Significant Difference In 30-day Mortality Research Articles

Mitral valve reoperation versus first-time surgery for mitral regurgitation: comparison of patient characteristics, type of surgery and mortality in a nationwide cohort

Abstract Background Mitral valve reoperation has been estimated to carry higher surgical risk than first-time mitral surgery. Contemporary data on this area is needed as these associations may lead to under-treatment of recurrent mitral valve disease requiring intervention. Purpose To compare patient characteristics, type of surgery, and early mortality related to mitral valve reoperation versus first-time surgery for mitral regurgitation in a nationwide setting. Methods We identified patients ≥18 years undergoing first-time surgery for mitral regurgitation 1996-2021 using Danish nationwide registries. Patients undergoing first-time surgery due to endocarditis were excluded. The study population was categorized into 1) patients who underwent first-time surgery only; 2) patients who underwent mitral reoperation. The first group was followed from date of first-time surgery, while second group was followed from date of reoperation, and baseline characteristics were defined according to their respective index dates. Mortality was examined during 180-day follow-up using the reverse Kaplan-Meier estimator and multivariate Cox analysis was used to compare mortality rates within 30 days and 180 days of follow-up. Subgroup analysis was conducted after excluding patients undergoing reoperation for infectious endocarditis (IE). Results We identified 7,470 patients; 7,058 (94.5%) underwent first-time surgery only and 412 (5.5%) underwent mitral reoperation. Compared to patients who only underwent first-time surgery, reoperated patients were younger (median age 60 vs. 67) and had fewer comorbidities at time of reoperation, Table 1. Prosthetic replacement was performed in 35.6% of first-time surgeries and 77.2% of reoperations. Mortality after 30 days was 5.2% after first-time surgery and 3.2% after reoperation, while 180-day mortality were 7.8% and 10.6%, respectively, Figure 1. Compared to first-time surgery, reoperation was associated with no significant difference in 30-day mortality (HR=0.68, 95%CI 0.39-1.19), but an increased rate of 180-day mortality (HR=1.60, 95%CI 1.17-2.19, p=0.003). After excluding patients with IE in the reoperation group (n=57), mortality was 2.8% and 8.8% after 30 and 180 days, respectively. In this subgroup, compared to first-time surgery, the 30-day rate of mortality was HR=0.61 (95%CI 0.32-1.14) and after 180 days HR=1.34 (95%CI 0.93-1.93, p=0.11). Conclusion Compared to patients who only underwent first-time mitral surgery, patients undergoing mitral reoperation were younger and had fewer comorbidities at time of reoperation. Repair was favoured for first-time surgery, while prosthetic replacement was favoured for reoperations. Compared to first-time surgery, reoperation was associated with an increased risk of 180-day mortality. Though patients undergoing reoperation for mitral valve disease are carefully selected, our findings suggest that this procedure should still be considered at high risk of an adverse outcome.Table 1Figure 1

Bicycle helmets are associated with fewer and less severe head injuries and fewer neurosurgical procedures

PurposeThis study explores the protective capabilities of bicycle helmets on serious head injury among bicyclists hospitalized in a Norwegian level 1 trauma centre.MethodInformation on helmet use, demographic variables, Abbreviated Injury Scale (AIS) and surgical procedure codes was retrieved from the Oslo University Hospital Trauma Registry for patients with bicycle-related injuries from 2005 through 2016. Outcomes were serious head injury defined as maximum AIS severity score ≥ 3 in the AIS region Head, any cranial neurosurgical procedure, and 30-day mortality.ResultsA total of 1256 hospitalized bicyclists were included. The median age was 41 years (quartiles 26–53), 73% were male, 5.3% had severe pre-injury comorbidities, and 54% wore a helmet at the time of injury. Serious head injury occurred in 30%, 9% underwent a cranial neurosurgical procedure, and 30-day mortality was 2%. Compared to non-helmeted bicyclists, helmeted bicyclists were older (43 years, quartiles 27–54, vs. 38 years, quartiles 23–53, p = 0.05), less often crashed during night-time (21% vs. 38%, p < 0.001), less frequently had serious head injury (22% vs. 38%, OR 0.29, 95% CI 0.22–0.39), and less often underwent cranial neurosurgery (6% vs. 14%, OR 0.36, 95% CI 0.24–0.54). No statistically significant difference in 30-day mortality between the two groups was found (1.5% vs. 2.9%, OR 0.50, 95% CI 0.22–1.11).ConclusionHelmet use was associated with fewer and less severe head injuries and fewer neurosurgical procedures. This adds evidence to the protective capabilities of bicycle helmets.

A time-series analysis examining implementation strategies to increase use of an early-supported discharge hospital at home model.

Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput. The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization. We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups. There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas. Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.

Association Between Arterial Pulse Waveform Analysis and Mortality in Patients With Septic Shock: A Retrospective Cohort Study Using Japanese Diagnosis Procedure Combination Data.

Purpose: Specialized pressure transducers for arterial pulse waveform analysis (S-APWA) devices are dedicated kits connected to an arterial pressure catheter that monitors hemodynamic parameters, such as cardiac output, pulse pressure variation, and stroke volume variation, less invasively. While the association between the use of S-APWA devices and clinical outcomes in perioperative patients has been previously evaluated, its assessment in patients with septic shock remains inadequate. Materials and Methods: This retrospective cohort study utilized a nationwide Diagnosis Procedure Combination database in Japan. Adult patients with septic shock admitted to the intensive care unit (ICU) with arterial pressure catheter placement on the admission day from August 2012 to February 2021 were included. Hospitalizations meeting the eligibility criteria were categorized into groups based on S-APWA device usage. The primary outcome, evaluated using Cox regression analysis, was 30-day all-cause mortality in the propensity score overlap-weighted population. Secondary outcomes included in-hospital mortality, ICU duration, and overall hospital stay. Results: Among 5130 eligible hospitalizations, 643 were in the S-APWA group and 4487 were in the conventional pressure transducer group. Cox regression analysis within the propensity score overlap-weighted population showed no significant difference in 30-day mortality (adjusted hazard ratio: 0.94; 95% confidence interval: 0.9-1.38; P = .58). Logistic regression analysis indicated no significant differences in the in-hospital mortality. While the S-APWA group had prolonged ICU stays, no significant difference in the overall hospital stay was observed according to linear regression analyses. Conclusions: Our study found no significant association between S-APWA use and 30-day mortality in patients with septic shock. These findings offer insights into optimizing monitoring systems in ICUs.

Outcome and Risk of Poststroke Pneumonia in Patients with Acute Ischemic Stroke After Endovascular Thrombectomy: A Post Hoc Analysis of the DIRECT-MT Trial.

In this study, we aimed to investigate the risk factors and impact of poststroke pneumonia (PSP) on mortality and functional outcome in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). This was a post hoc analysis of a prospective randomized trial (Direct intraarterial thrombectomy in order to revascularize AIS patients with large-vessel occlusion efficiently in Chinese tertiary hospitals: a multicenter randomized clinical trial). Patients with AIS who completed EVT were evaluated for the occurrence of PSP during the hospitalization period and their modified Rankin Scale (mRS) scores at 90days after AIS. Logistic regression analysis was conducted to investigate the independent predictors of PSP. Propensity score matching was conducted for the PSP and non-PSP groups by using the covariates resulting from the logistic regression analysis. The associations between PSP and outcomes were analyzed. The outcomes included 90-day poor functional outcome (mRS scores > 2), 90-day mortality, and early 2-week mortality. A total of 639 patients were enrolled, of whom 29.58% (189) developed PSP. Logistic regression analysis revealed that history of chronic heart failure (unadjusted odds ratio [OR] 2.011, 95% confidence interval [CI] 1.026-3.941; P = 0.042), prethrombectomy reperfusion on initial digital subtraction angiography (OR 0.394, 95% CI 0.161-0.964; P = 0.041), creatinine levels at admission (OR 1.008, 95% CI 1.000-1.016; P = 0.049), and National Institutes of Health Stroke Scale at 24h (OR 1.023, 95% CI 1.007-1.039; P = 0.004) were independent risk factors for PSP. With propensity scoring matching, poor functional outcome (mRS > 2) was more common in patients with PSP than in patients without PSP (81.03% vs. 71.83%, P = 0.043) at 90days after EVT. The early 2-week mortality of patients with PSP was lower (5.74% vs. 12.07%, P = 0.038). But there was no statistically significant difference in 90-day mortality between the PSP group and non-PSP group (22.41% vs. 14.94%, P = 0.074). The survivorship curve also shows no statistical significance (P = 0.088) between the two groups. Nearly one third of patients with AIS and EVT developed PSP. Heart failure, higher creatinine levels, prethrombectomy reperfusion, and National Institutes of Health Stroke Scale at 24h were associated with PSP in these patients. PSP was associated with poor 90-day functional outcomes in patients with AIS treated with EVT.

Derivation and validation of generalized sepsis-induced acute respiratory failure phenotypes among critically ill patients: a retrospective study

BackgroundSeptic patients who develop acute respiratory failure (ARF) requiring mechanical ventilation represent a heterogenous subgroup of critically ill patients with widely variable clinical characteristics. Identifying distinct phenotypes of these patients may reveal insights about the broader heterogeneity in the clinical course of sepsis, considering multi-organ dynamics. We aimed to derive novel phenotypes of sepsis-induced ARF using observational clinical data and investigate the generalizability of the derived phenotypes.MethodsWe performed a multi-center retrospective study of ICU patients with sepsis who required mechanical ventilation for ≥ 24 h. Data from two different high-volume academic hospital centers were used, where all phenotypes were derived in MICU of Hospital-I (N = 3225). The derived phenotypes were validated in MICU of Hospital-II (N = 848), SICU of Hospital-I (N = 1112), and SICU of Hospital-II (N = 465). Clinical data from 24 h preceding intubation was used to derive distinct phenotypes using an explainable machine learning-based clustering model interpreted by clinical experts.ResultsFour distinct ARF phenotypes were identified: A (severe multi-organ dysfunction (MOD) with a high likelihood of kidney injury and heart failure), B (severe hypoxemic respiratory failure [median P/F = 123]), C (mild hypoxia [median P/F = 240]), and D (severe MOD with a high likelihood of hepatic injury, coagulopathy, and lactic acidosis). Patients in each phenotype showed differences in clinical course and mortality rates despite similarities in demographics and admission co-morbidities. The phenotypes were reproduced in external validation utilizing the MICU of Hospital-II and SICUs from Hospital-I and -II. Kaplan–Meier analysis showed significant difference in 28-day mortality across the phenotypes (p < 0.01) and consistent across MICU and SICU of both Hospital-I and -II. The phenotypes demonstrated differences in treatment effects associated with high positive end-expiratory pressure (PEEP) strategy.ConclusionThe phenotypes demonstrated unique patterns of organ injury and differences in clinical outcomes, which may help inform future research and clinical trial design for tailored management strategies.

Preoperative Malnutrition Calculated Using the Geriatric Nutritional Risk Index in Off-Pump Coronary Artery Bypass Grafting

Background: The Geriatric Nutritional Risk Index (GNRI), which assesses nutritional status using the ideal body weight ratio and albumin level, is a useful predictor of long-term cardiovascular disease prognosis. This study aimed to investigate the impact of preoperative GNRI on off-pump coronary artery bypass (OPCAB) surgical outcomes. Methods: We analyzed 632 elective OPCAB procedures performed between July 2008 and July 2018. GNRI was calculated as 14.89 × albumin level (g/dL) + 41.7 × (current body weight [kg]/ideal body weight [kg]). Patients were divided into two groups: the low GNRI (≤98, L group, n = 155) and high GNRI (&gt;98, H group, n = 477) groups. We compared perioperative variables and mid-term outcomes, particularly survival rates and freedom from major adverse cardiac or cerebrovascular events (MACCE). Results: Patients in the L group were older (72.4 ± 8.6 vs. 67.9 ± 10.1 years, p &lt; 0.001) and had lower GNRI scores (90.9 ± 5.8 vs. 106.0 ± 4.8, p &lt; 0.001) than patients in the H group. Perioperative results, including operation time and number of anastomoses, were similar between the groups, with no significant differences in 30-day mortality, perioperative intra-aortic balloon pump use, bleeding, stroke, or mediastinitis rates were observed. However, patients in the L group had a longer postoperative hospital stay than those in the H group (15.4 ± 13.5 vs. 12.6 ± 5.8 days, p = 0.01). Analyses of long-term outcomes revealed a significant difference in 5-year survival rates (70.9% for the L group vs. 83.3% for the H group, p = 0.002) but no significant difference in 5-year MACCE rates (84.1% for the L group vs. 80.3% for the H group, p = 0.19). Conclusions: Despite the longer hospital stay for patients in the L group, other perioperative outcomes were similar between the groups, suggesting that a low GNRI should not preclude patients from undergoing OPCAB surgery.

Pre-hospital admission of heparin in patients with suspected non-ST segment elevation acute coronary syndrome.

Evidence supporting pre-hospital heparin administration in patients with suspected non-ST segment elevation acute coronary syndrome (NSTE-ACS) is lacking. We aim to evaluate if pre-hospital heparin administration by emergency medical service improves clinical outcome in patients with suspected NSTE-ACS. Patients with suspected myocardial infarction (MI) presenting to the emergency department were prospectively enrolled from 2013 to 2021, excluding those with ST segment elevation MI. Patients with and without prehospital heparin administration were compared using propensity score matching. To assess the association between pre-hospital heparin loading, 30-day and 1-year mortality, Kaplan-Meier estimations and Cox regression models were used. Among 1,234 patients, median age was 69years, 755 (61.2%) were male, 867 (70.5%) with known hypertension, 177 (14.4%) had diabetes, 280 (23.1%) were current smokers, and 444 (36.0%) had a history of CAD. Compared to patients without pre-hospital heparin administration, heparin pre-treated patients were more often active smokers (26.5% vs. 20.8%). After propensity matching, 475 patients with vs. without pre-hospital heparin administration were compared, with no significant difference in 30-day mortality (no-heparin 1.3% vs. heparin 0.4%) and 1-year mortality (no-heparin 7.2% vs. heparin 5.5%, adjusted HR 0.98, CI 0.95-1.01, p = 0.22). Bleeding events occurred at a low frequency (< 2%) and did not differ between groups. In this study, pre-hospital heparin administration was not associated with improved clinical outcome in patients with suspected NSTE-ACS. These findings question pre-hospital heparin therapy in this patient population and might potentially warrant a more restricted utilization pending in-hospital risk assessment.

The efficacy, safety and effectiveness of hyperoncotic albumin solutions in patients with sepsis: A systematic review and meta-analysis.

Intravenous fluid therapy is a ubiquitous intervention for the management of patients with sepsis, however excessive cumulative fluid balance has been shown to result in worse outcomes. Hyperoncotic albumin is presented in low volumes, is an effective resuscitation fluid and may have effects beyond plasma volume expansion alone. This systematic review aimed to assess the efficacy, safety and effectiveness of hyperoncotic albumin solutions in the management of sepsis. We searched four databases and two trial registries for controlled clinical trials of hyperoncotic albumin for management of sepsis. Review outcomes were mortality, need for renal replacement therapy, cumulative-fluid balance, and need for organ support. We used methods guided by the Cochrane Handbook for reviews of clinical interventions. Studies were assessed using Cochrane's Risk of Bias 2 tool. We performed pairwise meta-analysis where possible. Certainty of evidence was assessed using GRADE. We included six trials; four (2772 patients) were meta-analysed. Most studies had moderate or high risk of bias. There was no significant difference in 28-day mortality for septic patients receiving hyperoncotic albumin compared to other intravenous fluids (OR 0.95, [95% CI: 0.8-1.12]); in patients with septic shock (2013 patients) there was a significant reduction (OR 0.82 [95% CI: 0.68-0.98]). There was no significant difference in safety outcomes. Hyperoncotic albumin was associated with variable reduction in early cumulative fluid balance and faster resolution of shock. There is no good-quality evidence to support the use of hyperoncotic albumin in patients with sepsis, but it may reduce short-term mortality in the sub-groups with septic shock. It appears safe in terms of need for renal replacement therapy and is associated with reduced early cumulative fluid balance and faster resolution of shock. Larger, better quality randomised controlled trials in patients with septic shock may enhance the certainty of these findings. PROSPERO ref: CRD42021150674.

Outcomes following heart valve surgery in patients with infective endocarditis and preoperative septic cerebral embolism: insights from the CAMPAIGN study group.

This study aimed to analyse the impact of preoperative septic cerebral embolism on early and late postoperative outcomes in patients with infective endocarditis undergoing valve surgery. Retrospective multicentric study based on the Clinical Multicentric Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry comprising patients with infective endocarditis who underwent valve surgery between 1994 and 2018 at 6 German centres. Patients were divided into 2 groups for statistical comparison according to the presence or absence of preoperative septic cerebral embolism. Propensity score matching was performed for adjusted comparisons of postoperative outcomes. Primary outcomes were 30-day mortality and estimated 5-year survival. A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs 33.0% P < 0.001), large vegetations >10 mm (43.1% vs 30.0%, P < 0.001), and Staphylococcus species infection (42.3% vs 21.3%, P < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1% vs 22.8%; P = 0.14) and 5-year survival (47.8% vs 49.1%; stratified log-rank P = 0.77) in patients with and without preoperative cerebral embolism, respectively. Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality; therefore, it should not play a major role in deciding if surgery is to be performed.

Association between intra-arterial catheterization and mortality of acute heart failure patients without shock in ICU: A retrospective study

BackgroundAcute heart failure necessitates intensive care, and arterial catheterization is a commonly performed invasive procedure in the intensive care unit (ICU). We aimed to investigate the association between arterial catheterization and outcomes in acute heart failure patients without shock. MethodsWe utilized MIMIC-IV database records for acute heart failure patients at Beth Israel Deaconess Medical Center from 2008 to 2019. Employing doubly robust estimation, we examined the relationship between arterial catheterization and outcomes, including 28-day, 90-day, in-hospital mortality, and ICU-free days within 28 days. ResultsOf 6936 patients identified, 2078 met inclusion criteria; 347 underwent arterial catheterization during their ICU stay. We observed no significant difference in 28-day mortality (odds ratio [OR]: 0.61, 95 % confidence interval [CI]: 0.31–1.21, P = 0.155), though catheterization was associated with reduced in-hospital mortality (OR: 0.41, 95 % CI: 0.14–0.65, P = 0.02). No significant effects were observed on 90-day mortality or ICU-free days within 28 days. ConclusionOur findings suggest that arterial catheterization is not associated with 28- and 90-day mortality rates in acute heart failure patients without shock but is linked to lower in-hospital mortality. Additional research and consensus are required to determine the appropriate utilization of arterial catheterization in patients.

Effect of Fu Zheng Jie Du Formula on outcomes in patients with severe pneumonia receiving prone ventilation: a retrospective cohort study.

The effect of combining prone ventilation with traditional Chinese medicine on severe pneumonia remains unclear. To evaluate the effect of Fu Zheng Jie Du Formula (FZJDF) combined with prone ventilation on clinical outcomes in patients with severe pneumonia. This single-center retrospective cohort study included 188 severe pneumonia patients admitted to the ICU from January 2022 to December 2023. Patients were divided into an FZJD group (receiving FZJDF for 7 days plus prone ventilation) and a non-FZJD group (prone ventilation only). Propensity score matching (PSM) was performed to balance baseline characteristics. The primary outcome was the change in PaO2/FiO2 ratio after treatment. Secondary outcomes included 28-day mortality, duration of mechanical ventilation, length of ICU stay, PaCO2, lactic acid levels, APACHE II score, SOFA score, Chinese Medicine Score, inflammatory markers, and time to symptom resolution. After PSM, 32 patients were included in each group. Compared to the non-FZJD group, the FZJD group showed significantly higher PaO2/FiO2 ratios, lower PaCO2, and lower lactic acid levels after treatment (p < 0.05 for all). The FZJD group also had significantly lower APACHE II scores, SOFA scores, Chinese Medicine Scores, and levels of WBC, PCT, hs-CRP, and IL-6 (p < 0.05 for all). Time to symptom resolution, including duration of mechanical ventilation, length of ICU stay, time to fever resolution, time to cough resolution, and time to resolution of pulmonary rales, was significantly shorter in the FZJD group (p < 0.05 for all). There was no significant difference in 28-day mortality between the two groups. FZJDF as an adjuvant therapy to prone ventilation can improve oxygenation and other clinical outcomes in severe pneumonia patients. Prospective studies are warranted to validate these findings.

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications.

Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p=0.03), especially deep incisional infection (4.9% vs. 2.4%; p=0.04). Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

Celsior® vs. St Thomas® cardioplegia: analysis of myocardial protection and clinical safety in neonates.

To compare the effectiveness and safety of Celsior® crystalloid solution to St Thomas® solution as cardioplegia in pediatric arterial switch surgery. A retrospective study was conducted on 180 patients who underwent arterial switch operation (ASO) between 2005 and 2019. The patients were divided into two groups: the St Thomas group receiving St Thomas solution and the Celsior® group receiving Celsior® solution. The study aimed to assess myocardial protection while evaluating clinical outcomes of patients between groups. Baseline characteristics not different between groups. The postoperative troponin release trends and blood lactate levels were not different between groups. However, the Celsior® group had a significant lower incidence of delayed sternal closure (9.7% vs. 19.5%; p = 0.09) and mechanical circulatory support (ECMO) (4.9% vs. 24.7%; p < 0.001) compared to the St Thomas group. The length of stay in the intensive care unit (ICU) was significantly shorter in the Celsior® group (4.6 ± 3.36 days vs. 8.72 ± 5.08 days, respectively; p < 0.001). There was no significant difference in 30-day mortality between the two groups (2.9% vs. 2.6%; p = 0.147). The study suggests that Celsior® solution is effective and safe for myocardial protection in pediatric arterial switch surgery. It may offer potential benefits such as reduced need for delayed sternal closure and ECMO support, as well as shorter ICU stay. However, the study has limitations including its retrospective design and the use of different cardioplegic solutions during different time periods. Further prospective randomized trials are needed for confirmation. ClinicalTrials.gov, ID: NCT04616222.

Clinical characteristics and outcomes of Australian and Indian ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI)

IntroductionThe incidence of STEMI and subsequent mortality has been reported to be higher in Indian populations compared to developed countries. However, there is limited data directly comparing contemporary primary percutaneous coronary intervention (pPCI) treatment strategies and clinical outcomes for STEMI patients between developed and developing countries. Materials and methodsWe compared population demographics, procedural characteristics, times to reperfusion and mortality in STEMI patients treated with pPCI between two tertiary referral centers in India and Australia respectively over a 3-year period (1st Jan 2017–31st Dec 2019). ResultsA total of 1293 STEMI presentations (896 Indian vs 397 Australian) were included. On average, Indian patients had lower median BMI than Australian patients (BMI 25.4 vs 27.8; p < 0.001), were significantly younger (mean age 56.0 vs 63.2 years; p < 0.001), more likely male (84 % vs 80 %; p = 0.046) and diabetic (48 % vs 18 %); p < 0.001). Radial access (50 % vs 88 %; p < 0.001) and TIMI III flow post PCI was also significantly lower (85 % vs 96 %; p < 0.001) with median door-to-balloon time significantly shorter in the Indian cohort (20mins vs 43mins; p < 0.001); however, median symptom to balloon time was significantly longer (245mins vs 160mins; p < 0.001). No significant differences in 30-day mortality (4.0 % vs 2.8 % Australian; p = 0.209) or 1-year mortality (6.5 % vs 4.3 %; p = 0.120) were observed. ConclusionSignificant differences in demographics and presentation characteristics exist between Indian and Australian STEMI patients treated with pPCI. Indian patients had significantly longer pre-hospital delays and lower achievement of TIMI III flow post PCI, yet shorter in-hospital time to treatment.

Ulinastatin shortens the length of ICU stay in critical patients with organ failure: A 7-year real-world study.

Ulinastatin has been applied in a series of diseases associated with inflammation but its clinical effects remain somewhat elusive. We aimed to investigate the potential effects of ulinastatin on organ failure patients admitted to the intensive care unit (ICU). This is a single-center retrospective study on organ failure patients from 2013 to 2019. Patients were divided into two groups according to using ulinastatin or not during hospitalization. Propensity score matching was applied to reduce bias. The outcomes of interest were 28-day all-cause mortality, length of ICU stay, and mechanical ventilation duration. Of the 841 patients who fulfilled the entry criteria, 247 received ulinastatin. A propensity-matched cohort of 608 patients was created. No significant differences in 28-day mortality between the two groups. Sequential organ failure assessment (SOFA) was identified as the independent risk factor associated with mortality. In the subgroup with SOFA ≤ 10, patients received ulinastatin experienced significantly shorter time in ICU (10.0 d [interquartile range, IQR: 7.0∼20.0] vs 15.0 d [IQR: 7.0∼25.0]; p = .004) and on mechanical ventilation (222 h [IQR:114∼349] vs 251 h [IQR: 123∼499]; P = .01), but the 28-day mortality revealed no obvious difference (10.5% vs 9.4%; p = .74). Ulinastatin was beneficial in treating patients in ICU with organ failure, mainly by reducing the length of ICU stay and duration of mechanical ventilation.

Prevalence, predictive factors, and outcomes of refeeding syndrome among medically critically ill patients: A retrospective cohort study.

Refeeding syndrome (RFS) is a life-threatening metabolic derangement occurring when nutrition is reintroduced after prolonged starvation. Limited data exist regarding RFS prevalence, risk factors, and outcome, particularly in critically ill patients. A retrospective cohort study was conducted in a medical intensive care unit from June 2018 to August 2020. RFS diagnostic criteria from the National Institute for Health and Care Excellence (NICE) and the American Society for Parenteral and Enteral Nutrition (ASPEN) were used. The primary outcome was 30-day mortality. Among 216 patients, RFS was diagnosed in 22.7% and 27.3% of patients per the NICE and ASPEN criteria, respectively. There was no significant difference in 30-day mortality between patients with and without RFS (22/59 [37.3%] vs 53/157 [33.8%]; P = 0.627). Independent predictors of RFS were malignancy (odds ratio [OR] = 2.09; 95% CI = 1.06-4.15; P = 0.035), septic shock (OR = 2.26; 95% CI = 1.17-4.39; P = 0.016), and high NICE RFS risk classification (OR = 2.52; 95% CI = 1.20-5.31; P = 0.015). Factors associated with reduced RFS risk were Sequential Organ Failure Assessment (SOFA) scores >12 (OR = 0.45; 95% CI = 0.23-0.88; P = 0.020) and high-dose vasopressor treatment (OR = 0.34; 95% CI = 0.14-0.79; P = 0.012). RFS affected one-fourth of the critically ill patients but did not significantly impact 30-day mortality. Malignancy, septic shock, and high NICE RFS risk classification were positively associated with RFS, whereas high SOFA scores and extensive vasopressor use were linked to decreased risk.

Impact of P2Y12 inhibitors on clinical outcomes in sepsis-3 patients receiving aspirin: a propensity score matched analysis

BackgroundSepsis is a life-threatening disease accompanied by disorders of the coagulation and immune systems. P2Y12 inhibitors, widely used for arterial thrombosis prevention and treatment, possess recently discovered anti-inflammatory properties, raising potential for improved sepsis prognosis.MethodWe conducted a retrospective analysis using the data from Medical Information Mart for Intensive Care-IV database. Patients were divided into an aspirin-alone group versus a combination group based on the use of a P2Y12 inhibitor or not. Differences in 30-day mortality, length of stay (LOS) in intensive care unit (ICU), LOS in hospital, bleeding events and thrombotic events were compared between the two groups.ResultA total of 1701 pairs of matched patients were obtained by propensity score matching. We found that no statistically significant difference in 30-day mortality in aspirin-alone group and combination group (15.3% vs. 13.7%, log-rank p = 0.154). In addition, patients received P2Y12 inhibitors had a higher incidence of gastrointestinal bleeding (0.5% vs. 1.6%, p = 0.004) and ischemic stroke (1.7% vs. 2.9%, p = 0.023), despite having a shorter LOS in hospital (11.1 vs. 10.3, days, p = 0.043). Cox regression showed that P2Y12 inhibitor was not associated with 30-day mortality (HR = 1.14, 95% CI 0.95–1.36, p = 0.154).ConclusionP2Y12 inhibitors did not provide a survival benefit for patients with sepsis 3 and even led to additional adverse clinical outcomes.

Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis

IntroductionPatients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). MethodsWe conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. ResultsNine studies with a total of 2476 patients were included. There was no significant difference in 30-day Mortality between TAVR vs SAVR groups (OR = 0.65, 95% CI [ 0.09–4.61], P = 0.22). There was no difference between both groups regarding myocardial infarction at 30 days (OR = 0.63, 95% CI [0.1–3.89], P = 0.62). TAVR was associated with a significantly lower 30-day major bleeding and 2-year major bleeding, Pooled studies were homogeneous (OR = 0.44, 95% CI [0.31–0.64], P < 0.01, I2 = 0, P = 0.89), (OR = 0.4 ,95% CI [0.21–0.77], P = 0.03, I2 = 0%, P = 0.62) respectively. TAVR was associated with a lower rate of moderate PPM (OR = 0.6, 95% CI [ 0.44–0.84], p value = 0.01, i2 = 0%, p value = 0.44). The overall effect estimate did not favor any of the two groups regarding short-term Mild AR (OR = 5.44, 95% CI [1.02–28.91], P = 0.05) and Moderate/severe AR (OR = 4.08, 95% CI [ 0.79–21.02], P = 0.08, I2 = 0%, P = 0.59). ConclusionOur findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.

Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020.

This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment.