Predictors Of Good Outcome Research Articles

Letter: Frailty-Based Prehabilitation for Patients Undergoing Intracranial Meningioma Resection.

To the Editor: Intracranial meningioma resection (IMR) carries significant morbidity and mortality despite being a benign tumor and less aggressive than malignant brain tumors.1,2 In recent years, moving beyond chronological age, baseline frailty status has been identified as a more robust predictor of postoperative outcomes of IMR.3-8 Frail patients undergoing IMR have been reported to have increased incidence of postoperative complications, increased length of hospital stay, and nonhome discharge destination.3-8 Cole et al3 reported that frail patients undergoing resection of intracranial meningiomas were approximately 11 times more likely to develop postoperative adverse events. Frailty affects how the body responds to the alteration of homeostasis during surgery,9 and frailty-based prehabilitation of patients at risk can lead to improved outcomes. Although this association has been extensively demonstrated using various frailty indices and preoperative risk stratification tools in spine surgery patients,10,11 frailty-based prehabilitation remains yet to be implemented for brain tumor resection patients in general and for IMR in particular. This remains relevant for IMR as most of these patients (apart from high-grade meningiomas with obstructive symptoms) do not require emergent/urgent surgery and can undergo frailty-based prehabilitation for improved outcomes (Figure).FIGURE.: A graphical representation of frailty-directed prehabilitation measures to improve postoperative outcomes.Several studies have reported on worse postoperative outcomes predicted by poor preoperative frailty status assessed by using different indices (Table), including the Risk Analysis Index (RAI) and the Modified Frailty Index (MFI).12,13 RAI is a robust frailty score based on 11 variables that captures the true phenotypic manifestation of frailty—sex, age, cancer diagnosis (excluding melanoma), unintentional weight loss, renal failure, congestive heart failure, poor appetite, shortness of breath at rest, residence defined as not independent living, cognitive deterioration, and activities of daily living (ADL) defined as functional status. Each component of RAI has significance in frailty assessment and serves as a guide to prehabilitation. For instance, interventions such as smoking cessation and inspiratory muscle training target shortness of breath and have been shown to reduce the overall LOS after elective surgical procedures.14 Exercise and physical therapy helps reduce functional dependence before surgery.15 Other frailty-specific interventions that have proven efficacy in enhancing postoperative outcomes include nutritional rehabilitation to target poor appetite and cognitive behavioral therapy in patients with excessive fear or cognitive deterioration.11 The 5-factor MFI assigns 1 point each based on the presence of diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status.13 It is largely made up on comorbid conditions that may not capture true frailty, thus compromising its effectiveness in determining prehabilitative measures. RAI has proven to be a better predictor of outcomes after surgery and could be a more useful tool during prehabilitation measures.16 TABLE. - Predictive Ability of Preoperative Frailty Score on Postoperative Outcomes of IMR Author Year FI Outcomes OR (95% CI) Thommen et al 6 2022 RAI Major complications 2.94 (1.39-6.20) Clavien IV complications 3.99 (1.68-9.46) LOS 15.73 (7.45-33.24) Nonhome discharge destination 13.61 (6.40-28.94) Cole et al 3 2022 mFI-5 Mortality 11.17 (3.45-36.19) Major complications 4.15 (2.46-6.99) Unplanned readmission 4.37 (2.68-7.12) Unplanned reoperation 2.31 (1.17-4.55) Extended LOS 4.28 (2.74-6.68) Nonhome discharge 9.34 (6.03-14.47) Dicpinigaitis et al 4 2021 mFI-11 LOS (1.20, 1.10-1.32) Life-threatening complications/mortality (1.40, 1.17- 1.68) Theriault et al 5 2020 mFI-11 Nonhome discharge 0.131 (0.022-0.773) Readmission 0.131 (0.022-0.773) Taricotti et al 7 2022 FI Early (14.752, 1.463-148.777) and late (35.457, 25.210-41.318) postoperative functional deterioration Ikawa et al 8 2022 mFI-5 Worsening Barthel Index score 1.4 (1.1-1.7) In-hospital mortality 5.0 (2.2-11.1) Complications 1.7 (1.4-2.0) FI, Frailty Index; IMR, intracranial meningioma resection; LOS, length of stay; OR, odds ratio; RAI, Risk Analysis Index. A recent study by our group has shown RAI's robust predictive ability for brain tumor resection outcomes including IMR,6 thus raising the possibility of using RAI-based prehabilitaion for IMR patients. Emphasizing on preoperative rehabilitation measures for IMR could improve a patient's physiological reserve and reduce postoperative adverse events.7 Unlike malignant tumors, intracranial meningiomas are associated with lower rates of mortality and recurrence.17 We believe that the less urgent need to proceed with surgical resection in patients harboring these tumors could allow for preoperative optimization of a patient's physiological reserve. This would guide clinical decision-making by allowing for a tailored approach to improving a patient's ability to cope with surgery.

The clinical application of longitudinal layer specific strain as a diagnostic and prognostic instrument in ischemic heart diseases: A systematic review and meta-analysis.

2-dimensional Speckle-Tracking Echocardiography, to obtain longitudinal layer specific strain (LSS), has recently emerged as a novel and accurate non-invasive imaging technique for diagnosis as well as for prediction of adverse cardiac events. This systematic review and meta-analysis aimed to give an overview of the possible clinical implication and significance of longitudinal LSS. We conducted a systematic review and meta-analysis with all the studies involving layer specific strain in patients with ischemic heart disease (IHD). Of 40 eligible studies, 9 met our inclusion criteria. Studies that were included either investigated the prognostic value (n = 3) or the diagnostic value (n = 6) of longitudinal LSS. The pooled meta-analysis showed that longitudinal LSS is a significant diagnostic marker for coronary artery disease (CAD) in patients with IHD. Endocardial LSS was found to be a good diagnostic marker for CAD in IHD patients (OR: 1.28, CI95% [1.11-1.48], p < 0.001, per 1% decrease). Epicardial (OR: 1.34, CI95% [1.14-1.56], p < 0.001, per 1% decrease), Mid-Myocardial (OR: 1.24, CI95% [1.12-1.38], p < 0.001, per 1% decrease) and endocardial (OR: 1.21, CI95% [1.09-1.35], p < 0.001, per 1% decrease) LSS all entailed diagnostic information regarding CAD, with epicardial LSS emerging as the superior diagnostic marker for CAD in patients with SAP. Endocardial LSS proved to be the better diagnostic marker of CAD in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). LSS was shown to be a good prognostic maker of adverse cardiac events in IHD patients. Two studies found endocardial circumferential strain to be the good predictor of outcome in CAD patients and when added to baseline characteristics. Epicardial LSS emerged as best predictor in acute coronary syndrome (ACS) patients. In patients with SAP, epicardial LSS was the stronger diagnostic marker while in NSTE-ACS patients, endocardial LSS was the stronger diagnostic marker. In addition, endocardial circumferential strain is the better predictor of adverse outcome in CAD patients whilst in ACS patients, epicardial LSS was found to be a better predictor of outcome.

COVID-19 and processes of adjustment in people with persistent pain: the role of psychological flexibility.

The purpose of the current study was to investigate facets of Psychological Flexibility (PF) and Psychological Inflexibility (PI) and their relations with depression, anxiety, and insomnia in people with chronic pain during the COVID-19 pandemic. It was predicted that the full set of facets would significantly predict all three outcomes. The relative contributions of differing facets and dimensions was explored. Participants with pain were selected from a sample of 1,657 Swedish adults responding to an online survey of health and COVID-19. Persistent pain was defined as pain on most days, present for three months or more. A total of 560, 33.8% of the total sample, were included in the analyses. Standardized and validated measures were used to measure depression, anxiety, and insomnia, and the Multidimensional Psychological Flexibility Inventory (MPFI) was used to measure both PF and PI. Significant rates of depression, anxiety, and insomnia, at 43.1, 26.4, and 64.2%, respectively, were found in this sample. These rates appear higher than those found in a general sample in Sweden. PF was negatively associated with these problems while PI was positively associated with them. Better prediction of outcome was obtained by PI compared to PF. PF and especially PI appear to have played a role in relation to health outcomes in people with persistent pain during the COVID-19 pandemic. This group of people appears to have been especially vulnerable to the impacts of the pandemic. This study motivates further investigation and development of treatment approaches, possibly focusing on training PF, for people with persistent pain in the current pandemic context and in the future.

The Impact of Weather and Mode of Transport on Outcomes of Patients With Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

Efficient transfer to mechanical thrombectomy (MT)-capable centers is essential for patients with stroke. Weather may influence stroke risk, transportation, and outcomes. To investigate how weather affects stroke patient transfer and outcomes after MT. We retrospectively collected data for patients with stroke transferred from spoke to our hub hospital to undergo MT between 2017 and 2021. We examined associations between weather, transportation, and patient outcomes. We included 543 patients with a mean age of 71.7 years. The median National Institutes of Health Stroke Score increased from 14 to 15 after transportation. The median modified Rankin Scale was 4 at discharge and 90 days, and 3 at the final follow-up (mean 91.7 days). Higher daily temperatures were associated with good outcome, whereas daily drizzle was associated with poor outcome. More patients were transferred by air when visibility was better, and by ground during heavier precipitation, higher humidity, rain, mist, and daily drizzle, fog, and thunder . Patient outcomes were not associated with transportation mode. Among the independent predictors of good outcome, none was a weather variable. Lower hourly relative humidity ( P = .003) and longer road distance ( P < .001) were independent predictors of using air transportation, among others. During transportation, higher temperature was associated with good outcome, whereas daily drizzle was associated with poor outcome after MT. Although weather was associated with transportation mode, no differences in outcomes were found between transportation modes. Further studies are needed to modify transfer protocols, especially during cold and rainy days, and potentially improve outcomes.

Clinical perspective in relation to age in patients treated with thrombectomy for anterior circulation stroke in a stroke center in Colombia.

Endovascular treatment for cerebrovascular disease is accepted as a first-line option with level I evidence in patients with an early and late time of window of onset symptoms, and an additional option in patients who do not respond or with contraindications to systemic thrombolysis; nevertheless the efficacy and outcomes of some groups were not clear, one of them are patients aged 80 years and older, because they were excluded of the trials, so the evidence is controversial with significant heterogeneity, for that reason in our study, we decided to analyze the age in the patients treated in our stroke center, as a predictor of prognosis, and to provide a baseline for the establishment of personalized treatment plans. Observational, retrospective study of patients that received endovascular treatment for cerebrovascular disease in a Colombian stroke center between 2016 and 2020, continuous and categorical variables were compared using the Student's t test and Chi-Square. To determine cut-off points in the variable against death and Rankin score variable on 90th day. In total, 108 patients were recruited, 35 of them were of 80 or more years, and the mean age was 72.7 years, we found age as a significant variable to predict the risk in the population over 80 years of age [RR 3.37 CI (95% 1.14-103) p = 0.029]. Age younger than 80 is a significant predictor for results and long-term outcomes in patients suffering from stroke, and in patients older than 80 years old a Thrombolysis in Cerebral Infarction score 2b-3 is a predictor of good outcomes. Further studies are needed to evaluate the relationship between intrahospital complications and long-term outcomes.

Mismatch repair deficiency, next-generation sequencing-based microsatellite instability, and tumor mutational burden as predictive biomarkers for immune checkpoint inhibitor effectiveness in frontline treatment of advanced stage endometrial cancer

ObjectiveMolecular profiling is developing to inform treatment in endometrial cancer. Using real world evidence, we sought to evaluate frontline immune checkpoint inhibitor vs chemotherapy effectiveness in advanced endometrial cancer, stratified...

Smaller baseline subcortical infarct volume predicts good outcomes in patients with a large core in early acute ischemic stroke after endovascular treatment.

Patients with acute ischemic stroke (AIS) and a large core may benefit from endovascular treatment (EVT) in the early time window. To examine the prognostic factors for good outcomes in patients with a large core (70-130 ml) after EVT. We retrospectively reviewed 40 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0-2) and a poor outcome group (mRS 3-6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the factors that influence good outcomes. In particular, the infarct territories were quantified as subcortical infarct volume (SIV) and cortical infarct volume (CIV). Of the 40 patients included, good outcomes were observed in 11 (27.5%) patients. Younger age, smaller SIV and larger mismatch volume were noted in the good outcome group than in the poor outcome group (all P < 0.05). Multivariate logistic regression analysis showed that only a smaller SIV [odds ratio (OR) 0.801; 95% CI 0.644-0.996; P = 0.046] was an independent predictor for good outcomes. The receiver operating characteristic curve indicated a moderate value of SIV for predicting good outcomes, with an area under the receiver operating characteristic curve of 0.735 (95% CI 0.572-0.862; P = 0.007). Subcortical infarct volume was a potential useful predictor of good outcomes in patients with a large core after EVT in the early time window.

The interconnection between cellular metabolism and lymphocyte activation as a prognostic factor in patients affected by metastatic pancreatic ductal adenocarcinoma treated with gemcitabine and nab-paclitaxel as first line.

752 Background: Glucose and other metabolites (lactates and glutamine) in the tumor microenvironment (TME) may alter the activity of the immune system cells. Cancer cells consume glucose and its decrease in the TME affects the function of tumour-infiltrating lymphocytes (TILs). Moreover, tumor-infiltrated immunosuppressive cells and vascular endothelial cells also deplete nutrients, in the TME, enhancing an immunosuppressive environment. On the basis of the results coming from our previous works regarding lymphocytes to monocytes ratio (LMr) and diabetes, suggesting a role for each of them as predictors of better outcomes, in this study we evaluate both of them in order to establish a possible role of them as outcomes predictive factors. Methods: Data from 228 patients (pts) were collected retrospectively from 2016 to 2021: 175 from the Medical Oncology Unit of University Hospital of Cagliari; 53 from the Medical Oncology Unit, AOU Ospedali Riuniti di Ancona. All pts had stage IV disease and received gemcitabine plus nab-paclitaxel 1st line chemotherapy. Statistical analysis was performed with the MedCalc package. We aimed to evaluate the correlation between treated DM2 and lymphocytes to monocytes ratio (LMr) ≥ 4 with outcomes. Survival distribution was assessed by Kaplan-Meier curves. Multivariate analysis was performed taking into consideration the following prognostic factors: sex, ECOG-PS, LMr, NLr, LDH, Ca19.9, and metastatic sites. Results: Median age was 68 (±9), 123/228 (54%) were male, 94/232 (40,6%) were affected by DM2 (insulin or metfomin-treated) and 138 (59,4%) pts were not affected by DM2. 52/228 (23%) pts had a LMr ≥ 4, 176/228 (77%) pts had a LMr &lt; 4. In multivariate analysis, DM2 and LM ratio ≥ 4 were found to be independent factors associated with higher overall survival. Therefore, we divided the pts into 3 groups: co-presence DM2 and LM ≥ 4 (DM+LM+); absence of DM2 and LM ≥ 4 (DM-LM-); presence of DM2 or LM ≥ 4 (DM+LM- or DM-LM+). DM+LM+ demonstrated statistically significantly higher median OS than DM+LM-/DM-LM+ and DM-LM- (not reached versus 21 versus 9 months, respectively, p &lt; 0.0001). Furthermore, DM+LM+ showed a statistically significant better median PFS than DM+LM-/DM-LM+ and DM-LM- (11 versus 9 versus 6 months, respectively, p = 0,0036). Conclusions: Results showed a correlation between pts with DM2/LMr ≥ 4 and better outcomes. This may suggest the presence of a link between glucose metabolism and lymphocytes activation. Antidiabetic medications could promote the inhibition of Warburg effect in tumor cells, and, consequently, provide a better glucose intake to extracellular microenvironment, and immune cells, including T lymphocytes. This process leads to a higher activity of T-cells and a better treatment response. Further studies are warranted.

In multiple sclerosis, a Functional Independence Measure ≥ 107 is the best predictor of outcome after clean intermittent catheterization training.

Assessment of motor and cognitive functions is recommended before clean intermittent catheterization training. Two validated instruments, the Functional Independence Measure (FIM) and the Pencil and Paper Test (PP-Test), are associated with the ability to learn self-catheterization in people with multiple sclerosis. We aimed to compare the performance of these tools in predicting the outcome of clean intermittent catheterization training in multiple sclerosis. All people with multiple sclerosis attending a tertiary neuro-urology department between 2011 and 2019 and eligible for clean intermittent catheterization were included in this retrospective study. The reference standard was the ability to perform at least 2 trials of self-catheterization at the end of the training session. The 2 index tests, the FIM and PP-Test, were administered before the teaching session. Their diagnostic performance was estimated by calculating sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). The AUC values were compared by a two-sided DeLong test. We included 395 individuals (mean [SD] age 49.8 [12] years; 70% women). At the end of the session, 87% of the patients succeeded in learning self-catheterization. The optimal cut-offs for the FIM (107) and PP-Test (13) were estimated, resulting in sensitivity of 73% (95% confidence interval [68-77) and 73% (67-77) and specificity 73% (59-84) and 63% (49-76), respectively. The AUC values for the FIM and PP-Test were significantly different (0.79vs 0.73, p=0.049). The effect size was large for both the FIM (Cohen's d=1.14) and PP-Test (Cohen's d=0.87). An FIM value ≥107 has the best specificity to predict outcome after clean intermittent catheterization training for people with multiple sclerosis. The sensitivity of the FIM and PP-Test is similar, and both have a large effect size for the outcome of self-catheterization training in multiple sclerosis.

Predictive value of computed tomography perfusion for acute ischemic stroke patients with ASPECTS < 6 in an early time window

ObjectiveThe standard for computed tomography perfusion (CTP) assessment has not been well established in early acute ischemic stroke (AIS). We aimed to examine the prognostic factors for good outcomes in patients who received CTP, with an Alberta Stroke Program Early CT Score (ASPECTS) < 6 after endovascular thrombectomy (EVT) in the early time window (0–6 h). MethodsWe retrospectively reviewed 59 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0–2) and a poor outcome group (mRS 3–6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the influencing factors for good outcomes. ResultsOf the 59 patients included, good outcomes were observed in 21 (35.6%). Multivariate logistic regression analysis showed that smaller ischemic core volume (odds ratio [OR]: 0.950; 95% CI: 0.908–0.994; P = 0.026), lower National Institutes of Health Stroke Scale (NIHSS) score (OR: 0.750; 95% CI: 0.593–0.949; P = 0.017) and shorter stroke onset to reperfusion time (ORT) (OR: 0.981; 95% CI: 0.966–0.996; P = 0.016) were independent predictors for good outcomes at 90 days. ConclusionSmaller ischemic core volume based on CTP, lower NIHSS score and shorter ORT were significant independent predictors of good outcomes in patients with ASPECTS < 6 in the early time window after EVT.

Quick Sequential Organ Failure Assessment Score, Lactate, and Neutrophil-Lymphocyte Ratio Help in Diagnosis and Mortality Prediction during Golden Hour of Sepsis in Emergency Department.

Sepsis is a life-threatening condition with a very narrow golden period in which confirmatory diagnosis may change the outcome dramatically. No confirmatory biomarker is available till date for early diagnosis of sepsis. This study aimed to evaluate the combined and independent role of quick sequential organ failure assessment (qSOFA) score, lactate, and neutrophil-lymphocyte ratio (NLR) in diagnosis and mortality prediction in early sepsis. This was a hospital-based, single-center, prospective cohort study conducted in a tertiary care institute, Karnataka, India. Three hundred adult sepsis patients were recruited during 10-month period, and demographic data, qSOFA score, lactate, NLR, and culture samples were collected in ED within 1 h of admission. Outcome groups (survivor and nonsurvivor) were statistically analyzed with relative frequencies (%), median, mean ± standard deviation with 95% confidence interval (CI), univariate, bivariate, and multivariate logistic regression analysis, and Receiver -operating characteristic curve (ROC) curve to test the predictive ability of initial levels of three biomarkers. Sepsis was more prevalent among middle-aged male patients. Male gender (odds ratio [OR], 6.9; 95% CI: 1.61-30.1), qSOFA (OR, 154; 95% CI: 15-1565), and lactate (OR, 1.36; 95% CI: 22-833) show 97% (area under the curve) predictive accuracy of the model for sepsis on bivariate and multivariate logistic regression analysis. A significant rise in NLR was a poor outcome indicator on univariate analysis (P = 0.773). All three biomarkers are good outcome predictors whereas qSOFA and lactate have diagnostic significance in early sepsis. These markers can be used for patient triaging, minimizing culture report dependence for treatment and ultimately the outcome.

Evaluation of Outcomes in Chest Trauma Patients using Chest Trauma Scoring System

INTRODUCTION Chest trauma is a common surgical incidence all over the world. Chest Trauma scoring system (CTS) is found in many studies to be an effective tool to predict outcomes in chest trauma patients. The need for a universal system for thoracic trauma is justified to identify critical factors, to predict patient outcomes, urgent need for intervention, and requirement of intensive care and to communicate with the family. Therefore there is a need of study and scoring system which can predict possible outcome. MATERIAL AND METHODS This is a prospective, longitudinal, observational study conducted at Universal College of Medical Sciences, Bhairahawa from October 2019 to March 2021. The chest trauma score was used to evaluate the outcome in patient admitted with blunt trauma chest. Duration of hospital stay, respiratory complications, need of ICU and Ventilators and mortality were noted as outcomes. RESULTS In this study, 79 cases with blunt trauma chest were admitted with road traffic accident being major factor for admission. Most patients were in age group 45-65 years of age with male predominance (84.8%). The results showed that patient with high CTS ≥5 was associated with higher incidence of pneumonia and need of ICU. The ROC curve showed that CTS predict significantly mortality with sensitivity of 100% and specificity of 92.2% with cutoff value of 7.5. Similarly, mean duration of hospital stay of patients having CTS ≥5 was 6.57 days more than patients having CTS &lt;5. CONCLUSION Chest Trauma Score is a good predictor of outcome in patient with blunt chest trauma.

Blood Group and Response to Bariatric Surgery in Morbidly Obese Patients: A Retrospective Study in Saudi Arabia.

To explore the relationship between the blood group of patients and their response to bariatric surgery and to identify predictors of better outcomes. This was a retrospective cross-sectional analysis of patients who underwent laparoscopic sleeve gastrectomy for morbid obesity between 2014 and 2020 at King Saud University Medical City in Riyadh, Saudi Arabia. This study included 1434 individuals. The mean change in BMI (pre- versus post-BMI) differed statistically significantly between blood groups (p ≤ 0.01). The greatest drop in body weight was seen in individuals with the AB-negative blood type (56.0 (21.4) kg), which corresponds to the greatest percentage of reduction from baseline (47.7% (14.8)). The mean BMI of the patients decreased by 34.7% (9.2) from a mean pre-operation BMI of 45.5 (8.4) kg/m2 to 29.7 (6.1) kg/m2 (p ≤ 0.001). After laparoscopic sleeve gastrectomy, male patients and those with the B-negative blood type are more likely to see a greater BMI reduction (pre-operation compared to post-operation) (p ≤ 0.05). For morbidly obese patients, laparoscopic sleeve gastrectomy demonstrated promising weight loss outcomes. Blood groups may be able to predict the success rate of bariatric surgery in morbidly obese patients.

1083 RISK STRATIFICATION AND PREDICTORS OF OUTCOME IN ASYMPTOMATIC AORTIC STENOSIS: THE ROLE OF MULTIMODALITY IMAGING

Abstract Background Management of asymptomatic severe aortic stenosis is controversial and the decision to intervene requires careful assessment of the benefits and risks in an individual patient. Multimodality imaging approach is becoming an important tool to evaluate the severity and outcome of aortic stenosis (AS). Aim To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low-flow, low-gradients (LFLG) severe AS. Methods 70 (81.4±8.4yrs) prospective asymptomatic patients with AS were followed for 2.77±2.01yrs with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1. Results Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31 ±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13(18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p&amp;lt;0.001), pulse pressure (p=0.005) and dilated ascending aorta (p&amp;lt;0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA =1cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p&amp;lt;0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55AU/m2) and true severe in 12 (3388±1188 AU;1858 ±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations. Conclusions Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function.

A Decade of Improvement in Door‐to‐Puncture Times for Mechanical Thrombectomy But Ongoing Stagnation in Prehospital Care

Background Systems of care surrounding endovascular therapy for stroke have garnered much attention in recent years. In‐hospital metrics, such as “door‐to‐puncture” and procedure times have been areas for quality improvement. The temporal trend and clinical significance of prehospital “onset‐to‐door” time, however, remains unknown. Methods We performed a systematic review of time metric data from all published randomized controlled and investigational device exemption trials involving endovascular therapy for stroke between 2005 and 2019 (n=26). Second, we conducted a record‐level observational analysis on a total of 3512 patients from 3 real‐world registries (Mechanical Embolus Removal in Cerebral Ischemia [MERCI], Thrombectomy REvascularization of Large Vessel Occlusions in Acute Ischemic Stroke [TREVO], and TREVO Stent‐Retriever Acute Stroke [TRACK]), together with 4 prospective trials (MERCI trial, Multi‐MERCI, TREVO‐EU, and TREVO‐2). Only patients receiving mechanical thrombectomy within 9 hours from onset‐to‐puncture time were included. Predictors of good outcome were identified using generalized linear mixed modeling. Results Door‐to‐puncture times (slope=−5.83 min/y; R 2 =0.25; P =0.046), procedure times (slope=−3.78 min/y; R 2 =0.54; P &lt;0.001), and onset‐to‐reperfusion times (slope=−11.82 min/y; R 2 =0.57; P &lt;0.001) improved over the years among previously published randomized controlled trials/investigational device exemption trials from 2005 to 2019. The prehospital metric of onset‐to‐door time, however, remained statistically unchanged (slope=1.03 min/y; R 2 &lt;0.01; P =0.806). Pooled analysis from record‐level data demonstrated a similar temporal trend where door‐to‐puncture, procedure, and onset‐to‐reperfusion times declined by an average of 12 minutes (R 2 =0.45; P &lt;0.0001), 6 minutes (R 2 =0.27; P &lt;0.0001), and 8 minutes per year (R 2 =0.18; P &lt;0.0001), respectively, over a similar time period. Time from onset to door, however, did not improve (3.6 min/y; R 2 =0.34; P =0.005). In a backward‐selection regression model, onset‐to‐door time was found to be a significant predictor of patient outcomes, where every hour delay in hospital arrival correlated with a 14% reduction in the odds of a good outcome. Conclusions “Door‐to‐puncture” and procedure times have seen significant improvements over the past decade. The prehospital component of “onset‐to‐door” time, however, has remained stagnant. This presents an unrealized opportunity to enhance patient outcomes through improved systems of care in the prehospital setting.

Multicenter investigation of technical and clinical outcomes after thrombectomy for Proximal Medium Vessel Occlusion (pMeVO) by frontline technique.

Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR = 2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group. Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Multimodality imaging to assess severity and outcome in asymptomatic patients with aortic stenosis: a medium-long term follow-up study

Abstract Background Multimodality imaging approach is becoming more and more common in evaluating the severity and outcome of aortic stenosis (AS). Aim To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low flow, low gradients (LFLG) severe AS. Methods 70 (81.4±8.4 years) prospective asymptomatic patients with AS were followed for 2.77±2.01 years with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1. Results Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13 (18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p&amp;lt;0.001), pulse pressure (p=0.005) and dilated ascending aorta (p&amp;lt;0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA = 1 cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24 mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p&amp;lt;0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55 AU/m2) and true severe in 12 (3388±1188 AU; 1858±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations. Conclusions Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function. Funding Acknowledgement Type of funding sources: None.

COMPARISON OF THE ACCURACY OF THE GCS AND FOUR SCALE ASSESSMENTS TO THE PROGNOSIS OF INTEGRATIVE REVIEW CONSCIOUSNESS DISORDER PATIENTS

The FOUR Scale is an awareness assessment score. Its theoretical benefit over pre-existing scores is the evaluation of brainstem reflexes and breathing patterns which allows a better assessment of patients with severe impairment of consciousness. The article search was carried out using the Four Data Bases. Inclusion criteria were: human, adult, prospective randomized controlled trial; prospective, cohort/control, case series, prospective, and retrospective studies. Inclusion and exclusion criteria were applied to each article to get the final article for review. Results in the adult population are presented here. Data were reported following the preferred reporting items for integrative review and meta-analysis guidelines. Initial search returned 103 citations. after screening the remaining 65 were for full-text review and 45 were excluded because they were based on review titles and abstracts and did not meet study design and population criteria. Patient categories included traumatic brain injury, intraventricular hemorrhage, intracerebral hemorrhage, subarachnoid hemorrhage, ischemic stroke, general neurology/ combined and neurosurgery, general critical illness/medicine, and patients in the emergency department. Until the remaining 20 studied. Twelve studies demonstrated good interobserver reliability of the FOUR Scale. Three studies demonstrated the prognostic value of the FOUR Scale in predicting mortality and functional outcomes. Five studies demonstrated equivalence between the FOUR Scales compared with the Glasgow Coma Score in predicting mortality and functional outcome. The FOUR Scale has been shown to be a good predictor of outcome in many patients with decreased level of consciousness. So this can provide an overview to nurses in assessing a good level of awareness and reliability.

Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: A multicentre prospective cohort study

BackgroundGlasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting. MethodWe analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality. ResultsA total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS. ConclusionThis study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.

Evaluation of Gunshot Wounds to the Extremities: Correlation of Red Cross Wound Score and Initial Response to Management

Purpose: Gunshot wounds to the extremities are a major cause of death and disability. The Red Cross Wound Score (RCWS) is a simple classification system that is thought to fairly assess severity of injury, influence surgical management and a good predictor of outcome in gunshot wounds. This study aims to evaluate the correlation between the Red Cross Wound Score RCWS and initial response to management.&#x0D; Methodology: This was a prospective study recruiting all consenting patients who suffered gunshot wounds to any extremity and presented at the University of Port Harcourt Teaching Hospital (UPTH). The study was conducted over a 12-month period between October 2018 and September 2019. Data on demographics, anatomical region of the body involved, type of gun time between injury and hospital presentation were obtained using a proforma. Analysis of extracted data was done by the aid of SPSS for Windows version 20.&#x0D; Findings: A total of 106 wounds from 82 patients were analyzed; seventy males (85.4%) and 12 females. AK 47 rifles and locally fabricated pistols were the wounding weapons in 32.9% and the left leg (28.3%) was the most injured extremity. Fifty-two wounds (49%) were grade 3, 44 (41.5%) wounds grade 2 and 10 wounds (9.4%) grade 1. There was a positive association between RCWS grade 3 wounds and limb length discrepancy and joint stiffness. Vascular injuries were seen in 6 patients (0.07%). Wound infection (46.2%), joint stiffness (41.5%) and shortening (34%) were the common complications in the study. The study showed that young adult males suffered more gunshot wounds than females. Most of the wounds were RCWS grade 3 and there was a positive association between RCWS grade 3 wounds and limb length discrepancy and joint stiffness. Patients with longer mean presentation time had a higher infection rate.&#x0D; Recommendations: The Red Cross wound classification should be adopted as a useful scoring system. Also, patients with gunshot injuries should present earlier to the hospital to reduce complications.