High Risk For Poor Outcomes Research Articles

Thrombocytopenia as a Prognostic Marker in Patients with Acute Encephalitis at a Tertiary Care Center in Northern India.

Acute encephalitis (AE) is associated with a high burden of mortality and permanent disability and has a spectrum of underlying etiologies. The prognosis of encephalitis is difficult and almost all the patients seem to be at a high risk of poor outcomes. A number of physiological changes take place during encephalitis and have been evaluated for their prognostic value. Platelet count, which has been recognized as a surrogate prognostic marker in various viral illnesses, has recently been recognized to have a prognostic value in AE too. In the present study, we attempted to study the role of thrombocytopenia in the prognosis of AE. Total of 98 cases based on clinical, cerebrospinal fluid, and radiological profiles consistent with the diagnosis of AE were enrolled in the study. A clinical profile was noted, and platelet count was assessed. Thrombocytopenia was defined as platelet count <150,000/mm3. Platelet count 100,000-150,000, 50,000-99,999, and <50,000/mm3 were considered mild, moderate, and severe thrombocytopenia. The underlying etiology was explored, and patients were followed till discharge/outcome. The outcome was noted in terms of the Modified Rankin score (MRS). MRS 0-2 was considered good, 3-4 fair, and 5-6 as poor outcome. The mean age of patients was 34.06 ± 18.76 years. Majority of patients were women (54.1%). Prevalence of thrombocytopenia was 75.5%. A total of 34 (45.9%) had mild, 30 (40.5%) had moderate, and 10 (13.5%) had severe thrombocytopenia. Acute viral encephalitis (unclassified) was the most common etiology (33.7%), followed by scrub meningoencephalitis (24.5%) and Japanese encephalitis (12.2%), respectively. Good, fair, and poor outcomes were noted in 48 (49%), 21 (21.4%), and 29 (29.6%) cases. On univariate analysis, no significant association of poor outcome was seen with age, sex, duration of fever, and mechanical ventilation need (P > 0.05). Low Glasgow Coma Scale (GCS), splenomegaly, low platelet count, and Japanese encephalitis virus/scrub typhus etiologies were found to be significantly associated with poor outcomes (P < 0.05). Thrombocytopenia compared to normal platelet count and severe thrombocytopenia compared to mild and moderate thrombocytopenia were significantly associated with poor outcomes (P < 0.05). On multivariate analysis, GCS <8 (odds ratio [OR] =4.52; 95% confidence interval [CI] =1.56-13.20) and thrombocytopenia (OR = 11.92; 95% CI = 1.38-103.32) emerged as independent predictors of poor outcome. The findings of the study showed that low GCS and thrombocytopenia could be used as predictors of poor outcomes in AE cases.

Independent role of atherosclerotic plaque composition and extension in predicting the risk of cardiac events: a CLIMA substudy.

To investigate two different approaches to determine patient risk to develop cardiac events: the burden of coronary atherosclerosis, as assessed by the Gensini score, and plaque morphology, as assessed by intracoronary optical coherence tomography (OCT). We assessed the Gensini score and OCT features of plaque vulnerability in 847 patients from the CLIMA registry. Patients were divided into four Gensini quartiles. The main study endpoint was the 1-year composite of cardiac death, myocardial infarction (MI) and/or target vessel revascularization (TVR). A total of 56 patients (6.6%) experienced the one-year main composite endpoint. The composite endpoint was significantly affected by the Gensini score (hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.11-1.81, p = 0.005), with a low incidence in the first Gensini quartile (Q1 1.3%) and a higher incidence in the remaining groups (Q2 8.3%, Q3 8.9% and Q4 8.3%). At the multivariable analysis, the combined four OCT criteria (HR 6.4, 95%CI 3.0-13.7, p < 0.001), thin fibrous cap (HR 2.9, 95%CI 1.7-5.0, p < 0.001), lipid arc > 180° (HR 2.1, 95%CI 1.2-3.6, p = 0.010), minimum lumen area < 3.5 mm2 (HR 1.7, 95%CI 1.01-3.0, p = 0.047) and the Gensini score (HR 1.4, 95%CI 1.1-1.8, p = 0.017) were independent predictors of the main composite endpoint. In this post-hoc analysis of the CLIMA study, the burden of coronary atherosclerosis as assessed by the Gensini score and OCT plaque characteristics were independent predictors of cardiac events. Patients with the largest atherosclerosis burden and with plaque vulnerability by OCT were at the highest risk of poor outcome. Clinicaltrials.gov identifier: NCT02883088.

Unaccompanied homelessness among high school students across ten states: prevalence and risk in multiple domains

ABSTRACT Unaccompanied homelessness during adolescence is a risk factor for varied poor outcomes, yet enumeration efforts struggle to provide feasible results and few analyses consider how risk might differ for this group. We consider data from the 2019 Youth Risk Behavior Survey from 10 states that asked about unaccompanied homelessness and sleeping arrangement. Students who experienced any form of homelessness were at higher risk for poor outcomes and other risk experiences. Few students reported both unaccompanied homelessness and usually sleeping in a homeless situation. Youth experiencing unaccompanied homelessness had higher risk for alcohol problems and lower risk for severe drug use and poor grades compared to students who experienced other forms of homelessness; otherwise they had similar levels of risk for poor outcomes. Results are consistent with the view that students who experience unaccompanied homeless are a distinguishable subpopulation of students who experience homelessness and are at high levels of risk of poor outcomes.

Childhood cerebral malaria: Pattern of biochemical parameters and clinical outcome in a Nigerian tertiary hospital

BackgroundThe outcome of children with cerebral malaria involves an interplay of factors including clinical and biochemical parameters, a deep knowledge of these laboratory biochemical parameters is essential. Thus, this study aimed to assess the pattern of the biochemical parameters in children with cerebral malaria and how it may affect the clinical outcomes. MethodsA prospective observational cohort study among fifty subjects at the children's emergency unit. The participants were children aged 6 months to 12 years admitted with a history of fever and altered sensorium, demonstrable malaria parasite in the blood film and cerebrospinal fluid (CSF) analysis not suggestive of central nervous system (CNS) infections. Detailed history was taken with thorough examinations of each child. Samples were collected for malaria parasites, serum electrolytes, urea, creatinine, and blood glucose values. The clinical outcomes were correlated with the analyte levels. Results60 % of the children survived without any sequelae with the highest proportion (70 %) of survivors being children above five years. Children with hypoglycemia had a 3.5-fold higher risk of poor outcomes and this is statistically significant (RR = 3.65 p = 0.014). Hyperkalaemia was significantly associated with poor outcomes (RR = 2.57, p = 0.009). Subjects with hypochloraemia had three times the risk of poor outcome and mortality with statistically significant association (RR = 3.07, χ2 = 8.519, p = 0.004). There was a significant association between metabolic acidosis and poor clinical outcome. (RR = 1.99, χ2 = 4.089, p = 0.043). The parasite density was significantly associated with the serum bicarbonate (HCO3−) and Chloride, p-value < 0.05. ConclusionHypoglycaemia, hyperkalemia, hypochloremia and metabolic acidosis were significantly associated with poor outcomes, thus, good predictors of clinical outcomes in children diagnosed with cerebral malaria. Periodic evaluation and monitoring of these parameters is essential for prompt intervention to forestall devastating outcomes.

6909 Mortality and Readmission Rates for Inpatients with Diabetic Foot Ulcer in a Tertiary, Urban Medical Center: A Five-Year Retrospective Review

Abstract Disclosure: A. Herrera Chancay: None. R. Lopez Fanas: None. H. Tabassum: None. J. Daily: None. A. Myers: None. Background: Diabetic Foot Ulcer (DFU) is a severe complication of diabetes mellitus and is associated with high rates of morbidity and mortality. The incidence of DFUs and amputation disproportionately impact Black and Hispanic populations. DFU is also associated with a high rate of hospital readmissions and prolonged length of stay (LOS). The goal of this study was to examine 1-year mortality data, LOS and readmission rate. Methods: This study was a retrospective chart review of 1348 patients admitted to three hospitals in our system in the Bronx from 6/1/16 to 5/31/21. Data was extracted from the EPIC® electronic health records, based on the diagnoses ICD 10 codes, E10.621 and E11.622. Inclusion criteria was patients admitted with an active DFU regardless of other admission diagnosis, age 18 years or above. The index admission was defined as the first admission in our medical records within the date range. Patients were excluded if their index admission was not accessible through our EMR. Simple logistic regression and multiple logistic regression were used to analyze the association between variables of interest and mortality at index admission and at 1-year, LOS and re admissions. Results: Of the 650 eligible patients, the mean age was 59 + 13 years, 70% of patients were male, and majority were non-White (88%). Mortality was 1% during the index admission and the risk increased to 6% at 1 year after the index admission. Readmission with an active DFU from the index admission occurred in 15% of patients within 30-days, 32% of patients within 90 days, and 55% of patients within 1 year. The mean length of stay was 9 +7.5 days. Discussion: Our study in an urban region has identified high rates of mortality and costs associated with DFU, which has been reported in many settings. This patient population is high risk for poor outcomes and targeted programs are needed to reduce mortality and provide care to reduce readmissions. Future studies that explore the challenges of DFU health care and that test interventions are needed to improve DFU related health outcomes. Presentation: 6/2/2024

Positive Lymph Node Ratio as a new prognostic score in Geriatric patients with operated gastric cancer

ObjectiveThe pivotal prognostic determinant for recurrence and survival in surgically treated gastric cancer (GC) patients remains the lymph node status. Despite the adoption of D2 lymph node dissection as the standard approach in recent years, its association with increased morbidity in elderly patients raises concerns. This study aims to explore the prognostic significance of the Positive Lymph Node Ratio (PLNR) score in the context of recurrence and survival among elderly patients with surgically treated GC. Material and methodA retrospective review of files about surgically treated patients with GC was conducted. The prognostic impact of the PLNR score on overall survival (OS) was assessed through Receiver Operating Characteristic (ROC) analysis. ResultsThe cut-off value for the PLNR, determined through ROC analysis, was identified as 0.138. This value serves as a crucial threshold, as it distinguishes patients with a higher risk of poor outcomes. Patients with a PLNR score of 0.138 or below exhibited a median OS of 111 months, whereas those with a PLNR score above 0.138 had a significantly lower median OS of 22 months (p = 0.004). ConclusionOur findings revealed that the PLNR emerged as an independent predictor of survival and recurrence in patients undergoing GC resection.However, it's important to note that while valuable, the PLNR system has limitations. It does not encompass the T stage, a key factor in cancer staging. Therefore, it cannot be a direct substitute for the comprehensive information TNM staging provides. It should be used as a supplementary tool in predicting prognosis, particularly in elderly patients unsuitable for standard lymph node dissection.

Lateral QRS amplitude is independently associated with outcome after cardiac resynchronization therapy: advancing patient selection?

Cardiac resynchronization therapy (CRT) is a cornerstone in the treatment of selected heart failure patients. However, a relevant proportion of patients does not show beneficial response. Identification of simple, additive, and outcome-relevant selection criteria may improve patient selection. We sought to determine whether baseline QRS amplitude is associated with outcome in CRT. Quantification of intrinsic, pre-CRT-implantation QRS amplitude in an observational multinational two-center retrospective cohort analysis (derivation cohort Zurich, n=178, 2000-2015; validation cohort Leuven, n=183, 1999-2016) with a composite endpoint of all-cause mortality, ventricular assist device implantation or heart transplantation at 5 years. Higher baseline-to-peak amplitude in lateral leads (lead I and V6) was associated with a lower risk of reaching the composite endpoint (lead I: HR 0.86 [95%CI 0.78-0.95] per mV, p=0.002, lead V6: HR 0.94 [95%CI 0.88-1.00] per mV, p=0.043). Concordance index-based comparison of quartile-, spline-, and ROC curve analysis suggested cut-off values of 6mV for lead I and 3mV for V6 for optimal discrimination of outcome. External validation confirmed the cut-off of 3mV in lead V6 as highly significant discriminator of outcome (p<0.001), associated with a risk reduction of 65%. Low QRS amplitude in lateral ECG leads is associated with higher risk of poor outcome in CRT patients. A cut-off of 3mV in lead V6 proved highly discrimitative. Further studies need to confirm the additive value of QRS amplitude in patient selection for CRT and to assess whether CRT may be made available to more patients.

Impact of a mortality prediction tool on end-of-life (EOL) quality measures.

404 Background: Determining treatment options for patients with cancer can be difficult for providers, especially when it comes to deciding the appropriate time to stop therapy. Many factors come into play when making important treatment and quality of life decisions including cancer responsiveness to treatment, patient preferences, labs, and diagnostic studies. Providers use their experience, instinct, and patient input in making these decisions, and can still have a difficult time knowing the best option for the patient. To support providers in identifying patients at high risk for poor outcomes, we developed a 90-day mortality risk machine-learning model (MRM) for patients with metastatic cancer. The tool was designed to facilitate earlier advance care planning (ACP) discussions and prognostic awareness leading to alignment of treatment with patient goals and values. The US Oncology Network (The Network) implemented the MRM beginning in early 2021 through late 2022. We assessed the impact of the MRM using performance on 5 EOL Quality Measures included in Medicare’s Merit-based Incentive Payment System (MIPS) Program. Methods: MRM predictions were made every two weeks and provided to practices through a secure web-based dashboard. Practices customized their use of the MRM based on their unique workflow. MRM utilization was collected July – December 2023 and determined how frequently practices accessed the dashboard. Practices were separated into two groups based on MRM utilization: High Utilizers (HU) used the tool more than once a week and Low Utilizers (LU) did not use the tool or used it less than or equal to once a week. EOL MIPS measure performance was collected and evaluated from the 2023 calendar year. For each of the EOL MIPS measures, we compared the average score between the two practice groups. A 2-sample unequal variance t-test with 1-tailed distribution was used to determine if there was a significant difference between the two practice groups for each EOL MIPS measure. Results: A total of 25 practices had available EOL MIPS scores. Five practices were classified as a HU group and 20 were in the LU group. EOL MIPS measure scores were higher among HU. All results trended towards improvement with a statistically significant difference observed for PIMSH 1 and MIPS 457 for HU compared to LU. The table shows the average MIPS scores across the two practice groups. Conclusions: Practices with the highest reported utilization of the MRM also reported improved MIPS EOL quality scores for the 2023 calendar year. While each practice implemented MRM independently, those using the tool more than once per week had improved performance in their MIPS EOL quality scores. EOL MIPS Measure HU LU Delta P MIPS 047 ACP 80.7 59.8 20.9 0.066 PIMSH 1 ACP Stage 4 disease 67.7 40.2 27.5 0.002 MIPS 453 Chemo Last 14 days (inv) 10.7 11.7 -1.0 0.279 MIPS 457 Hospice &lt;3 days (inv) 11.7 14.8 -3.1 0.038 PIMSH 9 Supportive RX last 14 days (inv) 5.3 6.6 -1.3 0.119

Clinical and Laboratory Factors Associated with Mortality in ICU-Hospitalized COVID-19 Patients in a Western Center of Iran

Introduction: The purpose of this study was to investigate the demographic, clinical, and laboratory risk factors associated with mortality in Coronavirus disease 2019 (COVID-19) patients who were admitted to the intensive care unit (ICU) in Iran. Material &amp; Methods: This retrospective study analyzed data from 867 COVID-19 patients admitted to the ICU of Shahid Beheshti Hospital in Hamadan (west of Iran) from September 2020 to March 2022. The association between demographic, clinical, and laboratory factors and mortality rates was assessed using univariable and multiple logistic regression analysis. Results: During the study period, 512 (59.1%) patients were deceased from Covid-19. According to the adjusted logistic regression, the odds of death in patients with an age higher than 60 years were 1.12 (95% CI: 1.01- 1.24; p=0.026). The OR estimate of death in patients with bradycardia and tachycardia was 2.32 (95% CI: 1.72- 3.12; p &lt; 0.001) and 2.40 (95% CI: 1.67- 3.42; p &lt; 0.001), respectively. Moreover, SPO2 lower than 88%, WBC over 11 ×1000μL, K over 5.2 mEq/L, and LDH above 942 U/L were significantly associated with increased odds of death (p &lt; 0.05). Conclusion: The study identified several demographic, clinical, and laboratory risk factors associated with mortality in COVID-19 patients admitted to the ICU in Iran. These findings can help healthcare providers identify patients at higher risk of poor outcomes and tailor interventions accordingly.

Intervening on Metabolic Dysfunction-Associated Steatotic Liver Disease in Latino/a and Black Patients with Diabetes: A Feasibility Pilot.

Patients with type 2 diabetes (T2D), particularly those from historically marginalized racial and ethnic groups, are at high risk of poor outcomes from metabolic dysfunction-associated steatotic liver disease (MASLD). Evidence-based management (EBM) of MASLD can prevent its progression to cirrhosis and poor outcomes, yet rates of EBM of MASLD are low in T2D. In this pilot study of ten participants, we examined the feasibility and acceptability of a telehealth intervention that delivered EBM of MASLD in Latino/a and Black patients with T2D in the Duke Healthcare System. The intervention included: (a) MASLD education; (b) diet/lifestyle counseling; (c) T2D medication adjustment (i.e., to promote liver health) and (d) ordering of clinically indicated tests and referrals. This 3-month intervention was delivered by an endocrinologist over three virtual study visits. Phone interviews were conducted at study conclusion. We examined rates of recruitment, retention, T2D medication adjustment, and ordering of clinically indicated tests/referrals. The median age of our cohort was 54.0 (44.0, 59.0); six and four participants self-identified as Latino/a ethnicity and Black race, respectively. Retention rate in this study was 100% (n = 10/10), and all scheduled visits were completed (n = 30/30). Recruitment occurred over one month, and the rate was 25.8% (n = 8/31) by telephone call and 10% (n = 2/20) by electronic health record message. The intervention was highly acceptable based on a median Treatment Acceptability and Preferences score of 4.0 (4.0, 4.0). In exit interviews, all participants reported improved understanding of MASLD and its link to diabetes. All participants received T2D medication adjustment (n = 5/10) and/or clinically indicated testing/referral (n = 10/10) for the purpose of improving MASLD. We demonstrated that a telehealth intervention designed to proactively deliver EBM of MASLD was feasible and acceptable in a cohort of Latino/a and Black patients with T2D. Opportunities existed to better align each participants' care with guideline-based care of MASLD.

Impaired glucose metabolism and the risk of vascular events and mortality after ischemic stroke: A systematic review and meta-analysis

BackgroundDiabetes mellitus (DM), prediabetes, and insulin resistance are highly prevalent in patients with ischemic stroke (IS). DM is associated with higher risk for poor outcomes after IS.ObjectiveInvestigate the risk of recurrent vascular events and mortality associated with impaired glucose metabolism compared to normoglycemia in patients with IS and transient ischemic attack (TIA).MethodsSystematic literature search was performed in PubMed, Embase, Cochrane Library on 21st March 2024 and via citation searching. Studies that comprised IS or TIA patients and exposures of impaired glucose metabolism were eligible. Study Quality Assessment Tool was used for risk of bias assessment. Covariate adjusted outcomes were pooled using random-effects meta-analysis.Main outcomesRecurrent stroke, cardiac events, cardiovascular and all-cause mortality and composite of vascular outcomes.ResultsOf 10,974 identified studies 159 were eligible. 67% had low risk of bias. DM was associated with an increased risk for composite events (pooled HR (pHR) including 445,808 patients: 1.58, 95% CI 1.34–1.85, I2 = 88%), recurrent stroke (pHR including 1.161.527 patients: 1.42 (1.29–1.56, I2 = 92%), cardiac events (pHR including 443,863 patients: 1.55, 1.50–1.61, I2 = 0%), and all-cause mortality (pHR including 1.031.472 patients: 1.56, 1.34–1.82, I2 = 99%). Prediabetes was associated with an increased risk for composite events (pHR including 8,262 patients: 1.50, 1.15–1.96, I2 = 0%) and recurrent stroke (pHR including 10,429 patients: 1.50, 1.18–1.91, I2 = 0), however, not with mortality (pHR including 9,378 patients, 1.82, 0.73–4.57, I2 = 78%). Insulin resistance was associated with recurrent stroke (pHR including 21,363 patients: 1.56, 1.19–2.05, I2 = 55%), but not with mortality (pHR including 21,363 patients: 1.31, 0.66–2.59, I2 = 85%).DiscussionDM is associated with a 56% increased relative risk of death after IS and TIA. Risk estimates regarding recurrent events are similarly high between prediabetes and DM, indicating high cardiovascular risk burden already in precursor stages of DM. There was a high heterogeneity across most outcomes.

Acute Myocardial Injury in Spontaneous Intracerebral Hemorrhage: A Secondary Observational Analysis of the FAST Trial.

Acute myocardial injury is associated with poor outcomes in patients with acute ischemic stroke, but its prognostic significance in patients with spontaneous intracerebral hemorrhage remains unclear. We investigated whether acute myocardial injury and the direction of the cardiac troponin I (cTnI) change (rising versus falling) affect post-intracerebral hemorrhage outcomes. We re-analyzed the FAST (Factor-Seven-for-Acute-Hemorrhagic-Stroke) trial. Acute myocardial injury was defined as at least 1 cTnI value above the upper reference limit with a rise/fall of >20%. Logistic regression tested for associations (1) between acute myocardial injury (presence versus absence) and poor outcome (modified Rankin Scale 4-6) and mortality at 15 and 90 days; (2) among 3 groups (rising versus falling versus no acute myocardial injury) and outcomes. Among the 841 FAST participants, 785 patients were included. Acute myocardial injury was detected in 29% (n=227); 170 had rising cTnI. At 15 and 90 days, respectively, those with acute myocardial injury had higher odds of poor outcome (adjusted odds ratio) ([aOR] 2.3 [95% CI, 1.3-3.9]); and adjusted odds ratio 2.5 [95% CI, 1.6-3.9];, and higher odds of mortality (adjusted odds ratio 2.4 [95% CI, 1.4-4.3]; and adjusted odds ratio 2.2 [CI, 1.3-3.6]) than patients without. There was no interaction between FAST group assignment and myocardial injury, and associations between myocardial injury and outcomes were consistent across group assignments. Rising cTnI was associated with the highest risk of poor outcomes and mortality. In this secondary analysis of the FAST trial, acute myocardial injury was common and associated with poor outcomes. The direction of the cTnI change might provide additional risk stratification after intracerebral hemorrhage.

Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation: Cochrane systematic review and meta-analysis.

Depression and anxiety occur frequently in individuals with cardiovascular disease and are associated with poor prognosis. This Cochrane systematic review and meta-analysis assessed the effectiveness of psychological interventions on psychological and clinical outcomes in adults with coronary heart disease (CHD), heart failure (HF) or atrial fibrillation (AF). CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases were searched from January 2009 to July 2022 for randomised controlled trials of psychological interventions versus controls in adults with CHD, HF or AF. Twenty-one studies (n = 2591) were assessed using random-effects models. We found psychological interventions reduced depression (standardised mean difference [SMD] -0.36; 95% confidence interval [CI] -0.65 to -0.06; P = 0.02), anxiety (SMD -0.57; 95% CI -0.96 to -0.18; P = 0.004), and improved mental health-related quality of life (HRQoL) (SMD 0.63, 95% CI 0.01 to 1.26; P = 0.05) (follow-up 6-12 months), but not physical health-related quality of life, all-cause mortality or major adverse cardiovascular events compared with controls. High heterogeneity was present across meta-analyses. Meta-regression analysis showed that psychological interventions designed to target anxiety, were more effective than non-targeted interventions. This review found that psychological interventions improved depression, anxiety and mental HRQoL, with those targeting anxiety to show most benefit. Given the statistical heterogeneity, the precise magnitude of effects remains uncertain. Increasing use of multifactorial psychological interventions shows promise for incorporating patient needs and preferences. Investigation of those at high risk of poor outcomes, comparison of intervention components and those with AF is warranted.

Intensive Care Unit Management of Right Heart Failure and Lung Transplantation for Pulmonary Hypertension

: Pulmonary hypertension is associated with worse outcomes across systemic and cardiopulmonary conditions. Right ventricular (RV) dysfunction often leads to poor outcomes due to a progressive increase in RV afterload. Recognition and management of RV dysfunction are important to circumvent hospitalization and improve patient outcomes. Early recognition of patients at risk for RV failure is important to ensure that medical therapy is optimized and, where appropriate, referral for lung transplant assessment is undertaken. Patients initiated on parenteral prostanoids and those with persistent intermediate to high risk for poor outcomes should be referred. For patients with RV failure, identifying reversible causes should be a priority in conjunction with efforts to optimize RV preload and strategies to reduce RV afterload. Admission to a monitored environment where vasoactive medications can treat RV failure and its sequelae, such as renal dysfunction, is essential in patients with severe RV failure. Exit strategies need to be identified early on, with consideration and implementation of extracorporeal support for those in whom recovery or transplantation are viable options. Enlisting the skills and support of a palliative care team may improve the quality of life for patients with limited options and those with ongoing symptoms from heart failure in the face of medical treatments.

Stratified health care for low back pain using the STarT Back approach: Holy Grail or doomed to fail?

There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.

Investigation Into Potentially Inappropriate Prescribing Patterns of Loop Diuretics in a Nationally Representative Outpatient Population.

Loop diuretic therapy effectively treats edema related to heart failure, chronic kidney disease, and liver impairment; however, evidence supporting other indications is lacking. For indications such as hypertension or dependent edema or treatment of adverse events associated with other medications, the benefits likely do not outweigh the risks, putting patients at an unacceptably high risk of poor outcomes. What is the proportion of loop diuretic prescribing that occurs in the absence of a diagnosis of heart failure, chronic kidney disease, liver impairment, or other evidence-based indications? This was a national, retrospective, cross-sectional investigation conducted using the National Ambulatory Care Survey from 2013 to 2016. Outpatient visits for patients aged 18 years or older prescribed with loop diuretics were included. The primary end point was the frequency of potentially inappropriate loop diuretic prescribing. The secondary end point was a multivariable regression model that identified predictors of potentially inappropriate loop diuretic utilization. This analysis identified 5261 outpatient visits conducted during the study period in which loop diuretics were prescribed. Of these, 3648 visits (65.8% of weighted visits) were of patients without a history of heart failure, chronic kidney disease, or liver impairment. Positive predictors included age older than 65 years (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.38-2.13), concomitant calcium channel blocker (OR 1.42; 95% CI, 1.09-1.84), sodium-containing medication use (OR 2.78; 95% CI, 1.23-6.25), and office visit with a cardiology specialist (OR 2.84; 95% CI, 2.31-3.50). This analysis identified that loop diuretics are prescribed in the absence of evidence-based indications more frequently than they are prescribed for them. This prescribing pattern creates a unique opportunity for clinicians to optimize patient care. Further study of the outcomes associated with this prescribing pattern is warranted.

Forced vital capacity trajectories and risk of lung transplant and ILD-related mortality among patients with rheumatoid arthritis-associated interstitial lung disease.

We aimed to determine the prevalence and outcomes for forced vital capacity percent predicted (FVCpp) decline among patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). We identified patients with RA-ILD in the Mass General Brigham Healthcare system. RA-ILD diagnosis was determined by review of high-resolution computed tomography (HRCT) imaging by up to three thoracic radiologists. We abstracted FVCpp measurements, covariates, lung transplant, and ILD-related death from the medical record. We employed a relative FVCpp decline cutoff of > 10% within 24months. We also used a group-based trajectory model to obtain patterns of change from RA-ILD diagnosis. We then assessed for associations of each FVC decline definition with risk of lung transplant or ILD-related death using multivariable logistic regression. We analyzed 172 patients with RA-ILD with a median of 6 FVCpp measurements per patient over 6.5years of follow-up (mean age 62.2years, 36% male). There were seven (4%) lung transplants and 44 (26%) ILD-related deaths. Ninety-eight (57%) patients had relative decline of FVCpp by > 10% in 24months. We identified three trajectory groups of FVCpp change: rapidly declining (n = 24/168 [14%]), slowly declining (n = 90/168 [54%]), and stable/improving (n = 54/168 [32%]). The rapidly declining group and FVCpp > 10% had adjusted odds ratios (aOR) for lung transplant/ILD-related death of 19.2 (95%CI 4.9 to 75.5) and 2.8 (95%CI 1.3 to 6.1) respectively. Over half of patients with RA-ILD had declining FVCpp. The different trajectory patterns demonstrate the importance of FVC monitoring for identifying patients at the highest risk of poor outcomes. Key Points • Over half of patients with RA-ILD had declining FVCpp over a median of6.5years of follow-up. • The rapidly declining FVCpp trajectory group had stronger associations with lung transplant and ILD-related death compared to those with FVCpp decline by > 10%. • Clinicians can employ FVC monitoring to proactively treat patients who are at risk of poor outcomes.

A Nationwide Cohort Study of Delta and Omicron SARS-CoV-2 Outcomes in Vaccinated Individuals With Chronic Lung Disease

BackgroundIndividuals with chronic-lung-disease (CLD) are more susceptible to respiratory viral infections; however, there is significant heterogeneity in the literature on CLD and COVID-19 outcomes. Data is lacking on outcomes with newer variants (eg. Omicron) and in vaccinated/boosted populations. Research QuestionWhat are the outcomes of SARS-CoV-2 infection in individuals with CLD during Delta and Omicron transmission, in a highly vaccinated/boosted population-based cohort? Study Design and MethodsOutcomes of Delta/Omicron SARS-CoV-2 infection in a highly vaccinated/boosted cohort of adult Singaporeans with CLD (including asthma, chronic-obstructive-pulmonary-disease [COPD], bronchiectasis and pulmonary fibrosis) were contrasted against matched population controls. Calendar time-scale Cox regressions were used to compare risk of infection, COVID-19-related hospitalizations and severe COVID-19 disease, adjusting for sociodemographic factors/comorbidities. ResultsOverall, 68,782 individual patients with CLD and 534,364 matched population controls were included. 92.7% of CLD patients were boosted by the end of the Omicron wave. Compared with controls, higher risk of SARS-CoV-2 infection, COVID-19-related hospitalization and severe COVID-19 was observed amongst patients with CLD during both Delta (infection: adjusted-hazards-ratio, aHR=1.22[1.17-1.28]; hospitalization: aHR=1.76[1.61-1.92]; severe-COVID-19: aHR=1.75[1.50-2.05]) and Omicron waves (infection: aHR=1.15[1.14-1.17]; hospitalization: aHR=1.82[1.74-1.91]; severe-COVID-19: aHR=2.39[2.18-2.63]). During Omicron, significantly higher risk of infection, hospitalization and severe-COVID-19 was observed amongst patients with asthma (severe-COVID-19: aHR=1.31[1.10-1.55]) and COPD (severe-COVID-19: aHR=1.36[1.12-1.66]) compared with controls. Severe exacerbation (requiring hospitalization) in the preceding year was associated with higher risk of poorer outcomes (Delta-severe-COVID-19: aHR=9.84[6.33-15.28]; Omicron-severe-COVID-19: aHR=19.22[15.35-24.06]). Risk was attenuated in the boosted group, with numerically lower HRs against hospitalization/severe-COVID-19 in the 4-dose group compared with the 3-dose group. InterpretationIncreased risk of COVID-19-related hospitalization and severe-COVID-19 was observed amongst patients with CLD compared with matched population controls, during Delta/Omicron predominance. Boosting attenuated serious COVID-19 outcomes.

Derivation and Validation of a Scoring System for Predicting Poor Outcome After Posterior Circulation Ischemic Stroke in China.

Guidelines for posterior circulation ischemic stroke (PCIS) treatment are lacking and outcome prediction is crucial for patients and clinicians. We aimed to develop and validate a prognostic score to predict the poor outcome for patients with PCIS. The score was developed from a prospective derivation cohort named the Third China National Stroke Registry (August 2015-March 2018) and validated in a spatiotemporal independent validation cohort (December 2017-March 2023) in China. Patients with PCIS with acute infarctions defined as hyperintense lesions on diffusion-weighted imaging were included in this study. The poor outcome was measured as modified Rankin scale (mRS) score 3-6 at 3 months after PCIS. Multivariable logistic regression analysis was used to identify predictors for poor outcome. The prognostic score, namely PCIS Outcome Score (PCISOS), was developed by assigning points to variables based on their relative β-coefficients in the logistic model. The PCISOS was derived from 3,294 patients (median age 62 [interquartile range (IQR) 55-70] years; 2,250 [68.3%] men) and validated in 501 patients (median age 61 [IQR 53-68] years; 404 [80.6%] men). Among them, 384 (11.7%) and 64 (12.8%) had poor outcome 3 months after stroke in respective cohorts. Age, mRS before admission, NIH Stroke Scale on admission, ischemic stroke history, infarction distribution, basilar artery, and posterior cerebral artery stenosis or occlusion were identified as independent predictors for poor outcome and included in PCISOS. This easy-to-use integer scoring system identified a marked risk gradient between 4 risk groups. PCISOS performed better than previous scores, with an excellent discrimination (C statistic) of 0.80 (95% CI 0.77-0.83) in the derivation cohort and 0.81 (95% CI 0.77-0.84) in the validation cohort. Calibration test showed high agreement between the predicted and observed outcomes in both cohorts. PCISOS can be applied for patients with PCIS with acute infarctions to predict functional outcome at 3 months post-PCIS. This simple tool helps clinicians to identify patients with PCIS with higher risk of poor outcome and provides reliable outcome expectations for patients. This information might be used for personalized rehabilitation plan and patient selection for future clinical trials to reduce disability and mortality.

Community participation disparities among people with disabilities during the COVID-19 pandemic

Purpose To describe disparities in community participation during the COVID-19 pandemic among people with disabilities. Methods Respondents to Phase 3.3 of the COVID Household Pulse Survey (US Census Bureau) were classified by disability status. Risk ratios and risk differences were computed to compare the risk of poor outcomes on economic participation, community service use, and community activities by disability status - both overall (compared to the nondisabled reference) and by race/ethnicity (each subgroup compared to the White nondisabled reference). Results At least one type of disability was reported by 59.6% of respondents. People with disabilities were more likely to report in-person medical appointments but were at greater risk of poor outcomes across all other outcomes [risk ratio range = 1.01(1.01–1.02) to 1.91(1.80–2.01), risk difference range = 1.0(0.5–1.5) to 13.4(12.6–14.2)]. The disabled Black and disabled Hispanic/Latino groups experienced disproportionately high risk of poor outcomes across all indicators [risk ratio range = 1.0 (1.0–1.1) to 6.1 (5.0–7.1), risk difference range = 3.2 (1.9–4.4) to 33.1 (30.1–35.4)]. Conclusions The high number of people reporting disability, along with the notable disparities in community participation outcomes among those reporting disability, suggest the need for expanded rehabilitation services and community supports to enhance participation.