Differences In Baseline Characteristics Research Articles

Nirmatrelvir/ritonavir treatment and risk for postacute sequelae of COVID-19 in older Singaporeans

ObjectivesSignificant heterogeneity has been reported in cohort studies evaluating the impact of early oral antiviral treatment on preventing postacute sequelae after COVID-19. We evaluated the impact of early nirmatrelvir/ritonavir on risk of postacute cardiovascular, neurological, respiratory, and autoimmune diagnoses, as well as postacute symptoms amongst older Singaporeans. MethodsNational COVID-19 registries and healthcare claims databases were used to construct a retrospective population-based cohort enrolling all Singaporeans aged ≥60 years diagnosed with SARS-CoV-2 infection in primary care during Omicron transmission (18 March 2022–4 August 2023). The cohort was divided into nirmatrelvir/ritonavir-treated and untreated groups. Between-group differences in baseline characteristics were adjusted using overlap weighting. Risks of postacute cardiovascular, neurological, respiratory, and autoimmune diagnoses and postacute symptoms (31–180 days) after SARS-CoV-2 infection were contrasted in treated/untreated groups using competing risks regressions (adjusted for demographics/vaccination status/comorbidities). ResultsA total of 188 532 older Singaporeans were included; 5.8% (10 905/188 532) received nirmatrelvir/ritonavir. No significantly decreased risk of postacute sequelae (any sequelae: adjusted hazards ratio [aHR], 1.06; 0.94–1.19; cardiovascular sequelae: aHR, 1.01; 0.83–1.24; neurological sequelae: aHR, 1.09; 0.95–1.27; respiratory sequelae: aHR, 1.14; 0.84–1.55; autoimmune sequelae: aHR, 0.76; 0.53–1.09; or any postacute symptom: aHR, 0.97; 0.80–1.18) was observed up to 180 days post-infection in nirmatrelvir/ritonavir-treated individuals vs. untreated cases. Across all vaccination and age subgroups, no significantly decreased risk of any postacute diagnosis/symptom or any cardiovascular, neurological, respiratory, and autoimmune complications up to 180 days post-infection was observed. DiscussionEarly outpatient receipt of nirmatrelvir/ritonavir did not significantly reduce risk of postacute cardiovascular, neurological, respiratory, and autoimmune sequelae or the risk of postacute symptoms in a boosted cohort of older Singaporeans.

Comparison of Subsequent Inframalleolar Bypass Surgery and Repeat Endovascular Therapy for Infrapopliteal Restenosis in Patients With Chronic Limb-Threatening Ischemia Undergoing Primary Endovascular Therapy.

Although endovascular therapy (EVT) is considered a vital strategy for treating infrapopliteal lesions in chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT exceeds that after bypass surgery (BSX). The optimal approach for managing infrapopliteal lesion recurrence in patients with CLTI and unhealed ulcers remains uncertain. This study aimed to evaluate the clinical outcomes of repeat EVT and subsequent inframalleolar BSX for CLTI with infrapopliteal lesion recurrence. We conducted a retrospective analysis of 140 patients with CLTI (mean age, 70±10 years; male, 71.4%; diabetes mellitus, 73.6%; dialysis, 74.3%; Rutherford 5, 79.3%; and Rutherford 6, 20.7%) who had an unhealed wound due to the recurrence of infrapopliteal lesions between January 2015 and May 2020. We compared the clinical outcomes of 40 patients who underwent the subsequent inframalleolar BSX with those of 100 patients who underwent repeat EVT. The outcome measures were amputation-free survival (AFS) and wound healing rate. Propensity score matching analysis was conducted to minimize differences in baseline characteristics. Propensity score matching extracted 38 pairs (38 patients in the subsequent BSX group and 83 patients in the repeat EVT group). AFS was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). No baseline characteristics had any significant interaction effect on the association between repeat EVT, subsequent BSX, and failure of AFS. This study using propensity score matching revealed that the clinical outcomes following repeat EVT were comparable with those following subsequent inframalleolar BSX, indicating that repeat EVT may be a viable treatment option for CLTI with infrapopliteal lesion recurrence. Although endovascular therapy (EVT) has expanded the treatment options for chronic limb-threatening ischemia (CLTI), the recurrence rate after EVT is higher than that after bypass surgery (BSX). This retrospective study compared the clinical outcomes of repeat EVT with those of subsequent BSX for CLTI with infrapopliteal lesion recurrence. After propensity score matching, amputation-free survival (AFS) was not significantly different between the repeat EVT and subsequent BSX groups (81.9% vs 82.6% at 1 year, p=0.97). Neither was cumulative wound healing (42.8% vs 43.3% at 1 year, p=0.55). There was no difference between the 2 revascularization strategies when treating infrapopliteal restenosis lesions.

Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis

ObjectiveThe Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis. MethodsAll patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ2 tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality. ResultsA total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834). ConclusionsTCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. The current Centers for Medicare and Medicaid Services decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.

Bleeding and long-term survival after lung resections: nationwide observational cohort study.

Bleeding following lung surgery can lead to reoperation and blood transfusions, potentially impairing outcomes. This study aimed to assess how bleeding complications affect long-term survival and postoperative complications in a nationwide contemporary group of patients undergoing lung resections. Adult patients who underwent lung resections, for both malignant and nonmalignant diagnoses, between 2013-2021, were included from the Swedish national registry for thoracic surgery. Patients with bleeding complications, defined as requiring reexploration and/or transfusions, were compared to patients without bleeding complications regarding long-term survival and postoperative complications. We used propensity scores and optimal full matching to account for differences in baseline characteristics between the groups. The cohort comprised 15,617 adult patients, of which 646 patients (4.1%) had bleeding complications. The unadjusted 90-day mortality was 9.4% vs. 1.0% in the bleeding group vs. no bleeding group, respectively. After matching, the odds ratio (OR) for 90-day mortality in the bleeding group compared with the no bleeding group was 3.66 [95% confidence interval (CI): 2.17-6.17]. Long term overall survival was lower among patients in the bleeding group, adjusted hazard ratio (95% CI) for all-cause mortality was 1.47 (1.29-1.69). Postoperative complications were more common in the bleeding group (OR: 3.00, 95% CI: 2.38-3.79), including infections (OR: 2.80, 95% CI: 1.86-4.20). Bleeding complications were more frequent during the first third of the study time period as compared to the last third (P<0.001). Patients with bleeding complications had reduced long-term survival and higher incidence of postoperative complications. A declining trend in bleeding rates over time was noted.

Web-Based Warfarin Management (Alfalfa App) Versus Traditional Warfarin Management: Multicenter Prospective Cohort Study.

Poor anticoagulation management of warfarin may lead to patient admission, prolonged hospital stays, and even death due to anticoagulation-related adverse events. Traditional non-web-based outpatient clinics struggle to provide ideal anticoagulation management services for patients, and there is a need to explore a safer, more effective, and more convenient mode of warfarin management. This study aimed to compare differences in the quality of anticoagulation management and clinical adverse events between a web-based management model (via a smartphone app) and the conventional non-web-based outpatient management model. This study is a prospective cohort research that includes multiple national centers. Patients meeting the nadir criteria were split into a web-based management group using the Alfalfa app or a non-web-based management group with traditional outpatient management, and they were then monitored for a 6-month follow-up period to collect coagulation test results and clinical events. The effectiveness and safety of the 2 management models were assessed by the following indicators: time in therapeutic range (TTR), bleeding events, thromboembolic events, all-cause mortality events, cumulative event rates, and the distribution of the international normalized ratio (INR). This national multicenter cohort study enrolled 522 patients between June 2019 and May 2021, with 519 (99%) patients reaching the follow-up end point, including 260 (50%) in the non-web-based management group and 259 (50%) in the web-based management group. There were no observable differences in baseline characteristics between the 2 patient groups. The web-based management group had a significantly higher TTR than the non-web-based management group (82.4% vs 71.6%, P<.001), and a higher proportion of patients received effective anticoagulation management (81.2% vs 63.5%, P<.001). The incidence of minor bleeding events in the non-web-based management group was significantly higher than that in the web-based management group (12.1% vs 6.6%, P=.048). Between the 2 groups, there was no statistically significant difference in the incidence of severe bleeding and thromboembolic and all-cause death events. In addition, compared with the non-web-based management group, the web-based management group had a lower proportion of INR in the extreme subtreatment range (17.6% vs 21.3%) and severe supertreatment range (0% vs 0.8%) and a higher proportion in the treatment range (50.4% vs 43.1%), with statistical significance. Compared with traditional non-web-based outpatient management, web-based management via the Alfalfa app may be more beneficial because it can enhance patient anticoagulation management quality, lower the frequency of small bleeding events, and improve INR distribution.

Mid-term clinical outcomes of left bundle branch area pacing compared to accurate right ventricular septal pacing.

Although left bundle branch area pacing (LBBAP) reportedly results in fewer adverse outcomes after implantation than conventional stylet-guided right ventricular septal pacing (RVSP), previous studies have not compared LBBAP with accurate RVSP using a delivery catheter. The aim of this study was to compare clinical outcomes between LBBAP and accurate RVSP among patients with atrioventricular block (AVB). This single-center observational study enrolled 160 patients requiring RV pacing due to symptomatic AVB between September 2018 and December 2021. Primary composite outcomes included all-cause death, hospitalization due to heart failure (HF), and upgrading to biventricular pacing. Secondary composite outcomes included any procedural and postprocedural complications. Overall, 160 patients were analyzed (LBBAP, n = 81; RVSP, n = 79). No significant differences in baseline characteristics were observed between the two groups. The RV pacing burden at 1year after implantation was 90.8% ± 20.4% and 86.2% ± 22.6%, respectively (p = 0.21). During a mean follow-up of 840 ± 369days, the incidence of the primary outcome was significantly lower with LBBAP (4.9%) compared to RVSP (22.8%) (Log-rank p = 0.02). There was no significant difference in the incidence of the secondary outcome between the two groups (3.7% vs. 5.1%, p = 0.65). In the multivariate analysis, baseline QRS duration, RV pacing burden, and LBBAP were independently associated with the primary outcome (baseline QRS duration: hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.00-1.02; p < 0.001; RV pacing burden: HR, 1.01; 95% CI, 1.00-1.02; p < 0.001; LBBAP: HR, 0.45; 95% CI, 0.31-0.64; p < 0.001). In patients requiring frequent RV pacing, LBBAP was associated with reduced adverse clinical outcome compared to accurate RVSP using a delivery catheter.

Increasing Colorectal Screening Uptake in Spouses of Patients With Colorectal Cancer Using a Randomized Behavioral Trial.

Colorectal cancer (CRC) is one of the few cancers for which screening has been associated with better survival and morbidity, but screening uptake has been underexplored in spouses of existing patients with CRC. The objective of this study was to evaluate whether a brief, structured behavioral intervention delivered to spouses of patients with CRC in a colorectal clinical setting could increase fecal immunochemical test (FIT) uptake within 3 months of the study period. This study was designed as a block randomized, unblinded, parallel trial conducted in the colorectal outpatient clinics of 2 public tertiary hospitals in Singapore from December 2017 to February 2023. The intervention group received a structured informational pamphlet on CRC screening by the Singapore Ministry of Health and a printed guide with instructions on how to properly use a FIT kit. No significant differences in baseline characteristics were observed between the 2 groups. There was a statistically significant difference (P<.001) in FIT screening uptake between spouses in each group, with 86.2% (n=25) in the intervention group and 38.7% (n=12) in the control group. Our study demonstrated that a brief, structured behavioral intervention offered to spouses accompanying patients with CRC while they wait for the clinic appointment is useful in increasing FIT screening uptake rates. Colorectal clinics can consider setting aside 10 to 15 minutes to educate accompanying spouses in the future as a complementary avenue to holistically promote CRC prevention, subjected to the resources available in each clinic. gov identifier: NCT04544852.

Clinical efficacy and safety of flexible ureteroscopy and percutaneous nephrolithotomy for large kidney stones: A retrospective comparative study.

Renal stones ranging 20-40 mm are very common in China. Although no large-sample clinical studies have confirmed the clinical efficacy and safety of this method, there is also a lack of comparative data with traditional treatment. To investigate the clinical efficacy of flexible ureteroscopy (FURS) and percutaneous nephrolithotomy (PCNL) by postoperative stone clearance and changes in soluble vascular cell adhesion molecule 1 (sVCAM-1) and kidney injury molecule 1 (KIM-1) levels in patients with large kidney stones (> 2 cm in diameter). This single-center observational study was performed at a Chinese hospital between January 1, 2021, and October 30, 2023. All 250 enrolled patients were diagnosed with large kidney stones (> 2 cm) and divided into a FURS group (n = 145) and a PCNL group (n = 105) by the surgical method. The FURS group was treated with flexible ureteroscopy and the PCNL group was treated with percutaneous nephrolithotomy. The operation time, time to palinesthesia, intraoperative blood loss, drop in hemoglobin, length of hospital stay, stone clearance rate, and complications were recorded in the two groups. Preoperative and postoperative serum sVCAM-1 levels, erythrocyte sedimentation rate (ESR), urine KIM-1 levels, preoperative and postoperative pain visual analog scale (VAS) and Wisconsin Stone Quality of Life Questionnaire (WISQOL) scores were also documented. All 250 eligible patients completed the follow-up. There were no significant differences in baseline characteristics between the two groups (P > 0.05). The operation time in the FURS group was significantly greater than that in the PCNL group. The time to ambulation, intraoperative blood loss, decrease in hemoglobin, and length of hospital stay were significantly lower in the FURS group than in the PCNL group. The FURS group also had a significantly higher stone clearance rate and a lower incidence of postoperative complications. There was no significant difference in antibiotic use between the groups. Postoperative serum sVCAM-1 levels, urine KIM-1 levels, and VAS scores were lower in the FURS group than in the PCNL group, but postoperative ESR and WISQOL scores were greater in the FURS group than in the PCNL group. FURS demonstrated superior clinical efficacy in treating large kidney stones (> 2 cm in diameter) compared PCNL. It not only improved the postoperative stone clearance rate and reduced complications and recovery time but also positively affected serum SCM-1, ESR, and urine KIM-1 levels, subsequent improvement of patient quality of life.

Directional Femoral Ultrasound-Guided Compression Technique Using in Percutaneous Mechanical Thrombectomy for Acute Deep Vein Thrombosis: A Retrospective Cohort Study.

The study aimed to investigate the early results of directional femoral ultrasound-guided compression technique (UCT) using in percutaneous mechanical thrombectomy (PMT) for acute deep vein thrombosis (DVT). Consecutive single-center patients with acute iliofemoral DVT who underwent PMT from January 2020 to December 2021 were included. Directional femoral UCT was used to adjust the PMT catheter into the residual thrombus in the inguinal region by ultrasound compression to improve the thrombus clearance rate. Patients were retrospectively analyzed and divided into 2 groups based on PMT with or without directional femoral UCT. The primary efficacy outcome was the incidence of post-thrombotic syndrome (PTS) at 24-month follow-up. The secondary efficacy outcomes included common femoral venous thrombus removal grade, total thrombus removal grade, venous primary patency rate, and incidence of moderate-to-severe PTS at 24-month follow-up. The safety outcomes included complications, major bleeding events, and death at 24-month follow-up. A total of 96 patients were included in the study: 42 patients underwent PMT with directional femoral UCT and 54 patients underwent PMT without UCT. There was no significant difference in baseline characteristics between the 2 groups. The percentages of patients achieved common femoral venous thrombus removal grade 3 and total thrombus removal grade 3 were significantly higher in the PMT with UCT group than those in the PMT without UCT group (p<0.001). The 24-month primary patency rate was significantly higher in the PMT with UCT group than that in the PMT without UCT group (90.0% vs 71.2%, p=0.027). The incidence of PTS was significantly lower in the PMT with UCT group (10.0%) than that in the PMT without UCT group (28.8%) (p=0.027). PMT with directional femoral UCT could improve the thrombus clearance rate and primary patency rate of acute iliofemoral DVT and might decrease the incidence of PTS compared to traditional PMT treatment without UCT. Residual thrombus in common femoral vein is a difficult problem associated with higher incidence of PTS. Few studies have focused on common femoral venous thrombus clearance. PMT with directional femoral UCT could improve the thrombus clearance rate and primary patency rate of acute iliofemoral DVT, and might decrease the incidence of PTS compared to traditional PMT treatment without UCT. Directional femoral UCT is recommended in PMT treatment of acute iliofemoral DVT.

Genetic and clinical characteristics of single and compound types of patients with long QT syndrome type 3

Objective: To explore the genetic background and clinical features of patients with long QT syndrome type 3 (LQT3). Methods: This retrospective cohort included patients diagnosed with LQT3 at the Department of Cardiology, Renmin Hospital of Wuhan University from January 1998 to December 2022. Patients were categorized into compound type group and single type group based on the presence of a single SCN5A mutation. The two groups were followed up and the differences in baseline characteristics, electrocardiograms, and clinical events between the two groups and probands were compared. Kaplan-Meier curves were used for survival analysis, and the log-rank test was employed to compare the event-free survival rates of first cardiac events between the groups and probands. Results: A total of 97 LQT3 patients were enrolled, including 59 probands. The age at diagnosis was (23.45±19.86) years, with 46 patients (47.4%) being male. Among them, 89 patients were classified as single type group, while 8 patients were classified as compound type group. Genetic testing identified 49 SCN5A mutations, with missense mutations being the majority (91.8%), primarily located in transmembrane regions (40.8%, n=20), interdomain linker regions (28.6%, n=14), and C-terminus (22.4%, n=11). The first cardiac event occurred in 44 patients (45.4%), with an onset age of (13.82±12.50) years. The main trigger was identified as rest or sleep (54.5%, n=24). Compared with patients in single type group, patients in compound type group were younger at diagnosis ((10.35±10.28) years vs. (24.63±20.13) years, P=0.040), had a significantly higher proportion of syncope (87.5% (7/8) vs. 33.7% (30/89), P=0.009), aborted cardiac arrest (62.5% (5/8) vs. 11.2% (10/89), P=0.001), and a lower incidence of event-free survival rates of first cardiac events (12.5% (1/8) vs.58.4% (52/89), log-rank P=0.001). The probands in compound type group had a significantly higher proportion of aborted cardiac arrest comparing to probands in single type group (62.5% (5/8) vs. 17.6% (9/51), P=0.020), while the difference in the incidence rate of event-free survival rates of first cardiac events between the probands in two groups was not statistically significant (12.5% (1/8) vs. 39.2% (20/51), log-rank P=0.08). Conclusion: Compound type LQT3 patients are not uncommon. Such patients are diagnosed at a younger age and exhibit more severe phenotypes, requiring close follow-up and proactive intervention strategies.

Impact of COVID-19 pandemic on adolescents undergoing metabolic bariatric surgery

BackgroundWhile the lasting effect of the COVID-19 pandemic continues to unfold, the impact on adolescents undergoing bariatric surgery remains unseen. ObjectiveWe examined the impact of the pandemic on adolescents undergoing metabolic bariatric surgery. SettingAcademic hospital, New York, NY. MethodsA single-institution review of prospectively collected data evaluated adolescents who underwent laparoscopic sleeve gastrectomy between 2010 and 2023, forming two cohorts: pre-COVID (before March 1, 2019) and COVID (after March 1, 2020). Absolute and percent weight loss and body mass index (BMI) change at 6 and 12 months postsurgery were compared between cohorts. Multivariable linear regression models were constructed to estimate the association between weight loss, adjusting for age, gender, ethnicity, and BMI. ResultsA total of 358 patients were included: 245 in the pre-COVID cohort and 113 in the COVID cohort. There were no significant differences in baseline characteristics. There were no significant differences between cohorts at 6 months in weight loss (21.6 kg vs. 22.5 kg, P = .43), percent weight loss (18% vs. 18%, P = .63), and BMI change (8.0 vs. 8.4, P = .39) which was maintained at 12 months. In multivariate models, after adjusting for age, gender, ethnicity, and baseline BMI, undergoing surgery during the pandemic was not associated with a difference in weight loss or BMI change at 6 and 12 months postoperatively. ConclusionDespite the severe societal impact of the COVID-19 pandemic, laparoscopic sleeve gastrectomy remained a durable intervention for adolescent obesity, with no observed differences in weight loss in patients undergoing surgery during the pandemic compared to prepandemic.

Comparison of Blalock-Taussig-Thomas Shunts With Patent Ductus Arteriosus Ligated Versus Left Open.

The optimal approach to patent ductus arteriosus management during systemic-to-pulmonary artery shunt placement is currently unknown. The purpose of this study is to examine the outcomes of variable strategies for patent ductus arteriosus management during Blalock-Taussig-Thomas shunt surgery. A retrospective cohort study of infants who underwent shunt placement was performed, comparing those who had the ductus ligated with those who had the ductus left open. Indicators of low cardiac output syndrome, development of necrotizing enterocolitis, and secondary outcomes such as resuscitation events were examined. Thirty-six infants were included all of whom had their shunt placed via median sternotomy. Twenty infants had their ductus ligated at the time of the shunt, and they were compared with 16 infants whose ductus was left open. There was no statistical difference in preoperative baseline characteristics, including corrected gestational age, age in days, weight, mechanical ventilation, vasoactive use, heterotaxy, and gastrointestinal anomalies. There was also no statistical difference in postoperative indicators of low cardiac output, including urine production, total fluids given, renal injury, maximum lactate, and vasoactive-inotropic score. Three patients had postoperative renal injury, and all were in the ligated duct group. There was also no statistical difference in any secondary outcomes, including the development of necrotizing eneterocolitis, resuscitation events, reinterventions, length of intubation, total length of stay, and mortality. This study provides evidence that variable management of the ductus during shunt placement does not significantly impact outcomes. Leaving the ductus open allows for a potential rescue source of pulmonary blood flow and does not appear to increase the risk of postoperative low cardiac output.

Heparin-Induced Thrombocytopenia in Patients Suffering Cardiogenic Shock.

Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT. Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022. Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn. In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated. In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485). HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.

Reduction in Unindicated Cervical Cancer Screening in Adolescents in a Large Health Care System.

Evidence-based guidelines recommend against screening for cervical cancer (Pap testing) in average-risk adolescents <21 years old. Despite this, many still undergo unindicated screenings with subsequent detrimental reproductive health and economic consequences. Our aim was to reduce unindicated cervical cancer screening in individuals <21 years old in a large health care system by utilizing an electronic provider notification. Starting in July 2020, a Best Practice Advisory (BPA) appeared in the electronic medical record (EMR) if providers ordered Pap testing on individuals <21 years old. This BPA reiterated that screening was not indicated for average-risk adolescents and prompted users to choose an indication if they wanted to proceed.A retrospective chart review, pre/post intervention study was performed comparing individuals <21 years old with Pap testing performed before and after intervention (January 2019-June 2020 and July 2020-June 2021, respectively). Patient characteristics were extracted from the EMR and analyzed using Fisher exact tests, Kruskal-Wallis tests, and logistic regression. There were 140 subjects included: 106 preintervention and 34 postintervention. There were no differences in baseline characteristics. Neither Pap nor human papillomavirus testing results differed between the groups. Preintervention, 6.6% of cytology tests were indicated compared to 20.6% postintervention ( p = .042). The proportion of indicated human papillomavirus testing did not differ preintervention and postintervention at 65% and 45%, respectively ( p = .295). The overall reduction in unindicated cervical cancer screening postintervention was 13.9% (95% CI = 4.0-23.7). We demonstrated that incorporating a BPA to the EMR reduces unindicated cervical cancer screening.

Safety and efficacy of motor imagery-based physical activity in high-risk pregnancy: A randomized controlled study.

This study aimed to investigate the acute effects of motor imagery-based physical activity on maternal well-being, maternal blood pressure, heart rate, oxygen saturation, fetal heart rate, and uterine contractions in women with high-risk pregnancies. This randomized controlled trial was conducted in Izmir Tepecik Education and Research Hospital from August 2023 to January 2024. Seventy-six women with high-risk pregnancies were randomized into two groups: a motor imagery group (n = 38, diaphragmatic-breathing exercise and motor imagery-based physical activity) and a control group (n = 38, diaphragmatic-breathing exercise). Maternal well-being was determined using the Numerical Rating Scale-11. Digital sphygmomanometry was used to measure maternal heart rate and blood pressure, pulse oximetry for oxygen saturation, and cardiotocography for fetal heart rate and uterine contractions. Assessments were performed pre-intervention, mid-intervention, and post-intervention. There were no significant differences in baseline characteristics between groups (P > 0.05). There was a significant main effect of time in terms of maternal well-being and maternal heart rate (P = 0.001 and P = 0.015). In addition, there was a significant main effect of the group on oxygen saturation (P = 0.025). The overall group-by-time interaction was significant for maternal well-beingm with an effect size of 0.05 (P = 0.041). The combination of diaphragmatic-breathing exercises and a motor imagery-based physical activity program in women with high-risk pregnancies was determined to have no adverse effects on the fetus, did not induce uterine contractions, and resulted in a significant improvement in maternal well-being and oxygen saturation. Thus, imagery-based physical activity can be used in high-risk pregnancies where physical activity and exercise are not recommended.

Evaluation of pathologic response and surgical safety of total neoadjuvant therapy for patients with clinical stage III gastric cancer in a real-world setting

BackgroundPerioperative chemotherapy is the standard treatment for locally advanced gastric cancer. However, the potential benefit of extending therapy before surgery remains largely unknown. In this study, we aimed to evaluate the efficacy and safety of total neoadjuvant chemotherapy, with or without immune checkpoint blockade. MethodsA cohort of 174 patients with clinical stage III gastric cancer who underwent D2 gastrectomy from October 2021 to March 2024 in the real-world setting were included in this study. Among these patients, 101 were treated with total neoadjuvant therapy (TNT) and 73 were treated with perioperative neoadjuvant therapy (PNT). We compared the pathologic complete response (pCR) rate, ypN0 rate, recurrence-free survival (RFS), overall survival (OS), and postoperative complications between the 2 groups. Multivariate logistic regression analysis was conducted to identify factors associated with pCR or ypN0. ResultsCompared with the PNT group, the patients in the TNT group were more frequently treated with intensive chemotherapy with triplets + immunotherapy. Apart from this, there were no significant differences in baseline characteristics. There were no statistically significant differences in pCR (16.8% vs 12.3%), ypN0 (49.5% vs 38.4%), RFS, OS, and postoperative complications (27.7% vs 26.0%) between the TNT and PNT groups. Older age, diffuse type, and stable disease/progressive disease based on clinical efficacy evaluation were independently associated with non-pCR. Stable disease/progressive disease, linitis plastica, and poor differentiation were independently associated with ypN+. Neither the number of neoadjuvant therapy cycles nor the specific regimens were associated with pCR or ypN0. In the subgroup analysis of patients receiving total gastrectomy, there were still no statistically significant differences in pCR (16.7% vs 2.6%), ypN0 (43.8% vs 39.5%), and postoperative complications (45.8% vs 36.8%) between the 2 groups. ConclusionAlthough TNT did not increase the postoperative complication rate, it also did not provide any additional short-term benefits compared with PNT for clinical stage III gastric cancer.

Clinical comparison of total gastrectomy with single-vessel transection Roux-en-Y reconstruction vs total gastrectomy with conventional Roux-en-Y reconstruction for proximal gastric cancer

PurposeThis study aimed to investigate the clinical benefits of single-vessel transection Roux-en-Y (SR-Y) reconstruction after total gastrectomy. MethodsA total of 194 patients with proximal gastric cancer were prospectively recruited at Fudan University Shanghai Cancer Center between January 2021 and September 2022. This study included 97 patients who underwent conventional Roux-en-Y reconstruction and 97 patients who underwent SR-Y reconstruction. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were compared between the conventional and single-vessel transection groups. ResultsThere were no significant differences in baseline characteristics between the 2 groups in terms of age (P = .882), gender (P = .595), body mass index (P = .683), tumor location (P = .568), TNM stage (P = .122), tumor size (P = .927), anemia (P = .756), neoadjuvant chemotherapy (P = .730), and surgical approach (P = .592). However, compared with the conventional group, the single-vessel transection group had a shorter operation time (162.5 ± 37.6 vs 178.5 ± 48.3 min, respectively; P = .011) and less intraoperative bleeding (167.2 ± 91.8 vs 207.8 ± 167.5 mL, respectively; P = .037) after complete reservation of the terminal jejunal vascular arches. Nevertheless, there were no significant differences in tensions in the jejunal mesentery, durations of peritoneal drainage, postoperative hospital stay durations, the number of lymph node dissections, and early complications between the 2 groups. ConclusionSR-Y reconstruction can simplify surgical procedures, reduce operating time, and minimize intraoperative bleeding without increasing tensions in the jejunal mesentery or short-term complications. It is feasible and safe and worth further promotion in clinical practice.

Clinical observation of the subthreshold micropulse laser combined with ranibizumab for treatment of diabetic macular edema

Objective: To evaluate the efficacy and safety of the subthreshold micropulse laser (SMPL) combined with ranibizumab in treating diabetic macular edema (DME). Methods: This was a prospective randomized controlled study. Patients diagnosed with DME in the Ophthalmology Department of Beijing Hospital were enrolled from January 2020 to December 2022. Patients were randomized in a ratio of 1∶1 using a table of random numbers into the ranibizumab monotherapy group and the SMPL combined with ranibizumab therapy group. We compared the changes of best-corrected visual acuity, central macular thickness measured by optical coherence tomography and optical coherence tomography angiography parameters, including the vessel density of the superficial and deep capillary plexus (DCP), foveal avascular zone size and peripapillary vessel density, at baseline, 6 and 12 months after the treatment. After 12 months of follow-up, fundus fluorescein angiography results, adverse events, and the number of injections or laser therapies were recorded. The Fisher's exact test and group t-test were used for statistical analysis. Results: Seventy-two patients (72 eyes) were enrolled, with a mean age of (61.1±8.2) years. Patients in the combination therapy group included 19 males and 17 females, while patients in the ranibizumab monotherapy group were 17 males and 19 females. There was no statistically significant difference in baseline characteristics between the two groups (P>0.05). A significant improvement in best-corrected visual acuity was shown in both groups at 6 and 12 months [(58.5±12.9) and (58.2±12.2) ETDRS letters in the combination therapy group, and (63.3±13.1) and (63.8±12.5) ETDRS letters in the ranibizumab monotherapy group]. A significant reduction in central macular thickness was shown in both groups at 6 and 12 months [(451.0±185.5) and (380.4±159.3)μm in the combination therapy group, and (387.5±135.5) and (372.8±146.1)μm in the ranibizumab monotherapy group]. However, there was no significant difference between groups at each timepoint (all P>0.05). At 12 months, the vessel density of the superficial capillary plexus showed no statistical difference compared to the baseline value in each group or between groups (42.6%±5.9% in the ranibizumab monotherapy group and 42.2%±5.5% in the combination therapy group, P>0.05). The vessel density of the DCP in the combination therapy group significantly increased to 47.5%±5.6% at 12 months, significantly different from that in the ranibizumab group (43.4%±5.1%; P<0.05). The foveal avascular zone size in the ranibizumab monotherapy group reduced to (0.32±0.13) mm2, significantly different from that in the combination therapy group [(0.34±0.16) mm2] at 12 months (P<0.05). Patients in the ranibizumab monotherapy group received (7.3±2.5) intravitreal injections, while patients in the combination therapy group received 3 injections. No unfavorable outcomes on fundus fluorescein angiography or systemic or topical severe adverse events were observed during the follow-up. Conclusions: The SMPL combined with intravitreal ranibizumab injections was effective and safe in treating DME patients. The combination treatment significantly reduced the number of injections and improved the vessel density of the DCP and macular ischemia, compared to the ranibizumab monotherapy.

Efficacy analysis of mechanical thrombectomy combined with prolonged mild hypothermia in the treatment of acute middle cerebral artery occlusion: a single-center retrospective cohort study.

To determine the efficacy of mechanical thrombectomy combined with prolonged mild hypothermia compared with conventional treatment in managing acute middle cerebral artery occlusion, and to explore whether extending the duration of hypothermia can improve neurological function. From 2018 to June 2023, a retrospective analysis was conducted on 45 patients with acute middle cerebral artery occlusion treated at the NICU of Suzhou Kowloon Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. After thrombectomy, patients were admitted to the neurological intensive care unit (NICU) for targeted temperature management. Patients were divided into two groups: the mild hypothermia group (34.5-35.9°C) receiving 5-7 days of treatment, and the normothermia group (control group) whose body temperature was kept between 36 and 37.5°C using pharmacological and physical cooling methods. Baseline characteristics and temperature changes were compared between the two groups of patients. The primary outcome was the modified Rankin Scale (mRS) score at 3 month after surgery, and the secondary outcomes were related complications and mortality rate. Prognostic risk factors were investigated using both univariate and multivariate logistic regression analyses. Among 45 patients, 21 underwent prolonged mild hypothermia, and 24 received normothermia, with no significant differences in baseline characteristics between the two groups. The duration of mild hypothermia ranged from 5 to 7 days. The incidence of chills (33.3% vs. 8.3%, p = 0.031) and constipation (57.1% vs. 20.8%, p = 0.028) was significantly higher in the mild hypothermia group compared with the control group. There was no significant difference in mortality rates between the mild hypothermia and the control group (4.76% vs. 8.33%, p = 1.000, OR = 1.75, 95% CI, 0.171-17.949). At 3 month, there was no significant difference in the modified mRS (0-3) score between the mild hypothermia and control groups (52.4% vs. 25%, p = 0.114, OR = 0.477, 95% CI, 0.214-1.066). Infarct core volume was an independent risk factor for adverse neurological outcomes. Prolonged mild hypothermia following mechanical thrombectomy had no severe complications and shows a trend to improve the prognosis of neurological function. The Infarct core volume on CTP was an independent risk factor for predicting neurological function.

Different clinicopathological features between young and older patients with pulmonary adenocarcinoma and ground-glass opacity

After the recommendation of computed tomography as a routine procedure for lung cancer screening, an increasing number of young adults have been diagnosed with pulmonary ground-glass opacity (GGO). Up to 63% of pulmonary nodules with a GGO component can be malignant. Since young cancer patients have limited exposure to environmental mutagens, they have special characteristics and needs. This study sought to compare the clinicopathological characteristics of young and old patients with GGO-associated lung adenocarcinoma (GGO-LUAD). Clinicopathological data from 203 patients who underwent video-assisted thoracoscopic surgery between January 2018 and April 2020 for pulmonary GGO component nodules were reviewed. Lung nonmucinous adenocarcinoma patients younger than 40 years old and older than 40 years old were enrolled: 103 patients ≤ 40 years old and 100 patients > 40 years old. The relevant clinicopathological features, including sex, smoking status, tumor size, pathological characteristics, radiographic features and prognosis of pulmonary nodules, were evaluated. Univariate analyses were applied for comparisons between groups. The differences in baseline characteristics (sex, smoking status, tumor location) between the different age groups were not significant. Young patients were more likely to have tumors < 1 cm in size, while older patients predominantly had tumors > 2 cm in size. The mean percentage of invasive adenocarcinoma was greater in the elderly group. Young and older patients seemed to have similar subtypes of adenocarcinoma (p > 0.05) but had different degrees of differentiation (p < 0.001). The 3-year overall survival (OS) and recurrence-free survival (RFS) of the young group were 100% and 99.03%, respectively, while the 3-years OS and RFS of the older group were 99% and 98%, respectively. Our work revealed that young patients with malignant pulmonary nodules and GGOs have distinct pathological subtypes. Patients with GGOs of different ages have different clinicopathological characteristics. The 3-year prognosis of young patients with malignant pulmonary nodules with GGOs is satisfactory.