Outcomes In High-risk Patients Research Articles

A PROSPECTIVE STUDY ON MANAGEMENT OF CARDIOGENIC SHOCK WITH PERCUTANEOUS CORONARY INTERVENTION

Cardiogenic shock following acute myocardial infarction (AMI) is a critical condition with high mortality rates. Percutaneous coronary intervention (PCI) has emerged as a key intervention, but the outcomes and associated risk factors, including comorbidities such as hypertension, diabetes, and smoking, remain essential to understand for optimizing treatment and improving prognosis. Objective: To evaluate outcomes and identify risk factors in patients with cardiogenic shock secondary to acute myocardial infarction managed with percutaneous coronary intervention. Methods: A prospective observational study was conducted at a tertiary care hospital involving 70 patients aged 60 years and above who presented with cardiogenic shock due to AMI within 24 hours of symptom onset. Data were collected on demographics, clinical indicators of shock severity, and mechanical complications, including pump failure, papillary muscle rupture, ventricular septal rupture (VSR), and free wall rupture. The incidence of comorbidities, such as hypertension, diabetes, and smoking status, was documented. Mortality and recovery patterns were assessed during hospitalization and post-discharge. Statistical analysis was performed to examine associations between comorbidities and adverse outcomes. Results: The mean age of the cohort was 68.8 ± 4.5 years, with a male predominance of 57.1%. Key complications included pump failure in 31.4%, papillary muscle rupture in 11.4%, papillary muscle dysfunction in 34.3%, VSR in 7.1%, and free wall rupture in 4.3% of patients. Overall mortality was 12.9%. Hypertension was present in 67.1% of patients, diabetes in 61.4%, and smoking in 21.4%, all of which correlated with higher complication rates and adverse outcomes. Conclusion: Early PCI management in patients with cardiogenic shock secondary to AMI is associated with favorable survival rates. However, comorbidities such as hypertension and diabetes significantly increase complication rates. These findings underscore the importance of timely intervention and risk-targeted management to improve survival outcomes in high-risk patients.

TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery: the TRACS trial: TAVI in centers without on-site cardiac surgery

Transcatheter aortic valve implantation (TAVI) has emerged as an effective and safe treatment for patients with symptomatic aortic stenosis. The indication to TAVI should be agreed upon by a Heart Team, and the procedure should be performed in centers with on-site cardiac surgery. However, TAVI complications requiring emergent cardiac surgery (ECS) have become very rare. Concurrently, access disparities and prolonged waiting times are pressing issues due to increasing clinical demand of TAVI. Many solutions have been proposed and one of them is the possibility of performing TAVI in centers without on-site cardiac surgery. The TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with symptomatic severe aortic stenosis and deemed inoperable, at high surgical risk, or presenting with at least one clinical factor compromising the benefit/risk ratio for ECS, will be randomized to undergo TAVI either in centers with or without on-site cardiac surgery. The primary endpoint will be the composite occurrence of all-cause death, stroke, and hospital readmission for cardiovascular causes at one year. The safety endpoint will include death attributable to periprocedural complications actionable by ECS. The study aims to enroll 566 patients. The TRACS trial aims to address critical gaps in knowledge regarding the safety and efficacy of TAVI procedures performed in centers without on-site cardiac surgery, potentially improving access and outcomes for high-risk patients. ClinicalTrials.gov NCT05751577.

Intraoperative neurophysiologic monitoring during cardiac surgery: an observational cohort study

ObjectiveTo evaluate the impact of intraoperative neuromonitoring (IONM) on stroke and operative mortality after coronary and/or valvular operations.MethodsThis was an observational study of coronary and/or valvular heart operations from 2010...

Effects of glucagon-like peptide-1 receptor agonists on cardiovascular outcomes in high-risk type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

BackgroundGlucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been shown to provide cardiovascular benefits in patients with type 2 diabetes mellitus (T2DM). However, their cardiovascular protective efficacy in high-risk T2DM patients, particularly those with a history of cardiovascular events or severe chronic kidney disease, remains uncertain.MethodsA comprehensive search was conducted in PubMed, Embase, Web of Science, and The Cochrane Library to identify randomized controlled trials (RCTs) that evaluated the effects of GLP-1 RAs on cardiovascular outcomes in high-risk patients with T2DM. A random-effects model was used to calculate pooled hazard ratios (HRs) for cardiovascular outcomes. Subgroup analyses and GRADE assessment were also performed.ResultsNine RCTs involving 63,613 patients were included. GLP-1 RAs significantly reduced the risk of the primary composite outcome (HR: 0.86, 95% CI: 0.80–0.92), cardiovascular death (HR: 0.85, 95% CI: 0.78–0.93), all-cause death (HR: 0.87, 95% CI: 0.82–0.93), myocardial infarction (HR: 0.90, 95% CI: 0.82–0.98), stroke (HR: 0.85, 95% CI: 0.77–0.95), and heart failure (HF) hospitalization (HR: 0.90, 95% CI: 0.83–0.97). No significant difference in unstable angina (UA) hospitalization was observed (HR: 1.04, 95% CI: 0.95–1.15). Subgroup analyses indicated greater benefits with combination therapy, particularly in patients with chronic kidney disease. The quality of evidence was rated as “High” for six outcomes and “Moderate” for UA hospitalization.ConclusionsGLP-1 RAs significantly reduce cardiovascular risk in high-risk T2DM patients, especially with combination therapy and in those with chronic kidney disease. However, further research is needed to confirm their long-term effects.

IVUS-Guided vs Angiography-Guided PCIin Patients With Diabetes With AcuteCoronary Syndromes: The IVUS-ACS Trial.

Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk for clinical events in patients with acute coronary syndromes (ACS), compared with angiographic guidance. However, the benefits of IVUS guidance in high-risk patients with diabetes with ACS is uncertain. The aim of this prespecified stratified subgroup analysis from the IVUS-ACS randomized trial was to determine the effectiveness of IVUS-guided PCI vs angiography-guided PCI in patients with diabetes with ACS. From August 20, 2019, to October 27, 2022, 1,105 patients with diabetes with ACS were randomized, including 554 patients in the IVUS-guided group and 551 in the angiography-guided group. The primary endpoint was the rate of target vessel failure (TVF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization. At 1-year follow-up, TVF occurred in 20 patients in the IVUS guidance group and in 46 patients in the angiographic guidance group (Kaplan-Meier rates 3.6% vs 8.3%; HR: 0.46; 95%CI: 0.27-0.81; P=0.007), driven by a reduction in clinically driven target vessel revascularization (0.9% vs 3.8%; P=0.003). IVUS-guided PCI also reduced the risk for TVF without procedural myocardial infarction (2.0% vs 6.7%; HR: 0.29; 95%CI: 0.15-0.57; P< 0.001) and all-cause mortality (HR: 0.30; 95%CI: 0.10-0.93; P=0.037). There were no significant differences in the rates of stent thrombosis or major bleeding between the groups. In the large-scale IVUS-ACS trial, IVUS-guided PCI improved 1-year clinical outcomes in high-risk patients with diabetes with ACS. (1-Month vs 12-Month DAPT for ACS Patients Who Underwent PCI Stratified by IVUS: IVUS-ACS and ULTIMATE-DAPT Trials; NCT03971500).

Association Between Carbapenem-Resistant Enterobacterales (CRE) Colonization Status at Time of Hospital Admission and the Subsequent Development of CRE Infection and Mortality in High-Risk Patients.

The study aimed to determine the impact of Carbapenem-resistant Enterobacterales (CRE) colonization status on development of CRE infection and 30-day mortality outcomes in high-risk patients. This retrospective cohort study was conducted at King Faisal Specialist Hospital and Research Center in Jeddah, Saudi Arabia from October 2022 to July 2023. It included all patients aged 14 years and older admitted to the intensive care unit (ICU), the renal transplant unit and the oncology units who were screened for CRE colonization upon hospital admission. Overall, 246 patients comprised the study population and 37 patients (56.8% ICU, 13.5% renal transplant unit, and 29.7% oncology units) had a positive CRE screening test. The majority of the isolates (59.5%) were OXA-48. Almost one-third (32.1%) of the patients had diabetes mellitus and 55.3% had any underlying immunosuppression. Eight (3.3%) patients had a confirmed CRE infection and 35 (14.2%) patients died within 30 days of screening. A positive CRE screening test significantly increased the likelihood of 30-day mortality for this high-risk patient population (adjusted odds ratio [AOR] = 3.06, 95% CI = 1.10-8.51, p = 0.03). A substantial percentage of the high-risk patients had a positive CRE screening test at the time of hospital admission and CRE-colonization status predicted 30-day mortality. Further studies are needed to determine the best practices for CRE screening as a strategy to prevent infection and mortality.

Association of body composition and systemic inflammation for patients with locally advanced cervical cancer following concurrent chemoradiotherapy

Systemic inflammation and body composition are associated with survival outcomes of cancer patients. This study aimed to examine the combined prognostic value of systemic inflammatory markers and body composition parameters in patients with locally advanced cervical cancer (LACC). Patients who underwent concurrent chemoradiotherapy (CCRT) for LACC at a tertiary referral teaching hospital between January 2010 and January 2018 were enrolled. A predictive model was established based on systemic immune-inflammation index (SII) and computer tomography-derived visceral fat-to-muscle ratio (vFMR). Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method and Cox regression models. The model performance was assessed using discrimination, calibration, and clinical usefulness. In total, 212 patients were enrolled. The SII and vFMR were closely related, and both independently predicted survival (P < 0.05). A predictive model was established based on the above biomarkers and included three subgroups: high-risk [both high SII (>828) and high vFMR (>1.1)], middle-risk (either high SII or high vFMR), and low-risk (neither high SII nor high vFMR). The 3-year OS (PFS) rates for low-, middle-, and high-risk patients were 90.5% (86.0%), 73.9% (58.4%), and 46.8% (36.1%), respectively (P < 0.05). This model demonstrated satisfactory predictive accuracy (area under the curve values for predicting 3-year OS and PFS were 0.704 and 0.718, respectively), good fit (Hosmer-Lemeshow tests: P > 0.05), and clinical usefulness. Systemic inflammatory markers combined with body composition parameters could independently predict the prognosis of patients with LACC, highlighting the utilization of commonly collected indicators in decision-making processes. The SII and vFMR, as well as their composite indices, were promising prognostic factors in patients with LACC who received definitive CCRT. Future studies are needed to explore novel therapies to improve the outcomes in high-risk patients.

P222 PREDICTOR FACTORS OF UNCONTROLLED MASKED HYPERTENSION IN PATIENTS WITH HYPERTENSION WITH CHRONIC KIDNEY DISEASE

Background and Objective: Masked uncontrolled hypertension (MUCH) is commonly observed in patients with hypertension who are normotensive in the clinic. MUCH is associated with increased risk for target- organ damage and adverse cardiovascular and renal outcomes in high-risk patients, such as those with chronic kidney disease (CKD). The objective of this study was to evaluate predictors of MUCH in patients with hypertension and CKD. Methods: This was cross-sectional study that performed 24-hour ambulatory blood pressure (BP) monitoring (ABPM) in 220 patients with hypertension and CKD (glomerular filtration rate &lt;60 mL/min/1.73 m2) and controlled BP in the office (&lt;140/90 mmHg). We categorized participants into two groups: 1) controlled BP group (24-hour ABPM &lt;130/80 mmHg), and 2) MUCH group (24-hour ABPM ≥130/80 mmHg). Epidemiological, clinical, anthropometric variables and laboratory data were collected and compared between the two groups. We used logistic-regression models to identify the predictors of MUCH. Results: Approximately half of patients (n=109, 49.6%) had MUCH. Higher office BP values were observed in patients classified as controlled BP, both systolic (127 vs 125 mmHg, p=0.06) and diastolic BP (75 vs 72 mmHg, p=0.01). When analyzing anthropometric variables, a higher body mass index (BMI) was noted in the controlled BP group (26 vs 28 kg/m2, p&lt;0.01). Regarding laboratory data, higher levels of urine albumin-creatinine ratio (uACR) were observed in the MUCH group (275 vs 69 mg/g, p&lt;0.01). In a logistic regression model, were significant: diastolic BP in the office between 75 and 89 mmHg (OR: 1.93, 95%CI 1.03-3.64; p=0.04), BMI &lt;25Kg/m2 (OR: 2.21, 95%CI 1.08-4.52; p=0.03) and uACR greater than 300 mg/g (OR: 3.26, 95%CI 1, 71-6.19; p&lt;0.01). Conclusion: In patients with CKD and BP controlled at the office, diastolic BP in the office between 75 and 89 mmHg, BMI &lt;25 kg/m2 and uACR &gt;300 mg/g were predictive factors for MUCH.

Acute post-procedural inducibility is a poor predictor of clinical outcomes in high-risk patients (PAINESD > 17) undergoing scar-related ventricular tachycardia ablation.

Ventricular tachycardia (VT) non-inducibility in response to programmed ventricular stimulation (PVS) is a widely used procedural endpoint for VT ablation despite inconclusive evidence with respect to clinical outcomes in high-risk patients. The aim is to determine the utility of acute post-ablation VT inducibility as a predictor of VT recurrence, mortality, or mortality equivalent in high-risk patients. We conducted a retrospective analysis of high-risk patients (defined as PAINESD > 17) who underwent scar-related VT ablation at our institution between July 2010 and July 2022. Patients' response to PVS (post-procedure) was categorized into three groups: Group A, no clinical VT or VT with cycle length > 240 ms inducible; Group B, only non-clinical VT with cycle length > 240 ms induced; and Group C, all other outcomes (including cases where no PVS was performed). The combined primary endpoint included death, durable left ventricular assist device placement, and cardiac transplant (Cox analysis). Ventricular tachycardia recurrence was considered a secondary endpoint (competing risk analysis). Of the 1677 VT ablation cases, 123 cases met the inclusion criteria for analysis. During a 19-month median follow-up time (interquartile range 4-43 months), 82 (66.7%) patients experienced the composite primary endpoint. There was no difference between Groups A and C with respect to the primary [hazard ratio (HR) = 1.21 (0.94-1.57), P = 0.145] or secondary [HR = 1.18 (0.91-1.54), P = 0.210] outcomes. These findings persisted after multivariate adjustments. The size of Group B (n = 13) did not permit meaningful statistical analysis. The results of post-ablation PVS do not significantly correlate with long-term outcomes in high-risk (PAINESD > 17) VT ablation patients.

Poster 297: Clinical Outcomes and Return to Sports After Revision ACL Reconstruction With Lateral Extraarticular Tenodesis: Comparison to A Control Group of ACL Reconstruction Only at a Minimum 2-Year Follow-Up

Objectives: Lateral extraarticular tenodesis (LET) has been shown to decrease failure rate in settings of revision anterior cruciate ligament (ACL) reconstruction in young, high-demand patients. However, there is a paucity of literature comparing clinical outcomes and return to sports after patients who undergo revision ACL reconstruction LET compared to those without LET (control group). Methods: All patients who underwent revision ACL reconstruction with and without LET between January 2018 and February 2020 were queried at our institutional registry. The LET group was compared to the control group (revision ACL reconstruction without LET) were followed for a minimum of 24 months postsurgery to evaluate patients reported outcome measures, satisfaction, return to sports, rate of reoperation, and psychological readiness for return to sports (using the ACL-Return to Sport After Injury Scale, ACL-RSI). Results: A total of 81 patients with a mean follow-up of 2.75 years were included. The LET group contained 37 patients (76% female) with a mean age of 26.6 years and body mass index (BMI) of 23.5 kg/m^2 compared to 44 patients (80% female) with mean age of 28.2 years and BMI of 26.9 kg/m^2. There were no significant differences between the LET and control groups with respect to mean postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (47.7 vs 48.3, p = 0.46) and PROMIS Mobility scales (53.3 vs 52.9, p = 0.97). In addition, there were no differences in postoperative International Knee Documentation Committee (78.9 vs 78.3, p=0.45), Marx (7.9 vs 7.2, p = 0.64), or Single Assessment Numeric Evaluation (73.1 vs 74.2, p = 0.38) scores. The same held true with regards to postoperative ACL-RSI scores between the groups (43.3 vs 50.1, p = 0.38). Return to play rates after revision ACL were similar in the LET group compared to the control group (55% vs 45%, p = 0.40) with similar confidence to play their pre-injury sport (scale out of 100, 58.2 vs 56.2, p = 0.82). Lastly, overall reoperation rates were similar between the groups with the LET group having a rate of 21.2% compared to 19.4% for the control group. When isolated for revision due to graft tear, the LET group had a re-revision rate of 13.5% compared to 6.8% in the control group (p = 0.31). Conclusions: Satisfaction and patient reported outcome scores after revision ACL reconstruction are good with or without LET. While both groups have similar rates of return to play and reoperation at greater than 2- year follow-up, these results suggest the addition of LET may provide similar outcomes in high-risk patients when compared to isolated revision ACL reconstruction.

Mutational Profiles of Cutaneous Squamous Cell Carcinomas with Different Patterns of Clinical Aggression from Head and Neck Regions.

Cutaneous squamous cell carcinoma is a prevalent malignancy with a rising incidence and a notably high mutational load. Exploring the genetic nuances of cSCC and investigating molecular approaches stands as a potential avenue for improving outcomes in high-risk patients. This retrospective case-control study involved two cohorts, one of 14 patients (the "discovery cohort") and the other of 12 patients (the "validation cohort"), with cSCC located in the head/neck anatomical region and diagnosed at the pT2 stage. Overall, cases developed early local relapses of the disease, whereas controls never relapsed during the entire follow-up period. A next-generation sequencing (NGS) approach conducted on histological samples revealed that TP53 and CDKN2A were the most frequently mutated genes in our series. No specific mutations were identified as potential prognostic or therapeutic targets. Controls exhibited a tendency toward a higher mutational rate compared to cases. It is possible that an increased number of mutations could prompt the cSCC to expose more antigens, becoming more immunogenic and facilitating recognition by the immune system. This could enhance and sustain the immunological response, potentially preventing future recurrences.

The association of inflammatory biomarkers and long-term clinical outcomes in older adults with non-ST elevation acute coronary syndrome

BackgroundThe prognostic significance of inflammatory markers on the long-term risk of major adverse cardiovascular and cerebrovascular events (MACCE) in older NSTEACS patients remains unclear. MethodsNSTEACS patients aged 75 and older were recruited to the multicentre cohort study Improve Cardiovascular Outcomes in High-Risk PatieNts with Acute Coronary Syndrome (ICON1). Inflammatory markers including interleukin-6 (IL-6), myeloperoxidase (MPO), high-sensitivity C-reactive protein (hsCRP), fibrinogen and tumor necrosis factor-alpha (TNF-α) were collected at baseline. Primary outcome was MACCE consisting of all-cause mortality, reinfarction, stroke/transient ischaemic attack, urgent revascularization, and significant bleeding at 5-year follow-up. ResultsThere were 230 patients with baseline IL-6 (median age 80.9 [interquartile range (IQR):78.2–83.9] years). High IL-6 was not associated with MACCE, but it was independently associated with all-cause mortality (adjusted hazard ratio [aHR]: 2.26 [95% Confidence Interval (CI):1.34–3.82]; P = 0.002). For patients with hsCRP (n = 260, median age 80.9 [IQR:77.9–84.1] years), higher levels were significantly associated with increased risk of MACCE (aHR:1.77 [95% CI:1.26–2.49], P = 0.001). In the cohort with MPO (230 patients, median age 80.9 [IQR:78.2–83.9] years), lower MPO was independently associated with the risk of MACCE (aHR: 0.67 [95%CI:0.46–0.96]; P = 0.029). There was no prognostic significance with fibrinogen and TNF-α. ConclusionAmong older NSTEACS patients, elevated IL-6 and hsCRP were associated with increased risk of all-cause mortality and MACCE, respectively. Low MPO levels were associated with higher MACCE. Further studies are required to determine how these biomarkers should influence treatment strategy in this understudied subset. Clinical Trial RegistrationNCT01933581

Coronary Artery Plaque Phenotype and 5-Year Clinical Outcomes in Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Lesions with thin-cap fibroatheroma (TCFA), small luminal area and large plaque burden (PB) have been considered at high risk of cardiovascular events. Older patients were not represented in studies which demonstrated correlation between clinical outcome and plaque characteristics. This study aims to investigate the prognostic role of high-risk plaque characteristics and long-term outcome in older patients presenting with non-ST elevation acute coronary syndrome (NSTEACS). This study recruited older patients aged 75 years with NSTEACS undergoing virtual-histology intravascular ultrasound (VH-IVUS) imaging from the Improve Clinical Outcomes in high-risk patieNts with acute coronary syndrome (ICON-1). Primary endpoint was the composite of major adverse cardiovascular events (MACE) consisting of all-cause mortality, myocardial infarction (MI), and any revascularisation. Every component of MACE and target vessel failure (TVF) including MI and any revascularisation were considered as secondary endpoints. Eighty-six patients with 225 vessels undergoing VH-IVUS at baseline completed 5-year clinical follow-up. Patients with minimal lumen area (MLA) 4 demonstrated increased risk of MACE (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.00-5.59, p = 0.048) with a worse event-free survival (Log Rank 4.17, p = 0.041) than patients with MLA 4 . Patients with combination of TCFA, MLA 4 and PB 70% showed high risk of MI (HR 5.23, 95% CI 1.05-25.9, p = 0.043). Lesions with MLA 4 had 6-fold risk of TVF (HR 6.16, 95% CI 1.24-30.5, p = 0.026). Small luminal area appears as the major prognostic factor in older patients with NSTEACS at long-term follow-up. Combination of TCFA, MLA 4 and PB 70% was associated with high risk of MI. NCT01933581.

Identification of a lactate metabolism-related lncRNAs signature for predicting the prognosis in patients with kidney renal clear cell carcinoma.

Lactate metabolism-related (LMR) long noncoding RNAs (lncRNAs) play significant roles in various cancers, but their impact on kidney renal clear cell carcinoma (KIRC) remains unclear. This study aimed to explore the value of LMR lncRNA and develop a risk model for KIRC. Data on KIRC patients were downloaded from The Cancer Genome Atlas (TCGA) database. LMR lncRNAs were identified by co-expression, univariate and multivariate analyses, and least absolute shrinkage selection operator (LASSO) regression analysis. Subsequently, a prognostic signature was constructed and its accuracy was verified. To predict the prognosis of KIRC effectively, we established a nomogram based on this information. Enrichment analysis, tumor mutational burden (TMB) analysis, immune status and the therapeutic sensitivities of KIRC patients were also investigated. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect the expression of lncRNAs. We constructed and verified a predictive signature based on six LMR lncRNA (LINC00944, AC090772.3, Z83745.1, AP001267.3, AC092296.1, and AL162377.1) to assess the patient prognoses of KIRC. Survival analyses showed a more unfavorable outcome in high-risk patients (P<0.001). Enrichment analysis demonstrated that immune-related pathways were enriched in the high-risk group. Besides, patients classified by risk scores had distinguishable immune status, TMB, response to immunotherapy, and sensitivity to chemotherapy and targeted drugs. The LMR lncRNAs signature has significant implications for prognostic assessment and clinical treatment guidance in KIRC.

Revisiting Neuroblastoma: Nrf2, NF-κB and Phox2B as a Promising Network in Neuroblastoma.

Neuroblastoma is the most common solid extracranial tumor during childhood; it displays extraordinary heterogeneous clinical courses, from spontaneous regression to poor outcome in high-risk patients due to aggressive growth, metastasizing, and treatment resistance. Therefore, the identification and detailed analysis of promising tumorigenic molecular mechanisms are inevitable. This review highlights the abnormal regulation of NF-κB, Nrf2, and Phox2B as well as their interactions among each other in neuroblastoma. NF-κB and Nrf2 play a key role in antioxidant responses, anti-inflammatory regulation and tumor chemoresistance. Recent studies revealed a regulation of NF-κB by means of the Nrf2/antioxidant response element (ARE) system. On the other hand, Phox2B contributes to the differentiation of immature sympathetic nervous system stem cells: this transcription factor regulates the expression of RET, thereby facilitating cell survival and proliferation. As observed in other tumors, we presume striking interactions between NF-κB, Nrf2, and Phox2B, which might constitute an important crosstalk triangle, whose decompensation may trigger a more aggressive phenotype. Consequently, these transcription factors could be a promising target for novel therapeutic approaches and hence, further investigation on their regulation in neuroblastoma shall be reinforced.

Outcomes of Patients with Acute Type B Aortic Dissection and High-Risk Features

BackgroundRecently the SVS and STS published contemporary guidelines clearly defining complicated vs uncomplicated acute type B aortic dissections (TBADs) with an additional high-risk grouping. Few studies have evaluated outcomes associated with “high-risk” TBADs. The objective of this study was to assess differences in demographics, clinical presentation, symptom onset, and outcomes in high-risk patients that underwent either thoracic endovascular aortic repair (TEVAR) or best medical management for acute TBAD compared to those with complicated and uncomplicated acute TBAD. MethodsPatients admitted with acute TBADs from a single academic medical center from 10/ 2011 to 3/2020 were analyzed. Per STS/SVS 2020 guidelines, high-risk was defined as refractory pain/hypertension, bloody pleural effusion, aortic diameter >4cm, false lumen diameter >22mm, radiographic malperfusion, early readmission, and complicated was defined as ruptured/malperfusion presentation. Uncomplicated patients were those without malperfusion/rupture and without high-risk features. The primary end-point was inpatient mortality. Secondary end-points included complications, re-intervention and survival. ResultsOf 159 patients identified with acute TBAD, 63 (40%) met high-risk criteria. In the high-risk cohort, 38 (60%) underwent TEVAR (HR-TEVAR), with refractory pain as the most common indication, while 25 (40%) were managed medically (HR-Medical). Malperfusion or rupture was present in 63 (40%) patients (C-TBAD), all of whom underwent TEVAR. An additional 33 patients had no high-risk features and were all managed medically (U-TBAD). There were no differences in age, BMI, and race between groups. Among the four groups, there were variable distributions in sex, insurance status, and incidence of several baseline comorbidities including CHF, COPD, and renal dysfunction (p<0.05 for all). C-TBAD had increased length of stay (12, IQR 9-22) compared to HR-TEVAR (11.5, IQR 7-15), HR-Medical (6, IQR 5-8), and U-TBAD (7, IQR 5-10) (p<0.01). C-TBAD had decreased days from admission to repair (0, IQR 0,2) compared to HR-TEVAR (3.5, IQR 1-8) (p<0.01). C-TBAD patients had worse 3-year survival compared to other groups (log-rank p<0.01), although when in-hospital mortality was excluded, survival was similar among groups (p=0.37).Of patients initially managed medically, outpatient TEVAR was performed in 6 (24%) HR-Medical and 4 (12%) uncomplicated patients, with no difference between rate of intervention between groups (p=0.22). ConclusionsHigh-risk features, as defined in updated SVS/STS guidelines, are common in patients presenting with acute TBAD. High-risk patients had acceptable outcomes when managed either surgically or medically. High-risk patients that underwent TEVAR had improved perioperative outcomes and mortality compared to those undergoing TEVAR for complicated TBAD, a finding which may help guide preoperative risk stratification and patient counseling.

Completion pancreatectomy during pancreatoduodenectomy: A lifesaving solution in high-risk patients.

Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice. Between 2014 and 2023, 139 patients (76 men, median age 67years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison. Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14days [11; 18] vs. 17days [13; 24], p=0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p<0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates. The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.

Perioperative hyperoxia- impact on myocardial biomarkers, strain and outcome in high-risk patients undergoing non-cardiac surgery: Protocol for a prospective randomized controlled trial

BackgroundSupplemental oxygen is used during every general anesthesia. However, for the maintenance phase of a general anesthesia, in most cases the longest part of anesthesia, only scarce evidence of dosing supplemental oxygen exists. Oxygen is a well-known coronary vasoconstrictor and thus may contribute to cardiovascular complications especially in vulnerable high-risk patients with coronary artery disease undergoing major non-cardiac surgery. Myocardial biomarkers are early indicators of myocardial injury. Oxygen supply demand mismatches due to coronary artery disease aggravated by hyperoxia might be displayed by changes from the biomarker's baseline-values. This study is designed to detect changes in myocardial biomarkers levels associated with perioperative hyperoxia. MethodsThis prospective randomized controlled interventional trial investigates the impact of maintaining perioperative high oxygen supplementation in high-risk patients undergoing non-cardiac vascular surgery on cardiac biomarkers, myocardial strain and outcome in 110 patients. Patients are allocated to be supplemented with either 0.3 (normal) or 0.8 (high) fraction of inspired oxygen (FiO2) perioperatively. Included is a short crossover phase during which transesophageal echocardiography is used to evaluate myocardial function at FiO2 0.3 and 0.8 by strain analysis in each patient. Patients will be followed up for complications at 30 days and 1 year. ConclusionThe trial is designed to evaluate perioperative changes from baseline myocardial biomarkers associated with perioperative FiO2. Furthermore, exploration and correlation of changes in biomarkers, acute early changes in myocardial function and clinical outcomes induced by different FiO2 may be possible.

A novel equation for the estimation of low-density lipoprotein cholesterol in the Saudi Arabian population: a derivation and validation study

Low-density lipoprotein cholesterol (LDL-C) is typically estimated by the Friedewald equation to guide atherosclerotic cardiovascular disease (ASCVD) management despite its flaws. Martin–Hopkins and Sampson-NIH equations were shown to outperform Friedewald’s in various populations. Our aim was to derive a novel equation for accurate LDL-C estimation in Saudi Arabians and to compare it to Friedewald, Martin–Hopkins and Sampson-NIH equations. This is a cross-sectional study on 2245 subjects who were allocated to 2 cohorts; a derivation (1) and a validation cohort (2). Cohort 1 was analyzed in a multiple regression model to derive an equation (equationD) for estimating LDL-C. The agreement between the measured (LDL-CDM) and calculated levels was tested by Bland–Altman analysis, and the biases by absolute error values. Validation of the derived equation was carried out across LDL-C and triglyceride (TG)-stratified groups. The mean LDL-CDM was 3.10 ± 1.07 and 3.09 ± 1.06 mmol/L in cohorts 1 and 2, respectively. The derived equation is: LDL-CD = 0.224 + (TC × 0.919) – (HDL-C × 0.904) – (TG × 0.236) – (age × 0.001) – 0.024. In cohort 2, the mean LDL-C (mmol/L) was estimated as 3.09 ± 1.06 by equationD, 2.85 ± 1.12 by Friedewald, 2.95 ± 1.09 by Martin–Hopkins, and 2.93 ± 1.11 by Sampson-NIH equations; statistically significant differences between direct and calculated LDL-C was observed with the later three equations (P < 0.001). Bland–Altman analysis showed the lowest bias (0.001 mmol/L) with equationD as compared to 0.24, 0.15, and 0.17 mmol/L with Friedewald, Martin–Hopkins, and Sampson-NIH equations, respectively. The absolute errors in all guideline-stratified LDL-C categories was the lowest with equationD, which also showed the best classifier of LDL-C according to guidelines. Moreover, equationD predicted LDL-C levels with the lowest error with TG levels up to 5.63 mmol/L. EquationD topped the other equations in estimating LDL-C in Saudi Arabians as it could permit better estimation when LDL-C is < 2.4 mmol/L, in familial hyperlipidemia, and in hypertriglyceridemia, which improves cardiovascular outcomes in high-risk patients. We recommend further research to validate equationD in a larger dataset and in other populations.

Интракоронарное применение левокарнитина при стентировании коронарных артерий у пациентов высокого риска

The main causes of postoperative mortality associated with percutaneous coronary interventions involving the coronary artery stent insertion are perioperative myocardial infarction and acute heart failure due to inadequate protection of the myocardium against ischemia/reperfusion. The standard therapy includes beta blockers, anticoagulants, antiplatelet drugs. Two clinical cases of successful use of intravenous levocarnitine for cardioprotection in senile patients with acute forms of coronary heart disease with multivessel lesions are reported. The postoperative period went well, smooth dynamics of biomarker levels (troponin I, creatine phosphokinase, MB fraction of creatine phosphokinase) was observed, and ischemic ECG changes were relatively small. The expected results of the technique application include reduction of intraoperative and postoperative complications of ischemia/reperfusion and the increase in effectiveness of the stent insertion clinical outcomes in high-risk patients.