11210 research outputs found
Sort by
A Bayesian re-analysis of the STRESS trial
No full textBackground: Prophylactic steroids are often used to reduce the systemic inflammatory response to cardiopulmonary bypass in infants undergoing heart surgery. The STRESS trial found that the odds of a worse outcome did not differ between infants randomized to methylprednisolone (n=599) versus placebo (n=601) (adjusted odds ratio [OR], 0.86; P=0.14). However, secondary analyses showed possible benefits with methylprednisolone. To investigate further using a different probabilistic approach, we re-analyzed the STRESS trial using Bayesian analytics.
Methods: We used a covariate-adjusted proportional odds model using the original STRESS trial primary endpoint, a ranked composite of death, transplant, major complication and post-op length of stay. We performed Markov Chain Monte Carlo simulations to assess the probability of benefit (OR1). Primary analysis assumed a neutral probability of benefit versus harm with weak prior belief strength (nearly non-informative prior distribution). To illustrate magnitude of effect, we calculated predicted risk of death, transplant or major complications for methylprednisolone and placebo. Sensitivity analyses evaluated pessimistic (5%-30% prior likelihood of benefit), neutral and optimistic (70%-95%) prior beliefs, and controlled strength of prior belief as weak (30% variance), moderate (15%) and strong (5%). A secondary analysis derived empirical priors using data from four previous steroid trials.
Results: The posterior probability of any benefit from methylprednisolone was 92% and probability of harm was 8%. Composite death or major complication occurred in 18.8% of subjects with an absolute risk difference of -2% (95% CI -3%, +1%) for methylprednisolone. Each of 9 sensitivity analyses demonstrated greater probability of benefit than harm in the methylprednisolone group with 8 of 9 demonstrating \u3e80% probability of benefit and ≥1% absolute difference in risk of death, transplant or major complications. In secondary analysis deriving priors from previous steroid trials, results were consistent with a 95% posterior probability of benefit.
Conclusion: Our Bayesian re-analysis of the STRESS trial, using a range of prior beliefs, demonstrated a high probability that perioperative methylprednisolone reduces the risk of death or major complications in infants undergoing cardiopulmonary bypass compared with placebo. This more in-depth analysis expands the initial clinical evaluation of methylprednisolone provided by the STRESS trial
When support matters most: Considering the five Ws for specialized pediatric palliative care in the PICU
No full textImplementation of social needs screening and intervention in primary care : A systematic review of program-level determinants
No full textBackground: Health care systems are investing significant resources in social needs screening and intervention programs.
Purpose: To understand characteristics contributing to implementation of social needs screening and intervention programs in primary care.
Data sources: CINAHL, Cochrane, Ovid, PubMed, and Scopus (January 2015 to April 2025).
Study selection: U.S.-based programs using structured tools to screen adult patients for at least 1 Healthcare Effectiveness Data and Information Set measure (food insecurity, transportation, and housing insecurity) and addressing social needs in primary care settings.
Data extraction: Program characteristics; screening and intervention implementation processes; and patient screening, intervention, clinical, and health care use outcomes.
Data synthesis: The review included 23 studies. Seventeen reported on screening outcomes, 11 in populations characterized by a particular condition or health care use and 6 in the general population. Programs with the highest percentage of patients screened focused on fewer than 500 patients with a particular condition or health care use and received support from additional staff or volunteers (4 of 17 studies). Of patients screened, 10.1% to 100% reported a social need. Eleven studies reported on receipt of assistance or resources, with a higher percentage of patients receiving assistance or resources among programs that targeted a smaller population. Few studies reported clinical and health care use outcomes, with mixed findings.
Limitations: Few studies had complete reporting of screening and intervention rates and outcomes. Program characteristics and other screening and intervention processes varied across and within studies.
Conclusion: Social needs programs focused on smaller, targeted populations were more likely to screen and assist a higher percentage of patients. Programs with adequate staffing may also screen a higher proportion of patients. However, evidence is mixed, particularly for clinical and health care use outcomes. Considerable differences among screening and intervention programs preclude simple suggestions for universal implementation.
Primary funding source: Live Well Intramural Pilot Grant Program. (PROSPERO: CRD42023431151)
Timing of renal and bladder ultrasound after first febrile urinary tract infection: A hospitalist dilemma
No full textSimulation-based education for extracorporeal membrane oxygenation and strategies for implementation: A systematic scoping review
No full textSimulation-based education (SBE) in health care is expanding in both scope and relevance. As on-the-job training is challenging in extracorporeal membrane oxygenation (ECMO), SBE features strongly in its curricula, yet little is known regarding its efficacy. We searched 4 databases through May 13, 2022 and conducted a narrative synthesis of 28 studies investigating SBE in ECMO. Notably, there were no standardized SBE ECMO curricula among studies. Nonetheless, taken together, these articles suggest that simulation improves competency scores, confidence, teamwork, troubleshooting emergencies, and times to critical actions and cannulation. Though the reporting of SBE in ECMO is heterogeneous, simulation may be comparable to, or more effective than, conventional training methods. Retention of knowledge and skills over time remains unclear though regular simulation training may be beneficial. There is a need to establish standardized ECMO curricula, of which SBE should be a core component
Inside Aurora Sinai Medical Center, 2004 June
No full textAurora Sinai Medical Center, Milwaukee, WI: Internal employee newsletter with workplace anniversaries, news, and events.https://institutionalrepository.aah.org/alldocuments/2262/thumbnail.jp
Transcatheter versus surgical treatment in aortic stenosis with coronary artery disease: A meta-analysis of time-to-event data on 162,305 patients
No full textBackground: Severe aortic stenosis (AS) often coexists with coronary artery disease (CAD), present in about 50 % of patients undergoing valve intervention. Surgical aortic valve replacement (SAVR) with coronary artery bypass graft (CABG) has been the traditional standard, providing revascularization and durability, whereas transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) offers a less invasive option. PCI + TAVR may lower perioperative risk, but SAVR + CABG may confer superior survival, with conflicting evidence.
Objectives: This meta-analysis of time-to-event data aimed to compare PCI + TAVR with CABG + SAVR in patients with concomitant AS and CAD.
Methods: We systematically searched PubMed, Web of Science, Scopus, and Cochrane databases up to March 2025. Individual patient data (IPD) were reconstructed from published Kaplan-Meier curves to estimate hazard ratios (HRs) for all-cause mortality. Dichotomous outcomes were analyzed using risk ratios (RR) with 95 % confidence intervals (CI).
Results: Fifteen studies including 162,305 patients were analyzed. PCI + TAVR was associated with higher all-cause mortality at 48 months (HR 1.29, 95 % CI 1.23-1.35, p \u3c 0.001), but lower in-hospital acute kidney injury (RR 0.37, 95 % CI 0.21-0.66, p = 0.0007), short-term (≤30 days) major adverse cardiovascular events (RR 0.67, 95 % CI 0.50-0.91, p = 0.0093), and new-onset atrial fibrillation (RR 0.23, 95 % CI 0.17-0.32, p \u3c 0.0001). Conversely, long-term (\u3e30 days) myocardial infarction risk was higher (RR 1.61, 95 % CI 1.08-2.39, p = 0.01).
Conclusions: PCI+TAVR was associated with higher mortality or adverse event rates compared to CABG+SAVR, but lower perioperative complications. High-quality randomized trials are warranted to confirm these findings
Iron balance and cardiovascular health: The double-edged role of deficiency and overload
No full textCardiovascular disease is the leading cause of death worldwide, accounting for about a third of all deaths. Traditional risk factors like hypertension, diabetes, dyslipidemia, and obesity are well known, but iron also plays a crucial role in heart health. Iron is essential for oxygen transport, mitochondrial function, and heart muscle activity, and both deficiency and overload can harm cardiovascular outcomes. This review examines studies on iron metabolism, regulation via the hepcidin-ferroportin pathway, myocardial energy, oxidative stress, and clinical trials of iron supplementation or reduction in heart failure, chronic kidney disease, the elderly, women, and athletes. Iron deficiency affects over 60% of heart failure patients, leading to reduced energy, lower exercise capacity, and higher morbidity. Intravenous iron improves functional capacity, quality of life, and reduces hospitalizations, especially in patients with low transferrin saturation. Iron overload, on the other hand, increases oxidative stress, arrhythmias, and cardiomyopathy. Evidence shows a U-shaped relationship between iron and cardiovascular outcomes, emphasizing the importance of markers like transferrin saturation, soluble transferrin receptor, and hepcidin. Iron imbalance contributes to cardiovascular disease. Targeted assessment and treatment, including supplementation for deficiency and chelation or phlebotomy for overload, may improve outcomes. The ultimate aim of this review is to enhance perioperative management and long-term results for this highly vulnerable population by synthesizing current insights and addressing knowledge gaps
Outcomes in surgical management of Graves\u27 disease: Transcervical versus transoral thyroidectomy
No full textObjective: To compare surgical outcomes of patients with Graves\u27 disease undergoing total thyroidectomy through the transoral endoscopic thyroidectomy vestibular approach versus the transcervical approach.
Study design: Retrospective cohort study.
Setting: Tertiary care academic institution.
Methods: Patients were offered a choice of either approach, undergoing surgery between September 2016 (when TOETVA was first offered) and March 2024. Patients were excluded if they were under 18 years old or received a neck dissection or re-operation. Collected data includes demographics, clinical and surgical variables, pathology, and postoperative complications.
Results: In total, 152 transcervical and 81 transoral cases were included. The transoral group was younger (36.1 vs 45.3 years, P \u3c .0001) and had more females (95.1% vs 77.0%, P = .0003) but had comparable body mass index to the transcervical group. There were no significant differences in the median maximum lobe size (5.9 (transcervical) vs 5.6 (transoral) cm, P = .647). Complication rates were similar between groups. Of the minor complications, temporary hypoparathyroidism was the most prevalent with 12 (7.9%) cases in the transcervical and 7 (8.6%) in the transoral groups. There were 2 (1.3%) and 4 (5.0%) cases of major complications in transcervical and transoral groups, respectively. Multivariable regression for age, sex, length of admission, and surgery duration confirmed no significant associations between approach and complication rates.
Conclusion: Transcervical and transoral approaches for surgical management of Graves\u27 disease show statistically comparable rates of minor and major complications, even early in the learning curve. The choice of approach should involve shared decision-making between surgeon and patient, as highly motivated patients may not be excellent candidates