Outcomes Registry Research Articles

Assessing the Likelihood of Procedural Intubation During Percutaneous Coronary Intervention.

Preprocedural fasting is widely used before percutaneous coronary intervention (PCI). However, the incidence of procedural intubation during PCI is unknown. This study aims to identify the incidence and predictors for procedural intubation during PCI. A retrospective cohort study was performed on patients undergoing PCI between 2014 and 2021 within the Victorian Cardiac Outcomes Registry. Patients were classified into urgent, semiurgent, or elective PCI on the basis of recorded PCI indication. Those undergoing semiurgent or elective PCI were presumed to be fasted preprocedurally. The incidence of procedural intubation was reported for each PCI group. Inverse probability treatment weighting was used to determine the association between 30-day death and procedural intubation. Logistic regression was performed to determine clinical, procedural, and lesion characteristics associated with procedural intubation among fasted patients. Among 83 929 patients, the incidence of procedural intubation was 0.5%. Patients undergoing urgent PCI (odds ratio [OR], 19.68 [95% CI, 13.91-27.86]; P<0.01) had the highest risk of procedural intubation. Procedural intubation was associated with increased 30-day death (OR, 4.79 [95% CI, 3.29-6.96]; P<0.01). Among fasted patients, estimated glomerular filtration rate (OR, 0.99 [95% CI, 0.98-0.99]; P<0.01), cardiogenic shock (OR, 96.24 [95% CI, 56.01-165.35]; P<0.01), out-of-hospital cardiac arrest (OR, 3.42 [95% CI, 1.30-8.97]; P=0.01), femoral access (OR, 2.09 [95% CI, 1.38-3.19]; P<0.01), left main disease (OR, 5.77 [95% CI, 3.16-10.54]; P<0.01), type C lesions (OR, 3.86 [95% CI, 1.19-12.56]; P=0.03), and rotational atherectomy (OR, 2.20 [95% CI, 1.03-4.69]; P=0.04) were associated with procedural intubation. Despite an association with a worse 30-day mortality rate, the incidence of procedural intubation during PCI was low. Universal preprocedural fasting may be unnecessary and could be targeted at higher-risk groups.

Postpartum Wound Healing for Mothers with Inflammatory Bowel Disease: Cause for Worry? Insights from the Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes Registry.

Postpartum Wound Healing for Mothers with Inflammatory Bowel Disease: Cause for Worry? Insights from the Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes Registry.

Identifying biomarker-driven subphenotypes of cardiogenic shock: analysis of prospective cohorts and randomized controlled trials.

Cardiogenic shock (CS) is a heterogeneous clinical syndrome, making it challenging to predict patient trajectory and response to treatment. This study aims to identify biological/molecular CS subphenotypes, evaluate their association with outcome, and explore their impact on heterogeneity of treatment effect (ShockCO-OP, NCT06376318). We used unsupervised clustering to integrate plasma biomarker data from two prospective cohorts of CS patients: CardShock (N=205 [2010-2012, NCT01374867]) and the French and European Outcome reGistry in Intensive Care Units (FROG-ICU) (N=228 [2011-2013, NCT01367093]) to determine the optimal number of classes. Thereafter, a simplified classifier (Euclidean distances) was used to assign the identified CS subphenotypes in three completed randomized controlled trials (RCTs) (OptimaCC, N=57 [2011-2016, NCT01367743]; DOREMI, N=192 [2017-2020, NCT03207165]; and CULPRIT-SHOCK, N=434 [2013-2017, NCT01927549]) and explore heterogeneity of treatment effect with respect to 28-day mortality (primary outcome). Four biomarker-driven CS subphenotypes ('adaptive', 'non-inflammatory', 'cardiopathic', and 'inflammatory') were identified separately in the two cohorts. Patients in the inflammatory and cardiopathic subphenotypes had the highest 28-day mortality (p (log-rank test)=0.0099 and 0.0055 in the CardShock and FROG-ICU cohorts, respectively). Subphenotype membership significantly improved risk stratification when added to traditional risk factors including the Society for Cardiovascular Angiography and Interventions (SCAI) shock stages (increase in Harrell's C-index by 4% (p=0.033) and 6% (p=0.0068) respectively in the CardShock and the FROG-ICU cohorts). The simplified classifier identified CS subphenotypes with similar biological/molecular and outcome characteristics in the three independent RCTs. No significant interaction was observed between treatment effect and subphenotypes. Subphenotypes with the highest concentration of biomarkers of endothelial dysfunction and inflammation (inflammatory) or myocardial injury/fibrosis (cardiopathic) were associated with mortality independently from the SCAI shock stages. Dr Sabri Soussi was awarded the Canadian Institutes of Health Research (CIHR) Doctoral Foreign Study Award (DFSA) and the Merit Awards Program (Department of Anesthesiology and Pain Medicine, University of Toronto, Canada) for the current study.

Addressing the challenges of integrating digital health technologies to measure patient-centred outcomes in clinical registries.

Longitudinal patient registries generate important evidence for advancing clinical care and the regulatory evaluation of health-care products. Most national registries rely on data collected as part of routine clinical encounters, an approach that does not capture real-world, patient-centred outcomes, such as physical activity, fatigue, ability to do daily tasks, and other indicators of quality of life. Digital health technologies that obtain such real-world data could greatly enhance patient registries but unresolved challenges have so far prevented their broad adoption. Based on our experience implementing digital health technologies in registries and observational studies, we propose potential solutions to three practical challenges we have repeatedly encountered: determining what to measure digitally, selecting the appropriate device, and ensuring representativeness and engagement over time. We describe the example of a hypothetical patient registry for valvular heart disease, a condition for which there is substantial variation in treatment selection and postintervention outcomes, and for which patient-centred outcome data are urgently needed to inform clinical care guidelines and health-service commissioning.

Standards for Quality Improvement Registries on Abdominal Aortic Aneurysm Repair: A Delphi Consensus Report From VASCUNET and International Consortium of Vascular Registries

Outcome registries in vascular surgery are increasingly used to drive quality improvement by vascular societies. The VASCUNET collaboration, within the European Society for Vascular Surgery (ESVS), and the International Consortium of Vascular Registries (ICVR) developed a set of variables for quality improvement registries on abdominal aortic aneurysm (AAA) repair as a registry standard. Representatives from international vascular registries within VASCUNET, ICVR, and other nations with established registries were invited to provide the variables. The final variables were developed through a two stage modified Delphi process. Variables from the established registries with at least 60% consensus among all the registries were included for round 1. A five point Likert scale (strongly disagree to fully agree) was used. If the limit of consensual agreement was not reached in round 1, the variable was discussed again in round 2. For round 2, an array question method (yes, no to unsure) was used. Agreement of at least 70% resulted in the variable being included in the final dataset. A total of 88 out of 371 variables extracted from all AAA registries were circulated in the modified Delphi process as they reached the 60% consensus threshold. The questionnaire was circulated to 55 participants (round 1: 49; 89%; round 2: 43; 78%). After two rounds, 70 variables were recommended on consensual agreement. These variables comprised demographics (n = 4), pre-operative information (n = 28), intra-operative variables (n = 18), post-operative variables (n = 5), and follow up (n = 13). Based on this modified Delphi process, an international panel of vascular surgeons representing quality improvement registries recommended 70 core variables as standard in registries on AAA repair. The inclusion of a core set of variables in AAA vascular registries may help to further harmonise observational research and quality of AAA repair among global healthcare systems.

Stroke-bleeding risk score pairings within individuals in the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry.

Decisions about stroke prevention strategies in atrial fibrillation (AF) typically balance thromboembolism reduction against increased bleeding from oral anticoagulation therapy (OAC). When determining eligibility for OAC, guidelines recommend calculation of thromboembolic event rates using a validated score such as CHA2DS2-VASc. In contrast, routine calculation of bleeding scores is not recommended, in part because many patient factors associated with an increased risk of bleeding are associated with an even larger increased risk of ischemic stroke. We set out to characterize patients by paired stroke and bleeding risk scores to understand the level of concordance. Between 2010 and 2016, we identified 20,451 AF patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) I and II Registries. We grouped patients by stroke and bleeding risk pairings: low and high stroke risk (CHA2DS2-VASc < and ≥2), low and high bleeding risk (ORBIT < and ≥ 4) and described treatment rates with OAC and antiplatelet (AP) therapy. Most patients (68.6 %) were at high stroke and low bleeding risk. Patients at high bleeding risk (19.4 %) had high stroke risk (98.5 %). Treatment rates differed with combined OAC + AP therapy highest for patients at high stroke and bleeding risks. Ischemic and bleeding events were also highest in this group. Nearly all AF patients in this cohort with high bleeding risk (ORBIT score ≥ 4) had high stroke risk (CHA2DS2-VASc ≥ 2), supporting that bleeding risk should not obviate the need for stroke prevention. In contrast, most at high stroke risk were at low bleeding risk (ORBIT <4), supporting OAC for the majority. Bleeding scores, in combination with factors that specifically indicate a higher risk of bleeding, may identify patients who might be candidates for alternative stroke prevention such as left atrial appendage occlusion devices or bleeding mitigation strategies such as de-escalation of antiplatelet therapy.

Endoscopic Iliopsoas Fractional Lengthening as a Treatment for Refractory Iliopsoas Impingement After Total Hip Arthroplasty Shows Favorable Functional Outcomes With No Impact In Range of Motion

To report the minimum 2-year clinical outcomes of endoscopic iliopsoas fractional lengthening (IFL) in patients with recalcitrant iliopsoas tendinitis after total hip arthroplasty (THA). Data were prospectively collected from 2014 to 2020 for patients who underwent IFL after primary THA as part of our institutional hip outcomes registry. Patients were included if they had completed the following patient-reported outcomes preoperatively and at minimum 2-year follow-up: modified Harris Hip Score and visual analog scale score. Preoperative and postoperative data were available for the International Hip Outcome Tool 12 score, and patient satisfaction was analyzed. Patients included in the study reported irritation of the iliopsoas tendon after cementless THA, refractory to conservative treatment methods. IFL was recommended after a workup that included ruling out infection and aseptic loosening, as well as a positive response to an iliopsoas guided diagnostic injection. Seventeen patients were included in the study. The mean age at IFL was 56.42 years (range, 30.17-81.29 years). The mean interval between THA and IFL was 2.72 years (range, 0.25-8.34 years). There was a significant improvement in all evaluated patient-reported outcomes, and a high percentage of patients met the minimal clinically important difference for the modified Harris Hip Score (14, 82.35%), International Hip Outcome Tool 12 score (11, 91.66.00%), and visual analog scale score (16, 94.12%) (P < .05). Furthermore, 15 patients (88.2%) reported a positive response to the patient acceptable symptom state anchor question. No impact on preoperative versus postoperative active range of motion was observed, and no patient reported weakness at the latest follow-up (P > .05). Preoperative flexion was 106.33° (range, 85.0°-120.0°), and postoperative flexion was 106° (range, 90°-120°). Endoscopic IFL yielded significant improvements in functional outcomes with high patient satisfaction at minimum 2-year follow-up, with no reported complications. This procedure did not have a significant negative impact on hip range of motion. Level IV, retrospective case series.

Assessment of Maternal and Infant Health Status in Durham Region

I completed my practicum as a Student Epidemiologist at the Durham Region Health Department with the Health Analytics and Research Team (HART). HART is tasked with conducting population health assessments in the Durham Region. As a member of HART, I played a critical role in assessing the maternal and infant health status of the local population using data from the Better Outcome Registry and Network (BORN) information system (BIS), a database that contains critical reproductive and child health data in Ontario. Specifically, my primary responsibilities included data extraction and data coding, which encompassed a series of tasks, spanning from data cleaning to data analysis in STATA. By analyzing BORN data, I was able to refine my statistical and programming skills. Moreover, I collaborated with public health program staff to develop infographics that disseminated critical maternal and infant health information to various communities. The infographics I assisted with covered a wide range of maternal and infant health topics, including issues such as gestational diabetes and maternal mental health concerns. From here, I was able to effectively communicate health information in a concise and understandable manner. In addition, I had the opportunity to attend various public health workshops and group meetings during my practicum. These experiences not only expanded my knowledge of diverse public health topics but also afforded me greater familiarity with public health practice. In summary, my time at the Durham Region provided me with an exceptional opportunity to apply the knowledge I gained in school to real-world practice. It was a valuable and enriching experience that significantly contributed to my professional development in the field of public health.

The prevalence of threatened miscarriage in Malta

A retrospective cohort study was conducted in Malta to assess the prevalence of threatened miscarriage. The study focuses on cases managed at a local state hospital over a 12-month period. Currently, data on pregnancies prior to 22 weeks’ gestation are not publicly available, which hampers understanding of the frequency and impact of threatened miscarriage. This research provides the basis for a potential prospective study which analysis the epidemiology and outcomes of threatened miscarriage and advocates for early intervention and appropriate patient counselling. The study included females who visited the Accident and Emergency Department in a local state hospital in 2019 with first trimester vaginal bleeding. It excluded patients with incomplete medical records. Data from various hospital departments were collected, anonymised and analysed to track outcomes such as miscarriage, ongoing pregnancy, ectopic or molar pregnancy. The research aimed to create a comprehensive local registry of pregnancy outcomes following threatened miscarriage, reflecting the national situation. In 2019, 711 pregnant women in Malta experienced first-trimester vaginal bleeding. Of these, 241 had successful births beyond 22 weeks’ gestation, while 412 experienced miscarriages, with other outcomes including ectopic and molar pregnancies and 58 women had an unknown pregnancy outcome. A significant association was found between maternal age and risk of miscarriage, particularly higher for women aged 35–46 and those under 19. Birthweight data revealed that threatened miscarriage complications likely led to low birthweights in a significant proportion of newborns. This study analysed pregnancy outcomes which were preceded by first trimester vaginal bleeding in pregnant women in Malta. Establishing a local register of pregnancy outcomes following first trimester vaginal bleeding provides clinicians with enhanced insights into the current local context. This resource may improve patient counselling and informed policy decisions and lay the groundwork for future research in the field.

Abstract 4114497: Shape Variations in Right Ventricular 3D Geometry are associated with adverse outcomes in Hypoplastic Left Heart Syndrome Patients: A Fontan Outcomes Registry using CMR Examination (FORCE) Study

Introduction: Right ventricular (RV) function is critical to the long-term health of patients with hypoplastic left heart syndrome (HLHS). However, conventional measurements do not consider the range of RV morphology that may impact RV function and lead to adverse outcomes. In this study, we determined associations between RV shape and clinical outcomes of HLHS using statistical shape modeling (SSM) and a large cardiac magnetic resonance (CMR) multicenter registry. Methods: Three hundred and twenty-eight studies from unique HLHS patients in the F ontan O utcomes R egistry using C MR E xaminations (FORCE) were post-processed by a core lab at one institution, including volumetry and strain analysis. 3D end-diastolic models of RV were reconstructed using Mimics (Materialise). SSM was performed via Shapeworks Studio (NIH/NIGMS CIBC) to derive mean template and quantified shape variations (shape mode) representing deviation from the mean. RV shape relationship with mortality/heart transplant was assessed using bivariable/multivariable analyses with stepwise model selection. Results: The mean template from all 328 patients resembled a circumferentially dilated RV with loss of concavity in septal wall (Fig A). Several generalized variants were identified (Fig B), particularly p1 – a sigmoidal / “apical bulge” variant where the RV apex dilates and "wraps” around the hypoplastic left ventricle (Fig C). Twenty-eight patients (8.5%) experienced mortality/heart transplant at 2.5±2.4 years after CMR. On bivariable analysis, p1 was associated with mortality/heart transplant, along with larger indexed RV end-diastolic volume/mass and reduced global circumferential strain. On multivariable analysis, p1 and indexed RV mass were associated with mortality/heart transplant (Table). Conclusions: Statistical Shape Modeling can define the “usual” RV shape of HLHS. A sigmoidal shape variant is associated with adverse outcomes. SSM may provide patient-specific metrics to define RV dysfunction in HLHS.

Nationwide prevalence and geographic variation of idiopathic intracranial hypertension among women in the United States

The prevalence of idiopathic intracranial hypertension (IIH) is increasing, but this has not been examined on a nationwide scale. Our objective was to determine the nationwide prevalence and geographic distribution of IIH among women in the U.S. Retrospective cross-sectional study using Medicaid claims and electronic health record data from the IRIS® Registry (Intelligent Research in Sight) and Sight Outcomes Research Collaborative (SOURCE). Female Medicaid beneficiaries aged 18-55 with IIH diagnoses and prescriptions for acetazolamide or methazolamide in 2018, excluding those with other causes of intracranial hypertension. We also calculated the proportion of female IIH patients in the U.S. who were insured by Medicaid by combining analyses from the IRIS® Registry and SOURCE. To calculate the total number of IIH patients in the U.S. and by state, we divided the number of Medicaid beneficiaries with IIH by the proportion of IIH patients insured by Medicaid. We then used census data from the 2018 American Community Survey to calculate prevalence. We compared the geographic distribution of IIH to obesity prevalence data from the 2018 Behavioral Risk Factor Surveillance System, using the Moran's I statistic to test for spatial variation. In a validation study, we compared the calculated prevalence of IIH in Minnesota to similar data from the Rochester Epidemiology Project. Of 13,959 female Medicaid beneficiaries with IIH, 6,828 had a prescription for acetazolamide or methazolamide. In the IRIS® Registry and SOURCE, 25% of IIH patients were insured by Medicaid (95 % CI: 16-33%), suggesting that there were 27,312 women aged 18-55 with IIH taking acetazolamide or methazolamide in 2018 (6,828 / 0.25 = 27,312). Prevalence was 3.44 per 10,000 (95% CI: 2.61-5.39), and there was significant geographic variation (Moran's I statistic 0.20, P = 0.03) with higher prevalence in states where obesity was more common. The calculated prevalence of IIH in Minnesota was statistically equivalent to Rochester Epidemiology Project data (P < 0.05 for equivalence test). IIH affects 3.44 per 10,000 women aged 18-55 in the U.S., and there is significant geographic variation, some of which is explained by variation in obesity prevalence.

Predictors of Cardiac Rehabilitation Attendance and Completion: Analysis of 33,055 Patients from the Queensland Cardiac Outcomes Registry (2020–2022)

Cardiac rehabilitation (CR) under-attendance presents a global challenge. The Queensland Cardiac Outcomes Registry is a comprehensive clinical registry that routinely collects point-of-care CR data. We aimed to determine whether demographic, clinical, psychosocial, and behavioural characteristics of the population vary between those who (i) declined, (ii) commenced but did not complete, and (iii) completed CR. The cohort comprised 33,055 patients referred to one of 56 Queensland CR services extracted from the Queensland Cardiac Outcomes Registry (2020-2022). Bivariate and multivariable logistic regression analyses were used to identify factors associated with CR non-attendance and non-completion. Over the study period, 12,152 patients (37%) declined CR, 11,621 (35%) initiated but did not complete CR, and 9,282 (28%) completed CR. Significant predictors of CR non-attendance were aged ≥75 years (adjusted odds ratio [aOR] 1.51; 95% confidence interval [CI] 1.42-1.61), Indigenous status (aOR 1.65; 95% CI 1.50-1.81), living regionally (aOR 1.76; 95% CI 1.65-1.87) or remotely (aOR 2.33; 95% CI 1.92-2.82), and having arrhythmia (aOR 2.38; 95% CI 2.07-2.73), heart failure (aOR 1.54; 95% CI 1.37-1.74), non-ST-elevation myocardial infarction (aOR 1.30; 95% CI 1.21-1.40) or unstable angina (aOR 1.24; 95% CI 1.1.13-1.37). Significant predictors of CR non-completion were age <55 years (aOR 1.55; 95% CI 1.37-1.75), Indigenous status (aOR 1.60; 95% CI 1.29-1.98), living regionally (aOR 1.29; 95% CI 1.12-1.48), obesity (aOR 1.14; 95% CI 1.01-1.28), being a current (aOR 1.97; 95% CI 1.70-2.27) or former smoker (aOR:1.22, 95% CI 1.11-1.33) and having low social support (aOR 1.58; 95% CI 1.24-2.02). As one of the largest studies of CR participation to date, these findings can now be applied to develop targeted, co-designed initiatives to enhance CR participation, especially among First Nations populations, smokers, those with limited social support, people living regionally/remotely, patients with arrhythmia and heart failure, and those in varying age groups.

Outcomes after hospital discharge in children requiring post-cardiotomy extracorporeal membrane oxygenation: a binational retrospective cohort study

ObjectivesTo describe longer-term survival and morbidity outcomes after hospital discharge in a binational cohort of children who required extracorporeal membrane oxygenation after cardiac surgery. MethodsRetrospective cohort study from the Australia and New Zealand Congenital Outcomes Registry for Surgery database. All patients younger than 18 years of age (n=12,290) undergoing paediatric cardiac surgical procedures between 1 January 2013 and 31 December 2021 who required post-cardiotomy extracorporeal membrane oxygenation in the same admission were included. ResultsAmong 376 (3%) patients who required post-cardiotomy extracorporeal membrane oxygenation, 242 (64.4%) survived to hospital discharge. Median follow-up in survivors post-hospital discharge was 4.2 years (IQR 2.6 – 8 years). Kaplan-Meier survival at 1, 3, 5 and 8 years was 62%, 58.5%, 55.8%, and 52.6%. Post-discharge survival was 95.5%, 90.7%%, 87.1% and 81.9% at 1, 3, 5, and 8 years respectively. Survival was significantly poorer in patients with single ventricle physiology. 43.3% (n=105) of hospital survivors had at least one major morbidity at the last follow-up. The most common major morbidities were developmental delay, permanent neurological deficits, and growth restriction. Conclusions38% of children who required ECMO after cardiac surgery did not survive beyond 1 year. However, of patients who survived to hospital discharge, 95% were alive at one year. Approximately 80% of patients were alive at 5 years after hospital discharge. Outcomes were poorer in patients with single ventricle physiology. 40% of patients had significant morbidity after hospital discharge.

Conversion from minimally invasive surgery to open surgery among endometrial cancer patients in the SGO clinical outcomes registry

Conversion from minimally invasive surgery to open surgery among endometrial cancer patients in the SGO clinical outcomes registry

Performance and safety of complex percutaneous coronary intervention in centres without on-site cardiac surgery: a multi-centre australian registry study.

Abstract Background Performing complex percutaneous coronary intervention (PCI) procedures in hospitals with no on-site cardiac surgery (NOSCS) remains controversial due to a lack of contemporary data and guideline support. Methods Victorian Cardiac Outcomes Registry data was analysed including all PCI cases in the state of Victoria, Australia, from 2014 to 2022. Patients were stratified by PCI at sites with on-site cardiac surgery (OSCS) or NOSCS. Complex PCI was defined as PCI to unprotected left main, bifurcation lesions, rotational atherectomy or intravascular lithotripsy use, severe left ventricular systolic dysfunction, chronic total occlusion, or vein graft PCI. The primary outcome was composite MACCE comprising all-cause mortality, stroke, non-fatal MI, emergency CABG, unplanned revascularisation, definite stent thrombosis and major bleeding (BARC 3 &amp; 5) at 30-days. Risk ratio for average treatment effect in the NOSCS cohort was estimated using inverse probability treatment weighting. Results 94,268 total PCI procedures (32.6% NOSCS) were analysed, including 12,459 complex PCI cases (28.7% NOSCS). Patients from NOSCS were younger (65.0 vs 67.4, p&amp;lt;0.001), less likely to have had previous PCI (29.5% vs 34.5%, p&amp;lt;0.001) or CABG (4.6% vs 8.0% p&amp;lt;0.001) and presented more frequently with acute coronary syndromes (NSTEMI [32.0% vs 28.0%, p&amp;lt;0.001; STEMI [23.3% vs 15.2%], p&amp;lt;0.001). A propensity weighted sample of 30,850 OSCS patients and 30,692 NOSCS patients demonstrated no difference in adjusted 30-day MACCE (risk ratio 0.93, 95% CI 0.87-1.01, p=0.051) for all PCI procedures. In a propensity-weighted subgroup of 3,638 OSCS and 3,576 NOSCS patients who underwent complex PCI, there was also no difference in adjusted 30-day MACCE (risk ratio 0.97, 95%CI 0.86-1.09, p=0.60). Unadjusted rates of CABG at 30-days were very low (0.1 vs 0.1%, p=1.00). Conclusion Patients undergoing PCI and complex PCI at NOSCS centres had comparable 30-day outcomes to those treated at OSCS centres. Newer percutaneous therapies such as intravascular lithotripsy and percutaneous left ventricular assist devices may further improve safety and efficacy of high-risk PCI in NOSCS centres as operator experience increases. Increasing PCI and complex PCI capabilities at NOSCS is likely to increase equitable treatment access for more patients.

Trends and predictors of cardiac rehabilitation referrals and participation in patients undergoing elective percutaneous coronary intervention

Abstract Background Research evidence shows that greater cardiac rehabilitation (CR) referrals and participation can reduce cardiovascular mortality and morbidity, which leads to social and economic benefits (1). It remains unknown, however, what the CR referrals and participation are for patients following elective percutaneous coronary intervention (PCI). Aim Our aim was to identify the prevalence, trends, and predictors of CR referrals and participation in patients undergoing elective PCI between July 2017 and December 2021 among six public hospitals in one of the Australian states. Methods A retrospective observational study was conducted. Data were extracted from a state-wide Cardiac Outcomes Registry for patients who underwent elective PCI. Patients were identified if they were referred to CR following hospital discharge. CR participation has two assessments. The initial assessment focuses on a comprehensive cardiovascular risk factor review that occurs before attending a CR program, whereas the final assessment represents CR completion. We conducted descriptive and inferential statistical analyses. Results Out of 3081 patients who underwent elective PCI, 1845 (59.9%) had CR referrals. Of the 1845 patients who had CR referred, 1022 (55.4%) completed an initial assessment, and 400 (21.7%) completed both an initial and final assessment. The rate of CR referrals increased from 12.0% in 2017 to 23.5% in 2018 before decreasing slightly in 2019 and 2020 (21.0% and 22.8%, respectively). There was a decline in the proportion of patients who had an initial assessment from 44.0% in 2017 to 29.0% in 2021. The rate of the final assessment showed a slight increase from 32% in 2017 to 41% in 2021. Multivariate logistic regression showed that of those patients undergoing PCI, patients who stayed overnight were 9.9 times more likely to receive a CR referral than those with same-day discharge. However, for those who had CR referrals, overnight stay was not a predictor in completing the initial assessment. Similarly, of those who completed an initial assessment, overnight stay was also not a predictor in completing the final assessment; rather, those with a positive family history were more likely to complete the final assessment. Conclusion Our findings reveal a low CR referral rate in patients undergoing elective PCI, and overnight stay is a strong predictor for CR referrals. As a referral is a gateway to CR participation (2), more work is needed to explore the options to increase CR referrals, particularly for patients discharged on the same day as their procedure. Following referrals, overnight stay did not predict completion of initial and final assessments, indicating that other strategies are required to promote CR participation.

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale.

This study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO. Multicenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge. This study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3years [0.1, 9.0], ECMO duration of 5days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events. Short-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

The European Registry of Quality Outcomes for Cataract and Refractive Surgery: Benefits and Lessons of a Multinational Registry

Cataract surgery is the most commonly performed surgery worldwide. However, there is significant variation in practice both within and among countries. The European Registry of Quality Outcomes for Cataract and Refractive Surgery was established in 2007 to address this variation and improve the quality of care. Based on registry data from more than 500,000 surgeries, the registry developed the first European guidelines for cataract surgery, with plans to improve those guidelines continuously with registry-based studies. At this point, the registry has collected data from more than 4 million surgeries, creating opportunities for establishing guidelines, conducting research, and benchmarking. This article describes how the registry was developed, its achievements, planned refinements, efforts to expand participation, the challenges encountered, and future potential.

Jehovah's Witnesses: Challenges in liver disease management and in liver transplantation.

Patients of Jehovah's Witnesses faith who are in need of liver transplantation pose unique challenges. These patients should be seen at transplant centers with experience in caring for Jehovah's Witnesses to formulate careful preoperative, intraoperative, and postoperative strategies on an individualized basis with multidisciplinary input to mitigate the risk of bleeding complications and to prepare for potentially catastrophic scenarios. In-depth and individualized conversations about what constitutes acceptable bloodless transfusion strategies both for the patient and for the transplant center should begin as early as possible with an experienced coordinator or church liaison. A therapeutic physician-patient relationship is vital to formulating a safe care plan and to understanding the spectrum of beliefs among Jehovah's Witnesses. There remains a paucity of data on disparities in liver care and outcomes in patients of the Jehovah's Witnesses faith. Future research on liver diseases and liver transplantation in Jehovah's Witnesses should focus on creating registries of patient outcomes and centers with experience.

Pediatric Extracorporeal Membrane Oxygenation in Restrictive and Hypertrophic Cardiomyopathy: A Single Center Experience.

Patients with restrictive cardiomyopathy (RCM) and hypertrophic cardiomyopathy (HCM) were previously considered poor candidates for mechanical circulatory support due to technical limitations related to restrictive ventricular physiology and small ventricular size, limiting the ability to provide adequate flows and decompress the heart. Literature examining use of extracorporeal membrane oxygenation (ECMO) in this population consists of a single case series reporting no survivors. We report our experience providing ECMO in children with RCM or HCM at a large pediatric quaternary cardiac center. Between 2012 and 2022, five patients (four RCM, one HCM) were supported with seven ECMO runs. All patients were cannulated to ECMO with ongoing cardiopulmonary resuscitation. Four patients survived decannulation from ECMO (median support time 209 hr, interquartile range [IQR]: 48-265), of which three (60%) survived to hospital discharge after transitioning to a ventricular assist device (VAD) and undergoing orthotopic heart transplant (OHT). Two remain alive at long-term follow-up with normal or mildly impaired functional status. These findings suggest that while RCM and HCM have traditionally been considered contraindications to ECMO due to adverse outcomes, this population may be successfully supported with ECMO with survival comparable to international registry outcomes in select centers where VAD as a bridge to OHT is available.