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Temporary mechanical circulatory support utilization and outcomes in cardiogenic shock phenotypes: A comparative analysis of heart failure and acute myocardial infarction
No full textINTRODUCTION: Cardiogenic shock (CS) is marked by substantial morbidity and mortality. The two major CS etiologies include heart failure (HF) and acute myocardial infarction (AMI). The utilization trends of mechanical circulatory support (MCS) and their clinical outcomes are not well described.
METHODS: This study compares the rates of MCS utilization, factors associated with utilization, and clinical outcomes in patients who present with HF-CS and AMI-CS, using 2016-2020 National Inpatient Sample data.
RESULTS: The study included 329,280 patients, comprising 204,660 cases of AMI-CS and 124,620 of HF-CS. MCS utilization increased over the study period with variable degree among devices, and CS-phenotype. AMI-CS had higher intraaortic balloon pump (32.4 % vs. 8.9 %), extracorporeal membrane oxygenation (2.8 % vs. 2.4 %), and percutaneous ventricular assist device use (14.5 % vs. 8.1 %) compared to HF-CS (p \u3c 0.01). Factors linked to lower MCS use were female sex, age over 60 years, Black race, atrial fibrillation, chronic obstructive lung disease, diabetes mellitus, cirrhosis, previous stroke, or myocardial infarction. After adjusting for various factors, patients with HF-CS vs. AMI-CS had significantly fewer adverse outcomes, including inpatient death, stroke, tracheostomy, mechanical ventilation, and blood transfusion. However, HF-CS had higher odds of acute renal failure requiring dialysis. AMI-CS was associated with shorter hospital stays (8.8 vs. 15.0 days, p \u3c 0.001), lower charges (294,792, p \u3c 0.001), and were less likely to discharge home.
CONCLUSION: Despite the evolving trends in MCS utilization over time, CS patients still face high morbidity and mortality rates. The underlying shock etiology has a substantial impact on outcomes, with AMI cases demonstrating worse complications. This highlights the need for a standardized approach that also takes into consideration etiology, patient-specific factors, care availability, and equitable access
Hemodynamic Effects and Clinical Outcomes of Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) in Cardiogenic Shock
No full textLeft atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in CS is a novel mechanical cardiocirculatory support strategy that provides robust cardiocirculatory support and simultaneous left and right atrial venting via a multi-fenestrated transeptal catheter. We performed a single-center retrospective analysis of all patients aged ≥ 18 years with CS who underwent LAVA-ECMO at a quaternary care institution from 2018-2023. Clinical outcomes as well as pre- and post-hemodynamics were evaluated. A total of 68 patients were analyzed (75% male, 72% white, median age 63). Indications for LAVA-ECMO were CS due to myocardial infarction (29.4%), biventricular failure (26.5%), and/or valvular heart disease (26.5%). Trans-septal puncture was guided by intracardiac echocardiography (86.8%) or transesophageal echocardiography (13.2%). Arterial cannulation was performed via transcaval access in 25% of the cases. Post-LAVA-ECMO cannulation was associated with substantial improvement in the hemodynamics within 24 hours post cannulation, including reduction in right atrial pressure (absolute mean difference: -5.0 mmHg, p\u3c0.001), mean pulmonary artery pressure (-9.0 mmHg, p\u3c0.001), pulmonary capillary wedge pressure (-10.0 mmHg, p\u3c0.001), and LV end-diastolic pressure (-14.0 mmHg, p\u3c0.001). Survival to decannulation occurred in 69.1%, while 30-day survival from cannulation was 51.5%. In-hospital all-cause mortality was 51.5%. Only 5 patients (7.4%) required additional MCS (4 Impella, 1 VAV-ECMO). There were no complications related to transeptal placement of the venous ECMO cannula. In conclusion, LAVA-ECMO, a MCS strategy providing bi-atrial drainage, appears to also provide simultaneous LV venting as demonstrated by improved invasive hemodynamics. Although the procedure itself appears safe, with no direct complications to interatrial septal cannulation, post-cannulation complications remain high, and further studies are needed to evaluate the full safety profile of LAVA-ECMO compared to alternative MCS strategies
An Educational Intervention to Promote Central Nervous System-Active Deprescribing in Dementia: A Pilot Study
No full textBACKGROUND: Central nervous system (CNS)-active polypharmacy (defined as concurrent exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, or nonbenzodiazepine benzodiazepine receptor agonists) is associated with significant potential harms in persons living with dementia (PLWD).We conducted a pilot trial to assess a patient nudge intervention\u27s implementation feasibility and preliminary effectiveness to prompt deprescribing conversations between PLWD experiencing CNS-active polypharmacy and their primary care clinicians ( clinicians ).
METHODS: We used the electronic health record to identify PLWD prescribed CNS-active polypharmacy in primary care clinics from two health systems. Clinics were assigned to intervention (n = 10) or control (n = 12), with PLWD in intervention clinics mailed an educational brochure to prompt discussion with clinicians about the appropriateness of their CNS-active regimen. We conducted chart reviews for evidence of documentation related to these medications and used the electronic health record (EHR) to assess preliminary effectiveness 120 days after sending the brochure (e.g., number of CNS-active medications prescribed, change in total standardized daily dose [TSDD] of CNS-active medications, and change in prevalence of CNS-active polypharmacy). We interviewed 10 clinicians from intervention clinics to assess their perceptions about the acceptability of the intervention.
RESULTS: PLWD in the intervention group (n = 61) and control group (n = 68) had an average age of 72.4 years (standard deviation [SD] 9.7), 62.8% were female, and 84.5% were white. We did not find any documented evidence of conversations related to CNS-active medications between PLWD who received the brochure and their primary care clinicians. After 120 days, there was no significant between-group difference in the mean number of CNS-active medications prescribed (- 1.0 [SD 1.3] versus - 1.0 [SD 1.3]), mean TSDD (- 1.6 [SD 6.0] versus - 1.3 [SD 5.8]), or the percentage of patients with CNS-active polypharmacy (52.6% versus 50.4%). Interviews with clinicians suggested they were aware that combinations of CNS-active medications were not ideal; however, they reported inheriting patients who were already on these medications, and they did not have sufficient clinic time or access to safer alternatives to overcome patient hesitation to deprescribe.
CONCLUSIONS: A direct-to-patient mailed educational brochure did not demonstrate feasibility in provoking deprescribing conversations between PLWD and clinicians or preliminary effectiveness in decreasing CNS-active polypharmacy
Exploring itch in hidradenitis suppurativa with lessons from atopic dermatitis and psoriasis
No full textItch is a prominent symptom in many cutaneous disorders, including atopic dermatitis (AD), prurigo nodularis, and psoriasis. Itch is also a common but overlooked concern in patients with hidradenitis suppurativa (HS). Currently, the mechanisms underlying itch in HS remain unclear. To gain a better understanding, we reviewed the literature on pruritus in HS and other itch-predominant disorders, AD, and psoriasis. In HS, psoriasis, and AD, we found that itch often co-localized with pain and occurred more frequently at night. Furthermore, itch was found to negatively affect sleep and increase the risk for comorbid psychiatric disorders in HS, psoriasis, and AD. However, HS-, psoriasis-, and AD-related itch differ in temporality. Itch in AD is often described as chronic, while itch in HS and psoriasis is often described as episodic. HS-associated itch is likely multifactorial, and several mechanisms have been proposed including peripheral sensitization, central sensitization, and neuroinflammation. Prior studies in HS highlight enhanced IgE production and a dense infiltration of mast cells, along with a variety of cytokines and chemokines. Furthermore, alterations in the skin microbiome may contribute to itch in HS. To date, few therapies have been studied to treat itch in HS. Given the efficacy of several biologics and small molecules in treating itch in AD and psoriasis, similar agents may be explored in future HS studies. Alternative therapies to target neurological and psychiatric contributions to itch may include anticonvulsants, cannabinoids, and nonpharmacological treatments. In conclusion, pathomechanisms of itch in HS remain to be fully elucidated. However, we can draw on lessons from other pruritic disorders to begin addressing the symptom of it and identify important questions for future study
Cancer clinical trial participation: a qualitative study of Black/African American communities\u27 and patient/survivors\u27 recommendations
No full textBACKGROUND: Black/African Americans experience disproportionate cancer burden and mortality rates. Racial and ethnic variation in cancer burden reflects systemic and health-care inequities, cancer risk factors, and heredity and genomic diversity. Multiple systemic, sociocultural, economic, and individual factors also contribute to disproportionately low Black/African American participation in cancer clinical trials.
METHODS: The Participatory Action for Access to Clinical Trials project used a community-based participatory research approach inclusive of Black/African American community-based organizations, Henry Ford Health, and the University of Michigan Urban Research Center. The project aims were to understand Black/African Americans\u27 behavioral intentions to participate in cancer clinical trials and to obtain recommendations for improving participation. Audio-recorded focus group data were transcribed and coded, and searches were conducted to identify themes and subthemes. Representative text was extracted from the transcripts.
RESULTS: Six community focus group discussions (70 participants) and 6 Henry Ford Health patient/survivor focus group discussions (29 participants) were completed. General themes related to trial participation were identified, including (1) systemic issues related to racism, health disparities, and trust in government, health systems, and clinical research; (2) firsthand experiences with health care and health systems; (3) perceived and experienced advantages and disadvantages of clinical trial participation; and (4) recruitment procedures and personal decision-making processes. Specific recommendations on how to address barriers were obtained.
CONCLUSIONS: Community-based participatory research is effective in bringing communities equitably to the table. To build trust, health systems must provide opportunities for patients and communities to jointly identify factors affecting cancer clinical trial participation, implement recommendations, and address health disparities
The impact of sugammadex versus neostigmine reversal on return to intended oncological therapy-related outcomes after breast cancer surgery: a retrospective cohort study
No full textBACKGROUND: Early return to intended oncological therapy (RIOT) after cancer resection is a determinant for long-term oncological outcomes. Sugammadex is increasingly used to reverse the muscle relaxant effect of rocuronium during general anesthesia. It has been shown to improve early postoperative outcomes, but its impact on RIOT is unknown. This study tested the hypothesis that the administration of sugammadex during mastectomy for nonmetastatic breast cancer resection would be associated with better RIOT-related outcomes compared with neostigmine.
METHODS: Women ≥ 18 years who required mastectomy for nonmetastatic breast cancer resection from 2015 to 2022 were included in the retrospective study. They were grouped according to the administration of sugammadex or neostigmine. The study outcomes included time to RIOT, the incidence of RIOT at 90 and 180 days, length of hospital stay, and rate of 30-day hospital readmission. A multivariate analysis was conducted to test the association between sugammadex use and RIOT-related outcomes.
RESULTS: Of 888 patients who met the study criteria, 319 received neostigmine and 569 received sugammadex. Sugammadex patients achieved RIOT at 90 days in 81.9% of the cases, whereas 70.8% of neostigmine patients were able to achieve RIOT (P \u3c 0.001). Similar results were found for RIOT at 180 days (85.8% vs. 76.8%, respectively; P \u3c 0.001). Sugammadex patients achieved RIOT faster than neostigmine patients (37 days, 95% CI: 35-41 days; P \u3c 0.001). However, the multivariate analysis for RIOT initiation and time to RIOT did not show statistically significant differences.
CONCLUSION: The administration of sugammadex, compared with neostigmine, is not associated with significant improvements in RIOT-related variables after breast cancer surgery
Characteristics and Outcomes of ST-Segment Elevation Myocardial Infarction due to Left Main Coronary Artery Stenosis
No full textThere is limited data on the incidence and outcomes of ST-segment elevation myocardial infarction (STEMI) due to the left main coronary artery (LMCA) lesions. We aimed to examine the trends and outcomes of STEMI due to LMCA lesions. The Nationwide Readmissions Database was utilized to identify hospitalizations with LMCA STEMI between January 2016 and December 2022. The primary outcome was all-cause in-hospital mortality during index admission. Among 1,528,764 weighted hospitalizations with STEMI from 2016 to 2022, 4,885 (0.3%) were due to LMCA lesions, of which 2,156 (44.1%) had cardiogenic shock (CS). The number of LMCA STEMI hospitalizations and the incidence of CS increased over time. Mechanical circulatory support was used in 78.8% of the patients with LMCA STEMI and CS, with intra-aortic balloon pump being the most common modality (63%). Impella utilization increased from 4.5% in Q1 2016 to 34% in Q4 2022. Revascularization was performed in 78.2% of cases, with percutaneous coronary intervention (PCI) being the most common revascularization modality (62.1%). Among those who had PCI, intravascular imaging (IVI) was used in 18.3%, with a significant increase from 9.6% in Q1 2016 to 26.3% in Q4 2022. All-cause in-hospital mortality was 25.5% and was significantly higher among CS patients (43.4% vs. 11.4%, P\u3c 0.001). In conclusion, the incidence of LMCA STEMI increased from 2016 to 2022 with nearly half of the patients developing CS. IVI use in LMCA PCI was low (18.3%) but increased over time. More than 1 in 4 patients with LMCA STEMI died during the index hospitalization
Comparative effectiveness of high-intensity interval training and moderate-intensity continuous training on cardiometabolic health in patients with diabesity: a systematic review and meta-analysis of randomized controlled trials
No full textOBJECTIVE: To evaluate the effects of high-intensity interval training (HIIT) on cardiometabolic health-related outcomes in patients with type 2 diabetes mellitus and concurrent overweight/obesity (diabesity).
DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs).
DATA SOURCES: PubMed, Web of Science, Scopus, Science Direct, Cochrane Library, and Google Scholar databases were searched from inception up to January 31, 2025.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: RCTs comparing HIIT alone ≥ 2 weeks in duration with moderate-intensity continuous training (MICT). Participants were adults with diabesity.
RESULTS: A total of 26 RCTs qualified, involving 790 patients (50/50 female/male ratio; age: 59.8 ± 12.9 years; body mass index: 28.9 ± 4.2 kg/m(2)). HIIT revealed a significant reduction in fasting insulin [standardized mean differences (SMD) - 0.43, 95% CI - 0.82 to - 0.05] and homeostatic model assessment for insulin resistance (HOMA-IR; SMD - 0.52, 95% CI - 0.97 to - 0.07) compared to MICT. Additionally, HIIT significantly increased cardiorespiratory fitness (VO₂max; SMD 0.53, 95% CI 0.14 to 0.91) compared to MICT. Other clinically relevant cardiometabolic outcomes, including body composition, lipid profile, fasting blood glucose, glycated hemoglobin, and blood pressure, showed comparable changes between HIIT and MICT. Subgroup analyses of studies reporting comorbidities indicated a significant increase in high-density lipoprotein cholesterol (SMD 0.49, 95% CI 0.04 to 0.95) and a decrease in HOMA-IR (SMD - 0.83, 95% CI - 1.62 to - 0.04) for HIIT compared to MICT. However, these findings are limited by very low certainty evidence and non-robust sensitivity analyses.
CONCLUSIONS: The present findings suggest that HIIT may serve as an adjunctive non-pharmaceutical management solution for patients with diabesity. Open Science Framework registry: https://osf.io/9by24
