Higher Risk Of Adverse Events Research Articles

Potential of 6-mm-diameter fully covered self-expandable metal stents for unresectable malignant distal biliary obstruction: a propensity score-matched study

Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS.Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed.Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027).Conclusions: For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

Diabetes and Untoward Outcomes after ACL Reconstruction

Background Diabetes affects approximately 536.6 million adults worldwide and 32.2 million in the United States. Prior studies across multiple specialties have reported the presence of diabetes is associated with adverse outcomes following surgical operations. While several studies have identified diabetes as a risk factor for adverse outcomes following ACL reconstruction (ACLR), literature evaluating the relationship between diabetes status and outcomes after ACLR is lacking. Purpose We aimed to study surgical outcomes following primary ACLR among patients with diabetes compared to those without diabetes. Study Design Retrospective Cohort Study Methods We conducted a cohort study using data from an integrated healthcare system’s ACLR registry. Patients aged ≥12 receiving a primary unilateral ACLR were included (2005–2020). Preoperative diabetes status was the exposure of interest. The two primary outcomes were revision surgery and ipsilateral reoperation following primary ACLR, modeled using multivariable Cox proportional hazards regression that followed patients until an adverse event or loss to follow up. We also examined hospital readmission within 90 days post-surgery, modeled using logistic regression. All models compared patients with diabetes to those without diabetes, adjusting for age, gender, race, smoking status, body mass index, American Society of Anesthesiologist’s score, comorbid conditions, education level, income level, exercise, and graft type. Results There were 18,797 primary ACLR in the study sample with 383 (2.0%) occurring in patients with diabetes. The diabetes group exercised about 90 minutes less per week than the non-diabetes group. In unadjusted bivariate descriptive analyses, patients with diabetes had a lower rate of revision surgery (1.6% vs. 3.6%, p = 0.037) but a higher rate of ipsilateral reoperation (10.7% vs. 8.0%, p = 0.051). The 90-day readmission rate was higher among patients with diabetes compared to those without diabetes (1.8% vs. 0.7%, p = 0.016). However, after adjusting for covariates, these associations were no longer statistically significant. Conclusion After controlling for patient characteristics and other risk factors, the presence of diabetes was not associated with a higher risk of adverse events following primary ACLR.

Electrocardiogram-based machine learning for risk stratification of patients with suspected acute coronary syndrome.

The importance of risk stratification in patients with chest pain extends beyond diagnosis and immediate treatment. This study sought to evaluate the prognostic value of electrocardiogram feature-based machine learning models to risk-stratify all-cause mortality in those with chest pain. This was a prospective observational cohort study of consecutive, non-traumatic patients with chest pain. All-cause death was ascertained from multiple sources, including the CDC National Death Index registry. Six machine learning models were trained for survival analysis using 73 morphological electrocardiogram features (80% training with 10-fold cross-validation and 20% testing), followed by a variational Bayesian Gaussian mixture model to define distinct risk groups. The resulting classification performance was compared against the HEART score. The derivation cohort included 4015 patients (age 59 ± 16 years, 47% women). The mortality rate was 20.3% after a median follow-up period of 3.05 years (interquartile range 1.75-5.32). Extra Survival Trees outperformed other forecasting models, and the derived risk groups successfully classified patients into low-, moderate-, and high-risk groups (log-rank test statistic = 121.14, P < .001). This model outperformed the HEART score, reducing the rate of missed events by >90% with a negative predictive value and sensitivity of 93.4% and 85.9%, compared to 89.0% and 75.0%, respectively. In an independent external testing cohort (N = 3095, age 59 ± 15 years, 44% women, 30-day mortality 3.5%), patients in the moderate [odds ratio 3.62 (1.35-9.74)] and high [odds ratio 6.12 (2.38-15.75)] risk groups had significantly higher odds of mortality compared to those in the low-risk group. The externally validated machine learning-based model, exclusively utilizing features from the 12-lead electrocardiogram, outperformed the HEART score in stratifying the mortality risk of patients with acute chest pain. This may have the potential to impact the precision of care delivery and the allocation of resources to those at highest risk of adverse events.

Unsupervised clustering of intraventricular hemodynamic forces for the phenotyping of left-ventricular function in non-ischemic left ventricular cardiomyopathy.

Cardiac magnetic resonance (CMR) is essential for diagnosing cardiomyopathy, serving as the gold standard for assessing heart chamber volumes and tissue characterization. Hemodynamic forces (HDF) analysis, a novel approach using standard cine CMR images, estimates energy exchange between the left ventricular (LV) wall and blood. While prior research has focused on peak or mean longitudinal HDF values, this study aims to investigate whether unsupervised clustering of HDF curves can identify clinically significant patterns and stratify cardiovascular risk in non-ischemic LV cardiomyopathy (NILVC). A retrospective cohort of 279 patients with NILVC who underwent cardiac CMR at Vall d'Hebron University Hospital (Barcelona) was examined. Unsupervised clustering of longitudinal and transversal HDF curves was performed using Dynamic Time Warping for dissimilarity measurement and the Partitioning Around Medoids algorithm. Outcomes were defined as a composite of cardiovascular mortality, heart failure hospitalization, and ventricular arrhythmias. Median age was 65[57.0;74.0] years, with 27.2% females and 35.5% showing late gadolinium enhancement (LGE). Unsupervised clustering identified three distinct clusters, delineating risk groups with worsening LA and LV function, indicating a stepwise increase in cardiovascular risk profile. Over a median follow-up of 40 months, 60 patients experienced the composite outcome. After adjusting for LGE, LVEF and LV size, clusters 2 and 3 demonstrated a significantly higher risk of adverse events (both p<0.05) compared to cluster 1. Analyzing both longitudinal and transversal HDF throughout the cardiac cycle enables the identification of distinct phenotypes with prognostic value beyond ejection fraction and LGE in NILVC patients.

Blood pressure targets, medication considerations and special concerns in elderly hypertension III: Focus on stroke and neurodegenerative disorders.

Controlling hypertension has become an important issue in the elderly population in whom neurological comorbidities are highly prevalent. Most of the large-scale trials focusing on hypertension management in older populations have excluded patients with comorbid neurological disorders. However, this population requires special considerations, as the benefits of antihypertensive agents are mostly uncertain and there is a higher risk of adverse events. In this review article, we discuss current evidence regarding the management of elderly patients with hypertension and common neurological disorders, including stroke and neurodegenerative diseases. In elderly patient with a history of stroke, the blood pressure management strategy is generally similar to that for young patients, however the benefits of stroke prevention from blood pressure control are less significant. For patients with neurodegenerative disorders such as cognitive dysfunction and Parkinson's disease, achieving adequate blood pressure control may be beneficial in reducing cardiovascular risks, although the higher risk of adverse events from antihypertensive treatment may offset some of these benefits. Special considerations for factors such as orthostatic hypotension, risk of falls, polypharmacy, and significant drug-drug interactions are required but frequently neglected in clinical practice. More efforts are warranted to determine the optimal treatment strategy for elderly populations with neurological disorders.

Post-implant transcatheter aortic prosthesis deformation: tricuspid versus bicuspid valve.

We sought to assess whether post-implant transcatheter aortic valve prosthesis multi detector computed characteristics differ between patients with native tricuspid and bicuspid aortic valve stenosis, as well as the effect on valve performance and clinical implications. We analysed 100 consecutive post-implant multi detector computed tomography scans to assess self-expandable prosthesis non-uniform expansion at six pre-specified valvular levels, and other specific parameters, including valvular and perivalvular thrombosis at six months follow-up. Echocardiographic prosthesis performance and clinical outcome was also evaluated. Mean eccentricity was significantly higher in the bicuspid group (0.43 (0.09) vs 0.37 (0.08), p = 0.005, bicuspid vs tricuspid); valvular and perivalvular thrombosis were also significantly more frequent in the bicuspid than in the tricuspid group (81% vs. 36.9%, p = 0.031); there was no significant difference in terms of mean prosthetic gradient at follow-up between (7.31 (5.53 mmHg) vs 7.09 (3.05 mmHg), p = 0.825); EOAi was also similar between bicuspid and tricuspid (1.08 (0.12 cm2) vs 1.03 (0.13 cm2), p = 0.101), with no significant changes compared to discharge. However, the bicuspid valve was associated with a significantly higher risk of adverse events (HR:3.72, 95%CI: 1.07-13.4, p = 0.027). Higher level of eccentricity, which indicates prosthesis deformation, is often detected in bicuspid valves. Although echocardiographic performance was not affected, this might have led to an increased incidence of thrombosis at valvular and perivalvular levels and worse outcomes.

Nanotechnological approaches to improve corticosteroids ocular therapy.

The administration of corticosteroids is the first-line treatment of the clinical conditions with ocular inflammation. Nonetheless, ocular physiological mechanisms, anatomical barriers and corticosteroid properties prevent it from reaching the target site. Thus, frequent topical administered doses or ocular injections are required, leading to a higher risk of adverse events and poor patient compliance. Designing novel drug delivery systems based on nanotechnological tools is a useful approach to overcome disadvantages associated with the ocular delivery of corticosteroids. Nanoparticle-based drug delivery systems represent an alternative to the current dosage forms for the ocular administration of corticosteroids, since due to their particle size and the properties of their materials, they can increase their solubility, improve ocular permeability, control their release and increase bioavailability after their ocular administration. In this way, lipid and polymer-based nanoparticles have been the main strategies developed, giving rise to novel patent applications to protect these innovative drug delivery systems as a product, its preparation or administration method. Additionally, it should be noted that at least 10 clinical trials are being carried out to evaluate the ocular application of different pharmaceutical formulations based on corticosteroid-loaded nanoparticles. Through a comprehensive and extensive analysis, this review highlights the impact of nanotechnology applications in ocular inflammation therapy with corticosteroids.

Laser and light-based treatments for port-wine birthmarks - a systematic review and network meta-analysis.

Port-wine birthmarks (PWB) are common vascular malformations in infants. Despite various laser and light-based treatments, comparative data on their effectiveness is limited. This study compares different treatments for PWB using a systematic review and network meta-analysis (NMA). We searched for randomized controlled trials (RCTs) and ongoing studies up to November 2023: Primary outcomes were patient satisfaction, investigator-assessed reduction in redness, and long-term adverse events (AEs). Risk of bias was assessed using the Cochrane Risk of Bias2 Tool. We identified 27 RCTs for qualitative analysis and twelve RCTs for the NMA, covering 1033observations, 19 treatments, and three sub-networks. Seven studies reported on patient satisfaction. Hemoporfin-mediated photodynamic therapy was more effective in lesion clearance than PDL but had the highest risk of AEs. The 755nm alexandrite laser and the combination of 595nm PDL + 1064nm Nd:YAG also showed high AE risks. Treatment discontinuation rates due to AEs did not significantly differ. Most studies had unclear bias risks, mostly owing to insufficient reporting. This study is the first NMA comparing laser- and light-based therapies for PWB. Further well-designed studies are warranted to determine optimal methods and patient-influencing factors for individualized treatments.

Rectus femoris cross sectional area and timed up and go test potential useful of as a predictor of sarcopenia and mortality in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease often complicated by sarcopenia, significantly impacting patient outcomes. This study investigates the prevalence and clinical implications of sarcopenia in IPF patients using morphofunctional assessment methods. Eighty-four IPF patients (predominantly male) were evaluated for sarcopenia using the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria. Assessments included bioelectrical impedance vectorial analysis (Nutrilab, Akern), handgrip strength (HGS), Timed Up and Go test (TUG), and nutritional ultrasound (NU) measurements of rectus femoris and abdominal adipose tissue. Statistical analysis was performed (version 2.3.28 for macOS) to obtain sarcopenia cut-off points for the different techniques, and then the predictive capacity of these values for survival was analyzed using a Kaplan-Meier curve. Sarcopenia was prevalent in 20.2% of the cohort. Sarcopenic patients exhibited significantly lower forced vital capacity (FVC) (2,142 mL vs. 2745.6 mL, p < 0.05), higher GAP stages (p < 0.05), and worse quality of life (SGRQ impact scores: 45.2 vs. 27.5, p < 0.05). The identified cutoff values were 2.94 cm2 for RFCSA, 9.19 s for TUG, and 1.08 cm for the RF-Y-axis and body cell mass (BCM) cutoff of 25.4 kg. Kaplan-Meier analysis indicated a higher hazard ratio (HR) for mortality in sarcopenic patients. Specifically, RFCSA sarcopenia patients had a 2.37 times higher risk of events (HR = 2.37, 95% CI: 1.02-5.48, p = 0.045), and TUG sarcopenia presented a 4.89 times higher risk of adverse events (HR = 4.89, 95% CI: 1.43-16.70, p = 0.011). Sarcopenia is prevalent in IPF patients and is associated with greater disease severity and reduced quality of life. RFCSA, BCM, and TUG are good predictors of sarcopenia and 12-month mortality, improving the prognostic value of classical diagnostics based on EWGSOP2 criteria. Despite limitations such as a predominantly male sample and cross-sectional design, the findings emphasize the importance of early detection and targeted interventions. Future research should focus on longitudinal studies to better understand sarcopenia progression in IPF and evaluate the efficacy of various therapeutic approaches.

Adverse events in clinically complex elderly patients with atrial fibrillation according to oral anticoagulation status

Few data are available about the impact of oral anticoagulants (OAC) in patients with Atrial Fibrillation (AF) and clinical complexity (CC). We conducted a retrospective study utilising data from the TriNetX network. Based on ICD-10-CM codes entered between 2020 and 2022, AF patients aged ≥75 years on long-term OAC with CC were categorised into two groups based on OAC use in the year before entering the study (maintained vs discontinued). CC was defined as BMI ≤23kg/m2, and/or history of bleeding, and/or chronic kidney disease. The primary outcomes were the one-year risk of all-cause death, major cardiovascular events (MACE), and major bleeding. Cox regression analyses were used to calculate hazard ratios (HRs) and 95% CIs before and after 1:1 propensity score matching (PSM). We identified 6554 AF CC patients who discontinued OAC (mean age 81.5±6.0 years, 46.7% females) and 23,212 AF patients with CC who maintained OAC (81.3±6.0 years, 49.4% females). Before PSM, AF CC patients who discontinued OAC had a higher prevalence of intracranial, gastrointestinal haemorrhages, and antiplatelet use, with no significant differences after PSM. OAC discontinuation was associated with a higher risk of all-cause death (HR 1.22, 95% CI 1.11-1.35) and MACE (HR 1.38, 95% CI 1.25-1.53). The one-year risk of major bleeding was similar in those who discontinued or maintained OAC (HR 1.05, 95% CI 0.94-1.18), although it was significantly higher during the early follow-up (HR 1.51, 95% CI 1.24-1.83). The risk of primary outcomes decreased over time, with the risk of bleeding becoming not significant. AF CC patients who discontinued OAC have a high risk of adverse events. New antithrombotic and integrated care approaches to reduce thrombotic risk without increasing bleeding risk are needed in these patients. This study received no funding.

Endoscopic submucosal dissection vs. endoscopic mucosal resection in the treatment of early Barrett's neoplasia: Systematic review and meta-analysis.

Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia. An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence. A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04). Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.

Endoscopic Management of Benign Pancreatic Stricture Associated with Chronic Pancreatitis

The most common symptom of chronic pancreatitis is abdominal pain. Potential causes include ductal hypertension due to pancreatic stricture, bile duct stricture, duodenal stricture, the presence of a pseudocyst, and increased nociception. In the management of main pancreatic ductal strictures associated with chronic pancreatitis, an endoscopic pancreatic sphincterotomy is typically performed, followed by stricture dilation and the insertion of a single plastic stent. If pancreatic stones are present, extracorporeal shockwave lithotripsy may also be necessary. After placing a plastic stent in the pancreatic duct, regular stent exchanges should be performed, maintaining stenting for approximately 1 year. For refractory pancreatic ductal stricture, the placement of multiple plastic stents or a fully covered metal stent may be considered. Although metal stents are effective, they are associated with a higher risk of adverse events, including stent migration, bile duct obstruction, and the formation of de novo pancreatic ductal strictures. This review discusses the endoscopic management of benign pancreatic ductal stricture associated with chronic pancreatitis.

Impact of stress coping style on self-care behaviors and prognosis in patients with heart failure: A prospective longitudinal observational study

BackgroundHeart failure (HF) requires effective management and self-care education to improve outcomes. However, daily self-care routines necessary for managing HF can lead to psychological issues, including stress, potentially exacerbating the condition. Patient stress-coping behaviors may significantly impact prognosis. ObjectiveWe aimed to identify stress coping styles in patients with HF and examine their impact on self-care behavior and prognosis. s. MethodsThis study utilized a longitudinal prospective observational design. Patients were categorized into task-oriented (task), emotion-oriented (emotion), and avoidance (avoidance) coping groups using the Coping Inventory for Stress Situations. Stress levels and self-care behaviors were evaluated during hospitalization and 1 and 3 months after discharge. The primary outcome was a composite of HF readmission and all-cause mortality during the 180-day post-discharge period. Longitudinal changes in self-care behaviors were assessed according to stress intensity. ResultsWe included 151 patients (age, 74 [60–80] years; female, 37.1 %) hospitalized for HF exacerbation between August 2021 and August 2023. The task group comprised 45 patients (29.8 %); emotion group, 47 (31.1 %); and avoidance group, 59 (39.1 %). The avoidance group had a higher risk of adverse events during follow-up (task, emotion, and avoidance: 8.9 % vs. 14.9 % vs. 32.2 %, p = 0.004). The avoidance-coping style was the only independent predictor of the primary outcome (hazard ratio: 3.84, 95 % confidence interval: 1.40–10.53, p = 0.009). Self-care behaviors were notably poorer in the avoidance group, particularly under conditions of high stress. ConclusionsStress-coping strategies impact both prognosis and self-care outcomes in patients with HF, and education programs should consider incorporating these strategies.

Lower accuracy of estimated delivery date using last menstrual period recall and related factors of adverse events during childbirth: A sub-analysis of a birth cohort study in Makassar, Indonesia.

Early pregnancy ultrasound provides a more accurate estimate of the estimated delivery date (EDD) than the last menstrual period (LMP). However, LMP-based EDD calculation remains common in resource-limited settings. Inaccurate EDDs can contribute to adverse birth outcomes. However, research examining the accuracy of LMP-based EDDs and their association with delivery-related adverse events is limited. This study aimed to evaluate the accuracy of self-reported LMP in predicting EDD and its association with adverse events during delivery. Data were analyzed from 171 pregnant women participating in the Indonesian Birth Cohort Study based in Makassar, Indonesia. This study utilized a prospective cohort design, employing descriptive statistics and Poisson regression analysis in Stata. Adverse events were defined as any unexpected negative occurrence during delivery, including issues related to healthcare access, birth attendance, and the medical condition of the mother and newborn. Mode of delivery and categorized differences between actual delivery date and estimated delivery date (ADD-EDD) were significantly associated with adverse events during delivery. Cesarean delivery was associated with a higher risk of adverse events compared to vaginal birth (Adjusted Risk Ratio [ARR] 1.11, 95% CI: 1.02-1.22, p <0.001). Additionally, ADD-EDD differences of ≤-15 days (ARR 1.49, 95% CI: 1.35-1.65), -14 to -8 days (ARR 1.33, 95% CI: 1.19-1.49), and ≥15 days (ARR 1.37, 95% CI: 1.20-1.58) showed an increased risk (all p <0.001). An ADD-EDD difference of 8 to 14 days was marginally significant (ARR 1.20, 95% CI: 1.00-1.44, p = 0.046). The ADD-EDD distribution showed notable gaps, with ADD deviations occurring as early as 109 days before and as late as 45 days after the EDD. On average, the ADD occurred approximately one week earlier (-7.15 days) than the EDD. Lower accuracy of LMP-based EDDs and delivery mode is associated with increased adverse events during delivery. Transitioning from LMP-based EDDs to more accurate methods is necessary to improve maternal and neonatal care outcomes. Integrating routine early ultrasound for EDD calculation can better equip healthcare providers and nurses to plan deliveries, reduce risks, and improve patient outcomes in resource-limited settings.

Managerial tools used for the prevention of adverse events in Intensive Care Units

Patient safety in Intensive Care Units (ICUs) is a critical priority due to the complexity of care and the high risk of adverse events (AEs). Objective: This study aimed to identify the managerial tools used for the prevention of AEs in ICUs through an integrative literature review. Method: Searches were conducted in the Scielo, Virtual Health Library (VHL), and PubMed databases using descriptors such as "Patient Safety," "Intensive Care Unit," "Near Miss," "Adverse Events," "Reporting," "Nursing," and "Safety Culture." Inclusion criteria considered full-text articles available in English and Portuguese, while duplicate articles and those that did not directly address the prevention of AEs and patient safety in ICUs were excluded. Data analysis was performed using narrative synthesis, assisted by the Rayyan software. Managerial tools identified included the Hospital Survey on Patient Safety Culture (HSOPSC), the Global Trigger Tool (GTT), the Neonatal Trigger Tool, the U.S. Paediatric Trigger Tool, the Nursing Activities Score (NAS), and the Brazilian Nursing Work Index-Revised (B-NWI-R), all adapted for use in Brazil. These tools aim to prevent AEs and promote patient safety in ICUs. Results:The results highlight the need to strengthen the safety culture and invest in the continuous training of healthcare professionals. Conclusion:The implementation of a broad and continuous safety culture with investments in permanent education can reduce the occurrence of AEs and improve the quality of care in ICUs.

Left atrial strain in non-ischemic dilated cardiomyopathy in sinus rhythm: Prognostic implications and interrelationship with left ventricular deformation

BackgroundLeft atrial deformation analysis may identify patients at higher risk of adverse events in the setting of non-ischemic dilated cardiomyopathy (NIDCM). The purpose was to determine the association between peak longitudinal (PALS) and contraction (PACS) LA strain in NIDCM, accounting for left ventricular global longitudinal strain (LV-GLS). MethodsConsecutive patients with NIDCM, sinus rhythm and LV ejection fraction (LVEF)<50 % were included. PALS, PACS and LV-GLS were obtained from echocardiography images. The composite outcome was a combination of hospitalization for heart failure, cardiovascular death, or ventricular arrhythmia. The association with the composite outcome was assessed using Cox regression and a classification and regression tree (CART) analysis was performed. ResultsAmong 347 patients included (median age 66 years old, median LVEF 35 %), median PALS and PACS values of 16 % and 9 %. After a median follow-up of 3.6 years, the composite outcome occurred in 70 (20.2 %) patients. PACS ≤8 % was associated with the composite outcome (adjusted HR = 2.73, 95 %CI 1.33–5.60), mostly by increasing the risk of heart failure admission. LV-GLS increased the risk of the composite outcome among patients with PACS>8 % (HR = 1.20, 95 %CI 1.07–1.35). PALS more strongly correlated with LV-GLS (Spearmans' rho = −0.71) than PACS (rho = −0.5). A decreased PALS/LV-GLS ratio was associated with higher rates of the composite outcome. ConclusionLA dysfunction is a major determinant of the composite outcome in NIDCM with LVEF <50 % and should be routinely assessed. PACS may perform better than PALS when combined with LV-GLS, probably due to lesser dependency from mitral annular motion.

Chronic Gabapentinoid Use and Lumbar Fusion Outcomes

Study Design. Retrospective comparative cohort study Objectives. To examine the effects of chronic use of gabapentinoids (alone or with opiods) on the outcomes of lumbar fusions. Summary of Background Data. Opioids have historically been the mainstay medications for pain management, but the ongoing opioid epidemic led physicians to look for alternatives. Gabapentinoids (GPs) are used various indications, and chronic use for any indication may lead to a higher risk of adverse events, especially when combined with opioids. Methods. Patients ≥18 years of age who underwent posterior fusion of the lumbosacral spine and ≥1 year follow-up were included.Patients were grouped according to their preoperative chronic GP and opioid usage as GP and opioid non-user (-/-), GP user opioid non-user (+/-), GP non-user and opioid user (-/+) and GP and opioid user (+/+). Results. A total of 563 patients (M/F%=41/59, mean age 61.1 y) were included. 280 (49%) patients were in group -/-; while 110 (19%) were in +/-, 78 (15%) were in -/+ and 95 (17%) were in +/+. For ODI, back pain and leg pain, +/+ had the worst outcomes at all time points, while -/- had the best. Chronic GP users (+/-) showed back pain improvement similar to the -/- group, however the improvements in leg pain and ODI were considerably less. GP use resulted in increased postoperative opioid requirements, although not as much as chronic opioid use. Complication rates were similar. Conclusions. Chronic preoperative use of GPs may lead to inferior outcomes when compared with GP-naïve patients, and this is significantly accentuated when taken concurrently with opioids. Patients who are using both GPs and opioids had the worst results for almost every outcome measure. Given the significantly worse surgical outcomes documented in this study, concurrent use with opioids should be avoided.

Promising selective alpha-1 blocker silodosin as a new therapeutic strategy for premature ejaculation and analysis of its drug adverse effect: A systematic review and meta-analysis of randomized controlled trials.

Premature Ejaculation (PE) occurs in 31% of men aged 18-59 years, leading to disappointment and avoidance of sexual relations. The current guideline of treatment for PE is Dapoxetine, which possesses several adverse effects causing the limitation of its long-term use. Silodosin, an alpha-1 blocker, has been proposed as a new option for treating PE due to its minimal side effects. Therefore, our study aims to assess the efficacy of silodosin in treating PE. This systematic review and meta-analysis was in accordance with Cochrane Handbook guidelines. Comprehensive literature search was conducted in several databases including PubMed, ScienceDirect, and Cochrane Central Register of Controlled Trials. The studies were included if they met the following criteria: (1) Involving premature ejaculation patients; (2) Intervention using silodosin; (3) Comparing placebo or other therapies for PE (4) Outcome includes the Intravaginal Ejaculation Latency Time (IELT) and reported adverse events related to the therapy. Study quality was assessed using Cochrane risk-of-bias criteria. Statistical analysis in this study was performed using Review Manager 5.4 Results: A total of four studies were included in this meta-analysis. Our study showed that patients who received silodosin had a significantly longer IELT compared to control (MD: 132.54, 95% CI 51.51-213.57, p < 0.001). However, patient treated with silodosin also possessed significantly higher risk of adverse event for developing reduced semen ejaculation (OR 10.79, 95% CI 3.46-33.67, p < 0.0001). Silodosin significantly increased IELT. However, it also reduced semen ejaculation as its drug adverse effect. This result supports the clinical use of silodosin as an alternative treatment for premature ejaculation.

Relationship between SLCO1B1 polymorphisms and methotrexate intolerance in Mexican children with juvenile idiopathic arthritis.

The most frequent adverse events (AEs) of methotrexate (MTX) are gastrointestinal symptoms and hepatotoxicity, which can affect its adherence, leading to reduced effectiveness. The SLCO1B1 gene codes for a liver protein (OATP1B1) responsible for drug transportation. Genetic variations within the SLCO1B1 gene locus impact drug transport, leading to altered pharmacokinetic profiles, delayed MTX clearance, and increased risk of toxicity. This study aimed to determine the association between single nucleotide polymorphisms (SNPs) in the SLCO1B1 gene (rs4149056, rs2306283) with the development of AEs in patients with juvenile idiopathic arthritis (JIA) treated with MTX. We performed an observational retrospective study to analyze the relationship between SNPs in the SLCO1B1 gene and the development of AEs in pediatric patients treated with MTX for JIA. Thirty patients with JIA were included, 22 females (73.3%), with a median age of 11years (IQR 8.3-15). The most frequent JIA subtype was rheumatoid factor-positive polyarthritis (36.7%). Twenty patients (66.7%) reported AEs. The *1B haplotype was the most frequent in this group (53.3%) and conferred a higher risk of developing AEs (OR = 3.89, 95% CI = 1.23 -12.29, p = 0.03). Patients with the allele *1B may benefit from lower doses of MTX. SLCO1B1 genotyping is a promising technique to identify patients at higher risk of AEs during treatment with MTX, thus requiring dose optimization.

“The stay here is, of course, not appropriate for an old person”: the perspective of healthcare providers on older patients in the emergency department

BackgroundIn aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work.MethodsThe study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective.ResultsThe interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of ‘the geriatric patient’. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service.ConclusionHealthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients.