% and C in 18% of cases. MV-TF activity significantly correlated with decompensated cirrhosis (p = 0.005) and higher CP stage (p = 0.011). Finally, MV-TF activity significantly correlated with 12-month mortality (p = 0.021). MV-TF activity is elevated in patients with cirrhosis, showing a significant correlation with disease severity. MV-TF may play a role in the procoagulant imbalance of liver cirrhosis and their contribution in disease progression should be studied further.

The Impact of Rotational Malalignment Following Intramedullary Nailing for Intertrochanteric Fractures on Patients' Functional Outcomes: A Prospective Study.

Background & Aims: Rotational malalignment after intramedullary nailing of intertrochanteric fractures is a relatively common complication that may have a crucial impact on both functional outcome and a fracture's healing properties, ultimately affecting the patient's postoperative morbidity and mortality. Methods: 74 patients treated with intramedullary nailing due to an intertrochanteric fracture underwent a postoperative computed tomography (CT) scan of the hips and knees. The femoral anteversion difference (D angle) between the operated and healthy hip was calculated using the technique described by Jeanmart et al. The patients were divided into two groups according to their D angle values: a D angle less than 15° was considered an acceptable rotational alignment (group A), while a D angle equal to or more than 15° was considered a rotational deformity (group B). Postoperatively, the functional level of each patient was evaluated at the 6-month and 1-year follow-up visits and compared to the pre-fracture status using the modified Harris hip score (mHHS). Also, fracture union, other postoperative complications, and patient mortality were noted. Results: The mean femoral anteversion difference was 12.3° with a standard deviation of 10.3°. Of the 74 patients, 51 (68.9%) were assigned to group A and 23 (31.1%) to group B. At the 6-month postoperative follow-up, 67 (90.5%) patients had survived and 7 (9.5%) were deceased, with our statistical analysis indicating a linear trend (p-value = 0.048) between the presence of rotational malalignment and 6-month mortality. At the 1-year postoperative follow-up, 63 (85.1%) patients survived and 11 (14.9%) were deceased, with the statistical analysis indicating a significant relationship (p-value = 0.031) between the presence of rotational malalignment and the 1-year mortality. Regarding the functional outcome six months after the operation, the difference between the pre-fracture and the postoperative mHHS was 8.7/100 with a standard deviation of 6.1 for the 49 patients in group A and 14.5/100 with a standard deviation of 12.4 for the 18 patients in group B, with the statistical analysis indicating a significant difference (t = -2.536, significance < 0.05) in the functional level between the two groups. As for the functional outcome one year after the operation, the difference between the pre-fracture and the postoperative mHHS was 4.9/100 with a standard deviation of 7.8 for the 47 patients in group A and 8.3/100 with a standard deviation of 13 for the 16 patients in group B, with the statistical analysis indicating no significant difference (t = -1.266, significance > 0.05) in the functional level between the two groups. The only postoperative complication noted was fracture non-union, presenting in two patients (3%), with the statistical analysis indicating no significant relationship (p-value = 0.698) between this complication and the presence of rotational malalignment. Conclusions: In this study, rotational malalignment after intertrochanteric fracture intramedullary nailing presents in 31.1% of cases. The correlation between this malalignment and functional outcomes shows a decline in patients' functional abilities during the first six postoperative months, a condition that improves over time, with most patients returning to their preoperative functional status one year after the operation. Furthermore, our results indicate a possible relationship between rotational malalignment and mortality within one year. Future research should focus on creating a more detailed, functional evaluation system for the elderly and applying it to a larger sample to confirm these findings.

Extracorporeal liver support systems in patients with acute-on-chronic liver failure: An updated systematic review and meta-analysis.

The utilization of extracorporeal liver support systems is increasingly prevalent for the management of acute-on-chronic liver failure in clinical settings. Yet, the efficacy of these interventions in terms of tangible clinical benefits for patients remains a matter of debate, underscoring the need for meta-analysis. An updated meta-analysis was performed to elucidate the relationship between the application of extracorporeal liver support versus standard pharmacological treatment and the prognostic endpoints of patient survival, specifically assessing 1-month and 3-month mortality rates, as well as the incidence of complications such as hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Literature were searched via PubMed, EMBASE, and Web of Science. The meta-analysis revealed the following: the odds ratio for 1-month mortality was 0.63 (95% confidence interval [CIs]: 0.51-0.76), for 3-month mortality was 0.70 (95% CI: 0.61-0.81), for hepatic encephalopathy was 0.81 (95% CI: 0.67-0.97), for spontaneous bacterial peritonitis was 0.66 (95% CI: 0.44-0.99), and for hepatorenal syndrome was 0.68 (95% CI: 0.51-0.92). These results suggest that patients with acute-on-chronic liver failure undergoing extracorporeal liver support system therapy have significantly better survival rates and lower complication incidences compared to those receiving conventional drug therapy. Further subgroup analysis indicated that patients with lower model for end-stage liver disease (MELD) scores and reduced total bilirubin (Tbil) levels demonstrated greater benefits from extracorporeal hepatic support. This study establishes that in the management of acute-on-chronic liver failure, extracorporeal liver support systems confer a survival advantage and reduce complications relative to standard pharmacotherapy.

Thoracic Endovascular Aortic Repair For The Management of Aorto-Esophageal Fistulae: A Systematic Review.

Aorto-esophageal fistula (AEF) is a rare condition consisting in a fistula between the aorta and the esophagus. The thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for initial AEF management, but large series are not available and outcomes are questionable. This study aims at evaluating the current evidence of TEVAR in AEF. A search on PubMed/MEDLINE and EMBASE was conducted up to June 2023. Data on article type, patients' demographics, cause and type of AEF, clinical presentation, time from clinical presentation to TEVAR, strategies, mortality, and follow-up were analyzed. 106 reports published between 1997 and 2023 were deemed eligible for this study (92 case reports; 14 case-series). A total of 163 patients (mean age: 58.9±16.5 years), diagnosed with AEF and treated with TEVAR (with or without staged surgical repair of the esophagus or the aorta) were included. A thoracic aortic aneurysm (34.4%) was the most common cause of AEF, followed by esophageal cancer (25.2%), foreign body in esophagus (13.5%) and post-TEVAR complication (9.8%). Primary AEF were 129 (79.1%), and secondary AEF were 34 (20.9%). TEVAR alone was performed 80 times (49.1%), while TEVAR with staged esophageal or aortic surgery 83 times (50.9%). The overall 30-day mortality was 11.7% (n=19): 18.8% in TEVAR alone and 4.8% in TEVAR with staged surgery, respectively (p=0.006). Mean follow-up time was 12.3±14.7 months. The overall 6-month mortality was 34.4% (n=56): 48.8% in TEVAR alone and 20.5% in TEVAR with staged surgery (p<0.001). Bleeding for recurrence of AEF and sepsis were the main causes of death. In case of AEF, TEVAR can be urgently performed for bleeding management and hemodynamic control. TEVAR alone is a valuable yet not definitive procedure. Instead, TEVAR followed by surgical repair may provide better outcomes and should be recommended, when possible. This review summarizes the published papers on endovascular aortic repair for the treatment of aorto-esophageal fistulae. The clinicians can find several important details on how to manage the presence of an esophageal fistulae wich represents a potential life-threatening problem for the patients. The implantation of a thoracic endovascular aortic prosthesis represents a fast and reliable procedure in case of emergency but a second step surgical repair provides better outcomes and should be recommended in suitable patients.

Efficacy and safety of percutaneous mechanical circulatory support in patients with cardiogenic shock following acute myocardial infarction: A meta-analysis of randomized controlled trials.

Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI) with high mortality rates. While mechanical circulatory support devices like intra-aortic balloon pump (IABP) and Impella are used to manage CS, their comparative effectiveness remains unclear. This meta-analysis aims to evaluate the safety and efficacy of Impella in the treatment of AMI-associated CS. A comprehensive literature search was performed across PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science. The primary efficacy endpoint was 6-month all-cause mortality. Secondary efficacy endpoints included 30-day mortality, major bleeding, limb ischemia, sepsis, and left ventricular ejection fraction. Pooled odds ratios (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated using the random-effects model via Revman version 5.4. Statistical significance was determined at P < .05. Four RCTs with a total of 442 patients were included in this meta-analysis. The pooled analysis showed that the odds of 6-month all-cause mortality were significantly lower with Impella compared to standard of care (OR: 0.64, 95% CI: 0.43-0.95; P value: .03). However, 30-day mortality reported no statistically significant difference between the 2 groups (OR: 1.03; 95% CI: 0.43-2.48; P = .95). Our analysis found that the use of impella is associated with a statistically significant increase in the odds of major bleeding (OR: 3.61; 95% CI: 1.14-11.40; P = .03), limb ischemia (OR: 4.91; 95% CI: 1.37-17.59; P = .01), and sepsis (OR: 2.75; 95% CI: 1.25-6.08; P = .01). No statistical significance was found in left ventricular ejection fraction at follow-up between the 2 groups (SMD: -0.35; 95% CI: -0.78 to 0.07; P = .11). Impella significantly reduces 6-month all-cause mortality in patients with CS following AMI compared to standard of care. However, this survival benefit is offset by a substantial increase in major bleeding, limb ischemia, and sepsis risks associated with Impella. Future large scale trials are needed to validate these findings and refine clinical guidelines for the optimal use of Impella in treating CS.

Pre-admission opioid use disorder as a new predictor of in-hospital mortality and six-month outcomes in traumatic brain injury patients: a retrospective longitudinal cohort study.

The present study aimed to investigate the effect of pre-admission Opioid Use Disorder (OUD) on in-hospital mortality and 6-month follow-up TBI outcomes. This study included 2804 patients with TBI admitted to the Intensive Care Unit of Emtiaz (Rajaee) Hospital, a referral trauma center in Shiraz, Iran. Finally, 1087 eligible participants were selected from included patients. Then, 872 discharged patients were followed for six months. Subsequently, unfavorable neurological outcomes (Glasgow Outcome Scale-Extended ≤ 4) and the mortality rate were compared among the patients with and without OUD. The mean age of the patients was 38.0 ± 18.9 years old (84.7% men). About 9.2% of patients had OUD. Opioid users had a slightly lower risk of in-hospital mortality (OR = 0.62, 95% CI = [0.328, 1.183], P-value = 0.148). In contrast, 6-month follow-up mortality significantly increased in the survived patients with a history of pre-admission OUD (OR = 2.49, 95%CI= [1.29, 2.80], P-value = 0.007). Moreover, 6-month unfavorable outcomes were raised in OUD, though it was not significant (OR = 1.59, 95%CI= [0.89, 2.84], P-value = 0.121). Our results revealed that patients with OUD are at increased risk of 6-month follow-up complications and also death following moderate to severe TBI. Although OUD decreased in-hospital mortality, 6-month follow-up indicated that mortality and unfavorable outcomes were increased in the OUD group. Based on the existing evidence, this effect is probably not only due to the destructive impact of pre-admission OUD on brain physiology. However, it may also be due to an increase in opioid consumption to alleviate pain and withdrawal symptoms after hospital discharge.

Impact of hospital readmissions following hospitalisation with delirium on 12-month mortality: a quaternary Australian hospital experience.

Inpatient delirium and unplanned hospital readmissions are associated with increased mortality. This study aimed to determine the effect of 28-day unplanned hospital readmissions on 12-month mortality post-discharge in patients with delirium during index hospitalisation. Retrospective longitudinal cohort study of adults aged 65 or above with delirium during hospitalisation at a Victorian quaternary hospital was performed. Delirium was identified by the inclusion of ICD-10 (International Classification of Diseases, 10th revision) codes in the hospital medical discharge summary. Descriptive statistics was obtained for baseline characteristics. Cox proportional hazards model was developed to identify independent predictors of 12-month post-discharge mortality. One thousand six hundred thirty-four patients with delirium during in-patient admission were included. The overall 12-month mortality rate was 35% (572 patients). Of the 1,425 patients who survived their index admission, 11.2% had an unplanned 28-day readmission. In Cox regression analysis, unplanned readmission (hazard ratio (HR) 2.3, 95% confidence internal (CI) 1.7-2.9), older age (HR 1.38, CI 1.11-1.72), Charlson Comorbidity Index (HR 1.21, CI 1.17-1.27), and discharge to nursing home (HR 1.58, CI 1.23-2.02) were independent predictors of 12-month mortality. Readmitted patients with 12-month mortality were older, with higher rates of dementia, polypharmacy, and nursing home residence compared to readmitted patients who did not reach this endpoint. Unplanned hospital readmission within 28days of discharge is an independent predictor of 12-month mortality post in-hospital delirium admission. Admissions complicated by delirium and readmission episodes should instigate discussions regarding prognostication and goals of care. Greater research is required to minimise hospital readmission rates following discharge in this cohort.

Tenecteplase vs Alteplase in Acute Ischemic Stroke Within 4.5 Hours: A Systematic Review and Meta-Analysis of Randomized Trials.

The current European Stroke Organisation expedited recommendation on tenecteplase (TNK) for acute ischemic stroke (AIS) advocates that TNK 0.25 mg/kg can be used alternatively to alteplase (tissue plasminogen activator [TPA]) for AIS of <4.5 hours duration, based on a meta-analytical approach establishing noninferiority. Since the publication of these guidelines, 4 additional randomized controlled clinical trials (RCTs) have provided further insight. We conducted an updated systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of TNK 0.25 mg/kg compared with TPA for the treatment of AIS within 4.5 hours of onset. The primary outcome was defined as the excellent functional outcome at 3 months (modified Rankin Scale [mRS] score 0-1), whereas good functional outcome (mRS score 0-2), reduced disability at 3 months (≥1-point reduction across all mRS scores), symptomatic intracranial hemorrhage (sICH), and 3-month mortality were evaluated as secondary outcomes. Pooled estimates were calculated with random-effects model. A prespecified subgroup analysis was performed stratifying for TNK formulation, that is, original TNK vs biocopy: recombinant human TNK tissue-type plasminogen activator that is available in China and has a different production process. Eleven RCTs were included comprising a total of 3,788 patients treated with TNK vs 3,757 patients treated with TPA. TNK was associated with higher likelihood of excellent functional outcome (risk ratio [RR] 1.05, 95% CI 1.01-1.10; p = 0.012; I2 = 0%; risk difference 2.95%; 95% CI 0.76%-5.14%; p = 0.008; I2 = 0%) and reduced disability at 3 months (common odds ratio 1.10, 95% CI 1.01-1.19; p = 0.034; I2 = 0%) compared with TPA while good functional outcome (RR 1.03, 95% CI 0.99-1.07; p = 0.142; I2 = 28%) was similar between the groups. Regarding safety outcomes, similar rates of sICH (RR 1.12, 95% CI 0.83-1.53; p = 0.456; I2 = 0%) and 3-month mortality (RR 0.97, 95% CI 0.82-1.15; p = 0.727; I2 = 12%) were observed. When stratified for TNK regimen (original vs biocopy), statistical significance in achieving an excellent functional outcome at 3 months was retained for the original TNK (RR 1.05, 95% CI 1.00-1.10; p = 0.044; I2 = 0%). The updated meta-analysis confirms similar safety between TNK 0.25 mg/kg and TPA, while showing that TNK is superior to TPA regarding excellent functional outcome and reduced disability at 3 months. These findings support transitioning to TNK in clinical practice.

Abstract 4135517: Echocardiographic Biomarkers Enhance Mortality Predictions in Cirrhosis Patients

Introduction: Cirrhosis, a late-stage liver disease, is associated with numerous systemic complications, making long-term mortality prediction challenging. Traditional models like Child-Pugh and MELD are primarily designed for short-term (3-month) mortality. This study evaluates the impact of incorporating echocardiographic (echo) variables in predicting long-term mortality in cirrhosis patients. Methods: A retrospective cohort study was conducted using data from 60 patients with clinically diagnosed cirrhosis from Hippokration Hospital, Greece, spanning 2018 to 2022. Patients were followed for up to 52 months. Exclusion criteria included pre-existing cardiovascular diseases and significant co-morbidities. Patients were categorized into survived to end of study (n=31) and died during study (n=29) groups. Outcomes were analyzed using multivariate logistic regression and Cox proportional hazards models, and include parameters for age, blood pressure, lab-based biomarkers (potassium, pro-brain natriuretic peptide, hemoglobin, platelet count, aspartate transaminase, gamma-glutamyl transferase, uric acid), and echo/ecg measurements (QT interval, left ventricular (LV) ejection fraction, LV global longitudinal strain (GLS), left atrial GLS, annulus velocities, and E/A ratio). Results: The multivariate logistic regression model (MELD+) that included echo variables showed a 10% improvement in area under the curve (AUC: 0.901) compared to the MELD model alone (AUC: 0.817). MELD+ improved risk classification accuracy by nearly 10% with a conservative threshold. The Cox proportional hazards model with MELD+ also demonstrated superior performance (AUC: 0.923; C-index: 0.875; Brier Score: 0.097) compared to the MELD model alone (AUC: 0.892; C-index: 0.831; Brier Score: 0.134). The MELD+ model showed less variation in hazard ratio confidence intervals, indicating more consistent risk estimation. Conclusion: Incorporating echocardiographic measurements enhances the accuracy of long-term mortality predictions in cirrhosis patients. These findings suggest that cardiac imaging should be considered in risk assessments for cirrhosis patients, particularly for predicting survival beyond three months.

Abstract 4114198: Humanin Level is Inversely Correlated with NT-proBNP Level and Mortality in Heart Failure with Reduced Ejection Fraction

Background: Mitochondrial dysfunction contributes to heart failure (HF) progression via diminished energy supply, release of reactive oxygen species, and increased cell death. However, there has yet to be clinically relevant biomarkers that address mitochondrial-mediated cardiac injury in patients. Humanin (HN) is a mitochondria-derived peptide that protects cells through the interference of apoptosis and reduction of oxidative stress. The objectives of our study were to measure circulating plasma HN levels in patients with HF with reduced ejection fraction and describe the relationship of HN to validated, clinically relevant measures of HF. Methods: We conducted a prospective cohort study. To be included in the study, patients must have: 1) left ventricular ejection fraction &lt;40%, 2) high risk of future clinical instability, 3) medication and device treatment according to guidelines, and 4) stable medical therapy for at least 30 days prior to screening. Plasma HN levels were measured at time of study enrollment by an enzyme-linked immunoassay. Statistical analyses were performed to evaluate the relationships between HN levels and demographic variables, quantitative measures of HF, and clinical outcomes. Results: 54 HF patients were included in the study. Age and sex were not significantly associated with HN level. There was a significant difference in mean HN level by race with highest HN level seen in Caucasians and the lowest HN level seen in Hispanics (1310 pg/ml vs. 630 pg/ml, p=0.012). There was a significant inverse correlation between NT-proBNP level and HN level (r=-0.46, p &lt;0.001). After adjusting for race, higher NT-proBNP level, as both a continuous and categorical variable, was significantly associated with lower HN level. Furthermore, HN level was significantly lower in patients who died within 6 months compared to those who did not (520.7 pg/ml vs. 1146.9 pg/ml, p=0.013). After adjusting for race, lower HN level was significantly associated with increased odds of 6-month mortality (OR=0.784, 95% CI 0.620-0.943, p=0.018). Conclusions: To the best of our knowledge, this is the first study to describe plasma HN levels in HF patients. Its significant correlation with mortality and NT-proBNP level supports a potential role for HN as a novel prognostic biomarker in HF with reduced ejection fraction.

Lack of diversity in patients undergoing carotid artery stenting: Implications for the Distressed Community Index.

As the role of social determinants in carotid artery stenting (CAS) outcomes remains unclear, we investigated the association between the Distressed Community Index (DCI) (zip-code based) and post-CAS mortality/stroke outcomes. We analyzed patients undergoing CAS from 2015 to 2019 using the Medicare claims-linked Vascular Quality Initiative database. Patients were grouped based on high (DCI ⩾ 60) and low (DCI < 60) community distress. We analyzed 36-month mortality using Kaplan-Meier survival curves and hierarchical Cox regression, and 36-month stroke using cumulative incidence function curves and Fine-Gray models. The final cohort included 8717 patients (3032 DCI ⩾ 60), with a mean DCI score of 46.2 (± 28.5) and mean age of 74.7 (± 7.8) years. Most participants were men (64.3%), White (92.7%), and non-Hispanic/Latino (97.7%). There was no significant difference in the 36-month mortality incidence between high and low community distress groups (25.6% vs 23.5%, p = 0.22), and no significant association between high community distress and mortality (unadjusted HR: 1.04; 95% CI 0.90-1.21; adjusted HR: 1.02; 95% CI 0.89-1.17). The high community distress group experienced an elevated 36-month stroke incidence (26.8% vs 22.4%, p = 0.048), but no significant association with stroke was observed (unadjusted sub-HR: 1.12; 95% CI 1.00-1.24; adjusted sub-HR: 1.03; 95% CI 0.92-1.16). Our cohort showed underrepresentation in terms of sex, race, and ethnicity, with a skewed DCI distribution towards lower community distress. Contrary to what we know about community distress, no independent association between higher community distress and post-CAS stroke/mortality risk was found. Future work must examine whether accessibility barriers and selective CAS allocation explain our results.

Sex differences in risk factors and outcomes of ischemic stroke patients treated with tissue plasminogen activator (tPA): insights from the SITS International Registry

IntroductionStroke is the second leading cause of death and disability in Iran, with the incidence and burden differing between men and women. Studies have shown that the incidence, burden, clinical outcomes, risk factors, complications, and response to intravenous tissue plasminogen activator (tPA) vary by sex. However, due to heterogeneity and socioeconomic factors, these results cannot be generalized to all populations. Therefore, regional studies are necessary to investigate sex differences. The aim of this study is to compare the risk factors for ischemic stroke and to examine the outcomes of tPA treatment between men and women.MethodsThis study included 1759 ischemic stroke patients treated with tPA at the Vali-e-Asr Hospital Stroke Center in Zanjan, Iran, from August 2016 to June 2023. Major risk factors, stroke severity, 3-month and in-hospital mortality, functional outcomes, independency, and symptomatic intracerebral hemorrhage (sICH) were investigated between men and women using the Safe Implementation of Treatments in Stroke (SITS) registry database. All analyses were conducted using SPSS.ResultsSmoking was less prevalent among women, while men were more likely to suffer from hypertension (P < 0.001) and vascular disease (P = 0.021). A higher incidence of sICH [OR (95% CI) = 1.37 (0.73–2.58), P = 0.333] and a lower rate of in-hospital mortality [OR (95% CI) = 0.79 (0.60–1.05), P = 0.108] were observed among men, although these differences were not statistically significant. Additionally, men achieved favorable outcomes (mRS ≤ 1) [OR (95% CI) = 1.07 (0.88–1.32), P = 0.493] 3 months after discharge compared to women, but these differences were not statistically significant.ConclusionDespite significant differences in the prevalence of risk factors between men and women receiving tPA, there were no significant differences in in-hospital and 3-month clinical outcomes. The variation in risk factors could inform local strategies for both primary and secondary prevention. A comprehensive national evaluation is recommended to further explore these findings.

Impact of point-of-care birth test-and-treat on clinical outcomes among infants with HIV: A cluster randomized trial in Mozambique and Tanzania.

We assessed the impact of point-of-care (PoC) test-and-treat at birth on clinical outcomes and viral suppression among HIV-positive infants in Mozambique and Tanzania. This cluster-randomized trial allocated health facilities to intervention, providing PoC-testing and antiretroviral treatment (ART) at birth and week 4-8, or control, starting these at week 4-8. The primary outcome was proportions of clinical events (mortality, morbidity, retention, virological failure, toxicity) among HIV-positive infants at month-18. We estimated incidence rate ratios adjusted for timing of HIV-detection (aIRR) and reported viral suppression <1000 copies/mL. Among 6602 neonates enrolled October 2019-September 2021, 125 were diagnosed HIV-positive by week 12. In the intervention arm, 38/69 (55.1%) were diagnosed at birth with 35 initiating ART within two days. In the control arm, 27/56 (48.2%) were retrospectively detected HIV-positive at birth, of whom 6/56 (10.7%) died or were lost to follow-up before testing. Median age at ART initiation was 6 (intervention) versus 33 days (control). Birth test-and-treat was not associated with a significant reduction in clinical outcomes up to month-18 [53 (76.8%) versus 48 (85.7%); aIRR 0.857; 95% CI 0.505-1.492], but showed a 68% relative reduction in 6-month mortality. Viral suppression was poor overall, but improved in the intervention group at month 18 (65.7% versus 29.6%; p=0.005). PoC test-and-treat at birth is feasible in resource-poor settings and resulted in clinically-relevant reduction of early infant mortality, though improved clinical outcomes were not sustained to month-18. Poor viral suppression may undermine early survival benefits, calling for better paediatric treatments and tailored adherence interventions.

Protocol for a prospective, longitudinal cohort study on the incidence of dementia after the onset of delirium in patients with mild cognitive impairment: MDDCohort (Mild Cognitive Impairment Delirium Dementia)

BackgroundMild cognitive impairment (MCI) is a major risk factor for delirium. Few studies with mid- to long-term follow-up periods have examined delirium, MCI, and the conversion of MCI to dementia. This prospective, longitudinal cohort study aims to assess the incidence of dementia after delirium onset in patients with MCI and to develop an artificial intelligence algorithm for predicting the conversion of MCI to dementia.MethodsA 30-day evaluation for delirium will be performed for adults aged ≥ 65 years diagnosed with MCI who score 18–23 on the Korean Mini-Mental State Exam. Individuals exhibiting delirium at least once will be classified into the delirium group and the remainder into the non-delirium group. Over 3 years, patients will undergo follow-ups for survival and conversion to dementia at 30-day intervals to analyze risk factors for delirium and clinical outcomes. Differences between the two groups will be analyzed using the chi-square and independent t-tests. Kaplan-Meier survival and Cox proportional hazard regression will be used to assess the effects on 30-day, 60-day, 12-month, 24-month, and 36-month mortality, whereas linear regression will be used to assess the length of stay at long-term care facilities and medical costs.DiscussionThe results will emphasize the importance of preventing delirium in MCI patients, and preventive interventions can be strengthened.Trial RegistrationNCT05113446 (ClinicalTrials.gov). Registered 9 November 2021 - Retrospectively registered.

Prognostic significance of novel muscle quality index utilization in hospitalized adults with cancer: A secondary analysis.

This study aimed to investigate and propose novel approaches to calculate muscle quality index (MQI) using muscle mass derived from single-frequency bioelectrical impedance analysis (SF-BIA) and calf circumference in both unadjusted and body mass index (BMI)-adjusted forms. In addition, we examined their prognostic significance in patients with cancer. A secondary analysis was conducted on a prospective cohort study of patients with cancer. Handgrip strength was measured. SF-BIA was conducted to estimate appendicular lean soft tissue (ALST, in kilograms). MQI was calculated using three approaches: (1) the ratio of handgrip strength to ALST (MQISF-BIA), (2) the ratio of handgrip strength to calf circumference (MQIcalf circumference), and (3) the ratio of handgrip strength to BMI-adjusted calf circumference (MQIadj. calf circumference). Maximally selected log-rank was calculated to estimate their cutoff values to predict survival. Two hundred eighty-four patients were included (51.1% men; median age, 61 years). Solid tumors were the most frequent (89.8%). All approaches to MQI (MQISF-BIA, MQIcalf circumference, and MQIadj. calf circumference) were independent predictors of 6-month mortality. The found cutoffs were (1) MQISF-BIA (<1.52 for men, <0.63 for women), (2) MQIcalf circumference (<0.74 for men, <0.24 for women), and (3) MQIadj. calf circumference (<0.75 for men, <0.25 for women). This study introduces MQISF-BIA, MQIcalf circumference, and MQIadj. calf circumference as future potential surrogate methods for computing MQI in clinical practice when other robust procedures are unavailable, pending further validation.

The Effect of After-Hours Resection on the Outcomes in Patients with High-Grade Gliomas.

The "weekend effect" is the finding that patients presenting for medical care outside of regular working hours tend to have worse outcomes. There is a paucity of literature in the neuro-oncology space exploring this effect. We investigated the extent of resection and complication rates in patients undergoing after-hours high-grade glioma resection. A retrospective review was conducted on patients with high-grade glioma requiring emergent surgery between January 1, 2021, and March 31, 2023. After hours was defined as surgical resection on the weekend and/or evening (>50% of surgical time between 1630 and 0659). These patients were matched to patients undergoing resection during regular working hours. Groups were compared on the basis of the extent of resection, postoperative complications and 6-month mortality rate. A total of 38 patients were included in this study (19 after hours, 19 regular hours). There was no significant difference in age, sex, tumor grade and tumor size between the two groups (all p > 0.05). There was no significant difference in the extent of resection between the groups (p = 0.7442). There was no significant difference in the rate of intraoperative complications, postoperative complications, reoperation and death at 6 months between the groups (all p > 0.05). Estimated blood loss was significantly higher in the regular hours group (p = 0.0278). There was no significant difference in the total operative time (p = 0.0643) and length of stay (p = 0.0601). After-hours high-grade glioma surgery has similar outcomes to regular-hours surgery for lesions not requiring specialized functional mapping.

The Impact of Heart Failure Chronic Treatment Prior to Cardiac Transplantation on Early Outcomes.

Background and Objectives: Cardiac transplantation represents the option for patients with end-stage heart failure (HF), providing the best survival rate. However, the postoperative complications of transplant patients remain a challenge for clinicians. The objective of our study was to evaluate the effect of preoperative chronic HF treatment on the occurrence of in-hospital complications. Materials and Methods: We retrospectively included a total of 50 patients who underwent cardiac transplantation between January 2011 and December 2023 from the Emergency Institute for Cardiovascular Diseases and Transplantation of Targu Mures. We correlated the preoperative chronic HF treatment with the postoperative complications by Spearmen's correlation coefficient, respectively. With logistic regression, the associations between the treatment and specific complications were determined. Results: Significant negative correlations were found between Carvedilol treatment with 2-month mortality (r = -0.30; 95% CI: -0.53--0.02; p = 0.03), Ramipril with hospital stay (r = -0.38; 95% CI: -0.60--0.12; p < 0.01) and intensive care unit (ICU) stay (r = -0.37; 95% CI: -0.59--0.11; p = 0.01), and Spironolactone usage with hospitalization duration (r = -0.28; 95% CI: -0.52--0.01; p = 0.04). Furthermore, Carvedilol treatment represented a protective factor against early acute kidney injury (AKI) (OR: 0.22; 95% CI: 0.05-0.91; p = 0.03). Spironolactone treatment was a protective factor against AGR (OR: 0.12; 95% CI: 0.02-0.66; p = 0.01) treatment, in contrast to angiotensin-converting enzyme inhibitor (ACEI) therapy (OR: 5.30; 95% CI: 1.03-27.17; p = 0.04). Conclusions: Pre-transplant Carvedilol treatment was negatively correlated with the 2-month mortality rate. Ramipril and Spironolactone therapy were negatively correlated with hospitalization duration, and Ramipril was additionally correlated with ICU stay. Moreover, Carvedilol therapy represented a protective factor against early AKI. Pre-transplant Spironolactone was associated with lower event rates of AGR, in contrast to ACEI treatment. Prospective studies with larger cohorts are needed in order to draw drastic conclusions.

Mortality-related factors in older adults with delirium: A prospective observational study

BackgroundDelirium is a common and serious neuropsychiatric syndrome characterized by acute changes in attention, cognition, and consciousness. It is frequently encountered in various clinical settings, including critical care units and postoperative care, and is associated with significant morbidity and mortality. Understanding the factors contributing to delirium-related mortality is crucial for improving patient outcomes and healthcare practices. However, the factors associated with mortality in delirium have not been well-defined in the literature. ObjectivesThis study aimed to identify factors influencing 3-month mortality in older adults with delirium presenting to the emergency department (ED). MethodsThe study was conducted prospectively and delirium was screened using the brief Confusion Assesment Method (bCAM). The primary outcome was 3-month mortality. Mann-Whitney U and Chi-square tests compared groups, Spearman correlation analyzed correlations, and multivariate logistic regression identified risk factors. ResultsAmong 243 patients, 29.6% experienced in-hospital mortality, and 56.4% had 3-month mortality. Factors associated with increased mortality risk included prior delirium history (3.32-fold increase, 95%CI: 1.51-7.30), active malignancy (3.49-fold increase, 95%CI: 1.61-7.56) and increased respiratory rate (1.18-fold increase, 95%CI: 1.08-1.29). An increase in mean arterial pressure (MAP) was associated with a 0.98-fold decrease in mortality risk (95%CI: 0.96-0.99), increase in body temperature was associated with a 0.48-fold decrease in mortality risk (95%CI:0.31-0.76). ConclusionIn delirious older adults at the ED, higher respiratory rate, lower MAP, lower body temperature, active malignancy and prior delirium history signal elevated mortality risk.

Breaking Down Cardiogenic Shock: An Analytical Reflection on the DanGer-SHOCK and ECLS-SHOCK Trials

Mechanical circulatory support (MCS) devices, particularly the microaxial flow pump (mAFP), have gained traction in managing cardiogenic shock (CS) in patients with acute myocardial infarction (AMI). However, trials like DanGer-Shock and ECLS-Shock have reported differing outcomes, making it challenging to draw definitive conclusions. To explore this further, we conducted a comparative analysis of the 30-day and 6-month mortality rates from the DanGer-Shock and ECLS-Shock trials, examining differences in patient populations and risk profiles. The goal was to determine whether these differences could explain the conflicting outcomes or if the benefits observed in the DanGer-Shock trial were directly attributable to the mAFP strategy. One key finding is that, despite similar control group mortality rates, the intervention group in DanGer-Shock demonstrated a notably lower mortality rate at both 30 days and 6 months compared to the ECLS trial, with an absolute difference of about 8%. This benefit is not due to inherent risk differences but is instead attributed to the Impella-based strategy. Compared to standard care, mAFP data revealed a 7% mortality reduction at 30 days, which grew to 12.7% at 180 days, highlighting the long-term effectiveness of the mAFP strategy in maintaining hemodynamic stability and improving survival. These results suggest that, in CS management, the DanGer unloading strategy, when combined with percutaneous coronary intervention (PCI), plays a significant role in improving long-term survival through early intervention and ventricular unloading, independent of control group factors. Further research is needed to confirm the broader applicability of this approach in different patient populations.

Neutrophil-to-Lymphocyte Ratio is Associated with Clinical Outcomes in Patients Treated with Mechanical Thrombectomy for Posterior Circulation Large Vessel Occlusion

To investigate the potential of composite inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR), in predicting outcomes in patients with posterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT). We included patients who underwent MT for posterior circulation large vessel occlusion between February 2016 and December 2021. We then assessed composite inflammatory markers on day 1 post-MT. The primary outcome was the modified Rankin Scale score at 3 months (favorable score: 0-3). The primary safety measure was 3-month mortality. Receiver operating characteristic (ROC) curve analysis determined each marker's predictive values and optimal cutoff values. Multivariable regression analysis assessed the relationship between markers and outcomes. We included a total of 137 patients (median age: 71 years, 26% female, median National Institutes of Health Stroke Scale score: 23). NLR demonstrated the best predictive value for the prognosis of patients with posterior circulation large vessel occlusion who underwent MT. ROC analysis identified an optimal NLR cutoff of 12.5 (area under curve [AUC]: 0.741, 95% CI: 0.652-0.830) for favorable outcomes and 14.1 (AUC: 0.764, 95% CI: 0.662-0.865) for predicting death. Multivariate analysis determined an NLR <12.5 as an independent predictor of favorable post-MT outcomes (odds ratio [OR]: 10.43, 95% CI: 3.85-28.29, P<0.001), and NLR <14.1 as an independent predictor of post-MT survival (OR: 0.09, 95% CI: 0.03-0.25, P<0.001). Among the assessed markers, NLR emerged as the strongest predictor of clinical outcomes following MT for posterior circulation large vessel occlusion.