Significant Difference In Overall Mortality Research Articles

Abstract 4812: Evaluating racial and ethnic differences in advanced-stage laryngeal cancer treatment and outcomes in Florida: Unmasking the inequities

Abstract Purpose: To evaluate the association between race/ethnicity, treatment, and mortality among individuals with advanced-stage laryngeal cancer in Florida. Methods: We obtained data from the Florida Cancer Data System (FCDS) on non-Hispanic (NH)-White (the reference group), Hispanic, and NH-Black patients with advanced-stage (regional and distant) laryngeal cancer from 2009 to 2020. Sociodemographic factors were obtained from FCDS (age, marital status, and insurance) and the United States Census at the county level (education, household income, and rurality). Treatment strategies included chemoradiation, surgery followed by chemoradiation, chemotherapy, radiation, surgery, and surgery followed by chemotherapy. The primary outcome was overall mortality. Multivariable Cox proportional hazard models were used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) and to examine the association of race/ethnicity with treatment and survival, while adjusting for sociodemographic factors. Results: There were 4,522 participants with advanced-stage laryngeal cancer (57.9% <65 years, 79.5% male, 75.4% NH-White, 13.1% Hispanic, and 11.5% NH-Black) included in the analysis. Compared to NH-White patients, NH-Black patients were less likely to be married, have private insurance, and live in an urban county. Moreover, NH-Black individuals were less likely to receive chemoradiation alone and were more likely to receive surgery followed by chemoradiation. Government insurance was highly associated with chemoradiation receipt. In age-adjusted models, NH-Black patients with advanced-stage laryngeal cancer had a higher risk of death compared to NH-White patients (HR: 1.19; 95% CI: 1.06, 1.32), while Hispanic patients had a lower risk of death compared to NH-White patients (HR: 0.80; 95% CI: 0.71, 0.89). After adjusting for sociodemographic factors, there was no statistically significant difference in overall mortality in NH-Black patients compared to NH-White patients (HR: 1.07; 95% CI: 0.96, 1.20). However, among individuals who received chemoradiation, NH-Black patients had a higher risk of mortality, even after adjusting for sociodemographic factors, compared to NH-White patients (HR: 1.27; 95% CI: 1.04, 1.55). Conclusions: Among patients with advanced-stage laryngeal cancer in Florida, NH-Black patients experienced a higher risk of overall mortality compared to other racial and ethnic groups, but this discrepancy was primarily among those who received chemoradiation, even after accounting for sociodemographic factors. This study emphasizes the urgency of expanding laryngeal cancer care access for NH-Black individuals and investigating possible biological variations in their response to chemoradiation and subsequent survival outcomes. Citation Format: Caretia J. Washington, Chayil Lattimore, Dejana Braithwaite, Kristianna Fredenburg, Shama Karanth. Evaluating racial and ethnic differences in advanced-stage laryngeal cancer treatment and outcomes in Florida: Unmasking the inequities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4812.

The impact of endovascular stents types on perioperative outcomes of ruptured abdominal aortic aneurysms: a single-center experience.

Ruptured abdominal aortic aneurysm (rAAA) represents a critically urgent vascular surgical condition, and endovascular aneurysm repair (EVAR) is a clinically effective treatment option. This study aims to investigate whether the type of intravascular graft used for ruptured abdominal aortic aneurysms has an impact on perioperative outcomes of EVAR. A retrospective analysis was conducted on patients who underwent EVAR for ruptured abdominal aortic aneurysm at a single medical center from 2019 to 2022. Patients who required simultaneous stent implantation in the renal arteries or visceral arteries, as well as those with ruptured aneurysms located in the para-renal, supra-renal, or thoracoabdominal regions, were excluded from the analysis. Additionally, patients who underwent open surgery during the initial procedure or converted to open repair were excluded. The primary endpoint was perioperative mortality rate. Other study outcomes included perioperative complications, reoperation rates, and length of hospital stay. Characteristics and corresponding outcomes of patients receiving different endovascular stent treatments were compared using SPSS software. A total of 58 patients received treatment with two types of endovascular stents: Gore Excluder (n = 29) and Microport Hercules (n = 29). The number of other endografts was too small for statistical analysis. Compared to patients treated with Hercules, those treated with Excluder had a significantly increased likelihood of concomitant coronary atherosclerosis (P = 0.009) and potentially higher creatinine levels (P = 0.014). Additionally, Excluder was more commonly used in patients with shorter aneurysm necks (P < 0.001). There was a statistically significant difference in overall mortality between the two groups (Hercules 27.6%, Excluder 6.9%, P = 0.037). Furthermore, patients who received Excluder treatment had lower mortality rates in subgroups of non-alcohol users (P = 0.028), non-diabetic patients (P = 0.027), and patients with dispersed thrombosis at the proximal neck (P = 0.046). In the multivariate analysis, the type of stent used (OR 0.06, 95% CI 0.00-1.31) and the occurrence of intraoperative complications (OR 20.70, 95% CI 1.14-76.70) in patients with rAAA was identified as an independent risk factor for perioperative mortality. Our study suggests that the management of intraoperative complications may be a modifiable factor that can improve outcomes. Patients receiving Excluder treatment demonstrated better performance in EVAR for single-center rAAA patients compared to other endovascular stents, and this difference warrants further investigation.

Efficacy and safety of antiplatelet therapy in COVID-19: Insights from ameta-analysis of randomized controlled trials.

COVID-19 induces a pro-coagulant state with thrombotic events. This meta-analysis explores the efficacy and safety of antiplatelet-based therapy in COVID-19 patients through randomized controlled trials (RCTs). A systematic literature search until March 10, 2023, identified 7 RCTs involving 23,415 inpatients. Of these, 11,891 received antiplatelet-based treatment, and 11,524 received placebo/other drugs. Statistical analysis was performed using Review Manager 5.4. The included trials involved patients with a mean age ranging from 54.3 to 62.0 years and a prevalence of hypertension ranging from 10.9 to 65.0% and coronary artery disease ranging from 3.2 to 32.7%. The pooled analysis showed no significant difference in overall mortality between groups (RR 1.0, 95% CI 0.99-1.01, p=0.76). However, antiplatelet therapy significantly reduced major thrombotic events (RR 0.86, 95% CI 0.75-0.99, p=0.04). Conversely, it increased major bleeding risks (RR 1.62, 95% CI 1.24-2.12, p=0.0005). There was no significant difference in the incidence of invasive mechanical ventilation and respiratory death. Antiplatelet therapy does not confer mortality benefit in COVID-19 patients but lowers major thrombotic events while increasing major bleeding risks. Ongoing large RCTs will provide more information on the therapeutic value of this therapy.

Optimal Timing of Tracheostomy in the Setting of COVID-19 and Associated Pneumothorax.

Introduction At the beginning of the 2020 pandemic, no criteria were in place regarding the timing of tracheostomy placement in intubated COVID-19 patients, nor were there any data pertaining to pneumothorax incidence in this population. This study examines the timing of tracheostomy placement and its correlation with patient outcomes, along with pneumothorax incidence in COVID-19 patients who underwent a tracheostomy. Methods We performed a multi-institutional retrospective study of intubated COVID-19 patients admitted to intensive care units (ICUs) in North and South Dakota between April 2020 and December 2020. The timing of the tracheostomy was assessed, with primary outcomes being mortality, successful ventilator weaning, discharge to a long-term care facility, and overall length of stay. Patients were grouped by age, gender, ethnicity, and comorbidities. Pre- and post-tracheostomy pneumothorax was extracted from this dataset. Results We identified 85 patients who were intubated with COVID-19 and underwent a tracheostomy. The timing of tracheostomy varied widely, ranging from five to 53 days with an average time to tracheostomy being 17.3 days. Thirty-four of the patients expired, 32 patients were discharged to a long-term care hospital (LTCH), and 11 patients were discharged to an inpatient rehabilitation facility. Only three patients were discharged home. Regression analysis did not reveal statistically significant differences between patients who survived (N = 51) and patients who expired (N = 34) for almost all variables analyzed. Sixteen of the 85 patients were diagnosed with pneumothorax during their hospital stay. Half of these patients were diagnosed after a tracheostomy was placed. Conclusion This study did not demonstrate statistically significant differences in overall mortality or incidence of pneumothorax when it pertains to the timing of placement of tracheostomy. Variation in mortality was identified, in which younger patients were more likely to survive than older patients, a finding that was echoed in other studies. Considering this evidence, we cannot conclude that an association between the timing of tracheostomy and mortality from COVID-19; therefore, tracheostomy in the setting of COVID-19 can be performed at the provider's discretion.

Are liver abnormalities associated with hospital mortality in viral infections?

Objective: Patients hospitalised with severe viral infections may have abnormal liver function. Multiple studies have linked systemic-disseminated viral infections to liver damage. The progression, medical significance, and impact of atypical liver chemical levels on hospitalised infections are unknown. Aims: This study addresses these concerns and examines how liver-related biochemical abnormalities affect viral infection patients' clinical outcomes. Methods: A retrospective study was conducted at the royal medical services’ institutions, focusing on patients admitted over two years. The primary purpose was to gather information about patients who underwent testing. Patients with abnormalities in liver indices, specifically alanine transferase (ALT) and aspartate aminotransferase (AST), were included in the study. Patients with an AST/ALT ratio greater than 2 were excluded. Patients were classified as either having a lower liver disease status (Status I) or a higher liver disease status (Status II). The classification of liver disease statuses was based on the LDH to AST ratio (below 6.5 or higher than 6.5). The study used independent T-tests, Chi Square Test, and multiple logistic regression to analyze non-parametric data. A significance level of 5% was chosen, and SPSS ver 25 was used for the study. The study aimed to determine the effects of gender, severity group at admission, and composite predictors on the likelihood of admitted viral infected patients having liver diseases. Results: MAOVA analysis revealed a significant difference in overall mortality among individuals infected with SARS-VIRAL, based on the LDH: AST 1 and LDH: AST 2 ratios. The statistical test yielded an F-value of 1204.283 with degrees of freedom (2, 778), and a p-value of less than .0005. Additionally, Wilk's Lambda was found to be 0.244, indicating a strong effect size (partial η2 = 0.756). Conclusion: The involvement of the liver in viral infections is directly correlated with mortality, as this correlation is very clear. Therefore, it is of the utmost importance to incorporate hepatic enzymes as a criterion when evaluating patients who have viral infections. This is because of the impact that elevated liver enzymes have on immune cells and, as a result, the overall clinical outcomes. Since this is the case, it is essential for viral patients to undergo daily monitoring of their liver enzymes on a consistent basis.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)—356 patients or percutaneous coronary intervention (PCI)—679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis

BackgroundOur previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).MethodsSeven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.ResultsTwenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = − 1.85 days; 95% CI, [− 3.44, − 0.27]; P = 0.02; I2 = 0%).ConclusionsPermissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs.Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023

Efficacy of Treatment for Metastatic Hormone-Sensitive Prostate Cancer: An Umbrella Review of Systematic Reviews and Meta-Analyses.

This umbrella review focused on evaluating the efficacy and adverse events of the metastatic hormone-sensitive prostate cancer patients receiving any treatment regimens, including ADT alone or combination treatments. This study conducted an umbrella review following the PRISMA 2020 checklist, aiming to summarize the available studies to evaluate the efficacy of medical treatments for metastatic hormone-sensitive prostate cancer. A literature search was performed to identify systematic reviews and meta-analyses (SRMAs) that included only randomized controlled trials (RCTs) up to September 2023. This study summarized their findings, evaluated overlapping data (i.e., the same RCTs were included in >one SRMA), tested for excessive significance (i.e., observed number of statistically significant studies > expected number by chance) and assessed the quality of the studies. A total of 4191 studies were identified, but only 27 were included. Among those 27 studies, 12 were network meta-analyses and 15 were direct meta-analyses. Most studies showed no statistically significant difference in overall mortality among GnRH agonists, antagonists and bilateral orchiectomy. Combination treatment is more beneficial than ADT alone in both OS and PFS outcomes with more adverse events. Nevertheless, there is no OS advantage of any combination regimen over the others. Combination treatments demonstrated clear benefits in OS and PFS over ADT alone with more AEs. Further studies are needed to compare among combination treatments.

Cryoprecipitate-Poor Plasma Instead of Fresh Frozen Plasma As Replacement Therapy in Thrombotic Thrombocytopenic Purpura: A Systematic Review and Meta-Analysis

Background: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition characterized by the presence of small-vessel thrombi enriched with platelets, leading to thrombocytopenia, thrombotic microangiopathy (TMA), and on occasion, resulting in end-organ damage. The standard therapeutic plasma exchange (TPE) approach, initiated after suspicion of TTP, is done with fresh frozen plasma (FFP). Yet, the use of cryoprecipitate-poor plasma (CPP) has been suggested as alternative in recent decades given its absence of von Willebrand factor, which would benefit the pathophysiology of TTP. However, its efficacy over FFP remains unclear. Therefore, we aimed to conduct a meta-analysis to compare the safety and efficacy of CPP versus FFP in patients with TTP. Methods: We systematically searched PubMed, Cochrane Central and Embase for clinical studies published up to June 2023, comparing CPP to FFP as replacement fluids in TPP or TMA patients. Outcomes assessed were overall mortality, relapse rate, response to treatment and number of TPE sessions. We pooled outcomes as odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). We also performed a subgroup analysis with randomized controlled trials (RCTs). Statistical analysis was performed with Review Manager version 5.4.1. Heterogeneity was assessed with I 2 statistics. The protocol was registered in PROSPERO (ID: CRD42023440665). Results: A total of eight articles met inclusion criteria, of which three were RCTs. The combined dataset involved 290 patients, of which 144 (49.7%) were in CPP group and 146 (50.3%) in the FFP group. CPP significantly reduced overall mortality compared to FFP (OR 0.27; 95% CI 0.13-0.59; p=0.001; I 2=0%; Figure 1A). However, our subgroup analysis of RCTs showed no significant difference in overall mortality between groups (OR 0.49; 95% CI 0.13-1.84; p=0.29; I 2=0%; Figure 1B). Additionally, there were no significant differences between groups regarding relapses (OR 0.81; 95% CI 0.37-1.77; p=0.60; I 2=0%; Figure 1C), response to treatment (OR 2.20; 95% CI 0.69-7.07; p=0.18; I 2=44%; Figure 1D) or number of TPE sessions (MD 1.63; 95% CI -2.83 - 6.08; p=0.47; I 2=55%; Figure 1E). Conclusion: Our meta-analysis shows that the safety and efficacy of CPP in TTP patients is at least similar to FFP in reducing mortality, relapse rate, and improving response to treatment. The reduced mortality with CPP found in the whole pool of studies, along with the trend towards reduced mortality found in the RCT-only analysis indicates the potential benefit of CPP over FFP. However, larger population-based randomized trials should contribute to narrow confidence intervals and decrease bias of observational studies, providing clearer conclusions for treatment efficacy in the future.

Impact on all-cause mortality of a case prediction and prevention intervention designed to reduce secondary care utilisation: findings from a randomised controlled trial

BackgroundHealth coaching services could help to reduce emergency healthcare utilisation for patients targeted proactively by a clinical prediction model (CPM) predicting patient likelihood of future hospitalisations. Such interventions are designed...

Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis.

Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots. We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively. Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy. Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.

Management of Adult Unruptured Brain Arteriovenous Malformations: An Updated Network Meta-Analysis.

The management of unruptured brain arteriovenous malformations (ubAVMs) is a complex challenge to neurovascular practitioners. This meta-analysis aimed to identify the optimal management of ubAVMs comparing conservative management, embolization, radiosurgery, microsurgical resection, and multimodality. The search strategy was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Ovid Medline, Embase, Web of Science, and Cochrane Library databases to identify relevant papers. Using R version 4.1.1., a frequentist network meta-analysis was conducted to compare different management modalities for the ubAVMs. Overall, the conservative group had the lowest risk of rupture (P-score=0.77), and the lowest rate of complications was found in the conservative group (P-score=1). Among different interventions, the multimodality group had the highest rupture risk (P-score=0.34), the lowest overall complications (P-score=0.75), the best functional improvement (P-score=0.65), and the lowest overall mortality (P-score=0.8). However, multimodality treatment showed a significantly higher risk of rupture (odds ratio [OR]=2.13; 95% confidence interval [95% CI]=1.18-3.86) and overall complication rate (OR=5.56; 95% CI=3.37-9.15) compared to conservative management; nevertheless, there were no significant differences in overall mortality or functional independence when considered independently. Conservative management is associated with the lowest rupture risk and complication rate overall. A multimodal approach is the best option when considering mortality rates and functional improvement in the context of existing morbidity/symptoms. Microsurgery, embolization, and radiosurgery alone are similar to the natural history in terms of functional improvement and mortality, but have higher complication rates.

P54: Early mortality associated with combination Impella 5.5 and extracorporeal membrane oxygenation support as bridge to cardiac replacement therapy

Background: End stage heart failure is treated with durable left ventricular assist device (LVAD) or orthotopic heart transplant (OHT). Patients with severe ventricular dysfunction and/or cardiogenic shock may require temporary mechanical circulatory support (tMCS) while awaiting cardiac replacement therapy. Extracorporeal membrane oxygenation (ECMO) and the Impella 5.5 (Abiomed; Danvers, MA) are well-studied bridging therapies. However, investigations of concomitant ECMO and Impella 5.5 (ECpella 5.5) therapy are lacking. The aim of this study is to compare mortality at 30-days and at most recent follow-up across four groups with different tMCS bridging strategies. Methods: This is a retrospective study evaluating all patients who were bridged to durable LVAD or OHT between December 31, 2018 to January 31, 2023 at our institution. Patients were separated into the following groups: Group 1 (solo ECMO), Group 2 (solo Impella 5.5), Group 3 (ECMO followed by Impella 5.5), and Group 4 (Impella 5.5 followed by ECMO). Patient demographics and early (30-day) mortality were collected from chart review (table 1). Group comparisons for continuous variables were performed with analysis of variance (ANOVA), and chi-square test of independence and Fisher’s exact tests were used for outcome data comparisons between groups. Results: This study included 61 patients bridged to LVAD or OHT with ECMO and/or Impella 5.5. Mean (std) age was 49.4 (14.3) years and mean (std) time on tMCS was 10.5 (8.4) days. 49% of our cohort required solo ECMO (Group 1, n = 30), 25% required solo Impella 5.5 (Group 2, n = 15), 11% required Impella 5.5 following ECMO (Group 3, n = 7), and 15% required escalation to ECMO from Impella 5.5 (Group 4, n = 9). Mortality at 30-days for Group 1 was 16.7%. No patients died in the 30-day postoperative period in Groups 2-4. Mortality at most-recent follow-up was 33.3%, 6.7%, 28.6%, and 0% for Groups 1-4, respectively. ANOVA revealed significant between-group differences for days on tMCS (p < 0.01). Chi-square test of independence revealed no significant difference in overall mortality across treatment groups (p = 0.07). Further partitioning with pairwise Fisher’s exact tests between treatment groups revealed no significant differences in mortality at most recent follow-up. Conclusions: Limited data exists comparing mortality between different combinations of tMCS as bridge to cardiac replacement therapy, and even less is known about mortality associated with order of therapy initiation. This data demonstrates comparable mortality between solo ECMO, solo Impella 5.5, ECMO followed by Impella 5.5, and Impella 5.5 escalated to ECMO therapies. Large, randomized controlled trials are required to fully evaluate the impact of order of tMCS in bridging to cardiac replacement therapy. Table 1. - Patient demographics and outcomes ECMO (n = 30) Impella 5.5 (n = 15) ECMO + Impella 5.5 (n = 7) Impella 5.5 + ECMO (n = 9) Age, years 45.7 ± 17.3 55.1 ± 8.1 51.6 ± 11.7 51.0 ± 11.0 Female 20.0% 0.0% 14.3% 0.0% BMI 28.0 ± 6.2 26.5 ± 4.7 24.9 ± 4.0 29.8 ± 5.3 Time on MCS, days 9.0 ± 6.6 17.1 ± 11.6 6.7 ± 3.1 7.1 ± 3.1 Bridged to LVAD 50.0% 26.7% 85.7% 0.0% Bridged to OHT 50.0% 73.3% 14.3% 100.0% 30-day mortality 16.7% 0.0% 0.0% 0.0%

Enteral glutamine supplements for patients with severe burns: A systematic review and meta-analysis

PurposeOur previous study in 2009 concluded that glutamine may shorten the length of hospital stay (LOS) in patients with severe burns. Recent large-scale studies have suggested a decline in the effectiveness of glutamine in treating patients with severe burns over the last decade. Therefore, we conducted this systematic review and meta-analysis to update the status of glutamine uses in patients with severe burns. MethodsWe retrieved related literature prior to December 2022 from the PubMed, Web of Science, Cochrane Library, Embase, SinoMed, Wanfang, and CNKI databases. Terms such as glutamine, enteral and burn were linked for searching. Adults patients with severe burns were included and non-randomized controlled trials were excluded. Data from studies that compared enteral glutamine for severe burns with a control group were extracted. The primary outcomes of mortality and infectious morbidities were pooled and analyzed. The modified Jadad scale and Cochrane collaboration's tool were used to assess the risk of bias in RCTs, and the Review Manager 5.4 was used to pool and analyze the data. ResultsSix randomized controlled trials involving 1398 patients were included in the analysis. There were no significant differences in overall mortality (risk ratio (RR) = 0.37; 95% confidence interval (CI): 0.06 − 2.37; p = 0.300) or infectious morbidities (RR = 0.73; 95% CI: 0.41 − 1.31; p = 0.290). The incidence of multiple organ dysfunction syndrome was similar between the 2 groups (RR = 0.27; 95% CI: 0.03 − 2.24; p = 0.220). The LOS (mean difference (MD) = −8.97; 95% CI: −15.22 to −2.71; p = 0.005) and LOS/total burn surface area (MD = −0.27; 95% CI: −0.54 to 0.00; p = 0.050) decreased in the enteral glutamine group. The incidence of wound infection was significantly reduced (RR = 0.42; 95% CI: 0.16 − 1.06; p = 0.070). ConclusionCompared to the control group, enteral glutamine administration may not improve the mortality, although it may be associated with a shorter LOS, a lower LOS/total burn surface area ratio, and may reduce the risk of wound infection in patients with severe burns.

Role of rifaximin in the management of alcohol-associated hepatitis: A systematic review and meta-analysis.

Alcohol-associated hepatitis (AAH) is an acute, inflammatory liver disease with severe short-term and long-term morbidity and mortality. AAH can lead to severe complications including hepatic failure, gastrointestinal bleeding, sepsis, and the development or decompensation of cirrhosis. Rifaximin is an antibiotic that reduces bacterial overgrowth and gut translocation, and it may have a role in decreasing systemic inflammation and infection in patients with AAH. Therefore, we conducted a systematic review and meta-analysis to evaluate the role of rifaximin in the management of AAH. A comprehensive search strategy was used to identify studies that met our inclusion criteria in Embase, MEDLINE (PubMed), Cochrane Library, Web of Science Core Collection, and Google Scholar. Outcomes of interest included rates of infection, 90-day mortality, and overall mortality between the rifaximin versus non-rifaximin group. Open Meta Analyst software was used to compute the results. Three studies with a total of 162 patients were included in the final meta-analysis. Of the three studies, two were randomized control trials (RCTs), and one was a case-control study. There was a significantly lower rate of infection in the rifaximin group versus the non-rifaximin group (RR: 0.331, 95% CI: 0.159-0.689, I2 =0%, P=0.003). There was no significant difference in 90-day mortality in the rifaximin versus non-rifaximin group (RR: 0.743, 95% CI: 0.298-1.850, I2 =24%, P=0.523), nor was there a significant difference in overall mortality (RR: 0.624, 95% 95% CI: 0.299-1.3, I2 =7.1%, P=0.208). The use of rifaximin in AAH is associated with a lower rate of infection rate than the non-rifaximin group. Additional research is needed to determine whether this effect is more pronounced in patients concurrently being treated with prednisolone. Differences in 90-day or overall mortality did not reach statistical significance. Further studies, particularly large randomized controlled trials, are needed to establish the role of rifaximin in AAH, especially as an adjunct therapy with prednisolone.

Efficacy of a multidose acyclovir protocol against cyprinid herpesvirus 3 infection in koi (Cyprinus carpio).

To evaluate the effect of a multidose acyclovir protocol on koi herpesvirus (KHV) viral load and mortality in a cohabitation challenge. 180 koi fish. Forty fish (shedders) were immersed in a 0.5 KHV plaque-forming units/mL static bath for 8 hours. Mock shedders were treated similarly but exposed to cell culture media. KHV shedders were then transferred into 8 tanks (5 shedders per tank) containing 10 naïve fish (cohabitants) each. Fish in the acyclovir group (AT) received a 10 mg/kg acyclovir intracoelomic injection 1, 3, and 6 days after the first confirmed KHV mortality. Positive controls (PC) were treated similarly but received sterile saline injections. Negative controls (NC) were exposed to mock shedders. Morbidity and mortality were evaluated daily for 50 days post-challenge. Quantitative PCR was used to determine viral load in the gill biopsies of shedders and cohabitants collected at days 19 (T1), 22 (T2), 25 (T3), 34 (T4), and 50 (T5) post-challenge. Survival curves analyzed by the Gehan-Breslow-Wilcoxon method revealed a delayed onset of mortalities and a significantly lower KHV load at T2 and T3 detected in AT cohabitant fish (P = .042) compared to PC group. However, there were no significant differences in overall mortality or viral loads at T5. The acyclovir protocol used in this study did not control viral infection or mortality at the end of the 50-day trial. Shorter intervals between injections could improve outcomes, but the additional stress inflicted by handling should be considered. Exploring other therapeutic alternatives and doses is warranted.

Therapeutic plasma exchange: A potential therapeutic modality for critically ill adults with severe acute respiratory syndrome coronavirus 2 infection.

BackgroundSevere acute respiratory syndrome coronavirus 2 infection can be severe and fatal due to cytokine storm. Therapeutic plasma exchange (TPE) potentially mitigates the harmful effects of such cytokines. We investigated the use of TPE, as rescue therapy, in patients with severe Coronavirus disease 2019 (COVID‐19) infection.Study Design and MethodsA retrospective analysis on COVID‐19 patients admitted to the intensive care unit and treated with TPE from April 17, 2020 to July 2, 2020. This group was compared with COVID‐19 patients who received standard therapy without TPE. The following outcomes were analyzed: changes in laboratory parameters, length of hospital stay (LOS), days on mechanical ventilation, mortality at days 14 and overall mortality.ResultsA total of 95 patients were included, among whom 47% (n = 45) received TPE. Patients who received TPE had reductions in C‐reactive protein (P = .002), ferritin (P < .001) and interleukin‐6 (P = .013). After employing entropy‐balancing matching method, those on TPE were also more likely to discontinue inotropes (72% vs 21%; P < .001). However, they were more likely to be associated with longer LOS (23 vs 14 days; P = .002) and longer days on ventilatory support (14 vs 8 days; P < .001). Despite marginal mortality benefit at 14‐days (7.9% vs 24%; P = .071), there was no significant differences in overall mortality (21% vs 31%; P = .315) between the groups.ConclusionsTPE was effective in reducing inflammatory markers in patients with severe COVID‐19 infection, however, further research is warranted.

Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis.

The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81–0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79–0.95), and AKI (RR 0.85, 95% CI 0.77–0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90–1.03), need for RRT (RR 0.91, 95% CI 0.76–1.08), and ICU LOS (MD −0.25 days, 95% CI −3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82–1.02), AKI (RR 0.71, 95% CI 0.47–1.06), and need for RRT (RR 0.71, 95% CI 0.36–1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.

Outcomes In Heartmate 3 (HM3) Vs Heartware (HVAD) Patients: A Single Center Experience

Background HeartMate 3 (HM3) and Heartware (HVAD) are the contemporary left ventricular assist device (LVAD) options with limited comparative data. Methods We retrospectively included adult patients (>18 years) undergoing LVAD implantation at our center (Aug 2016 to Aug 2019). Overall baseline characteristics and major clinical outcomes were computed and compared using MOMENTUM 3 and ENDURANCE trial definitions. Subgroup analysis after propensity matching baseline characteristics and INTERMACS profile was also performed. Results A total of 93 patients were included, with six patients excluded as they died during the index implantation. Out of the remaining 87 patients, 33 (37.9%) had HM3 and 54 (62.1%) had HVAD. No significant difference in baseline characteristics were noted (Table 1A), except more patients with higher INTERMACS profile received HVAD (53.7% vs 27.3%; p=0.01). Device thrombosis and TIA/stroke were higher among HVAD patients (0 vs 18.5%; p = 0.009; 0 vs 11.1%: p= .04, respectively) (Table1B). No significant differences in overall mortality, GI bleeding, or driveline infections were noted. Propensity-matched cohort showed a higher rate of device thrombosis and TIA/stroke among HVAD (0 vs 13%: p = 0.07 and 0 vs 13%: p= 0.07, respectively) but was statistically non-significant (Table 1C). Cconclusion HVAD patients had higher thromboembolic complications, but no significant difference in other outcomes. Larger multicenter studies are needed to confirm these findings. HeartMate 3 (HM3) and Heartware (HVAD) are the contemporary left ventricular assist device (LVAD) options with limited comparative data. We retrospectively included adult patients (>18 years) undergoing LVAD implantation at our center (Aug 2016 to Aug 2019). Overall baseline characteristics and major clinical outcomes were computed and compared using MOMENTUM 3 and ENDURANCE trial definitions. Subgroup analysis after propensity matching baseline characteristics and INTERMACS profile was also performed. A total of 93 patients were included, with six patients excluded as they died during the index implantation. Out of the remaining 87 patients, 33 (37.9%) had HM3 and 54 (62.1%) had HVAD. No significant difference in baseline characteristics were noted (Table 1A), except more patients with higher INTERMACS profile received HVAD (53.7% vs 27.3%; p=0.01). Device thrombosis and TIA/stroke were higher among HVAD patients (0 vs 18.5%; p = 0.009; 0 vs 11.1%: p= .04, respectively) (Table1B). No significant differences in overall mortality, GI bleeding, or driveline infections were noted. Propensity-matched cohort showed a higher rate of device thrombosis and TIA/stroke among HVAD (0 vs 13%: p = 0.07 and 0 vs 13%: p= 0.07, respectively) but was statistically non-significant (Table 1C). HVAD patients had higher thromboembolic complications, but no significant difference in other outcomes. Larger multicenter studies are needed to confirm these findings.

Homograft Versus Valves and Valved Conduits for Extensive Aortic Valve Endocarditis with Aortic Root Involvement/Destruction: A Systematic Review and Meta-Analysis.

Aortic valve infective endocarditis is a life-threatening condition. Patients frequently present profoundly unwell and extensive surgery may be required to correct the underlying anatomical deficits and control sepsis. Periannular involvement occurs in more than 10% of patients with aortic valve endocarditis. Complex aortic valve endocarditis has a mortality rate of 10 to 40%. Longstanding surgical dogma suggests homografts represent the optimal replacement option in complex aortic valve endocarditis; however, there is a paucity of evidence and lack of consensus on the optimal replacement choice. A systematic review and meta-analysis was performed utilizing EMBASE, PubMed, and the Cochrane databases to review articles describing homografts versus aortic valve replacement and/or valved conduit graft implantation for complex aortic valve endocarditis. The outcomes of interest were mortality, reinfection, and reoperation. Eleven studies were included in this meta-analysis, contributing 810 episodes of complex aortic valve endocarditis. All included reports were cohort studies. There was no statistically significant difference in overall mortality (risk ratio [RR] 0.99; 95% confidence interval [CI], 0.61–1.59; p = 0.95), reinfection (RR 0.89; 95% CI, 0.45–1.78; p = 0.74), or reoperation (RR 0.91; 95% CI, 0.38–2.14; p = 0.87) between the homograft and valve replacement/valved conduit graft groups. Overall, there was no difference in mortality, reinfection, or reoperation rates between homografts and other valve or valved conduits in management of complex aortic endocarditis. However, there is a paucity of high-quality evidence in the area, and comparison of valve types warrants further investigation.