Significant Difference In Mortality Research Articles

Sodium bicarbonate treatment and clinical outcomes in chronic kidney disease with metabolic acidosis: a meta-analysis.

In patients with chronic kidney disease (CKD), impaired kidney acid excretion leads to the onset of metabolic acidosis (MA). However, the evidence is not yet conclusive regarding the effects of sodium bicarbonate in treating CKD with MA. Databases with PubMed, Embase, and the Cochrane Library were used to search for randomized controlled trials from the inception until November 11, 2023 to identify randomized controlled trials investigating the effect of sodium bicarbonate in participants with CKD and MA. The primary outcome was the change in estimated glomerular filtration rate (eGFR). Secondary outcomes included hospitalization rates, change in systolic blood pressure (SBP), all-cause mortality, and mid-arm muscle circumference (MAMC). A random-effects model was applied for analysis, and subgroup, sensitivity analyses were also performed. Fourteen RCTs comprising 2,037 patients demonstrated that sodium bicarbonate supplementation significantly improved eGFR (standardized mean difference [SMD]: 0.33, 95% CI: 0.03 to 0.63, P = 0.03). The group receiving sodium bicarbonate had a lower hospitalization rate (odds ratio: 0.37, 95% CI: 0.25 to 0.55, P < 0.001). Higher MAMC was observed with sodium bicarbonate treatment compared with those without (SMD:0.23, 95% CI: 0.08 to 0.38, P = 0.003, I2 < 0.001). However, higher risk of elevated SBP was found with sodium bicarbonate treatment (SMD:0.10, 95% CI: 0.01 to 0.20, P = 0.03). No significant difference in all-cause mortality was noted. In patients with CKD and MA, sodium bicarbonate supplementation may provide potential benefits in preventing the deterioration of kidney function and increasing muscle mass. However, treatment may be associated with higher blood pressure. Due to the risk of bias stemming from the absence of double-blinded designs and inconsistencies in control group definitions across the studies, further research is crucial to verify these findings.

Evolution of Pulmonary Embolism Response Teams in the United States: A Review of the Literature

Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, with varying presentations and management challenges. Traditional treatment approaches often differ, particularly for submassive/intermediate-risk PEs, because of the lack of clear guidelines and comparative data on treatment efficacy. The introduction of pulmonary embolism response teams (PERTs) aims to standardize and improve outcomes in acute PE management through multidisciplinary collaboration. This review examines the conception, evolution, and operational mechanisms of PERTs while providing a critical analysis of their implementation and efficacy using retrospective trials and recent randomized trials. The study also explores the integration of advanced therapeutic devices and treatment protocols facilitated by PERTs. PERT programs have significantly influenced the management of both massive and submassive PEs, with notable improvements in clinical outcomes such as decreased mortality and reduced length of hospital stay. The utilization of advanced therapies, including catheter-directed thrombolysis and mechanical thrombectomy, has increased under PERT guidance. Evidence from various studies, including those from the National PERT Consortium, underscores the benefits of these multidisciplinary teams in managing complex PE cases, despite some studies showing no significant difference in mortality. PERT programs have demonstrated potentials to reduce morbidity and mortality, streamlining the use of healthcare resources and fostering a model of sustainable practice across medical centers. PERT program implementation appears to have improved PE treatment protocols and innovated advanced therapy options, which will be further refined as they are employed in clinical practice. The continued expansion of the capabilities of PERTs and the forthcoming results from ongoing randomized trials are expected to further define and optimize management protocols for acute PEs.

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

ObjectiveTo compare the effectiveness and safety of Celsior® crystalloid solution to St Thomas® solution as cardioplegia in pediatric arterial switch surgery.MethodsA 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.ResultsBaseline 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 &amp;lt; 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 &amp;lt; 0.001). There was no significant difference in 30-day mortality between the two groups (2.9% vs. 2.6%; p = 0.147).ConclusionThe 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. Clinical Registration NumberClinicalTrials.gov, ID: NCT04616222.

Calcium supplementation during trauma resuscitation: a propensity score-matched analysis from the TraumaRegister DGU®

BackgroundIn major trauma patients, hypocalcemia is associated with increased mortality. Despite the absence of strong evidence on causality, early calcium supplementation has been recommended. This study investigates whether calcium supplementation during trauma resuscitation provides a survival benefit.MethodsWe conducted a retrospective analysis using data from the TraumaRegister DGU® (2015–2019), applying propensity score matching to balance demographics, injury severity, and management between major trauma patients with and without calcium supplementation. 6 h mortality, 24 h mortality, and in-hospital mortality were considered as primary outcome parameters.ResultsWithin a cohort of 28,323 directly admitted adult major trauma patients at a European trauma center, 1593 (5.6%) received calcium supplementation. Using multivariable logistic regression to generate propensity scores, two comparable groups of 1447 patients could be matched. No significant difference in early mortality (6 h and 24 h) was observed, while in-hospital mortality appeared higher in those with calcium supplementation (28.3% vs. 24.5%, P = 0.020), although this was not significant when adjusted for predicted mortality (P = 0.244).ConclusionIn this matched cohort, no evidence was found for or against a survival benefit from calcium supplementation during trauma resuscitation. Further research should focus on understanding the dynamics and kinetics of ionized calcium levels in major trauma patients and identify if specific conditions or subgroups could benefit from calcium supplementation.

Early creatinine changes after aortic valve replacement and late survival, heart failure and chronic kidney disease in a national registry

The impact of small increases in serum-creatinine after surgical aortic valve replacement (SAVR) that fail to meet the acute kidney injury stage 1 criteria is unknown. The aim was to investigate prognosis after primary SAVR in patients with small increases in postoperative serum-creatinine. In this observational cohort study, we included all adult patients who underwent primary SAVR in Sweden 2009-2022. The main outcome was all-cause mortality. Secondary outcomes were chronic kidney disease and heart failure. Regression standardization addressed confounding. In 16,766 patients, 4,074 (24.2%) had no change in postoperative serum-creatinine, 5,764 (34.3%) had a small increase in postoperative serum-creatinine (0.06 mg/dL≤Δserum-creatinine<0.3 mg/dL), and 2,753 (16.4%) fulfilled the KDIGO acute kidney injury stage 1 criteria. The mean age was 67 years and 31% were female. No significant difference in long-term all-cause mortality was observed in the no-change group at 13 years compared with the small-increase group (absolute survival difference: 2.3% (95%CI: 0-4.6)). A stepwise increase in the risk of 30-day mortality was observed with increasing change in serum-creatinine. At 13 years of follow-up, there was a significant difference in the risk of chronic kidney disease (absolute difference: 2.8% (95%CI: 1.0-4.5)) and heart failure (absolute difference: 3.5% (95%CI: 1.3-5.7)) between the no-change and small-increase groups. A small increase in postoperative serum-creatinine after SAVR was associated with increased risk of adverse outcomes. The acute kidney injury definition may benefit from including more reliable and specific biomarkers together with small creatinine increases to detect kidney injury.

Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support

IntroductionPatients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients.Materials and methodsA retrospective single-center study (2013–2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation.ResultsA total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7–17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07–50.01], p = 0.042).ConclusionUGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

Clinical efficacy of different therapeutic strategies in patients with spontaneous rupture of the esophagus: a multicenter retrospective cohort study.

The therapeutic strategy for patients with spontaneous rupture of the esophagus includes surgical repair, endoscopic therapy, supportive care, and others. However, no evidence exists to direct clinical decision-making regarding the choice of operative and nonoperative management. The aim of this study was to determine the clinical efficacy of different therapeutic strategies in both general and stratified patients. This study retrospectively analyzed a consecutive cohort of 101 patients at nine tertiary referral hospital centers in China. Patients were divided into operative and nonoperative groups based on the initial treatment. Short-term outcomes, including 90-day mortality, length of hospital stay, and postoperative leakage were compared. Subgroup analysis was performed based on treatment timing and Pittsburgh perforation severity score (PSS). Of 101 patients, 60 (58.4%) underwent operative management. A significant difference of 90-day mortality between operative and nonoperative groups was observed (15.0% vs. 34.1%, P=0.031). Operative management tend to yield similar therapeutic benefits in timely (OR, 0.250; 95% CI, 0.05-1.14, P=0.073) and delayed (OR, 0.42; 95% CI, 0.12-1.47, P=0.175) treatment groups. Based on PSS stratification, operative management significantly decreased the risk of 90-day mortality (OR, 0.211; 95% CI, 0.064-0.701; P=0.011) for patients in low- and moderate-risk groups but may be detrimental for patients in high-risk group (OR, 1.333; 95% CI, 0.233-7.626; P=0.746). Operative management might be superior to nonoperative management for low- and moderate-risk patients with spontaneous rupture of the esophagus. However, for patients at high risks, operative management might not provide additional benefits compared with nonoperative management. Further research involving larger sample sizes is required for accurate patient stratification and conclusive evidence-based guideline.

Surgical treatment of atrial fibrillation in elderly patients undergoing high risk cardiac surgery

BackgroundEvaluating outcomes of concurrent Cox-Maze procedures in elderly patients undergoing high-risk cardiac surgery.MehodsWe retrospectively identified patients aged over 70 years with Atrial Fibrillation (AF) from 2011 to 2017 who had two or more other cardiac procedures. They were subdivided into two groups: 1. Cox-Maze IV AF ablation. 2. No-Surgical AF treatment. A propensity match score was used to generate a homogeneous cohort and to eliminate confounding variables. Heart rhythm was assessed from Holter reports or 12-lead ECG. Follow-up data was collected through telephone consultations and medical records.ResultsThere were 239 patients. Median follow up was 61 months. 70 patients had Cox-Maze IV procedures (29.3%). Demographic, intra- and post-operative outcomes were similar between groups although duration of pre-operative AF was shorter in Cox-Maze group (p = 0.001). There was no significant 30-day mortality difference in propensity matched cohorts (n = 84. P = 0.078). Sinus rhythm at annual and latest follow-up was 84.9% and 80.0% respectively in Maze group – 160 patients (66.9%) were alive at long-term follow-up with good survival outcomes in Cox Maze group. There was a high proportion of patients in NYHA 1 status in Cox-Maze group. No differences observed in freedom from stroke (p = 0.80) or permanent pacemaker (p = 0.33) between the groups.ConclusionsSurgical ablation is beneficial in elderly patients undergoing high-risk surgery - promoting excellent long-term freedom from AF and symptomatic / prognostic benefits, without added risk. Therefore, surgical risk should not be reason to deny benefits of concomitant AF-ablation.Clinical trial registrationNot required.

Does total hip arthroplasty in elderly patients with femoral neck fractures reduce complications? A Japanese DPC study

BackgroundThe global increase in femoral neck fractures due to aging and osteoporosis is a major clinical challenge. The debate on the optimal surgical intervention for femoral neck fractures remains unresolved. This large-scale study explores femoral neck fractures among the elderly, focusing on the comparative outcomes of Total Hip Arthroplasty (THA) versus Bipolar Hemiarthroplasty (BHA) in Japanese patients. MethodsUsing the Japanese National Administrative Diagnosis Procedure Combination (DPC) database, we studied cases of femoral neck fracture from April 2016 to March 2023, and after propensity score matching by age, sex, and comorbidities, we examined the association between THA, complications, and clinical outcomes, and the usefulness of THA for elderly patients with femoral neck fracture. ResultsOne-to-one propensity score matching identified 7741 pairs of THA and BHA cases. There was no difference in length of stay between the THA and BHA groups. Significantly more blood transfusions were required in the THA group. There was no significant difference in mortality between the THA and BHA groups, but there was a reduced risk of pneumonia in the THA group, with a ratio of 0.547 (95% CI: 0.418–0.715). On the other hand, the THA group had a higher risk of pulmonary embolism, with a ratio of 1.607 (95% CI: 1.379–1.874). The THA group shows improved discharge rates directly home from the facility where the operation was performed, with a ratio of 1.798 (95% CI: 1.675–1.929). ConclusionThe findings of this research indicate that THA is more effective than BHA in enabling elderly Japanese patients with femoral neck fractures to be discharged directly home and in preventing pneumonia, despite concerns about pulmonary embolism. These findings suggest that THA may improve functional prognosis in elderly patients with femoral neck fractures, although there is a trade-off with an increased risk of pulmonary embolism.

Comparative study of short-and long-term results in patients with perihilar cholangiocarcinoma undergoing surgical resection: does the extent and side of resection really affect outcome?

The surgical management of perihilar carcinoma (pCCA) is still subject of ongoing debate. To provide more clarity, this study was conducted to evaluate outcomes related to the side and extent of heatectomy in patients with pCAA. A total of 32 patients with curative resection for pCCA were identified from our prospective database. Short-and long-term clinical outcome data and histopathological results were compared between right-sided (R-H) and left-sided (L-H) hepatectomy. Nine patients (28.13%) underwent left-sided hepatectomy while a right-sided hepatectomy was accomplished in 23 patients (71.87%). In the R-H group hepatic conditioning of the future liver remnant (FLR) prior to extended resection was necessary in 13 cases (56.52%), and simultaneous pancreaticoduodenectomy was performed in 5 patients (21.74%). The arterial and portal venous reconstruction rates were 17.39% and 11.11% (P=1.00), and 60.87% and 33.33% (P=0.243) in the R-H and L-H groups, respectively. No statistically significant differences in short-term morbidity and mortality between both groups were observed. The rate of R0 resections was comparable (R-H: 78.26% versus L-H: 66.67%; P=0.654) resulting in similar long-term overall and disease-free survival rates after right-and left hepatectomy. In patients with pCCA, both right- and left-sided resections appear to be safe and feasible options with similar postoperative morbidity and oncologic outcomes. Consecutively, the ideal surgical approach should be patient-tailored based on anatomical considerations and the functional future liver capacity.

Safety of Gastric Bypass with Same-Day Discharge: a Propensity Score-Matched Analysis of the Dutch Audit for Treatment of Obesity

BackgroundBariatric surgery with same-day discharge (SDD) is becoming increasingly common. Nevertheless, there is limited data available comparing gastric bypass patients with SDD to those with overnight hospitalization. ObjectiveThe aim of this study was to investigate the short-term outcomes of gastric bypass with SDD compared to overnight hospitalization in The Netherlands. SettingRetrospective database study with the use of the Dutch national registry. MethodsPatients who underwent gastric bypass surgery in 2022 were included, and propensity score matching was performed to compare SDD with patients discharged on postoperative days (POD) 1-4. The primary outcome was the occurrence of severe complications within 30 days postoperative. ResultsA total of 775 SDD patients were matched with 1550 patients discharged on POD 1-4. The occurrence of severe complications was 0.9% in both groups (p=1.000), and there were no significant differences in reoperations or mortality. A significant difference was observed in the readmission rate, with 3.9% in the SDD group compared to 1.6% in the other group (p=0.001). A proportionally small, yet statistically significant difference favored the control group regarding anastomotic leakages (0.6% vs 0%, p=0.004) and unspecified surgical complications (1.4% vs 0.5%, p=0.028). ConclusionGastric bypass with SDD is safe, with no increased risk of short-term severe complications, reoperations, or mortality. However, SDD is associated with a higher 30-day readmission rate compared to patients who stay overnight in the hospital after surgery.

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17 269 patients

Background: Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors’ meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR. Materials and methods: Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager. Results: Forty-eight studies were included having 17 269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50–1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95% CI:0.36–1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81–11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:−0.58; 95% CI:−1.08 to −0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:−0.67; 95% CI:−1.42 to 0.08; I2=84%; P=0.08) when compared to FS. Conclusions: While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

Meta-analysis: Over-the-scope clips in patients at high risk of re-bleeding following upper gastrointestinal tract bleeding.

Acute non-variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re-bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over-the-scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain. To confirm the role of OTSC in patients with UGIB at high risk of re-bleeding. We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non-variceal UGIB with high re-bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08-1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re-bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30-0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30-day mortality, or length of hospital or ICU stay. Moderate certainty evidence supports OTSC as a superior initial treatment for acute non-variceal UGIB with high re-bleeding risk. Further large-scale studies are needed to confirm OTSCs' role by exploring other prognostic outcomes and assessing cost-effectiveness and potential complications.

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease without pulmonary hypertension.

Balloon pulmonary angioplasty (BPA) is beneficial for patients with chronic thromboembolic pulmonary disease (CTEPD) with pulmonary hypertension (PH). However, the clinical benefit of BPA for the patients with CTEPD without PH remains unknown. In this study, we aimed to evaluate the efficacy, safety, and long-term outcomes of BPA in patients with CTEPD without PH. We retrospectively analyzed the data from 84 CTEPD patients with mean pulmonary artery pressure (mPAP) < 25 mmHg and 39 CTEPD patients with mPAP ≤ 20 mmHg (without PH). Among the 39 patients with CTEPD without PH, 14 underwent BPA (BPA-treated group), and the remaining 25 received no treatment (untreated group). In the patients with CTEPD without PH, BPA led to improvements in symptoms, pulmonary vascular resistance (3.6 ± 1.6 to 2.6 ± 1.1 Wood units, p < 0.001), peak oxygen consumption (16.1 ± 4.0 to 18.8 ± 4.3 mL/kg/min, p = 0.033), minute ventilation versus carbon dioxide production slope (41.4 ± 12.2 to 35.1 ± 6.7, p = 0.026), and mPAP/cardiac output slope (7.0 ± 2.6 to 4.4 ± 2.0 mmHg/L/min, p = 0.004) and facilitated the discontinuation of home oxygenation therapy, with no serious complications. Kaplan-Meier analysis showed no significant difference in all-cause mortality between the untreated and BPA-treated groups. BPA may be a safe treatment option for the patients with CTEPD without PH that can alleviate symptoms, improve exercise capacity, and facilitate weaning from home oxygen therapy. Further prospective randomized trials are needed to confirm these findings.

Impact of intensive prone position therapy on outcomes in intubated patients with ARDS related to COVID-19

BackgroundPrevious retrospective research has shown that maintaining prone positioning (PP) for an average of 40 h is associated with an increase of survival rates in intubated patients with COVID-19-related acute respiratory distress syndrome (ARDS). This study aims to determine whether a cumulative PP duration of more than 32 h during the first 2 days of intensive care unit (ICU) admission is associated with increased survival compared to a cumulative PP duration of 32 h or less.MethodsThis study is an ancillary analysis from a previous large international observational study involving intubated patients placed in PP in the first 48 h of ICU admission in 149 ICUs across France, Belgium and Switzerland. Given that PP is recommended for a 16-h daily duration, intensive PP was defined as a cumulated duration of more than 32 h during the first 48 h, whereas standard PP was defined as a duration equal to or less than 32 h. Patients were followed-up for 90 days. The primary outcome was mortality at day 60. An Inverse Probability Censoring Weighting (IPCW) Cox model including a target emulation trial method was used to analyze the data.ResultsOut of 2137 intubated patients, 753 were placed in PP during the first 48 h of ICU admission. The intensive PP group (n = 79) had a median PP duration of 36 h, while standard PP group (n = 674) had a median of 16 h during the first 48 h. Sixty-day mortality rate in the intensive PP group was 39.2% compared to 38.7% in the standard PP group (p = 0.93). Twenty-eight-day and 90-day mortality as well as the ventilator-free days until day 28 were similar in both groups. After IPCW, there was no significant difference in mortality at day 60 between the two-study groups (HR 0.95 [0.52–1.74], p = 0.87 and HR 1.1 [0.77–1.57], p = 0.61 in complete case analysis or in multiple imputation analysis, respectively).ConclusionsThis secondary analysis of a large multicenter European cohort of intubated patients with ARDS due to COVID-19 found that intensive PP during the first 48 h did not provide a survival benefit compared to standard PP.

Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis

BackgroundDespite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic...

Early versus delayed enteral nutrition in ICU patients with sepsis: a propensity score-matched analysis based on the MIMIC-IV database.

Early enteral nutrition (EN) is recommended for sepsis management, but its optimal timing and clinical benefits remain uncertain. This study evaluates whether early EN improves outcomes compared to delayed EN in patients with sepsis. We analyzed data of septic patients from the MIMIC-IV 2.2 database, focusing on those in the Medical Intensive Care Unit (MICU) and Surgical Intensive Care Unit (SICU). Patients who initiated EN within 3 days were classified into the early EN group, while those who started EN between 3 and 7 days were classified into the delayed EN group. Propensity score matching was used to compare outcomes between the groups. Among 1,111 patients, 786 (70.7%) were in the early EN group and 325 (29.3%) were in the delayed EN group. Before propensity score matching, the early EN group demonstrated lower mortality (crude OR = 0.694; 95% CI: 0.514-0.936; p = 0.018) and shorter ICU stays (8.3 [5.2, 12.3] vs. 10.0 [7.5, 14.2] days; p < 0.001). After matching, no significant difference in mortality was observed. However, the early EN group had shorter ICU stays (8.3 [5.2, 12.4] vs. 10.1 [7.5, 14.2] days; p < 0.001) and a lower incidence of AKI stage 3 (49.3% vs. 55.5%; p = 0.030). Subgroup analysis revealed that early EN significantly reduced the 28-day mortality rate in sepsis patients with lactate levels ≤4 mmol/L, with an adjusted odds ratio (aOR) of 0.579 (95% CI: 0.361, 0.930; p = 0.024). Early enteral nutrition may not significantly reduce overall mortality in sepsis patients but may shorten ICU stays and decrease the incidence of AKI stage 3. Further research is needed to identify specific patient characteristics that benefit most from early EN.

Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis

BackgroundDifferent studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel...

The Effectiveness and Safety of Leadless Pacemakers: An Updated Meta-Analysis.

Leadless pacemakers (LPs) are promising alternatives to traditional transvenous pacemakers (TVPs), but their comparative effectiveness and safety in clinical outcomes remain uncertain. We systematically searched PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov for studies comparing LPs and TVPs. A restricted maximum likelihood random-effects model was used for all outcomes. Heterogeneity was assessed using I2 statistics. We performed a subgroup analysis with studies with multivariate-adjusted data. We included 21 studies involving 47,229 patients, of whom 12,199 (25.8%) underwent LP implantation. Compared with TVPs, LPs were associated with a significantly lower risk of overall complications (OR 0.61; 95% CI 0.45-0.81; p < 0.01), dislodgement (OR 0.34; 95% CI 0.20-0.56; p < 0.01), and pneumothorax (OR 0.27; 95% CI 0.16-0.46; p < 0.01). No significant difference in all-cause mortality was observed in the overall analysis (OR 1.43; 95% CI 0.65-3.15; p = 0.35) and in studies with multivariate-adjusted data (OR 1.34; 95% CI 0.65-2.78; p = 0.43). However, LPs were associated with a higher risk of pericardial effusion (OR 2.47; 95% CI 1.39-4.38; p < 0.01) and cardiac tamponade (OR 3.75; 95% CI 2.41-5.83; p < 0.01). LPs also demonstrated a lower pacing capture threshold (MD -0.19V; 95% CI [-0.23V]-[-0.16V]; p < 0.01), but no significant difference in impedance (MD 32.63 ohms; 95% CI [-22.50 ohms]-[87.76 ohms]; p = 0.25). These findings suggest that LPs were associated with lower overall complication rates and similar effectiveness to TVPs. However, randomized controlled trials are warranted to validate these results.

Effects of a pharmacist designed clinical decision support system on antimicrobial stewardship

Background Clinical decision support systems (CDSS) are computer applications, which can be applied to give guidance to practitioners in antimicrobial stewardship (AS) activities, however, further information is needed for their optimal use. Objectives To analyze the implementation of a CDSS program in a primary-care hospital, describing alerts, recommendations, and the effect on consumption and clinical outcomes. Methods In October 2020, a pharmacist-driven CDSS designed for AS was implemented in a second-level hospital. The program provides a list of alerts related to antimicrobial treatment and microbiology, which were automatized for revision by the AS professionals. To analyze the implementation of the CDSS, a pre-post intervention, retrospective study was designed. AS triggered alerts and recommendations (total number and rate of acceptance) were compiled. The effect of the CDSS was measured using antimicrobial consumption, duration of antimicrobial treatments, in-hospital mortality and length of stay (LOS) for patients admitted for infectious causes. Results The AS team revised a total of 7,543 alerts and 772 patients had at least one recommendation, with an acceptance rate of 79.3%. Antimicrobial consumption decreased from 691.1 to 656.8 daily defined doses (DDD)/1,000 beds-month (P = 0.04) and the duration of antimicrobial treatment from 3.6 to 3.3 days (P &lt;0.01). In-hospital mortality decreased from 6.6% to 6.2% (P=0.46) and mean LOS from 7.2 to 6.2 days (P&lt;0.01) Conclusion The implementation of a CDSS resulted in a significant reduction of antimicrobial DDD, duration of antimicrobial treatments and hospital LOS. There was no significant difference in mortality.