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Early vs. late transcatheter aortic valve replacement in acute heart failure hospitalizations: A comparative nationwide analysis
No full textBackground: Severe aortic stenosis (AS) is the most common valvular disease in the USA. Patients undergoing urgent or emergent transcatheter aortic valve replacement (TAVR) have worse clinical outcomes than those undergoing non-urgent procedures. No studies have examined the impact of procedural TAVR timing on outcomes in AS complicated by acute heart failure (AHF).
Aims: We aimed to evaluate differences in in-hospital mortality and clinical outcomes between early (\u3c48 h) vs. late (≥48 h) TAVR in patients hospitalized with AHF using a real-world US database.
Methods: We queried the National Inpatient Sample database to identify hospitalizations with a diagnosis of AHF, aortic valve disease, and a TAVR procedure (2015-2020). The associations between TAVR timing and clinical outcomes were examined using logistic regression model.
Results: A total of 25,290 weighted AHF hospitalizations were identified, of which 6855 patients (27.1 %) underwent early TAVR, and 18,435 (72.9 %) late TAVR. Late TAVR patients had higher in-hospital mortality rate (2.2 % vs. 2.8 %, p \u3c 0.01) on unadjusted analysis but no significant difference following adjustment for demographic, clinical, and hospital characteristics [aOR 1.00 (0.82-1.23)]. Late TAVR was associated with higher odds of cardiac arrest (aOR 1.50, 95 % CI: 1.18-1.90) and use of mechanical circulatory support (aOR 2.05, 95 % CI: 1.68-2.51). Late TAVR was associated with longer hospital stay (11 days vs. 4 days, p \u3c 0.01) and higher costs (53,209, p \u3c 0.01).
Conclusion: Early TAVR was conducted in approximately 25 % of the AS patients admitted with AHF, showing improved in-hospital outcomes before adjustment, with no significant differences observed after adjustment.
Keywords: Acute heart failure; Clinical outcomes; In-hospital mortality; Transcatheter aortic valve replacement
Meditation for the reduction of perioperative anxiety in patients undergoing oncology surgery: A scoping review
No full textObjective: Patients undergoing surgery, particularly patients undergoing surgery for oncology diagnoses, experience anxiety. Surgery remains the primary treatment for many common types of cancer. One promising potential intervention to alleviate anxiety in the preoperative and postoperative period is meditation, an integrative medicine intervention. However, there remains a gap in the literature regarding the effectiveness of meditation to alleviate anxiety during the perioperative time period. Methods: The scoping review was conducted using the Arksey and O\u27Malley framework to synthesize the study findings and was reported with the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). The review included EMBASE, PubMed, Web of Science, CINAHL Plus, Scopus, and Cochrane Review databases from 2013 through 2024. All identified articles were exported to the online systematic review software, Covidence. Results: A total of 538 initial citations were identified, 415 titles and abstracts were screened, and 83 full-text articles reviewed. Six studies were finally included. The data extracted from the literature included: study purpose, study design, sample size, preoperative or postoperative timeframe, instrument to evaluate anxiety, and conclusions. Conclusions: For patients undergoing oncology surgery, the perioperative period can be filled with anxiety. Guided, mindfulness, and loving-kindness meditation may be helpful in reducing anxiety, particularly in patients undergoing surgery for breast cancer during the postoperative period. However, the current literature is extremely limited. Future research should expand on the preliminary effectiveness to broader populations and carefully target the highest-risk populations for the ideal time point for interventions
Racial/Ethnic, Sex, and Economic Disparities in the Utilization and Outcomes of Intracoronary Imaging
No full textBackground: Intracoronary imaging-guided percutaneous coronary intervention (PCI) is associated with improved outcomes compared with angiography-guided PCI. Data on racial/ethnic, sex, and economic disparities in the utilization and outcomes of intracoronary imaging in the United States are scarce.
Methods: We analyzed the National Inpatient Sample (2016-2020) to examine racial/ethnic, sex, and economic differences in the utilization of intracoronary imaging among patients who underwent PCI. Trends, in-hospital mortality, and safety of intracoronary imaging were also assessed.
Results: Among 2,212,595 weighted hospitalizations for PCI, 204,735 (9.2%) included intracoronary imaging. The utilization rate of intracoronary imaging was similar in Black and Hispanic patients compared with White patients (9.8% vs 10.2% vs 10.0%; P = .68) and lower for women compared with men (10.0% vs 10.3%; P = .01) and for patients with low and medium income compared with high income (9.2% vs 10.0% vs 12.5%; P \u3c .01). In multivariable regression analysis, low and medium income were independently associated with lower intracoronary imaging use compared with high income (both P \u3c .01). From 2016 through 2020, the use of intracoronary imaging in PCI increased significantly in all racial/ethnic, sex, and economic groups (all P trend \u3c .01). Among patients who underwent PCI with intracoronary imaging, Black race was associated with higher odds of acute kidney injury compared with White race (adjusted odds ratio, 1.40; 95% CI, 1.25-1.57). In-hospital mortality was similar between different racial/ethnic, sex, and economic groups.
Conclusions: Low and medium income are independently associated with lower intracoronary imaging use in PCI compared with high income. Further studies are needed to identify effective strategies to mitigate economic disparities in intracoronary imaging use.
Keywords: economic disparities; intracoronary imaging; intravascular ultrasound; percutaneous coronary angiography; racial disparities; sex disparities
When and how to transplant in myelofibrosis - recent trends
No full textAllogeneic hematopoietic stem cell transplantation (AHSCT) is currently the only treatment modality that is capable of curing myelofibrosis (MF). Although outcomes of AHSCT have improved vastly in recent years owing to advancements in HLA typing, conditioning regimens, and supportive care, it remains a procedure with a considerable risk in MF patients due to conditioning regimen related toxicity, higher rates of graft failure, infections, and graft versus host disease (GVHD). Recent progress in the treatment and prevention of GVHD with post-transplant cyclophosphamide has also rendered transplantation from alternative donors feasible and safer, thus improving access to patients without HLA-identical donors. Accordingly, all patients with intermediate or high-risk MF today should be referred for potential transplant evaluation to consider the pros and cons of an early versus a delayed transplant strategy. Individual risk assessment in MF is best facilitated by contemporary prognostic models that incorporate both clinical and genetic risk factors. The current review highlights new information regarding risk stratification in MF, anchored by practical algorithms that facilitate patient selection for specific treatment actions, including AHSCT.
Keywords: HCT; HSCT; Myelofibrosis; allogeneic stem cell; transplantation
The Role of Sex and Gender in Precision Emergency Medicine: A Scoping Review and Proposed Hierarchy
No full textBackground: Precision medicine utilizes individual patient data to guide decision making. Sex and gender medicine is likewise focused on individual patients\u27 biological sex or sociocultural gender as determinants of disease. How these two fields intersect with one another and with acute care medicine is unclear.
Methods: We conducted a scoping literature review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews to evaluate the primary research in three related areas: sex & gender medicine, emergency medicine, and precision medicine. We searched six databases and screened eligible studies for inclusion. Included studies were reviewed in full, and study characteristics were compiled using a standardized data extraction form. Research questions were drafted by workgroup members and ranked by all participants of the consensus conference.
Results: A total of 401 studies were screened for inclusion. Of these, 70 met inclusion criteria and were evaluated in full text. The majority (84%, 59/70) reported evaluating sex, whereas only 16% (11/70) reported evaluating gender. The most common clinical topics were cardiovascular diseases and trauma/injury prevention, comprising 50% (35/70) of the included manuscripts. Cumulatively, 77% (54/70) of the manuscripts reviewed cited at least one funding source. The vast majority (66/70, 94%) of studies were included because their statistical analysis accounted for sex or gender, and very few studies (4/70, 6%) were included due to their use of biomarker or genomic data.
Conclusions: Sex- and gender-based medicine and research commonly employ precision medicine concepts to evaluate the effects of sex and gender in a variety of clinical topic areas, but much of this literature is not commonly described as precision medicine. We propose a hierarchy to categorize, label, and advance sex and gender precision medicine research. Fundamental to this advancement are implementation of guidelines regarding the correct use of sex and gender and continued research funding for sex and gender precision EM research.
Keywords: Evidence Based Differences; Precision Medicine; Sex Differences; Sex and Gender
Routine Nil-per-os Before All Cardiac Catheterizations: Time to Reconsider?
No full textNil-per-os (NPO) is a common instruction before cardiac catheterization. NPO was originally adopted from general surgery to minimize gastric contents during procedures and reduce the risk of pulmonary aspiration in case of vomiting. However, NPO has since been associated with adverse effects on patient well-being, fasting-related complications, and increased healthcare costs. These burdens are multiplied by the large number of cardiac catheterizations performed. Advancements in anesthesia and contrast agents may have rendered pre-procedural fasting obsolete. Here, we examine the evidence for and against routine NPO practices, and consider the possible value of a more targeted approach. Current evidence strongly suggests that non-fasting before cardiac catheterization does not significantly increase the risk of pulmonary aspiration or other complications. Therefore, while further large-scale trials are on-going to confirm the safety of non-fasting, hospitals should begin to reduce fasting periods whenever possible. New guidelines should stratify patients by their risk of aspiration, reserving NPO only for those at high risk.
Keywords: ASA; Cardiac Catheterization; NPO
Improving perinatal depression screening uptake: The impact of Medicaid reimbursement policy in Massachusetts
No full textObjective: To evaluate the impact of the Massachusetts Medicaid program\u27s reimbursement policy change for perinatal depression screening on utilization rates.
Study setting and design: This study employed a difference-in-differences design to compare insurance-paid prenatal and postpartum depression screening rates as well as postpartum antidepressant receipt rates between Medicaid and privately insured individuals before and after policy implementation in May 2016.
Data sources and analytic sample: Data are from the 2014-2020 Massachusetts All-Payer Claims Database. The study included individuals with a live birth from October 10, 2014, to December 31, 2019, who were continuously insured either by Medicaid or private insurance.
Principal findings: Among 141,085 births, 42.6% were covered by Medicaid. Among those with Medicaid, 1.9% had a paid postpartum depression screening prior to the policy and 16.9% after (1.5% vs. 12.3% for prenatal screening); among privately insured, 3.8% had a paid postpartum screening prior to the policy and 10.6% after (0.9% vs. 6.7% for prenatal screening). Antidepressant receipt rose from 6.9% to 8.3% among Medicaid enrollees and from 3.3% to 4.9% among privately insured individuals after the policy. After regression adjustment, implementation of the Massachusetts Medicaid reimbursement policy was positively associated with perinatal depression screening rates with a differential increase of 10.0 percentage points (p \u3c 0.001) for postpartum screening and 3.5 percentage points (p \u3c 0.001) for prenatal screening among Medicaid enrollees versus privately insured. Despite increased depression screening, the policy was not associated with a statistically significant change in antidepressant receipt among Medicaid enrollees compared to privately insured individuals.
Conclusions: Separate payment for perinatal depression screening significantly improved screening rates among Medicaid beneficiaries, highlighting Medicaid\u27s critical role in identifying mental health needs for vulnerable populations. However, the persistence of sub-optimal screening rates among perinatal individuals underscores the need for a comprehensive approach to ensure universal screening and effective treatment for perinatal depression.
Keywords: Medicaid; health promotion/prevention/screening; incentives in health care; maternal and perinatal care and outcomes; mental health
Anaplastic lymphoma kinase1 positive inflammatory myofibroblastic tumor of the urinary bladder: A rare mesenchymal neoplasm with diagnostic and therapeutic implications
No full textInflammatory myofibroblastic tumors (IMTs) are rare mesenchymal neoplasms characterized by spindle-cell morphology with accompanying inflammatory infiltrates. Originally described in 1939, these tumors can arise in various anatomic locations, with the urinary bladder being a rare site of occurrence but the most common within the genitourinary tract. IMTs typically present as polypoid masses or firm submucosal nodules, often with painless hematuria in bladder cases. Histopathologically, IMTs are composed of myofibroblasts with myxoid stroma and mixed inflammatory cells, predominantly lymphocytes and plasma cells. Immunohistochemically, these tumors commonly express anaplastic lymphoma kinase1 (ALK1), vimentin, smooth muscle actin (SMA), and cytokeratin, with ALK1 serving as a crucial marker for diagnosis. This report details the case of a 31-year-old female presenting with hematuria, found to have a soft tissue mass in the urinary bladder (5.0 × 3.0 cm). Imaging revealed a well-defined lesion with vascularity. Histopathological examination confirmed an IMT, with immunohistochemistry showing diffuse ALK1 positivity, patchy SMA staining, and variable desmin expression, consistent with the diagnosis. IMTs are generally considered neoplasms of intermediate malignant potential. While metastasis is exceedingly rare in bladder IMTs, local recurrence has been reported, particularly in cases of incomplete surgical resection. Recent advances highlight the role of ALK inhibitors in managing unresectable cases, enabling partial cystectomy in select patients. This article underscores the importance of achieving complete surgical excision and highlights the role of ALK expression in diagnosis and differentiation from other spindle-cell neoplasms. Further studies are needed to elucidate the molecular and clinical factors influencing prognosis and to refine treatment strategies for IMTs.
Keywords: ALK; ALK1; Inflammatory myofibroblastic tumor (IMT); urinary bladder
Critical Perspectives on Global Health Policy, Diagnostic Access and Practice Gaps towards a Tuberculosis Free India
No full textTuberculosis (TB) poses a significant public health challenge in India. According to the World Health Organization (WHO), India tops the list of 30 countries responsible for 87% of global TB cases in 2023. Recent data indicates that India\u27s TB incidence rate was 195 cases per 100,000 population in 2023, accounting for approximately 26% of global TB cases. Global health organizations like the WHO and the Centers for Disease Control and Prevention (CDC) emphasize molecular techniques, such as Cartridge-Based Nucleic Acid Amplification Test (CB-NAAT), sequencing, and serological tests, to improve the accuracy and efficiency of TB diagnosis. The Government of India initiated the National Tuberculosis Elimination Program (NTEP), aiming for a TB-free India by 2025. Despite the efforts, practice gaps remain in diagnosis, treatment, and monitoring. Accelerated strategies focusing on early detection, management of latent TB, and control of drug resistance are critical. This review explores global guidelines, highlights implementation challenges, and suggests pathways for achieving effective TB control in India.
Keywords: Drug Resistance; Essential Diagnostics List; Global Health Challenge; Public Health; Tuberculosis
