Clinical Characteristics and Predictors of In-Hospital Mortality among Older Patients with Acute Heart Failure

Acute Heart Failure (AHF)-related hospitalizations and mortality are still high in western countries, especially among older patients. This study aimed to describe the clinical characteristics and predictors of in-hospital mortality of older patients hospitalized with AHF. We conducted a retrospective study including all consecutive patients ≥65 years who were admitted for AHF at a single academic medical center between 1 January 2008 and 31 December 2018. The primary outcome was all-cause, in-hospital mortality. We also analyzed deaths due to cardiovascular (CV) and non-CV causes and compared early in-hospital events. The study included 6930 patients, mean age 81 years, 51% females. The overall mortality rate was 13%. Patients ≥85 years had higher mortality and early death rate than younger patients. Infections were the most common condition precipitating AHF in our cohort, and pneumonia was the most frequent of these. About half of all hospital deaths were due to non-CV causes. After adjusting for confounding factors other than NYHA class at admission, infections were associated with an almost two-fold increased risk of mortality, HR 1.74, 95% CI 1.10–2.71 in patients 65–74 years (p = 0.014); HR 1.83, 95% CI 1.34–2.49 in patients 75–84 years (p = 0.001); HR 1.74, 95% CI 1.24–2.19 in patients ≥85 years (p = 0.001). In conclusion, among older patients with AHF, in-hospital mortality rates increased with increasing age, and infections were associated with an increased risk of in-hospital mortality. In contemporary patients with AHF, along with the treatment of the CV conditions, management should be focused on timely diagnosis and appropriate treatment of non-CV factors, especially pulmonary infections.

The emergency visits for back and neck pain during lockdowns

Purpose To assess the rate of visits to the emergency department of our medical center concerning low back or neck pain as a factor of COVID-19 confinement. Methods The study period was a 30-week interval during the COVID-19 pandemic contrasted by a similar stretch in the year preceding the epidemic. Visits to the emergency department prompted by low back or neck pain were recorded prior to and during lockdowns of the pandemic. The significance of the confinements for the development of pain syndromes was evaluated. Results A total of 1530 patients with newly diagnosed back or neck pain were enrolled. Most patients visited our emergency department for low back pain, commonly those older than 60 years. No significant gender variance was disclosed, although most visits of females were for low back pain. Low back pain presentations were curbed following confinement, but the rate of stays for neck pain swelled by more than 10%. Despite back pain predominance, visits for neck pain persisted. Before COVID-19, the average weekly number of emergency department visits was 38.5. This was followed by sharp drops during the COVID-19 lockdown (mean difference=-22.2, 95% CI=-28.7, -15.7, p<0.001) (not significant). Conclusions COVID-19 lockdowns have a significant impact on emergency department presentations due to back and neck pain. A higher rate of presentation for back pain compared to neck pain is probably related to COVID-19, without being affected directly by SARS-CoV-2: confinement-induced immobility might instigate musculoskeletal sequelae, which may be attributed to stress or other psychosocial afflictions.

Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Clinical significance of metabolism-related genes and FAK activity in ovarian high-grade serous carcinoma

Background Administration of poly (ADP-ribose) polymerase (PARP) inhibitors after achieving a response to platinum-containing drugs significantly prolonged relapse-free survival compared to placebo administration. PARP inhibitors have been used in clinical practice. However, patients with platinum-resistant relapsed ovarian cancer still have a poor prognosis and there is an unmet need. The purpose of this study was to examine the clinical significance of metabolic genes and focal adhesion kinase (FAK) activity in advanced ovarian high-grade serous carcinoma (HGSC). Methods The RNA sequencing (RNA-seq) data and clinical data of HGSC patients were obtained from the Genomic Data Commons (GDC) Data Portal and analysed (https://portal.gdc.cancer.gov/). In addition, tumour tissue was sampled by laparotomy or screening laparoscopy prior to treatment initiation from patients diagnosed with stage IIIC ovarian cancer (International Federation of Gynecology and Obstetrics (FIGO) classification, 2014) at the Saitama Medical University International Medical Center, and among the patients diagnosed with HGSC, 16 cases of available cryopreserved specimens were included in this study. The present study was reviewed and approved by the Institutional Review Board of Saitama Medical University International Medical Center (Saitama, Japan). Among the 6307 variable genes detected in both The Cancer Genome Atlas-Ovarian (TCGA-OV) data and clinical specimen data, 35 genes related to metabolism and FAK activity were applied. RNA-seq data were analysed using the Subio Platform (Subio Inc, Japan). JMP 15 (SAS, USA) was used for statistical analysis and various types of machine learning. The Kaplan-Meier method was used for survival analysis, and the Wilcoxon test was used to analyse significant differences. P < 0.05 was considered significant. Results In the TCGA-OV data, patients with stage IIIC with a residual tumour diameter of 1-10 mm were selected for K means clustering and classified into groups with significant prognostic correlations (p = 0.0444). These groups were significantly associated with platinum sensitivity/resistance in clinical cases (χ2 test, p = 0.0408) and showed significant relationships with progression-free survival (p = 0.0307). Conclusion In the TCGA-OV data, 2 groups classified by clustering focusing on metabolism-related genes and FAK activity were shown to be associated with platinum resistance and a poor prognosis.

Comparative Evaluation of the Prognosis of Septic Shock Patients from before to after the Onset of the COVID-19 Pandemic: A Retrospective Single-Center Clinical Analysis

In this study, we investigated the mortality of septic shock patients visiting emergency departments (ED) before and after the coronavirus disease (COVID-19) pandemic onset. We retrospectively reviewed medical records and National Emergency Department Information System data of septic shock patients who visited the ED of a tertiary medical center in South Korea from February 2019 to February 2021. Following the COVID-19 pandemic onset, revised institutional ED processes included a stringent isolation protocol for patients visiting the ED. The primary goal of this study was to determine the mortality rate of septic shock patients from before and after the onset of the COVID-19 pandemic. Durations of vasopressor use, mechanical ventilation, intensive care unit stay, and hospitalization were investigated. The mortality rates increased from 24.8% to 35.8%, before and after COVID-19-onset, but the difference was not statistically significant (p = 0.079). No significant differences in other outcomes were found. Multivariable analysis revealed that the Simplified Acute Physiology Score III (SAPS III) was the only risk factor for mortality (OR 1.07; 95% CI 1.04-1.10), whereas COVID-19 pandemic was not included in the final model. The non-significant influence of the COVID-19 pandemic on septic shock mortality rates in the present study belies the actual mortality-influencing potential of the COVID-19 pandemic.

Transarterial Radioembolization for Unresectable Hepatocellular Carcinoma: Real-Life Efficacy and Safety Analysis of Korean Patients

Transarterial radioembolization (TARE) has become widely used in the treatment of HCC, one of the most common causes of cancer mortality worldwide. Here we investigated the long-term clinical outcomes of patients with hepatocellular carcinoma (HCC) treated with TARE in a multi-medical center in Korea. A total of 149 patients treated with TARE from 2008–2014 were recruited. The pre-treatment HCC stage was classified according to the BCLC stage, of which C and D were defined as advanced HCC. Advanced HCC stage and Child–Turcotte–Pugh (CTP) score A were identified in 62 (42%) and 134 (90%) patients, respectively. Portal vein thrombosis (PVT) was identified in 58 patients (38.9%). The median time to progression (TTP) was 14 months, and the median overall survival (OS) and progression-free survival (PFS) were 18.6 and 8.9 months, respectively. The overall tumor response was 47%, and the disease control rate was 78%. OS and PFS differed significantly according to the presence of liver cirrhosis, extrahepatic metastasis, tumor response and curative treatment after TARE (all, p < 0.05). Multiple tumors and major PVT were other independent factors related to OS, while the des-gamma carboxy protein level predicted PFS (all, p < 0.05). Tumor size was an independent predictor of tumor response. TTP, OS and PFS all differed among BCLC stages. The serious adverse effect after TARE was clinically not significant. Therefore, TARE is safe and effective in treating early to advanced HCCs.

Association of red blood cell and platelet transfusions with persistent inflammation, immunosuppression, and catabolism syndrome in critically ill patients

The objective of this single-center retrospective cohort study was to investigate the relationship between blood transfusion and persistent inflammation, immunosuppression, and catabolism syndrome (PIICS). The study was conducted at the Critical Care Center at Toho University Omori Medical Center, Japan. We included 391 patients in the PIICS group (hospitalization for > 15 days, C-reactive protein > 3.0 mg/dL or albumin < 3.0 mg/dL or lymph < 800/μL on day 14) and 762 patients in the non-PIICS group (hospitalization for > 15 days and not meeting the PIICS criteria). We performed univariate and multivariate logistic regression analyses using PIICS as the objective variable and red blood cell (RBC) or fresh frozen plasma or platelet (PLT) transfusion and other confounding factors as explanatory variables. In addition, we conducted a sensitivity analysis using propensity score matching analysis. The multivariate and propensity score analyses showed that RBC and PLT transfusions were significantly associated with PIICS. This is the first study to report an association between RBC and PLT transfusions and PIICS. Our findings have contributed to better understanding the risk factors of PIICS and suggest that physicians should consider the risk of PIICS occurrence when administering blood transfusions in intensive care unit (ICU) patients.

Proactive Variant Effect Mapping to Accelerate Genetic Diagnosis for Pediatric Cardiac Arrest

While genetic testing is becoming standard of care for patients with potentially inherited cardiovascular disease, the prevalence of uncertain results severely limits its utility. One promising approach is to generate variant effect maps that report the function of all possible variants in a gene prospectively. The proactive clinical application of these maps is nascent, and requires careful integration with current American College of Medical Genetics guidelines for variant interpretation. Here, we describe three pediatric cases of cardiac arrest or sudden cardiac death with variants of uncertain significance in calmodulin genes. We demonstrate the prospective clinical utility of a calmodulin variant effect map to inform variant interpretation, and therefore diagnosis and family care, in each case. This study was approved by the Stanford University and Vanderbilt University Medical Center IRBs. Consent was waived based on low risk of de-identified retrospective data collection per the IRB.