The CADILLAC risk score accurately identifies patients at low risk for in-hospital mortality and adverse cardiovascular events following ST elevation myocardial infarction

Background The CADILLAC risk score was developed to identify patients at low risk for adverse cardiovascular events following ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI). Methods We performed a single center retrospective review of STEMI hospitalizations treated with PPCI from 2014 to 2018. Patients were stratified using the CADILLAC risk score into low risk, intermediate risk and high risk groups. Patients presenting with cardiac arrest or cardiogenic shock were excluded from the study. The primary outcome was adverse clinical events during initial hospitalization. Secondary outcomes were adverse clinical events at 30 days and 1 year following index hospitalization. Results The study included 341 patients. Compared to patients with a low CADILLAC score, adverse clinical events were similar in the intermediate risk group during hospitalization (OR 1.23, CI 0.37–4.05, p 0.733) and at 30 days (OR 2.27, CI 0.93–5.56, p 0.0733) while adverse clinical events were significantly elevated in the high risk group during hospitalization (OR 4.75, CI 1.91–11.84, p 0.0008) and at 30 days (OR 8.73, CI 4.02–18.96, p < 0.0001). At 1 year follow-up, compared to the low risk CADILLAC group (9.4% adverse clinical event rate), cumulative adverse clinical events were significantly higher in the intermediate risk group (22.9% event rate, OR 2.86, CI 1.39–5.89, p 0.0044) and in the elevated risk group (58.6% event rate, OR 13.67, CI 6.81–27.43, p < 0.0001). The mortality rate was 0% for patients defined at low risk by CADILLAC score during hospitalization, as well up to 1 year follow up. On receiver operating curve analysis, discrimination of in-hospital adverse clinical events was fair using CADILLAC (C = 0.66, odds ratio 1.18; 95% CI 1.04–1.33; p = 0.0064) with somewhat better discrimination at 30-day follow-up (C = 0.719) and 1-year follow-up (C = 0.715). Conclusion Patients defined as low risk by the CADILLAC score following a STEMI were associated with lower mortality and adverse clinical event rates during hospitalization and up to 1 year following STEMI when compared to those with an intermediate or high CADILLAC score.

Current experience with emphysematous cholecystitis

Background: Emphysematous cholecystitis (EC) is a rare variant of acute cholecystitis with a reported 15-25% mortality rate. Conventionally, EC is managed with an early open cholecystectomy. However, recent advancement in percutaneous intervention and laparoscopic techniques have influenced our management of this biliary pathology. This study reviews the management and outcomes of EC in a regional centre.Methods: Retrospective analysis of a clinical database constituting all patients diagnosed with EC at a regional Australian hospital in NSW from Jan 2010 to July 2019. Inclusion criteria: sepsis, abdominal pain and radiological evidence of gas in the gallbladder wall, lumen, and pericholecystic tissue in the absence of an abnormal connection between the gallbladder and gastrointestinal tract. We investigated patient risk factors, management and outcomes.Results: 16 patients with EC were identified. The mean age of the cohort was 73 years old. The majority of patients had co-morbidity including type 2 diabetes and ischemic heart disease (56 and 62% respectively). Laparoscopic cholecystectomies were performed in 9 patients during their index admissions and 7 patients were managed with PTC. 5 patients required ICU admission for septic shock, and all were managed with PTC drain placement. The overall mortality rate was 6%.Conclusions: Laparoscopic cholecystectomy on index admission is the treatment of choice for EC. Although more technically challenging, adverse clinical event including major complication and open conversion was avoided in our cohort while percutaneous cholecystostomy was reserved for unstable and poor surgical candidate.

Long-term Outcomes of contemporary Percutaneous Coronary Intervention with the Xience Drug-Eluting Stent: Results from a Multicentre Australian Registry

BackgroundSeveral large registries have evaluated outcomes after percutaneous coronary intervention (PCI) in the USA, however there are no contemporary data regarding long-term outcomes after PCI in Australia, and little information comparing new second generation drug-eluting stents (DES) with earlier DES. Also, approval of new-generation drug-eluting stents (DES) is almost exclusively based on non-inferiority trials comparing outcomes with first generation DES, and there are limited data comparing safety and efficacy outcomes of new second generation DES with bare metal stents (BMS). This study long-term outcomes after PCI with the Xience DES from a large national multicentre registry, the GenesisCare Outcomes Registry (GCOR).MethodsThe study population comprised the first 1500 patients consecutively enrolled from January 2015 to January 2019 who were treated exclusively with either Xience DES or BMS and were eligible for 1-year follow-up, from a total group of 4,765 PCI patients enrolled during that period. Baseline patient and procedural data, medications and major adverse cardiovascular events (MACE) in-hospital, at 30-days and 1-year were reported and analysed with respect to the type of stent used (Xience DES n = 1000, BMS n = 500).ResultsOf the 4,765 patients enrolled in GCOR during this period, DES were exclusively used in 3621 (76.0%), BMS were exclusively used in 596 (12.5%) with the remainder receiving a combination of DES and BMS. In the study cohort of 1,500 Xience and BMS patients the mean age was 68.4 ± 10.7 years, 76.9% were male, 24.6% had diabetes mellitus and 45.9% presented with acute coronary syndromes. Adverse clinical event rates In the study cohort were low in comparison to international reports at 30-days in terms of mortality (0.20%), target lesion revascularisation (TLR, 0.27%) and MACE (0.47%). Similarly, adverse clinical event rates at 12 months were low in terms of mortality (1.26%), TLR (1.16%) and MACE (1.78%).ConclusionsClinical practice and long-term outcomes of PCI with the Xience DES in Australia are consistent with international series. Recent trends indicate DES use has increased in parallel with good outcomes despite an increasingly complex patient and lesion cohort.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000899943This trial was registered retrospectively on 11/09/2020.

IL-10 / IL-6 serum ratio as a prognosis marker of STEMI

Introduction IL-6 and IL-10 are two major cytokines secreted at the acute phase of myocardial infarction (MI). IL-6 has a pro-inflammatory effect whereas IL-10 has anti-inflammatory effect. Objective Our objective was to assess the prognosis value of IL-6, IL-10 and IL-10/IL-6 ratio serum level at the acute phase of ST elevation MI (STEMI). Methods We prospectively enrolled 247 patients admitted for acute STEMI from 2016 to 2019. Blood samples were collected at 5 time points: admission, 4, 24, 48 hours and 1 month (H4, H24, H48, M1). IL-6 and IL-10 were assessed using ELISA. Patients underwent cardiac magnetic resonance imaging at one month for infarct size (IS) and left ventricular ejection fraction (LVEF) assessment. Clinical outcomes were prospectively recorded over 18 months. Results Patient mean age was 59±12 years. IL-6 reached a peak at H24 at 5.4 pg/mL interquartile range (IQR) [2.1–11.0] and IL-10 peaked as early as admission at 5.6 pg/mL IQR [8.7–29.3] followed by a decrease within the first month. Median IL-10/IL-6 ratio at admission was 4.2 [1.4–8.6] with a strong decrease at H24 (0.5 [0.2–1.3]). IL-6 and IL-10 levels at H24 were correlated with IS (respectively r=0.44, p&lt;0.0001, and r=0.29, p=0.0001) and inversely correlated with LVEF (respectively r=−0.42, p&lt;0.0001 and r=−0.26, p=0.0003). Patients with IL-10/IL-6 ratio ≥1 had smaller IS compared to patients with IL-10/IL-6 ratio &lt;1 (respectively 9.0% IQR [2.4–15.4] of LV versus 17% IQR [8.7–29.3] of LV, p&lt;0.0001) and they had higher LVEF (58.0% IQR [52.0–62.3] versus 49.0% IQR [41.5–56.0], p&lt;0.0001). Patients with IL-10/IL-6 ratio &lt;1 were more likely to have an adverse clinical event (MI, stroke, hospitalization for heart failure and all-cause death) during the first 18 months after STEMI compared to patients with IL-10/IL-6 ratio ≥1 (HR=2.7, 95% CI [1.2–5.5], p=0.04). Conclusion Serum IL-10/IL-6 &gt;1 was associated with a poor outcome after STEMI and might be a valuable prognostic marker. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospices Civils de Lyon, Fédération Française de Cardiologie

Gender difference in long-term clinical outcomes after percutaneous coronary intervention

Background The comparative gender-specific outcome after PCI in real-world practice is limited. We investigated the gender difference in the 5-year outcome after percutaneous coronary intervention (PCI). Methods A retrospective study. nationwide PCI registry. All PCI performed in Korea in year 2011 (N=48,783). Outcomes adjusted with age and propensity for clinical characteristics were compared. Primary outcome was 5-year cumulative incidence of major adverse clinical event (MACE) consisting of all-cause death, revascularization, shock, or stroke. Results In unadjusted analysis, women (N=15,710) were older (69.7±9.7 versus 62.0±11.1 year) and had higher frequency of comorbidities including hypertension, hyperlipidemia, and diabetes compared to men (N=33,073) (p&lt;0.001, all). Women had higher 5-year cumulative incidence of MACE than men (41.9% versus 37.2%; hazard ratio [HR] 1.16, 95% confidential interval [CI] 1.12–1.19; p&lt;0.001). In propensity score-matched 14,462 pairs, women had lower 5-year mortality risk (40.7% versus 46.0%, HR 0.85, 95% CI 0.82–0.88, p&lt;0.001). The lower 5-year MACE risk in women was consistent in subgroup analyses of age, risk factors, and clinical diagnosis including angina or acute myocardial infarction (p&lt;0.05, all). The risk of all-cause death, revascularization, and shock were also lower in women than men (p&lt;0.05, all) but the risk of stroke was not different between women and men. Conclusions The apparent worse outcome in women can be explained by older age and more common comorbidities in women. After adjusting these disadvantages, women had better outcome after PCI than men. Our result suggests presence of the reversal paradox in the gender-specific outcome following PCI. Women vs men, 5 year outcome Funding Acknowledgement Type of funding source: None

A 5 Year Retrospective Analysis of Leave against Advice from the Medical Wards of a Nigerian Tertiary Hospital

Self discharge (SD) of hospitalized patients is an adverse clinical event often resulting from a fundamental disagreement between the patient or an interested third party and the attending physician and / or the hospital environment. This culminates in the patient’s withdrawal of their initial voluntary consent for hospitalisation and abrupt termination of in - patient medical care. Patients who left hospital admission against the advice of their doctors are both a concern and a challenge for individuals in the health industry. It negatively impacts treatment outcomes and exposes the clinician and health care administrators to the hazards of litigations. The study was aimed at determining the incidence of SD and associated factors in medical admissions. It was a retrospective descriptive hospital based study of patients who self discharged from medical wards of Federal Medical Center, Makurdi from June 2012 – May 2017. Approval was obtained from the institution’s research ethics board. Thirty one individuals (0.62% of total admission) self discharged within the study period. Financial constraints was responsible for 32.2% (10) of SD followed by proximity to social support 19.4% (6). Five patients (16.1%) elected not to disclose any reasons. The incidence reduced from 0.21% to 0.02% at the start and end of study period respectively. Though SD was relatively low in this study, the incidence could be reduced further by expanding the scope of health insurance scheme, skilful communication and negotiating patient management using patient – centred methods.

P2814The long-term patterns of red blood cell transfusion and outcome in patients undergoing percutaneous coronary intervention - a Korean nationwide longitudinal cohort study

Aims Transfusion long after percutaneous coronary intervention (PCI) may pose a significant risk but is not sufficiently understood. We investigated the long-term patterns and impact of transfusion on the clinical outcome of patients undergoing PCI. Methods and results Five-year clinical outcomes of all Korean undergoing PCI using stent in year 2011 (n=48786) were investigated. Primary outcome was the incidence density of transfusion. The association of transfusion with major adverse clinical event (MACE) consisting all-cause death, revascularization, critically ill cardiovascular status, or stroke was assessed after reflecting the propensity of each patient for transfusion and adjusting transfusion frequency and intervals. The 5-year incidence density of transfusion was 4.74 (95% confidence interval [CI] = 4.70–4.79) per 100 person-year. Patients who received transfusion were older, were more often women, and had overall higher frequency of clinical risk factors (p<0.001, all). Transfusion was associated with MACE (hazard ratio [HR] = 3.0, 95% CI = 2.9–3.1, p<0.001) and with death, revascularization, critically ill cardiovascular status, and stroke (HR from 1.6 to 6.5, p<0.001, all). The period of transfusion coincided with the period of highest MACE incidence density and all other clinical events. Subgroup analyses classified by clinical characteristics showed consistent results. Year of transfusion and outcome Conclusions One out of every 4 Koreans undergoing PCI received transfusion within 5 years, and had 3-fold higher risk of MACE compared to patients without transfusion. These observational findings may warrant the establishment of transfusion strategies for patients undergoing PCI.

Variation in hospital charges in patients with external ventricular drains: comparison between the intensive care and surgical floor settings

OBJECTIVEPlacement of an external ventricular drain (EVD) is a common and potentially life-saving neurosurgical procedure, but the economic aspect of EVD management and the relationship to medical expenditure remain poorly studied. Similarly, interinstitutional practice patterns vary significantly. Whereas some institutions require that patients with EVDs be monitored strictly within the intensive care unit (ICU), other institutions opt primarily for management of EVDs on the surgical floor. Therefore, an ICU burden for patients with EVDs may increase a patient’s costs of hospitalization. The objective of the current study was to examine the expense differences between the ICU and the general neurosurgical floor for EVD care.METHODSThe authors performed a retrospective analysis of data from 2 hospitals within a single, large academic institution—the University of Washington Medical Center (UWMC) and Seattle Children’s Hospital (SCH). Hospital charges were evaluated according to patients’ location at the time of EVD management: SCH ICU, SCH floor, or UWMC ICU. Daily hospital charges from day of EVD insertion to day of removal were included and screened for days that would best represent baseline expenses for EVD care. Independent-samples Kruskal-Wallis analysis was performed to compare daily charges for the 3 settings.RESULTSData from a total of 261 hospital days for 23 patients were included in the analysis. Ten patients were cared for in the UWMC ICU and 13 in the SCH ICU and/or on the SCH neurosurgical floor. The median values for total daily hospital charges were $19,824.68 (interquartile range [IQR] $12,889.73–$38,494.81) for SCH ICU care, $8,620.88 (IQR $6,416.76–$11,851.36) for SCH floor care, and $10,002.13 (IQR $8,465.16–$12,123.03) for UWMC ICU care. At SCH, it was significantly more expensive to provide EVD care in the ICU than on the floor (p < 0.001), and the daily hospital charges for the UWMC ICU were significantly greater than for the SCH floor (p = 0.023). No adverse clinical event related to the presence of an EVD was identified in any of the settings.CONCLUSIONSICU admission solely for EVD care is costly. If safe EVD care can be provided outside of the ICU, it would represent a potential area for significant cost savings. Identifying appropriate patients for EVD care on the floor is multifactorial and requires vigilance in balancing the expenses associated with ICU utilization and optimal patient care.

Fields of promoted actions for facilitating multitasking activity during a medical emergency

BackgroundAn adverse clinical event requires emergency team coordination and multitasking activity. Based on studies in ecological psychology, we propose that a structured ambient environment can implicitly facilitate these requirements.MethodWe designed a new configuration of work in which spatial zones were specified as fields of promoted actions for doctors, nurses and nursing auxiliaries. 6 emergency teams were confronted with scenarios in a simulation setting, either with a traditional configuration of work or with the new configuration.ResultsSignificantly, each kind of caregiver respected the delimited spatial zones: 91.5% of occupation time for doctors, 97.1% for nurses and 95.3% for nursing auxiliaries. The mean durations of occupation of a same zone by the nursing auxiliaries and another caregiver decreased significantly, thus reducing the likelihood of mutual disturbance. Readiness for multitasking activity measured before and after experiencing the work configuration increased significantly among caregivers. An ergonomic evaluation scale showed a high level of satisfaction among caregivers (68.5 points out of 100). Participants also indicated the advantages and disadvantages of this new work configuration.ConclusionsThis study is a first step towards recommendations to standardise the positioning of emergency team members and for a new spatial arrangement of equipment.