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Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia
No full textBackground: A strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level.
Methods: In this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, \u3c10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days.
Results: A total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P = 0.07). Death occurred in 9.9% of the patients with the restrictive strategy and in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49).
Conclusions: In patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.)
Antithrombotic Therapy with Transcatheter Aortic Valve Replacement
No full textAortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon, and the implications for antithrombotic therapy, continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
Keywords: anticoagulant; antiplatelet; antithrombotic; thrombosis; transcatheter aortic valve
Expert Systematic Review on the Choice of Conduits for Coronary Artery Bypass Grafting: Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)
No full textSelf-Care in the Workplace
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2023/1034/thumbnail.jp
A Randomized Controlled Trial of the Impact of Titration Instruction Orders on Time to Achieving Hemodynamic Stability in a Simulated Setting
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2023/1031/thumbnail.jp
Can a Checklist Facilitate Recognition of a Transfusion Associated Adverse Event by Prelicensure Nurses
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2023/1029/thumbnail.jp
Reducing Pressure Injury Rates at Baystate Children’s Hospital
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2023/1021/thumbnail.jp
Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts
No full textObjective: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative.
Methods: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle.
Results: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle.
Conclusion: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes
Right to Left Cardiac Power Output- New Prognosticator in STEMI Patients with Cardiogenic Shock (R-Shock)
No full textBackground: ST elevation myocardial infarction (STEMI) is a leading cause of cardiogenic shock (CS) and carries substantial mortality. Cardiac power output (CPO) is the strongest predictor of clinical outcome in CS, and worse outcomes result from concomitant right and left ventricular failure. Right ventricular performance is calculated using right sided CPO. Our aim was to measure the right sided CPO and compute their ratio to predict in-hospital mortality in STEMI patients with cardiogenic shock.
Methods: This was a retrospective observational study of consecutive STEMI patients with CS that developed within the first 24hours of admission requiring left and right cardiac catheterization at a large tertiary care center from January 2014-December 2018.
Results: 164 patients identified with STEMI; 46% (75) excluded due to incomplete data. 88 remaining patients, 52.8% (47) developed CS. 98.9% within 24 hours. Mean left & right CPO 0.62 (SD 0.3) & 0.22 (SD 0.13), PAPi score 1.81. Logistic regression analysis indicated odds ratio of in-hospital mortality lower for low left CPO, high right CPO and low ratio of left to right CPO (95% CI; 0.69, 0.34, 1.20; 1.38, 0.87, 2.20; 0.52, 0.28, 1.00 respectively).
Conclusion: This is the first study to assess right sided CPO and ratio of right and left side CPO and mortality. Our study indicates that there is trend towards higher in-hospital mortality in patients with high right sided CPO and lower ratio of left to right CPO. The exploratory results of this study need to be confirmed in a larger population.
Keywords: Cardiogenic Shock; Ratio of Right to Left Cardiac Power Output; Right Cardiac Power Output; ST Elevation Myocardial Infarction
Effectiveness of a bivalent mRNA vaccine dose against symptomatic SARS-CoV-2 infection among U.S. Healthcare personnel, September 2022-May 2023
No full textBackground: Bivalent mRNA vaccines were recommended since September 2022. However, coverage with a recent vaccine dose has been limited, and there are few robust estimates of bivalent VE against symptomatic SARS-CoV-2 infection (COVID-19). We estimated VE of a bivalent mRNA vaccine dose against COVID-19 among eligible U.S. healthcare personnel who had previously received monovalent mRNA vaccine doses.
Methods: We conducted a case-control study in 22 U.S. states, and enrolled healthcare personnel with COVID-19 (case-participants) or without COVID-19 (control-participants) during September 2022-May 2023. Participants were considered eligible for a bivalent mRNA dose if they had received 2-4 monovalent (ancestral-strain) mRNA vaccine doses, and were ≥67 days after the most recent vaccine dose. We estimated VE of a bivalent mRNA dose using conditional logistic regression, accounting for matching by region and four-week calendar period. We adjusted estimates for age group, sex, race and ethnicity, educational level, underlying health conditions, community COVID-19 exposure, prior SARS-CoV-2 infection, and days since the last monovalent mRNA dose.
Results: Among 3,647 healthcare personnel, 1,528 were included as case-participants and 2,119 as control-participants. Participants received their last monovalent mRNA dose a median of 404 days previously; 1,234 (33.8%) also received a bivalent mRNA dose a median of 93 days previously. Overall, VE of a bivalent dose was 34.1% (95% CI, 22.6%-43.9%) against COVID-19 and was similar by product, days since last monovalent dose, number of prior doses, age group, and presence of underlying health conditions. However, VE declined from 54.8% (95% CI, 40.7%-65.6%) after 7-59 days to 21.6% (95% CI 5.6%-34.9%) after ≥60 days.
Conclusions: Bivalent mRNA COVID-19 vaccines initially conferred approximately 55% protection against COVID-19 among U.S. healthcare personnel. However, protection waned after two months. These findings indicate moderate initial protection against symptomatic SARS-CoV-2 infection by remaining up-to-date with COVID-19 vaccines.
Keywords: Bivalent; COVID-19; COVID-19 vaccines; Healthcare personnel; SARS-CoV-2; Vaccine effectiveness; mRNA vaccines