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Safety and Clinical Outcomes of Transvenous Lead Extraction for Cardiac Device Infections in the Very Elderly
No full textBackground: The increasing use of cardiac implantable electronic devices (CIEDs) has led to a rise in transvenous lead extractions (TLE), particularly for device-related infections. The elderly represent a growing subgroup undergoing TLE, but data on their outcomes are limited.
Objectives: To evaluate the safety and in-hospital outcomes of TLE in patients aged ≥ 80 years with device-related infections.
Methods: We analyzed the National Inpatient Sample (NIS) from 2016 to 2020 to identify hospitalizations involving TLE for device-related infections. Patients were stratified by age: \u3c 80 years and ≥ 80 years. The primary outcome was in-hospital mortality. Secondary outcomes included major procedural complications and length of stay. Multivariate logistic regression identified independent predictors of in-hospital mortality and complications.
Results: Among 30 670 patients who underwent TLE, 6530 (21.3%) were aged ≥ 80 years. In-hospital mortality did not differ significantly between groups (4.0% vs. 4.6%, p = 0.40), nor did overall complication rates (6.7% vs. 6.9%, p = 0.81). However, elderly patients had higher rates of post-procedural stroke (0.3% vs. 0.02%, p = 0.002) and bleeding (1.6% vs. 0.8%, p = 0.04). Independent predictors of mortality included chronic kidney disease (aOR 2.2, 95% CI: 1.2-4.2), cirrhosis (aOR 12.2, 95% CI: 1.1-133), and respiratory failure (aOR 50.7, 95% CI: 6-425). Elderly patients were more frequently discharged to rehabilitation facilities (40.3% vs. 25.5%, p \u3c 0.001).
Conclusion: Elderly patients undergoing TLE for infections had similar in-hospital mortality and complication rates compared to younger patients. Age alone should not preclude TLE. However, increased risks of stroke and bleeding warrant targeted perioperative assessment. Further studies are needed to assess long-term outcomes in this population.
Keywords: device infection; elderly; transvenous lead extraction
Racial and ethnic disparities in environmental chemical exposures and hypertensive disorders of pregnancy: The ECHO-wide cohort study
No full textHypertensive disorders of pregnancy (HDP) are a leading cause of maternal and infant mortality and morbidity worldwide. This prospective cohort study investigated the association of racial and ethnic disparities in HDP and explored the potential mediation effect of environmental chemical exposures on excess HDP risk among non-Hispanic Black pregnant people. A total of 3,279 pregnant people were included from 11 cohorts across the United States in the Environmental influences on Child Health Outcomes (ECHO) Program. We analyzed 20 environmental chemicals detected in over 70 % of biospecimens collected during pregnancy. Among Hispanic, non-Hispanic White, and non-Hispanic Black participants, 11.8 %, 10.8 %, and 16.6 % were diagnosed with HDP, respectively. Compared with non-Hispanic White participants, non-Hispanic Black participants had a higher risk of HDP (aRR = 1.48; 95 % CI 1.13-1.94) and higher levels of traditional phthalate metabolites, but lower levels of phthalate alternative metabolites and perfluorooctanoic acid. Hispanic participants had a lower risk of gestational hypertension (aRR = 0.62; 95 % CI 0.40-0.98) and lower levels of perfluoroalkyl substances than non-Hispanic White participants. Critically, despite these race/ethnicity-specific exposure patterns, individual chemical exposures did not mediate the association between racial/ethnic group and HDP. These findings highlight the need to investigate cumulative chemical mixtures and non-chemical environmental and social determinants as potential drivers of HDP disparities.
Keywords: Environmental exposures; Hypertensive disorders of pregnancy; Pre-pregnancy BMI; Racial and ethnic disparities
Glucagon-Like Peptide-1 Receptor Agonist Use and Outcomes in Peripartum Cardiomyopathy: A Propensity-Score Matched Analysis
No full textComparing outcomes of endovascular intervention vs bypass surgery for patients with chronic/critical limb ischemia
No full textBackground: Chronic Limb Threat Ischemia (CLTI) is a severe form of peripheral arterial disease characterized by various symptoms including nonhealing wounds, ulcers and gangrene ultimately leading to a possible amputation. Therefore, revascularization either through endovascular intervention (EVI) or surgical bypass (SB) is an important step in management. Literature review of various studies including Randomized clinical trials (RCTs), Meta-analysis and observational studies show varied results with some studies suggesting better outcomes with EVI while majority of the others favors superiority of SB. Our Systematic review and meta-analysis aims to ascertain underlying differences between the approaches.
Methods: We performed a Meta-analysis of observational studies and RCTs following the PRISMA guidelines. We searched Pubmed, and Cochrane databases. After removing duplicates and studies that did not meet the inclusion criteria, 9 studies were included which comprised of 4 RCTs and 5 observational studies. Outcomes measured include limb salvage, amputation free survival and Mortality. Random effects were applied to calculate Odds ratio (OR) and 95 % confidence Intervals (CI).
Results: A total of 6375 patients from 9 studies were included. The pooled analysis from the meta-analysis comparing Endovascular intervention vs Surgical Bypass showed no statistically significant difference between the outcomes. The Pooled OR was 0.990(95%CI 0.913-1.073). Additionally the heterogeneity among the studies was moderate (i2 = 34.7 %) suggesting some variability in the study results but not enough to conclude a significant difference. Additionally subgroup analysis was performed for above-knee and infra popliteal interventions which yielded statistically similar results.
Conclusions: Based on the results above, neither endovascular intervention nor bypass surgery showed superiority over the other for outcomes such as limb salvage, mortality and amputation free survival. Therefore, effectiveness of both interventions for revascularization is comparable.
Keywords: Critical limb ischemia/chronic limb-threatening ischemia (CLT/CLTI); Peripheral artery disease (PAD)
Managing pregnancy-associated breast cancer: A practical approach
No full textPregnancy-Associated Breast Cancer (PABC) is a rare but complex condition that presents both professional and ethical challenges. Diagnosis is often delayed due to breast changes associated with pregnancy and puerperium, which can mask malignant findings. Management requires a multidisciplinary approach that carefully balances maternal and fetal risks. Chemotherapy is generally reserved for the second and third trimesters to avoid teratogenicity, with anthracyclines being the most well-studied and safest agents in this setting. Surgical decisions are influenced by factors such as cancer stage, gestational age, and the timing of potential radiation therapy. Notably, radiation therapy, endocrine therapy, and most targeted therapies are contraindicated during pregnancy due to potential harm to the fetus. Comprehensive care should include robust social and mental health support for the mother and her family to help navigate the physical and emotional challenges during this period.
Keywords: Breast cancer; Cancer in pregnancy; Pregnancy; Pregnancy associated breast cancer
Feasibility of volume targeted- positive pressure ventilation for preterm infants requiring invasive ventilation in the delivery room
No full textBackground: Positive pressure ventilation (PPV) with high variability in delivered tidal volume (TV) may cause volutrauma. We aimed to assess feasibility of providing Volume Targeted-Positive Pressure Ventilation (VT-PPV) to preterm infants receiving invasive mechanical ventilation via endotracheal tube in the delivery room (DR).
Design/methods: TV measurements were available from a respiratory function monitor (RFM) to adjust peak inspiratory pressures to target TV of 4-6 ml/kg for participants in the intervention cohort (VT-PPV). This data was compared with a historic cohort (HC), where providers were blinded from RFM measurements.
Results: With VT-PPV, goal TV (4-6 ml/kg) was provided 40.1% of times (vs. HC:23.6%, p = 0.002); low TV (\u3c4 ml/kg) was provided 8.6% of times (vs. HC:28.1%, p ≤ 0.001). There was no difference in higher TV provided in the two cohorts.
Conclusion: Providing VT-PPV in intubated preterm infants may be feasible in DR and may result in increased number of breaths in target range
Comparison of Different PCI Strategies for Coronary DES In-stent Restenosis: A Bayesian Network Meta-analysis
No full textBackground: Though superior to bare-metal stents (BMS), drug-eluting stents (DES) based PCI still have significant in-stent restenosis (ISR). Balloon angioplasty (BA), drug-coated balloons (DCBs), and DES are common modalities to treat ISR. The existing guidelines recommend treating ISR with either DCB or DES for BMS-ISR and DES-ISR, despite differences in the underlying mechanisms. Because DES are currently the most used stents worldwide, we performed a network meta-analysis (NMA) to compare DES-ISR treatment strategies.
Methods: We searched Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus for relevant studies published until March 30, 2024 and performed a Bayesian NMA to synthesize direct and indirect evidence. The primary outcome was a target lesion revascularization (TLR) at follow-up.
Results: Of 1202 studies, 30 were deemed eligible, with 15 being randomized studies. This included 8016 patients with DES-ISR who were assigned to 12 different PCI strategies. In the NMA for DES-ISR, paclitaxel-eluting stent (76.42) was the most effective strategy for TLR; paclitaxel-coated balloon (PCB) and scoring balloon angioplasty (75.88) for major adverse cardiovascular events (MACE); sirolimus-coated balloon (SCB) for target lesion failure (64.16), myocardial infarction (93.57), and stent thrombosis (98.53); and PCB for all-cause death (76.39) and cardiac death (83.74) based on SUCRA value. BA-based strategies were less effective alternatives for DES-ISR treatment with DCB or DES.
Conclusions: DES and DCB PCI such as PCB and SCB should be considered for treatment of coronary DES-ISR to achieve the most clinical efficacy and safety benefits for MACE. Further studies are required for more robust evidence on different treatment strategies.
Keywords: drug-coated balloon; drug-eluting stents; in-stent restenosis
Cardiovascular Event Prevalence in Type 1 Versus Type 2 Diabetes: Veradigm Metabolic Registry Insights
No full textBackground: Diabetes mellitus type 1 (DM1) and type 2 (DM2) are well-established risk factors for cardiovascular disease but differ pathophysiologically in that DM1 results from insulin deficiency, whereas DM2 results from insulin insensitivity. The association between DM1 and DM2 and cardiovascular events remains undetermined.
Methods: For DM1 or DM2 patients aged 46 to 75 years receiving care at outpatient facilities with primary care and/or endocrinology enrolled in the National Cardiovascular Data Registry Veradigm Metabolic Registry 2017-2022, we compared the prevalence of incident cardiovascular events including myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, stroke, carotid revascularization, limb ischemia, and peripheral revascularization.
Results: The study population included 5823 DM1 patients (3.59%) and 156,204 DM2 patients (95.41%) with a total of 758,643 visits. DM1 patients were younger and had fewer comorbidities. A total of 11,096 incident cardiovascular events occurred with a prevalence ratio (PR) of 0.63 (95% CI, 0.55-0.71) for fewer events associated with DM1 than DM2. After adjustment for age, the PR was 0.66 (95% CI, 0.58-0.74). When analyzed by separate cardiovascular events, DM1 was associated with less myocardial infarction, percutaneous coronary intervention, stroke, and limb ischemia than DM2. Overall cardiovascular event probability was lower in DM1 than in DM2 across all 10-year age categories, in both female and male patients, before and during/after the coronavirus disease 2019 pandemic, and after adjustment for comorbidities, hemoglobin A1c, and serum creatinine.
Conclusions: DM1 was associated with a lower probability of incident cardiovascular events than DM2. Although DM1 may carry a lower risk of incident cardiovascular events than DM2, the pathophysiology, prevention, and treatment of cardiovascular disease in DM1 remain poorly understood.
Keywords: cardiovascular event; diabetes; diabetes mellitus type 1; diabetes mellitus type 2; myocardial infarction; stroke
Sequential decreases in basolateral amygdala response to threat predict failure to recover from PTSD
No full textAmygdala hyperreactivity early-post trauma has been a demonstrable neurobiological correlate of future posttraumautic stress disorder (PTSD). The basolateral amygdala (BLA) particularly is vital for fear memory and threat processing, but BLA functional dynamics following a traumatic event are unexplored. BLA reactivity to threat may be a trait that can predict PTSD and persist over time. Alternatively, BLA responsivity to threat cues may change over time and be related to PTSD severity. As part of a larger, multisite study, AURORA, participants 18-75 years old were enrolled in an emergency department (ED) within 72 h of a traumatic event (N = 304, 199 female). At 2-weeks and 6-months post-trauma, PTSD symptoms, BLA responses to threat (fearful\u3eneutral faces), and functional connectivity (FC) during fMRI were assessed. Generalizability of findings was assessed in an external replication sample of ED patients (n = 33). Two weeks post-trauma right BLA reactivity positively predicted later PTSD severity. However, left BLA reactivity to threat at 6 months post-trauma was negatively associated with PTSD severity at that timepoint (ΔPseudo-R2 = 0.04, IRR = 0.38, p \u3c 0.001). In addition, a decrease in BLA reactivity from 2-weeks to 6-months predicted greater PTSD severity at 6 months (ΔPseudo-R2 = 0.03, IRR = 0.58, p \u3c 0.001). This replicated in the external sample. A reduction in left BLA FC with the dorsal attention network predicted increased PTSD severity over time. These findings support a shift in BLA function within the first 6 months post-trauma that predicts PTSD pathology and stand in contrast to prior conceptualizations of amygdala hyperreactivity as a trait-like PTSD risk factor
Prehospital Blood Administration in Traumatic Hemorrhagic Shock
No full textFollowing the military\u27s advancement of prehospital blood into the field, civilian prehospital blood programs are becoming more prevalent. However, there are significant differences between civilian and military prehospital operations that should be considered. Civilian prehospital systems also vary widely in terms of resources, transport times, and patient types. Given these variations and the logistical challenges associated with establishing a prehospital blood program, careful consideration of the state of the science is warranted. Although blood is the preferred fluid for patients in hemorrhagic shock, there have only been a few high-quality studies that have examined the efficacy of administering blood in the prehospital setting. Given the conflicting results of these studies, individual medical directors must determine whether the risk-benefit analysis for their system warrants establishing such a resource-intensive operation. Efforts to establish a prehospital blood program should not supersede attempts to optimize the fundamental components of trauma operations and management.
Keywords: EMS blood administration; blood products; fresh frozen plasma (FFP); management of traumatic hemorrhagic shock; packed red blood cells (pRBCs); prehospital blood program; whole blood