Medical Management Research Articles

Extending the window in clinical decision making: the role for Impella 5.5 in cardiogenic shock

Abstract Background Acute decompensated heart failure (HF) refractory to medical management deteriorates quickly to cardiogenic shock, ultimately requiring mechanical circulatory support (MCS). These devices aim to provide circulatory support as a bridge to advanced therapies. We report patient outcomes with the latest minimally invasive temporary MCS device: Impella 5.5 with SmartAssist. Methods All patients who underwent Impella 5.5 implantation between January 2020 and December 2023 were analyzed. Duration of Impella support and peri-implant parameters were collected from electronic medical records. ANOVA was performed and utilized a p-value of <0.05 as significant for statistical analysis. Results During our review period, a total of 99 patients were supported with Impella 5.5 in the setting of cardiogenic shock. 92 were bridged to heart transplant (BTT), of which 17 also received combined kidney transplantation. Two underwent durable VAD implantation (BTVAD), and 3 had native heart recovery (BTR) and explant. Two patients died, yielding a survival rate of 98%. For BTT group, the median age was 60 years (52-65) at implant and a median BMI of 27 kg/m² (24-31) with a mean support duration of 29 days (SD ±24). Baseline GFR was 49 mL/min/1.73m² (35-65). In the BTVAD group, the median BMI was 43 kg/m² (39-46) with an average duration of support of 22 days (SD ±8) with a GFR of 55 mL/min/1.73m² (38-73). The BTR group had a median BMI of 29 kg/m² (27-30) with an average duration of support of 15 days (SD ±7) and a lower baseline GFR of 36 mL/min/1.73m² (26 – 37) compared to BTT or BTVAD. The two patients that died were supported for an average of 42 days (SD ±9.2) and expired due to non-candidacy in the setting of newly detected prostate cancer in one patient and multi-organ failure in another. All BTVAD and BTT patients did not have a stroke or major vascular complications before terminal therapy. Conclusion Our center highlights the role of early Impella 5.5 placement in the stabilization of patients in cardiogenic shock, thereby providing both patients and providers time for decision-making while optimizing end-organ perfusion beyond the accepted duration of 14 days.Impella Data - Entire CohortImpella Data - Stratified by Outcome

Overlapping markets and quality competition among community health centers.

To examine the response of community health center (CHC) quality to quality levels at neighboring CHCs in the presence of non-price competition. A quasi-experimental study of US community health centers. Outcome variables were indices that measured overall quality of CHC care. Using patient flow data, we constructed CHC-specific Hirschman-Herfindahl index (HHI) and competitors' composite quality measure. The plausibly exogenous change in characteristics of "competitors' competitors" was exploited to identify the relationship between competition and quality of care, using a generalized two-stage least square model with instrumental variables. Using the Health Center Program Uniform Data System (2014-2018), linked with American Community Survey and Medical Expenditure Panel Survey, we analyzed 1098 unique federally funded CHCs in 50 states and District of Columbia which had at least one neighboring CHC and had non-missing data for 2015-2018 (4226 CHC-years). Most of CHCs served populations in overlapping geographic markets, with median market concentration decreasing during the study period. A one-percent increase in competitors' quality was associated with a 0.71-percent increase in an index CHC's composite quality (p < 0.01), consisting of a 0.59-percent increase in chronic condition control rates (p < 0.01); a 0.68-percent increase in the screening and assessment rates (p < 0.01); and a 0.78-percent increase in medication management rates (p < 0.01). The association was stronger at CHCs serving a smaller proportion of uninsured patients. No significant quality reaction was observed at CHCs with a percentage of uninsured patients larger than the 75th percentile. We observed no significant associations between HHI and quality. Increasing competition does not harm quality of care at CHCs. A CHC appears to improve its quality if its competitors improved quality. The beneficial quality effect was less pronounced in CHCs providing a significant proportion of care to uninsured patients, suggesting lack of incentives faced by these CHCs.

Individual level risk factors associated with episodes of heat as recorded within primary care records: a time-stratified case-cross over study

Abstract Background A key recommended action outlined in Heat-Health Action Plans is to identify individuals at risk and deploy targeted interventions, however this is not routinely undertaken. A major contributing factor is a lack of understanding of individual-level risk factors to support an evidence-based approach to targeted prevention. Aim To use electronic health data to identify individual level characteristics associated with increased risk of mortality during heatwaves in England. Methods A time-stratified case-crossover analysis was undertaken of individual-level clinical and socio-environmental (SE) risk factors. Conditional logistic regression was used to characterise associations between temperature and the risk of death on hot days, with analysis stratified by potential risk modifying factors. Results Heat mortality risk was modified by a large range of chronic conditions, with cardio-respiratory, mental health and cognitive function conditions, diabetes and Parkinson’s, all increasing risk. Prescribed medications also increased odds of death during heatwaves. Heat mortality risk was modified by a range of SE determinants of health investigated, with ORs increasing with age; OR differences by sex, ethnicity and living arrangement; an increasing trend in ORs by alcohol intake and body mass index, excluding the obese-3 group. Results suggest the least deprived have the lowest OR and the most deprived have the highest. Conclusions This study has important implications for patient medication management during heat events, incorporating heat-risk considerations into other health policies. The results also provide important evidence on the role of disadvantage in driving the inequitable distribution of climate impacts, and the need for better socio-economic data sets linked to health records. The findings highlight the importance of incorporating an assessment of individual SE circumstances when prioritising patients at highest risk during heat events.

Impact of hypertension education on knowledge and healthy lifestyle practices among Indian adolescents: A quasi-experimental study

Background: This study aimed to establish the effectiveness of a hypertension knowledge education intervention among Indian adolescents to foster lifestyle changes aimed at preventing hypertension. Methods: The Hypertension Knowledge Test (HKT) was used to assess changes in knowledge using a repeated-measures one-way analysis of variance (ANOVA). The Healthy Lifestyle Practice Scale for Children and Adolescents (HELIPSCA) indexed healthy lifestyle practices, with paired t-tests used to compare pre- and post-intervention scores. A two-way mixed ANOVA examined changes in healthy lifestyle practices among adolescents divided in terms of early and late stage of development. Results: Significant mean differences were observed in overall hypertension knowledge across four domains: general awareness, lifestyle factors, causes and care, and medication management and across time periods. There was a significant improvement in HELIPSCA scores post-intervention, particularly among early adolescents. Conclusion: The hypertension knowledge intervention examined in this study was effective in establishing a cognitive base among school children, with knowledge retention observed for 3 months. Moreover, this knowledge increase was associated with a parallel change in improved healthy lifestyle practices, notably among early adolescents. These findings underscore the importance of providing school-based education programmes early in adolescence to promote awareness of chronic illnesses and encourage healthy lifestyle choices.

Pemphigus relapse: Mechanisms, risk factors, and agents associated with disease recurrence.

Pemphigus represents a spectrum of potentially life-threatening autoimmune-mediated skin blistering conditions caused by antibody production against desmoglein 1 and 3 (anti-DSG 1 and 3) in keratinocytes. Greater than 50% of pemphigus patients experience relapse, which complicates long-term medical management, including risks associated with re-treatment and complications such as infection and dehydration. This review aims to elucidate mechanisms, risk factors, and medications associated with pemphigus relapse. Mechanisms of relapse include the persistence of auto-reactive B-cell populations post-treatment and CD20- B-cell populations that reactivate after B-cell depletion therapy. Risk factors for relapse include high body surface area (BSA) of pemphigus involvement, high body mass index, high severity according to the Pemphigus Disease Area Index (PDAI) at onset, treatment delay, and high anti-DSG1 and DSG3 titers post-treatment. Targeted B-cell localization is associated with better clinical outcomes, including less frequent relapses. Rituximab is currently the gold standard of treatment for moderate-severe pemphigus and has relapse rates of 11%-44% in selected studies, with a mean time to relapse of 5.8 months to 36 months following treatment. Relapse rates across lymphoma dosing (375 mg/m2) versus rheumatoid arthritis dosing (1 g dosing weekly) was inconsistent; however, more frequent dosing, earlier treatment, and higher cumulative dosing were associated with lower relapse rates. Alternative agents that have clinical efficacy include corticosteroid monotherapy, mycophenolate mofetil, azathioprine, and intravenous immunoglobulin. Future studies should include head-to-head comparators over long follow-up periods to identify the best treatment agents associated with the least relapse risk.

Waste 4.0: transforming medical waste management through digitalization and automated segregation

Medical waste management is a crucial issue due to its potential health risks to humans and harm to the environment. The World Health Organization (WHO) advises separating medical waste into seven groups based on its type. However, despite the implementation of color-coded bin bags, cases of missegregation still occur frequently, leading to injuries and spreading diseases. Infectious waste such as sharps, human tissue, and body parts are often found mixed in waste bins, posing a severe threat to waste employees. To address this issue, this paper proposes exploring the potential of digitalization in waste segregation. The literature on current segregation methods and technology applications is analysed and compared, and a framework for utilizing barcode tagging and scanning to ensure waste is correctly categorized is presented. The barcodes and scanner will be connected through a monitoring system, which can notify waste generators and collectors of misplacing or mixed waste. This digitalization system is expected to serve as a monitoring agent for segregating waste before it is collected from any health facilities. Additionally, the exchanged data from waste generator bins can inform collectors and other waste stakeholders about the waste's condition, potentially opening up opportunities for recycling companies to purchase used plastics or metals from hospital wastes. By implementing digitalization in medical waste management, waste segregation can improve, reduce the spread of diseases and injuries, and promote the recycling of hospital waste materials.

Knowledge, Attitude and Practice of Nurses and Midwives towards Hepatitis B Infection and Control Measures in Alban Gaded Hospital, Khartoum, Sudan

Purpose: Infection with the hepatitis B virus (HBV) causes severe morbidity and death, burdening world health. Nurses and midwives, among other healthcare professionals, are more likely to contract the illness. Few studies have looked at the knowledge, attitude, and practices (KAP) of healthcare professionals in Sudan with regard to HBV infection, despite the fact that diverse components of KAP have an impact on health-related behaviors. This study's objective was to assess the knowledge, attitude, and practice (KAP) level of nurses and midwives concerning HBV viral infection in, Khartoum, Sudan.  Methods: In the Sudanese state of Khartoum, a public hospital (Alban Gaded Hospital) underwent a cross-sectional descriptive hospital-based study. To assess KAP's understanding of nurses and midwives about HBV infection. Self-administered questionnaires were used and approved by the supervisor for distribution to the population chosen for the study. The data was handed over to the Medical Director whom personally ensured the questionnaires were signed and filled by the Healthcare workers (HCWs) of the chosen criteria at the field. A member of group (23:B) took care of the supervision aside with the medical director, and made sure the data was collected as needed. The data at hand were subjected to statistical analysis using SPSS version 24.0 (Statistical Package for Social Sciences).  Results: 95 samples out of 99 were collected. According to participants’ knowledge: 67.95% have good knowledge about HBV, while 32.05% lack basic knowledge about it. The participants’ attitude towards HBV is above average showing 60.3% safe attitude. Lastly, the study shows excellent practice of the participants’ behavior towards HBV safety measures with a score of 92.3% safe practice. From the hospital, a total of 95 out of 99 nurses and midwives took part in the study. Two thirds of the respondents practiced safety, and the majority of respondents had a positive attitude about HBV preventative measures. More than half of the respondents (58.2%) had an average level of understanding. A minor but serious score of (12.6%) was noticed of the individuals, dealing with patients without wearing gloves. More over half of the nurses and midwives were not vaccinated against HBV; more than 50% of participants had incorrect ideas regarding the symptoms and route of HBV infection and all 95 participants voted (NO) for ever being infected by HBV.  Conclusion: In Alban Gaded hospital, the majority of the nurses and midwives were aware of HBV infection. But a sizeable majority of the participants lacked the necessary understanding of early immunization after birth. The study found a probability of high risk infection due to exposure under the poor level of HBV vaccine coverage rate. Moreover a clear point of limitation was noticed in Table 4 third question, where it asks whether you are or ever was infected by HBV. All the participants denied, showing a sense of partiality. Further occupational exposure prevention measures, training programs on HBV infection, including post-exposure prophylaxis, and increasing the vaccination rate of all HCWS are also strongly encouraged.

Recovery rate and predictors among children aged 6–59 months with severe acute malnutrition in Addis Ababa, Ethiopia: a retrospective follow-up study

IntroductionSevere acute malnutrition (SAM) is a critical public health concern in Ethiopia, contributing to high morbidity and mortality rates among children. Despite the improvement in hospital coverage and the development of standardized WHO treatment guidelines, recent reviews indicated a wide range in recovery rates (34%–88%) due to several context-specific factors. Understanding the factors influencing the recovery time can help inform targeted interventions and improve the overall management of SAM cases. Therefore, this study aimed to assess the time to recovery and predictors of children aged 6–59 months with severe acute malnutrition in Addis Ababa, Ethiopia, in 2023.MethodsAn institutional-based retrospective follow-up study was conducted among children aged 6–59 months who were admitted to Tirunesh Beijing Hospital (TBH), Addis Ababa, Ethiopia, from July 2019 to June 2023. The Kaplan–Meir estimate and survival curve were used to compare the time to recovery using a log-rank test among different characteristics. A Cox proportional hazard regression analysis model was used to identify significant predictors of time to recovery. Finally, a p-value of &amp;lt;0.05 was used to declare a significant association.ResultsThe median survival time to recovery was 17 (95% CI: 16.39–17.60) days, and the incidence rate of recovery from SAM was 37.8 per 1,000 child days. Moreover, exclusive breastfeeding [adjusted hazard ratio (aHR): 1.97, 95% CI: 1.45–2.68], amoxicillin provision (aHR = 1.62, 95% CI: 1.11–2.35), and deworming (aHR = 2.14, 95% CI: 1.48–3.09) were protective factors. However, complications at admission (aHR = 0.41, 95% CI: 0.23–0.73) and diarrhea during admission (aHR = 0.64, 95% CI: 0.45–0.91) were identified as risk factors of recovery from SAM.ConclusionThe time to recovery among the current study participants was low compared with the sphere standard. Besides, exclusive breastfeeding, complications at admission, diarrhea, amoxicillin provision, and deworming were independent predictors. Therefore, appropriate provision of routine medication and early management of medical comorbidity as per the national SAM management protocol can reduce the mortality of children with severe acute malnutrition significantly.

The Annual Economic Burden of Uterine Fibroids in the United States (2010 Versus 2022): A Comparative Cost-Analysis.

In 2010, the estimated annual cost of uterine fibroids in the United States ranged from 5.9 to 34.4billion USD. In the past decade, more uterine-sparing and fertility preserving interventions have become available to treat symptomatic fibroids. This comparative cost-analysis aims to evaluate change in societal costs of uterine fibroids in the US between 2010 and 2022 given changing fibroid and obstetric management, population growth, and inflation. A systematic review was conducted to update uterine fibroid, treatment, and obstetric complication prevalence, direct costs of medical and surgical interventions, indirect productivity costs, and obstetric costs attributable to fibroids in 2022. A comparative cost-analysis with paired t-tests was performed using baseline data published in 2010. Percent (%) changes between 2010 and 2022 were reported. NIH research funding for fibroids and other common diseases was compared. All costs were converted to 2023 USD. The number of US women with uterine fibroids increased by 10.6% from 2010 to 2022. Over this period, the economic burden of uterine fibroids increased up to 41.4billion USD compared to 34.4billion USD in 2010. Overall costs increased to 42.2billion USD after incorporating new costs associated with MRgFUS and infertility. Direct costs of medical management decreased while costs of surgical interventions increased as a result of evolving treatment-seeking behavior. Lost work costs continue to account for the largest proportion of the economic burden for fibroids. Cesarean section delivery remains the largest contributor (average 80.0%) to indirect obstetrical costs. Despite the rise in the number of individuals affected by uterine fibroids and its sizable annual cost to society, uterine fibroids research continues to be underfunded.

Family caregivers’ administration of medications at the end-of-life in China: a qualitative study

BackgroundEffective medication management is crucial for ensuring timely pain and symptom control at the end of life. Dying in pain is a major concern for patients, yet some find less effective pain control at home. Family caregivers (FCGs) play a vital role in managing pain and symptom control for dying patients. However, the experience of administering medications at home for terminal-stage patients has not been widely recognized or understood. Our study aimed to explore the experiences of FCGs in administering medications to adult dying patients.MethodsWe conducted a directed content analysis of data from 73 semi-structured interviews with FCGs across 19 Chinese provinces from 2021 to 2023. FCGs were recruited through the Voluntary Cooperative Network Research. We asked, “Could you recall the end-of-life care process for the patients?” We aligned the themes with the five issues identified by Wilson et al. (2018): administration, organizational skills, empowerment, relationships, and support.ResultsFCGs in China exhibit concerns about over-engagement and empowerment in medication administration, concealing medication information from the patient, and medication accessibility. FCGs faced significant challenges in accurately identifying and addressing pain and symptoms, determining appropriate dosages, accessing effective medications, and managing the emotional stress associated with potential medication errors. Financial burden, medication regulatory restrictions, geographical inequality, and travel restrictions during COVID impeded patients and FCGs from accessing medication. A culturally specific finding is the use of alternative medicine at the end of life.ConclusionOur findings build upon Wilson et al.‘s framework and extend their insights on empowerment, highlighting the need for policies to support home-based palliative care professionals in training FCGs for effective medication administration.

Stenting for symptomatic intracranial arterial stenosis with different qualifying arteries: a preplanned pooled individual patient data analysis

BackgroundThe efficacy of percutaneous transluminal angioplasty and stenting (PTAS) relative to medical management in treating symptomatic intracranial arterial stenosis (ICAS) varies based on the qualifying artery. This study aims to...

Pharmacist-led hospital intervention reduces unintentional patient-generated medication discrepancies after hospital discharge

BackgroundMedication reconciliation can significantly reduce clinically important medication errors at hospital discharge, but its impact on post-discharge medication management has not been investigated. We aimed to investigate the incidence of patient-generated medication discrepancies 30 days after hospital discharge and the impact of a pharmacist-led medication reconciliation coupled with patient counselling on clinically important discrepancies caused by patients.MethodsA pragmatic, prospective, controlled clinical trial was conducted at the University Clinic Golnik, Slovenia. Adult patients were divided into an intervention group and a control group. The intervention group received pharmacist-led medication reconciliation at admission and discharge, plus patient counselling at discharge. Medication discrepancies were identified by comparing the therapy prescribed in the discharge letters with the therapy 30 days after discharge, obtained through telephone patient interviews. Discrepancies were classified as intentional or unintentional, and their clinical importance was assessed.ResultsThe study included 254 patients (57.9% male, median age 71 years), with 136 in the intervention group and 118 in the control group. Discrepancies occurred with a quarter of the medicines (617/2,441; 25.3%) at 30 days after hospital discharge, and patients themselves caused half of the discrepancies (323/617; 52.4%), either intentionally (171/617; 27.7%) or unintentionally (152/617; 24.6%). Clinically important discrepancies occurred in 18.7% of intentional and 45.4% of unintentional patient-generated changes. The intervention significantly reduced the likelihood of clinically important unintentional patient-generated discrepancies (OR 0.204; 95%CI: 0.093–0.448), but not clinically important intentional patient-generated discrepancies (OR 2.525; 95%CI: 0.843–7.563). The latter were more frequent among younger, male patients and patients hospitalized for respiratory diseases.ConclusionThe study emphasizes the importance of addressing discrepancies made by patients after hospital discharge, which can result in potentially harmful outcomes. It also shows that a pharmacist-led hospital intervention can significantly reduce discrepancies in the early post-discharge period. These findings can guide the development of future services to improve patient support for medication management after hospitalization.

New approaches to standard of care in early-phase myeloproliferative neoplasms: can interferon-α alter the natural history of the disease?

The classical BCR::ABL-negative myeloproliferative neoplasms (MPN) include Polycythemia Vera (PV), Essential Thrombocytemia (ET), and Primary Myelofibrosis (PMF). They are acquired clonal disorders of the hematopoietic stem cells (HSC) leading to hyperplasia of one or several myeloid lineages. MPN are caused by three main recurrent mutations, JAK2V617F and mutations in the calreticulin (CALR) and the thrombopoietin receptor (MPL) genes. Here, we review the general diagnosis, the complications, and the management of MPN. Second, we explain the physiopathology of the natural disease development and its regulation, which contributes to MPN heterogeneity. Thirdly, we describe the new paradigm of the MPN development highlighting the early origin of driver mutations decades before the onset of symptoms and the consequence on early detection of MPN cases in the general population for early diagnosis and better medical management. Finally, we present the interferon alpha (IFNα) therapy as a potential early disease-modifying drug after reporting its good hematological and molecular efficacies in ET, PV and early MF in clinical trials as well as its mechanism of action in pre-clinical studies. As a result, we may expect that, in the future, MPN patients will be diagnosed very early during the course of disease and that new selective therapies under development, such as IFNα, JAK2V617F inhibitors and CALRmut monoclonal antibodies, would be able to intercept the mutated clones.

Novel Use of Obsidio Conformable Embolic in Thoracic Duct Embolization

AbstractChylothorax is a potentially serious condition resulting from thoracic duct injury. When chyle output remains high despite medical management, invasive interventions such as surgical ligation or percutaneous thoracic duct embolization (TDE) may be necessary. Obsidio is a novel conformable embolic agent that shares properties of both coil and liquid embolic agents. A 37-year-old man presented with left-sided chylothorax, refractory to medical management, following a high-speed motorcycle collision. The thoracic duct was successfully embolized using Obsidio placed between coil packs with fibered coils. This case report demonstrates the first successful use of Obsidio for TDE in a patient with traumatic chylothorax.

Exploring the Remote Administration of a Performance-Based Functional Assessment.

Performance-based assessments of instrumental activities of daily living (IADL) can detect subtle functional impairments better than self-reported questionnaires. While most performance-based IADL assessments were developed for in-person administration, remote administration could increase access to vulnerable older adults. This study compared in-person and remote administration of IADL tasks from the Performance Assessment of Self-Care Skills. Community-dwelling older adults completed tasks (shopping, checkbook balancing, and medication management) at baseline (in-person) and follow-up (either in-person or remote, with modifications) two years later. Scores between the two follow-up groups, change in scores from baseline to follow-up, and differential item functioning (DIF) between the two administration methods at follow-up were examined. There were no differences in scores between methods of administration, but remote tasks took longer, and one item had significant DIF (ps < .01). Clinicians found remote administration acceptable and feasible. With minor adaptations, remote administration of the three tasks was supported. Further validation research is needed.

A Concise Review of Marfan Syndrome with a Congenital Cardiac Surgery Focus.

Marfan syndrome is named after Antoine Marfan, who described a 5-year-old child with congenital elongation of the digits and other skeletal abnormalities in 1896. While Marfan syndrome is a systemic connective tissue disorder predominantly involving the skeletal, cardiovascular, and ocular systems, the cardiovascular system presents the most life-threatening complications. Most cardiovascular pathologies surround the left ventricular outflow tract and aorta, with aortic dissection requiring emergent surgical management to the progression of mitral regurgitation requiring elective surgery. Intensive care management, along with a tailored approach to the surgical management of a patient with Marfan syndrome, is critical to their survival. Current surgical operations for patients include aortic root surgery, valve-sparing root replacements, aortic root replacements with conduits, and mitral valve repairs. Further research is necessary to determine the molecular, endovascular, pharmaceutical, and surgical management of Marfan syndrome. This review attempts to concisely discuss the diagnosis, complications, and medical and intensive care management of Marfan syndrome while further divulging on the surgical management of those with this disease process.

Emergency medical supply planning considering prepositioning and dynamic in-kind donation management in healthcare coalitions.

This study tackles an integrated emergency medical supply planning problem, which incorporates supply prepositioning and dynamic in-kind donation management in healthcare coalitions. Although this problem is vital for field practice, it is not investigated in the existing emergency supply planning literature. To fill the gap, we propose a two-stage stochastic programming model, which facilitates the planning of emergency medical supply prepositioning before disasters and dynamic supply transshipment and in-kind donation solicitation and distribution after disasters. With a case study on the healthcare coalition of West China Hospital in Sichuan Province of China under the background of the COVID-19 epidemic, the proposed model and seven comparison models are optimally solved to show the effectiveness and benefits of our model. We conduct sensitivity analysis to generate managerial insights and policy suggestions for better emergency medical supply management practices in healthcarecoalitions.

Trigeminal Neuralgia in the Presence of a Vascular Loop and Response to Medical Management: Experience From Saudi Arabia

Trigeminal Neuralgia in the Presence of a Vascular Loop and Response to Medical Management: Experience From Saudi Arabia

Stroke thrombectomy for large infarcts with limited penumbra: Systematic review and meta-analysis of randomized trials.

Recent randomized trials have suggested that endovascular thrombectomy (EVT) is superior to medical management (MM) for stroke patients with large infarcts. However, whether or how perfusion metrics should be used to guide optimal patient selection for treatment is largely unknown. This was a meta-analysis of randomized controlled trials reporting the effectiveness of EVT for large infarcts stratified by perfusion mismatch profiles. Patients with mismatch ratio 1.2-1.8 or penumbra volume 10-15cc (intermediate mismatch) or mismatch ratio <1.2 or volume <10cc (low mismatch) were included. Odds of 90-day modified Rankin scale (mRS) 0 to 3 (good) and 5 to 6 (poor) were calculated and effect sizes were pooled using Mantel-Haenszel fixed-effects models. Two trials - SELECT2 and ANGEL-ASPECT - were included; 140 intermediate mismatch (75 EVT and 65 MM) and 60 low mismatch patients (23 EVT and 37 MM) were identified. EVT was significantly associated with higher odds of mRS 0 to 3 for intermediate mismatch (pooled OR 2.77 [95%CI 1.11-6.89], p=0.028; Figure 1), but not low mismatch (pooled OR 1.47 [95%CI 0.444.94], p=0.54; Figure 1). Similarly, in terms of 90-day poor outcomes (mRS 5 or 6), EVT for intermediate mismatch patients was significantly associated with lower odds (OR 0.49 [95%CI 0.24 to 0.99], p=0.046; Figure 2), while EVT for the low mismatch cohort was not (OR 0.66 [95%CI 0.22 to 1.96], p=0.45; Figure 2). There was no significant inter-study heterogeneity observed across study estimates. For patients with large infarcts, EVT appears to be likely beneficial for patients with perfusion mismatch ratio and volume of at least 1.2 and 10cc, but not for those with mismatch ratio <1.2 or volume <10cc. These data generally support the continued use of perfusion imaging to select patients with large infarcts for EVT if it is available at the treating institution. Future studies and trials should consider investigating the efficacy and safety of EVT for patients with large infarcts and low mismatch profiles. EVT = endovascular thrombectomy; MM = medical management; OR = odds ratio; CI = confidence interval.

Outcome Predictor of Spontaneous Supratentorial Intracerebral Hemorrhage Management

Background: Spontaneous intracerebral hemorrhage (SICH) is responsible for higher morbidity and mortality rates than ischemic stroke. Although SICH is less common than ischemic stroke. Identifying the predictors of outcome after spontaneous supratentorial intracerebral hemorrhage is crucial for a clinical decision-making framework and implementing efficient therapeutic measures. Aims: The study aimed to analyze the clinical profile, assess the outcome, and identify the outcome prognosticators after supratentorial SICH in the Neurosurgery Department of a tertiary care hospital in the southeastern part of Bangladesh. Materials and Methods: This prospective interventional study included 183 patients with computerized tomography (CT) evidence of supratentorial SICH above 18 years of age from the Department of Neurosurgery of Chittagong Medical College Hospital between September 2021 and February 2023.The variables analyzed were age, sex, comorbidities, Glasgow coma scale (GCS) score on admission, radiological features, treatment modality and outcome at 90-day. Glasgow outcome scale (GOS) score was used to assess the outcome. GOS score 4-5 was considered good outcome and GOS score 1-3 was considered as poor outcome. Results: The mean age of the patients was 58.9±14.4 years and 52.5% were male. The 90-day mortality rate was 50.8% and 55.2% patients had poor outcomes. On bivariate analysis, higher age, comorbid CKD state, low GCS score, higher hematoma volume, midline shift, hydrocephalus and intraventricular hematoma (IVH) were associated with poor outcome. Independent predictors of poor outcome included a higher baseline age (OR: 1.07, 95% CI:1.02-1.11, p=0.002), lower GCS on admission (OR: 0.55, 95% CI: 0.39- 0.76, p&lt;0.001), and medical management (OR = 30.56, 95% CI = 7.15-130.69, P &lt;0.001). Conclusions: In conclusion, SICH is associated with high mortality and morbidity. Higher age, low GCS on admission and medical management independently predicted poor outcome in the present study. Patients with a lower age, higher GCS on admission and who were managed surgically were more likely to have a good outcome. Bang. J Neurosurgery 2024; 13(2): 96-103