2 Minute Medicine Rewind October 17, 2022

Post-intensive care syndrome in out-of-hospital cardiac arrest patients: A prospective observational cohort study

1. Approximately half of patients with out-of-hospital cardiac arrest (OHCA) have signs of post-intensive care syndrome (PICS) at 3 and 12 months after ICU admission, including impairments to their physical, cognitive, and psychological well-being.

2. Risk factors for PICS for OHCA patients include increased length of stay in ICU, illness severity, intubation, poor functionality at discharge, and loss of work.

Evidence Rating Level: 2 (Good)

Post-intensive care syndrome (PICS) refers to the physical, cognitive, and psychological detriments that patients may face long-term after leaving the ICU. In particular, patients who suffer from out-of-hospital cardiac arrest (OHCA) have been associated with long-term negative impacts in these domains. Therefore, this study aimed to assess the prevalence and risk factors for PICS amongst adult OHCA survivors. This cohort study was based at a single centre in Switzerland, and conducted follow-up with OHCA patients 3 months and 12 months after admission to ICU. The level of physical impairment was measured using the EuroQol questionnaire (EQ-5D-3L), the cognitive domain was measured using the Cerebral Performance Category (CPC) and modified Rankin Scale (mRS), and the psychological domain was measured using the Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised (IES-R). The study population consisted of 139 patients at the 3-month follow-up and 110 patients at the 12-month follow-up, with a median age of 62.8 years, median ICU stay duration of 4 days, and median hospital stay of 13 days. The results showed that at 3 months follow-up, 49.6% of patients showed signs of PICS, with 36.7% demonstrating physical effects, 25.2% demonstrating cognitive effects, and 12.9% demonstrating psychological effects. Risk factors included intubation (OR 2.21, 95% CI 1.02-4.78, p = 0.043), length of ICU stay in days (OR 1.11, 95% CI 1.01-1.21, p = 0.022), work loss during period of follow-up (OR 14.53, 95% CI 1.8-117.56, p = 0.012), and poor functionality at discharge, as measured by mRS (OR 4.35, 95% CI 1.7-11.1, p = 0.002) and CPC (OR 3.39, 95% CI 1.46-7.88, p = 0.005). At 12 months follow-up, 47.3% demonstrated signs of PICS, with 36.7% demonstrating signs in the physical domain, 22.2% in the cognitive domain, and 12.7% in the psychological domain. Risk factors included initial illness severity as measured by the APACHE II score (OR 1.08, 95% CI 1.02-1.14, p = 0.008) and functionality at discharge, with lower risk of PICS found amongst patients not needing rehabilitation (OR 0.31, 95% CI 0.12-0.82, p = 0.019). Overall, this study showed that PICS affects approximately half of OHCA patients as far as 1 year after their admission to ICU, demonstrating the importance of screening and identifying patients at risk for PICS, and connecting them with relevant resources to support their physical, cognitive, and psychological recovery.

Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients

1. Black patients have a lower odds of receiving a surgical consultation for an emergency general surgery (EGS) diagnosis, compared to White patients.

Evidence Rating Level: 2 (Good)

In the United States, racial disparities between Black and White patients have manifested in numerous ways. For instance, Black patients get specialist referrals later in their illness and less often, and Black patients are under triaged in the Emergency Department. This current national cohort study is the first to investigate the disparities between Black and White patients with regards to receiving surgical consultations. This study included patients in the hospital with an emergency general surgery (EGS) condition as their primary diagnosis, who were 65.5 years and older. Consultations billed within 2 days of patient presentation were used as the primary outcome. The study found that out of 214,788 Black patients, 28.6% received a surgical consultation and 71.4% did not. Out of 1,472,152 White patients, 34.65 received a surgical consultation and 65.4% did not. After adjustment, Black patients had a 14% lower odds of getting a surgical consultation (OR 0.86, 95% CI 0.85-0.87). Even when comparing Black and White patients treated at the same hospital, there was an 8% lower odds for Black patients getting a surgical consultation (OR 0.92, 95% CI 0.90-0.93). Overall, this study demonstrated the pervasiveness of racial disparities in receiving a surgical consultation, and ultimately shows the importance of creating systemic change in the healthcare system, to identify racism and bridge the disparities that patients face.

Scoop thrombectomy: A declotting technique for the treatment of thrombosed autologous arteriovenous fistula. A single-center retrospective study

1. Scoop thrombectomy is a safe and effective novel technique for treating thrombosed arteriovenous fistulas (AVFs) used for hemodialysis.

Evidence Rating Level: 2 (Good)

For the millions of individuals worldwide with end-stage renal disease (ESRD), the creation of an arteriovenous fistula (AVF) is vital to receive hemodialysis. However, AVFs are prone to failure, particularly due to thrombi. Current treatments for AVF thrombi include surgical and endovascular intervention, which can have less-than-ideal patency rates, and can also have complications in 8-10% of patients, such as losing areas that would have been potential candidates for subsequent AVF creation. Therefore, this study proposed a novel scoop thrombectomy technique, and evaluated its patency and complication rates with a retrospective cohort. This scoop thrombectomy involves removing thrombi from an AVF with hemostatic forceps, then employing high-pressure balloon angioplasty, all under ultrasound guidance. The study consisted of 56 scoop thrombectomy procedures, with a mean time of 68 minutes. The results showed success in 98.2% of scoop thrombectomies, with the ability to use the AVF for hemodialysis right after. 1 patient (1.8%) had a failed procedure, which was attributed to significant calcification of the area. Additionally, the patency rates at 3, 6, and 12 months were 92.9, 83.8, and 73.3% respectively, with a mean time of 11.2 months (95% CI 10.4-12.1 months) before a subsequent procedure is done with regards to access for hemodialysis. Lastly, 2 patients (3.6%) had a complication, both of which were puncture site hematomas. In conclusion, this study demonstrated the efficacy and safety of the scoop thrombectomy procedure for thrombosed AVFs.

Effect of Exercise Training or Complex Mental and Social Activities on Cognitive Function in Adults With Chronic Stroke: A Randomized Clinical Trial

1. Chronic stroke patients randomized to a 6-month multicomponent exercise intervention performed better on cognitive function testing at the conclusion of the intervention, compared to individuals in a 6-month cognitive and social enrichment program or a 6-month light exercise and stretching program.

2. The differences in cognitive function did not persist 6 months after the intervention had been completed.

Evidence Rating Level: 1 (Good)

Due to the increased risk of dementia for patients who have suffered from strokes, it is vital that stroke patients have avenues to maintain and improve their cognitive functioning. While exercise has been linked to positive cognitive outcomes in the elderly, no study has examined the role of an exercise program to improve cognition for stroke patients. Therefore, this current single-blinded randomized clinical trial assessed the change in cognitive function for stroke patients who underwent a 6-month intervention, involving exercise or cognitive and social enrichment. This trial involved randomized patients to 3 groups, all participating in classes twice a week: The EX group underwent an exercise program encompassing strength, aerobics, agility, and balance; the ENRICH group underwent cognitive and social enrichment activities, including cognitive training through computers and apps; and the BAT group acted as the control, which included lighter intensity exercise, breathing and relaxation, grip strength, and stretching. The study population consisted of patients 55 years and older with chronic stroke, who did not have dementia, and who could walk at least 6 metres. The primary outcome of cognition was assessed using the 13-item Alzheimer Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus). In total, there were 120 participants, with 34 each in the EX and ENRICH groups, and 52 in the BAT group, with a mean (SD) age of 70 (8) years. At conclusion of the 6-month intervention, the EX group had improved cognitive scores compared to the BAT group (estimated mean difference -0.24, 95% CI -0.43 to -0.04, p = 0.02), although this difference was not present at 6-months post-intervention (estimated mean difference -0.08, 95% CI -0.29 to 0.12). As well, there were no differences between the ENRICH group and the BAT group at the conclusion of the intervention or 6-months post-intervention. Overall, this study demonstrated the potential for cognitive function improvements through exercise interventions in chronic stroke patients.

Identification of risk factors for incident cervical insufficiency in nulliparous and parous women: a population-based case-control study

1. Risk factors for incident cervical insufficiency (ICI) include history of cervical procedures, multi-fetal pregnancy, and number of miscarriages, although the strength of each risk factor varies depending on the parity of the pregnant patient.

2. For parous patients, PPROM and premature birth were risk factors for ICI, whereas macrosomia and prolonged second stage of labour were protective factors.

Evidence Rating Level: 3 (Average)

Incident cervical insufficiency (ICI) refers to a patient’s first presentation of a dilated cervix at an inappropriately early stage of pregnancy, particularly the 2^nd trimester, and is a leading cause of late miscarriage and preterm birth. It is important to identify patients at risk of cervical insufficiency, as interventions such as cerclage must be done before the cervix is too dilated or short. Some risk factors for ICI have been identified, such as history of procedures on the cervix, history of late miscarriage or preterm birth, and polycystic ovarian syndrome. However, the difference in risk factors between nulliparous and parous women for ICI are unclear. Therefore, this case-control study based out of Sweden aimed to elucidate these differences by examining national health registries. In this study, ICI was defined as a diagnosis of cervical insufficiency or a cervical cerclage procedure, and a random sample of pregnancies without cervical insufficiency were collected in a ratio of 1:10 cases to controls. The study collected data including country of birth, body mass index, age, parity, multi-fetal gestation, previous miscarriages, previous pregnancy complications, and history of cervical procedures. In total, the study included 2257 pregnancies with ICI, with approximately two-thirds occurring in parous individuals. Several risk factors were identified and quantified through this study. For instance, cervical procedures were correlated with a two-fold increased risk for both nulliparous (OR 2.48, 95% CI 1.80-3.42) and parous (OR 1.82, 95% CI 1.38-2.38) individuals. For parous individuals, preterm prelabour rupture of membranes (PPROM) and preterm birth were associated with ICI (OR 2.93, 95% CI 2.29-.374 and OR 2.71, 95% CI 2.35-3.11 respectively), whereas macrosomia and prolonged second labour stage were associated with decreased risk of ICI (OR 0.72, 95% CI 0.63-0.82 and OR 0.83, 95% CI 0.73-0.95 respectively). As well, multi-fetal pregnancies were associated with ICI, but more so with nulliparous (OR 8.44, 95% CI 5.20-13.68) than with parous (OR 1.19, 95% CI 0.73-1.95) individuals. Previous miscarriages were also associated with a greater risk for ICI, but more so in nulliparous than parous individuals (OR 4.23, 95% CI 3.43-5.22 and OR 2.03, 95% CI 1.71-2.40 respectively, for 1 miscarriage), with a larger difference in risk between nulliparous and parous with a greater number of miscarriages (OR 34.57, 95% CI 21.60-55.31 and OR 6.67, 95% CI 4.93-9.02 respectively, for 3 miscarriages). Overall, this study identified important risk factors for ICI in both nulliparous and parous individuals, while also highlighting the differences in risks for these two subgroups, which can allow for early identification of pregnant patients who could benefit from cerclage and other interventions for cervical insufficiency.

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