In symptomatic AF, cryoballoon ablation reduced progression to persistent AF vs. antiarrhythmic therapy at 3 y.

SOURCE CITATION: Andrade JG, Deyell MW, Macle L, et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med. 2023;388:105-16. 36342178.

A Clinical Diagnostic Test for Calcium Release Deficiency Syndrome.

Importance: Sudden death and cardiac arrest frequently occur without explanation, even after a thorough clinical evaluation. Calcium release deficiency syndrome (CRDS), a life-threatening genetic arrhythmia syndrome, is undetectable with standard testing and leads to unexplained cardiac arrest. Objective: To explore the cardiac repolarization response on an electrocardiogram after brief tachycardia and a pause as a clinical diagnostic test for CRDS. Design, Setting, and Participants: An international, multicenter, case-control study including individual cases of CRDS, 3 patient control groups (individuals with suspected supraventricular tachycardia; survivors of unexplained cardiac arrest [UCA]; and individuals with genotype-positive catecholaminergic polymorphic ventricular tachycardia [CPVT]), and genetic mouse models (CRDS, wild type, and CPVT were used to define the cellular mechanism) conducted at 10 centers in 7 countries. Patient tracings were recorded between June 2005 and December 2023, and the analyses were performed from April 2023 to December 2023. Intervention: Brief tachycardia and a subsequent pause (either spontaneous or mediated through cardiac pacing). Main Outcomes and Measures: Change in QT interval and change in T-wave amplitude (defined as the difference between their absolute values on the postpause sinus beat and the last beat prior to tachycardia). Results: Among 10 case patients with CRDS, 45 control patients with suspected supraventricular tachycardia, 10 control patients who experienced UCA, and 3 control patients with genotype-positive CPVT, the median change in T-wave amplitude on the postpause sinus beat (after brief ventricular tachycardia at ≥150 beats/min) was higher in patients with CRDS (P < .001). The smallest change in T-wave amplitude was 0.250 mV for a CRDS case patient compared with the largest change in T-wave amplitude of 0.160 mV for a control patient, indicating 100% discrimination. Although the median change in QT interval was longer in CRDS cases (P = .002), an overlap between the cases and controls was present. The genetic mouse models recapitulated the findings observed in humans and suggested the repolarization response was secondary to a pathologically large systolic release of calcium from the sarcoplasmic reticulum. Conclusions and Relevance: There is a unique repolarization response on an electrocardiogram after provocation with brief tachycardia and a subsequent pause in CRDS cases and mouse models, which is absent from the controls. If these findings are confirmed in larger studies, this easy to perform maneuver may serve as an effective clinical diagnostic test for CRDS and become an important part of the evaluation of cardiac arrest.

Is Virtual Team-Based Learning Feasible and Effective in Teaching Neurolocalisation?

We investigated the feasibility and effectiveness of virtual team-based learning (TBL) in teaching neurolocalisation (NL) in a sample of 18 student volunteers. Student satisfaction and knowledge outcomes were evaluated using the modified TBL Student Assessment Instrument and Extended Matching Questionnaire (EMQ), respectively. Mean student satisfaction rating was good at 3.9 out of 5.0 (SD 0.3). Participants achieved high mean EMQ scores of 84.2% (SD 2.9) with moderate correlation between individual assessment scores and EMQ scores (ρ = 0.587, p = 0.01). Virtual TBL is feasible for teaching NL with good student satisfaction and knowledge outcomes.

Viewing interprofessional collaboration through the lens of networked ecological systems theory.

Interprofessional collaboration (IPC) is key to ensuring safe quality care for patients. However, IPC intervention outcomes are variable, leading to calls for systems theories to understand complex interactions in healthcare. Using networked ecological systems theory (NEST), we aimed to uncover facilitators and barriers impacting the interactions between nurses and physicians in a specialty healthcare center. A qualitative study involving 55 non-participant observations and 17 individual semi-structured interviews was conducted at the National Neuroscience Institute of Singapore from April 2019 to March 2021. Template analysis was used to analyze the data. The most important IPC facilitators were exosystemic institutional support and physicians' willingness to engage in IPC in the microsystems that together enabled the establishment of disease-based outpatient programs fostering patient-centered interactions among different healthcare professionals (HCP). We also found that patient-, disease-, and systems-related knowledge played an important role in facilitating IPC. Macrosystemic entrenchments such as intraprofessional composition of ward rounds emerged as a significant barrier. However, microsystemic efforts such as chat groups connecting all HCP involved in the care of the patients in the wards have fostered IPC. Although still preliminary, these findings suggest NEST can be useful to inform systematic interventions to improve IPC.

Right Ventricular Function at Cardiac MRI Predicts Cardiovascular Events in Patients with an Implantable Cardioverter-Defibrillator.

Background Right ventricular ejection fraction (RVEF) is an independent predictor of death and adverse cardiovascular outcomes in patients with various cardiac conditions. Purpose To investigate whether RVEF, measured with cardiac MRI, is a predictor of appropriate shock or death in implantable cardioverter-defibrillator (ICD) recipients for primary and secondary prevention of sudden cardiac death. Materials and Methods This retrospective, multicenter, observational study included patients who underwent cardiac MRI before ICD implantation between January 2007 and May 2017. Right ventricular end-diastolic and end-systolic volumes and RVEF were measured with cardiac MRI. The primary end point was a composite of all-cause mortality or appropriate ICD shock. The secondary end point was all-cause mortality. The association between RVEF and primary and secondary outcomes was evaluated by using multivariable Cox regression analysis. Potential interactions were tested between primary prevention, ischemic cause, left ventricular ejection fraction (LVEF), and RVEF. Results Among 411 patients (mean age ± standard deviation, 60 years; 315 men) during a median follow-up of 63 months, 143 (35%) patients experienced an appropriate ICD shock or died. In univariable analysis, lower RVEF was associated with greater risks for appropriate ICD shock or death and for death alone (log-rank trend test, P = .003 and .005 respectively). In multivariable Cox regression analysis adjusting for age at ICD implantation, LVEF, ICD indication (primary vs secondary), ischemic heart disease, and late gadolinium enhancement, RVEF was an independent predictor of the primary outcome (hazard ratio [HR], 1.21 per 10% lower RVEF; 95% CI: 1.04, 1.41; P = .01) and all-cause mortality (HR, 1.25 per 10% lower RVEF; 95% CI: 1.01, 1.55; P = .04). No evidence of significant interactions was found between RVEF and primary or secondary prevention (P = .49), ischemic heart disease (P = .78), and LVEF (P = .29). Conclusion Right ventricular ejection fraction measured with cardiac MRI was a predictor of appropriate implantable cardioverter-defibrillator shock or death. © RSNA, 2021 See also the editorial by Nazarian and Zghaib in this issue. An earlier incorrect version of this article appeared online. This article was corrected on August 24, 2021.

Prognostic value of cardiovascular magnetic resonance left ventricular volumetry and geometry in patients receiving an implantable cardioverter defibrillator.

BACKGROUND: Current indications for implantable cardioverter defibrillator (ICD) implantation for sudden cardiac death prevention rely primarily on left ventricular (LV) ejection fraction (LVEF). Currently, two different contouring methods by cardiovascular magnetic resonance (CMR) are used for LVEF calculation. We evaluated the comparative prognostic value of these two methods in the ICD population, and if measures of LV geometry added predictive value. METHODS: In this retrospective, 2-center observational cohort study, patients underwent CMR prior to ICD implantation for primary or secondary prevention from January 2005 to December 2018. Two readers, blinded to all clinical and outcome data assessed CMR studies by: (a) including the LV trabeculae and papillary muscles (TPM) (trabeculated endocardial contours), and (b) excluding LV TPM (rounded endocardial contours) from the total LV mass for calculation of LVEF, LV volumes and mass. LV sphericity and sphere-volume indices were also calculated. The primary outcome was a composite of appropriate ICD shocks or death. RESULTS: Of the 372 consecutive eligible patients, 129 patients (34.7%) had appropriate ICD shock, and 65 (17.5%) died over a median duration follow-up of 61 months (IQR 38-103). LVEF was higher when including TPM versus excluding TPM (36% vs. 31%, p < 0.001). The rate of appropriate ICD shock or all-cause death was higher among patients with lower LVEF both including and excluding TPM (p for trend = 0.019 and 0.004, respectively). In multivariable models adjusting for age, primary prevention, ischemic heart disease and late gadolinium enhancement, both LVEF (HR per 10% including TPM 0.814 [95%CI 0.688-0.962] p = 0.016, vs. HR per 10% excluding TPM 0.780 [95%CI 0.639-0.951] p = 0.014) and LV mass index (HR per 10 g/m2 including TPM 1.099 [95%CI 1.027-1.175] p = 0.006; HR per 10 g/m2 excluding TPM 1.126 [95%CI 1.032-1.228] p = 0.008) had independent prognostic value. Higher LV end-systolic volumes and LV sphericity were significantly associated with increased mortality but showed no added prognostic value. CONCLUSION: Both CMR post-processing methods showed similar prognostic value and can be used for LVEF assessment. LVEF and indexed LV mass are independent predictors for appropriate ICD shocks and all-cause mortality in the ICD population.

Myocardial strain assessment using cardiovascular magnetic resonance imaging in recipients of implantable cardioverter defibrillators.

BACKGROUND: Cardiovascular magnetic resonance (CMR) is increasingly used in the evaluation of patients who are potential candidates for implantable cardioverter-defibrillator (ICD) therapy to assess left ventricular (LV) ejection fraction (LVEF), myocardial fibrosis, and etiology of cardiomyopathy. It is unclear whether CMR-derived strain measurements are predictive of appropriate shocks and death among patients who receive an ICD. We evaluated the prognostic value of LV strain parameters on feature-tracking (FT) CMR in patients who underwent subsequent ICD implant for primary or secondary prevention of sudden cardiac death. METHODS: Consecutive patients from 2 Canadian tertiary care hospitals who underwent ICD implant and had a pre-implant CMR scan were included. Using FT-CMR, a single, blinded, reader measured LV global longitudinal (GLS), circumferential (GCS), and radial (GRS) strain. Cox proportional hazards regression was performed to assess the associations between strain measurements and the primary composite endpoint of all-cause death or appropriate ICD shock that was independently ascertained. RESULTS: Of 364 patients (mean 61 years, mean LVEF 32%), 64(17.6%) died and 118(32.4%) reached the primary endpoint over a median follow-up of 62 months. Univariate analyses showed significant associations between GLS, GCS, and GRS and appropriate ICD shocks or death (all p < 0.01). In multivariable Cox models incorporating LVEF, GLS remained an independent predictor of both the primary endpoint (HR 1.05 per 1% higher GLS, 95% CI 1.01-1.09, p = 0.010) and death alone (HR 1.06 per 1% higher GLS, 95% CI 1.02-1.11, p = 0.003). There was no significant interaction between GLS and indication for ICD implant, presence of ischemic heart disease or late gadolinium enhancement (all p > 0.30). CONCLUSIONS: GLS by FT-CMR is an independent predictor of appropriate shocks or mortality in ICD patients, beyond conventional prognosticators including LVEF. Further study is needed to elucidate the role of LV strain analysis to refine risk stratification in routine assessment of ICD treatment benefit.

Structure-Activity Relationships of Voltaglue Organic Blends.

Voltage-activated, one-pot adhesives are an emerging platform with many potential advantages, but require multicomponent grafting of electrochemical donors and acceptors for operation in organic environments. This formulation strategy reduces throughput efficiency, organic solubility, and requires additional purification of the grafted dendrimers. A more advanced strategy is proposed for setting up the donor-acceptor conductive network by exploiting a flexible blending design, providing faster throughput of structure-activity analyses with less synthetic investment. The blend method investigates the ampere-dependent storage modulus and gelation time as a function of both donor and acceptor concentration. This blend strategy allows a rapid evaluation of donor-acceptor parameters involved in voltage-activated adhesive formulations.

Higher rates of carbapenem-related seizures in older hospitalised adults.

Clinical experience suggests higher occurrence of carbapenem-associated seizures in the elderly than what is reported in the available literature (range between 0.2% and 0.7%). An audit of 1345 patients with age 60 years or older, who received imipenem, ertapenem or meropenem during their acute hospitalisation found 32 (2.4%) subjects developed seizures. Subjects with more than one central nervous system disorders were 11.6 times more likely to develop seizures (odds ratio 11.61, P < 0.001) and subjects with prior history of seizures is associated with four times greater risks (odds ratio 4.02, P = 0.005). Physicians should exercise caution when prescribing carbapenems in elderly, especially those with known epilepsy and a high number of intracranial pathologies.

Morphological, Stability, and Hypoglycemic Effects of New Gliclazide-Bile Acid Microcapsules for Type 1 Diabetes Treatment: the Microencapsulation of Anti-diabetics Using a Microcapsule-Stabilizing Bile Acid.

When we administered orally a mixture of the anti-diabetic drug, gliclazide (G) and a primary bile acid, they exerted a hypoglycemic effect in a rat model of type 1 diabetes (T1D), but stability of mixture was limited. We aimed to develop and characterize microcapsules incorporating G with a microcapsule-stabilizing bile acid, ursodeoxycholic acid (UDCA). Sodium alginate (SA)-based microcapsules were prepared with either G or G with UDCA and analyzed in terms of morphological, physico-chemical, and electro-chemical characteristics at different pH and temperatures. The microcapsules' effects on viability on muscle cell line (C2C12) and on diabetic rats' blood glucose levels and inflammatory profiles were also examined. Bile acid-based microcapsules maintained their morphology, showed good stability, and compatibility profiles, and the incorporation of UDCA resulted in less G content per microcapsule (p < 0.01) and production of stronger microcapsules that were more resistant to mechanical pressure (p < 0.01). G-UDCA-SA microcapsules enhanced muscle cell viability at higher glucose concentrations compared with control (G-SA and UDCA-SA), and they had strong anti-inflammatory effects on diabetic rats. In addition, the incorporation of UDCA into G microcapsules enhanced the physical characteristics of the microcapsules and optimized G delivery after oral administration.

Attitudes of clinician educators towards interprofessional education and collaboration: Insights from two interprofessional scales.

The increasing complexity of healthcare needs underlines the growing importance of interprofessional education and collaborative practice (IPECP) in enhancing quality of patient care. In particular, clinician educators play an influential role in advocating IPECP. The primary goal of our exploratory pilot study is to explore 34 clinician educators' attitudes towards IPECP by using the adapted 14-item Attitudes Toward Health Care Teams Scale (ATHCTS) and 15-item Readiness for Interprofessional Learning Scale (RIPLS). Mean scores of ATHCTS and RIPLS were 3.81 (SD = 0.90) and 4.02 (SD = 0.79), respectively. Using exploratory factor analysis, we identified four factors: team value (ATHCTS), team efficiency (ATHCTS), teamwork and collaboration (RIPLS), and professional socialisation (RIPLS). The "team efficiency" factor on the ATHCTS scored lowest (factor mean = 3.49) compared with other factors (factor means = 3.87-4.08). Correlation analyses revealed that the "team efficiency" factor had small correlations with other factors (r = -0.05-0.37). Our clinician educators valued IPECP in promoting teamwork and professional socialisation but they perceived IPECP to compromise efficiency. The issue of perceived inefficiency by clinician educators merits attention in order to promote wider implementation of IPECP.

Improving your genetic literacy in epilepsy-A new series.

Advances in epilepsy genetics have been rapid, and it is challenging for clinicians on the ground to keep pace with these advances. The International League Against Epilepsy (ILAE) Genetics Commission has thus crafted a new Genetic Literacy series targeted at busy clinicians. Our goal is to help provide a concise, accessible resource on epilepsy genetics for the busy, on-the-ground clinician so that he/she can apply that knowledge at point-of-care to help patients. This new series is grounded in educational theories and evidence to ensure that learning is effective and efficient. We hope that by promoting and encouraging continuing medical education in epilepsy genetics, this eventually translates to better patient management and therefore better patient health outcomes.

An advanced microencapsulated system: a platform for optimized oral delivery of antidiabetic drug-bile acid formulations.

INTRODUCTION: In previous studies, we have shown that a gliclazide-cholic acid derivative (G-CA) mixture resulted in an enhanced ileal permeation of G (ex vivo). When administered orally to diabetic rats, it brought about a significant hypoglycaemic effect. In this study, we aim to create a novel microencapsulated-formulation of G-CA with uniform and coherent structure that can be further tested in our rat model of type 1 diabetes (T1D). We also aim to examine the effect of CA addition to G microcapsules in the morphology, structure and excipients' compatibility of the newly designed microcapsules. METHOD: Microencapsulation was carried out using our Buchi-based microencapsulating system developed in our laboratory. Using sodium alginate (SA) polymer, both formulations were prepared: G-SA (control) and G-CA-SA (test) at a constant ratio (1:3:30), respectively. Complete characterizations of microcapsules were carried out. RESULTS: The new G-CA-SA formulation is further optimized by the addition of CA exhibiting pseudoplastic-thixotropic rheological characteristics. Bead size remains similar after CA addition, the new microcapsules show no chemical interactions between the excipients and this was supported further by the spectral studies suggesting bead stability. CONCLUSION: The new microencapsulated-formulation has good and uniform structural properties and may be suitable for oral delivery of antidiabetic-bile acid formulations.

Case report: From palliative to potentially curative - the advent of immunotherapy providing hope to advanced gallbladder adenocarcinoma.

Introduction: Biliary tract cancers (BTC) are often diagnosed at an advanced stage where prognosis is poor and curative-intent surgery is infeasible. First-line cisplatin-gemcitabine chemotherapy for advanced gallbladder cancer has remained unchanged over more than a decade, but recent developments in immunotherapy such as durvalumab have highlighted promise as a combination treatment regime with current standard chemotherapy. Methods: In this case description, we present a case of locally-advanced gallbladder adenocarcinoma involving the biliary confluence that was initially planned for an extended right hepatectomy after portal vein embolization. Interval imaging revealed peritoneal metastasis, which was confirmed on diagnostic laparoscopy and biopsy. The patient underwent 8 cycles of cisplatin 25 mg/m2 and gemcitabine 1,000 mg/m2 chemotherapy on days 1 and 8 of each 21-day cycle, with durvalumab (Imfinzi®) 1,500 mg immunotherapy on day 1 of every cycle, in accordance with the treatment protocol of the TOPAZ-1 trial. Repeat imaging demonstrated a stable primary lesion with no further evidence of peritoneal disease. The patient subsequently underwent curative-intent conversion surgery with an extended right hepatectomy and Roux-en-Y hepaticojejunostomy, which were completed through a fully minimally-invasive laparoscopic approach. Results: Final pathological TNM classification was ypT1aN0, with near-complete pathological response to pre-surgical therapy, uninvolved margins (R0 resection) and tumour shrinkage from 2.5 centimetres on pre-operative cross-sectional imaging to 0.5 centimetres on final histology. The patient had an uneventful post-operative course, and was fit for discharge by the fourth post-operative day. He remained well after three months of routine post-operative follow-up, with no significant post-operative complications and biochemical or radiological evidence of disease recurrence. Conclusion: Our case description highlights the immense potential of combination durvalumab immunotherapy with cisplatin-gemcitabine chemotherapy in the treatment of advanced gallbladder adenocarcinoma. The patient's locally advanced disease was initially planned for complex open surgery, prior to discovery of peritoneal metastasis rendering it inoperable. This was successfully down-staged with combination therapy to eventual R0 resection via minimally-invasive surgery. In addition, this case description demonstrates the feasibility of a fully laparoscopic approach with postulated benefits of diagnostic re-evaluation of peritoneal disease, reduced wound pain and shorter length of hospital stay.

ICD Implantation Rates in Cardiac Arrest Survivors in Canada.

Background: Patients resuscitated from out-of-hospital cardiac arrest (OHCA) are at high risk of recurrence, posing a substantial burden on healthcare systems. Despite the established benefit of implantable cardioverter defibrillator (ICD) therapy in many such patients, and recommendations by guidelines, few studies have described the proportion of OHCA patients who receive guideline-concordant care. Methods: The Canadian Institute for Health Information Discharge Abstract Database dataset was used to identify OHCA patients admitted to hospitals across Canada, excluding Quebec. We analyzed all patients without a probable ischemic or bradycardia etiology of cardiac arrest, who survived to discharge, to estimate the ICD implantation rates in patients who were potentially eligible to have an ICD. Results: Between 2013 and 2017, a total of 10,435 OHCA patients who were admitted to the hospital were captured in the database; 4486 (43%) survived to hospital discharge, and 2580 survivors (57.5%) were potentially eligible to receive an ICD. Among these potentially eligible patients, 757 (29.3%) received an ICD during their index admission or within 30 days after discharge from the hospital. The ICD implantation rate during index admission increased from 13.8% in 2013 to 19.6% in 2017 (P-value for time trend < 0.05). The rate of ICD implantations in potentially eligible patients was higher in urban than in rural settings (19.5% vs 11.1%) and in teaching vs community hospitals (34.7% vs 9.8%). Conclusions: Although ICD implantation rates show an increasing trend among patients with OHCA who are likely eligible for secondary prevention, significant underutilization of ICDs persists in these patients.

Contexte: Les patients ayant survécu à un arrêt cardiaque extra-hospitalier (ACEH) présentent un risque élevé de récidive, ce qui impose un lourd fardeau aux systèmes de soins de santé. Malgré l'avantage établi de la mise en place d'un défibrillateur cardioverteur implantable (DCI) chez un grand nombre de ces patients, et les recommandations des lignes directrices, peu d'études décrivent la proportion de patients victimes d'un ACEH ayant reçu des soins conformes aux lignes directrices. Méthodologie: Nous avons recensé les admissions à l'hôpital de patients ayant subi un ACEH au Canada, à l'exception du Québec à partir de l'ensemble de données de la Base de données sur les congés des patients de l'Institut canadien d'information sur la santé. Nous avons inclus dans notre analyse tous les patients pour lesquels la cause de l'arrêt cardiaque n'était probablement pas ischémique ou bradycardique et qui avaient survécu jusqu'à leur congé de l'hôpital, afin d'estimer les taux d'implantation d'un DCI chez les patients potentiellement admissibles à cette intervention. Résultats: Entre 2013 et 2017, un total de 10 435 patients ayant subi un ACEH ont été hospitalisés selon la base de données; 4 486 (43 %) avaient survécu jusqu'à leur congé de l'hôpital, et 2 580 survivants (57,5 %) étaient potentiellement admissibles à l'implantation d'un DCI. Parmi les patients potentiellement admissibles, 757 (29,3 %) avaient reçu un DCI au moment de leur admission initiale ou dans les 30 jours suivant leur congé de l'hôpital. Le taux d'implantation de DCI lors de l'admission initiale est passé de 13,8 % en 2013 à 19,6 % en 2017 (valeur p pour la tendance au fil du temps < 0,05). Le taux d'implantation d'un DCI chez les patients potentiellement admissibles était plus élevé en milieu urbain qu'en milieu rural (19,5 % contre 11,1 %) et dans les hôpitaux d'enseignement/universitaires par comparaison avec les hôpitaux communautaires (34,7 % contre 9,8 %). Conclusions: Bien que les taux d'implantation de DCI affichent une tendance à la hausse chez les patients ayant subi un ACEH qui sont probablement admissibles à des interventions de prévention secondaire, les DCI demeurent largement sous-utilisés chez ces patients.

Evaluation of prognostic scores for status epilepticus in the neurology ICU: A retrospective study.

OBJECTIVE: Status epilepticus (SE) in the neurology intensive care unit (ICU) is associated with significant morbidity. We aimed to evaluate the utility of existing prognostic scores, namely the Status Epilepticus Severity Score (STESS), Epidemiology Based Mortality Score in Status Epilepticus (EMSE)-EACE and Encephalitis-Nonconvulsive Status Epilepticus-Diazepam Resistance-Image Abnormalities-Tracheal Intubation (END-IT), among SE patients in the neurology ICU. METHODS: Neurology ICU patients with SE requiring continuous electroencephalography (cEEG) monitoring over a 10 year period were included. The STESS, EMSE-EACE and END-IT scores were applied retrospectively. Receiver operating characteristic (ROC) analysis was performed to assess the discriminatory value of the scores for inpatient mortality and functional decline, as measured by increase in the modified Rankin Scale (mRS) on discharge. RESULTS: Eighty-five patients were included in the study, of which 71 (83.5%) had refractory SE. Inpatient mortality was 36.5%. Sixty - seven (78.8%) of patients suffered functional decline, with a median mRS of 5 upon hospital discharge. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with inpatient mortality were 0.723 (95% CI 0.613-0.833), 0.722 (95% CI 0.609-0.834) and 0.560 (95% CI 0.436-0.684) respectively. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with functional decline were 0.604 (95% CI 0.468-0.741), 0.596 (95% CI 0.439-0.754) and 0.477 (95% CI 0.331-0.623). SIGNIFICANCE: SE was associated with high mortality and morbidity in this cohort of neurology ICU patients requiring cEEG monitoring. The STESS and EMSE-EACE scores had acceptable AUCs for prediction of inpatient mortality. However, the STESS, EMSE-EACE and END-IT were poorly-correlated with discharge functional outcomes. Further refinements of the scores may be necessary among neurology ICU patients for predicting discharge functional outcomes.

Temporal Trends of Enrollment by Sex and Race in Major Cardiovascular Randomized Clinical Trials.

Background: Women and racialized minorities continue to be underrepresented in cardiovascular (CV) trial outcomes data, despite comprising a significant global burden of CV disease. This study evaluated the impact of trial characteristics on the temporal enrollment of women and racialized minorities in prominent CV trials published in the period 1986-2023. Methods: MEDLINE was searched for CV trials published in The Lancet, the Journal of the American Medical Association, and the New England Journal of Medicine. Participant and investigator demographics, types of interventions, clinical indications, and funding sources were compared according to the enrollment of women or racialized minorities. Results: From 799 studies, including 4,071,921 patients, the enrollment of women and racialized minorities significantly increased from 1986 to 2023 (both P ≤ 0.001). Although the enrollment of women varied by trial indication, comprising 25.0% of coronary artery disease, 35.2% of noncoronary and/or vascular disease, 13.8% of heart failure, 17.0% of arrhythmia, and 28.7% of other CV trials (P ≤ 0.001), it did not differ by peer-reviewed vs industry funding. First authors who were women were more likely than first authors who were men to enroll significantly more women (P = 0.01). Conclusions: Active efforts to increase diverse enrollment, along with improved reporting, including of sex and race, in future CV trials may increase the generalizability of their findings and applicability to global populations.

Contexte: Les femmes et les groupes racisés demeurent sous-représentés dans les données de résultats d'essais cliniques sur les maladies cardiovasculaires (CV) malgré l'important fardeau global associé à ces maladies. Cette étude visait à évaluer l'effet des caractéristiques des essais sur la sélection temporelle des femmes et des membres de groupes racisés dans les essais portant principalement sur les maladies CV durant la période de 1986 à 2023. Méthodologie: La base de données MEDLINE a été consultée à la recherche d'essais sur les maladies CV publiés dans The Lancet, Journal of the American Medical Association et New England Journal of Medicine. Les données démographiques des participants et des chercheurs, les types d'interventions, les indications cliniques et les sources de financement ont été comparés en fonction de la sélection des femmes ou des membres de groupes racisés. Résultats: Dans 799 études cumulant 4 071 921 patients, la sélection des femmes et des membres de groupes racisés a augmenté significativement entre 1986 et 2023 (p ≤ 0,001 dans les deux cas). Bien que la sélection des femmes variait en fonction des indications des essais, soit 25,0 % dans les essais portant sur les coronaropathies, 35,2 % pour les maladies non coronariennes et/ou vasculaires, 13,8 % pour l'insuffisance cardiaque, 17,0 % pour l'arythmie et 28,7 % pour d'autres maladies CV (p ≤ 0,001), elle ne différait pas selon que les études étaient révisées par des pairs ou qu'elles étaient financées par l'industrie. Lorsqu'une femme était l'autrice principale, le nombre de femmes sélectionnées était susceptible d'être plus élevé que lorsque l'auteur principal était un homme (p = 0,01). Conclusions: Des efforts actifs pour diversifier davantage la sélection des participants et mieux rendre compte des différences, notamment en ce qui concerne le sexe et la race, pourraient élargir la portée des conclusions des futurs essais sur les maladies CV et leur application à l'ensemble de la population.

Comparative prognostic value of T-wave inversion and ST-segment depression on the admission electrocardiogram in non-ST-segment elevation acute coronary syndromes.

BACKGROUND: ST-segment depression (STD) is predictive of adverse outcomes in non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but there are conflicting data on the incremental prognostic value of T-wave inversions (TWIs) on the admission electrocardiogram. METHODS: Admission electrocardiograms of 7,343 patients with NSTE-ACS from the Global Registry of Acute Coronary Events (GRACE) and ACS I registry were independently analyzed at a core laboratory and stratified by TWI and STD status. We performed multivariable analyses to determine the independent prognostic significance of TWI and tested for interaction between TWI and STD for adverse outcomes. RESULTS: Patients with TWI and/or STD had a higher prevalence of cardiovascular risk factors, higher Killip class, and higher GRACE risk scores. Among the 2,708 patients with available angiographic data, rates of 3-vessel or left main disease were similar between patients with TWI and those without TWI/STD. After adjusting for other established prognosticators, TWI did not independently predict in-hospital (adjusted odds ratio 1.03, 95% CI 0.75-1.42, P = .85) or 6-month mortality (adjusted odds ratio 1.02, 95% CI 0.80-1.30, P = .88); STD remained a strong independent predictor. There was no interaction between TWI and STD for these outcomes. No contiguous lead groups or cumulative number of leads with TWI provided independent prognostic information. CONCLUSIONS: TWI is associated with other high-risk clinical features but is not an independent predictor of adverse short- and long-term mortality in NSTE-ACS. T-wave inversion does not provide additional prognostication beyond the GRACE risk model, and its concomitant presence does not alter the prognostic value of STD.