1. In a cohort of young patients with a first-ever stroke, the cumulative 6-month and 5-year risk of any recurrent vascular event was 6.7% and 12.2%, respectively.
2. Elevated short-term risk of recurrence was significantly higher for patients with cervical artery dissection (CeAD), atherothrombotic stroke, other rare causes of stroke, and hypertension.
3. Elevated long-term risk of recurrence was significantly higher for patients with cardioembolic stroke, a history of diabetes, and a history of alcohol abuse.
Evidence Rating Level:Â 2 (Good)
Over the last 2 decades, the incidence of ischemic stroke in young adults has significantly risen. There is a paucity of literature on the risk of recurrent vascular events by stroke cause in young adults, and previous research suffered from small sample sizes, outdated prevention methods, and the inclusion of patients without neuroimaging proof. This study aims to assess the short- and long-term risk of recurrent vascular events by cause and to identify high-risk subgroups of patients. Data from the prospective, multicenter Observational Dutch Young Symptomatic Stroke Study was utilized to identify and evaluate 1216 patients with an index ischemic stroke confirmed on neuroimaging (median [IQR] age, 44.2 [38.4-47.7] years; 48.0% female; median [IQR] follow-up, 4.3 [2.6-6.0] years). 137 patients (11.3%) had recurrent vascular events with 82 patients (6.7%) having their first recurrence within 6 months of their index stroke. The cumulative 6-month and 5-year incidence for any vascular event was 6.7% (95% CI, 5.3%-8.1%) and 12.2% (95% CI, 10.2%-14.2%), respectively. The incidence rate per 100 person-years for any vascular event (14.1; 95% CI, 12.6-15.6) peaked in the first 6 months post-stroke, then decreased to 1.8 (95% CI, 1.2-2.3) between 6 months and 1 year. Patients with CeAD had the highest short-term cumulative risk of any recurrent event at 13.2%, while patients with atherothrombotic stroke had the highest long-term risk of recurrence at 22.7%. In multivariate analysis, the risk of any short-term vascular event was significantly higher for patients with CeAD (HR, 4.6; P<.001, atherothrombotic stroke (HR, 3.5; P = .02), and other rare causes of stroke (HR, 3.2; P = .008) compared with cryptogenic stroke. Hypertension was also associated with an elevated short-term risk of recurrence (HR, 2.6; P=.006). The long-term risk was significantly higher for patients with cardioembolic stroke (HR, 2.6; P=.04) compared with cryptogenic stroke and patients with a history of diabetes and alcohol abuse. Overall, a significant number of young patients experience a recurrent vascular event within 5 years, with the cause of stroke influencing recurrence rates.
Sequence of Epinephrine and Advanced Airway Placement After Out-of-Hospital Cardiac Arrest
1. In those with out-of-hospital cardiac arrest (OHCA) and attempted resuscitation by emergency medical services (EMS) personnel, patients who received epinephrine first had an increased likelihood of 1-month survival, 1-month survival with functional outcomes, and prehospital ROSC, compared with those who received advanced airway management (AAM) first.
Evidence Rating Level: 2 (Good)
Out-of-hospital cardiac arrest (OHCA) poses a significant public health challenge globally. Emergency medical services (EMS) provide crucial initial care, including interventions like epinephrine administration and advanced airway management (AAM). Current guidelines offer recommendations for their timing, but the optimal sequence remains unclear. This cohort study identified 259 237 patients (median [IQR] age was 79 (69-86) years; 58.7% male) with OHCA and attempted resuscitation by EMS personnel from the All-Japan Utstein Registry, a population-based OHCA registry, from January 2014 to December 2019 to assess the impact of the sequence of intra-arrest epinephrine and AAM on OHCA patient outcomes. Among 21,592 patients (8.3%) initially presenting with a shockable rhythm, 28.8% received epinephrine first, 69.4% received AAM first, and 1.8% received both in the same whole minute. Among the 237,645 patients (91.7%) with an initial non-shockable rhythm, 17.4% received epinephrine first, 81.4% received AAM first, and 1.2% received both in the same whole minute. Among those with an initial shockable rhythm, patients receiving epinephrine first had an increased likelihood of 1-month survival (odds ratio [OR], 1.19; 95% CI, 1.09-1.30), 1-month survival with favorable functional status (OR, 1.24; 95% CI, 1.10-1.39) and prehospital ROSC (OR, 1.74; 95% CI, 1.61-1.88) compared with patients receiving AAM first. Among those with an initial non-shockable rhythm (OR, 1.28; 95% CI, 1.19-1.37), patients receiving epinephrine first had an increased likelihood of 1-month survival, 1-month survival with favorable functional status (OR, 1.39; 95% CI, 1.17-1.64), and prehospital ROSC (OR, 2.59; 95% CI, 2.50-2.68). These findings were similar in patients who received epinephrine and AAM within the same minute. Overall, these findings support the administration of epinephrine before the placement of an advanced airway in cases of OHCA.Â
1. In this nationwide, population-based retrospective cohort study, dental procedures did not increase the risk of periprosthetic joint infections (PJI) in patients who have undergone primary and revision total knee arthroplasty (TKA).
2. Prophylactic antibiotics in these patients did not reduce the PJI risk, while posttraumatic arthritis was associated with PJI.
Evidence Rating Level: 2 (Good)
The efficacy of prophylactic antibiotics before dental procedures to prevent PJI post-total joint arthroplasty (TJA) remains uncertain despite multiple guideline revisions. Surgeons debate concerns about infection and antibiotic overuse. This nationwide, population-based, retrospective, comparative study used data from the Health Insurance Review and Assessment Service in South Korea from 2009 to 2019 to examine whether dental procedures increase the risk of PJI in TKA patients and assess the effect of prophylactic antibiotics. A total of 591,602 patients who underwent unilateral primary and revision TKA, had undergone a dental procedure at least 1 year after their index surgery, and had at least 2 years follow-up after the dental procedures, were enrolled in the study. 530,156 patients (mean age [SD], 68 [8]; 86% female) comprised the nondental cohort and 61,446 patients (mean age [SD], 71 [8]; 87% female) comprised the dental cohort, which was further stratified into prophylactic antibiotics and nonprophylactic groups. To compare cohorts, propensity score matching was used to control for covariates associated with PJI risk. Dental procedures did not increase the risk of PJI after primary or revision total knee arthroplasty TKA. The adjusted hazard ratio (HR) for primary TKA was 1.56 (95% CI 0.30 to 8.15; p = 0.60), and for revision TKA was 1.74 (95% CI 0.90 to 3.34; p=0.10). Prophylactic antibiotic use did not increase PJI risk after either primary (adjusted HR 1.28 [95% CI 0.30 to 5.42]) or revision (adjusted HR 0.74 [95% CI 0.45 to 1.23]; p = 0.25) TKA. While the type of surgery and prophylactic antibiotic usage did not impact PJI incidence after dental procedures, posttraumatic arthritis was significantly associated with PJI (adjusted HR 4.54, p = 0.046). Overall, this study suggests that dental procedures do not increase the risk of PJI for up to 2 years after dental procedures in patients who underwent primary or revision TKA and does not support the use of prophylactic antibiotics in these patients.
1. In geriatric patients with hip fractures on direct oral anticoagulants (DOACs), surgical treatment within 48 hours of their last preoperative DOAC dose had comparable complication rates and 1-year mortality compared with patients with surgery delayed past 48 hours.
2. Patients who underwent surgical management within 48 hours required fewer transfusions and had decreased length of stay, compared with those who underwent surgery beyond 48 hours.Â
Evidence Rating Level: 2 (Good)
Geriatric hip fractures are associated with 1-year mortality rates as high as 33%. Surgical delays beyond 24 hours increase the 30-day mortality risk, while those more than 48 hours increase the 1-year mortality risk. Rising use of DOACs complicates perioperative management due to consideration of bleeding risk, often leading to a required 48-hour discontinuation period before surgery. This retrospective cohort study used data from 3 level 1 trauma centers in the United States between 2010 and 2018, to investigate the relationship between the timing of the last DOAC dose before surgery (<48 vs. >48 hours) and postoperative complications and mortality rates. 205 patients (mean age [range], 81.9 [65-100] years; 65% female; mean Charlson Comorbidity Index [range], 6.4 [2-20]) were included in the study. 35% (71/205) of patients underwent surgery within 48 hours of their last preoperative DOAC dose. Patients with delayed surgery (>48 hours) experienced a mean time to surgery of 44.4 hours longer compared to those without delay. No significant differences were observed in total complications, readmission rates, 1-year mortality, estimated blood loss, or change in hemoglobin/hematocrit level, based on the timing of the last DOAC dose preoperatively. Notably, multivariate analysis controlling for age, CCI, DOAC prescribed, fracture type, sex, delayed surgery, and surgery type, demonstrated that patients delayed >48 hours from their last preoperative DOAC dose, were more likely to require a blood transfusion (OR 2.39, 95% CI, 1.05–5.44; P = 0.04). Compared with patients who waited more than 48 hours from their last preoperative DOAC dose, those who were treated within 48 hours had significantly shorter lengths of stay (5.9 vs. 7.6 days, P<0.005). Overall, this study found that geriatric patients with hip fractures who underwent surgery within 48 hours of their last preoperative DOAC dose had comparable mortality and complication rates, required fewer transfusions, and had decreased length of stay compared with patients delayed beyond 48 hours. These findings support early intervention for geriatric hip fractures rather than adherence to DOAC discontinuation guidelines.Â
1. In patients with traumatic rib fractures, the number of rib fractures was an independent risk factor for venous thromboembolism (VTE).
2. Surgical fixation of isolated rib fractures involving ≥3 ribs reduced the incidence of VTE compared with conservative treatment.
Evidence Rating Level:1 (Excellent)
Traumatic rib fractures increase VTE risk due to reduced mobility, trauma impact, and treatment interventions. Limited data exist on VTE incidence and risk factors in acute chest trauma patients, especially those with rib fractures. This retrospective study identified 5774 cases of traumatic rib fractures between October 2020 and September 2021 from 33 hospitals affiliated with the China Chest Injury Research Society to assess VTE incidence and contributing factors in this population. Of these patients, 466 patients (mean age [SD], 55.1 [13.7]; 31.3% female) experienced in-hospital VTE (overall VTE incidence of 8.1%). Patients with isolated rib fractures had a significantly lower incidence of VTE compared with patients who had rib fractures accompanied by other injuries (4.4% vs. 12.0%, P < 0.01). In a multifactorial analysis of all cases (combined and isolated rib fractures), age, smoking, prophylactic drug anticoagulation therapy, number of rib fractures, combined vertebral fractures, combined pelvic fractures, combined lower extremity fractures, and ventilator-assisted ventilation were independent risk factors for VTE. Patients who underwent surgical fixation of rib fractures had a lower risk of VTE (OR = 0.219, 95% CI: 0.164–0.292, P < 0.001). Among patients with isolated rib fractures, age, smoking, prophylactic drug anticoagulation therapy, number of rib fractures, and ventilator-assisted ventilation remained independent risk factors for VTE, and surgical fixation continued to be a protective factor (OR = 0.199, 95% CI: 0.118–0.335, P < 0.001). When examining surgical fixation further, there was no difference in VTE incidence between surgical and conservative treatment in patients with isolated rib fractures involving 1-2 ribs (0 vs. 1.5%, P = 0.786), while in patients with 3–6 and ≥ 7 ribs fractured, surgical treatment significantly lowered VTE incidence compared with conservative treatment (1.8% vs. 5.5% and 3.8% vs. 12.1%, respectively; P < 0.001). Overall, these findings demonstrate a substantial incidence of VTE in patients with rib fractures, correlated with the number of rib fractures. Targeted thromboprophylaxis and surgical stabilization can mitigate this VTE risk.
Image: PD
©2024 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.