Impact Patient Outcomes Research Articles

Multiple Types of Cancer Classification Using Histopathological Images Based on Learning Without Forgetting Powered Deep Learning Models

Cancer detection represents a paramount challenge in modern medicine, where the ability to accurately identify malignancies across various anatomical regions can profoundly impact patient outcomes. In this study, we introduce an innovative approach for the simultaneous detection of brain, lung, and breast cancers using histopathological images, which are rich in cellular information critical for diagnosis. Through the utilization of Convolutional Neural Networks (CNNs), our system achieves remarkable accuracy in distinguishing cancerous tissues amidst complex histological backgrounds. The seamless integration of CNN models with Flask for backend deployment and HTML, CSS, and Python for frontend web development ensures a user-friendly interface conducive to both healthcare professionals and patients. Extensive validation of our methodology, conducted on diverse datasets encompassing a spectrum of cancer types and stages, underscores its robustness and reliability. The results obtained showcase not only the high accuracy of our system in detecting individual cancer types but also its versatility in concurrently predicting multiple malignancies. Furthermore, our approach demonstrates promising generalization capabilities, indicating its potential applicability across various healthcare settings and patient populations. By harnessing the power of advanced machine learning techniques, our research represents a significant leap forward in the realm of cancer diagnostics. The implementation of our methodology has the potential to revolutionize clinical practice by enabling earlier detection, personalized treatment planning, and improved patient outcomes.

Frequency Of Anxiety in Pre-Operative Surgical Patients in the Tertiary Care Hospitals, Karachi

Background: Preoperative anxiety significantly impacts patient outcomes and healthcare delivery, with varying degrees of prevalence reported globally. Understanding and managing this anxiety are crucial for improving surgical experiences and patient recovery. This study focuses on tertiary care hospitals in Karachi, aiming to elucidate the frequency and determinants of preoperative anxiety among elective surgery patients. Objective: To ascertain the prevalence of preoperative anxiety among patients awaiting elective surgeries in various surgical units of tertiary care hospitals in Karachi and to identify significant contributing factors. Methods: In a prospective cross-sectional design, 400 patients scheduled for elective surgeries across six surgical units were assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). SPSS version 24 facilitated the analysis, focusing on global anxiety prevalence and its associations with demographic and clinical variables. Results: The study revealed a 62.0% prevalence of preoperative global anxiety. The APAIS scores indicated higher anxiety related to the surgery (mean = 7.27 ± 2.31) compared to anesthesia (mean = 5.14 ± 2.35). Significant associations were found between anxiety levels and age groups (p=0.002), surgical procedures (p<0.001), and type of anesthesia (p<0.001). ENT and urology patients exhibited notably higher anxiety, at 75.0% and 68.0% respectively. Multivariate analysis demonstrated a significant impact of gender on preoperative anxiety, with females showing increased vulnerability [aOR 1.91 (95% CI 1.13-3.21); p=0.015]. Conclusion: Preoperative anxiety remains a prevalent concern, with female patients exhibiting higher levels of anxiety than their male counterparts. The findings advocate for targeted counseling and informational support for patients, especially females, prior to surgery and anesthesia consultations, underscoring the need for healthcare professionals to address and mitigate preoperative anxiety effectively.

Abstract 6189: Deep-learning model trained on multiplex immunofluorescence-stained tissue samples predicts the survival of patients with non-small cell lung cancer better than PD-L1 TPS alone

Abstract In non-small cell lung cancer (NSCLC), the composition and structure of the tumor immune microenvironment (TME) critically impact patient outcomes, necessitating improved computational approaches to characterize the TME beyond traditional metrics like the PD-L1 tumor proportion score (TPS). Here, we developed an interpretable deep-learning model that robustly predicts patient overall survival (OS) and identifies unique PD-L1 enriched neighborhoods linked to patient prognosis. We utilized a dataset of 507 NSCLC patient biopsy samples prospectively acquired as part of the DFCI ImmunoPROFILE project. Each sample was stained for Cytokeratin as tumor marker, PD-L1, PD-1, CD8, and FOXP3 using a targeted multiplex immunofluorescence assay. Inner tumor regions of interest were automatically processed for spatially resolved identification and quantification of marker expression at the single-cell level. The dataset was divided into 380 patients for model development and 127 for testing. The deep-learning model, a graph neural network (GNN), was trained to predict OS based on local cell neighborhoods using a weakly supervised training paradigm. The GNN models neighborhoods as a graph, with cells and their corresponding marker expression representing nodes and edges connecting adjacent cells, for an average of 42 cells per neighborhood. Survival predictions were obtained by averaging predictions over all neighborhoods from one sample. The GNN model demonstrated robust performance with a concordance index (c-index) of 0.79 on the test data, surpassing traditional metrics such as TPS and immune marker density-based models (c-index: 0.50 and 0.74, respectively). Beyond assessing performance, we investigated the features learned by the GNN using k-means clustering in the model’s feature space. We identified three clusters that were notably enriched in PD-L1 positive tumor cells. The first cluster shows an especially “high TPS” phenotype, where the GNN predicted such neighborhoods to be generally poor for survival. The other two clusters were additionally enriched with PD-L1 positive immune cells (ICs) and associated with favorable survival predictions. Notably, one cluster was also enriched with other types of ICs (”PD-L1 IC mixed”), which the GNN predicted as especially favorable for survival compared to exclusive enrichment of PD-L1 ICs (”PD-L1 IC dominant”). A score summarizing these three PD-L1 expression patterns was significantly associated with OS (p-value: 0.01; HR: 0.72, 95% CI: 0.16-1.27), validating the features learned by the GNN. In sum, we developed a highly interpretable deep-learning model leveraging cellular neighborhood graphs, which effectively identifies expression patterns correlating with NSCLC prognosis, offering promise for developing personalized treatment strategies. Citation Format: Katharina Viktoria Hoebel, James R. Lindsay, Joao V. Alessi, Jason L. Weirather, Ian D. Dryg, Jennifer Altreuter, Mark M. Awad, Scott J. Rodig, William E. Lotter. Deep-learning model trained on multiplex immunofluorescence-stained tissue samples predicts the survival of patients with non-small cell lung cancer better than PD-L1 TPS alone [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6189.

IMPACT OF MALNUTRITION ON PEDIATRIC HEART FAILURE ANALYZING Z-SCORES AT PRESENTATION

Pediatric heart failure represents a critical health concern characterized by the heart's inability to effectively pump blood, often resulting from congenital heart defects, myocarditis, and cardiomyopathies. Malnutrition has emerged as a recognized comorbidity in pediatric heart failure, significantly impacting patient outcomes. This study aimed to investigate the relationship between malnutrition and pediatric heart failure by analyzing Z-scores at presentation to guide targeted interventions and improve patient management. The study employed a retrospective observational design and was conducted at the Department of Pediatric Cardiology, Lady Reading Hospital, Peshawar, from January 2023 to January 2024. A total of 764 pediatric patients with heart failure were included in the analysis. Nutritional status was assessed using weight and height measurements, and Z-scores were calculated based on WHO Child Growth Standards. Data analysis was performed using IBM SPSS version 22. Results revealed varying degrees of malnutrition among pediatric heart failure patients, with 62.8% classified as severely malnourished, 28.4% as moderately malnourished, and 8.8% as mildly malnourished. The calculated Z-score of -3.2 indicated significant malnutrition among the study population. Furthermore, a negative correlation (r = -0.32, p < 0.001) between Z-score and left ventricular ejection fraction was observed, suggesting a link between malnutrition severity and cardiac dysfunction. These findings underscore the high prevalence of malnutrition among pediatric heart failure patients and its substantial impact on outcomes. Early nutritional assessment and intervention are crucial for optimizing patient care and enhancing outcomes in children with heart failure. Collaborative, multidisciplinary approaches that integrate cardiac and nutritional management strategies can comprehensively address the diverse needs of this vulnerable population.

Abstract 2064: Unveiling the correlation between gemtuzumab-ozogamicin efficacy and CD33+ expression in AML primary samples using the novel AML vitroscreen

Abstract Acute myeloid leukemia (AML) poses a significant therapeutic challenge, with a rising incidence in recent times. This clonal hematopoietic disorder of progenitor and stem cells exhibits aggressive behavior, and despite initial remission, recurrence is common1. The conventional shift from chemotherapy to monoclonal antibodies and antibody-drug conjugates (ADCs) has been hindered by the absence of AML-specific antigens. Notably, CD33, expressed strongly in 80-90% of AML cells, has become a target for gemtuzumab-ozogamicin (Mylotarg), the sole FDA approved ADC for AML treatment2. While advancements in understanding AML molecular mechanisms have influenced clinical approaches, the lack of clinically representative models hinders therapeutic progress. Existing models, both in vivo and ex vivo, struggle to capture the heterogeneity and complexity of AML3. Addressing this, we present our proprietary assay, Champions AML VitroScreen®4, designed for testing therapeutic candidates in primary AML samples. Our diverse bank of deeply characterized AML samples encompasses multiple subtypes, allowing evaluation of therapeutic responses through cell viability, proliferation, and clonal composition analyses. To validate our novel assay, we employed the VitroScreen platform to test Mylotarg across various AML subtypes, considering CD33 expression levels. By assessing more than 20 AML models, we determined the IC50 for Mylotarg and observed dose-dependent responses, where sensitivity to the drugh correlated with CD33 expression. Through multiple endpoints, including viability, proliferation, apoptosis, and phenotyping, we categorized primary AML models as responders, low responders, or resistant, establishing a strong positive correlation between Mylotarg sensitivity and CD33 expression. Our innovative approach, utilizing deeply characterized AML patient samples in the AML VitroScreen® platform, facilitates high-throughput drug testing. This system, serving as an ideal clinical translational setting in preclinical research, holds promise for developing tailored therapeutic strategies. Ultimately, this approach could significantly impact patient outcomes by offering improved strategies for both primary and recurrent AML cases. Citation Format: Mara Gilardi, Garima Kaushik, Brandon Walling, Paolo Schiavini, Stefano Cairo, Marianna Zipeto. Unveiling the correlation between gemtuzumab-ozogamicin efficacy and CD33+ expression in AML primary samples using the novel AML vitroscreen [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2064.

Presenting Off-Hours, Door-to-Balloon Time, and Clinical Results in Patients Primary Percutaneous Coronary Intervention

Background: The timely management of ST-segment elevation myocardial infarction (STEMI) through primary percutaneous coronary intervention (PCI) significantly impacts patient outcomes. However, the influence of off-hours presentation (nights, weekends, and holidays) on door-to-balloon (D2B) time and clinical outcomes remains a pivotal concern, as it potentially affects the efficiency of care and patient prognosis. Objective: This study aims to evaluate the association between off-hours presentation, D2B time, and clinical outcomes in patients undergoing primary PCI for STEMI, to identify potential disparities in treatment efficacy and to inform strategies for improving cardiovascular emergency care. Methods: Conducting a retrospective cross-sectional analysis, this study included 90 patients admitted with STEMI who underwent primary PCI at a tertiary care center between March 2022 and March 2023. Patients were stratified into two groups based on the timing of hospital presentation: off-hours and regular hours. Primary outcomes assessed were D2B time, mortality rates, and incidences of cardiogenic shock and heart failure. Data were analyzed using descriptive statistics, t-tests, chi-square tests, and multivariable logistic regression to adjust for potential confounders. Results: The mean D2B time for patients presenting during off-hours was significantly longer (96.4 ± 12.3 minutes) compared to those presenting during regular hours (84.6 ± 9.8 minutes, p<0.001). No statistically significant differences were observed in mortality rates (off-hours 4.4% vs. regular hours 6.7%, p=0.155), cardiogenic shock (off-hours 6.7% vs. regular hours 4.4%, p=0.351), or heart failure (off-hours 8.9% vs. regular hours 6.7%, p=0.214). Multivariable analysis confirmed off-hours presentation as an independent predictor of prolonged D2B time (coefficient 11.8, 95% CI 8.2-15.5). Conclusion: Off-hours presentation is associated with significantly longer D2B times in STEMI patients undergoing primary PCI, underscoring the need for healthcare systems to address the disparities in care delivery during off-hours. However, no significant differences in short-term clinical outcomes were observed, suggesting that factors beyond D2B time contribute to patient prognosis. Further studies are warranted to explore comprehensive strategies to optimize care irrespective of presentation time.

Clinical features and risk factors of primary Sjögren's syndrome complicated with severe pneumonia: a case-control study.

To analyze clinical characteristics, risk factors, pathogen distribution, and prognostic markers in primary Sjögren's syndrome (pSS) patients with severe pneumonia (SP) compared to those without severe pneumonia (NSP). This case-control study included 24 hospitalized pSS patients with SP and 96 NSP at the first affiliated hospital of Soochow university from June 2014 to May 2023. Data encompassing demographics, comorbidities, treatments, and laboratory results were retrospectively collected. Univariate and multivariate regression analyses, ROC curves, and statistical analyses using SPSS 23.0 assessed risk factors. The study retrospectively analyzed clinical features and risk factors, highlighting distinct parameters between pSS patients with and without SP. Marked differences were observed in several parameters: pSS activity(P < 0.001), white blood cell (P = 0.043), lymphocyte (P < 0.001), neutrophils (P = 0.042), C-reactive protein (P = 0.042), and CD8+ T cell (P = 0.017). Notably, lymphocyte count and SS activity demonstrated robust discrimination ability (AUC > 0.85). C-reactive protein (CRP), procalcitonin, CD4+ T cell, and IgA showed significant associations with SP; higher CRP levels correlated with increased risk, while lower CD4+ T cell and IgA levels associated with increased risk. SS activity significantly impacted outcomes. Various biomarkers exhibited diverse discriminatory abilities but lacked strong predictive associations with outcomes. pSS patients with SP exhibited higher disease activity and altered immune profiles compared to those NSP. Lymphocyte count and SS activity emerged as robust discriminators. Higher CRP levels correlated with increased risk of SP, while lower CD4+T cell and IgA levels associated with increased risk. SS activity significantly impacted patient outcomes. Key Points • pSS patients with SP exhibited higher disease activity and altered immune profiles compared to those NSP. • Lymphocyte count and SS activity emerged as robust discriminators. • Higher CRP levels correlated with increased risk of SP, while lower CD4+ T cell and IgA levels associated with decreased risk. • SS activity significantly impacted patient outcomes.

Oncological Surgical Wound Care: A Comparison of Theruptor NXT Non-adherent Dressing and the Current Standard of Care.

Background Oncological surgeries pose an elevated risk of surgical site infections (SSIs) due to their complexity and various associated treatments, impacting patient outcomes and healthcare costs. This has prompted a focus on advanced wound dressings that provide microbial protection, exudate absorption, and improved product performance, enhancing patient satisfaction. Our study aimed tocompare the efficacy and safety of Theruptor NXT with the current standard of care (SOC) practice involving cotton/povidone/micropore dressings in the postoperative wound management of oncological surgeries. Methodology A total of 102 patients who underwent oncological surgeries in the Department of Surgical Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, India between May and September 2023 were randomized to Theruptor NXT and SOC dressing groups (51 patients each). The incidence of SSIs, wound pain score, cosmetic appearance of the wound, and adverse events were assessed in the two groups at various intervals, i.e., post-surgery day 2 ± 1, day of discharge, and post-surgery day 30 ± 7. Further, the subject satisfaction and product usage were evaluated on post-surgery day 2 ± 1. Results The baseline characteristics were found to be comparable in both groups, i.e., Theruptor NXT and SOC groups. Further, the SSI rates, scar outcomes, and physiological parameters were also similar between the Theruptor NXT and SOC groups, indicating a similar safety profile of both dressings (p > 0.05). However, the product usage assessment revealed statistically significant differences, favoring Theruptor NXT in terms of superior ease of application, stretchability, exudate management, breathability, and non-adherence properties (p < 0.05). Conclusions Our findings suggest that Theruptor NXT wound dressing is a promising, effective, and user-friendly alternative to SOC wound dressing in diverse clinical settings.

Feasibility of Fluid Responsiveness Assessment in Patients at Risk for Increased Intracranial Pressure.

Background: Effective fluid management is important for patients at risk of increased intracranial pressure (ICP). Maintaining constant cerebral perfusion represents a challenge, as both hypovolemia and fluid overload can severely impact patient outcomes. Fluid responsiveness tests, commonly used in critical care settings, are often deemed potentially hazardous for these patients due to the risk of disrupting cerebral perfusion. Methods: This single-center, prospective, clinical observational study enrolled 40 patients at risk for increased ICP, including those with acute brain injury. Informed consent was obtained from each participant or their legal guardians before inclusion. The study focused on the dynamics of ICP and cerebral perfusion pressure (CPP) changes during the Passive Leg Raise Test (PLRT) and the End-Expiratory Occlusion Test (EEOT). Results: The results demonstrated that PLRT and EEOT caused minor and transient increases in ICP, while consistently maintaining stable CPP. EEOT induced significantly lower ICP elevations, making it particularly suitable for use in high-risk situations. Conclusions: PLRT and EEOT can be considered feasible and safe for assessing fluid responsiveness in patients at risk for increased ICP. Notably, EEOT stands out as a preferred method for high-risk patients, offering a dependable strategy for fluid management without compromising cerebral hemodynamics.

Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations

BackgroundPharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care.MethodsThis study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site’s capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber).DiscussionThis study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients’ access to MOUD and treatment outcomes.Trial registration: The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www.clinicaltrials.gov/study/NCT05310786?id=NCT05310786&rank=1

Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery

In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25minute(95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P>.9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P<.001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P=.039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

Design Decision Support for Healthcare Architecture: A VR-Integrated Approach for Measuring User Perception

Changing the physical environment of healthcare facilities can positively impact patient outcomes. Virtual reality (VR) offers the potential to understand how healthcare environment design impacts users’ perception, particularly among those with brain injuries like stroke, an area with limited research. In this study, our objective was to forge a new pathway in healthcare environment research by developing a comprehensive, six-module ‘user-centered’ design decision support approach, utilizing VR technology. This innovative method integrated patient engagement, architectural design principles, BIM prototyping, and a sophisticated VR user interface to produce realistic and immersive healthcare scenarios. Forty-four stroke survivors participated, experiencing 32 VR scenarios of in-patient bedrooms, followed by interactive in-VR questions and semi-structured interviews. The results of the approach proved to be comparatively efficient and feasible, provided a high level of immersion and presence for the participants, and effectively elicited extremely rich quantifiable response data, which revealed distinct environmental preferences. Our novel approach to understanding end-user responses to stroke rehabilitation architecture demonstrates potential to inform user-centered evidence-based design decisions in healthcare, to improve user experiences and health outcomes in other healthcare populations and environments.

Effects of COVID-19 Pandemic on the Diagnosis of Melanoma and Keratinocyte Carcinomas: a Systematic Review and Meta-analysis.

Since December 2019, the COVID-19 pandemic has profoundly affected healthcare. The real effects of the COVID-19 pandemic on skin cancer are still unclear, more than 3 years later. This study aims to summarise the pandemic's impact on skin cancer diagnosis and outcome. A systematic review and meta-analysis was conducted, selecting studies comparing skin cancer diagnosis and prognosis post-pandemic with pre-pandemic data. A total of 27 papers were reviewed including 102,263 melanomas and 271,483 keratinocyte carcinomas. During the initial pandemic months (January-July 2020), melanoma surgeries dropped by 29.7% and keratinocyte carcinomas surgeries by 50.8%. Early pandemic tumours exhibited greater thickness and stage. In a long-term period beyond the initial months, melanoma surgeries decreased by 9.3%, keratinocyte carcinomas by 16.6%. No significant differences were observed in the Breslow thickness of melanomas after the start of the pandemic (mean difference 0.06, 95% confidence interval -0.46, 0.58). Melanomas operated on post-pandemic onset had an increased risk of ulceration (odds ratio 1.35, 95% confidence interval 1.22-1.50). Keratinocyte carcinomas showed increased thickness and worsened stage post-pandemic. However, studies included were mostly retrospective and cross-sectional, reporting diverse data. This review indicates that the pandemic likely caused delays in skin cancer diagnosis and treatment, potentially impacting patient outcomes.

Retrospective Comparison of Upper and Lower Extremity Intraosseous Access During Out-of-Hospital Cardiac Arrest Resuscitation

Objective Intraosseous (IO) access is frequently utilized during the resuscitation of out-of-hospital cardiac arrest (OHCA) patients. Due to proximity to the heart and differential flow rates, the anatomical site of IO access may impact patient outcomes. Using a large dataset, we aimed to compare the outcomes of OHCA patients who received upper or lower extremity IO access during resuscitation. Methods The ESO Data Collaborative public use research datasets were used for this retrospective study. All adult (≥18 years of age) OHCA patients with successful IO access in an upper or lower extremity were evaluated for inclusion. Patients were excluded if they had intravenous (IV) access prior to IO access, or if they had a Do Not Resuscitate order documented. Our primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included survival to discharge and survival to discharge to home. Mixed-effects multivariable logistic regression models adjusted for age, sex, etiology, witnessed status, pre-first responder cardiopulmonary resuscitation (CPR), initial electrocardiogram (ECG) rhythm, location [private/residential, public, or assisted living/institutional], and response time in addition to the primary airway management strategy (endotracheal intubation, supraglottic device, surgical airway, no advanced airway) were used to compare the outcomes of patients with upper extremity IO access to the outcomes of patients with lower extremity IO access. Results After application of exclusion criteria, 155,884 patients who received IO access during resuscitation remained (76% lower extremity, 24% upper extremity). Upper extremity IO access was associated with greater adjusted odds of ROSC (1.11 [1.08, 1.15]), and this finding was consistent across multiple patient subgroups. Secondary analyses suggested that upper extremity access was associated with increased survival to discharge (1.18 [1.00, 1.39]) and survival to discharge to home (1.23 [1.02, 1.48]) in comparison to lower extremity IO access. Conclusion In this large prehospital dataset, upper extremity IO access was associated with a small increase in the odds of ROSC in comparison to lower extremity IO access. These data support the need for prospective investigation of the ideal IO access site during OHCA resuscitation.

Rapid presentation of a de novo intracranial aneurysm: illustrative case.

Intracranial aneurysms are prevalent, particularly with advancing age. De novo aneurysms, occurring independently from the initial lesion, pose a unique challenge because of their unpredictable nature. Although risk factors such as female sex, smoking history, and hypertension have been proposed, the mechanisms underlying de novo aneurysm development remain unclear. A 79-year-old female developed a de novo saccular aneurysm within a year after management of a ruptured vertebral artery dissecting aneurysm. Her complex clinical course involved subarachnoid hemorrhage with diffuse vasospasm, stent occlusion of a dissecting aneurysm, discovery of a right 7- to 8-mm de novo middle cerebral artery aneurysm at the 1-year magnetic resonance angiography follow-up, and successful coil embolization. This rare occurrence challenges established timelines, as most de novo aneurysms manifest over a longer interval. Studies have attempted to identify risk factors, yet consensus remains elusive, particularly regarding the influence of treatment modality on de novo formation rates. This unique case urges reconsideration of posttreatment surveillance protocols, proposing shorter intervals for imaging and more vigilant follow-up strategies to detect asymptomatic de novo aneurysms. Timelier identification could significantly impact patient outcomes by averting potential ruptures. This emphasizes the need for further research to delineate effective monitoring and preventive measures for these enigmatic lesions.

Durable pulmonary vein isolationwith optimized high-power and very high-power short-duration temperature-controlled ablation: A step-by-step guide.

Through systematic scientific rigor, the CLOSE guided workflow was developed and has been shown to improve pulmonary vein isolation durability. However, this technique was developed at a time when using power-controlled ablation catheters with conventional power ranges was the norm. There has been increased adoption of a high-power and very high-power short-duration ablation practice propelled by the availability of the temperature-controlled radiofrequency QDOT MICRO catheter. There are fundamental differences in biophysics between very high-powered temperature guided ablation and conventional ablation strategy that may impact patient outcomes. The catheter's design and ablation modes offer flexibility in technique while accommodating the individual operator's clinical discretion and preference to deliver a durable, transmural, and contiguous lesion set. Here, we provide recommendations for 3 different workflows using the QDOT MICRO catheter in a step-by-step manner for pulmonary vein isolation based on our cumulative experience as early adopters of the technology and the data available in the scientific literature. With standardization, temperature-controlled ablation with the QDOT MICRO catheter provides operators the flexibility of implementing different ablation strategies to ensure durable contiguous pulmonary vein isolation depending on patient characteristics.

Predictors for anaemia, blood transfusion and outcome in plastic surgery patients.

In patients undergoing plastic surgery, to identify specific risk factors for anaemia and use of blood products, and assess their impact on patient outcome. For this retrospective study, data were analysed from patients who attended the Plastic Surgery Department at our hospital over a three-year period (2018 to 2020). Adult patients who presented with traumatic injuries, oncologic patients who underwent reconstructive procedures, and patients with soft tissue infections (STIs) who required plastic surgery for tissue coverage were included. Demographic and injury data, hospital admission characteristics, surgical procedures, laboratory test results, transfusion events, and in-hospital complications were extracted from patient records. Of the 350 patients included in the study, 228 (65%) presented with trauma, 76 (22%) underwent reconstructive surgery for cancers and 46 (13%) had STIs. In total, 175 (50%) patients developed anaemia, and 37 (11%) received blood transfusions; these were 20 (54%), 5 (14%), and 12 (32%) patients in the trauma, cancer and STI groups, respectively. Associated comorbidities and upper and lower limb surgery were the most significant risk factors for anaemia, while the number of surgeries and NSTIs were identified as risk factors for blood transfusions. Direct wound closure was consistently a protective factor for both anaemia and blood transfusions. Blood transfusions were independently associated with a high risk of sepsis, wound complications, and prolonged hospital stay. While transfusions are necessary and even lifesaving in surgical patients, blood is a finite resource and its use may negatively impact patient outcome. Therefore, ongoing research must focus on providing safe and restrictive clinical practices while developing sustainable and accessible alternatives.

Planting the Seed for Blood Pressure Control: The Role of Plant-Based Nutrition in the Management of Hypertension.

Hypertension results in significant morbidity, mortality, and healthcare expenditures. Fortunately, it is largely preventable and treatable by implementing dietary interventions, though these remain underutilized. Here, we aim to explore the role of healthy dietary patterns in hypertension management and describe approaches for busy clinicians to address nutrition effectively and efficiently with patients. DASH, Mediterranean, vegetarian, and vegan diets that include minimally processed, plant-based foods as core elements have consistently shown positive effects on hypertension. Recommendations that distill the most healthful components of these diets can significantly impact patient outcomes. Clinicians can harness evidence-based dietary assessment and counseling tools to implement and support behavioral changes, even during brief office visits. Healthful plant-based dietary patterns can often effectively prevent and treat hypertension. Clinicians may help improve patient outcomes by discussing evidence-based nutrition with their patients. Future work to promote infrastructural change that supports incorporating evidence-based nutrition into medical education, clinical care, and society at large can support these efforts.

Improved Waitlist Outcomes in Liver Transplant Patients With Mid-MELD-Na Scores Listed in Centers Receptive to Use of Organs Donated After Circulatory Death.

Liver transplant (LT) using organs donated after circulatory death (DCD) has been increasing in the United States. We investigated whether transplant centers' receptiveness to use of DCD organs impacted patient outcomes. Transplant centers were classified as very receptive (group 1), receptive (2), or less receptive (3) based on the DCD acceptance rate and DCD transplant percentage. Using organ procurement and transplantation network/UNOS registry data for 20 435 patients listed for LT from January 2020 to June 2022, we compared rates of 1-y transplant probability and waitlist mortality between groups, broken down by model for end-stage liver disease-sodium (MELD-Na) categories. In adjusted analyses, patients in group 1 centers with MELD-Na scores 6 to 29 were significantly more likely to undergo transplant than those in group 3 (aHR range 1.51-2.11, P < 0.001). Results were similar in comparisons between groups 1 and 2 (aHR range 1.41-1.81, P < 0.001) and between groups 2 and 3 with MELD-Na 15-24 (aHR 1.19-1.20, P < 0.007). Likewise, patients with MELD-Na score 20 to 29 in group 1 centers had lower waitlist mortality than those in group 3 (scores, 20-24: aHR, 0.71, P = 0.03; score, 25-29: aHR, 0.51, P < 0.001); those in group 1 also had lower waitlist mortality compared with group 2 (scores 20-24: aHR0.69, P = 0.02; scores 25-29: aHR 0.63, P = 0.03). One-year posttransplant survival of DCD LT patients did not vary significantly compared with donation after brain dead. We conclude that transplant centers' use of DCD livers can improve waitlist outcomes, particularly among mid-MELD-Na patients.

Debunking the July Effect in lung transplantation recipients

ObjectiveThe “July Effect” is a theory that the influx of trainees from July to September negatively impacts patient outcomes. We aimed to study this theoretical phenomenon in lung transplant recipients given the highly technical nature of thoracic procedures. MethodsAdult lung transplant hospitalizations were identified within the National Inpatient Sample (2005-2020). Recipients were categorized as academic Q1 (July to September) or Q2-Q4 (October to June). In-hospital mortality, operator-driven complications (pneumothorax, dehiscence including wound dehiscence, bronchial anastomosis, and others, and vocal cord/diaphragm paralysis, all 3 treated as a composite outcome), length of stay, and inflation-adjusted hospitalization charges were compared between both groups. Multivariable logistic regression was performed to assess the association between academic quarter and in-hospital mortality and operator-driven complications. The models were adjusted for recipient demographics and transplant characteristics. Subgroup analysis was performed between academic and nonacademic hospitals. ResultsOf 30,788 lung transplants, 7838 occurred in Q1 and 22,950 occurred in Q2-Q4. Recipient demographic and clinical characteristics were similar between groups. Dehiscence (n = 922, 4% vs n = 236, 3%), post-transplant cardiac arrest (n = 532, 2% vs n = 113, 1%), and pulmonary embolism (n = 712, 3% vs n = 164, 2%) were more common in Q2-Q4 versus Q1 recipients (all P < .05). Other operator-driven complications, in-hospital mortality, and resource use were similar between groups (P > .05). These inferences remained unchanged in adjusted analyses and on subgroup analyses of academic versus nonacademic hospitals. ConclusionsThe “July Effect” is not evident in US lung transplantation recipient outcomes during the transplant hospitalization. This suggests that current institutional monitoring systems for trainees across multiple specialties, including surgery, anesthesia, critical care, nursing, and others, are robust.