High Mortality Research Articles

Plasmapheresis combined with rituximab treatment of a case of thrombotic thrombocytopenic purpura with Sjögren syndrome and renal impairment: A case report.

Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy caused by reduced activity of the von Willebrand factor-cleaving protease (ADAMTS13), which can be life-threatening. The patient reported in this case study also had concurrent Sjögren syndrome and renal impairment, presenting multiple symptoms and posing a great challenge in treatment. A 25-year-old woman in the postpartum period visited the hospital due to indifference in consciousness for more than 1 day following cesarean section 8 days prior. Notable decreases were observed in platelets, hemoglobin, creatinine, and ADAMTS13 levels. After a consultative examination by an ophthalmologist, she was diagnosed with retinal hemorrhage in the right eye and dry eye syndrome in both eyes. Having been diagnosed with TTP with Sjögren syndrome and renal impairment, she received repeated treatments with plasmapheresis combined with rituximab. Following treatment and during the follow-up period, the patient's platelet counts and bleeding symptoms significantly improved. TTP has a high mortality rate, and when combined with Sjögren syndrome and renal impairment, it poses an even greater challenge in treatment. However, after administering standard plasmapheresis combined with rituximab treatment, the treatment outcome is favorable.

Prognostic Significance of Nuclear Factor kappa B (p65) among Breast Cancer Patients in Cape Coast Teaching Hospital.

Breast cancer is the most prevalent cancer among African women, with high mortality rates in Ghana. Nuclear factor kappa B (NF-kB) has been associated with tumor progression in breast cancer. However, its clinical validation is controversial and understudied with no known published data on NF-kB (p65) among breast cancer patients in Ghana and other African countries. This study assessed the prognostic significance of NF-kB(p65) expression and its association with various clinicopathological features in breast cancer patients. 90 formalin-fixed breast cancer tissues and 15 normal breast tissues were used to determine the expression of NF-kB (p65) using immunohistochemistry. We explored the correlation between expression of NF-kB (p65) and clinicopathological features. NF-kB (p65) was expressed in 86.7% of breast cancer tissues. There was a significant relationship between NF-kB (p65) expression and tumor grade, proliferation index (Ki67), and molecular subtype. High NF-kB (p65) expression in tumor grade 3 was about 10 times that of grade 1 (54.2% versus 5.1%), and Ki67 > 20 was 79.7% compared to 20.3% for Ki67 ≤ 20. Patients with triple-negative breast cancer (TNBC) had 49.1% overexpression of NF-kB (p65) compared to 17%, 25.4% and 8.5% for luminal A, luminal B, and HER 2 cases respectively. This study demonstrates that NF-kB (p65) was highly expressed among breast cancer patients at Cape Coast Teaching Hospital, Ghana especially in TNBC. NF-kB (p65) could serve as a biomarker for cancer stage, progression, prognosis, and as a therapeutic target.

Myxoedema coma secondary to severe hypothyroidis

Introduction: Myxoedema is a medical emergency associated with a highmortality rate. It is a rare presentation of severe hypothyroidism andsalient features usually seen include Decreased Mental Status,Hypothermia. Other features like Bradycardia, hypotension, hypoglycaemia,hypoventilation, signs of cognitive impairment like confusion, agitation,disorientation, and even psychotic features could be seen.Precipitants like alcohol, sedative drugs, MI, sepsis, exposure to cold mayalso result in severe hypothyroidism; hence effort should be made toreverse precipitating factors rapidly.The incidence of Myxoedema Coma is very low in developed countriesas there is improved diagnosis and treatment; early, aggressive treatmentis necessary due to the high mortality rate (30–60%). Groups of patientsat risk include elderly patients, those with a compromise cardiovascularsystem, reduced consciousness, sepsis etc. usually have a poorer outcome.Mainstay of treatment is thyroid hormone therapy, supportive-reversalof precipitating factors. Adrenal insufficiency should be excluded; glucocorticoidsare given to the patient.Case report-discussion & results: I present an 89-year-old woman who presentedwith Back Pain, Confusion following opioid medications prescribedby the GP. However on admission, there was hypothermia,hypotension with cold peripheries, pedal discolouration and ulceration,pitting oedema. The patient was initially managed for pneumonia, acutekidney injury secondary to poor intake. Patient was rehydrated andplaced on antibiotics. ECG, Transthoracic Echocardiography, ChestX-Ray, Blood tests, Brain CT showed nil tumour or acute changes. CTTAP showed nil malignancy or bony changes.Few days following admission to the ward, patient tested positivefor COVID and was isolated. Following COVID Stepdown, the patientdeveloped altered sensorium, hypotension, and seizures. Lactate washigh, EEG showed nil evidence of encephalitis. A confusion screen whichincluded Thyroid Function Test (TFT) was requested. The lab called ina few hours later due to a very high level of TSH (63) and low T4 (5.1)and Levothyroxine was commenced. Referral was made to the endocrinologist.Gentle rewarming using blankets with the room heater at roomtemperature was done and the patient was also placed on antibiotics.Relatives were updated as events evolved, and diagnosis changed withtime. Repeat TFT showed that the TSH level increased and there was clinicalworsening of the patient’s mental state. A diagnosis of Myxoedemacoma was made.Conclusion: A low threshold for requesting investigations like TFT, especiallyin at-risk patients and a high index of suspicion is required clinically.Could Covid have contributed to the precipitating factors? Areferral was made to the Palliative Care Team. There was good multidisciplinaryteam input with relatives updated from time to time with mentionof limited prognosis.

Tumor necrosis serves as an important pathological characteristic of stage I-II colon cancer.

The long-term prognosis of colon cancer patients remains little changed with relatively high mortality and morbidity. Since the most widely used prognostic parameter TNM staging system is less satisfactory in predicting prognosis in early-stage cancers, numerous clinicopathological factors, including tumor necrosis, have been proposed for prognosis stratification, but substantial evidences are still lacking for early-stage colon cancer. In the retrospective study, a total of eligible 173 stage I-II colon cancer patients, who received tumor radical resection and lymphadenectomy in the local hospital between January 1, 2010, and December 31, 2018, were enrolled for analyzing the prognostic role of tumor necrosis. The primary endpoints included 5-year overall survival (OS) and progression-free survival (PFS). The median follow-up of enrolled early-stage colon cancer patients was 58.3 months. The 2-year and 5-year OS rates were 88.3% and 68.2%, respectively, and the 2-year and 5-year PFS rates were 85.6% and 62.7%, respectively. Seventy-eight patients (45.1%) were diagnosed with tumor necrosis by pathological examination. Demographic analysis revealed a significant association of tumor necrosis with larger tumor size and a marginal association with vascular invasion. Kaplan-Meier survival curves demonstrated that tumor necrosis was associated with worse OS (log-rank P = 0.003) and PFS (log-rank P = 0.002). The independent unfavorable prognostic effect of tumor necrosis was further validated in univariate and multivariate Cox regression analysis (hazard ratio = 1.91 (1.52-2.40), P = 0.004). The current study confirmed the independent prognostic role of tumor necrosis from pathological review in early-stage colon cancer patients. This pathological criterion promises to help in identifying high-risk subgroup from early-stage colon cancer patients, who may benefit from strict follow-up and adjuvant therapy.

Perioperative Acute Renal Injury: Revisiting Pathophysiology.

Acute renal dysfunction and subsequent acute renal failure after cardiac surgery are associated with high mortality and morbidity. Early therapeutic or preventive intervention is hampered by the lack of an early biomarker for acute renal injury. Recent studies showed that urinary neutrophil gelatinase-associated lipocalin (NGAL or lipocalin 2) is upregulated early (within 1 to 3 h) after murine renal injury and in pediatric acute renal dysfunction after cardiac surgery. The authors hypothesized that postoperative urinary NGAL concentrations are increased in adult patients developing acute renal dysfunction after cardiac surgery compared with patients without acute renal dysfunction. After institutional review board approval, 81 cardiac surgical patients were prospectively studied. Urine samples were collected immediately before incision and at various time intervals after surgery for NGAL analysis by quantitative immunoblotting. Acute renal dysfunction was defined as peak postoperative serum creatinine increase by 50% or greater compared with preoperative serum creatinine. Sixteen of 81 patients (20%) developed postoperative acute renal dysfunction, and the mean urinary NGAL concentrations in patients who developed acute renal dysfunction were significantly higher early after surgery (after 1 h, mean ± SD, 4,195±6,520 vs. 1,068±2,129ng/ml; P < 0.01) compared with patients who did not develop acute renal dysfunction. Mean urinary NGAL concentrations continued to increase and remained significantly higher at 3 and 18 h after cardiac surgery in patients with acute renal dysfunction. In contrast, urinary NGAL in patients without acute renal dysfunction decreased rapidly after cardiac surgery. Patients developing postoperative acute renal dysfunction had significantly higher urinary NGAL concentrations early after cardiac surgery. Urinary NGAL may therefore be a useful early biomarker of acute renal dysfunction after cardiac surgery. These findings may facilitate the early detection of acute renal injury and potentially prevent progression to acute renal failure.

Outcomes of mechanical thrombectomy in anticoagulated patients with acute distal and medium vessel stroke.

Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood. This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications. Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p < 0.001) and had a higher prevalence of atrial fibrillation (77% vs 26%; p < 0.001). Their baseline National Institutes of Health Stroke Scale (NIHSS) scores were also higher (median 12 vs 9; p = 0.002). Before propensity score matching (PSM), anticoagulated patients had similar rates of favorable 90-day outcomes (mRS 0-1: 30% vs 37%, p = 0.1; mRS 0-2: 47% vs 50%, p = 0.41) but higher mortality (26% vs 17%, p = 0.008). After PSM, there were no significant differences in outcomes between the two groups. Anticoagulated patients undergoing MT for AIS due to DMVO did not show significant differences in 90-day mRS outcomes, reperfusion, or hemorrhage compared to non-anticoagulated patients after adjustment for covariates.

Persistent Severe Headache After Removal of Fungus Ball From the Sphenoid Sinus: A Case Report.

Granulomatous invasive fungal sinusitis (GIFS) is a rare and life-threatening disease, whereas fungus ball (FB) is the most common form of noninvasive fungal sinusitis. Both GIFS and FB primarily develop in immunocompetent patients, with the former associated with higher mortality and morbidity. A chart review and review of the literature. We present the case of a 77-year-old woman with mixed fungal sinusitis who was successfully treated with voriconazole. GIFS and FB can coexist in extremely rare cases, known as mixed fungal sinusitis; however, the diagnosis and subsequent treatment of mixed fungal sinusitis can be delayed because of a lack of awareness of the underlying concept. Therefore, it is crucial for clinicians to recognize the concept of mixed fungal sinusitis.

The advantages and intraoperative management of the laparoscopic approach in perforated appendicitis.

Gangrene/perforated appendicitis entails high rates of morbidity and mortality. The purpose of this study is to discuss the reliability, surgical management and post-operative complications of laparoscopic interventions in the treatment of perforated appendicitis. One hundred and ten patients (50 men and 60 women) diagnosed with perforated appendicitis based on history, physical examinations, laboratory and computed tomography findings between January 2016 and May 2022 were analysed retrospectively. Preoperative laboratory and radiological findings, surgical methods and post-operative complications were evaluated. Abdominal pain defence and rebound were present in all patients. In terms of radiological findings, intra-abdominal free fluid was present in all patients and abscess in 42. Post-operative abdominal surgical site infection developed in six patients. No intra-abdominal abscess or incisional hernia was observed during follow-ups. As a diagnostic tool, permitting better visualisation of the abdominal cavity, entailing fewer post-operative complications and obviating the need for large incisions, laparoscopy can represent the approach of choice in the treatment of perforated appendicitis.

Personalized Approaches to Cardiovascular Disease: Insights into FDA-Approved Interventions and Clinical Pharmacogenetics.

Cardiovascular diseases place a considerable burden on global health systems, contributing to high rates of morbidity and mortality. Current approaches to detecting and treating Cardiovascular Diseases (CVD) often focus on symptomatic management and are initiated after the disease has progressed. Personalized medicine, which tailors medical interventions to individual characteristics, has emerged as a promising strategy for improving cardiovascular health outcomes. This article provides an overview of personalized medicine in the context of CVD, with a specific emphasis on FDA-approved interventions. It explores the potential benefits, challenges, and future directions of personalized medicine in cardiovascular disorders. By reviewing the advancements in this field, this article underscores the importance of early detection, intervention, and innovative treatment options in reducing the impact of CVD on individuals and society.

Jejunal strongyloidiasis mimicking crohn's colitis: A diagnostic dilemma!

We report an unusual case of jejunal strongyloidiasis presenting as chronic malabsorption and intractable small bowel diarrhea in an immunocompetent adolescent boy who posed a diagnostic challenge for pathologists, radiologists, and gastroenterologists. Histopathology revealed chronic active colitis and was consistent with the clinicoradiological diagnosis of Crohn's colitis but nonresponse to immunomodulators warranted full-thickness jejunal biopsy through laparotomy which showed numerous larvae and eggs of Strongyloides. There is a need to increase the awareness of Strongyloides colitis given its high rate of misdiagnosis and mortality as the correct diagnosis can avoid a fatal outcome of this curable disease.

Exploration of quantitative-effectiveness association between acupuncture temporal parameters and stable chronic obstructive pulmonary disease: A systematic review and dose-response meta-analysis of randomized controlled trials

IntroductionChronic Obstructive Pulmonary Disease (COPD) is a globally common chronic respiratory disease with a high morbidity and mortality rate. Acupuncture has been proven effective for COPD. A dose-response meta-analysis was conducted to assess the correlation between the acupuncture temporal parameters(session, frequency, and duration) and its effectiveness in patients with stable COPD. MethodsAcupuncture randomized controlled trials on COPD were searched in eight databases from their inception to June 2023. The "doses" were defined as the acupuncture session, frequency, and duration. The outcomes mainly included Forced Expiratory Volume in one-second rate (FEV1%) and Six-minute Walking Distance (6MWD). The assessment of bias risk and literature quality were conducted independently using the Cochrane risk of bias tool and the Standards for reporting interventions in clinical trials of acupuncture. The dose-response relationship was modeled using robust error element regression, and meta-analysis was operated by R 4.3.1 and Stata 15.0. The protocol was registered in PROSPERO with the registration number CRD42023401406. ResultOut of 1669 records, 17 RCTs with 1165 participants were finally included in the meta-analysis. There was notable heterogeneity among the studies, but sensitivity analysis demonstrated good robustness. The findings revealed a significant improvement in the following outcomes for stable COPD patients in the acupuncture group: FEV1% (MD=3.50, 95%CI: 2.05–4.95), 6MWD (MD=47.39, 95%CI: 29.29–65.50), St. George's respiratory questionnaire (SGRQ; MD=−8.25, 95%CI: −11.38 to −5.12); COPD assessment test (CAT; MD=−2.91, 95%CI: −3.99 to −1.83). The relationship between the acupuncture session, duration, and FEV1%, 6MWD followed a "Λ" curve pattern, while the relationship between acupuncture frequency and FEV1%, 6MWD exhibited logarithmic growth. Firstly, After 12 acupuncture sessions, FEV1% and 6MWD increased by 7.06% (95%CI: 4.56–9.55) and 36.28 m (95%CI: 20.37–52.20), respectively. The peak improvement in FEV1% and 6MWD was observed after 18 acupuncture sessions (MD=7.89, 95% CI: 5.33–10.45) and 45 sessions (MD=125.43, 95% CI: 72.80–178.07) each. Additionally, weekly acupuncture resulted in a 4.14% improvement in FEV1% (95% CI: 2.55–5.72) and a 42.49 m increase in 6MWD (95%CI: 17.16–67.81). Notably, the maximum effects on FEV1% and 6MWD improvement were achieved with different acupuncture frequencies, specifically three times a week (MD=6.00, 95% CI: 5.34–6.66) and once a day(MD=112.41, 95% CI: 77.27–147.56), respectively. Furthermore, after a 28-day duration of acupuncture treatment, FEV1% increased by 4.74% (95% CI: 3.73–5.75) and 6MWD increased by 47.34 m (95%CI: 22.01–72.67). During 60 days of acupuncture treatment, the FEV1% and 6MWD improvement reached their highest levels at 8.76% (95% CI: 7.05–10.47) and 88.06 m (95% CI: 45.96–130.16), respectively. ConclusionAcupuncture was effective in improving FEV1%, 6MWD, SGRQ, and CAT in patients with stable COPD. There was a dose-response relationship between the time parameters of acupuncture (session, frequency, and duration) and the efficacy of COPD treatment (FEV1% and 6MWD). The minimal clinically important difference could be achieved after 12 acupuncture sessions. Acupuncture with a medium-frequency (2–3 times per week) over 60 days may result in the greatest improvement in FEV1%, while higher-frequency acupuncture (5–7 times per week) for 2 months may lead to the maximum improvements in 6MWD. It indicated that the optimal acupuncture duration for different indicators remains consistent, while the optimal frequencies may differ. To confirm these results, it is necessary to conduct multicenter, large-scale randomized controlled trials. Ethics and disseminationEthical approval is not required for literature-based studies. The results will be published in peer-reviewed journals or conferences.

Management and Consideration of Anesthesia Procedures in Eclampsia: A Case Report

Introduction: Eclampsia is a serious pregnancy complication with high maternal and fetal mortality rates. The choice of anesthetic technique in eclamptic patients must consider various factors, including the condition of the mother and fetus, the risk of complications, and the experience of the anesthesia team. Case presentation: We report the case of a 21-year-old 39-week-old primigravida (G1P0A0) with severe eclampsia who experienced two tonic-clonic seizures. The patient was intubated in the emergency room and underwent an emergency caesarean section under general anesthesia. The patient was treated in the ICU for one day and extubated on the second day. Conclusion: The choice of anesthetic technique in eclamptic patients must be done individually by considering various factors. The anesthesia team must be experienced in treating eclamptic patients and have the readiness to deal with complications that may occur.

Mechanism of efferocytosis in atherosclerosis.

Atherosclerosis (AS) is a chronic inflammatory vascular disease that occurs in the intima of large and medium-sized arteries with the immune system's involvement. It is a common pathological basis for high morbidity and mortality of cardiovascular diseases. Abnormal proliferation of apoptotic cells and necrotic cells leads to AS plaque expansion, necrotic core formation, and rupture. In the early stage of AS, macrophages exert an efferocytosis effect to engulf and degrade apoptotic, dead, damaged, or senescent cells by efferocytosis, thus enabling the regulation of the organism. In the early stage of AS, macrophages rely on this effect to slow down the process of AS. However, in the advanced stage of AS, the efferocytosis of macrophages within the plaque is impaired, which leads to the inability of macrophages to promptly remove the apoptotic cells (ACs) from the organism promptly, causing exacerbation of AS. Moreover, upregulation of CD47 expression in AS plaques also protects ACs from phagocytosis by macrophages, resulting in a large amount ofresidual ACs in the plaque, further expanding the necrotic core. In this review, we discussed the molecular mechanisms involved in the process of efferocytosis and how efferocytosis is impaired and regulated during AS, hoping to provide new insights fortreatingAS.

Supraglottitis: An airway emergency

Supraglottitis is a life-threatening condition and refers to inflammation of the epiglottis and the surrounding supraglottic structures. Children usually present with only a swollen epiglottis, termed epiglottitis. Fortunately, the incidence of epiglottitis in children has declined following routine Haemophilus influenzae type B vaccination, but the incidence in adults has increased. Supraglottitis has a high morbidity and mortality from the associated risk of airway obstruction. Therefore, early recognition and urgent secondary care referral is paramount. However, the presentation of this condition can be subtle and differs between children and adults; this can lead to difficulties in diagnosis. This article will review the clinical presentation and management of supraglottitis, an important differential for acute sore throat and hoarse voice.

Epidemiological observations and management challenges in extrapedal mycetoma: A three-decade review of 420 cases.

Mycetoma is a serious, destructive, disfiguring chronic granulomatous inflammatory disease affecting the subcutaneous tissues that spread to involve the skin, deep tissues and bone. The disease predominately affects the limbs, and extrapedal mycetoma is rarely reported. The reported extrapedal ones are characterised by high morbidity and mortality. This communication reports on 420 patients with extrapedal mycetoma seen and managed at the Mycetoma Research Centre (MRC), University of Khartoum, between January 1991 and December 2021. In this descriptive, cross-sectional, hospital-based study, the electronic records of all mycetoma-confirmed patients seen during the study period were carefully and meticulously reviewed. The confirmed patients with extrapedal mycetoma were included in this study. The study included 420 patients with extrapedal mycetoma, 298 (70.7%) had eumycetoma, and 122 (29.3%) had actinomycetoma. There were 343 male patients (81.7%) and 77 (18.3%) females, with a male-to-female ratio of 4:1. Their ages ranged between 1.5 and 95 years, with a median of 28 years. Most of the patients were students and farmers. The majority of patients were from El Gezira, North Kordofan, and the White Nile States. Mycetoma was painful in 21%, and a family history of mycetoma was recorded in 11.5% of patients. The buttocks (37.9%) and head and neck (16.9%) were affected most. Less frequently affected sites were the trunk and back (12%) each, abdominal and chest walls (4.5%) each and loin (1%). The prominent clinical presentation findings were multiple sinuses discharging grains (55%), massive swellings (46%), and lymphadenopathy (11.5%). Less commonly observed clinical findings were local hyperhidrosis (5.3%) and dilated tortuous veins close to mycetoma lesions (0.5%). The study showed that 204 patients (48.6%) had clinical improvement in terms of decreased lesion size and healing of sinuses following medical therapy. Sixty-six patients (15.7%) had no noticeable improvement. The lesion continued progressing despite treatment in 44 patients (10.5%). In the study, 118 patients were on regular follow-up, and in this group, a cure was documented in 25 patients (21.1%) with eumycetoma and 23 (19.4%) with actinomycetoma. Post-operative recurrence among eumycetoma patients was 40%, with a 1% mortality rate. The treatment outcome was unsatisfactory, characterised by a low cure rate, high recurrence (40%) and follow-up dropout (57%) rates. This emphasises the importance of early case detection and management, objective health education programmes and thorough patient counselling to urge people to seek treatment early and reduce dropouts.

Incidence of Various Types of Bleeding Disorders Associated with Canine Vector Borne Diseases in Chennai, Tamil Nadu, India

Background: Animals with various stages of bleeding tendencies are often presented with obvious blood loss and life threatening complications, although some animals are relatively stable, showing only minimal clinical signs. Canine vector-borne diseases and associated bleeding disorders are commonly encountered in routine practice with high morbidity and mortality. Diagnosis, therapeutic outcome and management of bleeding disorders have always been challenging. The objective is to study the incidence of various types of bleeding disorders with their clinical features in CVBD in the city of Chennai, Tamil Nadu. Methods: During the study period (2018-2020) a total of 76, 051 dogs were presented to the Madras Veterinary College Teaching Hospital, Chennai. Sixteen thousand five hundred and twenty nine (16529) dogs were presented with signs of bleeding disorders. Dogs affected with vector borne diseases had various stages of bleeding tendencies (1593 dogs) were subjected to detailed clinical, haematological, biochemical and coagulation profile assessments. Under each etiological group, the dogs were further divided into three groups based on various stages bleeding disorders in order to evaluate the clinicopathological changes in dogs. Result: The observed incidence of bleeding disorders due to canine vector borne diseases in this study were Babesiosis 41.87 per cent, Ehrlichiosis 52.7 per cent and hepatozoonosis 5.5 per cent. The incidence of Ehrlichiosis, Babesiosis and H. canis in the study population was found to be 5.2 per cent, 4.04 per cent and 0.53 per cent. Dogs due to E. canis, 51 per cent had anaemia and thrombocytopenia, 26.1 per cent had pancytopenia and 22.9 per cent had pancytopenia and DIC. Dogs due to B. gibsoni, 47.7 per cent had anaemia and thrombocytopenia, 28.5 per cent had pancytopenia and 23.8 per cent had pancytopenia and DIC.

Age-Related Quality of Life in Cardiac Surgical Patients with Extracorporeal Life Support.

The rationale of the study was to analyze the impact of age on quality of life (QoL) in patients who had undergone cardiac surgery with consecutive extracorporeal life support (ECLS) treatment. The study population consisted of 200 patients, operated upon between August 2006 and December 2018. The patient cohort was divided into two groups following an arbitrary cutoff age of 70 years. Comparative outcome analysis was calculated utilizing the European Quality of Life-5-Dimensions-5-Level Version (EQ-5D-5L). A total of 113 patients were 70 years or less old (group young), whereas 87 patients were older than 70 years (group old). In 45.7% of cases, the ECLS system was established during cardiogenic shock and external cardiac massage. The overall survival-to-discharge was 31.5% (n = 63), with a significantly better survival in the younger patient group (young = 38.9%; old = 21.8%, p = 0.01). Forty-two patients (66%) responded to the QoL survey after a median follow-up of 4.3 years. Older patients reported more problems with mobility (y = 52%; o = 88%, p = 0.02) and self-care (y = 24%; o = 76%, p = 0.01). However, the patients' self-rated health status utilizing the Visual Analogue Scale revealed no differences (y = 70% [50-80%]; o = 70% [60-80%], p = 0.38). Likewise, the comparison with an age-adjusted German reference population revealed similar QoL indices. There were no statistically significant differences in the EQ-5D-5L index values related to sex, number of comorbidities, and emergency procedures. Despite the limited sample size due to the high mortality rate especially in elderly, the present study suggests that QoL of elderly patients surviving ECLS treatment is almost comparable to younger patients.

Urinary liver-type fatty acid-binding protein level as a prognostic indicator of acute kidney injury secondary to severe falciparum malaria.

Acute kidney injury (AKI) secondary to severe falciparum malaria possesses a high mortality rate; however, a prognostic marker of renal dysfunction has not yet been identified. Thus, we reported a case of a patient with AKI secondary to falciparum malaria who underwent hemodialysis and a renal biopsy due to prolonged renal dysfunction. The male patient, in his 50s, presented to our hospital with vomiting, diarrhea, fever, and decreased level of consciousness. The Giemsa-stained peripheral blood film revealed approximately 5% parasitemia, and a rapid diagnostic test was positive for Plasmodium falciparum. He was diagnosed with severe falciparum malaria and was started on quinine hydrochloride. Hemodialysis was initiated due to the decreased urine output and fluid retention. Subsequently, he was weaned off hemodialysis. The histopathological analysis of a renal biopsy revealed interstitial fibrosis, tubular atrophy, and chronic inflammatory cell infiltration; thus, malarial nephropathy was diagnosed. Thereafter, his renal function stabilized, and he was discharged from the hospital. The urinary liver-type fatty acid-binding protein (L-FABP) level decreased before renal function improved. Our report highlighted that long-term follow-up is essential for severe AKI secondary to malaria. The urinary L-FABP level may be a useful prognostic indicator of AKI secondary to severe falciparum malaria.

Higher mortality among off-hours versus regular-hours admissions to the cardiac intensive care unit (CICU): insights from the critical care cardiology trials network registry (CCCTN)

Abstract Funding Acknowledgements None. Background The outcomes of patients admitted to general intensive care units vary significantly according to the time of admission. Whether this applies to the CICU setting is unknown. Purpose We sought to determine if patient characteristics, admission source, critical care therapy utilization, and clinical outcomes differ according to whether CICU admission occurred during regular-hours or off-hours. Methods CCCTN is a multicenter prospective registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. For this analysis of admissions during calendar year 2022, "regular-hours" was defined as 7 a.m.- 7 p.m. Monday-Friday, and "off-hours" was defined as 7 p.m.- 7 a.m. on weekdays or at any time on Saturday or Sunday. Logistic regression analysis was used to adjust in-hospital mortality rates for admission time (on-hours vs. off-hours), age, sex, SOFA score, and cardiac arrest. Results Among 5238 CICU admissions, 2956 (56.4%) occurred during off-hours. Patient demographics (mean age: 67.0 years, 35.7% female, 51.1% white) and comorbidities were generally similar among off-hours and regular-hours admissions. The median SOFA score was 3.0 in both groups. Compared to regular-hours admissions, off-hours admissions were more likely to originate from the ED (39.9% vs. 29.4%, p&amp;lt;0.0001) and less likely to originate from a procedural area (24.5% vs. 41.8%, p&amp;lt;0.0001). ST-elevation MI was a more common admission diagnosis among off-hours vs. regular-hours admissions (19.2% vs. 16.4%, p=0.009). Primary CICU indications of respiratory insufficiency, unstable arrhythmia, cardiac arrest, and distributive/mixed shock were more common among off-hours admissions (Table). Mechanical ventilation, IV vasoactive therapy, and targeted temperature management (TTM) were utilized more frequently among patients admitted during off-hours. Median ICU (2.5 vs. 2.0d) and hospital length of stay (6.2 vs. 5.8d) were longer for off-hours admissions (both p&amp;lt;0.0001). Crude CICU mortality (11.4% vs. 8.5%, p=0.0005) and in-hospital mortality (15.6% vs. 11.7%, p&amp;lt;0.0001) were significantly higher among off-hours admissions (Figure). After adjustment, off-hours admission remained significantly associated with higher in-hospital mortality (OR 1.2, 95% CI 1.02 – 1.49, p=0.03). Conclusions Off-hours and regular-hours admissions to the CICU had similar baseline characteristics but differed significantly regarding source of admission, indication for admission, and utilization of critical care therapies. These differences were associated with worse clinical outcomes among off-hours admissions, which may suggest the need for more intensive staffing in CICUs during these times.FigureTable

Impact of misdiagnosis on the treatment and prognosis of acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Acute aortic syndrome (AAS) embraces a spectrum of pathologies with relatively low prevalence but associated with high mortality. The clinical presentation of AAS is highly variable and the differential diagnosis with other much more common diseases such as myocardial infarction (AMI) or pulmonary embolism (PE) is often difficult to achieve. AAS detection requires a high index of suspicion and the delay in diagnosis is associated with increased morbidity and mortality. Purpose The aim of this study is to characterize the diagnostic approach to AAS patients in the emergency department (ED) and to study the impact of the initial diagnostic suspicion on the treatment and prognosis of patients with AAS. Methods The "Aorta Code" is an inter-hospital and interdisciplinary care protocol for the management of patients with AAS in a 4-Hospital network. Patients with AAS were prospectively and consecutively collected from 2019 to 2022. The sample was classified into two groups according to whether the initial suspicion was AAA or another clinical entity. The diagnosis of AAS was established by computed tomography in all patients. Time, clinical, treatment and prognostic variables were analyzed. Results A total of 113 patients with AAS were included. Of them, only 38% (34) were initially suspected of having an AAS (Figure). AMI and PE were the initial diagnosis in 34% of patients (Figure). There were no significant differences in age, history of hypertension or other cardiovascular risk factors between the groups (table). Anterior chest pain was more frequent in the "AAS-suspicion" group. The diagnostic time delay was longer in patients with initial misdiagnosis (table). Patients with type A AAS with initial misdiagnosis underwent surgery in a lower proportion (table). Although the differences were not significant, patients with initial misdiagnosis had more postoperative complications and higher mortality. Conclusion It is essential to maintain a high index of diagnostic suspicion for AAS in the ED. Initial misdiagnosis is associated with a delayed diagnosis, delayed surgical treatment and a lower rate of surgery. In addition, although it is a small sample size, this group of patients had more postoperative complications and higher mortality.