Frailty in elderly patients with acute colonic diverticulitis is associated with worse in-hospital outcomes: a nationwide analysis.

Background: Frailty has been identified as an independent predictor of mortality in the elderly. We investigated the effects of frailty status on in-hospital outcomes of acute colonic diverticulitis (ACD) in the elderly, using the Hospital Frailty Risk Score. Methods: We used the National Inpatient Sample (NIS) databases from 2016-2020 to identify patients aged ≥75 years hospitalized with ACD. Using a 1:1 matching method, we created propensity-matched cohorts of frail (Hospital Frailty Risk Score ≥5) and non-frail (Hospital Frailty Risk Score ≤4) patients within the ACD population. Results: We identified 53.3% ACD patients as frail. We matched 21,720 frail ACD patients to an equal number of non-frail ACD patients using propensity score matching. Frail patients exhibited significantly higher mortality rates, longer hospital stays, and greater median inpatient costs. Frail patients also experienced a greater number of complications, including abscess formation, intestinal perforation, gastrointestinal fistula formation, sepsis without shock, sepsis with shock, acute kidney injury, hypovolemic or hemorrhagic shock, need for blood transfusion, cardiac arrest, and need for intensive care (all P-values <0.001). Additionally, frail patients underwent open colectomy and colostomy procedures more frequently, while laparoscopic colectomies were performed less frequently (all P-values <0.001). Conclusions: In this nationwide analysis, frailty in ACD is strongly associated with worse mortality, longer hospital stays and higher costs, as well as a greater incidence of local and systemic complications. Furthermore, frailty is linked to a greater need for open colectomy and colostomy procedures.

The Intersectionality of Race and Gender in Palliative Care Services Utilization Among Critically-Ill Necrotizing Pancreatitis Patients: Analysis of a Large Nationwide Database in the United States.

OBJECTIVE: Necrotizing pancreatitis (NP) is a severe form of pancreatitis that often necessitates intensive care and can result in significant morbidity and mortality. This study aimed to investigate racial and gender disparities in palliative care (PC) utilization among mechanically-ventilated patients with NP. METHODS: In this retrospective analysis using the National Inpatient Sample from 2016 to 2020, we investigated 84 335 patients with NP requiring invasive mechanical ventilation, and the utilization of PC services and their disparities based on gender and race. To adjust for potential confounding factors, we employed multivariable logistic regression, ensuring that our findings account for various influencing variables and provide a robust analysis of the data. RESULTS: Among the patients studied, 15.4% utilized PC consultations. Notably, female patients were 12% more likely to utilize PC than their male counterparts (OR 1.1, 95% CI: 1.003-1.2; P = .008). Racial disparities were pronounced: African Americans (OR 0.8, 95% CI 0.7-0.9, P < .001), Hispanic (OR 0.8, 95% CI 0.7-0.9, P = .001), and Asian or Pacific Islander patients (OR 0.74, 95% CI 0.57-0.97; P = .03) had significantly lower odds of utilizing PC compared to White patients. The cohort utilizing PC had a higher in-hospital mortality rate (74.7% vs 24.8%; OR 8.2, 95% CI 7.7-9.2) but a shorter mean hospital stays and lower associated costs. CONCLUSIONS: Our findings indicate significant racial and gender disparities in the utilization of PC for intubated patients with NP, with lower utilization among males and minority populations. These findings emphasize the urgent requirement for comprehensive changes in healthcare protocols.

Colorectal Leiomyosarcoma: Demographics Patterns, Treatment Characteristics, and Survival Analysis in the U.S. Population.

BACKGROUND: Colorectal leiomyosarcoma (CR-LMS) is a rare neoplasm arising from smooth muscle cells. It accounts for less than 0.1% of all colorectal malignancies. In this population-based study, we aim to understand the demographics, treatment characteristics, and pathologic factors associated with survival in CR-LMS. METHODS: Data from the SEER Program (2000-2018) were analyzed using SEER*Stat and SPSS. Statistical methods included descriptive analysis, Kaplan-Meier survival curves, log-rank tests, and Cox proportional hazards regression to assess the impact of various factors on disease-specific and overall survival. RESULTS: A total of 191 cases of CR-LMS were identified. Most patients were 60-69 years of age (median: 64 years) and Caucasian (78%). There was nearly the same distribution in sex (M:F ratio; 1:1.2). The overall 5-year observed survival was 50.3% (95% C.I., 46.3-54.2). The 5-year disease-specific survival (DSS) was 66.1% (95% C.I., 62.0-70.1). The 5-year overall survival after resection was 60.8% (95% C.I., 56.3-65.3). Multivariable analysis identified grades III and IV (p = 0.028) as negative predictors of overall survival. Regional spread and distant stage are negative predictors of overall survival (p < 0.01). CONCLUSION: Our data reveals that colorectal leiomyosarcoma (CR-LMS) often presents in patients around 64 years old with advanced stages and poor differentiation. Key adverse prognostic factors include older age, high tumor grade, large tumor size, and distant metastases, with surgical resection showing the best survival outcomes. To improve outcomes, further research and consolidation of data are essential for developing targeted therapies and comprehensive guidelines.

Safety of procedural sedation in emergency department settings among the adult population: a systematic review and meta-analysis of randomized controlled trials.

Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.

Prognostic Nomogram Predicting Survival and Propensity Score Matching with Demographics and Comparative Analysis of Prostate Small Cell and Large Cell Neuroendocrine Carcinoma.

Background: This retrospective study aims to examine the patient demographics, survival rates, and treatment methods for small-cell neuroendocrine carcinoma (SCNEC) and large-cell neuroendocrine carcinoma (LCNEC) of prostate origin while also identifying the main differences between common types of prostate cancer with comparative analysis for survival. Methods: Our analysis utilized the Surveillance, Epidemiology, and End Results database (SEER), and data was collected from 2000-2020. Cox proportional hazards and chi-squared analysis were used for statistical analysis. Results: A total of 718 cases of prostate small and large neuroendocrine carcinoma were identified. The median age was 71.5 years, and the median follow-up was 11.0 years (95% confidence interval (95% CI) = 9.2-12.8). Most patients were over the age of 80 years (33.8%) and Caucasian (74.4%). The overall 5-year survival was 8.0% (95% CI = 6.8-9.2). The 5-year OS for Caucasians was 7.3% (95% C.I. 6.0-8.3). For Black Americans, the 5-year OS was 11.9% (95% C.I. 7.3-16.5). For Hispanics, the 5-year OS was 12.2% (95% C.I. 7.7-16.7). The 5-year cause-specific survival (CSS) was 16.2% (95% CI = 14.3-18.1). For treatment modality, the five-year survival for each were as follows: chemotherapy, 3.5% (95% CI = 2.1-4.9); surgery, 18.2% (95% CI = 13.6-22.8); multimodality therapy (surgery and chemotherapy), 4.8% (95% CI = 1.7-7.9); and combination (chemoradiation with surgery), 5.0% (95% CI = 1.0-9.0). The prognostic nomogram created to predict patient survivability matched the findings from the statistical analysis with a statistical difference found in race, income, housing, stage, and nodal status. The nomogram also indicated a slight increase in mortality with tumors of greater size. This analysis showed a slight increase in mortality for patients of Asian race. In addition, there was a significant increase in death for patients with stage 3 tumors, as well as patients who underwent surgery and radiation. Furthermore, we performed propensity score matching for survival differences, and no survival difference was found between SCNEC and LCNEC. Conclusions: Asian patients, larger tumor size, and distant disease were associated with worse long-term clinical outcomes. By leveraging insights from registry-based studies, clinicians can better strategize treatment options, improving patient outcomes in this challenging oncology arena.

Gender and Racial Differences in the Provision of Palliative Care Services Among Critically ill Necrotizing Fasciitis and Septic Shock Geriatric Patients: Analysis of a Nationwide Database in the United States.

Introduction: Necrotizing fasciitis (NF) and sepsis shock (SS) are both severe and life-threatening conditions requiring specialized care, including palliative care (PC), to optimize comfort. However, data on the utilization of PC in this population, including racial and gender differences, are limited. Methods: We used the National Inpatient Sample (NIS) database from 2016 to 2020 to extract data on patients with NF and SS as well as PC utilization. Chi-squared tests and multivariate linear regression models were utilized to analyze relationships between categorical and continuous variables, respectively. Multivariable logistic regression was used to determine adjusted odds ratios (aORs) and 95% confidence intervals (CI) for various outcomes among various gender and racial groups. Mann-Kendall trend test was used to assess mortality trends over time. Results: Among the 11,260 patients with NF and SS, 2,645 received PC whereas 8,615 did not. Female patients had significantly higher odds of receiving PC versus males (aOR: 1.42, 95% CI 1.27-1.58). No significant racial differences in PC utilization were observed. Patients receiving PC had higher odds of in-hospital mortality (aOR: 1.18, 95% CI 1.03-1.35). No significant trend in in-hospital deaths was observed over the study period. PC was associated with significantly shorter length-of-stay and lower costs. Conclusion: Our study provides comprehensive insights, and identifies gender differences in PC utilization in NF and SS patients. Further research must aim to refine delivery strategies and address potential differences in PC.

Impact of pneumothorax on mortality, morbidity, and hospital resource utilization in COVID-19 patients: a propensity matched analysis of nationwide inpatient sample database.

BACKGROUND: Spontaneous pneumothorax (PTX) is more prevalent among COVID-19 patients than other critically ill patients, but studies on this are limited. This study compared clinical characteristics and in-hospital outcomes among COVID-19 patients with concomitant PTX to provide insight into how PTX affects health care utilization and complications, which informs clinical decisions and healthcare resource allocation. METHODS: The 2020 Nationwide Inpatient Sample was used analyze patient demographics and outcomes, including age, race, sex, insurance status, median income, length of hospital stay, mortality rate, hospitalization costs, comorbidities, mechanical ventilation, and vasopressor support. Propensity score matching was employed for additional analysis. RESULTS: Among 1,572,815 COVID-19 patients, 1.41% had PTX. These patients incurred significantly higher hospitalization costs ($435,508 vs. $96,668, p < 0.001) and longer stays (23.6 days vs. 8.6 days, p < 0.001). In-hospital mortality was substantially elevated for PTX patients (65.8% vs. 14.4%, p < 0.001), with an adjusted odds ratio of 14.3 (95% CI 12.7-16.2). Additionally, these patients were more likely to require vasopressors (16.6% vs. 3.3%), mechanical circulatory support (3.5% vs. 0.3%), hemodialysis (16.6% vs. 5.6%), invasive mechanical ventilation (76.9% vs. 15.1%), non-invasive mechanical ventilation (19.1% vs. 5.8%), tracheostomy (13.3% vs. 1.1%), and chest tube placement (59.8% vs. 0.8%). CONCLUSIONS: Our findings highlight the severe impact of PTX on COVID-19 patients, characterized by higher mortality, more complications, and increased resource utilization. Also, being Hispanic, male, or obese increased the risk of developing concomitant PTX with COVID-19.

Clinicopathologic patterns and survival patterns among prostate carcinosarcoma patients in the United States: An analysis of SEER database.

INTRODUCTION: Prostatic carcinosarcoma comprises <1% of all prostate neoplasms. The literature on this disease is limited to a few case studies, primarily due to the rarity of this malignancy. We aimed to investigate the demographic, clinical, and histologic factors, prognosis, and survival of prostatic carcinosarcoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with prostatic carcinosarcoma from 2000-2018. Demographic and clinical data, including age, race, sex, tumor grade, stage, tumor size, lymph node status, metastasis, and treatment modalities, were recorded. RESULTS: Prostatic carcinosarcoma had a median age of 72 years at diagnosis, with a majority of cases among White individuals (93%). When reported, the histologic grade comprised moderately differentiated (3.3%), poorly differentiated (56.7%), and undifferentiated/anaplastic (40%) subtypes. In patients with reported data, tumor size varied between 2-5 cm (15.8%) and >5 cm (84.2%). Distant metastasis most commonly occurred in the liver (12.5%) and lung (12.5%), followed by the bone (8.3%). The most common treatment performed was surgery with radiation (32.4%). The five-year overall survival was 11.9%. CONCLUSIONS: Prostatic carcinosarcoma affects men in the seventh decade of life. Regional and distant tumor stage is considered an indicator of survival. Prostate carcinosarcoma is rare; due to its aggressive nature, a deeper understanding, and an improved personalized therapeutic approach are necessary for improving patient outcomes in this challenging arena of oncology.

Remimazolam for sedation in gastrointestinal endoscopy: A comprehensive review.

Worldwide, a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort. Propofol, benzodiazepines and opioids continue to be widely used. However, in recent years, Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal (GI) endoscopy. It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation. Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase, volume of distribution, total body clearance, and negligible drug-drug interactions. It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy. Furthermore, studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol, which is currently a gold standard for procedural sedation in most parts of the world. However, the use of Propofol is associated with hemodynamic instability and respiratory depression. In contrast, Remimazolam has lower incidence of these adverse effects intra-procedurally and hence, may provide a safer alternative to Propofol in procedural sedation. In this comprehensive narrative review, highlight the pharmacologic characteristics, efficacy, and safety of Remimazolam for procedural sedation. We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

Efficacy and Safety of Endoscopic Through-the-Scope Suture System for Gastrointestinal Defects: A Systematic Review and Meta-analysis.

OBJECTIVE: Recently, a through-the-scope suturing (TTSS) system has received FDA approval and has been evaluated for closing mucosal defects postintervention. We hereby performed a systematic review and pooled meta-analysis of available studies to assess the safety and efficacy of this intervention. METHODS: We queried the following databases through April 26, 2023: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection. Endoscopists utilizing TTSS for the following reasons were included: endoscopic mucosal resection, endoscopic submucosal dissection, peroral endoscopic myotomy, perforation, fistula closure, and/or stent fixation. The outcomes assessed were technical success, primary clinical success (closure of defect without additional intervention), and overall clinical success (closure of defect with/without additional intervention). Random effects model with the DerSimonian Laird approach was used to report event rates expressed as proportions with a 95% CI. RESULTS: A total of 12 studies with 512 patients (mean age of 61.5 ± 18.4 y, 54.6% females) were included. The technical success rate was 96.0% (CI: 94.3%-97.7%). The primary clinical success rate was 74.8% (CI: 65.5%-84.1%). The overall clinical success rate was 95.4% (CI: 92.6-98.2%). Only 1 mortality case unrelated to intervention was reported. CONCLUSION: The TTSS appears safe and effective for closing mucosal defects after therapeutic endoscopic interventions. Further cost-effective studies should be performed comparing with endoclips for use in clinical settings.

Left Atrial Strain as a Predictor of Early Anthracycline-Induced Chemotherapy-Related Cardiac Dysfunction: A Pilot Systematic Review and Meta-Analysis.

Background: Chemotherapy-related cardiac dysfunction (CTRCD) significantly affects patients undergoing anthracycline (AC) therapy, with a prevalence ranging from 2% to 20%. Reduced left ventricular ejection fraction (LVEF) and left ventricular global longitudinal strain (LV GLS) are prognostic parameters for CTRCD detection. Our study aimed to investigate the role of emerging parameters such as left atrial strain (LAS). Methods: We searched multiple databases for studies comparing LAS changes post-AC versus pre-AC therapy in patients with cancer. Primary outcomes included left atrial reservoir strain (LASr), left atrial conduit strain (LAScd), and left atrial contractile strain (LASct). RevMan (v5.4) was used to pool the standardized mean difference (SMD) under a random effects model, with p < 0.05 as the threshold for statistical significance. Results: In an analysis of 297 patients across five studies, AC therapy significantly lowered LASr (SMD = -0.34, 95% CI:-0.55, -0.14, I2 = 0%, p = 0.0009) and LAScd (SMD = -0.41, 95% CI: -0.59, -0.23, I2 = 0%, p < 0.00001) levels. Conversely, LASct demonstrated no significant change (SMD = 0.01, 95% CI: -0.21, 0.23, I2 = 9%, p = 0.95). AC therapy also significantly reduced LV GLS (SMD = -0.31, 95% CI: -0.51, -0.11, I2 = 0%, p = 0.003). While not statistically significant, LVEF decreased (SMD = -0.20, 95% CI: -0.42, 0.03, I2 = 0%, p = 0.09), and left atrial volume index trended higher (SMD = 0.07, 95% CI: -0.14, 0.27, I2 = 0%, p = 0.52) after AC therapy. Conclusions: AC treatment led to reduced LAS and LV GLS values, indicating its potential as an early CTRCD indicator. Larger trials are required to fully explore their clinical significance.

Efficacy and outcomes of bempedoic acid versus placebo in patients with hypercholesterolemia: an updated systematic review and meta-analysis of randomized controlled trials.

Introduction: Bempedoic acid (BA) has shown varied efficacy in managing hyperlipidemia. We conducted the most extensive up-to-date meta-analysis, the first to include recent studies by Nissen et al., which boast the largest sample size. Methods: Literature search was done on Medline, EMBASE, and Cochrane Library. The primary endpoint was a change in low-density lipoprotein-cholesterol (LDL-C) levels, while secondary endpoints encompassed changes in lipid parameters, clinical endpoints, and safety endpoints. The least-square mean (LSM) percent change was utilized for lipid changes, with statistical significance set at P < 0.05. Results: This analysis included 12 randomized control trials with 22,249 participants. BA exhibited a substantial reduction in LDL-C levels [LSM % change, -24.34; 95% confidence interval (CI), -27.80 to -20.88; P < 0.0001], total cholesterol levels (LSM % change, -16.62; 95% CI, -21.70 to -11.54; P < 0.00001) and high-density lipoprotein-cholesterol (HDL-C) levels (LSM % change, -4.22; 95% CI, -5.51 to -2.92; P < 0.00001) compared to the placebo. Conclusions: BA significantly lowers LDL-C, total cholesterol, HDL-C, non-HDL-C, high sensitivity C reactive protein, and apolipoprotein levels.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review.

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Predictive Nomogram and Propensity Score Matching in Neuroendocrine Carcinoma of the Tubular Gastrointestinal Tract: A US Population-Based Clinical Outcome Study.

Background: Neuroendocrine carcinomas (NECs) of the tubular gastrointestinal tract (GI-NECs) are rare and associated with worse clinical outcomes. This population-based study aims to highlight key demographics, clinicopathological factors, and survival outcomes in the US population. Methods: Data from 10,387 patients with GI-NECs were extracted from the Surveillance, Epidemiology, and End Result (SEER) database from 2000 to 2020. Results: Most patients were >40 years old at the time of presentation with a median age of 63 years old, with almost equal ethnic distribution per US population data. The most common primary tumor site was the small intestine (33.6%). The metastatic spread was localized in 34.8%, regional in 27.8%, and distant in 37.3% of cases, and the liver was the most common site of metastasis (19.9%) in known cases of metastases. Most NEC patients underwent surgery, presenting the highest 5-year overall survival of 73.2% with a 95% confidence interval (CI) (95% CI 72.0-74.4%), while chemotherapy alone had the lowest 5-year survival of 8.0% (95% CI 6.4-10.0%). Compared to men, women had a superior 5-year survival rate of 59.0% (95% CI 57.6-60.5%). On multivariate analysis, age > 65 (HR 2.49, 95% CI 2.36-2.54%, p ≤ 0.001), distant metastasis (HR 2.57, 95% CI 2.52-2.62%, p ≤ 0.001), tumor size > 4 mm (HR 1.98, 95%, CI 1.70-2.31%, p ≤ 0.001), esophageal (HR 1.49, 95% CI 0.86-2.58%, p ≤ 0.001), transverse colon (HR 1.95, 95% CI 1.15-3.33%, p ≤ 0.01), descending colon (HR 2.12, 95% CI 1.12, 3.97%, p = 0.02) anorectal sites, and liver or lung metastases were associated with worse survival. Surgical intervention and tumors located in the small intestine or appendix showed a better prognosis. Conclusion: GI-NECs are a group of rare malignancies associated with a poor prognosis. Therefore, epidemiological studies analyzing national databases may be the best alternative to have a more comprehensive understanding of this condition, assess the impact of current practices, and generate prognosis tools.

Comparison of Outcomes Between Right and Left Upper Extremity Access in Endovascular Aortic Repair for Patients with Thoracoabdominal and Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis.

Traditionally, left-sided upper extremity (LUE) access has been preferred in patients undergoing endovascular aortic repair (EVAR) to manage aortic aneurysms and decrease the risk of cerebrovascular adverse events. Recently, right-sided upper extremity access (RUE) has gained popularity owing to its greater maneuverability and ergonomics. However, synthesized data comparing the safety and efficacy of RUE and LUE accesses are limited. A comprehensive literature search was conducted on various databases from inception to September 2023 to retrieve all studies that compared RUE and LUE access in EVAR. Data on stroke, 30-day mortality, technical success, access-site complications, total time required for fluoroscopy, and contrast agent requirement were extracted, pooled, and analyzed. Forest plots were generated using a random-effects model on review manager by pooling the risk ratios (RRs) and standard mean differences (SMDs). Ten observational studies with a total of 3994 patients were included in our analysis with 1186 patients in the RUE and 2808 patients in the LUE access groups. EVAR using RUE access was associated with a significantly lower amount of contrast agent requirement than the LUE access group [SMD, -0.23; 95% confidence interval (CI), -0.45 to -0.02; P = 0.03]. There was no significant difference between the 2 groups in terms of the risk of stroke (RR, 1.62; 95% CI, 0.81-3.22; P = 0.17), 30-day mortality (RR, 1.42; 95% CI, 0.50-4.06; P = 0.51), rate of technical success (RR, 0.98; 95% CI, 0.95-1.01; P = 0.18), risk of access-site complications (RR, 1.00; 95% CI, 0.72-1.39; P = 0.99), and total time required for fluoroscopy (SMD, 0.07; 95% CI, -0.39 to 0.26; P = 0.69). The use of RUE access in EVAR appears to be comparable to LUE access in terms of the risk of stroke, access-related complications, all-cause mortality, technical success rate, and fluoroscopy duration. The RUE group required a lower volume of contrast agent.

Exploring Acute Kidney Injury Following Aortic Dissection: A Comprehensive Review of Machine Learning Models for Predicting Risk, Management Strategies, Complications, and Racial and Gender Disparities.

Both types of aortic dissection (AD), Stanford type A and type B, can result in complications such as acute kidney injury (AKI) and aortic rupture. Renal complications in AD arise from compromised renal perfusion affecting the renal arteries. Understanding the intricate connection between AD and AKI is crucial for navigating the complexities of tailored treatment and formulating specific management plans. Concerning machine learning models, in patients with type A aortic dissection, factors such as decreased platelet count on admission, increased D-dimer level, longer cardiopulmonary bypass duration, elevated white blood cell levels, the need for blood transfusion, longer aortic clamp time, extended surgery duration, advanced age, and an elevated body mass index were positively associated with the development of AKI. For the risk of AKI after type B aortic dissection, elevated Nt-pro brain natriuretic peptide, prolonged activated partial thromboplastin time, elevated admission systolic blood pressure, and a higher contrast agent requirement during operative repair were found to predict the risk. Male gender was associated with a higher risk of AKI, and nonwhite race was linked to a higher risk of AKI, a greater likelihood of requiring more urgent procedures, and lower levels of insurance coverage. The treatment of AKI following AD requires a multifaceted approach. Identifying and addressing the underlying cause, such as low blood pressure, renal artery involvement, or medication-induced injury, is crucial for effective management and preventing further kidney damage. Maintaining proper fluid balance is essential for improving renal perfusion, but careful monitoring is necessary to avoid complications. The evolving landscape of research, particularly in biomarkers and AI programs, reveals a promising role in predicting the risk for and managing AKI post-AD.

Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta-analysis.

Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access-site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random-effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40-0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38-0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32-0.53, p < 0.00001], and shortens fluoroscopy time [SMD: -0.62; 95% CI: -1.00 to -0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: -0.33; 95% CI: -0.61 to -0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30-day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large-scale randomized controlled trials are warranted to confirm and strengthen these findings.