Evaluating the role of ivabradine in acute decompensated heart failure: A systematic review and meta-analysis.

BACKGROUND: Acute decompensated heart failure (ADHF) presents a significant global health challenge, with high morbidity, mortality, and healthcare costs. The current therapeutic options for ADHF are limited. Ivabradine, a selective inhibitor of hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, has emerged as a potential therapy for ADHF by reducing the heart rate (HR) without negatively affecting myocardial contractility. However, the evidence regarding the efficacy and safety of ivabradine in patients with ADHF is limited and inconsistent. This meta-analysis aimed to evaluate the efficacy and safety of ivabradine for ADHF based on observational studies. METHODS: A systematic literature search was conducted following PRISMA guidelines to identify relevant observational studies comparing ivabradine with placebo in adult patients with ADHF. Data were pooled using a random-effects model, and heterogeneity was assessed. The risk of bias was evaluated using the Newcastle-Ottawa Scale. RESULTS: Four observational studies comprising a total of 12034 patients. Meta-analysis revealed that ivabradine significantly reduced all-cause mortality (RR: 0.66, 95 % CI: 0.49-0.89, p < 0.01) and resting HR (MD: -12.54, 95 % CI: -21.66-3.42, p < 0.01) compared to placebo. However, no significant differences were observed in cardiovascular mortality, hospital readmission for all causes, changes in LVEF, or changes in LVEDD. Sensitivity and publication bias assessments were conducted for each outcome. CONCLUSION: Ivabradine may be beneficial for reducing mortality and HR in patients with ADHF. However, its impact on other clinical outcomes such as cardiovascular mortality, hospital readmission, and cardiac function remains inconclusive. Further research, particularly well-designed RCTs with larger sample sizes and longer follow-up durations, are warranted.

Initial report on special operations clinical training at a civilian academic medical center.

BACKGROUND: Military-civilian partnerships for combat casualty care skills training have mostly focused on traditional, combat surgical team training. We sought to better understand US Special Forces (SF) Medics' training at West Virginia University in Morgantown, West Virginia, a Level 1 trauma center, via assessments of medical knowledge, clinical skills confidence, and technical performance. METHODS: Special Forces Medics were evaluated using posttraining medical knowledge tests, procedural skills confidence surveys (using a 5-point Likert scale), and technical skills assessments using fresh perfused cadavers in a simulated combat casualty care environment. Data from these tests, surveys, and assessments were analyzed for 18 consecutive SF medic rotations from the calendar years 2019 through 2021. RESULTS: A total of 108 SF Medics' tests, surveys, and assessments were reviewed. These SF Medics had an average of 5.3 years of active military service; however, deployed experience was minimal (73% never deployed). Review of knowledge testing demonstrated a slight increase in mean test score between the precourse (80% ± 14%; range, 50-100%) when compared with the postcourse (82% ± 14%; range, 50-100%). Skills confidence scores increased between courses, specifically within the point of injury care ( p = 0.09) and prolonged field care ( p < 0.001). Technical skills assessments included cricothyroidotomy, chest tube insertion, and tourniquet placement. CONCLUSION: This study provides preliminary evidence supporting military-civilian partnerships at an academic Level 1 trauma center to provide specialty training to SF Medics as demonstrated by increase in medical knowledge and confidence in procedural skills. Additional opportunities exist for the development technical skills assessments. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS: We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS: 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION: Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.

Common Tenets in Repair of Primary Paraesophageal Hernias: Reducing Tension and Maximizing Length.

Tension-free repair remains the most important principle of surgical management of giant paraesophageal hernias. The axial tension is relieved by generous circumferential mobilization of the esophagus in the mediastinum to the level of subcarina. An esophageal lengthening procedure may be necessary for a true short esophagus. The radial tension is managed by mobilizing the left and right diaphragmatic crus. Adjunctive procedures such as pleurotomy or diaphragmatic relaxation incisions may be needed to further reduce the tension on the repair.