Nearly 500,000 open-heart operations are performed annually in the United States, with complications such as postcardiotomy cardiogenic shock (PCCS) occurring in 2-9% of cases. Extracorporeal membrane oxygenation (ECMO) is a critical salvage therapy for patients unable to wean from cardiopulmonary bypass (CPB). This study aims to review our institution's experience with ECMO in managing PCCS and to analyze patient outcomes. Following IRB approval, a retrospective observational study was conducted on adult patients aged 32-84 years who underwent open-heart procedures with the use of CPB requiring ECMO support due to failed wean from CPB from 1 April 2014 to 31 December 2022. Data were analyzed from electronic medical records for demographics, procedural details, ECMO therapy duration, and outcomes. Of 45 patients identified from 6346 open-heart procedures, 33 were male, and 12 were female, with an average age of 59.9 years. The majority of patients were Caucasian (88.8%, n = 40). Extracorporeal membrane oxygenation was initiated using venoarterial configurations in 100% (n = 45) of cases, with three patients transitioning to venovenous configurations. The median ECMO duration for all patients in the study was 4 days. In-hospital mortality was 51.1% (n = 23), while 48.9% (n = 22) of patients survived to discharge. Survivors were discharged to rehabilitation facilities (54.5%, n = 12), home (31.8%, n = 7), long-term acute care hospitals (9.1%, n = 2), or detention centers (4.5%, n = 1). Extracorporeal membrane oxygenation remains a valuable rescue therapy for PCCS, achieving a 48.9% survival rate. This study highlights the importance of timely intervention and underscores the need for future research into optimizing patient selection and perioperative management.
Blood urea nitrogen (BUN) reflects renal function and metabolic catabolism and thus can be a potential biomarker in severe illness. The purpose of this investigation was to assess whether independent associations exist between admission BUN concentrations and hospital mortality in critically ill adults with acute myocardial infarction (MI) or cardiogenic shock (CS). Associations were assessed using tertiles of mean BUN during the hospital admission and mean BUN within 24 h of ICU entry. Using MIMIC-IV (v3.1), we conducted a retrospective cohort study of first ICU admissions (2008-2019) in adults identified by ICD-9/10 codes for acute myocardial infarction and/or cardiogenic shock. The primary exposure was mean BUN during hospitalization, categorized into tertiles; first-24-h BUN was analyzed as a sensitivity exposure. Analyses used complete cases. We included 6719 patients. In-hospital mortality climbed from 5.2% to 25.8% across average BUN tertiles. In multivariable logistic regression, higher mean BUN was associated with increased odds of in-hospital mortality across tertiles and per standard-deviation increase. Findings were directionally consistent when first-24-h BUN was used as the exposure. Model diagnostics supported acceptable collinearity and fit. Among critically ill adults with acute myocardial infarction and/or cardiogenic shock, higher BUN, particularly mean BUN during hospitalization, was independently associated with in-hospital mortality. Early BUN (first 24 h) showed a similar signal, supporting BUN as a simple adjunct for bedside risk assessment.
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To ascertain the impact of a 3-month pause in the NHS Breast Screening Programme (NHSBSP) during COVID-19 on numbers, characteristics and outcomes of breast cancer patients. We compared numbers, referral sources (NHSBSP/GP), tumour characteristics, treatments, and survival before and during COVID-19 using chi-square tests and Kaplan-Meier estimates. Patients were grouped into: (a) all cases from 2019 to 2021 (n = 3353) and (b) six selected months in 2019 and 2020 (n = 325). The study was conducted with the breast units of two large London NHS hospitals as a local audit to understand the impact of COVID-19 on breast cancer management. Patients diagnosed with breast cancer from 2019 to 2021 were analysed. Temporal variation in the number of breast cancer cases by referral source and the impact of the pause in screening mammography due to the COVID-19 pandemic on changes in tumour characteristics, treatments and survival. Overall, there were 31% fewer patients in 2020 vs. 2019 (886 vs. 1281, p = .002), due to fewer screen-detected (851 vs. 398) rather than symptomatic cases (432 vs. 459), p < .00001), with no corresponding increase in 2021 (n = 1186) In the detailed analysis, there were significantly fewer grade 1 cancers (11/120 vs. 37/204, p = .028) in 2020 vs. 2019, but there was no stage shift from smaller or less advanced (node-negative) tumours to larger or more advanced tumours, and no difference in extent of surgery, i.e., ratios of breast conservation to mastectomy, or sentinel node biopsy to axillary clearance. There was no difference in time from referral to diagnosis between the two time periods. The median follow-up was 3.8 years; K-M survival curves overlapped, with no difference in 3-year survival (90.5% vs. 91.7%, HR=1.09, p = .83). During the COVID-19-induced NHSBSP pause, good-prognosis (grade 1) cancers reduced without an increase in larger, or node-positive cancers, or more extensive surgery, and 3-year survival remained unchanged, suggesting that pausing NHSBSP may have avoided overdiagnosis without causing harm.
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To describe trends in chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD)-related mortality in the United States from 1999 to 2020 using data from CDC WONDER. This study analyzed mortality data from CDC WONDER, identifying decedents aged 25 years and above using ICD-10 codes. A total of 1,459,562 deaths occurred between 1999 and 2020. Annual crude and age-adjusted mortality rates (AAMRs) per 100,000 were calculated and stratified by age, sex, race, and region. Annual percentage changes (APC) were determined using Joinpoint regression. The overall AAMR declined from 24.78 in 1999 to 18.5 in 2020, with a gradual decrease from 1999 to 2018 (APC = -2.06 [95% CI: -2.27, -1.90]) and a subsequent rise through 2020 (APC = 4.53 [95% CI: 0.56,6.41]). Males had higher AAMRs (28.2) than females (13.95). Non-Hispanic Whites had the highest AAMRs (21.93). Mortality among adults aged 45-64 was stable until 2008, then increased through 2020. For adults ≥ 65 years, AAMRs declined until 2018 but rose sharply thereafter. Non-metropolitan areas (AAMR: 26.29) had higher mortality than metropolitan areas (AAMR: 18.42). States in the 90th percentile, such as Tennessee and Kentucky, had AAMRs approximately three times higher than those in the 10th percentile, including Arizona and Hawaii. Substantial demographic and regional disparities persist in COPD and IHD-related mortality, necessitating targeted interventions in high-risk populations.
Sepsis-associated myocarditis is a major challenge in critical care, driving global morbidity and mortality through cardiac dysfunction. Despite advances in diagnostics, consensus on optimal management remains lacking. This review explores epidemiology, clinical complexities, and research gaps. A systematic search of OVID MEDLINE and Scopus (2000-2025) using terms "sepsis," "myocarditis," "cardiac dysfunction," and "inflammatory cardiomyopathy" identified 10,344 records. After removing duplicates (2323) and applying filters for human studies (1840), English language (1775), and publication year (1340), 87 articles were eligible. Thirty were excluded for lacking outcome data, leaving 57 studies for final analysis, supplemented by 13 additional articles that highlight therapeutic strategies, emerging directions, and supportive evidence. Study quality was assessed using PRISMA 2020 guidelines. Sepsis-associated myocarditis is characterized by myocardial inflammation and impaired cardiac function, often worsened by systemic inflammatory responses. Left ventricular dysfunction is frequent, influenced by infectious agents, immune dysregulation, and drug toxicities. While diagnostic modalities have improved, therapeutic approaches remain inconsistent, with no standardized protocols established. Current management typically involves intravenous fluids, antibiotics, and vasopressors, yet patient outcomes vary widely. The absence of consensus highlights an urgent need for targeted research to clarify mechanisms, define effective interventions, and improve survival in this high-risk population.
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Hormone replacement therapy (HRT) is used to manage menopausal symptoms, but its perioperative use raises concerns about increased venous thromboembolism (VTE) risk. Clinical guidelines vary, with some advising temporary discontinuation before surgery. This scoping review aims to synthesise evidence and guidance on whether perioperative cessation of HRT influences postoperative VTE risk. A systematic search of PubMed and the Cochrane Library identified studies evaluating pre-operative HRT and VTE outcomes. Search terms included Hormone Replacement Therapy, HRT, Venous Thromboembolism, Venous Thrombosis, Pulmonary Embolism, Perioperative Care and Surgical Procedures, Operative. Studies included adult women on HRT undergoing surgery and assessed discontinuation and VTE risk. Data were synthesised narratively. The search identified 246 records, four of which met the inclusion criteria: three primary studies and one systematic review. Only one study compared perioperative continuation versus cessation of HRT and found no significant increase in postoperative VTE with continued use. Other studies examined HRT among multiple VTE risk factors, with inconsistent findings. Clinical guidelines recognise oral oestrogen as a VTE risk factor and distinguish between higher-risk oral and lower-risk transdermal formulations; however, few provide explicit perioperative recommendations. Evidence is limited and insufficient to support routine perioperative HRT cessation. The only comparative study found no significant increase in VTE with continuation, though limitations restrict interpretation. Overall, the literature reflects uncertainty. Given limited and heterogeneous data, perioperative HRT management should be individualised. Further prospective research is needed to determine whether temporary withdrawal, particularly of oral oestrogen, reduces postoperative VTE risk.
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Severe aortic stenosis typically presents with reduced exercise tolerance, exertional chest pains, or syncope. We report on a case of a young female on therapeutic anticoagulation and a history of nephrotic syndrome, who presented with subacute limb ischaemia resulting from axillary artery thrombus. Urgent echocardiogram demonstrated a bicuspid aortic valve with critical stenosis, and she underwent surgical aortic valve replacement. Her presenting symptoms resolved after three months of warfarin therapy. This case highlights the importance of systemic evaluation of unexplained arterial thrombosis.
To map the global research on the impact of plastic-based health products and their packaging across the product lifecycle in order to inform equitable, sustainable governance for the role of plastics in health products. A scoping review of primary research and systematic reviews examining plastic-related outcomes in the context of health products or packaging using a systematic search of the MEDLINE, EMBASE, SCOPUS, GEOBASE and Compendex databases November 2024 with no date or language restrictions. Studies spanning global and disciplinary contexts. Primary research or systematic reviews that examined plastic-related outcomes in the context of health products or packaging. We descriptively analyzed characteristics and outcomes of the included articles according to the product lifecycle stage. We screened 14,695 articles and included 572 articles published between 1960-2024. Only 8% (45/572) of articles studied more than one lifecycle stage. The evidence is otherwise siloed by focus, setting, and discipline: articles focused on clinical use and storage outcomes (266/572, 46.5%), were conducted primarily in high income countries (230/266, 86.5%) and within biomedical disciplines (207/266, 86.5%); articles focused on end-of-life outcomes (n=257/572, 44.9%) were conducted more frequently in middle-income countries (158/257, 61.7%), and within engineering and environmental sciences (208/257, 80.9%). We documented a multi-decade interest in plasticizer leaching from plastic devices and packaging. A research agenda that is lifecycle oriented, prevention focused, and precautionary will produce robust, actionable evidence to support treaty decision-making and implementation. We conclude with recommendations for research priorities that include interventions to reduce the use of plastics in healthcare, to measure the health and environmental impacts of the chemicals in plastics, and identification and assessment of safe, toxics-free, sustainable alternatives.
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This qualitative study captured the perspectives of patients and healthcare professionals to better understand COVID-19 vaccine decision-making among South Asians in London. In-depth semi-structured telephone and virtual interviews were conducted using convenience and purposive sampling to explore narratives about COVID-19 decision-making processes, pandemic experiences, and perceptions of living through a period of unprecedented uncertainty and turbulence. UK. 12 London-based individuals including patients, clinicians, and a medical receptionist. Respondents were categorised as either COVID-19 vaccine compliant or non-compliant based on their vaccination status. The variation and dynamic nature of the vaccination trajectories described in this study suggest that the decision to vaccinate or not against COVID-19 comprises a fluid, continually evolving process shaped by personal experiences and ongoing risk assessments. This study examines the possibility that some individuals form an 'epistemic community of uncertainty,' influenced by the pervasive 'infodemic' surrounding COVID-19 vaccines, which has created substantial ambiguity about truth and trust, reminiscent of the Rashōmon effect. Developing a nuanced understanding of this effect in the context of the COVID-19 era is a critical step towards addressing such ambiguity and fostering deeper critical thinking about vaccine decision-making. This research highlights the need for more flexible and innovative strategies to navigate the complex factors influencing decision-making. Furthermore, the study advocates for a more refined and discerning personalised approach to engagement, which is vital for improving scientific and health literacy within society and overcoming common barriers to making informed and autonomous choices.
Hypertrophic cardiomyopathy (HCM) stands as the most common monogenic cardiac disease, with an estimated prevalence historically reported as 1:500, but likely closer to 1:200 based on contemporary population studies in the general population. The past decade has marked a fundamental shift in therapeutic strategy: from symptomatic relief toward interventions directly targeting pathological sarcomeric hypercontractility. Conventional therapy relies on beta-blockers and non-dihydropyridine calcium channel antagonists, which provide symptomatic benefits through negative inotropic effects. For refractory left ventricular outflow tract obstruction, disopyramide constitutes an effective third-line option, although its anticholinergic profile requires cautious administration. Cardiac myosin inhibitors, mavacamten and aficamten, have introduced a novel therapeutic paradigm through direct modulation of actin-myosin cross-bridge formation. Pivotal clinical trials have demonstrated significant improvements in exercise capacity, reduction in obstruction severity, and enhancement of functional status, validating for the first time a therapeutic strategy that directly targets the underlying sarcomeric mechanism of hypercontractility. The therapeutic horizon includes next-generation myosin modulators, metabolic pathway interventions, and gene-based strategies. Current challenges involve accessibility to these therapies, substantial costs, and the requirement for mandatory regular echocardiographic monitoring. Future perspectives are oriented toward precision personalized medicine, integrating molecular therapeutics with genetic profiling to enable increasingly individualized risk stratification and therapeutic decision making.
Lowering low-density lipoprotein cholesterol (LDL-C) is a cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention, with robust evidence supporting the principle that "the lower, the better," particularly in secondary prevention. Contemporary guidelines recommend intensive LDL-C lowering to <70 mg/dL in high-risk patients and <55 mg/dL in very high-risk populations, including those with acute coronary syndrome and familial hypercholesterolemia. In addition to statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, including monoclonal antibodies and small interfering RNA, have emerged as highly effective therapies, demonstrating substantial LDL-C reduction and cardiovascular event risk reduction, as exemplified by the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial. Patients with peripheral arterial disease, including lower extremity arteriosclerosis obliterans, represent a particularly high-risk population in whom PCSK9 inhibition provides marked absolute risk reduction. Despite intensive LDL-C lowering, considerable residual cardiovascular risk persists. Accumulating evidence indicates that elevated triglyceride (TG) levels are independently associated with cardiovascular events. However, clinical trials targeting TG reduction, including fibrate-based therapies such as pemafibrate, have not consistently demonstrated cardiovascular benefit, highlighting the complexity of lipid metabolism and the limitations of TG lowering alone. Lipoprotein(a) [Lp(a)] has recently gained recognition as a genetically determined, independent risk factor for ASCVD. Emerging antisense and RNA-targeted therapies have shown profound Lp(a)-lowering effects and are currently being evaluated in large-scale outcome trials. Future lipid management strategies will require a comprehensive approach that integrates LDL-C lowering, residual risk modification, and novel therapeutic targets such as Lp(a), with personalized risk stratification to optimize clinical benefit and cost-effectiveness.