Lower Mortality Research Articles

Comparison of Outcomes Between Partial and Radical Laparoscopic Nephrectomy for Localized Renal Tumors Larger Than Four Centimeters: A Systematic Review and Meta-Analysis.

Earlier studies have juxtaposed different laparoscopic methods for treating renal tumors; however, extensive evidence with a particular focus on large kidney tumors remains lacking. The objective of this meta-analysis was to assess the perioperative outcomes, kidney performance, and cancer-related results of laparoscopic partial nephrectomy (LPN) versus laparoscopic radical nephrectomy (LRN) for treating extensive, localized, non-metastatic kidney tumors (cT1b-cT2N0M0). We systematically searched multiple databases from database inception until December 2023 for relevant studies. Selected data were analyzed with the Cochrane Collaboration's Review Manager 5.4 software using a random-effects model. Outcomes were expressed as odds ratios and weighted mean differences with 95% confidence intervals, considering a P value of < 0.05 as significant. Data from nine studies encompassing 1,303 patients (529 LPN, 774 LRN) revealed that LPN was associated with lengthier surgeries and increased blood loss compared to LRN. While LPN exhibited higher postoperative complication rates, the disparity did not reach statistical significance. LPN led to improved postoperative renal function, manifesting as a reduced estimated glomerular filtration rate (eGFR) decline and fewer incidents of new chronic kidney disease cases. Both groups demonstrated comparable tumor recurrence and overall mortality rates, but LPN exhibited significantly lower cancer-specific mortality rates. LPN, despite longer operative times and greater intraoperative blood loss, was found to be superior to LRN in preserving postoperative renal function. Oncologically, LPN and LRN have comparable overall mortality rates, but LPN showed a significant advantage in terms of lower cancer-specific mortality rates.

Effect of Stroke Etiology on Endovascular Treatment for Acute Basilar-Artery Occlusion: A Post Hoc Analysis of the ATTENTION Randomized Trial.

Stroke etiology could influence the outcomes in patients with basilar-artery occlusion (BAO). This study aimed to evaluate the differences in efficacy and safety of best medical treatment (BMT) plus endovascular treatment (EVT) versus BMT alone in acute BAO across different stroke etiologies. The study was a post hoc analysis of the ATTENTION trial (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute BAO were classified into 3 groups according to stroke etiology (large-artery atherosclerosis [LAA], cardioembolism, and undetermined cause/other determined cause [UC/ODC]). The primary outcome was a favorable outcome (modified Rankin Scale score of 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. A total of 340 patients with BAO were included, 150 (44.1%) had LAA, 72 (21.2%) had cardioembolism, and 118 (34.7%) had UC/ODC. For patients treated with BMT plus EVT and BMT alone, respectively, the rate of favorable outcome at 90 days was 49.1% and 23.8% in the LAA group (odds ratio, 3.08 [95% CI, 1.38-6.89]); 52.2% and 30.8% in the cardioembolism group (odds ratio, 2.45 [95% CI, 0.89-6.77]); and 37.5% and 17.4% in the UC/ODC group (odds ratio, 2.85 [95% CI, 1.16-7.01]), with P=0.89 for the stroke etiology×treatment interaction. The rate of symptomatic intracranial hemorrhage in EVT-treated patients with LAA, cardioembolism, and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the BMT-treated patients. Lower 90-day mortality was observed in patients with EVT compared with BMT alone across 3 etiology groups. Among patients with acute BAO, EVT compared with BMT alone might be associated with favorable outcomes and lower 90-day mortality, regardless of cardioembolism, LAA, or UC/ODC etiologies. The influence of stroke etiology on the benefit of EVT should be explored by further trials. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04751708.

Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients.

Occurrence of mydriasis during the prehospital management of traumatic brain injury (TBI) may suggest severe intracranial hypertension (ICH) subsequent to brain herniation. The initiation of hyperosmolar therapy to reduce ICH and brain herniation is recommended. Whether mannitol or hypertonic saline solution (HSS) should be preferred is unknown. The objective of this study is to assess whether HSS, compared with mannitol, is associated with improved survival in adult trauma patients with TBI and mydriasis. A retrospective observational cohort study using the French Traumabase national registry to compare the ICU mortality of patients receiving either HSS or mannitol. Patients aged 16 years or older with moderate to severe TBI who presented with mydriasis during prehospital management were included. We performed propensity score matching on a priori selected variables [i.e. age, sex and initial Coma Glasgow Scale (GCS)] with a ratio of 1 : 3 to ensure comparability between the two groups. The primary outcome was ICU mortality. The secondary outcomes were regression of pupillary abnormality during prehospital management, pulsatility index and diastolic velocity on transcranial Doppler within 24 h after TBI, early ICU mortality (within 48 h), ICU and hospital length of stay. Of 31 579 patients recorded in the registry between 2011 and 2021, 1417 presented with prehospital mydriasis and were included: 1172 (82.7%) received mannitol and 245 (17.3%) received HSS. After propensity score matching, 720 in the mannitol group matched 240 patients in the HSS group. Median age was 41 years [interquartile ranges (IQR) 26-60], 1058 were men (73%) and median GCS was 4 (IQR 3-6). No significant difference was observed in terms of characteristics and prehospital management between the two groups. ICU mortality was lower in the HSS group (45%) than in the mannitol group (54%) after matching [odds ratio (OR) 0.68 (0.5-0.9), P = 0.014]. No differences were identified between the groups in terms of secondary outcomes. In this propensity-matched observational study, the prehospital osmotherapy with HSS in TBI patients with prehospital mydriasis was associated with a lower ICU mortality compared to osmotherapy with mannitol.

Prognostic value of first 24-hour urine output in patients with acute myocardial infarction in intensive care units: a retrospective study based on the MIMIC-IV database.

To investigate the effect of first 24-hour (24-h) urine output (UO) on in-hospital and 1-year mortality in patients admitted to intensive care units due to acute myocardial infarction. This was a retrospective cohort study based on the medical information mart for intensive care IV database involving patients admitted to intensive care units due to acute myocardial infarction. Patients were classified as low UO (LUO), high UO (HUO), and middle UO with a first 24-h UO below 800ml, over 2500ml, or in between, respectively. The primary outcome was in-hospital mortality and the secondary outcome was 1-year mortality. A total of 4337 patients were involved. Taking middle UO group as reference, after adjusting for confounders including age, gender, height, weight, comorbidity, occurrence of cardiogenic shock, revascularization, blood pressure, creatinine, N-terminal pro-brain natriuretic peptide, and use of loop diuretics, LUO was independently associated with higher in-hospital mortality [odds ratio 4.05, 95% confidence interval (CI): 3.12-5.26], while HUO was an independent protective factor (odds ratio 0.52, 95% CI: 0.35-0.77). In the multivariant Cox regression model, LUO was an independent risk factor for 1-year mortality (hazard ratio 2.65, 95% CI: 2.16-3.26), while HUO did not show significant association. In patients admitted to intensive care units due to acute myocardial infarction, first 24-h UO <800ml was a strong predictor for higher in-hospital and 1-year mortality, while first 24-h UO over 2500ml was associated with lower in-hospital mortality but not long-term mortality.

Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management.

To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM). Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25). VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004). VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

Associations Between Drug Overdose Mortality and Recovery Ecosystems in the United States: A County-Level Analysis Using a Novel Index.

Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI). The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores. Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate. REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.

Impact of anticoagulation therapy on outcomes in patients with cirrhosis and portal vein thrombosis: A large-scale retrospective cohort study

IntroductionPortal vein thrombosis in cirrhotic patients presents a significant clinical challenge. This study aims to (1) explore the impact of anticoagulation therapy on patient outcomes; (2) comparative outcomes in portal vein thrombosis treated between direct oral anticoagulant and Vitamin K Antagonist (VKA). Materials and methodsWe leveraged the TriNetX database to analyze a cohort comprising 4224 patients with liver cirrhosis and PVT who were treated with anticoagulation, alongside a comparison group of 15,300 patients with the same conditions but not receiving anticoagulation therapy. ResultsThe anticoagulated group showed a significant reduction in mortality (27.9 % vs. 34.2 %, HR = 0.723, 95 % CI: 0.678–0.770, P < 0.001). When comparing direct oral anticoagulant versus. VKA, in compensated liver cirrhosis, the direct oral anticoagulant group exhibited significantly lower mortality rates compared to VKA (17.7 % vs. 26.5 %, HR = 0.655, 95 % CI: 0.452–0.951, P = 0.025), with no significant difference in liver transplantation rates (4.0 % vs. 4.7 %, P = 0.080). In decompensated liver cirrhosis, the direct oral anticoagulant group exhibited lower mortality compared to the VKA group (23.6 % vs. 30.6 %, HR = 0.732, 95 % CI: 0.629–0.851, P < 0.001), and a higher frequency of liver transplantation was observed in the VKA group (10.6 % vs. 16.0 %, HR = 0.622, 95 % CI: 0.494–0.784, P < 0.001). Hospitalization rates were significantly lower in the direct oral anticoagulant group compared to the VKA group in decompensated cirrhosis (33.4 % vs. 38.3 %, HR = 0.830, 95 % CI: 0.695–0.992, P = 1.937). ConclusionsOur study offers compelling evidence supporting the use of anticoagulation therapy in liver cirrhosis with portal vein thrombosis. The use of DOACs in patients with both compensated and decompensated liver cirrhosis showed a marked mortality benefit.

Mortality and failure-to-rescue after esophagectomy in the procedure-targeted National Surgical Quality Improvement Program registry.

The association between procedural volume and esophagectomy outcomes has been established, but the relationship between higher levels of care and esophagectomy outcomes has not been explored. This study aims to investigate whether hospital participation in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) esophagectomy-targeted registry is associated with superior outcomes. The 2016-2020 ACS NSQIP standard and esophagectomy-targeted registries were queried. Esophagectomy outcomes were analyzed overall and stratified by esophagectomy type (Ivor Lewis vs. transhiatal vs. 3-field McKeown). A total of 2181 and 5449 esophagectomy cases were identified in the standard and targeted databases (68% Ivor Lewis esophagectomy). The median age was 65years and 80% were male. Preoperative characteristics were largely comparable. On univariate analysis, targeted hospitals were associated with lower mortality (2% vs. 4%, p<0.01) andfailure-to-rescue rates (11% vs. 17%, p<0.01), higher likelihood of an optimal outcome (62% vs. 58%, p=0.01), and shorter hospital stay (median 9 vs. 10days, p<0.01). On multivariable analysis, Ivor Lewis esophagectomy at targeted centers was associated with reduced odds of mortality [odds ratio (OR) 0.57 and 95% confidence intervals 0.35-0.90] and failure-to-rescue [OR 0.54 (0.33-0.90)] with no difference in serious morbidity or optimal outcome. There was no statistically significant difference in odds of mortality or failure to rescue in targeted versus standard centers when performing transhiatal or McKeown esophagectomy. Esophagectomy performed at hospitals participating in the targeted ACS NSQIP is associated with roughly half the risk of mortality compared to the standard registry. The factors underlying this relationship may be valuable in quality improvement.

Living Donor Availability Improves Patient Survival in a North American Center: An Intention-to-treat Analysis.

Assess the impact of having a living donor on waitlist outcomes and overall survival through an intention-to-treat analysis. Living-donor liver transplantation (LDLT) offers an alternative to deceased donation in the face of organ shortage. An as-treated analysis revealed that undergoing LDLT, compared to staying on the waiting list, is associated with improved survival, even at Model for End-stage Liver Disease-sodium (MELD-Na) score of 11. Liver transplant candidates listed at the Ajmera Transplant Centre (2000-2021) were categorized as pLDLT (having a potential living donor) or pDDLT (without a living donor). Employing Cox proportional-hazard regression with time-dependent covariates, we evaluated pLDLT's impact on waitlist dropout and overall survival through a risk-adjusted analysis. Of 4,124 candidates, 984 (24%) had potential living donors. The pLDLT group experienced significantly lower overall waitlist dropouts (5.2%vs. 34.4%, P<0.001) and mortality (3.8%vs. 24.4%, P<0.001) compared to the pDDLT group. Possessing a living donor correlated with a 26% decline in the risk of waitlist dropout (adjusted hazard ratio 0.74, 95%CI 0.55-0.99, P=0.042). The pLDLT group also demonstrated superior survival outcomes at 1- (84.9%vs. 80.1%), 5- (77.6%vs. 61.7%), and 10-year (65.6%vs.52.9%) from listing (log-rank P<0.001) with a 35% reduced risk of death (adjusted hazard ratio 0.65, 95%CI 0.56-0.76, P<0.001). Moreover, the predicted hazard ratios consistently remained below 1 across the MELD-Na range 11-26. Having a potential living donor significantly improves survival in end-stage liver disease patients, even with MELD-Na scores as low as 11. This emphasizes the need to promote awareness and adoption of LDLT in liver transplant programs worldwide.

The utility of axial imaging among selected patients in the early postoperative period after pancreatectomy

BackgroundPostoperative computed tomography imaging has been shown to play an important role in avoiding failure-to-rescue. We sought to examine the impact of the timing of such imaging studies on outcomes after pancreatectomy. MethodsPatients who underwent pancreatic resection at our institution from 2017 to 2022 were reviewed retrospectively to identify those undergoing computed tomography for any indication before discharge. Patients were subdivided by the postoperative day that the first computed tomography scan was obtained: immediate (postoperative day <3), early (postoperative day 3–7), and delayed (postoperative day >7). ResultsOf 370 patients, 110 (30%) had a computed tomography during the initial surgical stay. The 3 timing groups were similar in age, comorbidities, pathology, operative time, and number of scans. When comparing the early with the delayed group, we found that antibiotic usage, percutaneous drainage, and overall invasive interventions during surgical stay were all similar. However, those patients who were scanned in the early period had significantly shorter length of stay (17.05 vs 22.82, P = .0008) and fewer composite days hospitalized (20.1 vs 24.9, P = .01) relative to the delayed group. Importantly, early computed tomography imaging was found to be the only independent predictor of a postoperative length of stay ≤15 days on multivariate analysis. Surgical stay mortality rates were significantly lower in the early compared with delayed group (0% vs 11%, P = .02). A change in treatment was observed in 59% after computed tomography, with 15% undergoing invasive interventions, 27% treated medically, and 16% with expectant management. ConclusionIn our cohort, patients imaged early after pancreatectomy experienced shorter hospital stays and lower inpatient mortality relative to those scanned after the first postoperative week.

Machine Learning Predicts Unplanned Care Escalations for Post-Anesthesia Care Unit Patients during the Perioperative Period: A Single-Center Retrospective Study

Background: Despite low mortality for elective procedures in the United States and developed countries, some patients have unexpected care escalations (UCE) following post-anesthesia care unit (PACU) discharge. Studies indicate patient risk factors for UCE, but determining which factors are most important is unclear. Machine learning (ML) can predict clinical events. We hypothesized that ML could predict patient UCE after PACU discharge in surgical patients and identify specific risk factors. Methods: We conducted a single center, retrospective analysis of all patients undergoing non-cardiac surgery (elective and emergent). We collected data from pre-operative visits, intra-operative records, PACU admissions, and the rate of UCE. We trained a ML model with this data and tested the model on an independent data set to determine its efficacy. Finally, we evaluated the individual patient and clinical factors most likely to predict UCE risk. Results: Our study revealed that ML could predict UCE risk which was approximately 5% in both the training and testing groups. We were able to identify patient risk factors such as patient vital signs, emergent procedure, ASA Status, and non-surgical anesthesia time as significant variable. We plotted Shapley values for significant variables for each patient to help determine which of these variables had the greatest effect on UCE risk. Of note, the UCE risk factors identified frequently by ML were in alignment with anesthesiologist clinical practice and the current literature. Conclusions: We used ML to analyze data from a single-center, retrospective cohort of non-cardiac surgical patients, some of whom had an UCE. ML assigned risk prediction for patients to have UCE and determined perioperative factors associated with increased risk. We advocate to use ML to augment anesthesiologist clinical decision-making, help decide proper disposition from the PACU, and ensure the safest possible care of our patients.

Genomic surveillance and vaccine response to the dominant SARS-CoV-2 XBB lineage in Rio Grande do Sul

The COVID-19 pandemic has been marked by novel viral variants, posing challenges to global public health. Recombination, a viral evolution mechanism, is implicated in SARS-CoV-2's ongoing evolution. The XBB recombinant lineage, known for evading antibody-mediated immunity, exhibits higher transmissibility without increased disease severity. We investigated the prevalence and genomic features of XBB in SARS-CoV-2-positive cases in Rio Grande do Sul (RS), Brazil. We sequenced 357 samples from epidemiological weeks (EW) 47/2022 to 17/2023, and included 389 publicly available sequences. Clinical and epidemiological data were obtained from DATASUS, e-SUS, and SIVEP GRIPE (data recording systems of the Brazilian Ministry of Health). Of these, 143 were classified as XBB and 586 were other Omicron lineages. In March 2023 (EW 10), XBB became dominant, accounting for 83.3% of cases. 97.7% of XBB-infected patients successfully recovered from the infection, with a low mortality rate (2.3%). Even after receiving three vaccine doses and having been previously infected, 59.5% of the patients experienced reinfection with XBB. However, for 54% of the individuals, the interval between their XBB infection and the last vaccine dose exceeded one year, potentially leading to a decline in antibody levels. In addition, we identified 90 mutations in RS circulating XBB, spread throughout the genome, notably in the Spike protein region associated with immune resistance. This study provides insights into the dynamics and impact of a recombinant variant becoming predominant for the first time in the state. Continued surveillance of SARS-CoV-2 genomic evolution is crucial for effective public health management.

Transsphenoidal Approach for Pituitary Macroadenoma: Complications

Transsphenoidal surgery (TSS) is a popular method for resecting pituitary tumors, but it has been associated with severe consequences such as perioperative medical issues, endocrine problems, and surgical complications. The pituitary gland, a bilobed endocrine organ, contains eight hormones and is surrounded by the sella turcica, tuberculum sellae, dorsum sellae, and cavernous sinus dura. The gland's structure is complex, with the optic chiasm and sphenoid sinus being significant structures. The sphenoid sinus, which grows with age and has variable septal and cavitary architecture, can make the transsphenoidal approach more difficult to perform in cases of bleeding, vision loss, or cranial nerve palsy. Understanding the anatomy of the sphenoid sinus is crucial for a safe sellar approach and tumor removal. The operative microscope introduced in the 1960s has further improved surgical outcomes with low morbidity and mortality rates. Pituitary adenomas are extra-arachnoidal tumors that develop outside the boundaries of the cerebrospinal fluid (CSF). They can cause iatrogenic leaks if the arachnoid membrane is ruptured and a cerebrospinal fluid fistula is introduced. Delayed postoperative epistaxis can result from the sphenopalatine artery and the intracavernous internal carotid artery (ICA). Loss of vision can result from physical injuries to the optic nerves or chiasm, which can occur at multiple stages of the operation. Other causes include cerebral vasospasm, traction injury, empty sella syndrome with chiasm prolapse, ophthalmoplegia, and internal injuries to the carotid artery. Injuries to the sphenoid sinus, including proximity to essential tissues, thin or absent bone, and loss of bone, increase the risk of iatrogenic injury. Packing is the initial therapy, and postoperative angiography should be performed afterward. Embolization is considered in situations where packing is inadequate or when there is development to pseudo-aneurysms or carotid cavernous fistulae. Chronic Insipidus Diabetes (DI) is a common disturbance in patients following transsphenoidal surgery (TSS), causing water and electrolyte problems. DI can manifest in various clinical patterns, including transitory, permanent, and triphasic phenotypes. Postoperative syndrome of antidiuretic hormone secretion (SIADH) is also a risk factor, with hyponatremia often delayed and symptomatic. Improved or newly developed hypopituitarism is a risk, with the hypothalamic-pituitary-adrenal (HPA) axis being the most susceptible. Transcranial procedures with HPA or other axis deficits may cause damage to normal residual glands, especially in large tumors. Transsphenoidal techniques can mitigate the risk of dissecting an attenuated gland, but understanding pituitary physiology and sellar anatomy is crucial for improving the procedure and encouraging innovation. Transcranial procedures have a low death rate and risk of significant impairment, but understanding the underlying medical, endocrine, and surgical consequences is essential for successful PA excision.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries

BackgroundMost countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries’ (LMICs’) midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration.MethodsUsing the most recent available data from publicly available global databases for the period 2000–2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality.ResultsIn LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10–15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country.ConclusionsA complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

Independent effects of the glucose-to-glycated hemoglobin ratio on mortality in critically ill patients with atrial fibrillation

BackgroundThe glucose-to-glycated hemoglobin ratio (GAR) represents stress hyperglycemia, which has been closely associated with adverse outcomes in cardio-cerebrovascular diseases. No studies have examined the association between stress hyperglycemia and atrial fibrillation (AF) in critically ill patients. This study aims to explore the relationship between GAR and the prognosis of critically ill patients with AF.MethodsA retrospective cohort of patients was selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The GAR was calculated based on fasting blood glucose and glycated hemoglobin levels measured after admission. The primary outcome was the 30-day mortality rate, with secondary outcomes being the 90-day and 365-day mortality rates. The GAR was divided into tertiles, and Kaplan–Meier analysis was employed to compare differences in mortality rates between groups. The Cox proportional hazards model and restricted cubic splines (RCS) were utilized to evaluate the relationship between the GAR and mortality. Subsequently, a segmented regression model was constructed to analyze threshold effects in cases where nonlinear relationships were determined.ResultsIn this cohort, the second tertile of the GAR exhibited lower mortality rates at 30 days (10.56% vs 6.33% vs 14.51%), 90 days (17.11% vs 10.09% vs 17.88%), and 365 days (25.30% vs 16.15% vs 22.72%). In the third tertile, the risk of mortality at 30 days increased by 165% (HR = 2.65, 95% CI 1.99–3.54, p < 0.001), at 90 days increased by 113% (HR = 2.13, 95% CI 1.68–2.70, p < 0.001), and at 365 days increased by 70% (HR = 1.70, 95% CI 1.68–2.70, p < 0.001). The association between the GAR and patient mortality demonstrated a “J-shaped” non-linear correlation. Once the GAR exceeded 15.915, each incremental unit increase in the ratio was associated with a 27.2% increase in the risk of 30-day mortality in critically ill atrial fibrillation patients (HR = 1.262, 95% CI 1.214–1.333, p < 0.001).ConclusionThe GAR is associated with both short-term and long-term mortality in critically ill patients with AF in a J-shaped relationship. Both low and excessively high GAR values indicate poor prognosis.

Recognition patterns of acute kidney injury in hospitalized patients

Abstract Background and Objectives Acute Kidney Injury (AKI) during hospitalization is associated with increased complications and mortality. Despite efforts to standardize AKI management, its recognition in clinical practice is limited. Methods To assess and characterize different patterns of AKI diagnosis, we collected clinical data, serum creatinine (sCr) levels, comorbidities, and outcomes from adult patients using the Hospital Discharge Form (HDF). AKI diagnosis was based on administrative data and according to KDIGO criteria by evaluating sCr variations during hospitalization. Additionally, patients were also categorized based on the timing of AKI onset. Results Among 56 820 patients, 42 900 (75.5%) had no AKI, 1 893 (3.3%) had AKI diagnosed by sCr changes and coded in HDF (Full-AKI), 2 529 (4.4%) had AKI reported on HDF but not meeting sCr-based criteria (HDF-AKI), and 9 498 (16.7%) had undetected AKI diagnosed by sCr changes but not coded in HDF (KDIGO-AKI). Overall, AKI incidence was 24.5%, with a 68% undetection rate. Patients with KDIGO-AKI were younger, had a higher proportion of females, lower comorbidity burden, milder AKI stages, more frequent admissions to surgical wards, and lower mortality compared to Full-AKI. All AKI groups had worse outcomes than those without AKI, and AKI, even if undetected, was independently associated with mortality risk. Patients with AKI at admission had different profiles and better outcomes than those developing AKI later. Conclusions AKI recognition in hospitalized patients is highly heterogeneous, with a significant prevalence of undetection. This variability may be affected by patients ‘characteristics, AKI-related factors, diagnostic approaches, and in-hospital patient management. AKI remains a major risk factor, emphasizing the importance of ensuring proper diagnosis for all patients.

Pre-Injury Statin Exposure is Associated With Improved Outcomes in Injured Patients That Receive Whole Blood.

Introduction: Whole blood (WB) is associated with improved mortality while lowering blood product utilization. Furthermore, statin medications are associated with favorable outcomes in traumatic brain injury and risk reduction of venous thromboembolism. However, the use of statin medications has not been evaluated in those receiving WB. The objective of this study is to determine the effects of pre-injury statin exposure on patients receiving WB.Methods: Patients that underwent WB first resuscitation and received pre-injury statins were compared to those that did not receive pre-injury statins. Demographics as well as complication rates, blood product transfusion volumes, and mortality were evaluated. Univariate and multivariable analyses were used to determine independent predictors of mortality.Results: In the study period, 785 patients received WB as part of their resuscitation. One hundred and thirty five patients (17.3%) took statin medications prior to injury. Patients that were exposed to a pre-injury statin had a lower mortality rate than those that were not exposed (21.5% vs 32.5%, P = .01). After adjusting for imbalances, age, ISS, Glasgow Coma Scale, admission systolic blood pressures, and pre-injury statin use were independent predictors of mortality following multiple logistic regression. When evaluating outcomes based on statin intensity, the use of high-intensity statins was associated with lower mortality (OR: .37, 95% CI: .13-.93), whereas moderate and low-intensity statins were not.Conclusion: In patients resuscitated with WB, pre-injury statins use was associated with improved outcomes. Specifically, patients that received high-intensity pre-injury statins appeared to be the population that benefited.

Chronic Kidney Disease and Charcot Neuro-Osteoarthropathy of Foot in Diabetes.

Charcot neuro-osteoarthropathy (CNO) occurs late in diabetes and may cause fracture, deformity, and higher mortality. Diabetic kidney disease (DKD) affects bone metabolism and contributes to mortality. However, there is no data on prevalence of CNO and its outcomes with coexisting DKD (or chronic kidney disease [CKD]). To ascertain the prevalence of CKD (pick CKD or DKD) among patients with CNO and delineate the remission of active CNO and subsequent lower extremity amputation and all-cause mortality during prospective follow-up. Consecutive patients with diabetic CNO (active or inactive) were enrolled and subsequently divided into those with and without CKD (pick CKD or DKD) (Group A and Group B, respectively). A preestablished timeframe of 36 weeks was utilized to evaluate the remission proportion of active CNO. A total of 493 CNO patients were observed and 449 subjects (150 patients had active CNO) were further evaluated. The overall prevalence of diabetic nephropathy (DKD or CKD?) CNO was 43.7%. The proportion of patients achieving remission was significantly lower in Group A compared to Group B (OR 0.468, CI [0.239-0.934], P = .025), however, the median time for achieving remission was similar between the 2 groups (14 weeks vs 16 weeks, P = .885). Overall, all-cause mortality was notably higher Group A compared to Group B (OR 2.23, 95% CI [1.474-3.368]) over a median follow-up of 4 years. No significant differences were observed in rates of diabetic foot ulcers (58.2% vs 54.9%; P = .584) and amputations (17.4% vs 15.12%; P = .889) between Group A and Group B. Patients of CNO with coexisting CKD have poor prognosis both in terms of likelihood of active CNO remission and higher mortality.

Comparison of the Efficacy and Safety of Sacubitril/Valsartan and Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers in Patients With Reduced Ejection Fraction Combined With Moderate-to-Severe Chronic Kidney Disease.

Background and Objectives: The efficacy and safety of a lower target dose of sacubitril/valsartan (angiotensin receptor neprilysin inhibitor [ARNI]) for treating heart failure with reduced ejection fraction (HFrEF) in Chinese patients with moderate-to-severe chronic kidney disease (CKD) remain unknown. We performed a retrospective study to compare the efficacy of ARNI with that of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) in patients with HFrEF and moderate-to-severe CKD. Methods: This retrospective study included 129 patients. An inverse probability of treatment weighting (IPTW) analysis was performed to compare the baseline characteristics and outcomes between the 2 groups. The incidence of death due to cardiovascular disease, rehospitalization due to heart failure after treatment, and improvement in cardiac function symptoms (New York Heart Association [NYHA]) were assessed after 12 months. Improvements of ejection fraction (EF), N-terminal pro-brain natriuretic peptide (NT-proBNP) level, left ventricular end-systolic diameter (LVESD), and left ventricular end-diastolic diameter (LVEDD) were compared. Results: Compared with the ACEI/ARB group, the ARNI group, with 90.77% (59/65) in the lower target dose group, showed a lower rate of death due to cardiovascular disease (6.6% vs 0.9% after IPTW) and a lower incidence of rehospitalization (46.5% vs 30.4% after IPTW). NYHA class, estimated glomerular filtration rate, EF, NT-ProBNP levels, LVEDD, and LVESD improved in the ARNI group. None of the patients withdrew from treatment because of adverse drug reactions. Conclusion: Our study showed that ARNI resulted in a greater improvement in heart failure than ACEIs/ARBs in patients with HFrEF and moderate-to-severe CKD.

Outcomes Following Multivalve Reoperation in Adults with Congenital Heart Disease: A 30-Year, Single Center Study

As patients with congenital heart disease (CHD) increasingly live into adulthood, reoperative surgery is frequently required. While half of these are valve-related procedures, little is known regarding early and late outcomes, and factors associated with adverse outcomes. From 1993-2022, 1,960 adult CHD (ACHD) patients underwent repeat median sternotomy at our institution. Of these, 502 patients (26%) underwent intervention on ≥2 valves and constituted the study cohort. The median age was 39 (27, 51) years and 275 patients (55%) were females. A second sternotomy was performed in 265 patients (53%), third in 135 (27%), fourth in 75 (15%), and ≥fifth in 27 (5%). Interventions were performed on 2 valves in 436 patients (87%), 3 valves in 64 patients (12%), and 4 valves in 2 patients (1%). The most common combinations were pulmonary and tricuspid in 241 patients (48%), followed by mitral and tricuspid in 85 (17%), aortic and pulmonary in 42 (8%), and aortic and mitral in 41 (8%). Early mortality was 4.2% overall and 2.7% for elective operations. Non-elective operations and CHD of major complexity were independently associated with early mortality. Median follow-up was 14 years. One, 5-, and 10-year survival were 93.6%, 89.3%, and 79.5%, respectively. Factors independently associated with overall mortality were age, ventricular dysfunction, coronary artery disease, renal failure, double valve replacement, non-elective operations, and bypass time. Multiple valve interventions are common and confer low early mortality in the elective setting. Referral prior to ventricular dysfunction and in an elective setting optimizes outcomes.