Abstract Objective To establish the risk factors and impact of re-exploration for bleeding in a large modern cardiac surgical cohort. Methods At a tertiary referral center, baseline, index ...procedural, re-exploration, outcome and readmission characteristics of 16,793 consecutive adult cardiac surgical patients were prospectively entered into dedicated clinical databases. Correlates of re-exploration for bleeding, as well as its association with outcomes and readmission, were examined with multivariable regression models. Results Mean age was 65.9±12.1 years, and 11,991 (71.4%) patients were male. Perioperative mortality was 458/16,132 (2.8%) in those who did not undergo re-exploration for bleeding and 81/661 (12.0%) in those who had re-exploration for bleeding, corresponding to a 3.4±0.5 odds ratio (P<.001) over other mortality predictors including Euroscore II. Mortality was highest in patients who underwent re-exploration subsequent to the day of index surgery (odds ratio 6.4±1.1). Hospital stay was longer in patients who had re-exploration for bleeding (median 12 versus 7 days in patients who did not have re-exploration; P<.001), to an extent beyond any other correlate. Re-exploration for bleeding also was independently associated with new onset postoperative atrial fibrillation, renal insufficiency, ICU readmission, and wound infection. Risk factors for re-exploration for bleeding were tricuspid valve repair, on-pump versus off-pump CABG, emergency status, cardiopulmonary bypass (CPB) duration, low body surface area, and lowest CPB hematocrit of less than 24%. Conclusions Re-exploration for bleeding is a lethal and morbid complication of cardiac surgery, with a detrimental effect that surpasses any other known potentially modifiable risk factor. All efforts should be made to minimize the incidence and burden of re-exploration for bleeding, including further research on transfusion management during CPB.
Asthma accounts for considerable burden on health care, but in most cases, asthma can be controlled. Quality-of-care indicators would aid in monitoring asthma management. We describe the quality of ...asthma care using a set of proposed quality indicators.
We performed a retrospective cross-sectional study using health databases in Saskatchewan, a Canadian province with a population of about 1 million people. We assessed 6 quality-of-care indicators among people with asthma: admission to hospital because of asthma; poor asthma control (high use of short-acting beta-agonists, admission to hospital because of asthma or death due to asthma); no inhaled corticosteroid use among patients with poor control; at least moderate inhaled corticosteroid use among patients with poor control; high inhaled corticosteroid use and use of another preventer medication among patients with poor control; and any main preventer use among patients with poor control. We calculated crude and adjusted rates with 95% confidence intervals. We tested for differences using the chi2 test for proportions and generalized linear modelling techniques.
In 2002/03, there were 24 616 people aged 5-54 years with asthma in Saskatchewan, representing a prevalence of 3.8%. Poor symptom control was observed in 18% of patients with asthma. Among those with poor control, 37% were not dispensed any inhaled corticosteroids, and 40% received potentially inadequate doses. Among those with poor control who were dispensed high doses of inhaled corticosteroids, 26% also used another preventer medication. Hospital admissions because of asthma were highest among those aged 6-9 years and females aged 20-44 years. Males and those in adult age groups (predominantly 20-44 years) had worse quality of care for 4 indicators examined.
Suboptimal asthma management would be improved through increased use of inhaled corticosteroids and preventer medications, and reduced reliance on short-acting beta-agonist medications as recommended by consensus guidelines.
Abstract Background The outcomes of acute cardiovascular symptom presentations are potentially modifiable with the use of biomarkers to accelerate accurate diagnosis. This randomized trial tested ...troponin and B-type natriuretic peptide before hospital guidance in patients with acute cardiovascular symptoms. Methods Patients with either chest pain or shortness of breath were randomized to usual care or biomarkers analyzed using a point-of-care device in the ambulance. The primary end point was time to final disposition (discharge from the emergency department or admission to hospital). The trial was stopped prematurely because of less than expected enrollment of patients of interest and no difference in the primary end point. Results We randomized 491 patients; 480 formed the final cohort. Patients were 49% male; median age 70 years; 42% had previous acute coronary syndrome; and 28% diabetes. The B-type natriuretic peptide level before hospital arrival was ≥ 100 pg/mL in 36.4%. Troponin was > 0.03 ng/mL in 13.4%; 3.6% had troponin > 0.1 ng/mL. After adjudication, 16% had acute coronary syndrome, 6.5% acute heart failure, 3.3% angina, and 74.2% another diagnosis. The primary end point was 9.2 (interquartile range, 7.3-11.1) hours in the biomarker group and 8.8 (interquartile range, 6.3-12.1) hours in the usual care group ( P = 0.6). None died in the ambulance or in the emergency department: all-cause 30-day mortality was 2.1% (usual care) and 1.7% (biomarker). Conclusions To our knowledge, this is the first randomized trial of biomarkers before hospital arrival to guide emergency management of suspected acute cardiovascular disease which showed no benefit and was terminated early because of futility. The results have important implications for the use of biomarkers in emergency management of heart disease and for the design of future randomized trials on this important topic.
Background.
Immunocompromised individuals have been excluded from landmark studies of messenger RNA vaccinations for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). In such ...patients, the response to vaccination may be blunted and may wane more quickly compared with immunocompetent patients. We studied the factors associated with decreased antibody response to SARS-CoV-2 vaccination and risk factors for subsequent breakthrough infections in liver transplant (LT) patients undergoing coronavirus disease 2019 vaccination with at least 2 doses of messenger RNA vaccine from April 28, 2021, to April 28, 2022.
Methods.
All LT recipients received at least 2 doses of the BNT162b2 (Pfizer BioNTech) vaccine 21 d apart. We measured the antibody response against the SARS-CoV-2 spike protein using the Roche Elecsys immunoassay to the receptor-binding domain of the SARS-CoV-2 spike protein, and the presence of neutralizing antibodies was measured by the surrogate virus neutralization test (cPass) before first and second doses of vaccination and also between 2 and 3 mo after the second dose of vaccination.
Results.
Ninety-three LT recipients who received 2 doses of BNT162b2 were included in the analysis. The mean time from LT was 110 ± 154 mo. After 2-dose vaccination, 38.7% of LT recipients (36/93) were vaccine nonresponders on the cPass assay compared with 20.4% (19/93) on the Roche S assay. On multivariable analysis, increased age and increased tacrolimus trough were found to be associated with poor neutralizing antibody response (
P
= 0.038 and 0.022, respectively). The use of antimetabolite therapy in conjunction with tacrolimus approached statistical significance (odds ratio 0.21; 95% confidence interval, 0.180-3.72;
P
= 0.062). Breakthrough infection occurred in 18 of 88 LT recipients (20.4%). Female gender was independently associated with breakthrough infections (
P
< 0.001).
Conclusions.
Among LT recipients, older age and higher tacrolimus trough levels were associated with poorer immune response to 2-dose SARS-CoV-2 vaccination. Further studies are needed to assess variables associated with breakthrough infections and, hence, who should be prioritized for booster vaccination.
To determine the association between systemic medication use and intraocular pressure (IOP) in a population of older British men and women.
Population-based, cross-sectional study.
We included 7093 ...participants from the European Prospective Investigation into Cancer–Norfolk Eye Study. Exclusion criteria were a history of glaucoma therapy (medical, laser, or surgical), IOP asymmetry between eyes of >5 mmHg, and missing data for any covariables. The mean age of participants was 68 years (range, 48–92) and 56% were women.
We measured IOP using the Ocular Response Analyzer. Three readings were taken per eye and the best signal value of the Goldmann-correlated IOP value considered. Participants were asked to bring all their medications and related documentation to the health examination, and these were recorded by the research nurse using an electronic case record form. The medication classes examined were angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, α-blockers, β-blockers, calcium channel blockers, diuretics, nitrates, statins, insulin, biguanides, sulfonylureas, aspirin, and other nonsteroidal anti-inflammatory drugs. We examined associations between medication use and IOP using multivariable linear regression models adjusted for age, sex, and body mass index. Models containing diabetic medication were further adjusted for glycosylated hemoglobin levels.
Mean IOP of the right and left eyes.
Use of systemic β-blockers (−0.92 mmHg; 95% CI, −1.19, −0.65; P<0.001) and nitrates (−0.63 mmHg; 95% CI, −1.12, −0.14; P = 0.011) were independently associated with lower IOP. The observed associations between statin or aspirin use with IOP were no longer significant after adjustment for β-blocker use.
This is the first population-based study to demonstrate and quantify clinically significant differences in IOP among participants using systemic β-blockers or nitrates. Lower IOP observed in participants using statins or aspirin was explained by concurrent systemic β-blocker use. The study findings may have implications for the management of glaucoma patients with comorbidity, and may provide insight into the pathophysiologic processes underlying IOP.
Patients on conventional hemodialysis (HD) have elevated markers of oxidative stress and chronic inflammation, which may contribute to a high prevalence of cardiovascular disease. Glutathione (GSH), ...an important intracellular antioxidant, requires cysteine as a rate-limiting amino acid for its synthesis and riboflavin for its regeneration.
We aimed to examine whether erythrocyte GSH (eGSH) concentrations and riboflavin status are influenced by the increased dialysis dose provided to vitamin-supplemented patients receiving home nocturnal hemodialysis (HNHD) (6-8 hours/session, 5-7 nights/week) compared with patients on standard hemodialysis (SHD) (4 hours/session, 3 days/week).
This was a cross-sectional comparative study involving 30 patients undergoing SHD or HNHD regimens and a group of 15 healthy control subjects (HC). We measured eGSH concentration by liquid chromatography-tandem mass spectrometry, riboflavin status by eGSH reductase activity coefficient (EGRAC) as well as plasma total cysteine (Cys) and total homocysteine (Hcy), vitamin C by high-performance liquid chromatography, and C-reactive protein (CRP) by standard method. Estimated dietary protein and energy intakes were determined by 3-day food records, and nutritional status was assessed by subjective global assessment (SGA).
There were no significant differences among groups in eGSH concentration, EGRAC, dietary protein intake, and SGA score. SHD patients had significantly higher plasma Cys (P < .001) and Hcy compared with HNHD and HC groups (P = .048). Vitamin C was significantly lower (P = .01) and CRP significantly higher (P = .048) in both HD groups compared with HC.
eGSH concentration appears to be unaffected by dialysis dose in well-nourished HD patients.
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