Defining levels of care in cardiogenic shock.

Background: Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Methods: Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Results: Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. Conclusion: This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.

Pseudoaneurysm Formation After "Preclose"-Assisted Impella Insertion in a Patient With Cardiogenic Shock.

The use of mechanical support devices such as the Impella CP (Abiomed, Danvers, MA) is a growing form of treatment for patients with cardiogenic shock (CS). Despite the increase in usage, there remains a dearth in literature regarding potential complications. Vascular complications such as pseudoaneurysms (PAs) are rare but important potential complications that can occur with use of the Impella. We present Impella-assisted percutaneous coronary intervention (PCI) in a patient with CS, "Preclosed" with the Perclose ProGlide (Abbott, Plymouth, MN) device complicated by development of a PA. A 62-year-old male patient with a history of diabetes and hypertension presented to our emergency room (ER) with chest pain and electrocardiogram (ECG) findings consistent with an acute anterior wall ST-elevation myocardial infarction (STEMI). This was further complicated by refractory CS. The patient was urgently taken to the cardiac catherization laboratory. After exchange of sequential dilators, a single Perclose device was used prior to the insertion of the Impella sheath. The patient then underwent a successful Impella-assisted PCI of his left anterior descending artery. Upon stabilization of hemodynamics, the patient was taken to the catheterization laboratory for Impella removal. After removal of Impella, imaging detected extravasation of contrast, without development of hematoma, later confirmed to be a PA via computed tomography (CT) scans and ultrasound Doppler imaging. The PA was successfully managed with injection of thrombin. The PA was likely caused by shearing forces of the dilators, the 14-F Impella sheath and foot of the device. We propose deploying the Perclose device earlier in the process of dilating the access site to avoid such complication. This is one of the first case reports that detail the occurrence and management of a PA with Impella insertion.

Preoperative optimization for vascular involvement complicating revision total hip arthroplasty.

Vascular complications in revision total hip arthroplasty may occur in cases where the components of the hip implant migrate through the acetabular wall, through the iliopectineal line of the pelvis, and into the pelvic cavity. This migration may lead to substantial intrapelvic vascular compromise, drastically increasing the surgical complexity and potential risk for morbidity and mortality in these surgical cases. Here, we present a case of a 78-year-old woman with significant acetabular protrusio, which resulted in intraoperative compromise of the external iliac artery with rapid extravasation. As a result of prudent preoperative planning, interdisciplinary collaboration, and precautionary measures, significant patient morbidity and mortality was averted. LEVEL OF EVIDENCE: Level V, Case Report.

Comparative non-metric and morphometric analyses of rats at residential halls of the University of Benin campus, Nigeria.

BACKGROUND: In mammals and across rat species, the variation in conformation is markedly observed in the head and the variation in the shape of the head is mostly determined by the shape of the skull. Hence comparative topographic analysis and morphometry is a veritable tool in precise categorization of peri-domestic rats and species identification. METHODS: Killed rodents around residential dwellings of students on campus were collected and measurements taken of external morphology. Thirty-one external head and corporal parameters; and 40 cranial measurements respectively were obtained. Topographic features and specific anatomical landmarks measured were matched using congruent anatomical landmarks and compared to referenced standard measurements. RESULTS: External morphometry suggests that all retrieved samples were more closely related to the species Rattus rattus. However, craniodental analysis of captured rats reveals variations from the mean of typical R. rattus. In comparison with Mastomys natalensis, the mean averages of the rat species were perceptibly different for only two of the parameters viz palatine fissure length (PL) (p=0.039) and distance between interparietal bone (DP) (p=0.06). In contrast, the mean of whole length of skull (WL), length of diastema (PI), length of nasal bone (NL), length of frontal bone (LF) and occipital width (OH) were significantly different from that of R. rattus with p values of 0.047, 0.036, 0.048, 0.032 and 0.034 respectively. CONCLUSION: This study focuses on peridomestic rat's identification within the University campus based on morphometry, providing unique landmarks for differentiation between Mastomys, Mus, Rattus and other rat species with emphasis on the need for more comprehensive investigation, categorization and morphometric profiling of rat population in Nigeria. Metric data generated for rat profiling in Nigeria is pivotal for a more comprehensive strategy for prevention of Lassa fever.

Death Associated Protein Kinase (DAPK) -mediated neurodegenerative mechanisms in nematode excitotoxicity.

BACKGROUND: Excitotoxicity (the toxic overstimulation of neurons by the excitatory transmitter Glutamate) is a central process in widespread neurodegenerative conditions such as brain ischemia and chronic neurological diseases. Many mechanisms have been suggested to mediate excitotoxicity, but their significance across diverse excitotoxic scenarios remains unclear. Death Associated Protein Kinase (DAPK), a critical molecular switch that controls a range of key signaling and cell death pathways, has been suggested to have an important role in excitotoxicity. However, the molecular mechanism by which DAPK exerts its effect is controversial. A few distinct mechanisms have been suggested by single (sometimes contradicting) studies, and a larger array of potential mechanisms is implicated by the extensive interactome of DAPK. RESULTS: Here we analyze a well-characterized model of excitotoxicity in the nematode C. elegans to show that DAPK is an important mediator of excitotoxic neurodegeneration across a large evolutionary distance. We further show that some proposed mechanisms of DAPK's action (modulation of synaptic strength, involvement of the DANGER-related protein MAB-21, and autophagy) do not have a major role in nematode excitotoxicity. In contrast, Pin1/PINN-1 (a DAPK interaction-partner and a peptidyl-prolyl isomerase involved in chronic neurodegenerative conditions) suppresses neurodegeneration in our excitotoxicity model. CONCLUSIONS: Our studies highlight the prominence of DAPK and Pin1/PINN-1 as conserved mediators of cell death processes in diverse scenarios of neurodegeneration.