Long-term Rates Research Articles

Association between cardiac consultation and outcomes in patients with perioperative myocardial infarction/injury

Abstract Introduction Perioperative cardiac complications are a frequent occurrence and can lead to high short- and long-term mortality rates after major noncardiac surgery. No single intervention has yet demonstrated its effectiveness in treating perioperative myocardial infarction/injury (PMI). In this large prospective multicentre study, we aimed to evaluate the association between postoperative cardiac consultation and major adverse cardiac event (MACE) and all-cause death within 365 days in patients with PMI after undergoing major noncardiac surgery. Methods We prospectively included consecutive patients undergoing major inpatient noncardiac surgery at two hospitals who were eligible for the institutional active PMI surveillance and response programme. For this analysis, only patients with PMI who were directly transferred to the regular ward following surgery were included. In the case of a PMI, the standardised structured institutional response included assessing the patient for possible symptoms, recording a 12-lead ECG and a cardiac consultation. The specific scope of the PMI workup and management was determined by the attending clinical cardiologist following an institutional flowchart. Our primary endpoint was the occurrence of MACE (defined as a composite of cardiovascular death, MI, AHF, and life-threatening arrhythmia) within 365 days, excluding the initial PMI. All-cause death after 365 days was the secondary endpoint. Multivariable Cox proportional hazard models were used to evaluate the association of cardiac consultation with MACE and all-cause death after 365 days. Results During the period between October 2014 and September 2019, the BASEL-PMI study programme enrolled 14294 patients. After the exclusion of patients without PMI, with a postoperative ICU stay, multiple inclusion, or palliative setting 1048 patients remained. Among those, 434 patients received postoperative cardiac consultation (41.4%). Patients had a median age of 77 years and 44.8% were female. After adjustment, patients who received a postoperative cardiac consultation had a lower risk of having MACE after 365 days (adjusted hazard ratio [aHR] = 0.54, 95% confidence interval [CI] 0.37 - 0.79, p-value = 0.001) and a lower risk of death of any cause after 365 days (aHR = 0.66, 95%CI 0.44 - 1.00, p-value = 0.048). Conclusion In a large multicentre prospective cohort study, postoperative cardiac consultation in patients with PMI was associated with a reduced risk of MACE and all-cause death after 365 days.Kaplan-Meier curve for MACE

Real world data on SVT ablation in Denmark Higher risk of need for reablation in todays patient population a Nationwide registry based Danish study

Abstract Introduction Supraventricular tachycardias (SVTs) are a common reason for healthcare contacts and can have significant impact on patient’s quality of life. Today, ablation therapy is considered the treatment of choice for many cardiac tachyarrhythmias, and it is increasingly utilized to treat SVT-patients with chronic symptoms. Ablation therapy for SVTs is considered a safe procedure with high periprocedural success rates. However, recent studies on today’s patient population have shown a tendency towards higher age and more comorbidity, which might affect these success rates. Therefore, there is a need to explore more real-world data on long-term outcomes of catheter ablations in today’s population. Purpose To examine the long-term success rates of ablation therapy by investigating risk of reablation in patients treated for either an accessory pathway (AP), atrioventricular nodal re-entry tachycardia (AVNRT) or ectopic atrial tachycardia (EAT). Methods Using Danish nationwide registries, patients of 18 years or older who underwent RFA for AP, AVNRT or EAT between January 1st 2010 and January 1st 2019 were included. Comorbidities and use of antiarrhythmic drugs were analyzed. The cumulative incidences of reablation for either AP, AVNRT or EAT were estimated at 5-year follow-up. Results Figure 1 shows the baseline characteristics of the study population. A total of 5.905 patients were included in the study, with a median age of 52 [38, 65], and 47% were male. Among them, the AP group comprised 1.575 patients, with a mean age of 42 [29, 55], and 61% were male. The AVNRT group consisted of 3.598 patients, with a mean age of 56 [43, 67], and 42% were male. In the EAT group, there were 732 patients, with a mean age of 57 [42, 67], and 44% were male. The comorbidity burden was generelly higher in EAT patients, who also had the highest use of antiarrhythmic drugs. Figure 2 shows the 5-year cumulative incidence of reablation for AP, AVNRT or EAT-patients. Risk of reablation after 5 years was 12%, 5% and 12% for AP-, AVNRT- and EAT patients respectively. After 1 year the risk was 9%, 3% and 9% for AP-, AVNRT- and EAT patients respectively. Conclusion Despite the generally safe nature of ablation therapy with high periprocedural success rates, our findings highlight a notable risk of reablation, particularly for AP and EAT patients, after 5 years of follow-up.Baseline Characteristics5year cumulative incidence of reablation

The relation between atrial arrhythmias and heart failure in adult patients with congenital heart disease

Abstract Background Advances in care have significantly improved survival in patients with adult congenital heart disease (ACHD). This growing population is now confronted with new challenges due to their structural malformations, surgical scars, cyanosis and/or longstanding abnormal pressure and volume load that lead to progressive atrial fibrosis. Atrial arrhythmias (AA) and heart failure (HF) have become the leading causes of hospitalisation in patients with ACHD and pose specific challenges in management. Purpose To assess the relationship between a first AA diagnosis and development of HF in patients with ACHD and investigate the impact of HF on the treatment success of radiofrequency ablation (RFA) for AA. Methods This single-centre, retrospective study included 3995 patients with ACHD. AA was defined as: (I) Atrial fibrillation (AF); (II) Intra-atrial re-entrant tachycardia (IART); (III) Atrial flutter (AFL); or (IV) Focal atrial tachycardia (AT). HF was defined as clinical signs and/or symptoms of HF necessitating medical intervention, along with one of the following: (I) impaired ventricular function with elevated intracardiac pressures; (II) elevated N-terminal B-type natriuretic peptide; (III) peak oxygen consumption in the lowest quartile as per specific ACHD subtype; or (IV) distinctive HF manifestations in patients with a Fontan circulation. Both AA and HF were collected with corresponding dates of first presentation. Details on RFA procedures were collected and acute and long-term success rates were calculated using Kaplan-Meier analysis. Results The mean age of the ACHD cohort at last follow-up was 35.4 ± 13.2 y. As per Bethesda complexity classification, 28.0% of ACHD patients had mild defects, 59.4% moderate and 12.6% severe defects. AA was documented in 348 (8.7%) patients with mean age at first presentation of 37.3 ± 19.6 y (Figure 1). Patients with Fontan circulation (38.5%), cyanotic ACHD (21.0%), and systemic right ventricle (24.2%) were more likely to present with AA. Furthermore, patients with a Fontan circulation (18.8 ± 12.4 y) or a systemic right ventricle (29.7 ± 16.1 y) presented with AA at younger age. The overall prevalence of HF was 6.4%. A total of 130 (3.3%) patients were diagnosed with AA as well as HF. Of these, 103 (79.2%) patients were diagnosed with AA 8.2 ± 7.4 y before HF diagnosis. RFA procedures were performed in 119 patients (34.2%), of which 45 (21.0%) were performed in patients with HF. Overall, 72% of patients undergoing RFA remained free from AA at 2 years after RFA (Figure 2.A). Acute success rates were higher and recurrence rates lower in those without HF (Figure 2.B, p=0.0001). Conclusions In patients with ACHD AA and HF are prevalent, especially in complex ACHD, and a first AA occurs on average 8 years prior to HF diagnosis. The main outcome is driven by HF and not AA. RFA can be an effective treatment for AA with 72% being recurrence free 2 years after RFA, but outcome is affected by coinciding HF.Overview of relation between AA and HFKaplan-meier analysis of AA RFA.

The Cross-Verification of Different Methods for Soil Erosion Assessment of Natural and Agricultural Low Slopes in the Southern Cis-Ural Region of Russia

The conventional measuring methods (runoff plots and soil morphological comparison) and models (WaTEM/SEDEM and regional model of Russian State Hydrological Institute (SHI)) were tested with regard to the Southern Cis-Ural region of Russia, along with data from rainfall simulation for assessing soil erosion. Compared with conventional methods, which require long-running field observations, using erosion models and rainfall simulation is less time-consuming and is found to be fairly accurate for assessing long-term average rates of soil erosion and deposition. In this context, 137Cs can also be used as a marker of soil redistribution on the slope. The data of soil loss and sedimentation rates obtained by using conventional measuring methods were in agreement with the data based on the used contemporary modeling approaches. According to the erosion model calculations and data on the fallout of radionuclides in the Southern Cis-Ural (54°50–25′ N and 55°44–50′ E), the average long-term annual soil losses were ~1.3 t·ha−1 yr−1 in moderate (5°) arable slopes and ~0.2 t·ha−1 yr−1 in meadows. In forests, surface erosion is negligible, or its rates are similar to the rate of soil formation of clay–illuvial chernozems. The rates of soil erosion and sediment deposition on the arable land obtained using different methods were found to be very close. All the methods, including the WaTEM/SEDEM, allowed us to measure both soil erosion and intra-slope sedimentation. The regional SHI model fairly accurately assesses soil erosion in the years when erosion events occurred; however, soil erosion as a result of snowmelt did not occur every year, which should be taken into account when modeling. The concentrations of 137Cs in the topsoil layer (0–20 cm) varied from 0.9 to 9.8 Bq·kg−1, and the 137Cs inventories were 1.6–5.1 kBq·m−2, with the highest values found under the forest. The air dose rate in the forest was higher than in open areas and above the average of 0.12 μSv·h−1 on the slope (0.1 μSv·h−1 in the meadow and 0.08 μSv·h−1 on the arable land), with the value increasing from the watershed to the lower part of the slope in all the areas. The γ-background level in the studied ecosystems did not exceed the maximum permissible levels.

Dynamics of Sandy Shorelines and Their Response to Wave Climate Change in the East of Hainan Island, China

Beach erosion and shoreline dynamics are strongly affected by alterations in nearshore wave intensity and energy, especially in the context of global climate change. However, existing works do not thoroughly study the evolution of the sandy coasts of eastern Hainan Island, China, nor their responses to wave climate change driven by climate variability. This study focuses on the open sandy coast and assesses shoreline evolutionary dynamics in response to wave climate variability over a 30-year period from 1994 to 2023, using an open-source software toolkit that semi-automatically identify the shorelines (CoastSat v2.4) and reanalysis wave datasets (ERA5). The shorelines of the study area were extracted from CoastSat, and then tidal correction and outlier correction were performed for clearer shorelines. Combining the shoreline changes and wave conditions derived from ERA5, the dynamics of the shorelines and their response to wave climate change were further studied. The findings reveal that the average long-term shoreline change rate along the eastern coast of Hainan Island is 0.03 m/year, with 44.8% of transects experiencing erosion and 55.2% showing long-term accretion. And distinct evolutionary patterns emerge across different sections. Interannual variability is marked by alternating erosion and siltation cycles, while most sections of the coast experiences clear seasonal fluctuations, with accretion typically occurring during summer and erosion occurring in winter. El Niño–Southern Oscillation (ENSO) cycles drive changes in parameters including significant wave height, mean wave period, wave energy flux, and mean wave direction, leading to long-term changes in wave climate. The multi-scale behavior of the sandy shoreline responds distinctly to the ongoing changes in wave climate triggered by ENSO viability, with El Niño events typically resulting in accretion and La Niña periods causing erosion. Notably, mean wave direction is the metric most closely linked to changes in the shoreline among all the others. In conclusion, the interplay of escalating anthropogenic activities, natural processes, and climate change contributes to the long-term evolution of sandy shorelines. We believe this study can offer a scientific reference for erosion prevention and management strategies of sandy beaches, based on the analysis presented above.

Serial troponin sampling over 60-minutes allows early distinction between myocardial infarction and chronic myocardial injury in patients presenting to emergency departments

Abstract Background High-sensitivity cardiac troponins (hs-cTn) are key clinical biomarkers in the assessment and diagnosis of patients with suspected acute coronary syndromes presenting to Emergency Departments (ED). These tests facilitate rapid triage through 0h/1h blood sampling regimens. Most patients will not have myocardial infarction (MI) diagnosed, having either hs-cTn levels below the upper reference limit (URL) or stable elevations. The latter group of complex, often multimorbid, patients is termed chronic myocardial injury (CMI) according to the 4th Universal Definition of MI (4thUDMI). These patients have long-term morbidity and mortality rates higher than those with type 1 MI. Early distinction of CMI from MI remains challenging with debate regarding optimal hs-cTnT delta cut-offs; both 3ng/L and 5ng/L over one-hour have been proposed. Methods and Results We prospectively collected 0-, 30- and 60-minutes (+/- 5 min) hs-cTnT samples from 185 patients presenting to Liverpool Hospital ED (Sydney, Australia) between March and August 2023. Diagnoses were adjudicated according to the 4thUDMI as follows: 16 (8.6%) MI ruled-in, 66 (35.7%) CMI and 103 (55.7%) MI ruled-out. Linear regression was used to calculate individual hs-cTnT slopes for each patient. Between CMI and MI, each 1 ng/L/hour increase in the slope of hs-cTnT resulted in a two-fold (95% CI: 1.5 to 2.9) greater likelihood of MI being diagnosed (P < 0.001). A stable hs-cTnT trajectory was observed in CMI, which ranged between 0 and 3 ng/L/hour in all patients with an initial hs-cTnT level ≤ 50 ng/L. Chronic myocardial injury patients with an initial hs-cTnT level > 50ng/L (n=12), exhibited more kinetic slopes ranging up to 8ng/L/hour (P <0.001). Unexpectedly, three MI patients had a non-linear slope, of whom two patients would not have displayed a significant rise had the additional 30-minute sample not been collected. These outlying patients presented at 9-12 hours and over 12 hours from symptom onset. Conclusion This study offers a novel characterisation of CMI, which has not previously been investigated in an unselected ED cohort using three serial samples over one hour. It validates a hs-cTnT delta of 3ng/L/hour in the recent ESC guidelines. However, there is a need for greater characterisation of short-term hs-cTn variability for more personalised MI risk stratification and to guide more targeted observation and further investigation of CMI patients.

Comparative safety outcomes of leadless versus transvenous cardiac pacemaker: a systematic review and meta-analysis

Abstract Introduction Leadless Cardiac Pacemakers (LCP) have emerged as a promising alternative to Transvenous Pacemakers (TVP) for managing bradyarrhythmias, especially in cases where TVP options are limited, such as venous access issues in haemodialysis patients or high infection risk individuals. However, long-term safety data, including mortality and hospitalisation rates, are lacking, hindering informed clinical adoption decisions. Purpose This systematic review and meta-analysis compares safety endpoints of LCP with TVP. Methods A systematic search of PubMed, Medline, Embase, Scopus, Web of Sciences, and gray literature was conducted following PRISMA guidelines from release of the Micra LCP to market until May 15, 2023. Meta-analysis was performed using RevMan 5.4. Results Twenty-four studies including data from 33,450 patients (12,802 LCP, 20,648 TVP) were evaluated. The mean age of the population was 77.5 ± 10.6 years, with a mean left ventricular ejection fraction (LVEF) of 58.6 % ± 6.7. Follow-up durations ranged from 6 to 36 months. Compared to TVP, the LCP was associated with significantly fewer overall complications, major complications, acute, mid-term complications, hospitalisations, re-interventions, and device dislodgements (p<0.05). Mortality, tricuspid regurgitation, pacemaker-induced cardiomyopathy, and heart failure hospitalisation rates did not significantly differ. Although LCP showed higher cardiac injury risk, no significant difference in cardiac tamponade rates was observed (Figure 2). LCP exhibited increased vascular-related complications but decreased lung injury, endocarditis, device, and pocket-related issues. Conclusion In the largest review of LCPs, we report that LCP is associated with significantly lower rates of overall complications compared to conventional TVP. This knowledge is critically important as more LCPs enter clinical practice and serves as a baseline against which future data can be evaluated. Nevertheless, proper skill training may help to mitigate the risk of vascular and cardiac injury. These findings underscore the importance of conducting randomized controlled trials to comprehensively evaluate the safety of LCP compared to TVP.Cardiac complication

How much does elective cardioversion increase the risk of ischaemic stroke compared to the baseline risk in atrial fibrillation? A nationwide study

Abstract Background Patients with atrial fibrillation (AF) undergoing cardioversion (CV) are exposed to an increased risk for stroke during the post-cardioversion period, but the exact magnitude of this risk after elective CV with preceding appropriate oral anticoagulant (OAC) therapy is unknown. Purpose We explored the rate of ischaemic stroke (IS) after elective CV and compared the IS rate during the post-cardioversion period with the long-term stroke rate in patients with AF using guideline-recommended OAC therapy. Methods This is a nationwide register-based study, including all AF patients undergoing their first-ever elective CV between 2012-18 in Finland. Data were collected from the Finnish health care registers covering uniquely all levels of care. Visual assessment of the survival curve identified a cut-off point in IS rate at 1 week after CV. Therefore, the follow-up time was split into two intervals, the 1-week post-cardioversion period and the subsequent period up to 360 days. Stroke rates were calculated separately for these periods. Unadjusted and adjusted incidence rate ratios were estimated with Poisson regression. Moreover, interaction between the two follow-up periods and conventional IS risk factors as well as OAC treatment was assessed. Results A total of 9625 AF patients undergoing their first elective CV were identified (mean age 67.7±9.9 years, 61.2% men, mean CHA2DS2-VASc score 2.6±1.6). Warfarin was used in 6 245 (64.9%) and non-vitamin K oral anticoagulants in 3 380 (35.1%) patients. Overall, 92 (1.0%) patients suffered an IS during the year after CV. The survival plot displayed a higher incidence of IS within the first week after CV, stabilizing thereafter to a consistent level (Figure). In the adjusted regression analyses, IS rate within the first week after elective CV was 13.6-fold (95% confidence interval [CI]: 8.6-21.5) compared the subsequent rate of IS (Table). We observed no significant interaction between any of the conventional IS risk factors or OAC treatment and the two follow-up time periods, indicating that their association with IS rate did not differ during the post-cardioversion period compared to the subsequent time period. Conclusions In this nationwide study, the rate of IS was roughly 14 times higher during the first week after elective CV compared to the subsequent follow-up time.Cumulative risk of IS after elective CVIncidence rates of IS after elective CV

Dapagliflozin versus empagliflozin and major adverse cardiovascular events in type 2 diabetes: a nationwide cohort study

Abstract Background Large randomized clinical trials have shown that sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure, chronic kidney disease, or type 2 diabetes mellitus (T2DM) at high risk of atherosclerotic cardiovascular disease. Whether these effects might differ between individual SGLT2-inhbitors remain unclear given the lack of head-to-head comparisons. Purpose To examine the association between treatment with dapagliflozin versus empagliflozin and the long-term rate of major adverse cardiovascular events (MACE) in patients with T2DM. Methods Using nationwide registries, all Danish residents with T2DM, who initiated treatment with dapagliflozin or empagliflozin from 2015 to 2020, were identified. Only treatment with dapagliflozin or empagliflozin was considered in the present analysis, since approximately 3% initiated treatment with other SGLT2-inhibitors (i.e., canagliflozin and ertugliflozin). Patients were followed from date of the first claimed prescription of dapagliflozin or empagliflozin until the outcome of interest, emigration, death, or end of study (December 31, 2021). The primary outcome was a composite endpoint of major adverse cardiovascular events (i.e., time to first heart failure hospitalisation, acute myocardial infarction (AMI), stroke, or all-cause mortality). The primary outcome was compared between the dapagliflozin and empagliflozin group, overall and in prespecified subgroups of interest, with multivariable Cox proportional hazards regression models. Results In total, 61,031 patients with T2DM initiated treatment with dapagliflozin (N=21,028; 34.5%) or empagliflozin (N=40,003; 65.5%). The median age of study population was 62.6 years (25th-75th percentile, 54.2-70.8 years), and 62.6% were men. There were no clinically significant differences between the dapagliflozin and empagliflozin group with respect to age, sex, and clinical characteristics. The median follow-up was 3.1 years (25th-75th percentile, 1.9-4.5 years). The adjusted long-term hazard ratios of the primary outcome, overall and in prespecified subgroups of interest, are displayed in the Figure. Compared with empagliflozin, treatment with dapagliflozin was not associated with a significantly different rate of the primary outcome (HR 1.02 [95% CI, 0.97-1.07]). The observed association was consistent across clinically relevant subgroups, including in patients with and without heart failure, chronic kidney disease, and atherosclerotic cardiovascular disease. Conclusion In a large, nationwide cohort of patients with T2DM, treatment with dapagliflozin was associated with a similar rate of major adverse cardiovascular outcomes compared with empagliflozin, and this association was consistent across clinically relevant subgroups. These findings suggest that the benefits of SGLT2-inhibitors can be characterized as a class-effect.

Long-term risk of heart failure and postoperative atrial fibrillation following noncardiac surgery: not so different from non-surgical atrial fibrillation

Abstract Background Atrial fibrillation (AF) is associated with the development of heart failure (HF). However, it is unclear if postoperative AF (POAF) after noncardiac surgery differs from non-surgical AF in terms of the risk of HF. Objectives To investigate the long-term rate of incident HF in patients developing new-onset POAF after noncardiac surgery relative to patients with non-surgical nonvalvular AF (NVAF). Methods Using Danish nationwide registries, all patients aged ≥30 years who developed POAF following noncardiac, nonobstetric surgery from 1996 to 2020 were identified. These patients were matched in a 1:3 ratio by age, sex, selected comorbidities, and year of inclusion with patients with non-surgical NVAF. The primary outcome was incident HF. Secondary outcomes were HF hospitalization and all-cause mortality. Results A total of 1,846 patients with POAF were matched with 5,538 patients with non-surgical NVAF (median age: 76 years [25th-75th percentile: 67-83 years]; 53.1% females). The median follow-up was 7.6 years. Compared with patients with non-surgical NVAF, patients with POAF did not have a significantly different rate of incident HF (2.7 versus 3.0 events per 100 person-years; HR 0.89 [95% CI, 0.78-1.03]) or HF hospitalization (2.2 versus 2.4 per 100 person-years; HR 0.88 [95% CI, 0.76-1.03]), but they had a higher rate of all-cause mortality (10.0 versus 8.7 per 100 person-years; HR 1.27 [95% CI, 1.18-1.37]) (Figure 1). Conclusions Patients with new-onset postoperative atrial fibrillation did not have a significantly different rate of incident heart failure or heart failure hospitalization, but they had a higher associated rate of all-cause mortality compared to patients with non-surgical atrial fibrillation. This finding suggests that postoperative atrial fibrillation may be regarded as non-surgical atrial fibrillation in terms of the long-term risk of heart failure. This highlights the importance of increased awareness among physicians of the risk of adverse outcomes, including heart failure, in patients with postoperative atrial fibrillation after noncardiac surgery. Closer postoperative follow-up and monitoring, as well as aggressive treatment of cardiovascular risk factors, may be warranted to reduce the risk of adverse outcomes in these patients.

Postoperative atrial fibrillation following noncardiac surgery is associated with long-term heart failure: insights from a nationwide cohort

Abstract Background Atrial fibrillation (AF) is associated with the development of heart failure (HF). Whether postoperative AF (POAF) also confers a greater risk of HF is unclear. Purpose To investigate the long-term rate of incident HF in patients developing new-onset POAF after noncardiac surgery relative to patients who did not develop POAF after noncardiac surgery. Methods In this cohort study, the Danish nationwide registries were used to identify all patients aged ≥30 years who developed POAF following noncardiac, nonobstetric surgery from 1996 to 2020. These patients were matched in a 1:3 ratio by age, sex, type of surgery, selected comorbidities, and year of inclusion with patients without POAF after noncardiac surgery. The primary outcome was incident HF. Secondary outcomes were HF hospitalization and all-cause mortality. Results A total of 2,270 patients with POAF were matched with 6,810 patients without POAF (median age: 75 years [25th-75th percentile: 67-82 years]; 53.5% females). The median follow-up was 7.2 years. Compared with patients without POAF, those with POAF had a higher associated long-term rate of incident HF (2.6 versus 1.2 events per 100 person-years; HR 2.39 [95% CI 2.06-2.78]]), HF hospitalization (2.2 versus 1.0 events per 100 person-years; HR 2.33 [95% CI 1.97-2.74]), and all-cause mortality (9.8 versus 7.4 events per 100-person-years; HR 1.55 [95% CI 1.45-1.66]) (Figure 1). Conclusions Patients with new-onset postoperative atrial fibrillation following noncardiac surgery had a higher associated long-term rate of incident heart failure compared to those without postoperative atrial fibrillation following noncardiac surgery. These findings highlight the importance of increased awareness among physicians of the risk of adverse outcomes, including heart failure, in patients with postoperative atrial fibrillation after noncardiac surgery. Closer postoperative follow-up and monitoring, as well as aggressive treatment of cardiovascular risk factors, may be warranted to reduce the risk of adverse outcomes in these patients.

Drug-use-associated infective endocarditis in Denmark

Abstract Introduction Infective endocarditis (IE) has high mortality and the incidence is rising. Intravenous drug use is a risk factor for IE and poses challenges in clinical care. Amid the opioid crisis in many countries, rates of drug-use-associated IE (DU-IE) are increasing. While drug use in Denmark has remained stable the last decade, little is understood about the features and prognostic impact of DU-IE in developed nations not facing a current opioid crisis. Further, with multiple preventive measures deployed in local Danish regions, data on the evolution of DU-IE are warranted. Purpose To examine the temporal evolution, baseline characteristics, and long-term rates of all-cause mortality and IE recurrence in patients with DU-IE compared with patients with non-DU-IE. Methods This nationwide cohort study identified all first-time IE-patients (1999-2018) and categorized them in 1) patients with DU-IE, and 2) patients with non-DU-IE. Drug use was defined using ICD-8/10 codes or treatment for opioid use disorder. Patients were followed from the date of discharge, and absolute one-year rates of mortality and IE recurrence were examined with Kaplan-Meier estimates and the cumulative incidence function, respectively. Outcomes were compared with a multivariable adjusted Cox model. Results We identified 8,843 patients with IE: 407 (4.6%) with DU-IE (61% male, median age 44 years) and 8,436 (95.4%) with non-DU-IE (66% male, median age 72 years). While the absolute number of DU-IE increased, the proportion of DU-IE decreased from 5.9% in 1999-2003 (n=87) to 3.8% in 2014-2018 (n=114). Patients with DU-IE had a higher proportion of bloodstream infection with Staphylococcus aureus (49.4% vs 26.7%, p<0.001); conversely, they had a lower proportion of bloodstream infections with Streptococcusspecies (14.4% vs. 26.2%, p<0.011). Patient with DU-IE had lower in-hospital mortality compared with non-DU-IE (15.5% vs. 20.9%, p<0.001). Among those surviving admission, the one-year cumulative incidence of all-cause mortality was 16.9% in DU-IE and 17.3% in non-DU-IE (p=0.82), yet in adjusted analysis, DU-IE was associated with a higher one-year mortality rate (HR 1.64 [95% CI:1.23-2.21]) (Figure). The one-year cumulative incidence of IE recurrence was 12.8% in DU-IE and 4.3% in non-DU-IE, which corresponded to an adjusted HR of 3.39 (95% CI:2.35-4.88) in DU-IE. Conclusion While an increase in the absolute number of patients with DU-IE was observed, the proportion among all IE-patients was on the decline in Denmark until 2018—which contrasts with other countries where physicians currently battle collateral damage of the opioid crisis. Although drug use was associated with lower in-hospital mortality, it was striking that even though patient with DU-IE was almost 30 years younger, they still had higher rates of all-cause mortality and a more than three-fold increase in IE recurrence one year following discharge.

Evaluating the Effectiveness of Ahmed Glaucoma Valve Implantation in Reducing Intraocular Pressure in Refractory Glaucoma in the Saudi Arabian Population at a Tertiary Care Centre

Objectives: To assess the efficacy of Ahmed glaucoma valve implantation (AGVI) in lowering intraocular pressure (IOP) in patients with refractory glaucoma. Methods: In this retrospective study, we analyzed the medical records of 60 patients who received AGVI for refractory glaucoma. Data collected included demographics, type of glaucoma, preoperative and postoperative IOP, number of glaucoma medications, and any surgical complications. Success was defined as achieving an IOP <21 mmHg at the final follow-up visit. Results: At the final follow-up (mean duration of 11.6 months), AGVI achieved successful IOP control (IOP of <21 mmHg) in 40 eyes (66.7%). The mean number of glaucoma medications decreased significantly from 2.95 preoperatively to 1.98 postoperatively (p < 0.001). Neovascular glaucoma (NVG) had a lower success rate compared to other types of glaucoma. Prior glaucoma surgery was associated with a higher risk of failing to reach target IOP, although this trend was not statistically significant (p = 0.108). Conclusion: AGVI implantation effectively lowered IOP in patients with refractory glaucoma, especially in the short term. However, long-term success rates were lower, and NVG showed less favorable outcomes. AGVI is a valuable option for managing refractory glaucoma, but careful patient selection is essential. Further research is needed to evaluate long-term efficacy and refine treatment strategies.

Effect of Physical Function on Access to Repeat Kidney Transplantation.

Background: The long-term success rate of kidney transplantation is disappointing, with repeat transplantation necessary for more than half of recipients. When a repeat kidney transplantation is needed, patients are often elderly and suffer from underlying advanced kidney disease, comorbidities, and adverse effects of immunosuppressants, leading to physical function limitations. Limited physical function is known to hinder access to an initial kidney transplantation, but there is no information about its impact on repeat transplantations. Objective: This study aimed to determine the effect of physical function on access to wait-listing for repeat transplantation. Methods: Data from the national registry was utilized to analyze 28,884 kidney transplant recipients. Physical function was assessed with Karnofsky scores, and patients were categorized into three strata: total assistance, some assistance, and no assistance. Logistic regression and multivariate Cox proportional hazard models were used to assess the impact of physical function on waiting list access and duration until wait-listing, respectively. Results: Patients with greater physical independence were more likely to be wait-listed for repeat kidney transplantation. Highly sensitized patients, those with diabetes, Black patients, and elderly individuals had a lower likelihood of access to wait-listing after kidney failure. Interestingly, those with limited physical function, provided they remained in the work-up process, experienced a relatively shorter duration to wait-listing after graft failure.Conclusions: These findings highlight the need to promote and support physical function throughout the kidney transplant journey to improve access to repeat transplantation and subsequent patient outcomes.

Investigating the effect of synbiotic supplementation on inflammatory indices in critically ill septic children: a protocol study for randomized control trial

BackgroundSepsis, a severe inflammatory response to infection, is a global health priority due to its high mortality and long-term disability rates. Its pathophysiology involves both inflammation and immune suppression. Managing sepsis requires significant healthcare resources and expenditure, with sepsis being a leading cause of hospital costs. Gut microbiotas play a crucial role in sepsis, and probiotics show promise in managing it by restoring microbial balance. Despite advances, targeted therapies for sepsis remain elusive, necessitating innovative approaches such as probiotic therapy.MethodFifty-four eligible patients with sepsis will be randomly assigned to either the synbiotic or placebo group. The synbiotic supplement, KidiLact, comprises ten probiotic strains and prebiotic fructooligosaccharides. Participants will receive two sachets daily for 7 days, mixed with sterile water and administered orally or via gavage. Inflammatory factors including interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) will be evaluated. Anthropometric measurements, nutritional assessment, biochemical analysis, and clinical evaluation will be conducted to assess treatment outcomes. Statistical analysis will be performed to compare results between the two groups, employing SPSS version 19 with a significance level of P < .05.ConclusionThis randomized clinical trial aims to evaluate synbiotic supplementation effects on inflammatory markers and clinical outcomes in pediatric sepsis patients in the pediatric intensive care unit (PICU). Probiotics have shown promise in reducing proinflammatory cytokines like IL-6, TNF-α, and CRP, which are vital in the inflammatory response. Synbiotics can enhance gut integrity, preventing pathogen translocation and reducing inflammation. If our expectations regarding the effects of probiotics are correct, we can use them as a cost-effective supplement to improve the condition of pediatric sepsis in hospitals.Trial registrationIRCT,IRCT20230523058266N1 Registered 30 October 2023, https://irct.behdasht.gov.ir/trial/71397.

Outcomes of fenestration versus none in extracardiac total cavopulmonary connection.

Fenestrated total cavopulmonary connection has gained popularity due to its capacity to reduce systemic venous pressure and enhance cardiac output. However, there is ongoing debate about the immediate and long-term advantages of fenestration in this context. A retrospective cohort study was conducted involving 97 patients who underwent extracardiac total cavopulmonary connection at Chiang Mai University Hospital between January 1999 and December 2019. The patients were initially categorized into two groups: fenestrated (n = 71) and nonfenestrated (n = 26). After exclusion and reassignment, the long-term outcomes were analyzed for the fenestrated (n = 68) and nonfenestrated (n = 25) groups. To address potential confounding factors between the two groups, propensity scores were computed using logistic regression analysis. The study found no significant differences in preoperative and operative data. Immediate postoperative outcomes showed no significant variations in major complications, intensive care unit stay, oxygen saturation, and posttotal cavopulmonary connection pressure. In the long-term assessment, the fenestrated group demonstrated significantly lower rates of mortality, protein-losing enteropathy, liver mass, and cirrhosis. However, after employing a multilevel model stratified by propensity score analysis, only long-term mortality rate was significantly lower in the fenestrated group (hazard ratio = 0.12, 95% confidence interval = 0.02-0.97). Fenestration patency closed gradually through spontaneous closure and device intervention. The study found no major differences in immediate postoperative outcomes. In the fenestrated cohort, significantly lower incidences of protein-losing enteropathy, liver mass, cirrhosis, and long-term mortality were observed. However, multilevel model stratified by propensity score analysis indicated that only the lower long-term mortality demonstrated a major effect.

Inguinal Hernia Repair: Comparative Study between TEP versus Extended Totally Extraperitoneal.

Inguinal hernia repair is a common surgical procedure, with laparoscopic techniques offering advantages over open surgery. The extended Totally Extraperitoneal (eTEP) technique provides a larger working space compared to the traditional Totally Extraperitoneal (TEP) approach, potentially improving outcomes. A prospective study was conducted comparing eTEP and TEP techniques for inguinal hernia repair at Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. Forty patients (20 in each group) aged 15-65 with uncomplicated inguinal hernias were included. Surgical procedures were performed based on patient preference. Data on surgical duration, pain scores, hospital stay, and complications were collected and analyzed using statistical methods. eTEP surgery had a significantly shorter mean duration (48.70 ± 7.505 minutes) compared to TEP surgery (74.20 ± 7.78 minutes; P = 0.00). Patients undergoing eTEP experienced lower mean pain scores (3.75 ± 0.55) compared to those undergoing TEP (5.15 ± 0.745; P = 0.00). Hospital stay following eTEP surgery was shorter (1.70 ± 0.657 days) than following TEP surgery (3.65 ± 1.137 days; P = 0.00). eTEP had lower incidences of hematoma and surgical emphysema but higher seroma complications. TEP surgeries were associated with more post-operative complications and a higher likelihood of requiring conversion to open surgery. The eTEP technique offers several advantages over TEP, including shorter surgical duration, less post-operative pain, and shorter hospital stays. However, TEP had more complications related to seroma. Individual patient factors and surgeon experience should guide the choice of technique. The eTEP technique appears to be a promising option for inguinal hernia repair, offering advantages over TEP in terms of surgical outcomes. However, further studies are needed to evaluate long-term outcomes and complication rates comprehensively.

Sex Differences in Outcomes After Elective and Acute Aortic Surgery—A Single-Centre Experience over the Last Two Decades

Background/Objectives: Recent studies show conflicting results regarding sex-related differences in outcomes following aortic surgery. This study primarily evaluated 20-year mortality rates, along with 30-day and one- and five-year rates, and postoperative complications in female and male patients who underwent elective and acute ascending aortic surgery at a tertiary care centre. Methods: This retrospective observational study analysed data from 676 adult patients who underwent ascending aortic surgery in Amsterdam UMC, between January 2001 and December 2020. Descriptive statistics, Fisher’s Exact test, Kaplan–Meier survival analysis, and logistic regression were used to assess differences in mortality rates. Results: Patient characteristics for elective and acute procedures were different. Females were generally older (elective: 69 vs. 62 years, p &lt; 0.001, acute: 70 vs. 62 years, p = 0.002), with smaller body surface area (elective/acute: 1.8 vs. 2.1 m2, p &lt; 0.001), lower preoperative haemoglobin (elective: 8.3 vs. 8.9 mmol/L, p &lt; 0.001, acute: 7.8 vs. 8.4 mmol/L, p &lt; 0.001) and estimated glomerular filtration rate (elective: 64 vs. 91 mL/min, p &lt; 0.001; acute: 67 vs. 83 mL/min, p = 0.004). Females undergoing elective procedures had a lower body mass index (25.0 vs. 26.6 kg/m2, p = 0.006), better left ventricle function (p = 0.048) and higher incidence of chronic obstructive pulmonary disease (15 vs. 8%, p = 0.032). In elective procedures, the 20-year mortality rate (49% vs. 30%, p &lt; 0.001) was significantly higher in females, especially those under 60 years (OR of 3.158 [1.2–8.6], p = 0.024). Mortality rates up to one year were comparable. Five-year mortality rate (26% vs. 16%, p = 0.027) was higher. Females had longer ventilation times (32% vs. 15%, p &lt; 0.001) and intensive care unit stays (2 vs. 1 days, p = 0.005). For acute procedures, morbidity and mortality rates were comparable between sexes. Conclusions: Females under 60, undergoing elective ascending aortic surgery showed higher long-term all-cause mortality rates. Implementing sex-specific management strategies and extended follow-up could be essential for improving outcomes in this group.

One-year mortality and associated factors in older hospitalized COVID-19 survivors: a Nationwide Cohort Study in Korea

This study aimed to evaluate the 1-year mortality rate among older patients with COVID-19 discharged from hospital and to identify risk factors associated with this outcome. Using a COVID-19 dataset from the Korean National Health Insurance System, this study’s evaluation period spanned from October 8, 2020, through December 31, 2021. The primary outcome was the 1-year mortality rate following hospital discharge. A logistic regression model was employed for multivariable analysis to estimate the odds ratios for the outcomes, and the Kaplan-Meier method was used to analyze differences in 1-year survival rates. Among the 66,810 COVID-19 patients aged 60 years or older who were hospitalized during the study period, the in-hospital mortality rate was 4.8% (n = 3219). Among the survivors (n = 63,369), the 1-year mortality rate was 4.9% (n = 3093). Non-survivors, compared to survivors, were significantly older (79.2 ± 9.5 vs. 68.9 ± 7.8, P < 0.001) and exhibited a lower rate of COVID-19 vaccination (63.0% vs. 91.7%, P < 0.001). Additionally, non-survivors experienced a higher incidence of organ dysfunction, along with a greater proportion of required mechanical ventilation (14.6% vs. 1.0%, P < 0.001) and extracorporeal membrane oxygenation (4.0% vs. 0.1%, P < 0.001). Multivariable logistic regression analysis identified older age, male sex, cardiovascular disease, immunosuppression, organ dysfunction, illness severity, and corticosteroid use during hospitalization as factors associated with death within 1 year after hospital discharge. However, vaccination was found to have a long-term protective effect against death among COVID-19 survivors. The 1-year mortality rate after hospital discharge for older COVID-19 patients was comparable to the in-hospital mortality rate for these patients in Korea. The long-term mortality rate among hospitalized older COVID-19 patients was influenced by demographic factors and the severity of illness experienced during hospitalization.

Report of the First Completed On-site Vascular Neurosurgery Fellowship Program in Cameroon

Background and Aim: Vascular neurosurgical expertise is highly in demand in African countries.To create a sustainable environment for treating the patients, local neurosurgeons have tobe trained and be able to operate under the local circumstances, and equipment and on-sitefellowship programs are needed. We have reported the results of the first completed on-sitecerebrovascular fellowship in Cameroon and to our knowledge, in central Africa. Methods and Materials/Patients: Forty-two cerebrovascular cases (38 aneurysms) wereoperated by the cerebrovascular expert and his fellows microsurgically from April 2021to November 2022. The expert traveled to Cameroon four times. Online conferences andtheoretical courses were organized.Results: The overall morbidity rate was 10.5% with a long-term functional morbidity rate of5.2%. The intraoperative mortality rate was 0 and the 30-day mortality rate was 2.7%. Aftercompletion of the program, the fellow’s surgical skills concerning operating time, intraoperativecomplications, and mortality improved significantly. Conclusion: The on-site cerebrovascular fellowship program in sub-Saharan countries is feasibleand provides the patient with high-quality surgery with outcomes similar to Western countries.The caseload in two years is sufficient enough to provide excellent training to the local fellows.There is a high demand for further fellowships, like the one we described. It is important for thetrainer to stay dedicated to the program until the completion of it. To provide the fellows with ahigh caseload, only two fellows should be trained, which are participating in every case