Gender disparities related to clinical characteristics and outcomes of patients undergoing transseptal procedures.

PURPOSE: Explore gender disparities in patients undergoing transseptal puncture (TSP) for selected transcatheter cardiac intervention procedures. METHODS: Patients who underwent TSP from January 2015 through September 2021 were reviewed. Primary outcomes were procedural and in-hospital major adverse events. Secondary endpoints were procedural success and hospitalization length of stay (LOS) >1 day. Unadjusted and multivariable-adjusted logistic regression analyses were performed to assess gender differences for in-hospital adverse events. RESULTS: The study cohort comprised 510 patients (mean [SD] age, 74 [14.0] years); 246 women (48 %) underwent TSP for left atrial appendage occlusion (LAAO) or transcatheter edge-to-edge-repair (TEER). Compared with men, women were younger, had higher CHA2DS2-VASc scores, and were more likely to have had a prior ischemic stroke, but were less likely to have paroxysmal atrial fibrillation. After multivariable adjustment, there were no differences between genders in aborted or canceled procedures (odds ratio [OR]: 0.43; 95 % confidence interval [CI]: 0.10-1.96; p = 0.277), any adverse events (OR: 1.00; 95 % CI: 0.58-1.70; p = 0.98), major adverse events (OR: 1.60; 95 % CI: 0.90-2.80; p = 0.11), or death (OR: 1.00; 95 % CI: 0.20-5.00; p = 0.31). Subgroup analysis for LAAO procedures showed that at 30 days, women had higher rates of adverse events, major adverse cardiac events, and LOS >1 day. CONCLUSIONS: Men and women showed no differences in procedural success and in-hospital adverse outcomes in unadjusted analysis and after multivariable adjustment, despite women having a higher risk profile among patients undergoing TSP. However, compared with men, women undergoing LAAO experienced a higher rate of in-hospital adverse events irrespective of TSP.

The Use of Telemedicine to Improve Hypertension in an Urban Primary Care Clinic and Predictors of Improved Blood Pressure.

BACKGROUND AND OBJECTIVE: Meta-analysis of randomized controlled trials have demonstrated the efficacy of telemedicine in blood pressure (BP) management when compared to conventional care. We initiated a hypertension telehealth clinic in our urban primary care clinic and through this study aim to evaluate the strengths and limitations of telemedicine in hypertension (HTN) control. The primary outcome of the study is to identify the proportion of patients with improved HTN. Secondary outcomes included identifying: predictors for lower BP, predictors of missing telehealth appointments, and comorbid conditions that are more likely to necessitate use of more than 1 antihypertensive medication. METHODS AND ANALYSIS: Patients seen in the HTN telehealth clinic from May 1st, 2022 to October 31st, 2022 were identified. A retrospective chart review was done to compare the BP during in-person visit prior to first telehealth visit, telehealth visit home BP readings and last recorded in-office BP on chart at end of study period. Descriptive statistical analysis, Chi Square test, and multivariable logistic regression was used to analyze data. RESULTS: Of the 234 appointments, 83% were conducted and 154 patients were seen. A remarkable decrease in percentage of patients with BP >140/90 was seen when comparing in-office visit BP to first telehealth visit home BP, 72% versus 45% respectively. No remarkable difference was noted in percentage of patients with BP >140/90 when comparing first telehealth visit home BP to last in-office BP recorded on chart, 45% and 41% respectively. Patients with diabetes had lower odds of missing appointments, adjusted odds ratio (aOR): 0.34 ([0.12-0.91], P = .03). Patients with partners were more likely to have lower BP at the telehealth visit, aOR:3.2 ([1.15-9.86], P = .03) while patients with obstructive sleep apnea (OSA) (aOR 0.27 ([0.08-0.77], P = .02) and CAD, aOR 0.24 ([0.06-0.8], P = .03) were less likely to have lower BP. CONCLUSION: The study demonstrated telemedicine as a great tool to prevent overtreatment of hypertension as significant difference between in-office BP and home BP during telehealth visits was noted. We did not see a significant change in blood pressure when comparing home BP at first telehealth visit to the last in-person clinic BP at end of study period.

Risk Factors and Outcomes Associated With Re-Intubation Secondary to Respiratory Failure in Patients With COVID-19 ARDS.

BACKGROUND: COVID-19 is associated with variable symptoms and clinical sequelae. Studies have examined the clinical course of these patients, finding a prolonged need for invasive ventilation and variable re-intubation rates. However, no research has investigated factors and outcomes related to re-intubation secondary to respiratory failure among patients with COVID-19 with ARDS. METHODS: We conducted a single-center, retrospective study on subjects intubated for ARDS secondary to COVID-19. The primary outcome was re-intubation status; secondary outcomes were hospital and ICU stay and mortality. Data were analyzed using between-group comparisons using chi-square testing for categorical information and Student t test for quantitative data. Univariate and multivariate logistic regression was performed to determine factors related to re-intubation and mortality as dependent variables. RESULTS: One hundred and fourteen subjects were included, of which 32% required re-intubation. No between-group differences were detected for most demographic variables or comorbidities. No differences were detected in COVID-19 treatments, noninvasive respiratory support, mechanical circulatory support, or duration of ventilation. Midazolam (odds ratio [OR] 5.55 [95% CI 1.83-16.80], P = .002), fentanyl (OR 3.64 [95% CI 1.26-10.52], P = .02), and APACHE II scores (OR 1.08 [95% CI 1.030-1.147], P = .005) were independently associated with re-intubation (area under the curve = 0.81). Re-intubated subjects had extended hospital (36.7 ± 22.7 d vs 26.1 ± 12.1 d, P = .01) and ICU (29.6 ± 22.4 d vs 15.8 ± 10.4 d, P < .001) stays. More subjects died who failed extubation (49% vs 3%, P < .001). Age (OR 1.07 [95% CI 1.02-1.23], P = .005), male sex (OR 4.9 [95% CI 1.08-22.35], P = .041), positive Confusion Assessment Method for the ICU (CAM-ICU) (OR 5.43 [95% CI 1.58-18.62], P = .007), and re-intubation (OR 12.75 [95% CI 2.80-57.10], P < .001) were independently associated with death (area under the curve = 0.93). CONCLUSIONS: Midazolam, fentanyl, and higher APACHE II scores were independently associated with re-intubation secondary to respiratory failure in subjects with COVID-19-related ARDS. Furthermore, age, male sex, positive CAM-ICU, and re-intubation were independently associated with mortality. Re-intubation also correlated with prolonged hospital and ICU stay.

A Systematic Review and Meta-Analysis of Randomized Controlled Trials on Supine vs. Nonsupine Endotracheal Intubation.

Background: This systematic review and meta-analysis of randomized controlled trials (RCTs) was performed to compare the safety and efficacy of supine vs. nonsupine positions during intubation. Methods: Based on the literature from inception to October 2020, 13 studies with nonemergent intubation in supine and nonsupine positions were chosen using PRISMA and MOOSE protocols. Pooled estimates were calculated using random-effects models with 95% confidence interval (CI). The primary outcome was a successful intubation, attempt, and duration of intubation. The secondary outcome was adverse events (trauma and hypoxia). Bias was evaluated qualitatively, by visual analysis, and quantitatively through the Egger test. Results: The final analysis included 13 clinical trials with 1,916 patients. The pooled success rates in the supine vs. lateral positions were 99.21% and 98.82%. The supine vs. semierect positions were 99.21% and 98.82%. The 1st attempt success rate in the supine vs. lateral position was 85.35% and 88.56% compared to 91.38% and 90.76% for the supine vs. semierect position. The rate of total adverse events in the supine position was 3.73% vs. 6.74% in the lateral position, and the rate of total adverse events in the supine position was 0.44% vs. 0.93% in semierect position. Low to substantial heterogeneity was noted in our analysis. Discussion. There is no significant difference between total successful intubations and success from 1st intubation attempt between supine and nonsupine positions. However, there are slightly higher rates of adverse events in nonsupine position. Addition of more recent studies on supine vs. nonsupine intubations would improve this study. Given these findings, it is important to develop more studies regarding different intubation positions and techniques with the aim of improving efficacy and decreasing adverse outcomes. Other. This review is not registered in a public database. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Impact of Preoperative Echocardiograms on In-Hospital Outcomes of Patients Undergoing Surgical Hip Fracture Repair and Their Clinical Appropriateness.

OBJECTIVES: Preoperative transthoracic echocardiograms (TTE) before hip fracture repairs are controversial. This study aimed to quantify the frequency of ordering TTE, the appropriateness of testing based on current guidelines, and the impact of TTE on in-hospital morbidity and mortality outcomes. METHODS: This retrospective chart review of adult patients admitted with hip fracture compared the length of stay (LOS), time to surgery, in-hospital mortality, and postoperative complications between TTE and non-TTE groups. TTE patients were risk stratified using the Revised Cardiac Risk Index (RCRI) to compare TTE indication according to current guidelines. RESULTS: Of the 490 patients included in this study, 15% received preoperative TTE. The median LOS of the TTE and non-TTE groups was 7.0 and 5.0 d, respectively, whereas the median time to surgery was 34 and 14 h, respectively. The odds of in-hospital mortality remained significantly higher in the TTE group after adjusting for RCRI but not when adjusted for the Charlson Comorbidity Index. Significantly more patients in the TTE groups had postoperative heart failure and up triage in the intensive care unit. Furthermore, 48% of patients with an RCRI score of 0 received preoperative TTE, with cardiac history as the most typical indication. TTE changed perioperative management in 9% of patients. CONCLUSIONS: Patients subjected to TTE before hip fracture surgery had a longer LOS and time to surgery, with higher mortality and intensive care unit up triage rates. TTE evaluations were typically conducted for inappropriate indications, which rarely made meaningful changes to patient management.