Tertiary Academic Hospital Research Articles

Canadian computed tomography head rule and New Orleans criteria in mild traumatic brain injury: Comparison at an urban tertiary care facility in Pakistan

Background: Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide, with road traffic accidents being the predominant cause in Pakistan. Computed tomography (CT) scans have become the cornerstone of investigation for all TBIs, but their widespread use raises concerns about cost-effectiveness, radiation exposure, and incidental findings. This study aimed to validate the applicability of the Canadian CT head rule (CCHR) and New Orleans Criteria (NOC) in the Pakistani population and compare their sensitivity and specificity. Methods: A cross-sectional study was conducted in a tertiary care academic hospital in Pakistan, including consecutive patients with acute, mild brain injury. The primary outcome was “clinically important brain injury,” while the secondary outcome was “need for neurosurgical intervention.” Univariate analysis using Chi square was performed for each variable to assess association with CT findings. Sensitivity, specificity, and accuracy were calculated to evaluate the performance of each decision rule. Results: Most of the patients in our study had a Glasgow Coma Scale (GCS) score of 15 (92.6%). Headache was the most common parameter overall (61.7%). Clinically important CT was detected in 68 (6.7%) patients. Only 1 of the NOC and 4 CCHR variables demonstrated statistically significant association with clinically significant CT. The CCHR was 64% sensitive for detecting clinically important CTs in trauma patients with GCS of 13–15, and the NOC was 86% sensitive, with respective specificities of 70% and 33%. For predicting the need for neurosurgical intervention, the sensitivities of CCHR and NOC were 61% and 85%, and specificity was 68% and 32%, respectively. Conclusion: We concluded that the CCHR was more specific and accurate, and it has the potential to have a greater influence on CT ordering rates than the NOC. Further studies are recommended to validate the tools for the Pakistani population.

A Prospective Evaluation of Health Literacy Levels of Pregnant Women in Antenatal Classes: Impact on Delivery Outcomes in Nulliparous and Multiparous Women.

Backgrounds/Objectives: Modern technology and educational activities, such as antenatal classes (ACs), increase patient informedness in medicine and improve collaboration between physicians and patients. The present study aimed to evaluate and compare the impact of maternal health literacy (HL) on delivery outcomes between nulliparous and multiparous women who attended antenatal classes. Methods: This prospective study recruited 281 pregnant women who regularly attended ACs, but only 188 who gave birth at our academic tertiary hospital were included in the final analysis. Socio-demographic characteristics, peripartum data (cervical dilatation at the time of admission to the hospital, duration of labor, and mode of delivery), and obstetric interventions (cesarean section (C/S) rate and rate of instrumental vaginal birth and episiotomy) were recorded, and the level of HL was assessed using the European Health Literacy Survey Questionnaire (HLS-EU-Q16). HL levels did not significantly affect peripartum and postpartum outcomes. Results: The study results showed that HL levels did not impact labor duration and newborn Apgar scores (p > 0.05). Patient education levels and employment status affected the peripartum duration of labor (p = 0.048 and p = 0.001, respectively). There were no differences in the HL total score and subscale scores (p > 0.05) between nulliparous and multiparous patients, and the rate of primary C/S was similar in both groups. Conclusions: HL levels did not impact delivery (peripartum) outcomes in pregnant women who attended antenatal classes. However, the primary C/S rate was similar between the nulliparous and multiparous groups, which may indicate that antenatal education services can correct the negative impact of low HL levels on the primary C/S rate.

Managing Angiography Unit Failure in Interventional Radiology: Lessons in Crisis Management and Considerations in Prevention.

Functional and efficient medical equipment is at the core of modern healthcare delivery, particularly in medical imaging. Growing healthcare costs and constrained budgets can delay equipment renewal. Aging equipment risks malfunction, potentially causing injury to patients and staff, and downtimes delaying patient care and impacting departmental revenue. Extensive equipment failure can lead to significant operational disruption which can compromise the delivery of timely and quality healthcare. Although extensive equipment failure is uncommon, 2 interventional radiology divisions at tertiary academic hospitals in Canada and the UK recently faced such a crisis. Their experiences of crisis and recovery inform this review of angiography equipment failure, and the principles learned. The concept of organizational resilience is introduced as a framework through which we review the crises. This concept can be split into successive and cooperative stages of anticipation, coping, and adaptation. Resilient organizations can identify potential threats, cope with unexpected crises, and recover swiftly to ensure future success. The author's experience of critical angiography unit failure, their response, and lessons learned are reviewed. We find these principles are broadly applicable to other medical imaging divisions and relevant to any system reliant on technology for healthcare delivery.

Abstract Sa1101: Association Between Changes in Hypoxic-Ischemic Brain Injury and Neurological Outcomes in Cardiac Arrest Survivors.

Aim: Quantitative analysis of hypoxic-ischemic brain injury (HIBI) using apparent diffusion coefficient (ADC) values from brain magnetic resonance imaging (MRI) is used to predict poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Our study aimed to determine the association between changes in HIBI and neurological outcomes in OHCA survivors using two types of MRI. Methods: This observational study used data collected prospectively from a tertiary academic hospital. The study included adult comatose OHCA survivors who underwent targeted temperature management (TTM) and brain MRI within 6 hours (first) and 72–96 hours (second) using the same MR scanner. We analyzed the neurological outcomes based on brain volumes below a specific ADC value using 10-step intervals within the range of 200–1200 × 10 -6 mm 2 /s for the first and second MRIs. ADC-R(x) represents the proportion of total brain volume occupied by voxels, with ADC values ranging from 200 × 10 -6 mm 2 /s to each threshold. Additionally, ADC(x) represents the proportion of total brain volume occupied by voxels that are “threshold - 10” at each threshold. Poor neurological outcomes were categorized as cerebral performance levels 3–5, observed 6 months after OHCA. Results: Overall, 122 patients (25% female) were included in the analysis, of whom 61 (50%) showed poor neurological outcomes. Higher ADC-R(x) were observed in the poor neurological outcome group on both the first and second MRI scans at all ADC intervals (all P < 0.05) (Figure 1). In the Good Neurological Outcome group, the ADC-R values ranged between 370 and 940, with the second MRI value being smaller than that of the first (right shift, P < 0.05). In contrast, the Poor Neurological Outcome group showed ADC-R values ranging between 340 and 1190, with the second MRI value being higher than that of the first (left shift, P < 0.05) (Figure 2). The difference in ADC(x) between the second and first MRI based on neurological outcome showed a positive change in ADC below 620 for a poor neurological outcome and a positive change in ADC above 740 for a good neurological outcome (Figure 3). Conclusions: In this cohort study, we observed that the initial HIBI that occurred during OHCA worsened or returned to normal depending on the neurological outcome after TTM. Prospective multicenter studies are required to generalize our findings.

QOL-29. PREVALENCE, MANAGEMENT, AND OUTCOMES OF PROCARBAZINE-ASSOCIATED HYPERSENSITIVITY REACTIONS IN PATIENTS RECEIVING PCV FOR LOW-GRADE GLIOMA

Abstract Procarbazine is an alkylating agent commonly used to treat low-grade gliomas as part of the PCV regimen. The use of procarbazine is frequently limited by the development of hypersensitivity reactions (HSRs), which often require dose reduction or cessation of procarbazine therapy prior to the completion of a planned treatment course. The prevalence, clinical characteristics, and potential predictors of these reactions are not well defined. We conducted a retrospective cohort study of patients with low-grade glioma who received PCV between January 2016 and January 2024 at a tertiary academic hospital. Data on patient demographics, tumor type, clinical characteristics, treatment course, and hypersensitivity reactions were collected and analyzed. 61 total patients were included. The overall prevalence of HSRs was 60.7% (95% CI: 48.4% - 72.9%). The median cycle during which HSRs occurred was cycle 3 (IQR: 2-4, Range: 1-5). All HSRs involved the development of rash, with 86.5% being pruritic and 21.6% involving the face. Treatments for HSRs included antihistamines (62.2%), topical corticosteroids (35.1%), and systemic corticosteroids (27.0%). Three patients with HSRs presented to the emergency department with concern for anaphylaxis, and one required treatment with epinephrine. Out of six patients rechallenged with procarbazine after experiencing HSRs, one patient redeveloped a diffuse, pruritic rash that resolved with systemic corticosteroids. A multiple logistic regression analysis was performed to assess the association between HSRs and gender, age at PCV C1D1, elevated liver enzymes, and concomitant anticonvulsant use, but no significant correlation was observed. In summary, our study provides a contemporary and comprehensive analysis of the prevalence and severity of HSRs to procarbazine in patients with low-grade glioma. The high rate of HSRs in this population, including a relatively high rate of suspected anaphylaxis, should be considered carefully by clinicians in choosing chemotherapy for low-grade glioma and warrants routine counseling and close monitoring.

NCOG-47. DEFINING PERIOPERATIVE RISK FACTORS IN STEREOTACTIC BRAIN BIOPSIES AMONG DIFFERENT HISTOLOGIC DIAGNOSES

Abstract INTRODUCTION Stereotactic brain biopsies (SBB) are critical for diagnosing neoplastic central nervous system pathologies including gliomas, metastatic carcinomas (cA), and lymphomas. While SBB-related complications have been cited in the literature, we sought to characterize the perioperative risk factors/outcomes. METHODS We conducted a retrospective review of 615 patients who underwent a SBB at the same tertiary academic hospital between 2000-2020. Logistic regression was conducted across all recorded variables to assess the relative impact on intra/postoperative complications, and Kaplan-Meier curves were calculated to assess probability of 1-year hospice enrollment. RESULTS Of the 615 patients, the average (+/- SD) age was 56+/- 19 years with 286 (46.5%) female patients and the following histological groups: glioma (n=422), lymphoma (n=74), and metastatic cA (n=22). Complications included intraoperative bleeding (7.1%), general postoperative hemorrhage (34%), symptomatic postoperative hemorrhage (3.3%), and discharge-to-hospice (6.8%). General hemorrhage and discharge-to-hospice were most common in glioma (p < 0.001) and lymphoma patients (p=0.003), respectively. Independent risk factors for general hemorrhage included medical history (mental status deficits, glioma, GBM; p= 0-0.02) and biopsy characteristics (parietal lobe, subcortical, eloquent, M8 hole, multiple depths; p= 0-0.05). Preoperative systematic workups and history of lymphoma were independently associated with lower hemorrhage risk (p= <0.001). Risk factors for hospice discharge included preoperative deficits (gait, speech, and mental status; p=0.001-0.05) and postoperative complications (prolonged ICU, UTI, pneumonia; p<0.001). Of the 15 cases of symptomatic hemorrhage, there was a significantly greater representation of glioma patients (p<0.001) with 67% GBM patients and 50% with multiple-depth biopsies. These patients had similar probability of 1-year hospice enrollment compared to non-hemorrhagic patients (p= 0.92). DISCUSSION While complication rates were relatively similar among different histological categories, perioperative risk factors broadly differed based on the type of complication. Understanding perioperative risk factors in SBB may help inform surgical decision making and prognostication.

Management of Prenatal Expanded Genetic Carrier Screening Results for Autosomal Recessive Sensorineural Hearing Loss.

Expanded carrier screening (ECS) identified couples at-risk to have a baby with an autosomal recessive genetic condition. Several genes implicated in sensorineural hearing loss (SNHL) are included in prenatal or preconception genetics ECS testing. Early identification of SNHL risk may enable prognostication of hearing loss, early educational intervention, and minimization of unnecessary diagnostic testing. We sought to describe cases where ECS enabled early SNHL-risk identification. Retrospective chart review. Maternal-Fetal Care Center and Otolaryngology department at an academic tertiary hospital. Medical records of parent-infant dyads with positive ECS results for variants in autosomal recessive SNHL genes were reviewed. Data regarding genetic diagnostic testing, newborn hearing screening, time to HL diagnosis, audiological evaluation, and clinical consultations were compiled. Fifteen pregnant with positive ECS results for SNHL were referred for consultation with a pediatric otolaryngologist and genetic counselor. Generally, these couples were highly educated and adequately insured. 14 had pathogenic variants for GJB2 and 1 for USH2A. Four couples pursued prenatal genetic diagnosis via amniocentesis; 11 couples deferred genetic testing to the postnatal period or waited for initial hearing evaluation. Six babies inherited biallelic GJB2 mutations. Four were found to have SNHL on ABR by age 5 weeks and received follow-up management, 1 had a normal hearing evaluation despite being gene-positive, and 1 was lost to follow-up before hearing evaluation. Carrier screening and confirmatory prenatal or neonatal genetic testing provided considerable lead time for early audiometric testing and appropriate intervention services including hearing aid fitting.

Outcomes of Universal Suicide Risk Screening in Medical Inpatients

Objectives Universal screening for suicide risk has not been shown to reduce suicide rates or reliably predict suicide, but there have been few studies assessing other potential benefits of this practice. We aimed to investigate the feasibility of implementing a universal inpatient suicide risk screening protocol and determine if a positive suicide screen was predictive of the need for psychiatric admission, and if it reduced the length of stay prior to psychiatric admission. Methods We conducted a retrospective chart review of non-psychiatric admissions over 1 year at a tertiary care academic hospital. We calculated the proportion of patients screening positive for suicidal ideation (SI), and among those screening positive, the proportion receiving a psychiatric consult and being admitted to psychiatry. Length of stay among groups was determined. We performed chi square analysis and adjusted multivariate logistic regression comparing different demographics. Results 97.2% of patients were screened, with 2.6% screening positive. Of these patients, 44.6% received a psychiatric consultation and 9.2% were admitted to psychiatry. Psychiatric admissions who screened positive for SI averaged 5.7 days until transfer to psychiatry, compared to 17.9 days for those who screened negative. Suicide risk screening had a sensitivity of 62.0%, specificity of 97.6%, positive predictive value of 9.2%, and a negative predictive value of 99.8% for psychiatric admission. Conclusions Universal suicide risk screening is feasible and may help identify patients requiring psychiatric care sooner, reducing length of stay of those requiring psychiatric admission.

Candida auris fungaemia outbreak in a tertiary care academic hospital and emergence of a pan-echinocandin resistant isolate, Greece, 2021 to 2023.

After the start of the COVID-19 pandemic, a rapid rise in reported numbers and wide geographic spread of Candida auris-related invasive infections has been observed globally. However, the contemporary epidemiology of C. auris fungaemias in Greece remains unknown. An outbreak of C. auris bloodstream infections has been ongoing for almost 3 years in a Greek tertiary care academic hospital, with 89 C. auris-driven episodes appearing in five waves every 6-7 months following peaks in colonisation rates by 3-4 months. All isolates clustered in clade I and were genetically related, 84% were fluconazole-resistant and all were non-resistant to amphotericin B and echinocandins, except one pan-echinocandin-resistant isolate (FKS1S639F mutant) recovered from a patient on empiric therapy with anidulafungin. Notably, C. auris was in 2023 the most prevalent (34%) cause of candidaemia in our hospital. The accelerated and long-term transmission dynamics of C. auris fungaemia underscore the need for rigorous infection control measures, while antifungal stewardship is warranted to contain the selection of echinocandin-resistant isolates.

Clinical and audiological characteristics in adults with tinnitus in South Africa

Background: In South Africa, the prevalence of tinnitus and its associated clinical and audiological characteristics remain underexplored, posing challenges in the assessment and management of the condition. This knowledge gap affects clinician preparedness and effectiveness in treating tinnitus.Objectives: This study aimed to explore the clinical and audiological characteristics of adult patients reporting tinnitus at a tertiary academic hospital in South Africa.Method: A quantitative, non-experimental, retrospective review of 129 patient audiological records from the Audiology Department at Helen Joseph Hospital was conducted. Among these, 71 records were of patients who reported experiences of tinnitus.Results: Tinnitus was reported by 55% of patients, with a higher prevalence in females (76%). The mean age of patients was 51.9 years. Unilateral tinnitus was present in 28% of cases, while 78% of patients had hearing loss, predominantly sensorineural. Common audiological characteristics included vertigo (24%), otalgia (14%), otorrhea (17%) and perforated tympanic membrane (15%). Clinical conditions associated with tinnitus included hypertension (32%), heart disease (28%), diabetes (9%) and head trauma (9%). Findings regarding age and gender differences in the clinical and audiological manifestations of tinnitus are presented.Conclusion: Further research with larger, diverse samples and prospective designs is necessary to confirm these findings and explore possible underlying causes.Contribution: The findings highlight the significant prevalence of tinnitus and its association with various clinical and audiological conditions in the South African context. Understanding these characteristics will enhance the clinician‘s ability to accurately assess, diagnose and manage tinnitus, leading to improved treatment outcomes.

Characteristics and outcomes of pediatric brucellosis cases collected from a tertiary academic hospital in Saudi Arabia

Brucellosis is a zoonotic disease caused by Brucella spp., affecting different body systems and leading to multiple complications. Although brucellosis is prevalent in several regions, including Saudi Arabia, limited research has focused on childhood brucellosis. This study aimed to characterize the features and outcomes of brucellosis in pediatric patients. We conducted a retrospective descriptive study involving children (<18 years) with confirmed brucellosis (diagnosed through culture, serology, or both) who received antibiotic therapy. Subjects were stratified into two groups based on age: younger (≤8 years) and older (>8 years). We assessed treatment outcomes, including clinical cure, mortality, and hospital length of stay. A total of 20 patients were included, with 52.3% in the younger group and 47.7% in the older group. The majority were male (65%), with a mean age of 8.9 years, and 45% required hospitalization. Out of all the patients, only 6 (30%) reported consuming dairy products. Serologically, the baseline median antibody titers for Brucella melitensis and Brucella abortus were 1:1280 and 1:640, respectively. In the younger group, half reported arthralgia and presented with fever. While white blood cell elevation was not significant, C-reactive protein, erythrocyte sedimentation rate, and liver enzymes were elevated at baseline. The administered regimen varied, but about half of the patients received at least three antibiotics. All patients experienced clinical cures, and there were no deaths. This study highlights the characteristics of pediatric brucellosis in a country where the disease is endemic and provides evidence of positive prognosis associated with appropriate antibiotic therapy.

Vascular Complications After Venoarterial Extracorporeal Membrane Oxygenation Support: A CT Study.

Vascular complications after venoarterial extracorporeal membrane oxygenation (ECMO) remains poorly studied, although they may highly impact patient management after ECMO removal. Our aim was to assess their frequency, predictors, and management. Retrospective, observational cohort study. Two ICUs from a tertiary referral academic hospital. Adult patients who were successfully weaned from venoarterial ECMO between January 2021 and January 2022. None. Vascular complications frequency related to ECMO cannula. A total of 288 patients were implanted with venoarterial ECMO during the inclusion period. One hundred ninety-four patients were successfully weaned, and 109 underwent a CT examination to assess for vascular complications until 4 days after the weaning procedure. The median age of the cohort was 58 years (interquartile range [IQR], 46-64 yr), with a median duration of ECMO support of 7 days (IQR, 5-12 d). Vascular complications were observed in 88 patients (81%). The most frequent complication was thrombosis, either cannula-associated deep vein thrombosis (CaDVT) (n = 63, 58%) or arterial thrombosis (n = 36, 33%). Nonthrombotic arterial complications were observed in 48 patients (44%), with 35 (31%) presenting with bleeding. The most common site of CaDVT was the inferior vena cava, occurring in 33 (50%) of cases, with 20% of patients presenting with pulmonary embolism. There was no association between thrombotic complications and ECMO duration, anticoagulation level, or ECMO rotation flow. CT scans influenced management in 83% of patients. In-hospital mortality was 17% regardless of vascular complications. Vascular complications related to venoarterial ECMO cannula are common after ECMO implantation. CT allows early detection of complications after weaning and impacts patient management. Patients should be routinely screened for vascular complications by CT after decannulation.

CT-guided Coaxial Lung Biopsy: Number of Cores and Association with Complications.

Background Percutaneous CT-guided lung core-needle biopsy is a frequently performed and generally safe procedure. However, with advances in the management of lung cancer, there is a need for a greater amount of tissue for tumor genomic profiling and characterization. Purpose To determine whether the number of core samples obtained with percutaneous CT-guided lung biopsy is associated with postprocedural complications. Materials and Methods This retrospective study included consecutive patients who underwent percutaneous CT-guided coaxial lung core-needle biopsy for suspected primary lung cancer between November 2012 and August 2023 at an academic tertiary referral hospital. Patient data from medical records were collected, including demographics, lesion size and distance from pleura, and number of obtained biopsy samples. Postprocedural complications of pneumothorax, chest tube placement, perilesional hemorrhage, and hemoptysis were recorded. Multivariable logistic regression models were used to assess whether the number of cores was a predictive factor for lung biopsy complications. Results A total of 827 patients (mean age, 70.9 years ± 9.6 [SD]; 474 [57.3%] female patients) were included. The median lesion size was 22 mm (IQR, 15-34 mm), with 517 of 827 (62.5%) patients diagnosed with lung adenocarcinoma. Pneumothorax was noted in 171 of 827 (20.7%) patients, with a chest tube placed in 32 of 827 (3.9%), perilesional hemorrhage in 353 of 827 (42.7%), and hemoptysis in 20 of 827 (2.4%) patients. The median number of samples obtained was four (range, one to 12). Multivariable analysis showed no evidence of an association between the number of core samples obtained and any complications: pneumothorax (coefficient, -0.02; P = .81), chest tube (coefficient, 0.18; P = .26), perilesional hemorrhage (coefficient, -0.03; P = .63), or hemoptysis (coefficient, -0.10; P = .60). Conclusion In patients suspected of having lung cancer who underwent percutaneous CT-guided coaxial lung core biopsy, there was no evidence of an association between the number of core biopsy samples obtained and any postprocedural complications. © RSNA, 2024 See also the editorial by Zuckerman in this issue.

Pediatric Early Warning Scores Before Rapid Response Poorly Predict Intensive Care Unit Transfers.

The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation. A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds. Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613). PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

Influence of Right and Left Bundle Branch Block in Patients With Cardiogenic Shock and Cardiac Arrest.

The study investigates the prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in patients with cardiogenic shock (CS) compared with no bundle branch block (BBB). In patients with heart failure, existence of RBBB and LBBB has influence on prognosis. Prospective registry-study. ICU of a tertiary academic hospital in Germany. Adult patients with CS. None. Consecutive patients with CS were included. The prognostic impact of RBBB and LBBB on 30-day all-cause mortality was tested within the entire cohort and in the subgroup of CS patients with cardiac arrest at admission. The final study cohort comprised 248 patients. Patients with RBBB showed the highest 30-day all-cause mortality followed by LBBB and no BBB (72.5% vs. 52.9% vs. 50.0%; log-rank p = 0.015). These findings were consistent even after solely including CS patients with cardiac arrest (90.0% vs. 73.3% vs. 62.2%; log-rank p = 0.008). After adjustment for lactate, norepinephrine, troponin I, Acute Physiology Score, Society of Cardiovascular Angiography & Interventions shock stage, and heart rate in a multivariable Cox regression analysis, RBBB still revealed a negative impact on 30-day all-cause mortality (hazard ratio [HR], 1.807; 95% CI, 1.107-2.947; p = 0.018), whereas LBBB was not associated with 30-day all-cause mortality. In this multivariable Cox regression model lactate (HR, 1.065; 95% CI, 1.018-1.115; p = 0.006), troponin I (HR, 1.003; 95% CI, 1.001-1.005; p = 0.001), and Acute Physiology Score (HR, 1.033; 95% CI, 1.001-1.066; p = 0.041) were as well associated with 30-day all-cause mortality. Finally, no association of RBBB was found with the incidence of liver or severe renal failure. Besides the Acute Physiology Score, lactate, and troponin levels, RBBB was associated with an increased 30-day all-cause mortality in consecutive CS patients with and without cardiac arrest, whereas LBBB showed no prognostic impact.

5-year valve academic research consortium-3 outcomes and predictors of mortality in a 10-year Asian transcatheter aortic valve implantation registry

Abstract Background Transaortic valvular implantation (TAVI) has revolutionised the management of aortic stenosis (AS). Uptake in Asia has caught up in recent years, after an initial lag due to expensive cost, limited subsidies, and scarce accessibility. Hence, longitudinal outcomes of TAVI remain largely unknown in Asian patients. Purpose This study aims to present the 5-year mortality endpoints in an Asian cohort followed up over a decade. Methods 253 patients with symptomatic severe aortic stenosis status post TAVI were retrospectively enrolled at a tertiary academic hospital from 2010-2021. The main outcomes were defined as short-term (30-day), mid-term (1-year) and long-term (5-year) all-cause mortality. Baseline demographics, procedural findings and clinical outcomes were analysed. Kaplan-Meier curves and multiple Cox regression analyses were constructed. Results The mean age was 75.2 + 10.2 years. 120 (47.4%) patients were female and 167 (66%) were Chinese. 168 patients (66.7%) received balloon-expandable valves, 80 patients (31.7%) underwent self-expandable valves, and 4 patients (1.6%) had mechanical-expandable valves. Malignancy was associated with worse short-term mortality at 30-days (HR 3.65, p = 0.054), while pulmonary disease and previous stroke were associated with worse long-term mortality at 5-years (HR 2.27, p = 0.012 and HR 2.02, p = 0.064). Worse all-cause mortality at 30-days, 1-year and 5-years were associated with high NT-Pro BNP levels (HR 1.04, p = 0.046; HR 1.05, p = 0.002 and HR 1.04, p < 0.001), the presence of peripheral arterial disease (PAD) (HR 4.32, p = 0.056; HR 4.48, p = 0.006 and HR 2.43, p = 0.023) and chronic kidney disease (CKD) (HR 6.19, p = 0.006; HR 6.77, p < 0.001 and HR 2.09, p = 0.008). Society of Thoracic Surgery (STS) score (HR 1.11, p = 0.001; HR 1.13, p < 0.001 and HR 1.12, p < 0.001) and Valve Academic Research Consortium (VARC) III endpoints of acute kidney injury (AKI) (HR 6.68, p = 0.047, HR 10.8, p < 0.001 and HR 6.99, p < 0.001), cardiogenic shock (HR 26.3, p < 0.001, HR 12.0, p < 0.001 and HR 4.29, p = 0.011) and structural complications (HR 40.3, p < 0.001, HR 18.1, p < 0.001 and HR 5.18, p = 0.008) were associated with worse all –cause mortality at time-points of 30-days, 1-year and 5-years respectively. On multivariate analyses adjusted for comorbidities and outcomes, STS score and structural complications were independent predictors of 30-day, 1-year, and 5-year all-cause mortality (HR 1.16; p = 0.003, HR 1.09, p = 0.003 and HR 1.10, p < 0.001) and (HR 62.7, p < 0.007; HR 18.9, p < 0.001 and HR 10.6, p = 0.001) respectively. Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use was protective of survival within 1-year (HR 0.37, p = 0.022). Conclusions STS score and VARC III endpoints of structural complications were reliable predictors of all-cause mortality in Asian patients with TAVI. ACE inhibitor and ARB use was protective against mortality at 1-year.Cox regression analysesKaplan-Meier curves

Long-term mortality outcomes of southeast asian patients with aortic stenosis

Abstract Background Limited data exists on mortality outcomes of aortic stenosis (AS) in Southeast Asians. Insights into this may confer prognostic benefits and affect therapeutic targets. Purpose Our study aims to provide insights into 10-year mortality outcomes and prognostic indicators of AS in this cohort. Methods Consecutive patients (n = 703) with echocardiographic diagnoses of AS at a tertiary academic hospital in Southeast Asia were studied. Demographics, co-morbidities and outcomes were collected. Multivariate Cox regression model was constructed. Results 55.2% (n = 388) of patients had mild AS, 29.3% (n = 206) had moderate AS, and 15.5% (n = 109) had severe AS. Out of 431 deaths, 35.8% (n = 86) of known cases were cardiovascular. The leading cause of cardiovascular mortality was coronary-linked in 20.8% (n = 50); 7.9% (n = 19) was valvular aortic stenosis; 2.5% (n = 6) was cardiac failure, 1.3% (n = 3) was sudden cardiac death, and 2.9% (n = 7) was ischaemic stroke. Of 154 (64.2%) non-cardiovascular mortality, sepsis caused 40% (n = 97) of deaths, malignancy in 11.7% (n = 28), renal failure in 5% (n = 12) and respiratory failure in 1.7% (n = 4). 44.3% (n = 191) of cases were unknown. Higher proportions of AS patients with cardiovascular death had hyperlipidaemia (p = 0.027) and coronary artery disease (p = 0.028). Multivariable Cox regression showed age (HR 1.041, 95% CI: 1.020-1.062, p < 0.001), anaemia (HR 2.121, 95% CI: 1.535-2.930, p < 0.001) and prior cardiovascular hospitalisation (HR 1.420, 95% CI: 1.040-1.938, p = 0.027) to be significant predictors of all-cause mortality. Aortic valve replacement was a significant protective factor of all-cause mortality after adjustments for age, gender, comorbidities, and echocardiographic findings (HR 0.313, 95% CI 0.131-0.747, p = 0.009). Conclusions Non-cardiovascular death was the leading cause of mortality in Southeast Asians with AS. Ischaemic heart disease was the commonest cause of cardiovascular mortality. Predictors of all-cause mortality included age, anaemia and prior cardiovascular hospitalisation. Valvular replacement was protective of all-cause mortality in AS.

A cradle-to-grave life cycle assessment of the endoscopic sinus surgery considering materials, energy, and waste.

Operating rooms generate 1.8 million tons of waste annually, or 20%‒30% of the total healthcare waste in the United States. Our objective was to perform a life cycle assessment (LCA) for endoscopic sinus surgeries (ESSs) in order to analyze its environmental impact. A comprehensive LCA of ESS was performed considering energy, climate, and water use impacts associated with the materials and processes used. It focuses on the ESS performed at a large tertiary academic hospital and then extends the impacts to consider annual US surgeries. The assessment considers end-of-life waste management at both landfills and incinerators. Single-use instrument production constitutes 89%‒96% of the total impacts throughout the life cycle of an ESS. Waste-to-energy incineration is shown to be a preferred end-of-life destination, as it recovers much of the input production energy of plastic items, ultimately reducing the input to 36%, although this is done at the expense of higher greenhouse gas emissions. For multi-use items, decontamination dominates environmental impact (>99% of totals), but consideration of reusable items reduces overall energy consumption and global warming potential (GWP) by 25%‒33%. Single-use items dominate the total environmental impact of ESS. While multi-use items require additional decontamination over their lifetimes, results show that their incorporation reduces energy consumption and GWP by 25%‒33%, demonstrating the clear environmental benefit.

Prevalence and predictors of confirmed infection in patients receiving empiric antimicrobials in the intensive care unit: a retrospective cohort study

BackgroundInfection diagnosis in Intensive Care Units (ICUs) is a challenge given the spectrum of conditions that present with systemic inflammation, the illness severity and the delay and imprecision of existing diagnostic methods. We hence sought to analyze the prevalence and predictors of confirmed infection after empirical antimicrobials during ICU stay. Methodsretrospective cohort of prospectively collected ICU data in an academic tertiary hospital in São Paulo, Brazil. We included all adult patients given a new empirical antimicrobial during their ICU stay. We excluded patients using prophylactic or microbiologically guided antimicrobials. Primary outcome was infection status, defined as confirmed, probable, possible, or discarded. In a multivariable analysis, we explored variables associated with confirmed infection. ResultsAfter screening 1721 patients admitted to the ICU from November 2017 to November 2022, we identified 398 new antimicrobial prescriptions in 341 patients. After exclusions, 243 antimicrobial prescriptions for 206 patients were included. Infection was classified as confirmed in 61 (25.1%) prescriptions, probable in 39 (16.0%), possible in 103 (42.4%), and discarded in 40 (16.5%). The only factor associated with infection was deltaSOFA (OR = 1.18, 95% CI 1.02 to 1.36, p = 0.022). ConclusionSuspected infection in the ICU is frequently not confirmed. Clinicians should be aware of the need to avoid premature closure and revise diagnosis after microbiological results. Development and implementation of new tools for faster infection diagnosis and guiding of antimicrobial prescription should be a research priority.

Gather "Round": An Integrated Care Model for the Emergency Department Multi-Visit Patient.

Emergency departments (EDs) are a vital component of the United States healthcare system and care for over 130 million patient visits annually. Nonurgent ED visits can contribute to crowding, delays in care, and adverse effects. Many high-utilizing ED patients may present with complex medical, behavioral, and social needs that are not necessarily emergent or urgent in nature. The authors created an Integrated Care Model, called the Multi-Visit Patient (MVP) program, for patients with 5 or more visits to the ED in a rolling 12-month period. The MVP program incorporated an interdisciplinary group of ED leadership and case management (CM) to identify, engage, and intervene with ED MVPs, aiming to improve their ED utilization. Patients received comprehensive screenings for depression, falls, alcohol use disorder, caregiver support, social determinants of health, and more. Based on these screenings, the CM team implemented interventions such as connecting patients with outpatient specialists and linking patients to community-based organizations to optimize stability, wellness, and reduce ED utilization. The collaboratively developed MVP program was implemented in the ED of a large, suburban, tertiary care academic hospital. The MVP program identified 221 MVP patients over a 20-month period and successfully connected with 89% of them. Of these 221 patients, 78% (172 patients) chose to engage in the MVP program, with 160 completing their engagement with an outcome. Among the patients who completed their engagement and for whom the study could match separate utilization data (151 patients), the study observed a 57% reduction in ED visits. Case managers play a crucial role in the effectiveness of the MVP program by coordinating comprehensive care for high-utilizing ED patients. The MVP program includes transition of care initiatives designed to improve patient outcomes. Through screenings and targeted interventions, case managers identify and address the complex medical, behavioral, and social needs of MVP patients. This collaborative, interdisciplinary approach underscores the importance of timely and coordinated care, benefiting both patients and the health system. The MVP program exemplifies the critical role of case managers in reducing unnecessary ED visits and enhancing overall patient care.