Retrospective Study Research Articles

Photon-Counting CT Iodine Maps for Diagnosing Chronic Pulmonary Thromboembolism

Objectives The aim of this study was to evaluate the feasibility and efficacy of chronic pulmonary thromboembolism assessment using photon-counting detector computed tomography (PCD-CT) iodine maps of the lung parenchyma. Materials and Methods This institutional review board–approved retrospective study included 83 subjects (49.4% male, aged 62.4 ± 13.4 years; 50.6% female, aged 59.9 ± 17.1 years) who underwent clinically indicated PCD-CT scan to rule out chronic thromboembolic pulmonary hypertension (CTEPH). Two blinded readers used iodine maps and corresponding sharp-kernel CT reconstructions in the lung window to evaluate perfusion defects and identify patients with chronic pulmonary thromboembolism (CTEPH, CTEPH overlap with other causes of pulmonary hypertension [PH], chronic thromboembolic disease [CTED]). No other clinical or imaging information was given. Discordance was resolved in a subsequent consensus read. The clinical diagnosis was reviewed in an interdisciplinary clinical setting. The accuracy, sensitivity, and specificity of radiologic evaluation and clinical diagnosis were calculated. Results Of the 83 subjects included, 32 were diagnosed with CTEPH, CTEPH overlap, or CTED, 35 were diagnosed with PH caused by other pathologic mechanisms, 10 had no PH, and 6 had suffered previous acute pulmonary embolism, which resolved. The interreader agreement was good (Cohen κ = 0.74). The consensus reached high accuracy (0.88), sensitivity (0.94), and specificity (0.84), as well as good agreement with interdisciplinary clinical diagnosis (Cohen κ = 0.75). No cases with confirmed CTEPH as the primary cause of PH or CTED were missed. Patients with pulmonary arterial hypertension were most frequently rated false-positive. The mean effective dose (±standard deviation) was 1.3 (±0.76) mSv. Conclusions Accurate, sensitive, and specific diagnosis of pulmonary chronic thromboembolism at low radiation dose is possible using iodine maps reconstructed from PCD-CT scans.

Procedural outcomes of the transradial versus transfemoral approach for diagnostic cerebral angiograms according to BMI: a propensity score-matched analysis.

BMI has been shown to affect choice of access site in coronary intervention procedures, with lower complications reported during transradial (TR) access. To the authors' knowledge, the effect of BMI on outcomes in patients undergoing diagnostic cerebral angiography remains undescribed. This study compares outcomes for BMI subgroups based on access site (TR vs transfemoral [TF] access). The authors conducted a single-center retrospective study of patients who underwent diagnostic cerebral angiography between December 2019 and January 2024. Propensity score matching was used to create two similar cohorts (TR and TF). These cohorts were subdivided based on BMI: underweight (BMI < 18.5), normal (BMI 18.5-25.0), overweight (BMI 25.1-29.9), and obese (BMI ≥ 30). Linear regression analysis and the chi-square test were used to compare outcomes. Nine hundred thirty-six patients were stratified into two groups of 468 patients each. Procedure time was significantly shorter for TR access for all BMI subgroups, with a 13-minute reduction in procedure time among underweight patients. Patients with normal BMI, overweight patients, and obese patients experienced a reduction in procedure time of approximately 11, 10, and 13 minutes, respectively. Obese patients experienced significantly shorter length of stay (LOS; 1.33 days) with TR access. There were no significant differences between each BMI subgroup in access site complications, postoperative complications, and conversion of access from TR to TF. TR access in diagnostic cerebral angiography is associated with shorter procedure times and no increased risk of complications compared to TF access across all BMI subgroups. Obese patients experienced shorter LOS with TR access. This study adds to the literature on the safety and efficacy of TR access across all BMI subgroups. Further studies are necessary to validate these preliminary results.

Nationwide Epidemiology and Outpatient Healthcare Resource Use of Children with Respiratory Syncytial Virus from 2005 to 2021.

Respiratory syncytial virus (RSV) poses a global health challenge, particularly among younger children. While the disease burden in Japan has been preliminarily quantified in short-term or inpatient settings, a comprehensive understanding of outpatient settings at a national level is still lacking. In this retrospective cohort study, we followed 697,802 children until they reached 60 months of age, amounting to 25,680,468 million person-months, using two nationally representative databases from the fiscal years 2005-2021. We analyzed trends in the epidemiology of RSV infections and associated outpatient health resource use. Incidence rates of RSV and associated hospitalizations among infants showed fluctuations of 50-100 cases and 20-30 hospitalizations per 1000 person-years, respectively, during the 2010s. These rates dropped to 8.7 cases and 2.2 hospitalizations per 1000 person-years in 2020, then returned to the same levels in the 2010s. Similar patterns were noted for RSV testing, outpatient visits, healthcare cost and the proportion of cases hospitalized (case-hospitalization risk). Whereas antibiotic use decreased from 56.4% in 2005 to 27.8% in 2021, palivizumab use increased from 95.2-195.9 days of therapy per 1000 person-years. Applying the calculated incidence rates to national data, annual outpatient healthcare costs for RSV infections were estimated to be 7-9 billion JPY (50-64 million USD) for children aged <60 months in the late 2010s. Our study highlights the changes in epidemiology and outpatient health resource utilization for children with RSV infections. These findings are valuable for policymakers and clinicians aiming to develop strategies, including newly developed maternal vaccines and single-dose long-acting monoclonal antibodies.

Caloric requirement targets for nutritional support in adult autoimmune encephalitis: a retrospective cohort study.

Autoimmune encephalitis (AE) is a severe neurological disease often accompanied by consciousness disturbances, severe swallowing difficulties, and gastrointestinal dysfunction, increasing the risk of malnutrition. However, the optimal caloric intake target during the acute phase of AE remains unclear. This study aims to evaluate the impact of caloric intake on short-term clinical outcomes in AE patients, specifically focusing on the improvement in Clinical Assessment Scale for Autoimmune Encephalitis (CASE) scores, to provide recommendations for nutritional support during the acute phase. A retrospective study analyzed clinical data from 128 adult AE patients requiring nutritional support, admitted to West China Hospital, Sichuan University, from January 2020 to January 2024. Patients were categorized into low-calorie intake (below 70% of requirements), standard-calorie intake (70-100% of requirements), and high-calorie intake (above 100% of requirements) groups. Multivariate linear and logistic regression models were used to quantify the associations. Higher caloric intake was significantly associated with improved CASE scores (β = 8.58, SE = 3.75, 95% CI = 1.14 to 16.03, p = 0.02). Low caloric intake negatively impacted the improvement of CASE scores (p = 0.049), particularly in seizures and speech problems. The low-calorie intake group had significantly longer hospital stays and nutrition therapy durations (45.79 ± 30.98 days, p < 0.01; 40.39 ± 31.92 days, p = 0.02). Adequate caloric intake has a significant positive impact on the short-term clinical outcomes of AE patients, suggesting that meeting or exceeding caloric requirements may promote neurological recovery in AE patients. Future prospective studies are needed to validate these findings and further optimize nutritional support strategies.

Sex-related differences in the association of obesity described by emergency medical teams on outcomes in out-of-hospital cardiac arrest patients.

Out-of-hospital cardiac arrests (OHCA) are a major global health concern, occurring frequently worldwide. Obesity may impact outcomes in OHCA patients. This study aimed to assess the impact of obesity on the return of spontaneous circulation (ROSC) in OHCA patients, considering sex differences. A retrospective cohort study was conducted, analyzing medical records of patients assisted by the Emergency Medical System (EMS) in Poland from January 2021 to June 2022. The study included 33,636 patients with OHCA. Obesity status was determined using ICD-10 codes (E66) and descriptive diagnoses recorded by EMS teams. Univariate analysis indicated that obesity decreased the odds of ROSC by 25.47% (odds ratio (OR) = 0.75, 95% confidence interval (95% CI): 0.61-0.92) in women and by 19.76% (OR = 0.80, 95% CI: 0.66-0.97) in men. However, multivariate analysis, adjusting for confounding variables, did not confirm a statistically significant impact of obesity on ROSC outcomes. The likelihood of ROSC was significantly higher in individuals with an initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) rhythm compared to Asystole/pulseless electrical activity (PEA), being 4.204 times higher in women (95% CI: 3.525-5.014) and 3.655 times in men (95% CI: 3.320-4.023). Out-of-hospital cardiac arrest in a public place increased the odds of ROSC more than twofold for both sexes (women: OR = 2.20, 95% CI: 2.00-2.43; men: OR = 2.13, 95% CI: 1.98-2.29). Among women without obesity, hypertension decreased the odds of ROSC by 11.11% (OR = 0.89, 95% CI: 0.81-0.99). Our study demonstrated that obesity was not an independent predictor of ROSC in OHCA patients. Different predictors of ROSC were identified for men and women. Initial VF/pVT rhythm, location of OHCA and age were the significant factors influencing ROSC.

Quantitative Assessment of Collagen Architecture to Determine Role of Tumor Stroma During Vestibular Schwannoma Progression.

The primary objective was to characterize the abundance and architecture of collagen in the extracellular matrix in vestibular schwannoma (VS). The secondary objective was to investigate the association between collagen architecture and tumor size. Retrospective cohort study. Academic referral center. Tumor samples were obtained from patients with sporadic VS undergoing microsurgical resection. Histological analyses were performed including picrosirius red (PSR) staining under polarized light. Collagen architecture was quantified using an automated fiber detection software. Second Harmonic Generation (SHG) microscopy and immunofluorescence (IF) were utilized to characterize collagen architecture. Eleven tumor specimens were included (mean tumor diameter = 2.80 cm, range 1.5-4.0 cm), and were divided into large (mean diameter = 3.5 ± 0.4 cm) and small (mean tumor diameter = 2.0 ± 0.4 cm) cohorts based on size. The large VS cohort showed significantly higher collagen density (27.65% vs 12.73%, P = .0043), with more thick fibers (mature Type I, 24.54% vs 12.97%, P = .0022) and thin fibers (immature Type I or mature Type III, 23.55% vs 12.27%, P = .026). Tumor volume correlated with greater degree of collagen fiber disorganization (P = .0413, r2 = 0.298). Specifically, collagen type I intensity was significantly higher in large VS compared to small tumors (P < .001) and peripheral nerve (P = .028). Larger VS exhibit increased collagen abundance in the tumor stroma, and a more disorganized collagen architecture compared to smaller VS and normal peripheral nerve tissue. This finding indicates that collagen organization may play a significant role in extracellular matrix remodeling and the progression of VS.

Neighborhood Socioeconomic Disadvantage Increases Risk of Severe Acute Respiratory Syndrome Coronavirus 2-Mediated Otologic Dysfunction.

We aim to use the Area Deprivation Index (ADI) to investigate the correlations between neighborhood socioeconomic disadvantage (NSD), SARS-CoV-2 vaccination rates, infection severity, and subsequent audiovestibular symptoms. In this retrospective cohort study, surveys were administered to participants ≥18 years of age who received a SARS-CoV-2 vaccination and/or tested positive for SARS-CoV-2 infection between January 2020 and September 2022. ADI scores were calculated for each patient to quantify NSD. Statistical analyses were performed to compare demographic and clinical characteristics between ADI quintiles. Of 2415 participants, the majority were female (62.8%) and White (87%), with a mean age of 60.8 years. Individuals in ADI Quintile 5 were less likely to receive second booster doses than those in Quintile 1 (58% vs. 71%, p < 0.0001). Among those infected with SARS-CoV-2, those in ADI Quintile 5 were 2.5 times more likely to be hospitalized (relative risk = 2.46, 95% confidence interval [1.03, 5.88]) than those in Quintile 1. Symptoms more likely to be experienced by participants in ADI Quintile 5 than those in Quintile 1 immediately following SARS-CoV-2 infection included headaches (28% vs. 21%, p = 0.02), aural fullness (14% vs. 6%, p < 0.0001), change of hearing (8% vs. 4%, p = 0.01), dizziness (15% vs. 8%, p < 0.01), and otalgia (8% vs. 4%, p < 0.01). Individuals experiencing greater NSD were found to have lower SARS-CoV-2 vaccine booster rates, higher rates of postinfection hospitalization, and increased rates of certain otologic and neurotologic symptoms following infection. III Laryngoscope, 2024.

Clinical characteristics and functional outcomes of pediatric Guillain-Barré syndrome admitted to the Neuro-intensive care unit: a decade-long retrospective observational study.

Guillain-Barré Syndrome (GBS) remains a significant contributor to acute flaccid paralysis in pediatric patients worldwide. Despite its impact, studies focusing on pediatric GBS requiring intensive care unit (ICU) management are limited. This study aimed to address this gap by exploring the clinical and outcome characteristics of pediatric GBS necessitating ICU care. This retrospective observational study, spanning a decade, analyzed the records of 75 pediatric GBS patients admitted to the Neuro-ICU of a tertiary care center in South India. Data included demographics, prodromal symptoms, clinical features, investigations, treatment modalities, and outcomes. The majority (55/75) of patients were male, with a median age of 12 years. The highest incidence of GBS requiring ICU admission was in the monsoon season. Prodromal symptoms were observed in 56%. Most patients (93.33%) presented with typical GBS symptoms, and 40% had respiratory distress on ICU admission. Acute motor axonal neuropathy (AMAN) was the most common subtype. Approximately 80% required mechanical ventilation, with a median duration of 22.5 days. No in-hospital mortality was recorded. At discharge, most patients had a GBS disability score of 4, improving to 2 at a median follow -up of 228 days. Pediatric GBS patients requiring ICU care exhibit distinctive characteristics, including a higher prevalence of AMAN subtype, seasonal clustering, and favorable outcomes with intensive treatment. The absence of in-hospital mortality underscores the effectiveness of prompt ICU admission and dedicated Neuro-intensive care.

Non-liver malignancies as main cause of mortality after HCV eradication among people living with HIV

Background. In people living with HIV (PLWH) with HCV infection, liver and non-liver-related mortality significantly decreased after receiving direct acting antivirals (DAAs). We aimed to assess main causes and predictors of mortality after sustained virological response (SVR) induced by DAAs. Methods. Retrospective study in antiretroviral treatment-experienced PLWH with HCV infection, followed at San Raffaele Hospital, Milan, Italy, who achieved SVR after DAAs. Kaplan-Meier analysis and log-rank test were used to estimate cumulative probability of death for any cause. Cox proportional hazards model was used to estimate adjusted hazard ratio (aHR) of death and the corresponding 95% confidence interval (95%CI); Baseline variables included in the model were: age, diabetes, hepatocellular carcinoma (HCC), α-fetoprotein (AFP), ALBI grade. Results. Among 663 people included with a median follow-up of 4.4 years (IQR=3.5-5.5), 49 died. Overall 5-year cumulative probability of death was 8.0% (95%CI=5.5%-10.4%); 63.2% (n=31/49) died from non-liver-related events [mainly non-liver malignancies (18/49) and cardiovascular events (7/49)].-. At multivariate analysis, death was more likely in older people [aHR (adjusted Hazard Ratio) (5-year older)=1.46, 95%CI=1.16-1.83, p=0.0009], and in people with diabetes [aHR=2.98, 95%CI=1.55-5.71, p=0.001], ALBI grade ≥2 [aHR=2.13, 95%CI=1.17-3.90, p=0.014] and AFP ≥3.4 ng/mL [aHR=1.96, 95%CI=1.01; 3.84, p=0.049]. Conclusions. In our cohort, non-liver-related events and malignancies were the most common cause of death after HCV eradication. Diabetes, ALBI grade ≥2 and AFP≥ 3.4 ng/L were associated with higher risk of death. In PLWH after HCV eradication, regardless of liver disease stage, surveillance of non-liver events, particularly malignancies, should be recommended.

The MangLE score: A novel simple tool to identify patients who are unlikely to require amputation following severe lower extremity injury

BACKGROUND There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort. METHODS This is a retrospective study using the 2013–2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score. RESULTS The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80–0.82) and 0.82 (95% confidence interval, 0.81–0.84), respectively. The negative predictive value for a score of &lt;8 is 99%. CONCLUSION The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort. LEVEL OF EVIDENCE Prospective and Epidemiologic; Level IV.

Effect of postoperative complications on 5-year survival following laparoscopic surgery for resectable colorectal cancer: a retrospective study.

The purpose of this study was to investigate the effects of postoperative complications on long-term survival after laparoscopic surgery for resectable colorectal cancer. We retrospectively included 204 patients who underwent laparoscopic surgery for colorectal cancer from January 2016 to June 2020. Overall, 68 (33.3%) patients had postoperative complications, twelve (17.6%) of which were classified as Clavien-Dindo class 3a or higher. The 5-year overall survival rate of the non-complication and complication groups were 93.0% and 81.7%, respectively (p = 0.048; Kaplan-Meier analysis and log-rank test), and those among patients with stage III disease were 87.0% and 61.3%, respectively (p = 0.045). The 5-year disease-free survival rates were 85.6% and 77.4%, respectively (p = 0.042). Multivariable Cox proportional-hazards analysis revealed that nodal stage (hazard ratio, 8.392; 95% confidence interval, 1.892-37.175; p = 0.005) was an independent prognostic factor for overall survival, and postoperative complications (hazard ratio, 2.996; 95% confidence interval, 1.076-8.340; p = 0.036) were independent prognostic factors for disease-free survival. Postoperative complications were associated with poor oncological outcomes, especially among patients with stage III colorectal cancer, and independent prognostic factors for disease-free survival.

Development and Validation of Deep Learning–Based Infectivity Prediction in Pulmonary Tuberculosis Through Chest Radiography: Retrospective Study

Background Pulmonary tuberculosis (PTB) poses a global health challenge owing to the time-intensive nature of traditional diagnostic tests such as smear and culture tests, which can require hours to weeks to yield results. Objective This study aimed to use artificial intelligence (AI)–based chest radiography (CXR) to evaluate the infectivity of patients with PTB more quickly and accurately compared with traditional methods such as smear and culture tests. Methods We used DenseNet121 and visualization techniques such as gradient-weighted class activation mapping and local interpretable model-agnostic explanations to demonstrate the decision-making process of the model. We analyzed 36,142 CXR images of 4492 patients with PTB obtained from Severance Hospital, focusing specifically on the lung region through segmentation and cropping with TransUNet. We used data from 2004 to 2020 to train the model, data from 2021 for testing, and data from 2022 to 2023 for internal validation. In addition, we used 1978 CXR images of 299 patients with PTB obtained from Yongin Severance Hospital for external validation. Results In the internal validation, the model achieved an accuracy of 73.27%, an area under the receiver operating characteristic curve of 0.79, and an area under the precision-recall curve of 0.77. In the external validation, it exhibited an accuracy of 70.29%, an area under the receiver operating characteristic curve of 0.77, and an area under the precision-recall curve of 0.8. In addition, gradient-weighted class activation mapping and local interpretable model-agnostic explanations provided insights into the decision-making process of the AI model. Conclusions This proposed AI tool offers a rapid and accurate alternative for evaluating PTB infectivity through CXR, with significant implications for enhancing screening efficiency by evaluating infectivity before sputum test results in clinical settings, compared with traditional smear and culture tests.

A retrospective examination of risk factors for central line-associated bloodstream infections in home parenteral nutrition patients from a Queensland tertiary hospital.

Central line-associated bloodstream infections (CLABSIs) are a potential complication for home parenteral nutrition (HPN) patients. We sought to analyse risk factors of developing HPN-related CLABSI and assess CLABSI management in the Australian context. A retrospective observational cohort study was conducted on 34 adult patients receiving HPN via a central venous catheter (CVC) at a Queensland tertiary referral centre between 2016 and 2023. Patient charts were reviewed, and Kaplan-Meier analysis was employed to determine associations between characteristics and time to CLABSI in the first CVC using Peto-Peto Prentice test. A total of 39 CLABSI episodes occurred in 19 patients. Patients with ≥1 CLABSI used regular opioids more than those without CLABSI (P = 0.016). Fourteen (41%, n = 14/34) patients developed a CLABSI in their first CVC. No patient or line characteristics were found to be predictive of CLABSI in their first CVC. The CLABSI rate was 1.02/1000 catheter days. Most CLABSIs were caused by Enterobacterales (22%, n = 12/55) and Candida sp. (22%, n = 12/55). Empiric antimicrobial therapy was adequate in only 25% (n = 7/28), and the median time to effective antibiotic therapy was 22.7 h (interquartile range 4.8-29.8). There were three successful CVC salvages (8%, n = 3/39). In this cohort of patients, regular opioid use was associated with increased risk of developing CLABSI. Based on our findings, an empiric antimicrobial regime of vancomycin, cefepime and caspofungin will provide adequate coverage for most HPN-related CLABSIs in Australian IF units with a similar antimicrobial distribution and resistance pattern.

Comorbidity problems in patients with osteoporosis

BACKGROUND: Osteoporosis is a metabolic skeletal disease characterized by decreased bone mass, impaired microarchitecture of bone tissue and, as a consequence, fractures with minimal trauma. The social significance of osteoporosis is determined by its consequences — fractures of the vertebral bodies and bones of the peripheral skeleton, leading to high medical costs and causing a high level of disability, including disability and mortality. Osteoporosis is most often combined with cardiovascular diseases caused by atherosclerosis, which are widespread and are the leading cause of disability and mortality. A small number of studies have been devoted to the study of the features of clinical manifestations of cardiovascular diseases in the combination of coronary heart disease and osteoporosis. AIM: To identify the frequency and severity of comorbid diseases and their risk factors in postmenopausal osteoporosis. MATERIALS AND METHODS: A retrospective and prospective cohort study was conducted from 2013 to 2023. 8250 women with postmenopausal osteoporosis were examined and the data from the medical records of these patients who applied to the Osteoporosis Center of the North-Western State Medical University named after I.I. Mechnikov of the Ministry of Health of the Russian Federation from 2013 to 2020 were analyzed. At the prospective stage, two comparison groups of 100 patients with and without postmenopausal osteoporosis were formed from 500 patients with comorbid diseases (coronary heart disease, hypertension, type 2 diabetes, stroke, transient ischemic attack). Bone mineral density was assessed based on the Hologic Discoveri Wi dual-energy X-ray absorptiometry at 2 points in the lumbar spine (L1–L4) and the femoral neck. Along with traditional laboratory examination methods, bone metabolism markers (total calcium, phosphorus, vitamin D, urine analysis for deoxypyridinoline, C-terminal telopeptide of type 1 collagen, osteocalcin, alkaline phosphatase, parathyroid hormone) were assessed dynamically. In all the patients, along with a general clinical examination, an assessment of risk factors for cardiovascular disease and osteoporosis was performed. RESULTS: Body mass index was higher in the group of patients with osteoporosis — 28.4 (26.9–32.4) kg/m2 (p 0.001), versus 27.64 (25.8–30.0) kg/m2 (p 0.05). Bone mineral density in the group of patients with osteoporosis was statistically lower than in the group without osteoporosis. In the group of patients with osteoporosis, the risk of fractures was high and amounted to 37 (95% confidence interval 15.0–38.50) %, p 0.001), versus in the control group 9.55 (95% confidence interval 7.67–15.0) % (p 0.001) according to the FRAX questionnaire for the Russian Federation. In the group of patients with osteoporosis, the Charlson index values were 5.1 (95% confidence interval 4.7–5.6) points. As a result of the correlation analysis, a reliable positive relationship was revealed between low bone mineral density L1–L4 and hip with bone metabolism: alkaline phosphatase, C-terminal telopeptide of type 1 collagen, vitamin D, osteocalcin, urinary deoxypyridinoline. We found a negative relationship between bone mineral density and the Charlson index, absolute ten-year risk of hip fracture and the duration of early menopause, and the level of hypertension. To assess the dependence of QRISK3-2018 on osteoporosis risk factors in the group of patients with osteoporosis, multiple linear regression was performed. This model was characterized by a statistically significant correlation between the factors and the dependent variable of high tightness. The coefficient of determination was 0.608, indicating a 60.8% contribution of the factors taken into account in the model to the variance of QRISK3-2018. CONCLUSIONS: In women with postmenopausal osteoporosis, comorbid pathology is more common, aggravating the course of the disease. Knowledge of the prevalence of concomitant pathology and joint risk factors will make it possible to simultaneously form groups at increased risk of development, which will ensure prevention of both diseases with the same non-medical means and drugs.

Association Between Direct Oral Anticoagulant Score and Bleeding Events in Patients With Atrial Fibrillation Following Transcatheter Aortic Valve Replacement: A Retrospective Multicenter Cohort Study.

The Direct Oral Anticoagulant (DOAC) Score can predict bleeding risk in patients with atrial fibrillation taking DOACs; however, it lacks external validation. Therefore, this study aimed to assess the association between the DOAC Score and bleeding events in patients with atrial fibrillation who underwent transcatheter aortic valve replacement. This retrospective multicenter cohort study included patients with atrial fibrillation who underwent transcatheter aortic valve replacement, as registered in a Japanese multicenter registry. The primary end point was the incidence of bleeding. Patients were categorized based on their DOAC Score: low and moderate- (≤7 points), high- (8-9 points), and very high-risk (≥10 points) groups. Among 1230 patients (mean age 84.6±5.1 years; 457 men), 465 (37.8%) received a vitamin K antagonist, and the remaining patients received DOACs. The low and moderate-, high-, and very high-risk groups included 380 (30.1%), 497 (40.4%), and 353 patients (28.7%), respectively. The 3-year cumulative incidence of all bleeding events was significantly different among the 3 groups (low and moderate risk: 6.6%, high risk: 6.9%, and very high risk: 14.0%; P<0.01). Multivariable Cox regression analysis revealed that significant increments in the DOAC Score were associated with a risk of all bleeding events at 3 years in the overall cohort (hazard ratio [HR], 1.22 [95% CI, 1.08-1.38]; P<0.01), in the DOAC cohort (HR, 1.20 [95% CI, 1.01-1.42]; P=0.04), and in the vitamin K antagonist cohort (HR, 1.25 [95% CI, 1.04-1.50]; P=0.02). The DOAC Score was significantly associated with bleeding events in patients with atrial fibrillation after transcatheter aortic valve replacement, aiding in clinical decision-making for anticoagulant management. URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023585; Unique identifier: UMIN000020423.

Performance of Risk Models for Antimicrobial Resistance in Adult Patients With Sepsis

ImportanceThe results of prediction models that stratify patients with sepsis and risk of resistant gram-negative bacilli (GNB) infections inform treatment guidelines. However, these models do not extrapolate well across hospitals.ObjectiveTo assess whether patient case mix and local prevalence rates of resistance contributed to the variable performance of a general risk stratification GNB sepsis model for community-onset and hospital-onset sepsis across hospitals.Design, Setting, and ParticipantsThis was a retrospective cohort study conducted from January 2016 and October 2021. Adult patients with sepsis at 10 acute-care hospitals in rural and urban areas across Missouri and Illinois were included. Inclusion criteria were blood cultures indicating sepsis, having received 4 days of antibiotic treatment, and having organ dysfunction (vasopressor use, mechanical ventilation, increased creatinine or bilirubin levels, and thrombocytopenia). Analyses were completed in April 2024.ExposureThe model included demographic characteristics, comorbidities, vital signs, laboratory values, procedures, and medications administered.Main Outcomes and MeasuresCulture results were stratified for ceftriaxone-susceptible GNB (SS), ceftriaxone-resistant but cefepime-susceptible GNB (RS), and ceftriaxone- and cefepime-resistant GNB (RR). Negative cultures and other pathogens were labeled SS. Deep learning models were developed separately for community-onset (patient presented with sepsis) and hospital-onset (sepsis developed ≥48 hours after admission) sepsis. The models were tested across hospitals and patient subgroups. Models were assessed using area under the receiver operating characteristic curve (AUROC) and area under precision recall curve (AUPRC).ResultsA total of 39 893 patients with 85 238 sepsis episodes (43 207 [50.7%] community onset; 42 031 [48.3%] hospital onset) were included. Median (IQR) age was 65 (54-74) years, 21 241 patients (53.2%) were male, and 18 830 (47.2%) had a previous episode of sepsis. RS contributed to 3.9% (1667 episodes) and 5.7% (2389 episodes) of community-onset and hospital-onset sepsis episodes, respectively, and RR contributed to 1.8% (796 episodes) and 3.9% (1626 episodes), respectively. Previous infections and exposure to antibiotics were associated with the risk of resistant GNB. For example, in community-onset sepsis, 375 RR episodes (47.1%), 420 RS episodes (25.2%) and 3483 of 40 744 (8.5%) SS episodes were among patients with resistance to antimicrobial drugs (P &amp;amp;lt; .001). The AUROC and AUPRC results varied across hospitals and patient subgroups for both community-onset and hospital-onset sepsis. AUPRC values correlated with the prevalence rates of resistant GNB (R = 0.79; P = .001).Conclusions and RelevanceIn this cohort study of 39 893 patients with sepsis, variable model performance was associated with prevalence rates of antimicrobial resistance rather than patient case mix. This variability suggests caution is needed when using generalized models for predicting resistant GNB etiologies in sepsis.

Delivery-Related Maternal Morbidity and Mortality Among Patients With Cardiac Disease

OBJECTIVE: To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD). METHODS: This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications. RESULTS: Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0–13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4–55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0–417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7–17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0–11.0%). CONCLUSION: CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

Platelet-Function-Monitoring-Guided Therapy After Emergent Carotid Artery Stenting

Background/Objectives: Antiplatelet therapy after emergent carotid stenting (eCAS) represents a challenge in balancing the risk of intracerebral hemorrhages (ICHs) and in-stent thrombosis (IST). Post-procedural platelet function monitoring may guide antiplatelet therapy and could potentially improve outcomes due to fewer post-procedural complications. Methods: Consecutive eCAS patients (2019–2021) were included in a single-center retrospective observational study. Patients treated with eCAS received peri-procedural eptifibatide followed by dual antiplatelet treatment with aspirin and clopidogrel. The effect of platelet ADP inhibition by clopidogrel was monitored using the Multiplate® Analyzer (Roche). Clopidogrel non-responders were changed to ticagrelor treatment. The primary outcome was defined as a favorable outcome at 90 days using the modified Rankin Scale (mRS) of 0–2 versus 3–6. Safety outcomes included ICH, IST, and mortality. Data were analyzed and compared in clopidogrel- and ticagrelor-treated patients using Fischer’s exact test and multivariate logistic regression. Results: A total of 105 patients had eCAS, and 28 patients (27%) were clopidogrel non-responders and were changed to treatment with ticagrelor. The favorable outcome was more frequent in ticagrelor-treated patients, 23 (82%), than in clopidogrel-treated patients, 44 (57%), p = 0.036. Numerically, ICH, IST, and mortality were more frequent in clopidogrel-treated patients, but none of the differences were statistically significant. In multivariate analyses, ticagrelor treatment was significantly associated with the favorable outcome, OR = 3.89 (95% CI: 1.09–13.86), p = 0.036. Conclusions: One in four eCAS patients were clopidogrel non-responders. This study suggests that personalized antiplatelet treatment therapy was safe, and that changing treatment to ticagrelor in clopidogrel non-responders was associated with better outcomes in eCAS patients.

Recurrent Hospitalizations for Fluid Overload in Diabetes with Kidney Failure Treated with Dialysis

Background &amp; Aims Diabetes Mellitus is the most common cause of end-stage kidney disease (ESKD) in Singapore. ESKD patients have high disease burden and are at increased risk of recurrent hospitalizations, including fluid overload. This study aimed to characterize the risk factors associated with readmissions for fluid overload that will identify high-risk hospitalizations for interventions to reduce readmissions. Methods Retrospective cohort study of all hospitalizations for fluid overload in adults with diabetes and ESKD on dialysis in SingHealth hospitals between 2018 and 2021. Fluid overload was defined by discharge codes for fluid overload, heart failure, pulmonary edema, and generalized edema until 30th December 2022. Multivariable Cox regression analysis using the Prentice, Williams and Peterson Total Time (PWP-TT) model was performed for the outcomes of readmissions for fluid overload within 30 days and 90 days of discharge. Results Among 3234 hospitalizations for fluid overload, readmission for fluid overload within 30-day and 90-day occurred in 585 (18.1%) and 967 (29.9%) hospitalizations, respectively. Ischemic heart disease, peripheral vascular disease and lower hemoglobin level were independently associated with readmissions for fluid overload within 30 and 90 days. Additionally, heart failure, hemodialysis (compared to peritoneal dialysis) and lack of statin at discharge were associated with increased 90-day readmission risk. Conclusion Modifiable (hemoglobin level, statin use) and non-modifiable factors (ischemic heart disease, peripheral vascular disease and heart failure) influenced the risk of readmission for fluid overload. These results may guide risk stratification and inform targeted interventions to reduce avoidable, unplanned readmissions for recurrent fluid overload among individuals with diabetes and ESKD.

Serum concentration threshold and risk factors of tigecycline-induced hypofibrinogenaemia in critically ill patients

Abstract Objectives Hypofibrinogenaemia is a serious adverse reaction associated with tigecycline (TGC) therapy and may lead to the discontinuation of the treatment. This study aimed to explore the relevant factors of TGC-induced hypofibrinogenaemia and determine the thresholds of serum concentration as a predictive indicator of TGC-induced hypofibrinogenaemia. Methods A retrospective single-centre study was conducted on patients with severe infection who were treated with TGC. Clinical data and serum concentration parameters were extracted from the electronic medical records of these patients. Patients were divided into the hypofibrinogenaemia group (&amp;lt; 2.0 g/L) and the normal fibrinogen group (≥ 2.0 g/L) in order to evaluate risk factors associated with TGC-induced hypofibrinogenaemia. Logistic regression analysis and receiver operating characteristic curves were utilized to identify the risk factors associated with TGC-induced hypofibrinogenaemia and to establish plasma concentration thresholds as predictive indicators. Results A total of 114 patients were enrolled in this study, with 59.6% experiencing hypofibrinogenaemia. The multivariate regression analysis indicated that baseline fibrinogen level, trough concentration (Cmin), peak concentration (Cmax), the concentration at 6 h after the dosing (C6h) and the area under the concentration–time curve over a 24-h period (AUC0–24) were significantly associated with hypofibrinogenaemia (P &amp;lt; 0.05). Furthermore, it was found that AUC0–24 is the optimal predictor of TGC-induced hypofibrinogenaemia. The optimal cut-off for the AUC0–24 of TGC in ICU patients was determined to be 17.03 mg h/L. Conclusions TGC exposure is highly predictive of TGC-induced hypofibrinogenaemia. We recommend closely monitoring plasma concentrations of TGC in patients to ensure patient efficacy and safety.