Death In Patients Research Articles

Understanding Intensive Care Unit Family Caregivers' Vulnerability to Post-Traumatic Stress Disorder: The Impact of Neurotic Personality Traits, Emotional Suppression, and Perceptions of Unexpected Death.

Rationale: Family members of patients who die in an intensive care unit (ICU) are at heightened risk of post-traumatic stress disorder (PTSD) symptoms. Not all surrogates develop these symptoms and heterogeneity exists in PTSD symptom clusters. Objectives: The study tested a personality model of PTSD symptoms in bereaved family caregivers of ICU patients. It was hypothesized that family members endorsing higher levels of neurotic personality traits would report higher levels of PTSD symptom clusters and that these associations would be explained by tendencies to view the patient's death as unexpected and to cope by suppressing their emotions. Methods: Participants were family members of ICU patients at an urban, academic medical center who either died or were discharged to an inpatient hospice unit. Participants were contacted for participation at least six months after the patient's death. Participants completed measures of personality, emotion regulation, and PTSD symptoms. Data were analyzed using path analysis. Results: Approximately one-third (35%) of the sample of 162 caregivers endorsed at-risk levels of PTSD. Individuals reporting higher levels of neurotic personality traits reported more PTSD symptoms (r = 0.53, p < 0.001). Perceptions that the patient death was unexpected partially explained the association of neuroticism with the intrusive re-experiencing PTSD symptoms (B = 0.45, p = 0.031). In contrast, emotional suppression partially explained the association of neuroticism with avoidance (B = 0.70, p = 0.010) and hyperarousal symptom clusters (B = 0.37, p = 0.041). Conclusions: Family vulnerability to PTSD after an ICU death can be conceptualized based on neurotic personality traits. Tendencies to view the patient's death as unexpected may contribute to intrusive thoughts and memories of the ICU experience. Individuals may avoid reminders and remain at heightened levels of arousal when they suppress their emotional experiences. Key Message: Family members who experience the death of a loved one following ICU treatment are vulnerable to PTSD symptoms. These reactions to ICU-related losses may be shaped by family members' personalities, expectations, and emotion regulation styles. Understanding these characteristics could inform family screening and intervention efforts in the ICU.

Impact of patient death on physicians’ mental health

IntroductionPhysicians often encounter stressful situations that can impact their mental well-being. The death of a patient represents one of the most difficult situations in routine medical practice. Literature notably lacks comprehensive studies into physicians’ personal experiences with patients’ deaths. However, it does underscore heightened levels of sorrow, guilt, and stress stemming from the passing of terminally ill patients. As a majority of studies in this realm adopt qualitative methodologies, there is merit in supplementing existing research with a quantitative approach that employs validated psychometric scales. Furthermore, the study of phenomena associated with stress, particularly the perceived professional support by physicians in stressful events, can contribute to the implementation of preventive measures to help physicians cope. ObjectiveOur study aims to measure the traumatic impact on resident and intern physicians at national university hospitals following the death of patients, as well as to assess the perceived level of professional support among these physicians. Materials and methodsWe conducted a nationwide cross-sectional, descriptive, and analytical study. Participants included interns and residents from various specialties (medical, surgical and laboratory) at national university hospitals in Morocco. Assessing the traumatic impact of patients’ death on doctors was conducted using two psychometric scales: the Peri-Traumatic Distress Inventory (PDI) and the Revised Impact of Event Scale (IES-R). Additionally, we used the Perceived Professional Social Support Scale (QSSP-P) to evaluate how supportive the professional environment was towards these doctors. All scales utilized in the study are validated in the French language. ResultsThe study included 96 participants, with 67.7% being female. The average age was 26.8 years, ranging from 23 to 39 years. The majority of participants managed more than nine patients simultaneously (58.3%) while 41.7% were scheduled for more than six 24h shifts per month. During their training, over 64.6% of interns and residents faced more than ten patients’ death incidents, and 68.8% considered their first patient death as the most traumatizing. Half of the physicians evaluated the patients’ care as moderately appropriate, with 46.9% believing that the incident could have been prevented. Notably, 70.8% of interns and residents involved in patient care experienced self-blame and attributed a share of responsibility to themselves for the patient's demise. The majority of participants, 82.3%, exhibited peri-traumatic distress with a PDI score exceeding 15. Among the studied factors, only the perceived responsibility and a management system centered on a single physician (rather than a team) demonstrated a noteworthy correlation with PDI scores. The mean score on the IES-R scale was 25.6, with almost half of the sample (54.2%) reporting moderate to severe PTSD symptoms. The severity of these symptoms was significantly correlated with higher age, high number of patient's deaths experienced and the physician's perceived sense of responsibility. Participants in our study were more satisfied with support from colleagues compared to support functions (paramedical staff, administrative officials) or superiors. Moreover, only colleagues’ support was statistically significantly associated with low scores on the traumatic impact scales. ConclusionPhysicians maintain a unique relationship and therapeutic alliance with their patients. Therefore, the death of a patient can have a significant psychological impact on the physician. This study allowed us to objectively measure this psychological impact and evaluate professional support. The results of these studies encourage further exploration of the issue and the implementation of measures to reduce this psychological impact.

Real-world outcomes following ibrutinib dose reduction in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma.

This study used real-world data from three separate United States (US) databases to evaluate dosing patterns and time to next treatment (TTNT) following the first-incident adverse event (AE) in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) treated with first-line ibrutinib with and without dose reduction (DR). Median TTNT or death in patients with and without a DR following an AE in each database was as follows: Optum Clinformatics Data Mart (CDM): 59.5 and 30.6months; ConcertAI: 27.1 and 18.0months; and Medicare Fee-for-Service (FFS): 49.8 and 22.0months, respectively. Median TTNT or death in patients with cardiac AEs, with and without a DR, was: Optum CDM: 44.4 and 22.9months; ConcertAI: 29.9 and 18.3months; and Medicare FFS: 49.6 and 14.0months, respectively. Ibrutinib DR was associated with fewer outpatient visits and lower CLL/SLL-related medical costs. These findings suggest that utilizing ibrutinib DR may effectively manage tolerability without compromising clinical efficacy.

Predictive Value of Combined Detection of Serum LGALS3BP and GDF-15 for the Prognosis of ICU Sepsis Patients.

This study aims to investigate the effectiveness of combining serum lectin galactoside-binding soluble 3 binding protein (LGALS3BP) with growth differentiation factor 15 (GDF-15) for predicting outcomes in sepsis patients in an intensive care unit (ICU) setting. The study involved 208 sepsis patients from the ICU of our hospital. These patients were categorized based on their 28-day survival outcomes into two groups: 166 in the survival group and 42 in the mortality group. The serum levels of LGALS3BP and GDF-15 were measured using the ELISA technique. Pearson and Spearman methods were utilized for correlation analysis. Factors affecting mortality in ICU sepsis patients were evaluated through multivariate logistic regression analysis. The efficacy of these biomarkers in prognosis prediction was assessed using receiver operating characteristic (ROC) curve analysis. The proportion of septic shock, APACHE II score, SOFA score, and serum LGALS3BP and GDF-15 levels in ICU sepsis patients in the death group were obviously higher than those in the survival group (P<0.05). The severity of ICU sepsis patients, APACHE II score, and SOFA score were obviously positively correlated with serum LGALS3BP and GDF-15 levels (P<0.05). LGALS3BP (OR: 95% CI=2.745:1.583~4.761) and GDF-15 (OR: 95% CI=2.639:1.423~4.893) were independent risk factors for death in ICU sepsis patients (P<0.05). The AUC of serum LGALS3BP and GDF-15 levels alone in predicting death in ICU sepsis patients was 0.859 and 0.854, obviously lower than the AUC of the combination, 0.943 (Z=2.704, 2.287, P<0.05). The AUC for predicting mortality in ICU sepsis patients using the APACHE II and SOFA scores were 0.832 and 0.842, respectively. The differences in comparison to the AUCs of LGALS3BP and GDF-15 were not statistically significant (P > 0.05). Serum levels of LGALS3BP and GDF-15 can both be used as predictive indicators for death in ICU sepsis patients, and their combined predictive efficacy is better.

Inpatient and postdischarge mortality among children with anaemia and malaria parasitaemia in Kenya: a cohort study

BackgroundAnaemia and malaria are leading causes of paediatric hospitalisation and inpatient mortality in sub-Saharan Africa. However, there is limited empirical data on survival following hospital discharge. We aimed to estimate...

Events preceding death after high-risk surgery analyzed by Global Trigger Tool and reflective-thematic approach.

Postoperative mortality might be influenced by postoperative care, vigilance, and competence to rescue. This study aims to describe the course of events preceding death in a high-risk surgical cohort. We analyzed hospital records of patients who died within 30 days after surgery in 4 high volume hospitals using (1) reflective narrative thematic approach to identify recurring themes reflecting issues with conduct of care and (2) Global Trigger Tool to describe incidence, timing, and types of adverse events (AEs) leading to harm. Preoperative predicted median risk of death in the studied group was 9%/13% according to SORT/P-POSSUM, respectively. Nine recurring themes were identified. Prominent themes were "consensus concerning aim and/or risk with planned surgery," "level of (intraoperative) competence and monitoring," and in the postoperative period "level of care and vigilance" on signs of deterioration. We found a total of 303 AEs, with only three patients (5%) having no adverse events. Most common severity category was "I," that is "contributed to patient's death" (n = 110, 36% of all AEs). Of these, 60% were classified as preventable or probably preventable. The peak incidence of AEs was seen on the day of index surgery. Most common types of AEs were "failure of vital functions" (n = 79, 26%), followed by infections (n = 45, 15%). A high predicted risk of death and a peak of adverse events on the day of index surgery were detected. Identified themes reflect lack of documented multi-professional consensus on how to handle prevalent perioperative risk, vigilance, and postoperative level of care.

Serum microRNA-181a Expression Level in Patients with Acute Liver Failure and Its Correlation with Prognosis.

This paper examined miR-181a expression in the serum of patients with acute liver failure (ALF) and investigated the impact of its expression in the prognosis of ALF patients. A total of 112 ALF patients (ALF group) and 100healthy controls during the same period (control group) were recruited as study subjects, and ALF patients were separated into the survival group and the death group. Serum ALT, AST, SCr, TBil, PTA, and International Normalized Ratio (INR) indices as well as serum miR-181a expression were assessed by using a fully automated biochemistry analyzer and RT-qPCR. Patients in the ALF group were evaluated using the Model for End-Stage Liver Disease (MELD) score. Correlation between serum miR-181a expression and MELD scores of ALF patients was processed by Pearson correlation analysis, and the diagnostic value of miR-181a level for the occurrence of ALF was estimated by ROC curve analysis. Multivariate logistic regression analysis was executed to assess the factors influencing the occurrence of death in ALF patients. ALF patients had higher levels of ALT, AST, TBiL, SCr, INR and miR-181a and lower PTA levels in comparison to healthy controls. Serum miR-181a expression level in ALF patients revealed a significant positive correlation with MELD score. Multivariate logistic regression analysis unveiled that TBil, INR, SCr, and miR-181a were the independent risk factors for the occurrence of death in ALF patients, and that PTA was an independent protective factor for the prognosis of ALF patients. miR-181a exhibited a favorable diagnostic value in ALF and its prognosis. miR-181a expression is upregulated in the serum of ALF patients, and it can be utilized as an indicator for ALF diagnostic and prognostic assessment.

LDL-C and hs-CRP Jointly Modify the Effect of Lp(a) on 5-Year Death in Patients With Percutaneous Coronary Intervention.

Recent studies have suggested that adverse events associated with lipoprotein(a) [Lp(a)] might be modified by low-density lipoprotein cholesterol (LDL-C) or high-sensitivity C-reactive protein (hs-CRP) levels, but whether LDL-C and hs-CRP jointly mediate the outcome of Lp(a) remains unknown in patients with coronary artery disease. A prospective study was conducted, enrolling consecutive 10 724 patients with percutaneous coronary intervention (PCI) in 2013. The endpoint event was all-cause death. A total of 10 000 patients with complete baseline data were finally included. During a median follow-up of 5.1 years, Lp(a) ≥ 30 mg/dL was an independent risk factor of all-cause death in the overall population, LDL-C ≥ 70 mg/dL, and hs-CRP ≥ 2 mg/L population, respectively. According to concurrent LDL-C (70 mg/dL) and hs-CRP (2 mg/L) levels, further analysis revealed that when LDL-C < 70 mg/dL regardless of hs-CRP levels, Lp(a) ≥ 30 mg/dL was not an independent predictor of all-cause death. However, when LDL-C ≥ 70 mg/dL, Lp(a) ≥ 30 mg/dL was independently associated with a higher risk of all-cause death in hs-CRP ≥ 2 mg/L (HR: 1.488, 95% CI: 1.059‒2.092), but not in hs-CRP < 2 mg/L (HR: 1.303, 95% CI: 0.914‒1.856). Among PCI patients, Lp(a)-associated outcome was jointly affected by LDL-C and hs-CRP. As long as LDL-C is well controlled, the adverse effects of increased Lp(a) on cardiovascular risk seem to be weakened, and only when LDL-C and hs-CRP increase at the same time, elevated Lp(a) is associated with poorer long-term outcome.

Distinguishing among Causes of Death in Patients with Kidney Failure on Hemodialysis

Distinguishing among Causes of Death in Patients with Kidney Failure on Hemodialysis

Effectiveness of peritoneal lavage fluid circulating tumour cells and circulating tumour DNA in the prediction of metachronous peritoneal metastasis of gastric cancer (pT4NxM0/pT1-3N+M0) after radical resection: protocol of a prospective single-centre clinical study

BackgroundGastric cancer (GC) is the fourth leading cause of cancer mortality worldwide. Peritoneal metastasis (PM) is a significant cause of death in patients with GC, and presents a major challenge...

Valtrate Suppresses TNFSF14-Mediated Arrhythmia After Myocardial Ischemia-Reperfusion by Inducing N-linked Glycosylation of LTβR to Regulate MGA/MAX/c-Myc/Cx43.

Myocardial ischemia-reperfusion (MIR)-induced arrhythmia remains a major cause of death in patients with cardiovascular diseases. The reduction of Cx43 has been known as a major inducer of arrhythmias after MIR, but the reason for the reduction of Cx43 remains largely unknown. The aim of this study was to find the key mechanism underlying the reduction of Cx43 after MIR and to screen out an herbal extract to attenuate arrhythmia after MIR. The differentially expressed genes in the peripheral blood mononuclear cell (PBMCs) after MIR were analyzed using the data from several gene expression omnibus data sets, followed by the identification in PBMCs and the serum of patients with myocardial infarction. Tumor necrosis factor superfamily protein 14 (TNFSF14) was increased in PBMCs and the serum of patients, which might be associated with the injury after MIR. The toxic effects of TNFSF14 on cardiomyocytes were investigated in vitro . Valtrate was screened out from several herbal extracts. Its protection against TNFSF14-induced injury was evaluated in cardiomyocytes and animal models with MIR. Recombinant TNFSF14 protein not only suppressed the viability of cardiomyocytes but also decreased Cx43 by stimulating the receptor LTβR. LTβR induces the competitive binding of MAX to MGA rather than the transcriptional factor c-Myc, thereby suppressing c-Myc-mediated transcription of Cx43. Valtrate promoted the N-linked glycosylation modification of LTβR, which reversed TNFSF14-induced reduction of Cx43 and attenuated arrhythmia after MIR. In all, valtrate suppresses TNFSF14-induced reduction of Cx43, thereby attenuating arrhythmia after MIR.

Phosphate Loading per Nephron Predicts CKD Progression and All-Cause Death in Patients with Nondialysis-Dependent CKD: The Fukuoka Kidney Disease Registry (FKR) Study

Phosphate Loading per Nephron Predicts CKD Progression and All-Cause Death in Patients with Nondialysis-Dependent CKD: The Fukuoka Kidney Disease Registry (FKR) Study

Impact of Lupus on Mortality and Causes of Death in Patients on Dialysis: Okinawa Dialysis Study (OKIDS) Registry

Impact of Lupus on Mortality and Causes of Death in Patients on Dialysis: Okinawa Dialysis Study (OKIDS) Registry

Characteristics, Outcomes and Factors for Place of Death in Patients Admitted to Community-Based Palliative Care Services in Shanghai China: A Multicenter Retrospective Cohort Study.

Community-based palliative care (CBPC) is only available in large cities in mainland China and little is known about who utilizes it. This study examined the characteristics, outcomes, and factors associated with place of death (PoD) among inpatient CBPC patients. This was a multicenter retrospective cohort study. All patients admitted to the inpatient CBPC unit in four community health centers in 2021 in Shanghai, China, were included. Characteristics and outcome data were extracted from electronic health records and paper version notes between September 4 and December 29, 2022. PoD was followed up on May 12, 2023. Data were analyzed using descriptive analysis and categorized using two-step clustering. Decision tree analysis was used to identify factors associated with PoD. The cohort admitted in 2021 included 290 participants (Age: 75.7 ± 12.7 years; Male: n = 155, 53.4%) including two children, with a mortality rate of 59.0% and a median length of stay (LoS) of 14 days upon December 29, 2022. The primary diagnosis for 80.3% of participants was tumor. Two clusters were identified. Cluster 1 was smaller than Cluster 2 (n = 45, 15.5% vs. n = 245, 84.5%) and dominated by noncancer participants (n = 37, 82.2%), whereas Cluster 2 included 91.8% (n = 225) tumor patients. Greatest significant differences in age, sex, marital status, education level, awareness of diagnosis and/or prognosis, mortality, LoS, and costs were found between the clusters. In total, 265 deaths derived from the cohort upon May 12, 2023, occur in inpatient CBPC units (75.5%), at home (18.9%), and in hospital wards (5.7%), influenced largely by participants' marital status and age. Establishing contextualized inpatient CBPC services in more places nationwide that are tailored to different characteristics between cancer patients (i.e., younger and shorter inpatient stay) and noncancer patients (i.e., older and longer stay) is essential to maintain that more dying patients remain in their community.

Associations of Proteinuria Trajectories with Kidney Failure and Death in Patients with CKD

Associations of Proteinuria Trajectories with Kidney Failure and Death in Patients with CKD

Automated Digital Sfigmomanometer Prototype Testing

Abstract Blood pressure is the pressure of blood flow in the arteries generated by the heart. Abnormal blood pressure can lead to hypertension and hypotension. Hypotension, or low blood pressure, has a prevalence of 5% to 34% among individuals aged 17 to 19, and over 50% in the elderly. Hypertension can cause death in patients with heart disease. About 39.7% of people suffer from hypertension, especially those over the age of 60. Blood pressure measurement needs to be done regularly because it has impact such as early detection of blood pressure health conditions and monitoring of health conditions for those already diagnosed with abnormal blood pressure. Unfortunately, only 59% of the population in Indonesia regularly measure their blood pressure. Accurate blood pressure measurement can be performed using an invasive method. Another method is non-invasive, which can be done using a sphygmomanometer that applies the oscillometric method. This method uses pressure oscillations in the cuff influenced by the pulse in the blood vessels. When using this method, several factors need to be considered, such as body position, cuff size, and the technique used during the measurement. In this study, a fully automatic digital sphygmomanometer has been developed with a cuff attached to the device, equipped with a thermal printer to print out the measurement results and classify blood pressure categories. The advantage of the developed prototype is that it has a smaller relative error value, with 1.03% for systolic blood pressure and 1.45% for diastolic blood pressure, and has already been integrated with a thermal printer to directly print the measurement results.

Development and Validation of Machine-Learning Model to Predict the Risk of Major Cardiovascular Events and Death for Patients with Kidney Failure Having Noncardiac Surgery

Development and Validation of Machine-Learning Model to Predict the Risk of Major Cardiovascular Events and Death for Patients with Kidney Failure Having Noncardiac Surgery

Reexamining Transplant Outcomes in Acute Kidney Injury Kidneys Through Machine Learning.

Despite many people awaiting kidney transplant, kidney allografts from acute kidney injury (AKI) donors continue to be underutilized. We aimed to cluster kidney transplant recipients of AKI kidney allografts using an unsupervised machine learning (ML) approach. Using Organ Procurement and Transplantation Network-United Network for Organ Sharing (OPTN/UNOS) data, a consensus clustering cohort analysis was performed in 12356 deceased donor kidney transplant recipients between 2015 and 2019 in whom donors had a terminal serum creatinine ≥1.5mg/dL. Significant cluster characteristics were determined, and outcomes were compared. The median donor terminal creatinine was 2.2 (interquartile range [IQR] 1.7-3.3) mg/dL. Cluster analysis was performed on 12356 AKI kidney recipients, and three clinically distinct clusters were identified. Young, sensitized kidney re-transplant patients characterized Cluster 1. Cluster 2 was characterized by first-time kidney transplant patients with hypertensive and diabetic kidney diseases. Older diabetic recipients characterized Cluster 3. Clusters 1 and 2 donors were young and met standard kidney donor profile index (KDPI) criteria; Cluster 3 donors were older, more likely to have hypertension or diabetes, and meet high KDPI criteria. Cluster 1 had a higher risk of acute rejection, 3-year patient death, and graft failure. Cluster 3 had a higher risk of death-censored graft failure, patient death, and graft failure at 1 and 3 years. Cluster 2 had the best patient-, graft-, and death-censored graft survival at 1 and 3 years. Compared to non-AKI kidney recipients, the AKI clusters showed a higher incidence of delayed graft function (DGF, AKI: 43.2%, 41.7%, 45.3% vs. non-AKI: 25.5%); however, there were comparable long-term outcomes specific to death-censored graft survival (AKI: 93.6%, 93.4%, 90.4% vs. non-AKI: 92.3%), patient survival (AKI: 89.1%, 93.2%, 84.2% vs. non-AKI: 91.2%), and overall graft survival (AKI: 84.7%, 88.2%, 79.0% vs. non-AKI: 86.0%). In this unsupervised ML approach study, AKI recipient clusters demonstrated differing, but good clinical outcomes, suggesting opportunities for transplant centers to incrementally increase kidney utilization from AKI donors.

The association of perioperative serum uric acid variation with in-hospital adverse outcomes in coronary artery bypass grafting patients.

Previous studies proposed the predictive value of baseline serum uric acid (SUA) in the prognosis of coronary artery bypass grafting (CABG) patients. The association of perioperative SUA variation with in-hospital adverse outcomes in CABG patients is unknown. A total of 2,453 patients were included in the study and were divided into four groups (G1-G4) according to perioperative SUA variation (ΔSUA) (G1, ΔSUA ≤ -90 μmol/L; G2, -90 μmol/L < ΔSUA < 0; G3, 0 ≤ ΔSUA < 30 μmol/L; G4, 30 μmol/L ≤ ΔSUA.) The basic characteristics and incidence of adverse outcomes were compared between the groups in the overall population and the subgroups. Multivariate logistic regression was performed to explore the association between perioperative SUA increases and adverse outcomes, and receiver operating characteristic analysis was used to obtain the cutoff value of SUA increases. The patients had a mean age of 60.9 years and the majority were males (76.7%). In the group with the most significant increase in SUA (G4), incidences of in-hospital all-cause death and fatal arrhythmia were higher than in other groups in the overall population and the subgroups. Multivariate logistic regression showed that an increase in the SUA level of ≥30 µmol/L was significantly associated with in-hospital all-cause death and fatal arrhythmia, independent of the baseline SUA level and renal function. This association was significant in most subgroups for in-hospital fatal arrhythmia and in the ≥60 years, myocardial infarction, and female subgroups for in-hospital all-cause death. The cutoff values of SUA increases in the overall population were 54.5 µmol/L for in-hospital all-cause death and 42.6 µmol/L for in-hospital fatal arrhythmia. The perioperative SUA increase significantly correlated with a higher incidence of in-hospital all-cause death and fatal arrhythmia in CABG patients, independent of the baseline SUA level and renal function. Perioperative SUA variation may provide complementary information in the identification of patients potentially at risk.

Initial Cannulation Strategy Impacts Perioperative Outcomes of Acute Type A Dissection in High Volume Centers

We performed an intention to treat analysis of initial cannulation strategy to assess impact on perioperative outcomes in acute type A dissection using multicenter data. All patients undergoing surgical repair of acute type A dissection from a multicenter national registry of 9 high-volume aortic centers were analyzed. Cannulation strategies included in the analysis were: Axillary, Femoral, Direct Aortic, and Innominate. Among 950 patients, we excluded those with chronic, type B dissections, and unknown initial cannulation strategy. Patients with multiple cannulation strategies were included if the sequence in which strategies were initiated was known. The final cohort consisted of 936 patients. Primary outcomes were stroke and death. Multivariable logistic regression was performed to adjust for baseline differences. P values represent Tukey's post hoc comparisons. Among 936 patients, cannulation strategies in descending order included: Axillary (n=502, 53%), Femoral (n=268, 29%), Aortic (n=104, 11%), and Innominate (n=59, 6%). Of these 46 (5%) had a change in the initial cannulation strategy prior to initiating circulatory arrest, mainly for poor axillary flow or initial femoral cannulation for hemodynamic instability followed by axillary. Femoral patients were younger (61.3±13.8) than Aortic patients (66.4±12.52, p=0.01) and more likely to present with malperfusion (n=123, 45.9%) compared to Aortic, Axillary, or Innominate patients (p <0.01). Femoral patients also had the longest duration of cerebral ischemia (Femoral: 16.9±16min, Aortic: 11.5±11.8min; Axillary: 4.41±10.3min; Innominate: 2.53±6min, p<0.01 for all vs Femoral). Unadjusted risk of death, stroke, and prolonged ventilation was lowest among Axillary and Innominate patients (Figure 1A). Length of stay was also reduced among Innominate patients. Multivariable regression demonstrated Axillary [OR 0.52 (0.36-0.75), p=0.004] and Innominate [OR 0.19 (0.07-0.54), p=0.009] cannulation to be associated with significantly reduced risk of stroke (Figure 1C). A non-significant signal of reduced death in Axillary patients remained [OR 0.66 (0.45-0.96), p=0.07]. In high volume aortic centers, an initial cannulation strategy using Axillary access is associated with reduced risk of stroke compared to Femoral. Axillary cannulation should be the preferred strategy in experienced centers if anatomy and stability allow.