Large Tertiary University Hospital Research Articles

Analysis of factors influencing the choice for a centre for obstetrical and gynaecological patients.

The purpose of this study was to analyse the factors that influence patients` choice of obstetric and gynaecological medical centre. Patients attending the gynaecological and obstetric outpatient department (gyn./obs.) at a large tertiary university hospital were asked to voluntarily complete an anonymous 34-item-questionnaire on factors influencing their choice of medical centre at a large tertiary university hospital. Apart from epidemiological factors the preferences were analysed using a Likert scale of 1-5 (1 least, 5 most). Between 10/2023 and 04/2024, 445 outpatients (170 gynaecological, 275 obstetric) were included. In both outpatient departments (gynaecological/obstetric), the most important factors (4&5/5 possible points) were considered to be clear communication (90%/92%), sufficient time for consultation with the medical staff (90%/90%), friendly care (89%/92%), good professional qualifications (86%/89%), treatment according to the latest findings (85%/86%) and empathy (83%/91%). The following factors were considered less important: Doctor's degree was considered important by only 31%/28%, appearance by 32%/35%, internet rating by 41%/36% and professional background by 35%/38% of patients. Regarding organisational structures, medical care was most important (91%/93%), followed by availability by telephone or e-mail (88%/82%), clear communication of possible costs (79%/76%) and organisation of consultations (76%/69%). Less important were short waiting times (67%/63%), flexible opening hours (63%/56%), the facilities (46%/68%) and the location (43%/66%). Patients often prioritise interpersonal factors when choosing a centre for medical treatment, external factors such as academic qualifications or organisational issues appear to be less important. While it is unsurprising that the best medical treatment is of paramount importance, the other findings can help to increase patients´ satisfaction and experience of the treatment.

Prognostic impact of left ventricular ejection fraction improvement after transcatheter aortic valve replacement

Abstract Introduction Transcatheter aortic valve replacement (TAVR) has become an efficient and save alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) is known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to improvement in LVEF. So far, little is known about the prognostic implication of LVEF-improvement as a sole predictor of outcomes. Purpose The aim of this study was to assess the prognostic significance of early LVEF improvement in patients undergoing TAVR. Materials and Methods Patients undergoing TAVR in a large tertiary university hospital have been consecutively included in a large prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after TAVR before discharge, at 1 month and annually thereafter. Significant LVEF improvement was defined as >10% relative increase of LVEF at 30 days compared to baseline LVEF. Primary outcome was all-cause mortality at 5 years. Secondary outcome were major adverse cardiovascular events (MACE), including death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve. Results Among 1481 patients undergoing TAVR between September 2011 and June 2023, LVEF at baseline and at 30 days was available in 1013 patients. 665 patients (65.6%) had normal LVEF at baseline, whereas 348 patients (34.4%) had a reduced LVEF. Of these, 137 patients (13.5%) showed significant improvement of LVEF ≥10%) after 30 days, while 266 patients (26.3%) showed no significant LVEF-improvement (<10%). The combined patients with persevered LVEF at baseline had significantly better outcomes than those with impaired EF (p=<0.001). LVEF improvement was not associated with mortality at 5 years (p= 0.51), however with lower MACE rate at 5 years (p=0,024). Conclusion Normal LVEF before TAVR is an independent predictor for improved outcomes. In addition, early improvement of LVEF is associated with beneficial outcomes in patients undergoing TAVR.Course of LVEF after TAVROutcomes after TAVR

Metabolic Profiles of Critically Ill COVID-19 Patients: A Comparative Analysis of Energy Expenditure.

Introduction and aims The COVID-19 pandemic has placed a significant burden on healthcare systems worldwide, especially in the management of critically ill patients. Accurate assessment of energy expenditure (EE) is crucial for providing optimal nutritional support and improving clinical outcomes in these patients. Indirect calorimetry (IC) is the preferred method for measuring EE, yet its use in critically ill COVID-19 patients has not been extensively documented. This study aims to evaluate EE in critically ill patients with and without COVID-19 to identify differences that may impact nutritional support strategies. Methods We conducted a retrospective observational study at a large tertiary university hospital, focusing on critically ill patients. The study compared calorimetry data between patients with and without COVID-19. Data collected included resting energy expenditure, energy expenditure per kilogram, and respiratory exchange rate quotient using IC. Statistical analysis was conducted using SPSS Version 28, with a significance level set at p < 0.05. Results The study included 95 critically ill patients, comprising 61 non-COVID-19 patients and 34 COVID-19 patients. It was found that COVID-19 patients had significantly lower Simplified Acute Physiology Score (SAPS) II compared to their non-COVID-19 counterparts. Although no significant differences in energy needs over time were detected between the two groups or within the COVID-19 group alone, there was a trend towards lower energy needs in COVID-19 patients. Significant differences were noted in respiratory quotient among COVID-19 patients, particularly between those with and without pulmonary thromboembolism, with the latter group exhibiting lower RQ values. Conclusion Our study suggests that while overall EE may not significantly differ between critically ill COVID-19 and non-COVID-19 patients, there are potential differences in substrate use that underline the necessity for individualized nutritional support. These findings highlight the importance of tailoring nutritional interventions to meet the specific needs of critically ill patients, particularly those with COVID-19.

Prognostic Impact of Left Ventricular Ejection Fraction Improvement after Transcatheter Aortic Valve Replacement.

Introduction: Transcatheter aortic valve replacement (TAVR) has become an efficient and safe alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) are known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to an improvement in LVEF. Thus far, little is known about the prognostic implication of LVEF improvement as a sole predictor of outcomes. Therefore, the aim of this study was to assess the prognostic impact of LVEF impairment before TAVR, as well as early LVEF improvement in patients undergoing TAVR. Materials and Methods: Patients undergoing TAVR in a large tertiary university hospital were consecutively included in a prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after 1 month and annually thereafter. Significant LVEF improvement was defined as a relative increase of ≥10% in LVEF at 30 days compared to baseline LVEF. The primary outcome was all-cause mortality at 1 year. Secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve at 5 years. Results: Among 1655 patients who underwent TAVR between September 2011 and April 2024, the LVEF at baseline was available for 1556 patients. Of these, 1031 patients (66.2%) had preserved LVEF at baseline (LVEF ≥ 53%), whereas 303 patients (19.5%) had moderately reduced LVEF (40-52%) and 222 patients (14.3%) had severely reduced LVEF (<40%). Out of the patients with impaired LVEF, 155 (40.4%) patients showed a significant improvement in LVEF ≥10% after 30 days, while 229 (60.6%) patients showed no significant LVEF improvement (<10%). Patients with preserved LVEF at baseline had significantly better mortality outcomes than those with severely reduced LVEF (p < 0.001). LVEF improvement was associated with a survival benefit after 1 year (p = 0.009, HR 2.68, 0.95 CI 1.23-5.85) which diminished after 5 years (p = 0.058), but patients with LVEF improvement showed lower MACE rates at 5 years (p < 0.001). Conclusions: Preserved LVEF before TAVR is an independent predictor for improved outcomes. Additionally, early improvement in LVEF is associated with beneficial outcomes in patients undergoing TAVR.

Infection Risk Prediction in Healthcare Settings: Lessons from COVID-19 Contact Tracing.

Contact tracing aids epidemic control by enabling early detection and isolation without overburdening healthcare systems despite potential challenges. This study aimed to evaluate the practical application of contact and risk assessment-based models in predicting SARS-CoV-2 infection following exposure among healthcare workers in a large tertiary public university hospital in Türkiye. The study was designed as a retrospective cohort study, including contact tracing data from 3389 exposed healthcare workers from March 23, 2020, to October 22, 2021. Contact-based (mask use, contact duration and distance) and exposure risk-assessment-based (low, medium, high-risk) models with and without having symptoms were generated using logistic regression. SARS-CoV-2 infection was defined as having a positive SARS-CoV-2 RT-PCR test result. Adjustments were made to the models for demographic and occupational variables, previous infection, and vaccination. Model parameters were compared. Of 3389 exposed healthcare workers, 2451 underwent RT-PCR testing. Among those tested, RT-PCR positivity was 5.9% (144/2451). Lack of personal protective equipment use (odds ratio [OR]=1.64, 95% confidence interval [CI]=1.03-2.66) and ≥15 minutes of contact duration (1.89, 1.21-3.09) were significantly associated with RT-PCR positivity. In the risk-assessment model, being a high-risk contact increased the odds of RT-PCR positivity (OR=2.76, 95% CI=1.61-5.03). Adding the presence of symptoms to contact-based and risk assessment models improved model parameters (Akaike information criterion [AIC]: from 1086.1 to 1083.1; Tjur's R2: from 0.016 to 0.019, respectively). The inclusion of being symptomatic improved the contact-based and risk assessment-based models. Institutions should be encouraged to incorporate symptom inquiries into risk assessment protocols in response to newly emerging respiratory virus epidemics. Institutions lacking the capacity for extensive contact tracing are recommended, at minimum, to track symptomatic exposed workers for epidemic control.

Electrocardiographic parameters and mortality in patients with SARS-CoV-2 infection: A single center study.

Coronavirus disease 2019 (COVID-19) is a pandemic outbreak of RNA coronaviruses (SARS-CoV-2), associated with acute respiratory distress syndrome, multiple organ failure, and death. The surface electrocardiogram is the first line assessment of cardiac electrical system. We aimed to interpret classically the electrocardiographic parameters at admission and during hospital course and association of them with prognosis in patients admitted with diagnosis of infection with SARS-CoV-2. Surface electrocardiograms (ECG) were obtained from 180 patients with SARS-CoV-2 infection at a large tertiary referral university hospital at north of Iran in Babol. The electrocardiographic waves, intervals and segments in addition to supraventricular and ventricular arrhythmias were depicted. Our cohort included two groups: discharged alive and dead during the hospital course. We compared the ECG characteristics of patients who died vs. survived ones. Some ECG parameters of 180 hospitalized patients were significantly associated with mortality, like heart rate (p< 0.001), bundle branch block (P= 0.035), fragmented QRS (P= 0.015), ST elevation (P= 0.004), T p-e duration (P= 0.006), premature atrial and ventricular complexes (P= 0.030, P= 0.004) and atrial fibrillation (P= 0.003). The SARS-CoV-2 infection had several impacts on cardiac electrical system which may monitored with a simple and easily accessible tool like ECG. This tool also helpful in the risk stratification of patients.

Risk of Preterm Birth among Secundiparas with a Previous Cesarean due to a Failed Vacuum Delivery

Background: Studies have found an association between second-stage cesarean sections (SSCSs) and subsequent preterm birth (PTB). We aimed to evaluate if secundiparas with previous second-stage cesarean sections due to a failed vacuum delivery (SSCS-F-VD) are associated with PTB in the subsequent delivery compared with secundiparas with previous spontaneous vaginal birth (SVB) at term. A secondary aim was to compare this association with secundiparas with a previous SSCS at term. Methods: A historical, prospective, longitudinal cohort study was conducted in a large tertiary university hospital between 2006 and 2019. Matched mothers who experienced first and second births at the indexed hospital, excluding those with a previous miscarriage or multiple pregnancy in either the first or second birth were grouped based on the mode of delivery and gestational week of the first birth. Results: Parturients with term SVB and term SSCSs were less likely to experience PTB in the following delivery compared with those who underwent an SSCS-F-VD, with 496/14,551 (3.4%) versus 6/160 (3.8%) versus 5/61 (8.2%), respectively, at p &lt; 0.001. A logistic regression model revealed that secundiparas with previous SSCS-F-VD had an association with PTB in the following delivery compared with term SVB, with an OR of 2.756 (1.097; 6.922, p = 0.031). Conclusion: Previous SSCS-F-VD is associated with PTB in the following delivery, offering valuable insights for pregnancy management and patient counseling.

Incidence and Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Valves.

Transcatheter aortic valve replacement (TAVR) has become a widely used, comparably efficient and safe alternative to surgical aortic valve replacement (SAVR). Its utilization continues to grow, especially among younger patients. Despite improvements in durability, degeneration and subsequent re-interventions of failed prosthetic valves are still common. Even though valve-in-valve procedures have become more frequent, little is known about the trends over time or about clinical and echocardiographic long-term outcomes. Patients who underwent a valve-in-valve procedure between December 2011 and December 2022 in a large tertiary university hospital were analyzed. Primary outcomes were defined as procedural and device successes as well as event-free survival. Secondary analyses between subsets of patients divided by index valve and date of procedure were performed. Among 1407 procedures, 58 (4%) were valve-in-valve interventions, with an increased frequency observed over time. Overall, technical success was achieved in 88% and device success in 85% of patients. Complications were predominantly minor, with similar success rates among TAVR-in-SAVR (TiSAVR) and TAVR-in-TAVR (TiTAVR). Notably, there were significant and lasting improvements in mean echocardiographic gradients at 1 year. Event-free survival was 76% at one month and 69% at one year. Over the last decade, a rising trend of valve-in-valve procedures was observed. Despite an increase in procedures, complications show a contrasting decline with improved technical and device success over time. TiSAVR and TiTAVR showed comparable rates of procedural and device success as well as similar outcomes, highlighting the utility of valve-in-valve procedures in an aging population.

Protocol Adherence for Adult Sickle Cell Patients Presenting with Vaso-Occlusive Crises on a Tertiary Teaching Hospital Emergency Department

Background Patients with Sickle cell disease (SCD) suffer from frequent vaso-occlusive crises (VOC) that heavily contribute to morbidity and mortality. VOC's constitute the principal cause of emergency department (ED) presentation and hospital admission and the ED visit serves to diagnose underlying disorders, VOC complications and to institute pain relieve most often requiring intravenous opioids. The need for prompt and adequate treatment and pain relieve is reflected by standardized protocols for acute care in SCD. Adherence to these protocols has been shown to increase the quality of care, while improving overall patient pain control, decreasing frequency of ED visits and ED patient crowding and decreasing total hospital days. Several studies have demonstrated that negative health care provider attitudes interfere significantly with adequate assessment of pain and in turn may lead to insufficient treatment. We recently (October 2019) introduced novel protocols for management of SCD patients presenting with VOC's at the ED, but local the actual protocol adherence has not been evaluated. Aim Retrospective analysis of adherence to ED protocols for management of SCD patients on the ED. Methods We included all patients with SCD presenting at the ED between March 2021 and March 2022. Children and patients that presented for alternative causes than a VOC were excluded from analysis. The SCD protocol contained a circumscriptive manual with indicated timing of interventions that could be analysed for adherence. Interventions were divided into three groups: diagnostics, supportive care and analgesics. Diagnostics contained physician consultation within 60 minutes of arrival, measurement of vital parameters (SpO2, respiratory frequency, heart rate, blood pressure and body temperature), and extensive laboratory testing. In patients with chest pain it prescribed chest imaging and arterial blood gas analysis. Supportive measures included oxygen supplementation in hypoxic patients and administration of intravenous hyper hydration in absence of contraindications such as a history of fluid overload. Analgesia included treatment using a predefined personalized pain plan (PPP) if available. In all other patients, treatment consisted of acetaminophen, NSAIDs and opioids until the NRS pain score was 6 or lower or pain was deemed acceptable by the patient. Opioid treatment consisted of IV fentanyl in a maximal cumulative dose of 2 mcg/kg within the first hour followed by opioid escalation with intravenous (IV) morphine in a maximal cumulative dose of 50mg. In patients with renal failure (eGFR<30 ml/min), buprenorphine was advised instead of morphine. When analgesic treatment remained insufficient after 15 minutes the protocol prescribed consultation of the pain specialist for administration of clonidine or esketamine. Results We analyzed data from a total of 109 ED visits of 70 unique patients (median age: 31,1 years (IQR 14,0), 49.5% male) between March 2021 and March 2022 in a tertiary teaching hospital in The Netherlands. Results of protocol adherence are shown in table 1. Adherence to the complete protocol was extremely low (0.9%). For most individual components of the protocol adherence was above 50%. For fluid administration, timing of initial fentanyl and morphine escalation, adherence was 39.4%, 19.3% and 11.9%, respectively. Conclusion In patients with sickle cell disease, protocols aim to increase accuracy and speed of diagnostics and analgesia which is related to outcomes such as overall patient pain control, frequency of ED visits and total hospital days. This study evaluates protocol adherence in a large tertiary university hospital. Whereas adherence to individual components of the SCD is above 50%, total patients in which complete protocol adherence is observed is extremely low. We identify fluid administration and opioid administration as protocol components to which adherence is most insufficient. Further research on the reasons for these impaired adherence together with training of medical and nursing staff is required to improve the quality of healthcare for this patient group. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Incidence and predictors of cardiac arrhythmias in patients with COVID-19 induced ARDS

IntroductionRecent studies suggest cardiac involvement with an increased incidence of arrhythmias in the setting of coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the risk of potentially lethal arrhythmias and atrial fibrillation in patients with COVID-19-induced acute respiratory distress syndrome (ARDS) and to elicit possible predictors of arrhythmia occurrence. Methods and resultsA total of 107 patients (82 male, mean age 60 ± 12 years, median body mass index 28 kg/m2) treated for COVID-19-induced ARDS in a large tertiary university hospital intensive care unit between March 2020 and February 2021 were retrospectively analyzed. Eighty-four patients (79%) had at least moderate ARDS, 88 patients (83%) were mechanically ventilated, 35 patients (33%) received vvECMO. Forty-three patients (40%) died during their hospital stay. Twelve patients (11%) showed potentially lethal arrhythmias (six ventricular tachycardia, six significant bradycardia). Atrial fibrillation occurred in 27 patients (25%). In a multivariate logistic regression analysis, duration of hospitalization was associated with the occurrence of potentially lethal arrhythmias (p = 0.006). There was no association between possible predictive factors and the occurrence of atrial fibrillation. Invasive ventilation, antipsychotics, and the QTc interval were independently associated with acute in-hospital mortality, but this was not arrhythmia-driven as there was no association between the occurrence of arrhythmias and mortality. ConclusionIn this relatively young population with COVID-19-induced ARDS, the incidence of potentially lethal arrhythmias was low. While overall mortality was high in these severely affected patients, cardiac involvement and arrhythmia occurrence was not a significant driver of mortality.

Invasive fungal infections in critically ill COVID-19 patients in a large tertiary university hospital in Israel.

An increasing number of studies have tried to determine the incidence of invasive fungal infections (IFIs) in COVID-19 patients. Challenges in the diagnosis of pulmonary aspergillosis in these patients have led to new definitions of COVID-19-associated pulmonary aspergillosis (CAPA). The aim of this study was to determine the incidence and outcomes of and risk factors for IFIs in critically-ill COVID-19 patients, using the new definitions, in a tertiary center in Israel.MethodsA case-controlled study (from 1 September 2020 to 31 March 2021) in which data from COVID-19 critically-ill patients with a diagnosis of IFI were collected and compared to a control group without IFI.ResultsThe incidence of IFI amongst 311 COVID-19 critically-ill patients was 6.1%. 3.5% had CAPA and 3.5% had candidemia. In-hospital mortality was higher amongst patients with IFI compared to those without IFI (89.4% vs 60%, p < 0.03). The most significant predictors of IFI were cardiovascular co-morbidity and carbapenem use.ConclusionsThe low incidence of CAPA in our group of COVID-19 critically-ill patients was consistent with recent reports, underscoring the importance of differentiating between true infection and colonization. Awareness and timely diagnosis of IFIs in COVID-19 critically-ill patients are imperative considering the associated high mortality.

Effect of the 2020/21 season influenza vaccine on SARS-CoV-2 infection in a cohort of Italian healthcare workers

ObjectivesHealthcare workers (HCWs) are a priority group for seasonal influenza vaccination (SIV). The 2020/21 SIV campaign was conducted during the second wave of the COVID-19 pandemic. Vaccines, including SIV, may exert non-specific protective effects on other infectious diseases which may be ascribable to the concept of trained immunity. The aim of this study was to explore the association between 2020/21 SIV and SARS-CoV-2 positivity in a cohort of Italian HCWs. MethodsIn this observational study, a cohort of HCWs employed by a large (ca 5000 employees) referral tertiary acute-care university hospital was followed up retrospectively until the start of the COVID-19 vaccination campaign. The independent variable of interest was the 2020/21 SIV uptake. Both egg-based and cell culture-derived quadrivalent SIVs were available. The study outcome was the incidence of new SARS-CoV-2 infections, as determined by RT-PCR. Multivariable Cox regression was applied in order to discern the association of interest. ResultsThe final cohort consisted of 2561 HCWs who underwent ≥1 RT-PCR test and accounted for a total of 94,445 person-days of observation. SIV uptake was 35.6%. During the study period, a total of 290 new SARS-CoV-2 infections occurred. The incidence of new SARS-CoV-2 was 1.62 (95% CI: 1.22–2.10) and 3.91 (95% CI: 3.43–4.45) per 1000 person-days in vaccinated and non-vaccinated HCWs, respectively, with an adjusted non-proportional hazard ratio of 0.37 (95% CI: 0.22–0.62). E-values suggested that unmeasured confounding was unlikely to explain the association. ConclusionsA lower risk of SARS-CoV-2 infection was observed among SIV recipients.

Assessment of mortality and performance status in critically ill cancer patients: A retrospective cohort study.

IntroductionGiven clinicians’ frequent concerns about unfavourable outcomes, Intensive Care Unit (ICU) triage decisions in acutely ill cancer patients can be difficult, as clinicians may have doubts about the appropriateness of an ICU admission. To aid to this decision making, we studied the survival and performance status of cancer patients 2 years following an unplanned ICU admission.Materials and methodsThis was a retrospective cohort study in a large tertiary referral university hospital in the Netherlands. We categorized all adult patients with an unplanned ICU admission in 2017 into two groups: patients with or without an active malignancy. Descriptive statistics, Pearson’s Chi-square tests and the Mann-Whitney U tests were used to evaluate the primary objective 2-year mortality and performance status. A good performance status was defined as ECOG performance status 0 (fully active) or 1 (restricted in physically strenuous activity but ambulatory and able to carry out light work). A multivariable binary logistic regression analysis was used to identify factors associated with 2-year mortality within cancer patients.ResultsOf the 1046 unplanned ICU admissions, 125 (12%) patients had cancer. The 2-year mortality in patients with cancer was significantly higher than in patients without cancer (72% and 42.5%, P <0.001). The median performance status at 2 years in cancer patients was 1 (IQR 0–2). Only an ECOG performance status of 2 (OR 8.94; 95% CI 1.21–65.89) was independently associated with 2-year mortality.ConclusionsIn our study, the majority of the survivors have a good performance status 2 years after ICU admission. However, at that point, three-quarter of these cancer patients had died, and mortality in cancer patients was significantly higher than in patients without cancer. ICU admission decisions in acutely ill cancer patients should be based on performance status, severity of illness and long-term prognosis, and this should be communicated in the shared decision making. An ICU admission decision should not solely be based on the presence of a malignancy.

Limiting spread of COVID-19 in an orthopaedic department-a perspective from Spain.

Besides national and international recommendations, orthopaedic departments face significant changes in daily activity and serious issues to maintain their standards in musculoskeletal care during the pandemic Covid-19 crisis that we are facing. This report retrospectively addresses measures that were progressively put in place to modify in a week time the activity of a busy orthopaedic department in a large tertiary university hospital in face of the pandemic. Surgical priorities and surgical outcomes are key aspects to consider. The experience may offer some insight to areas where the spread of the disease may be slower or delayed. Abrupt stop of scheduled surgery and clinics is useful to adapt an orthopaedic department to the overall hospital resource reorganization. Orthopaedic surgeons need to be aware of the risks to patients and personnel in view of underdiagnosed cases, which make pre-operative Covid-19 evaluation mandatory for all surgical cases.

The epidemiology and clinical features of selective immunoglobulin M deficiency: A single-center study in China.

BackgroundSelective immunoglobulin M deficiency (SIgMD) is a rare primary immunodeficiency that is frequently reported in Western countries. However, large epidemiological and clinical studies of SIgMD in China are still lacking. Herein, we describe a cohort of SIgMD subjects in a large tertiary university hospital in China.MethodsA cross‐sectional study included 139 668 participants at First Affiliated Hospital of Wenzhou Medical University from January 2014 to October 2018 was conducted. Individuals with a serum IgM level less than 0.3 g/L with normal levels of serum IgA and IgG were defined as having SIgMD.ResultA total of 63 subjects met the criteria for SIgMD(63/139668, 0.045%), with a male‐to‐female ratio of 0.85, aged from 19 to 99 years. The most common clinical manifestation was autoimmune disorders (38/63, 60.32%), while the second most common manifestation was infections (21/63, 33.33%). Neither allergies nor tumors were found among these 63 SIgMD subjects. Most importantly, there were 30 patients with systemic lupus erythematosus among these 63 SIgMD subjects, accounting for 47.62% of all SIgMD subjects.ConclusionTo our knowledge, we describe here the first large single‐center cohort of adult patients affected by SIgMD in China. The most common clinical manifestation was autoimmune disorders, specifically systemic lupus erythematosus.

P3719Myocardial injury during TAVI with self-expanding prosthesis is not associated with patient-prosthesis features, hemodynamics or clinical outcome

Abstract Background Transcatheter aortic valve implantation (TAVI) has been associated with increases in markers of myocardial injury but underlying mechanisms as well as relevance for prosthesis hemodynamics, cardiac function and clinical outcome remain unclear. Purpose To study the trajectory of high-sensitivity troponin T (hs-TnT) during TAVI and elucidate putative associations with demographics, anatomical and procedural features, as well as clinical and echocardiographic outcome. Methods This prospective real-world registry study included all patients (n=275) undergoing transfemoral TAVI using a self-expanding or balloon-mounted system at a large tertiary university hospital over the most recent three-year period. Plasma levels of hs-TnT (reference level 0–14 ng/l) at 24 hours (h) before TAVI and at 9h, 18h, 30h, 42h and 72h after TAVI were analyzed. Patients with ongoing myocardial ischemia and acute coronary syndrome were excluded. We studied the association between hs-TnT values and patient characteristics, echocardiographic and CT findings at baseline as well as procedural features including the use of pre- and postdilatation. Moreover, we studied the association between hs-TnT and and echocardiography and clinical outcome at 1 year after TAVI. Results In this real-world TAVI cohort (median age 83.2±0.2 years; 48.7% women; 5.2±0.2 comorbidities; eGFR 58.0±6.0 ml/min/1.73m2; mean±standard error), 100% of patients exhibited significant elevations of hs-TnT at approximately 9-fold (207.0±11.0) compared to baseline (23±0.2 ng/L, median±SE). Peak hs-TnT values were reached at 9 h post-TAVI (207±11 ng/L) with subsequent gradual decline (figure). Myocardial injury was confirmed by elevated creatin kinase (CK) and CKMB isozyme. No significant association was found between peak hs-TnT, delta hs-TnT (peak minus baseline values) or area under the curve (AUC) of hs-TnT on the one hand, and patient demographics including renal dysfunction, comorbidity, age and gender on the other side. Moreover, no significant association between hs-TnT and anatomical features, prosthesis sizing, or use of pre- and postdilatation was found. No association between hs-TnT during TAVI and NYHA functional class, transvalvular pressure gradient, cardiac function or survival at 1 year was found. In subjects with at least one year of follow-up after TAVI (n=138), NYHA functional class (1.7 vs 2.7) and NT-proBNP plasma levels (1126±316 vs 1581±563 ng/L) were significantly lower compared to pre-TAVI. Conclusions Modest transient elevations of hs-TnT occur in all patients undergoing TAVI and are consistent with subtle myocardial injury. The lack of significant association between the extent of myocardial injury during TAVI and clinical and hemodynamic outcome as well as all-cause mortality is reassuring for current real-world practice.

Long-term outcome of conservative and invasive treatment in patients with hypertrophic obstructive cardiomyopathy

Background and objective: Treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM) can be either conservative or invasive (alcohol septal ablation (ASA) and myectomy). As there is no clear consensus on the long-term effects of these different strategies, the aim was to compare the long-term outcome in a large tertiary referral university hospital. Methods: We retrospectively included 106 HOCM patients. Twenty-nine (27.4%) patients were treated conservatively, 25 (23.6%) underwent ASA and 52 (49.0%) myectomy. Endpoints were all-cause mortality and sudden cardiac death (SCD)-related events (including SCD, aborted SCD and appropriate ICD shocks). Kaplan–Meier survival analysis and Cox proportional hazard regression models were used. Results: The mean follow-up period was 7.7 ± 4.9 years. Overall, there was no significant difference in survival between the three treatment strategies (p = 0.7). Annual rates of SCD-related events at 5 years and the complete follow-up period were significantly higher (p = 0.034) after conservative treatment (4.9%/year and 2.7%/year, respectively) compared to ASA (0.9%/year, 0.5%/year) and myectomy (1.0%/year, 0.6%/year). Independent predictors of SCD-related events were: conservative treatment (HR 10.66; 1.88–60.55), a known mutation (HR 9.36; 1.43–61.20), left ventricular wall thickness (LVWT) > 30 mm (HR 6.48; 1.05–39.92) and non-sustained VT (HR 16.82; 2.29–123.29). Invasive treatment resulted in a significant higher proportion of patients requiring pacing (p = 0.033). Conclusions: Long-term mortality rates for patients with HOCM are similarly low between treatment groups. However, conservative treatment was associated with SCD-related events, as were known mutations, increased LVWT and non-sustained VT. Invasive treatment was associated with a higher need for implantation of a pacemaker.

The Clinical Frailty Scale Predicts Inpatient Mortality in Older Hospitalised Patients with Idiopathic Parkinson'S Disease

We conducted an observational retrospective study in a large tertiary university hospital between October 2014 and October 2016. Routinely measured patient characteristics included demographics (age and sex), Clinical Frailty Scale, acute illness severity (Emergency Department Modified Early Warning Score), the Charlson Comorbidity Index, discharge specialty, history of dementia, history of depression and the presence of a new cognitive impairment. Outcomes studied were inpatient mortality, death within 30 days of discharge, new institutionalisation, length of stay ≥ 7 days and readmission within 30 days to the same hospital. There were 393 first admission episodes of idiopathic Parkinson's disease patients aged 75 years or more; 166 (42.2%) were female. The mean age (standard deviation) was 82.8 (5.0) years. The mean Clinical Frailty Scale was 5.9 (1.4) and the mean Charlson Comorbidity Index was 1.3 (1.5). After adjustment for covariates, frailty and acute illness severity were independent predictors of inpatient mortality; odds ratio for severely/very severely frail or terminally ill = 8.1, 95% confidence interval 1.0-63.5, p = 0.045 and odds ratio for acute illness severity: 1.3, 95% confidence interval 1.1-1.6, p = 0.005). The Clinical Frailty Scale did not significantly predict other hospital outcomes. The Clinical Frailty Scale was a significant predictor of inpatient mortality in idiopathic Parkinson's disease patients admitted to the acute hospital and it may be useful as a marker of risk in this vulnerable population.

Candidemia in Adults at a Tertiary Hospital in China: Clinical Characteristics, Species Distribution, Resistance, and Outcomes.

Candidemia is one of the most common nosocomial bloodstream infections. Early diagnosis and antifungal treatment improve clinical outcomes in some studies but not all, with diverse data reported from different institutions. Similarly, antifungal resistance is more common in the USA than in Europe, but there is little data regarding the microbiology and clinical course of candidemia in adult patients in Asia. (1) To capture species distribution and drug resistance rates among Candida bloodstream isolates, (2) to describe clinical features of candidemia, and (3) to identify factors associated with all-cause mortality, with emphasis on early initiation of antifungal treatment, at a large tertiary University Hospital in China. In this single-center retrospective study, we identified all patients with candidemia, between 2008 and 2014. Demographic and clinical characteristics, microbiological information, details of antifungal therapy and clinical outcomes were collected. We studied 166 patients. 71 (42.8%) had cancer. Candida albicans was the most frequent species (37.3%), followed by C. parapsilosis (24.1%), C. tropicalis (22.8%), and C. glabrata (14.5%). Antifungal resistance was more frequent in non-albicans strains and especially C. glabrata. Twenty patients received inappropriate treatment with all-cause mortality of 35%. The remaining 146 patients had significantly lower mortality (21.9%, P = 0.045). Among patients who received antifungal treatment, mortality rate increased with time to appropriate antifungal therapy (AAT): 13.7%, for < 24h, 21.1% for 24-48h, 23.1% for > 48h, and 32.4% among patients who received no AT (χ2 for trend P = 0.039). Initiating AAT more than 24h after blood culture collection was an independent risk factor for mortality, after adjustment for other confounders (OR 7.1, 95% CI 1.3-39.4, P = 0.024). Candida albicans was the most frequent cause of candidemia at a large tertiary hospital in China, but antifungal resistance is a growing concern among non-albicans Candida species. The mortality rate of patients treated with ineffective antifungal agents based on in vitro susceptibilities was similar to that of patients who received no treatment at all, and delayed initiation of antifungal treatment was associated with increased risk of death.

Predictors of In-Hospital Mortality in Patients Admitted with Acute Myocardial Infarction in a Developing Country.

BackgroundLimited data are available on the predictors of mortality in patients hospitalized with acute myocardial infarction (AMI) in developing countries. In this study, we analyze the predictors for in­-hospital mortality in patients hospitalized with AMI (ST segment elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI)) in a large tertiary referral university hospital in Lebanon.MethodsThis was a retrospective study of 503 patients admitted to the American University of Beirut Medical Center with AMI (228 with STEMI and 275 with NSTEMI).ResultsThe in-hospital mortality rate was 7.8%. The multivariate predictors of mortality in the overall population were similar to what has been reported in large registries in the USA and Europe. They included older age (> 65 years) (OR = 2.99, 95% CI = 1.22 - 7.36, P = 0.02), systolic blood pressure < 100 mm Hg (OR = 2.75, 95% CI = 1.12 - 6.76, P = 0.03), history of stroke (OR = 4.28, 95% CI = 1.29 - 14.17, P = 0.02), history of coronary artery bypass graft (CABG) (OR = 2.68, 95% CI = 1.15 - 6.23, P = 0.02), heart failure (OR = 3.92, CI = 1.62 - 9.49, P = 0.002) and ejection fraction (EF) < 35% (OR = 2.32, 95% CI = 1.05 - 5.14, P = 0.04). In a separate analysis of STEMI and NSTEMI patients, age, heart failure and a low EF continued to be multivariate predictors of mortality in both subgroups. In addition, prior stroke was an added predictor in STEMI patients, and prior CABG was an added predictor in NSTEMI.ConclusionPredictors of in-hospital mortality in patients hospitalized with AMI in a tertiary referral university hospital in the Middle East are similar to what has been reported in large registries in the USA and Europe.