Background:Patients with out-of-hospital cardiac arrest (OHCA) undergoing extracorporeal cardiopulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are at high risk of nosocomial infections, and prophylactic antibiotics may reduce the infections, but there is limited evidence. This study evaluated the effectiveness of prophylactic antibiotic administration on survival and neurological outcomes in patients with OHCA receiving VA-ECMO. Methods:As a prespecified research question within the Survey of Survivors after Cardiac Arrest in the Kanto Area in 2017 (SOS-KANTO 2017) study, we conducted a multicenter observational study analyzing 153 patients with OHCA who underwent VA-ECMO between September 2019 and March 2021. Patients were categorized into the prophylactic antibiotic group (n = 106) or control group (n = 47). The primary endpoint was 30-day survival, and the secondary endpoints were ECMO-free days and a 30-day cerebral performance category of 1 or 2. Results:After Inverse Probability of Treatment Weighting (IPTW), the 30-day survival was significantly higher in the antibiotic group than in the control group (42.8% vs. 20.3%; p < 0.001) and also ECMO-free days were higher in the antibiotic group (7.1 days vs. 1.4 days; p < 0.001). However, there was no significant difference in neurological outcomes (13.2% vs. 11.1%; p = 0.584). Conclusions:Prophylactic antibiotic administration during VA-ECMO was associated with improved 30-day survival in patients with OHCA. Although these findings suggest a potential benefit, further randomized controlled trials are required to establish clinical recommendations.
BACKGROUND:Worsening renal function (WRF) in acute heart failure (AHF) has been associated with poor outcomes; however, when accompanied by hemoconcentration, WRF is not necessarily associated with adverse outcomes. The associations of WRF and hemoconcentration with renal outcomes and longitudinal changes in renal function remain unclear. METHODS:In this multicenter retrospective study, 2556 hospitalized patients with AHF (median 80 years; 60% male) were categorized into four groups according to WRF and hemoconcentration status. WRF was defined as a ≥20% decrease in estimated glomerular filtration rate (eGFR) from admission to discharge. Hemoconcentration was defined as concurrent increases in hemoglobin and hematocrit levels from admission to discharge. The primary outcome was a composite of initiation of maintenance dialysis, decline in eGFR to <10 mL/min/1.73 m2, or ≥40% reduction in eGFR within one year after discharge. RESULTS:The WRF/hemoconcentration group had less frequent inotrope use and lower N-terminal pro-B-type natriuretic peptide levels at discharge. The cumulative incidence of the primary outcome was 18.4%, 15.9%, and 20.0% in the No WRF/No hemoconcentration, No WRF/hemoconcentration, and WRF/No hemoconcentration groups, respectively, and was lowest at 9.5% in the WRF/Hemoconcentration group. In multivariable analysis, this group was significantly associated with a lower risk of the primary outcome, compared with the No WRF/No hemoconcentration group (subdistribution hazard ratio 0.58, 95% confidence interval 0.36 to 0.93, p = 0.025). The longitudinal changes in renal function differed significantly across the groups; the WRF/Hemoconcentration group showed an attenuated decline or even improvement in eGFR (+3.6 mL/min/1.73 m2/year), whereas the No WRF/No hemoconcentration group exhibited the steepest decline (-6.2 mL/min/1.73 m2/year). CONCLUSIONS:Renal function changes after AHF hospitalization were heterogeneous, and WRF accompanied by hemoconcentration was associated with favorable renal outcomes within one year after discharge.
It remains unclear whether frailty and white matter lesions are risk factors for surgical treatment of unruptured intracranial aneurysms in older adults. We conducted a prospective multicenter study of 397 patients aged >= 60 years with unruptured intracranial aneurysms enrolled from 20 hospitals in Japan. Unruptured intracranial aneurysms were treated by either microsurgical clipping or endovascular treatment according to institutional protocols. The primary endpoint was functional outcome at discharge assessed using the modified Rankin scale (mRS). Poor outcome was defined as a deterioration of 1 or more points in the mRS score at discharge compared with the preoperative baseline. Unruptured intracranial aneurysm size ranged from 2.1 to 26 mm (mean, 6.93 mm). Poor outcome occurred in 52 patients (13.1%). There was no significant association between poor outcome and age (p = 0.089) or treatment modality (clipping vs. coiling, p = 0.4739). In multivariate regression analysis, poor outcome was significantly associated with larger unruptured intracranial aneurysm size (p = 0.033), higher Clinical Frailty Scale score (p = 0.006), higher preoperative mRS score (p = 0.039), lower hemoglobin level (p = 0.016), absence of regular exercise (p = 0.046), slower walking speed (p = 0.002), severe white matter lesions (p = 0.001), and lower intraoperative blood pressure (p = 0.032). Severe white matter lesions were associated with a higher risk of postoperative ischemia (p <= 0.042) and intracranial hemorrhage (p = 0.0017). These findings indicate that preoperative frailty and severe white matter lesions are significant predictors of poor outcomes after unruptured intracranial aneurysm surgery in older adults. Trial registration: umin.ac.jp/ctr Identifier: UMIN 000029977
