Medical Management Group Research Articles

Clinical outcomes of roux-en-Y gastric bypass versus medical therapy in type 2 diabetes mellitus: a systematic review and meta-analysis.

The growing incidence of obesity has led to a proportionate rise in type 2 diabetes mellitus (T2DM) and its associated complications. We aimed to compare the long-term outcomes of Roux-en-y Gastric Bypass surgery (RYGB) and conventional medical management in T2DM obese patients. PubMed, Google Scholar, and Clinicaltrial.gov were searched from inception to September 2023. Randomized Controlled Trials (RCTs) and cohort studies were included in this meta-analysis. The primary outcomes were the T2DM remission at 1, 2, 3, and 5years and the accomplishment of the ADA composite triple treatment goal. The revised Cochrane risk of bias tool 2.0 and New-Castle Ottawa scale were used to assess the quality of the studies. This meta-analysis was registered prospectively on PROSPERO CRD42023466324. Of the 3,323 studies yielded from our initial search, 22 were included in this evidence analysis, with 5,176 total patients (1,984 and 3,192 patients in RYGB and conventional medical management groups). A significant increase in the accomplishment in the ADA's composite triple treatment goal was observed in RYGB group as compared to the conventional medical management group (RR 2.41, 95% CI 1.39-4.15, p-value 0.002, I2 35%). Diabetes remission was a clinically successful outcome after 1, 2, 3, and 5years of the RYGB surgery in the patients (1year; RR 4.74, 95%CI 2.46-9.12, p-value < 0.00001, I2 0%, 2years; RR 8.95, 95% CI 1.71-46.71, p-value 0.009, I2 92%3years; RR 18.18 95%CI 7.57-43.62, p-value < 0.00001, I2 0%, 5years; RR 0.22, 95% CI 2.31-16.75, p-value 0.0003, I2 = 71%). The pooled analysis of the given data concluded that the RYGB surgery was more effective in treating T2DM in patients than conventional medical management. The online version contains supplementary material available at 10.1007/s40200-024-01526-z.

Analysis of Predictors of Self-Management in Patients With Rheumatoid Arthritis and the Impact of Self-Management on Quality of Life: A Latent Profile Analysis.

To investigate the latent profiles and correlates of self-management behaviours in Chinese rheumatoid arthritis patients and the effects of different latent profiles on the quality of life of rheumatoid arthritis patients. A cross-sectional survey was used to study rheumatoid arthritis patients. The five dimensions of the Rheumatoid Self-Management Competence Scale were used as exogenous indicators for potential categorisation, and the effects of potential categorisation were analysed by mixed regression to explore the effects of different categorisations on quality of life. Self-management behaviours of rheumatoid arthritis patients were classified into three latent profiles: low self-management daily life management group (25.7%), medium self-management medical behaviour management group (57.3%) and high self-management daily life management group (17.0%). Age, literacy level, per capita monthly income, joint functional status, self-efficacy, health literacy, disease perception level and social support were significant correlates of self-management status in patients with rheumatoid arthritis. Patients in the 'high self-management daily life management group' reported the best quality of life, while those in the 'low self-management daily life management group' reported the worst quality of life. There was significant heterogeneity in self-management skills among rheumatoid arthritis patients. Healthcare professionals should develop personalised interventions based on self-management profiles in patients with rheumatoid arthritis in order to enhance patients' self-management ability and improve their quality of life. Few studies have discussed the differences in the various dimensions of rheumatoid self-management levels, and self-management care measures need to be improved for different levels of self-management. This study categorised the level of self-management in rheumatoid arthritis patients into three profiles. The results of this study may provide more personalised interventions for patients with rheumatoid arthritis. The study adhered to the STROBE checklist. The subjects of the study were outpatient rheumatoid arthritis patients. Prior to the survey, patients were informed about the purpose of the study, informed consent was given to them and signed and they filled out the questionnaire independently. For patients who were unable to fill out the questionnaire, the study members explained it objectively to them and helped them select the appropriate option.

Functional outcomes in pediatric large vessel occlusion treated with endovascular treatment: results from Chinese Pediatric Ischemic Stroke Registry, a multicenter, prospective registry study.

Endovascular treatment (EVT) has become the standard of care for selected adult patients with large vessel occlusion (LVO), but its efficacy in pediatric patients remains limited. This study aimed to assess the clinical outcomes of EVT in pediatric patients with LVO and compare it with medical management. The Chinese Pediatric Ischemic Stroke Registry (CPISR) is a multicenter, prospective observational study. Eighty-five centers across 20 provinces in China reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischemic stroke (AIS) caused by LVO who received either EVT or medical treatment. The primary outcome was the pediatric modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included excellent outcome (pediatric mRs 0-1), favorable outcome (pediatric mRs 0-2) and 90-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to address imbalances across groups. A meta-analysis integrating the currently available evidence was performed to systematically compare the two groups. In this study, 64 patients with LVO were finally included in this analysis. After PSM, EVT was associated with increased odds of improved shift pediatric mRS scores (OR 3.20, 95% CI 1.03 to 9.97) and excellent outcome (OR 10.0, 95% CI 1.10 to 90.59). There was no significant difference in 90-day mortality between EVT and medical management groups (OR 1.70, 95% CI 0.10 to 28.43). Meta-analysis also demonstrated the superiority of EVT over medical treatment, showing better mRS shift at 90 days (OR 2.56, 95% CI 1.44 to 4.54), a high possibility of excellent outcome (OR 4.44, 95% CI 1.90 to 10.33) and favorable outcome (OR 2.16, 95% CI 1.15 to 4.05). This matched-control study and meta-analysis showed that EVT was associated with better functional outcomes in pediatric patients with LVO. These findings support the use of EVT as a treatment approach for pediatric patients with LVO.

Sex-Related Differences in Endovascular Treatment Outcomes for Acute Large Infarcts: The ANGEL-ASPECT Subanalysis.

The outcomes of endovascular therapy (EVT) across sexes for large infarcts remain unclear. This study aimed to evaluate the impact of sex on the outcomes of EVT or medical management for patients with large infarcts. In this secondary analysis of the ANGEL-ASPECT (Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core) randomized controlled trial conducted at 46 stroke centers across China between October 2, 2020, and May 18, 2022, we compared baseline characteristics and clinical outcomes between males and females, and each cohort further divided into EVT and medical management groups. The primary outcome was the 90-day modified Rankin Scale score distribution. Safety outcomes included symptomatic intracranial hemorrhage within 48 hours and mortality within 90 days. There were 176 of 455 patients enrolled in the ANGEL-ASPECT trial who were female. There were 54.0% (95/176) of females and 48.4% (135/279) of males who underwent EVT. The treatment effect of EVT did not vary in both sexes with large infarcts (all P>0.05 for interaction). Compared with medical management, EVT improved 90-day functional outcomes for both males (3 [2-5] versus 4 [3-5]; common odds ratio, 1.94 [95% CI, 1.27-2.97]; P=0.002) and females (4 [3-6] versus 5 [4-6]; common odds ratio, 2.50 [95% CI, 1.41-4.45]; P=0.002). The symptomatic intracranial hemorrhage rate was not different in both treatment groups across both sexes (males, 5.2% versus 2.8%; odds ratio, 2.05 [95% CI, 0.56-7.50]; P=0.278; females, 7.4% versus 2.5%; odds ratio, 2.89 [95% CI, 0.55-15.14]; P=0.210). In patients with large ischemic core, the treatment effect of EVT did not differ between females and males, with better outcomes with EVT versus medical management, without an increased risk of symptomatic intracranial hemorrhage. These findings emphasize the need for equal attention and care for both sexes with large infarcts in clinical practice. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04551664.

SAFETY AND EFFICACY OF FOCUSED LINEAR LOW-INTENSITY EXTRACORPOREAL SHOCKWAVES FOR ERECTILE DYSFUNCTION: A COMPARATIVE CLINICAL STUDY

Abstract Objectives The objective of this study was to evaluate the safety and efficacy of focused Li-ESWT in the treatment of vasculogenic ED compared to medical managment over 12 weeks. Methods In this prospective clinical STUDY, 50 participants diagnosed with vasculogenic ED were allocated into two groups: 25 patients received Li-ESWT (Group A) and 25 patients were treated with medical management alone (Group B). Both groups were followed for 12 weeks, and treatment outcomes were assessed using the International Index of Erectile Function-5 (IIEF-5), Erection Hardness Score (EHS), and Self-Esteem and Relationship (SEAR) questionnaire. Results The study revealed no significant differences between groups in demographic or baseline characteristics (P &amp;gt; 0.05). Both groups showed significant improvements in IIEF-5 and EHS scores compared to baseline at 6 and 12 weeks (P &amp;lt; 0.05); however, the differences between the two groups were not statistically significant (P &amp;gt; 0.05). SEAR scores also improved significantly for both groups, with Li-ESWT showing a statistically significant advantage at 6 and 12 weeks (P = 0.02). Regarding safety outcomes, Li-ESWT was associated with minimal adverse effects (8% mild penile pain, 4% bruising), while the medical management group reported a higher incidence of side effects (44%), including muscle pain (20%), headache (16%), and nausea (8%) (P &amp;lt; 0.05). Conclusions Li-ESWT demonstrated safety and efficacy comparable to medical management for the treatment of vasculogenic ED. Its non-invasive nature and lower incidence of side effects make it a promising alternative for patients seeking treatment beyond pharmacological approaches. Further large-scale studies are needed to confirm these findings and assess the cost-effectiveness of Li-ESWT. Conflicts of Interest None.

Clinical characteristics and medical versus interventional management of carotid artery webs: a systematic review and meta-analysis.

A carotid web (CaW) is a non-atheromatous, shelf-like intraluminal projection, commonly affecting the internal carotid artery. It can be associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. The natural history of CaW is not well-established. Several studies have reported on outcomes after interventional and medical therapy with variable results. To synthesize the literature and report the clinical characteristics and management outcomes of patients with CaWs. A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. 33 studies comprising 737 patients (mean age 50.2 years, female 59.4%, African American 65%) with 835 CaWs were included. The majority of the CaWs were symptomatic (72.9%) with a mean National Institutes of Health Stroke Scale (NIHSS) admission score of 7.5. Atherosclerotic plaques and intramural thrombi were each present in 33% of patients. The classic atherosclerotic and stroke risk factors were prevalent as follows: hypertension 37.8%, diabetes 14.6%, smoking 21.7%, dyslipidemia 16.7%. In total, treatment outcomes were available for 376 patients with 448 symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet or anticoagulation medications, while interventional treatment included carotid artery stenting (CAS), carotid endarterectomy (CEA), and internal carotid artery resection and primary anastomosis (ICRA). The interventional group was associated with a significantly lower risk of recurrent ischemic events compared with the medical group (interventional 0%, medical 36.1%; OR 14.18, 95% CI 3.17 to 63.46, P=0.001) over a mean follow-up of 21.2 months. The odds ratio of cerebral ischemic event recurrence was correlated with the need for thrombectomy at the first event and history of dyslipidemia. Most CaWs were found during stroke work-up. Prevention of secondary ischemic events was superior in the interventional management group (CAS, CEA, ICRA) compared with the medical management group.

Right atrial remodelling and prognosis in patients with severe atrial functional tricuspid regurgitation.

Atrial functional tricuspid regurgitation (AFTR) is increasingly recognized as a distinct cause of tricuspid regurgitation, yet data on outcomes and their determinants are limited. This study examines the prognostic role of right atrial (RA) remodelling in patients with severe AFTR. This retrospective study included consecutive patients with severe AFTR. The primary outcome was all-cause mortality. Cutoff values for RA and right ventricular (RV) sizes related to mortality were identified using receiver operating characteristic curves and maximally selected rank statistics. The cohort included 155 patients with severe AFTR, 96.1% of whom had atrial fibrillation. Of these, 121 received medical treatment, and 34 underwent surgery during follow-up. In the medical management group, 42 deaths (34.7%) occurred over a median of 3.3years. Patients with high RV end-diastolic area and RA area indices (>14.5cm2/m2 and >22cm2/m2) had significantly lower survival compared to their counterparts (P=0.012 and P=0.001, respectively). Cox analyses demonstrated that increased RV end-diastolic area and RA area indices were associated with higher mortality (RV end-diastolic area index, per 1cm2/m2 increase: adjusted hazard ratio 1.11, 95% confidence interval 1.02-1.22, P=0.019; RA area index, per 1cm2/m2 increase: adjusted hazard ratio 1.06, 95% confidence interval 1.02-1.10, P=0.006). Mortality was highest in patients with both high RV end-diastolic area index (>14.5cm2/m2) and RA area index (>22cm2/m2) and lowest in those with low values for both indices (P=0.001). In the surgical intervention group, four post-surgical deaths (11.8%) occurred exclusively in patients with both high RA area and RV end-diastolic area indices. RA and RV enlargement are poor prognostic factors in patients with severe AFTR. These findings underscore the importance of assessing RA and RV remodelling to optimize the timing of intervention in this population.

Corneal breakdown in thyroid eye disease: Presentation and outcomes over a decade.

Corneal breakdown in thyroid eye disease (TED) is an ocular emergency. This study aimed to assess the outcome of multimodal management for corneal breakdown in TED. This retrospective audit included all consecutive corneal breakdowns in TED patients between November 2011 and May 2023. The primary outcome measure was the best corrected visual acuity (BCVA), and secondary outcome measures included proptosis, clinical activity score (CAS), and proportion of globe salvage. In all, 35 TED patients (50 eyes; 15 bilateral) were included in this study. The mean age was 50.6 + 16 years (range 17-83), and 23 were male. Median TED duration was 5 months (range 1-108). Seven patients (nine eyes) developed corneal breakdown ≥2 years after disease onset. Corneal breakdown was graded as superficial punctate keratopathy in 18, microbial keratitis in 14, and microbial keratitis with thinning and/or perforation in 18 eyes. At median follow-up of 17 months (range 2-72), in the orbital decompression group, overall mean BCVA before and after orbital decompression showed improvement from 1.2 to 0.7, mean proptosis from 25.4 ± 3.5 to 20.7 ± 2.1 mm, and median CAS from 4.2 ± 1.3 to 0.3 ± 0.6. In the medical management group, the mean BCVA changed from 1.7 to 1.5, mean proptosis from 22.5 ± 2.5 to 22.3 ± 2.4 mm, and CAS from 3.0 ± 1.4 to 1.1 ± 1.4 before and after treatment, respectively. At the final follow-up, 44 eyes (88%) achieved globe salvage, while six eyes were eviscerated. Corneal breakdown necessitates expeditious and intensive multimodal management - topical medications, systemic medications, eyelid surgery, and orbital decompression surgery. In severe corneal breakdown with microbial keratitis with thinning and perforation, multimodal management helps achieve a high percentage of vision and globe salvage.

Surgical management is associated with improved survival for endocarditis after transcatheter aortic valve replacement.

Prosthetic valve endocarditis is a rare yet devastating complication following transcatheter aortic valve replacement (TAVR). This study aims to investigate the outcomes of surgical versus medical management of post-TAVR endocarditis. Between 2011 and 2024, 67 patients with post-TAVR endocarditis were identified, comprising 24 (35.8%) patients managed surgically and 43 (64.2%) managed medically. All cases were reviewed by our multidisciplinary endocarditis team to determine the optimal treatment strategy. The overall incidence of post-TAVR endocarditis was 1.4%. The number of endocarditis cases increased over time from 1-2 in 2015-2018 to 18 in 2023. The most frequent source of endocarditis was unknown (32.8%), and the predominant causative organism was enterococcus species (25.4%). Notably, among the 43 medically managed patients, 19 (44.2%) exhibited surgical indications, predominantly due to large vegetations with or without embolic complications (n=11; 57.9%). The medical management group had a higher proportion of females and more frequent use of self-expandable valves compared to the surgical group. The time interval between TAVR and endocarditis diagnosis was similar across both groups. In the surgically managed cohort, isolated aortic valve replacement was uncommon, with most patients undergoing complex TAVR explantations coupled with concomitant procedures, most frequently aortic root repair (n=11; 45.8%). The 30-day and 1-year mortality rates for the three groups (surgical, medical without surgical indications, and medical with surgical indications) were 0%, 4.2%, and 31.6% (P=0.002), and 4.2%, 20.8%, and 73.7% (P<0.001), respectively. Surgical management was associated with significantly improved survival compared to medical management for post-TAVR endocarditis. The poor clinical outcomes in the medically managed group were primarily due to patients who did not undergo surgery despite having surgical indications. Prudent clinical judgment and timely surgical intervention when indicated are critical to enhancing the overall clinical outcomes of this challenging condition.

Clinical advantages of reduced expiratory positive airway pressure setting in adaptive servo-ventilation therapy.

The clinical ramifications of adaptive servo-ventilation (ASV) therapy have stirred debate within the medical community. Given the potential detrimental effect of elevated expiratory positive airway pressure (EPAP) on cardiac output, we hypothesized that relatively lower EPAP may be recommended for successful ASV therapy. In-hospital patients with congestive heart failure refractory to medical therapy were included in the prospective cohort study of ASV therapy on prognosis in repeatedly hospitalized patients with chronic heart failure: longitudinal observational study of effects on readmission and mortality (SAVIOR-L) study. Assignment to either the ASV treatment group or the medical management group was at the discretion of the attending physicians. For the purposes of this retrospective study, our focus remained solely on the ASV cohort. We conducted an extensive analysis to elucidate the influence of lower EPAP settings on midterm mortality. A total of 108 patients were included. The median age was 74years, and 83 (77%) patients were male. The median EPAP setting employed was 4 cmH2O, with 60 patients subjected to EPAP levels below 5 cmH2O. There were no significant differences in the baseline characteristics between the lower and higher EPAP groups, which were divided at the EPAP cutoff of 4.5 cmH2O (p > 0.05 for all). A trend toward reduced mortality emerged among patients with EPAP settings below 5 cmH2O, exhibiting a hazard ratio of 0.48 (95% confidence interval 0.22-1.07, p = 0.072) after adjusting for potential confounding factors: 2-year mortality 26% vs. 38%; p = 0.095. Heart failure readmission rates were not significantly different between the two groups (p = 0.61). The adoption of relatively lower EPAP settings during ASV therapy may be advisable. Such an approach has the potential to ameliorate mortality rates while concurrently maintaining heart failure recurrence rates at levels commensurate with those with default EPAP settings.

Calcimimetics or parathyroidectomy for kidney transplant recipients: is there still a question? a systematic review, meta-analysis and trial sequential analysis.

Secondary hyperparathyroidism is one of the most common complications of chronic kidney disease. The optimal treatment for chronic kidney disease nowadays is kidney transplant. Nonetheless, hyperparathyroidism does not always resolve after transplantation leading to tertiary hyperparathyroidism. The management of tertiary hyperparathyroidism can be either medical (calcimimetics) or surgical (parathyroidectomy). The aim of this study is to compare the medical and surgical treatment in terms of control of hyperparathyroidism and long-term implications on kidney graft function. We carried out a systematic review and meta-analysis of relevant studies up to March 2024 on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases. We compared the parathyroid hormone, calcium, creatinine and estimated glomerular filtration rate between the groups of patients that were treated with parathyroidectomy and those that were treated with calcimimetcs. Subsequently, we performed a trial sequential analysis to corroborate our findings. Four studies were included in the final analysis with a total number of 247 patients. Parathyroidectomy resulted in a greater decrease in parathyroid hormone and calcium levels (WMD 149.37, CI 95% 126.81-171.93, p < 0.0001 and WMD 0.7, CI 95% 0.45-0.96, p < 0.0001 respectively) but there was no difference between the surgical and medical management groups in the creatinine and eGFR levels (CI 95%, -0.62-0.17, p = 0.27 and CI 95%, -8.06 - 20.54 p = 0.39). The trial sequential analysis corroborated these findings. Parathyroidectomy is more effective in controlling hyperparathyroidism in kidney transplant recipients, as it leads to a greater decrease in parathyroid hormone and calcium levels. However, there is no difference in the long-term function of the kidney graft, as the creatinine and estimated glomerular filtration values were similar in the surgical and medical management groups.

Bariatric Surgery Impact on Women with Polycystic Ovary Syndrome: A Prospective Cohort Study.

Bariatric surgery has emerged as a promising intervention for obese women with polycystic ovary syndrome (PCOS), a condition strongly associated with obesity and anovulatory infertility. While weight management is a key therapeutic strategy, the optimal approach remains uncertain. A recent randomized controlled trial evaluated the impact of bariatric surgery on ovulation rates in obese women with PCOS. However, methodological limitations, including baseline body mass index discrepancies and minimal weight loss in the medical management group, necessitate cautious interpretation of the findings. To further investigate this issue, we conducted a prospective cohort study involving 192 women with PCOS who had undergone bariatric surgery. We assessed 30 reproductive and metabolic parameters at baseline and at 3, 6, and 12 months postoperatively. Most metabolic parameters improved significantly by 3 months postsurgery but plateaued thereafter, with only triglycerides and high-density lipoprotein cholesterol showing continued improvement. Reproductive outcomes demonstrated sustained improvements in ovulatory dysfunction, coinciding with a reduction in luteinizing hormone levels. However, testosterone levels and polycystic ovarian morphology showed limited improvement, while anti-Müllerian hormone levels remained unchanged. Despite the total weight loss exceeding 30%, further weight reduction did not proportionally enhance outcomes. These findings suggest that while bariatric surgery effectively improves metabolic health and ovulation in PCOS, its long-term hormonal and ovarian effects remain unclear and require further investigation. Head-to-head comparisons with emerging therapies are also urgently needed to refine weight management strategies for this high-risk population.

The impact of shelter-in-place during the COVID-19 pandemic on social support for mental health recovery: A prescribing-oriented qualitative study of patient perspectives.

The COVID-19 pandemic created unprecedented challenges for social connectivity and mental health, especially during mandated shelter-in-place periods. For patients engaged in mental health treatment, the social impact of their shelter-in-place experience remains an area of active investigation. This is particularly relevant in the context of social prescribing, a growing area of clinical intervention where healthcare providers actively refer patients to local social resources or activities to enhance mental health and wellbeing. Here, we investigated patient perspectives on their social supports during shelter-in-place, with an eye toward informing future social prescribing and counseling steps that mental health clinicians can take to foster social resiliency of patients. We conducted semi-structured phone interviews with 12 participants receiving mental health treatment at Kaiser Permanente San Jose Adult Psychiatry clinics. Interviews were transcribed and analyzed for themes. The sample consisted of 8 female and 4 male participants between the ages of 21 to 44, who received services including outpatient medication management, outpatient therapy, and/or outpatient group therapy. Analysis revealed two thematic categories that participants identified: (A) Specific ways that shelter-in-place impacted their social experience and (B) specific types of social relationships that participants felt were important to their mental health and wellbeing. In the first category, thematic factors that affected the social experience included (1) COVID-19-related health concerns, (2) participants' baseline socialization patterns (degree of introversion/extroversion) and (3) the use of online and social media communication channels. For the second category of themes, specific functions of social relationships identified included those centered around (a) instrumental support, (b) emotional support, (c) community connection. Many relationships served more than one function during shelter-in-place, and many participants cited perceived community connection as a particularly important element in their mental health recovery. These themes highlight key contributors to the social experience of the shelter-in-place period for individuals in mental health recovery and inform future ways that clinicians can structure social prescribing practices to better assist the needs of patients.

Predictors of treatment success in corneal surface disorder: A comparative analysis of amniotic membrane grafting and medical management

Aim: The aim of the study was to determine the predictors of treatment success in corneal surface disorders.Materials and Methods: The study included a total of 40 patients who were divided into two groups: Group A underwent Amniotic Membrane Grafting, while Group B received Conventional Medical Management. The patients were followed for a duration of 8 weeks after treatment. At the end of the 8-week period, visual acuity was measured using the Snellen chart, and any remaining symptoms were assessed.Result: The study included 40 cases of corneal ulcer, with 23 (57.5%) being male and 17 (42.5%) female. Ocular surface disorders observed in the cases included persistent epithelial defect (55%), impending perforated corneal ulcer (25%), symblepharon due to chemical injury (10%) and perforated corneal ulcer (10%). Relief from symptoms such as pain levels (n=1), photophobia (n=1), foreign body (FB) sensation (n=0), eye watering (n=1), redness (n=1), and discharge (n=0) was observed earlier (4th week) in Group B compared to Group A (8th week). The majority of patients in Group B experienced relief from these symptoms by the end of the follow-up period. The success rate of the AMG-treated group was higher (85%) compared to the conventional medical management group (60%). Baseline uncorrected visual acuity (UCVA) improved from 2.67 logMAR to 1.03 logMAR within 1 to 4 weeks after surgery and to 0.76 logMAR at the last follow-up in Group B, while it improved from +2.67 to +0.85 at the last follow-up in Group A.Conclusion: Amniotic membrane grafting is an effective treatment choice for promoting healing in corneal wounds that do not respond to conventional treatment.

Abstract 4139545: Impact of Catheter Ablation(CA) in patients with Heart failure with preserved ejection fraction(HFpEF) : A meta-analysis of RCTs

Introduction: CA has been shown to be superior to medical management in improving mortality and hospitalization in patients with heart failure with reduced ejection fraction. However, literature concerning the benefit of CA in patients with HFpEF are scarce. There have been some non-randomized clinical trials which have attempted to bridge the gap. Therefore, we conducted a systematic review and meta-analysis of RCTs focusing on the impact of catheter ablation in patients with HFpEF. Objective: To systematically review and perform a meta-analysis by comparing the outcomes of CA versus medical therapy in patients with HFpEF, focusing on all-cause mortality, cardiovascular mortality, all- cause hospitalizations and cardiovascular hospitalizations. Methods: We conducted a systematic search on PubMed, Cochrane library, Scopus database, and Web of Science using the appropriate search strategy through to April 2024. Only English original RCTs that compared CA with medical management were included for data extraction. The outcomes of interest were as follows- All-cause mortality, Cardiovascular mortality, all- cause hospitalizations and cardiovascular hospitalizations. Results: Four RCTs which included a total of 1620 patients (796 in the intervention group and 824 patients in the medical management group). Follow up duration ranged between (24 – 72 months). Improvement in Heart failure hospitalizations or events was seen in the CA group as compared with the medical management group (OR: 0.57, 95% CI 0.43-0.77, P= 0.0002). There was also a reduction in All- cause hospitalizations in the CA group with an OR of 0.67, 95% CI 0.44-0.82, p=0.005. With regards to cardiovascular mortality and all cause mortality in the CA group the OR was 0.74, 95% CI 0.40-1.35, P= 0.59 and 0.68, 95% CI 0.46-1.03, P= 0.07 respectively. These were found not to be statistically significant. Conclusion: Using CA in patients with atrial fibrillation and HFpEF showed a statistically significant reduction of heart failure hospitalizations and all cause hospitalizations. Despite the trend towards CA, cardiovascular mortality and all cause mortality were found not to be statistically significant when comparing catheter ablation and medical management. This is the largest meta-analysis in this sub-population till date. With the advent of pulsed field ablation, it will also be intriguing to see how those results contrast CA in atrial fibrillation management in patients with HFpEF.

Abstract 4136203: Risk of Mortality and Heart Failure with Myosin Inhibition Among Hypertrophic Cardiomyopathy Patients

Background: While prior studies have established that mavacamten therapy in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) leads to significant clinical and functional improvement, long-term data on the effect of mavacamten on mortality and heart failure with reduced ejection fraction (HFrEF) in these patients is lacking. Methods: In this retrospective cohort study utilizing electronic health record data from the TriNetX Network, we aimed to assess the association of mavacamten therapy with mortality and HFrEF compared to medical management among patients with oHCM between 04/2022 and 04/2024. The hazard ratio (HR) and 95% confidence interval (CI) for the study outcomes were estimated by comparing propensity-score matched groups. Results: Among 47,601 adults (45.4% females; mean age: 63.5±16.6 years), 701 and 46,900 patients were included in the mavacamten and medical management groups, respectively. (Table) In the propensity-matched analysis, mavacamten was associated with a lower risk of mortality (HR=0.40;95%CI:0.21-0.73,p=0.002), but a similar risk of incident HFrEF (HR=1.03;95%CI:0.56-1.88,p=0.93) compared with medical management. (Figure) Conclusions: The current study is among the first to report improved survival with mavacamten therapy among patients with oHCM utilizing real-world data. The similar risk of HFrEF between the mavacamten and medical management cohorts highlighted in this study indicates the efficacy of the Risk Evaluation and Mitigation Strategy (REMS) program in maintaining patient safety and offsetting any potential excess risk of HFrEF.

Abstract 4120957: Endovascular Thrombectomy Versus Medical Management for Acute Ischemic Stroke with Large Infarct: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke due to large vessel occlusions. Despite the increasing evidence for EVT, its efficacy remains understudied in patients with acute ischemic stroke with large infarcts. Patients with large-volume ischemic strokes are excluded from major randomized controlled trials (RCTs) despite contributing up to 25% of all acute ischemic strokes. Aim: This study aimed to compare clinical outcomes with endovascular thrombectomy versus medical management in patients with acute ischemic stroke with large infarct. Methods: We conducted a systematic literature review on PubMed, Embase, Scopus and Cochrane Library from inception to 15th May 2024 for RCTs. The inverse-variance random-effects model was used to pool odds ratio (OR) and risk ratio (RR) with 95% confidence intervals. The statistical significance was set at p&lt;0.05. Results: 6 RCTs with 1887 patients (945: EVT and 942: medical management) were included. The mean age in both EVT and medical management groups was 70 ± 11.4 years. EVT was associated with a better modified Rankin Score (mRS) at 90 days [OR: 1.68; 95% CI: 1.38, 2.04; p&lt;0.00001], mRS at 90 days (0-2) [OR: 2.47; 95% CI: 1.87, 3.27; p&lt;0.00001], mRS at 90 days (0-3) [OR: 1.96; 95% CI: 1.56, 2.46; p&lt;0.00001], and early neurological improvement [RR: 2.35; 95% CI: 1.79, 3.10; p&lt;0.00001] compared to medical management. EVT was also associated with a higher risk of symptomatic intracranial hemorrhage [RR: 1.71; 95% CI: 1.09, 2.66; p=0.02]. The 90-day mortality [RR: 0.86; 95% CI: 0.72, 1.02; p=0.08] was comparable between the two groups. Conclusion: Patients with acute ischemic stroke with large infarct had superior functional outcomes with EVT as compared to medical management alone. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage, with comparable 90-day mortality risk. Further large RCTs are warranted to evaluate the outcomes with EVT in acute ischemic stroke with large infarct.

Spontaneous recanalization in acute large core ischemic stroke due to large vessel occlusion: a post-hoc analysis of the ANGEL-ASPECT trial

BackgroundPrevious studies have indicated that a subset of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) experience spontaneous recanalization (SR), but the prognosis and factors associated...

Vertebrobasilar Artery Occlusion Treatment Outcomes Within 24 hours of Estimated Occlusion Time.

The aim of this study was to investigate the efficacy and safety of endovascular treatment (EVT) in patients with acute vertebrobasilar artery occlusion (VBAO) within 24 hours of estimated occlusion time (EOT) and to evaluate the effect of early and late time window in a cohort of patients with VBAO treated with EVT. Retrospective analysis was conducted on patients within 24 hours of the EOT in 65 stroke centers in China. Favorable outcome was defined as modified Rankin Scale ≤3 at 90 days. Patients were divided into the medical management (MM) group and the EVT group. Times were dichotomized into early (EOT ≤6 hours) and late (>6 hours) time windows. Multivariate logical regression models were used to evaluate the efficacy and safety of EVT and the effect of time windows on outcomes in EVT patients. Among 4124 patients, 2473 and 1651 patients were included in the early and late windows, respectively. 1702 patients received MM and 2422 were treated with EVT. EVT was associated with a higher rate of a favorable outcome at 90 days both in early (odds ratio [OR] 2.16, 95% CI 1.94-2.41) and late (OR 1.89, 95% CI 1.65-2.17) time windows. No differences were found regarding favorable outcome (OR 0.95, 95% CI 0.87-1.03) between VBAO patients treated with EVT within and beyond 6 hours. Patients with acute VBAO who received EVT within 24 hours were associated with improved favorable outcome compared with patients who received MM. EVT beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

Decompressive craniectomy in trauma: What you need to know.

Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.