Higher Risk Of Mortality Research Articles

Management of Pulmonary Hypertension during Pregnancy

: Pregnancy in patients with pulmonary arterial hypertension (PAH) is a high-risk condition associated with high morbidity and mortality. Patients with severe PAH are often advised against pregnancy. Still, those patients who pursue pregnancy require a dedicated and multidisciplinary approach since the progression of fetal growth will accompany significant hemodynamic changes, which can be challenging for patients with a poorly functioning right ventricle. In this article, we describe the approach to the unique cardiovascular, respiratory, hematologic, and social challenges that pregnant patients with PAH face throughout pregnancy. We discuss the impact of these physiologic changes on diagnostic studies commonly used in PAH and how to incorporate diagnostic data in making the diagnosis and risk stratifying pregnant patients with PAH. The pharmacologic challenges of pulmonary vasodilators in pregnancy are discussed as well. Pregnant patients with PAH are at particularly high risk of mortality around the time of delivery, and we discuss the multidisciplinary approach to the management of these patients, including the use of anesthesia, inotropic support, type of delivery, and postpartum care, providing clinicians with a practical approach to the management of this difficult condition.

Activation of neurotoxic A1-reactive astrocytes by SFTS virus infection accelerates fatal brain damage in IFNAR1-/- mice.

Severe fever with thrombocytopenia syndrome (SFTS) has a high mortality rate compared to other infectious diseases. SFTS is particularly associated with a high risk of mortality in immunocompromised individuals, while most patients who die of SFTS exhibit symptoms of severe encephalitis before death. However, the region of brain damage and mechanisms by which the SFTS virus (SFTSV) causes encephalitis remains unknown. Here, we revealed that SFTSV infects the brainstem and spinal cord, which are regions of the brain associated with respiratory function, and motor nerves in IFNAR1-/- mice. Further, we show that A1-reactive astrocytes are activated, causing nerve cell death, in infected mice. Primary astrocytes of SFTSV-infected IFNAR1-/- mice also induced neuronal cell death through the activation of A1-reactive astrocytes. Herein, we showed that SFTSV induces fatal neuroinflammation in the brain regions important for respiratory function and motor nerve, which may underlie mortality in SFTS patients. This study provides new insights for the treatment of SFTS, for which there is currently no therapeutic approach.

AB022. Management of first recurrence or progression of craniopharyngioma after resection alone: a systematic review and individual-participant data meta-analysis.

The initial management of craniopharyngioma is generally either gross total resection (GTR) or subtotal resection (STR) with adjuvant radiotherapy (RT). However, the optimal management strategy for recurrent/progressive craniopharyngioma remains unclear. PubMed and Embase were systematically reviewed for studies that compared the outcomes of surgery and/or RT for the first recurrence/progression of craniopharyngioma after resection alone. The exposure was the treatment that was administered for the first recurrence/progression, and the outcomes were tumor regrowth and overall survival (OS). Subgroup analyses were performed by age at the treatment for the first recurrence/progression (<18 or ≥18 years old), duration between the first treatment and the first recurrence/progression (<2 or ≥2 years), and the initial treatment that was administered (STR or GTR). Of the 2,932 studies screened, 11 studies reporting a total of 80 patients were included. Across almost all subgroups, patients who received RT for the first recurrence/progression had a significantly lower risk of tumor regrowth than those who did not, regardless of whether surgery was performed and the extent of resection. There was no significant association between the treatment administered for the first recurrence/progression and OS, except for patients with a recurrence/progression <2 years after the first treatment, where GTR was associated with a higher risk of mortality. For patients with the first recurrence/progression of craniopharyngioma after resection alone, RT should be considered for better local control. In cases where RT is not administered, GTR is preferred over STR provided it can be safely performed, for improved local control.

Impact of Long-Term Non-Communicable Diseases on SARS-COV-2 Hospitalized Patients Supported by Radiological Imaging in Southern Pakistan.

COVID-19 patients with already existing chronic medical conditions are more likely to develop severe complications and, ultimately, a higher risk of mortality. This study analyzes the impacts of pre-existing chronic illnesses such as diabetes (DM), hypertension, and cardiovascular diseases (CVDs) on COVID-19 cases by using radiological chest imaging. The data of laboratory-confirmed COVID-19-infected hospitalized patients were analyzed from March 2020 to December 2020. Chest X-ray images were included to further identify the differences in X-ray patterns of patients with co-morbid conditions and without any co-morbidity. The Pearson chi-square test checks the significance of the association between co-morbidities and mortality. The magnitude and dimension of the association were calibrated by the odds ratio (OR) at a 95% confidence interval (95% CI) over the patients' status (mortality and discharged cases). A univariate binary logistic regression model was applied to examine the impact of co-morbidities on death cases independently. A multivariate binary logistic regression model was applied for the adjusted effects of possible confounders. For the sensitivity analysis of the model, receiver operating characteristic (ROC) was applied. Patients with different comorbidities, including diabetes (OR = 33.4, 95% CI: 20.31-54.78, p < 0.001), cardiovascular conditions (OR = 24.14, 95% CI: 10.18-57.73, p < 0.001), and hypertension (OR = 16.9, 95% CI: 10.20-27.33,p < 0.001), showed strong and significant associations. The opacities present in various zones of the lungs clearly show that COVID-19 patients with chronic illnesses such as diabetes, hypertension, cardiovascular disease, and obesity experience significantly worse outcomes, as evidenced by chest X-rays showing increased pneumonia and deterioration. Therefore, stringent precautions and a global public health campaign are crucial to reducing mortality in these high-risk groups.

Gender-Dependent Association of Pulmonary Hypertension with Adverse Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

The relationship between pulmonary hypertension (PH) and outcomes after transcatheter aortic valve replacement (TAVR) has been shown to be unfavorable. The impact of gender on TAVR outcomes remains controversial. There have been no studies evaluating the simultaneous effects of both factors on TAVR outcomes. We retrospectively analyzed a prospective cohort of patients who underwent TAVR between January 2016 and December 2022. The patients were stratified by gender and the presence of PH. The primary outcome of the study was all-cause mortality. Secondary outcome was a composite of all-cause mortality and heart failure hospitalization. We identified a total of 133 female patients without PH, 179 males without PH, 87 females with PH, and 122 males with PH. The median follow-up period was 18 months. Female patients without PH demonstrated a lower cumulative mortality rate compared to those with male gender and/or PH. Adjusted multivariate Cox proportional hazard analyses revealed that male gender and PH status, either individually or in combination, were independently associated with long-term mortality when compared to female patients without PH. Specifically, females with PH (HR 6.80, 95% confidence interval (CI): 1.49-31.12, P=0.013), males without PH (HR 6.45, 95% CI: 1.47-28.22, P=0.013), and males with PH (HR 7.2, 95% CI: 1.63-31.81, P=0.009) demonstrated significantly higher risk for mortality. Patients who were male or had PH status had a higher risk of mortality. However, there was no synergistic effect between being male and having PH on the prognosis after TAVR.

Open ankle fractures in the elderly: predisposing factors and the associated mortality.

The purpose of this study was to investigate the independent effect of open ankle fractures on postoperative mortality and to identify factors leading to open ankle fractures in the elderly population. This is a retrospective case-control study of 1,045 patients aged 65years and older, with ankle fractures undergoing surgical fixation between 2010 and 2020 at three medical centers (Levels 1-2). A logistic regression analysis was used to identify risk factors for open fractures. Propensity score matching and survival analysis were used to measure the hazard of mortality attributable to open versus closed ankle fractures. There were 128 (12.2%) patients with open ankle fractures. Patients with open ankle fractures were more likely to be older, to be active smokers (OR = 1.7, p = 0.049), and tended to have a higher number of medical comorbidities including hypertension (OR = 2, p = 0.006) and chronic kidney disease (OR = 2.9, p = 0.005). Open ankle fractures were, independently of comorbid conditions and age, associated with higher risk of mortality (HR = 1.7, p = 0.03).

Risk of recurrent stroke and dementia following acute stroke by changes in kidney function: results from the Perindopril Protection Against Recurrent Stroke Study.

Limited data exist on the relationship between declining kidney function and cardiovascular events, dementia, and mortality in patients with a history of stroke.Thus the aims of the study were to investigate functional relationships between dynamic kidney function change and cardiovascular outcomes, and clarify whether adding kidney parameters to conventional cardiovascular risk factors improves model discrimination. Post hoc analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) clinical trial of blood pressure lowering for the secondary prevention of stroke. We examined the association between dynamic kidney function defined as percentage change (declines of >30%, and >0 to ≤30%, and increases of ≥0 to <30%, and ≥30%) in estimated glomerular filtration rate (eGFR) over 2 years and recurrent stroke, major cardiovascular events, dementia and all-cause death over the next 2 years using Cox proportional hazard models controlling for eGFR at registration and potential confounders. Restricted cubic splines were used to assess the functional relationships. C-statistics and Net Reclassification Improvement (NRI) at 2 years were used to assess model discrimination. In 4591 patients followed for a mean of approximately 2 years, 254 (5.5%) developed recurrent stroke, 391 (8.5%) had a major cardiovascular event, 221 (4.8%) developed dementia, and 271 (5.9%) died. Reverse J-like or U-like relationships were observed for percent declines in eGFR and outcomes. Using declines in eGFR of >0 to ≤30% as a reference, increased risks were evident for a greater decline (>30%) in relation to recurrent stroke [adjusted hazard ratio 1.85, 95% confidence interval (CI) 1.20-2.85], major cardiovascular event (2.24, 1.62-3.10) and all-cause death (2.09, 1.39-3.15). A larger increase (≥30%) in eGFR was also associated with a greater risk of all-cause death (1.96, 1.14-3.37). Improvements in the C-statistic were found by adding baseline eGFR and percent change compared with a model with conventional cardiovascular risk factors alone, for major cardiovascular events, dementia, and all-cause mortality. Declining kidney function following an incident cerebrovascular event is associated with additional risk of a major cardiovascular events, dementia, and 2-year mortality. However, a large increase in kidney function was also found to be associated with a higher risk of mortality.

Efficacy of Antibiotic Regimens for Meningitis in Young Infants Aged 0-59 Days: A Systematic Review.

Meningitis is associated with high mortality risk in young infants, yet the optimal treatment regimen is unclear. To systematically evaluate the efficacy of antibiotic regimens to treat meningitis in young infants aged 0 to 59 days on critical clinical outcomes. MEDLINE, Embase, CINAHL, WHO Global Index Medicus, and Cochrane Central Registry of Trials. We included randomized controlled trials (RCTs) of young infants with meningitis (population) comparing the efficacy of antibiotic regimens (interventions) with alternate regimens (control) on clinical outcomes. We extracted data on study characteristics and assessed risk of bias in duplicate. Grading of Recommendations Assessment, Development, and Evaluation was used to assess certainty of evidence. Of 1088 studies screened, only 2 RCTs were identified. They included 168 infants from 5 countries and were conducted between 1976 and 2015. Neither study compared current World Health Organization-recommended regimens. One multisite trial from 4 countries compared intrathecal gentamicin plus systemic ampicillin/gentamicin to systemic ampicillin/gentamicin and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41-1.53; 1 trial, n = 98, very low certainty of evidence) or adverse events (no events in either trial arm). Another trial in India compared a 10-day versus 14-day course of antibiotics and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41-1.53; 1 trial, n = 98, very low certainty of evidence) or other outcomes. Trial data on the efficacy of antibiotic regimens in young infant meningitis are scarce. Rigorous RCTs are needed to inform recommendations for optimal antibiotic regimens for meningitis treatment in this vulnerable population, particularly within the context of changing epidemiology and increasing antimicrobial resistance.

Trajectories of affective well-being and survival in middle-aged and older adults.

Affective experiences are key components of subjective well-being with important implications for health. However, little is known about heterogeneous longitudinal affect trajectories and their links to survival. This study identified joint trajectory subgroups based on 18-year changes in positive affect (PA) and negative affect (NA) and examined their differential associations with mortality risk. Participants were 3,250 adults (aged 39-93 years) from the Midlife in the U.S. study assessed over three waves (1995-2013). Parallel growth mixture modeling revealed three subgroups: (a) improving (increasing PA, decreasing NA), (b) deteriorating (decreasing PA, increasing NA), and (c) flourishing (high, stable PA, low, stable NA). Adjusting for baseline demographic and health covariates, Cox proportional-hazard results showed the improving group had the lowest mortality risk (HR = 0.82, 95% CI [0.35, 1.32]) and the deteriorating group had the highest mortality risk (HR = 1.86, 95% CI [1.34, 3.55]), relative to flourishing. These findings highlight the importance of modeling multidimensional trajectories of affective well-being and their heterogeneous links to survival. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Postoperative outcomes in patients with anemia undergoing carotid revascularization

BackgroundPreoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. Study designThis is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. ResultsOur study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with a decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. ConclusionsIn this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS was associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.

Four-Strata Risk Assessment in Patients with Pulmonary Arterial Hypertension Treated with Selexipag in Real-World Settings (EXPOSURE Study).

Risk assessment can aid management of pulmonary arterial hypertension (PAH) and clinical decision-making. This analysis describes characteristics, treatment patterns and outcomes of patients with PAH, categorised by risk status at time of treatment escalation with selexipag in clinical settings. Patients initiating selexipag in the ongoing multicentre, prospective EXPOSURE (EUPAS19085) study were grouped as low, intermediate-low, intermediate-high or high risk of 1-year mortality according to the ESC/ERS 4-strata method. As of November 2022, 77% (535/698) of patients initiating selexipag had data allowing for risk calculation; 14% (N = 76) were low, 31% (N = 168) intermediate-low, 34% (N = 182) intermediate-high and 20% (N = 109) high risk of 1-year mortality. Overall, patients were predominantly female (71%), with idiopathic/heritable PAH (56%) or PAH associated with connective tissue disease (CTD-PAH; 27%), median age of 60years and prevalent (2years) disease. From low to high risk, proportion of CTD-PAH and age increased (from 12%-40% and 46-68years, respectively); time from diagnosis decreased and presence of cardiovascular risk factors increased. Most patients across risk groups (74-81%) initiated selexipag as part of triple oral combination therapy. Overall median (Q1, Q3) selexipag exposure duration was 10.1 (3.5, 24.1) months. Proportions of hospitalised patients increased with increasing risk group (16-42% from low to high, respectively); more hospitalisations were PAH-related for the high risk (71%) versus other risk groups (47-54%). Kaplan-Meier survival estimates were 98%, 98%, 93% and 80% at 1-year and 98%, 92%, 81% and 67% at 2-years, from low to high risk, respectively. In clinical settings, selexipag is initiated across all risk groups, predominantly as triple therapy. Only 45% of patients being at low/intermediate-low risk at selexipag initiation suggests an opportunity for more frequent patient monitoring and earlier treatment escalation, given that 4-strata risk assessment was prognostic for hospitalisations and survival in this contemporary PAH cohort. A graphical abstract is available with this article.

Association Between Postoperative Decrease of Albumin and Outcomes in Patients Undergoing Craniotomy for Brain Tumors

Serum albumin reflects nutritional status and is associated with postoperative complications and mortality. Delta albumin (ΔAlb), defined as the difference between preoperative and lowest postoperative levels, could predict complications and mortality, even with postoperative levels above 30g/L prompting albumin infusions. This study aimed to assess how ΔAlb relates to outcomes in craniotomy patients with brain tumors. This retrospective study screened patients diagnosed with a brain tumor who underwent cerebral surgery from a single Chinese hospital between December 2010 and April 2021. Patients were divided into 4 groups based on their ΔAlb levels: <5g/L (normal), 5-9.9g/L (mild ΔAlb), 10-14.9g/L (moderate ΔAlb), and ≥15g/L (severe ΔAlb). The primary outcome was postoperative 30-day mortality. Among the 9660 patients undergoing craniotomy for brain tumors, the median ΔAlb level after craniotomy was 7.3g/L. ΔAlb was associated with increased postoperative 30-day mortality; odds ratios for mild, moderate, and severe ΔAlb were 1.93 (95% confidence interval [CI], 1.17-3.18, P= 0.01), 2.21 (95% CI, 1.28-3.79, P= 0.004), and 7.26 (95% CI, 4.19-12.58, P<0.01), respectively. Significantly, ΔAlb >5g/L was found to have a strong association with a higher risk of mortality, even when the nadir Alb remained greater than 30g/L (odds ratio, 1.84; 95% CI, 1.13-3.00, P= 0.014). Among patients undergoing craniotomy for brain tumor resection, a mild degree of ΔAlb was associated with increased 30-day mortality, even if the nadir Alb remained greater than 30g/L. Moreover, ΔAlb was associated with postoperative complications and longer lengths of stay.

Electronic consultation to improve care outcomes in patients with suspected and confirmed heparin-induced thrombocytopenia

BackgroundHeparin-induced thrombocytopenia (HIT) is a complication of heparin exposure associated with high risk for morbidity and mortality. Diagnosis and management are complex due to limitations of laboratory testing and the need for nonheparin anticoagulation. ObjectivesTo increase the delivery of evidence-based care of patients with suspected and confirmed HIT via electronic consultation (e-consult). MethodsWe describe the creation and implementation of an e-consult service for patients with concern for HIT at a large academic medical center. Hematology physicians with HIT expertise performed real-time chart review of all patients with a positive screening immunoassay result and provided written recommendations in their electronic health record. ResultsComparison of outcomes for 1 year before and the year after the e-consult service implementation identified improvements in direct thrombin inhibitor stewardship, increased diagnostic accuracy, and decreased length of stay of patients with confirmed HIT. ConclusionThe e-consult platform is a novel method for rapid, targeted consultative guidance, and this single-institution pilot demonstrates its feasibility and effectiveness to improve the care of patients with suspected and confirmed HIT.

Risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i: higher mortality risk among Native Hawaiians and other Pacific Islanders.

To estimate mortality rates and identify specific risk factors associated with 1-year mortality after osteoporotic hip fracture in Hawai'i. A retrospective review of adults (≥ 50years) hospitalized with an osteoporotic hip fracture at a large multicenter healthcare system in Hawai'i from 2011 to 2019. The Kaplan-Meier curves and log-rank tests examined survival probability by sex, age group, race/ethnicity, primary insurance, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status classification. After accounting for potential confounders, adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were obtained from Cox proportional hazards regression models. We identified 1755 cases of osteoporotic hip fracture. The cumulative mortality rate 1year after fracture was 14.4%. Older age (aHR 3.50; 95% CI 2.13-5.76 for ≥ 90 vs 50-69), higher ASA score (aHR 5.21; 95% CI 3.09-8.77 for ASA 4-5 vs 1-2), and Native Hawaiian/Pacific Islander (NHPI) race (aHR 1.84; 95% CI 1.10-3.07 vs. White) were independently associated with higher mortality risk. Female sex (aHR 0.64; 95% CI 0.49-0.84 vs male sex) and higher BMI (aHR 0.35; 95% CI 0.18-0.68 for obese vs underweight) were associated with lower mortality risk. In our study, men, older adults, higher ASA score, lower BMI, and NHPI race were associated with significantly higher mortality risk after osteoporotic hip fracture. NHPIs are an especially vulnerable group and comprise a significant portion of Hawai'i's population. Further research is needed to address the causes of higher mortality and interventions to reduce hip fractures and associated mortality.

Anti-SARS-CoV-2 Antibodies versus Vaccination Status in CAD Patients with COVID-19: A Prospective, Propensity Score-Matched Cohort Study.

Despite the currently prevailing, milder Omicron variant, coronary artery disease (CAD) patients constitute a major risk group in COVID-19, exhibiting 2.6 times the mortality risk of non-CAD patients and representing over 22% of non-survivors. No data are currently available on the efficacy of antibody levels in CAD patients, nor on the relevance of vaccination status versus antibody levels for predicting severe courses and COVID-19 mortality. Nor are there definitive indicators to assess if individual CAD patients are sufficiently protected from adverse outcomes or to determine the necessity of booster vaccinations. A prospective, propensity-score-matched, multicenter cohort study comprising 249 CAD patients and 903 controls was conducted. Anti-SARS-CoV-2-spike antibodies were measured on hospital admission. Prespecified endpoints were in-hospital mortality, intensive care, and oxygen administration. After adjustment for potential confounders, CAD patients exhibited 4.6 and 6.1-times higher mortality risks if antibody levels were <1200 BAU/mL and <182 BAU/mL, respectively, compared to CAD patients above these thresholds (aOR 4.598, 95%CI 2.426-8.714, p < 0.001; 6.147, 95%CI 2.529-14.941, p < 0.001). Risk of intensive care was 3.7 and 4.0 (p = 0.003; p < 0.001), and risk of oxygen administration 2.6 and 2.4 times higher below these thresholds (p = 0.004; p = 0.010). Vaccination status was a weaker predictor of all three outcomes than both antibody thresholds. Antibody levels are a stronger predictor of outcome in CAD patients with COVID-19 than vaccination status, with 1200 BAU/mL being the more conservative threshold. Measuring anti-SARS-CoV-2 antibodies in CAD patients may ensure enhanced protection by providing timely booster vaccinations and identifying high-risk CAD patients at hospital admission.

Patient Comorbidities, Their Influence on Lumbar Spinal Fusion Surgery, and Recommendations to Reduce Unfavorable Outcomes.

Improvements in healthcare management have led to a decrease in perioperative and postoperative complications. However, perioperative medical complications and mortality rates continue to increase in patients undergoing elective spinal surgeries. This trend is driven by the increase in the older population and the rise in the number of patients with more than two comorbidities. Managing patients with multiple comorbidities requires additional resources, augmenting the financial and societal burden. Despite the high risk of complications and mortality, patients with multiple comorbidities undergo spinal surgery for degenerative spinal conditions daily. These findings highlight the need for heightened awareness, patient education, and management of comorbidities before elective spinal surgeries. This article comprehensively reviews literature on the effects of medical comorbidities on spinal fusion surgery outcomes to increase awareness of the surgical complications associated with comorbidities. In addition, suggested preoperative and postoperative comorbidity management strategies are outlined.

Characteristics, management and outcome of patients with late-arrival STEMI in the Acute Coronary Syndrome Israeli Surveys (ACSIS)

IntroductionPatients with ST-elevation myocardial infarction (STEMI) and late arrival (>12 h) after symptom onset, are at high risk for mortality and heart failure and represent a challenge for management. We aimed to define patient characteristics, management, and outcome of late-arrival STEMI in Israel over the last 20 years. MethodsWe analyzed data of late-arrival STEMI (12–48 h and > 48 h) from the biennial acute coronary syndrome Israeli Surveys (ACSIS), as well as time-dependent changes [early (2000–2010) Vs. late (2013–2021) period]. ResultsData regarding time from symptom onset to hospital arrival was available in 6,466 STEMI patients. Of these, 9.6 % arrived 12–48 h and 3 % >48 h from symptom onset. Late-arrival patients were more likely to be older women with diabetes and high GRACE score and less likely to have prior myocardial infarction.In recent years, 95 % of patients arriving 12–48 h and 96 % of those arriving > 48 h had coronary angiography, as opposed to 75 % and 77 % in the early years (p = 0.007). Percutaneous coronary intervention (PCI) increased from 60 % and 55 % respectively to 85 % (p ≤ 0.001).TIMI-3 flow after primary PCI was 89–92 %, irrespective of arrival time. Late arrival patients (12–48 h but not > 48 h) who had PCI had better adjusted 1-year survival, HR 0.49 (95 %CI 0.29–0.82), p = 0.01. ConclusionsLate-arrival STEMI patients have higher risk characteristics. Most late-arrival patients undergo coronary angiography and PCI and have TIMI-3 flow after primary PCI. In patients arriving 12–48 h after symptom onset PCI is associated with better survival.

Association between atherogenic index of plasma and all-cause mortality and specific-mortality: a nationwide population‑based cohort study

BackgroundAtherogenic index of plasma (AIP), a marker of atherosclerosis and cardiovascular disease (CVD). However, few studies have investigated association between AIP and all-cause mortality and specific-mortality in the general population.MethodsThis study included data from 14,063 American adults. The exposure variable was the AIP, which was defined as log10 (triglycerides/high-density lipoprotein cholesterol). The outcome variables included all-cause mortality and specific-mortality. Survey-weighted cox regressions were performed to evaluate the relation between AIP and all-cause mortality and specific-mortality. Weighted restricted cubic spline was conducted to examin the non-linear relationship.ResultsDuring 10 years of follow-up, we documented 2,077, 262, 854, and 476 cases of all-cause mortality, diabetes mortality, CVD mortality and cancer mortality, respectively. After adjustment for potential confounders, we found that atherogenic index of plasma (AIP) was significantly associated with an increased risk of diabetes mortality when comparing the highest to the lowest quantile of AIP in female (p for trend = 0.001) or participants older than 65 years (p for trend = 0.002). AIP was not significantly associated with all-cause mortality, CVD mortality and cancer mortality (p > 0.05). Moreover, a non-linear association was observed between AIP and all-cause mortality in a U-shape (p for non-linear = 0.0011), while a linear relationship was observed with diabetes mortality and non-diabetes mortality (p for linear < 0.0001).ConclusionsIn this study, there is a no significant association between high AIP levels and a high risk of all-cause and cardiovascular mortality. Besides, a higher AIP was significantly associated with an increased risk of diabetes mortality, which only found in women older than 65 years. AIP was associated with all-cause mortality in a U-shape. This association could be explained by the finding that higher AIP predicted a higher risk of death from diabetes, and that lower AIP predicted a higher risk of death from non-diabetes causes.

Timing of Embolization, Radiosurgery, and Resection of Arteriovenous Malformations in Pediatric Patients: A Retrospective, Descriptive Study

ObjectiveCerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization and stereotactic radiosurgery (SRS). There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/SRS and resection is not well explored in the literature. Here we present a series of pediatric AVM patients, with special attention paid to the timing of treatment. MethodsElectronic medical records of all pediatric patients (<18 years at treatment) with AVMs treated at our institution were retrospectively reviewed after IRB approval. Demographic information, AVM characteristics, treatment variables and outcomes were recorded. Results27 total patients were included. 21 (77.8%) presented with a ruptured AVM. 6 patients (28.6%) had an GCS of 3 to 10, and underwent treatment within 24 hours of presentation. 10 patients (47.6 %) with a GCS of 12 to 15 were treated between 24 to 120 hours. 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. 96% of our cohort, regardless of rupture status, had mRS of 1-2 at most recent follow-up. ConclusionsWe present our institution’s experience with pediatric AVM’s, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status.

Bedside assessment of sarcopenia in hospitalized patients with liver cirrhosis: Magnitude and clinical implications.

Sarcopenia is associated with many adverse outcomes in patients with cirrhosis. The tools currently in use for assessing sarcopenia have numerous flaws. We evaluated the utility of portable ultrasonography and a dynamometer for the bedside assessment of sarcopenia and its implications in hospitalized cirrhosis patients. A dynamometer was used to test the hand-grip strength (HGS) and ultrasound was used to measure the thickness of the forearm and quadriceps muscles. HGS value < 27kg for men and < 16kg for women was taken as significant according to the European Working Group on Sarcopenia in Older People (EWGSOP2) criteria. The lower normal limit of muscle mass (5th percentile) was determined on 100 matched healthy controls. According to the EWGSOP2 criteria and HGS values, the prevalence of sarcopenia and probable sarcopenia among 300 cirrhosis patients were 56% and 62.3%, respectively. HGS alone identified sarcopenia in 88.9% of patients, while overestimated it in 6.3% of cases. The prevalence rate of sarcopenic obesity was 11%. Compared to patients without sarcopenia, sarcopenic patients had more complications of cirrhosis such as ascites, variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, sepsis, hepatorenal syndrome and refractory ascites. In-hospital (p = 0.037), three-month (p < 0.001), and six-month (p < 0.001) mortality rates were all higher among sarcopenic patients. On cox regression survival analysis, overall six-month mortality was significantly higher in sarcopenic patients compared to patients without sarcopenia (hazard ratio, 6.37; 95% confidence interval, 3.15-12.8, p < 0.001). Bedside assessment of sarcopenia using a portable ultrasound machine and a dynamometer detects liver cirrhosis patients with high risk of complications and mortality.