The impact of acute kidney injury stages on the outcomes of veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: Although acute kidney injury (AKI) has been established as an independent risk factor for in-hospital mortality for patients on veno-arterial (V-A) extracorporeal membranous oxygenation (ECMO), the impact of Kidney Disease Improving Global Outcomes (KDIGO) stages of AKI has yet to be elucidated as a risk factor. METHODS: We conducted a retrospective analysis of patient outcomes based on KDIGO stages of AKI at a single institution. The analysis was a cohort of 179 patients; 66 without AKI, 19 with stage 1 AKI, 18 with stage 2 AKI, and 76 with stage 3 AKI. RESULTS: Every 1-year increase in age was associated with 4% increased odds of mortality at 30 days (95% confidence interval [CI] 1.01, 1.07; p = 0.004). The presence of AKI at any stage was associated with 59% increased odds of 30-day mortality (95% CI 0.81, 3.10; p = 0.176). The presence of stage 1 AKI was associated with a 5% decreased odds of 30-day mortality (95% CI 0.32, 2.89). The presence of stage 2 AKI (odds ratio [OR] 2.29, 95% CI 0.69, 7.55; p = 0.173) and stage 3 AKI (OR 1.68, 95% CI 0.81, 3.46; p = 0.164) was associated with increased odds of 30-day mortality. CONCLUSION: Based on our single-center study, higher KDIGO stages of AKI likely have increased odds of mortality at 30 days. Larger studies are needed to confirm these findings.

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.

Beta-blockers and Ambulatory Inotropic Therapy.

BACKGROUND: Continuous infusion of ambulatory inotropic therapy (AIT) is increasingly used in patients with end-stage heart failure (HF). There is a paucity of data concerning the concomitant use of beta-blockers (BB) in these patients. METHODS: We retrospectively reviewed all patients discharged from our institution on AIT. The cohort was stratified into 2 groups based on BB use. The 2 groups were compared for differences in hospitalizations due to HF, ventricular arrhythmias and ICD therapies (shock or antitachycardia pacing). RESULTS: Between 2010 and 2017, 349 patients were discharged on AIT (95% on milrinone); 74% were males with a mean age of 61 ± 14 years. BB were used in 195 (56%) patients, whereas 154 (44%) did not receive these medications. Patients in the BB group had longer duration of AIT support compared to those in the non-BB group (141 [1-2114] vs 68 [1-690] days). After adjusting for differences in baseline characteristics and indication for AIT, patients in the BB group had significantly lower rates of hospitalizations due to HF (hazard ratio [HR] 0.61 (0.43-0.86); P = 0.005), ventricular arrhythmias (HR 0.34 [0.15-0.74]; P = 0.007) and ICD therapies (HR 0.24 [0.07-0.79]; P = 0.02). CONCLUSION: In patients with end-stage HF on AIT, the use of BB with inotropes was associated with fewer hospitalizations due to HF and fewer ventricular arrhythmias.

Effect of Dosage Reduction of Hypoglycemic Multidrug Regimens on the Incidences of Acute Glycemic Complications in People With Type 2 Diabetes Who Fast During Ramadan: A Randomized Controlled Trial.

Objective: We aimed to investigate the effect of dosage reduction of four hypoglycemic multidrug regimens on the incidences of acute glycemic complications in people with type 2 diabetes who fast during Ramadan. Methods: We conducted an open-label, parallel-group, randomized controlled trial at a tertiary care center in Amman, Jordan. We recruited adults with type 2 diabetes who expressed an intention to fast during Ramadan and were adherent to one of four regimens-namely: metformin and glimepiride; metformin and vildagliptin; metformin and insulin glargine U100; or, metformin, insulin glargine U100, and human regular insulin. We randomly assigned participants in a 2:1 ratio to low- or regular-dosage therapy. The primary outcomes were the incidences of hypoglycemia and hyperglycemia during the 29 days of Ramadan 2017, and the secondary outcomes were the incidences of diabetic ketoacidosis and hyperosmolar hyperglycemic state during the same period. Results: We randomly assigned 687 participants to low-dosage therapy (n = 458) or regular-dosage therapy (n = 229) and included 678 (452 and 226, respectively) in the final analysis. The incidence of hypoglycemia was lower in the low-dosage group compared with the regular-dosage group (19 [4.2%] vs. 52 [23.0%], respectively; OR, 0.15 [95% CI, 0.08-0.26]; P < 0.001). The incidence of hyperglycemia did not differ between the low- and regular-dosage groups (319 [70.6%] vs. 154 [68.1%], respectively; OR, 1.12 [95% CI, 0.79-1.58]; P = 0.5). No participants experienced diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each 1% decrease in the baseline HbA1c concentration was associated with a 19.9-fold (95% CI, 9.6-41.5; P < 0.001) increase in the odds of hypoglycemia, and each 1% increase in the baseline HbA1c concentration was associated with a 15.7-fold (95% CI, 10.0-24.6; P < 0.001) increase in the odds of hyperglycemia. Conclusion: Dosage reduction decreases the incidence of hypoglycemia without a concomitant increase in the incidences of hyperglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state in people with type 2 diabetes who fast during Ramadan. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04237493.

Association of Parental Consanguinity With Papillary Thyroid Carcinoma: A Case-Control Study.

CONTEXT: Papillary thyroid carcinoma (PTC) is the most common type of nonmedullary thyroid carcinoma. Uncommonly, PTC is associated with multiple genetic alterations and chromosomal abnormalities and displays familial patterns of inheritance. Parental consanguinity increases susceptibility to many genetic disorders. OBJECTIVE: This work aimed to investigate the association of parental consanguinity with PTC. METHODS: This case-control study of PTC patients compared with healthy controls took place in a tertiary referral hospital. We recruited 200 PTC patients who were managed at the endocrinology outpatient clinics of the Jordan University Hospital, and we recruited 515 healthy controls from a nonclinical setting. We interviewed all participants and collected sociodemographic data. We reviewed the family pedigrees of each participant four generations back and excluded any participant who was related. We established whether the parents of each participant were first cousins, first cousins once removed, second cousins, or unrelated. We then used binary logistic regression to assess the association of parental consanguinity with PTC adjusted for age, sex, smoking status, body mass index, and parental education. RESULTS: We recruited 715 participants. The numbers of PTC patients and healthy controls were 200 (28.0%) and 515 (72.0%), respectively. The rate of parental consanguinity was 25.5% in PTC patients and 12.2% in healthy controls. Parental consanguinity was significantly associated with PTC (adjusted odds ratio, 2.60; 95% CI, 1.63-4.17; P < .001). CONCLUSION: Parental consanguinity is a risk factor for PTC. Our findings should be considered during familial risk assessment and genetic counseling, especially in populations with high rates of consanguinity.