Weiss Memorial Hospital

BACKGROUND:Many patients remain functionally limited after transcatheter aortic valve replacement (TAVR) despite successful correction of aortic stenosis. Exercise-based cardiac rehabilitation (EBCR) is effective in other cardiac populations, but its benefits after TAVR remain uncertain. This study evaluated the impact of EBCR on functional capacity, cardiac function, quality of life, and safety outcomes in post-TAVR patients. METHODS:A systematic review and meta-analysis of randomized controlled trials (RCTs) published through February 2025 was conducted using major databases. Outcomes were pooled using mean differences or risk ratios with 95% confidence intervals. RESULTS:Six RCTs with 272 patients were included. No significant difference was found between EBCR and usual care for peak VO2 change (MD: 1.46, 95% CI: [-0.16 to 3.08], p = 0.076) and six-minute walk distance (6MWD) change (MD: 18.72, 95% CI: [-2.24 to 39.68], p = 0.08). Similarly, no significant difference was observed between EBCR and usual care for left ventricular ejection fraction (LVEF) change (MD: 1.31, 95% CI: [-2.06 to 4.69], p = 0.45), and aortic valve orifice area change (AVOA) (MD: -0.03, 95% CI: [-0.24 to 0.18], p = 0.78). CONCLUSION:EBCR did not significantly improve outcomes after TAVR; however, near-significant trends in functional capacity warrant further large-scale investigation. PROTOCOL REGISTRATION:PROSPERO ID CRD420250652719.

INTRODUCTION:Non-variceal upper gastrointestinal bleeding (NVGIB) represents an urgent medical condition with high mortality. Standard endoscopic therapies (ST) still carry a high rebleeding rate. Novel modalities such as the over-the-scope clip (OTSC) and hemostatic powder (HP) could be promising alternatives, but their efficacy and cost-effectiveness remain to be explored. METHODS:A network meta-analysis and cost-effectiveness analyses were conducted to compare OTSC vs HP vs ST. Primary endpoints include 30-day rebleeding and 30-day further bleeding. Markov models with a 12-month time horizon were created across 3 different health care settings: the United States, Thailand with Boston Scientific products (TH-BOS), and Thailand with China-manufactured alternatives (TH-CHN). Incremental cost-effectiveness ratio (ICER) was evaluated at a willingness-to-pay of $100,000 per quality-adjusted life year for the US model and THB 150,000 per quality-adjusted life year for the TH-BOS and TH-CHN models. RESULTS:Ten randomized controlled trials with 1,120 patients with NVGIB were included in the network meta-analysis. Lowest 30-day rebleeding was seen in OTSC ( P -score: 0.996), followed by ST (0.296) and HP (0.208). Similarly, OTSC also achieved lowest 30-day further bleeding (0.906), followed by HP (0.570) and ST (0.024). In cost-effective analysis, the US model reported OTSC as a dominant approach compared with HP (ICER: -$314) and ST (-$3,112). In the TH model, OTSC still dominated ST (ICER: -THB 28,423 for TH-BOS and -22,858 for TH-CHN) and was more cost-effective than HP (THB 1,833 for TH-BOS and THB 2,026 for TH-CHN). DISCUSSION:OTSC was superior to HP and ST in efficacy and cost-effectiveness, favoring its use as a first-line endoscopic hemostasis intervention for NVGIB.

Background: The timing of coronary artery bypass grafting (CABG) in patients with non-ST-elevation myocardial infarction (NSTEMI) may critically impact clinical outcomes, yet the ideal surgical window remains unclear. We aimed to evaluate the association between time-to-CABG and in-hospital outcomes among NSTEMI admissions undergoing CABG. Methods: This retrospective cohort study utilized the US National Inpatient Sample database from 2017 to 2021 to evaluate the association between time-to-CABG and key in-hospital outcomes, including mortality, cardiac arrest, cardiogenic shock, ischemic stroke, acute kidney injury, and blood transfusion rates, while assessing length of stay (LOS) and hospital charges exclusively among survivors. Adult admissions with principal diagnosis of NSTEMI who underwent CABG without prior interhospital transfer were grouped by the calendar day of CABG from admission (0, 1, 2, 3, 4, 5, 6, and ≥7). Multivariate regression models were used to assess the outcomes across these eight groups. Results: Of 142,200 included admissions, same-day CABG (hospital day 0) was associated with the highest rates of in-hospital mortality, cardiac arrest, cardiogenic shock, and ischemic stroke. The adjusted odds of mortality, cardiac arrest, and cardiogenic shock were lower among admissions undergoing CABG between days 2 and 5. Likewise, the adjusted odds of ischemic stroke were lowest when CABG occurred on days 2 to 4. The odds of AKI increased when CABG was delayed beyond day 6, whereas blood transfusion rates showed no statistically significant association with time-to-CABG. Among survivors, LOS and hospital charges progressively increased with delayed CABGs. Conclusions: Among NSTEMI admissions undergoing CABG, CABG performed on hospital days 2 to 4 was associated with lower adjusted odds of several adverse in-hospital outcomes compared with same-day CABG. Further prospective studies are needed to validate these results and guide clinical decision-making.

BACKGROUND:Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune rheumatic disease whose epidemiology and clinical prognosis vary by race and sex. Observed disparities in SLE may be partly attributable to cognitive processes in clinical decision-making, which can influence diagnostic accuracy and clinical management. We aimed to examine variation in primary care physicians' (PCP) diagnosis and management of SLE when all content of a clinical case is identical, apart from race and sex. METHODS:We distributed an online randomized factorial survey from 04/11/2024-06/10/2024 to PCPs across the US. Participants were presented with one of four possible SLE vignettes - Black female, White female, Black male, White male - for which all other clinical content was identical. Block randomization was used to randomly modify the race (Black/White) and sex (female/male) of the SLE "case". Primary outcomes were correct text-based responses for SLE diagnosis at initial case presentation and after reviewing additional lab results. Secondary outcomes were participants' review time and planned next steps (treatment, referral, tests) as a proxy for cognitive bias and certainty, respectively. We calculated descriptive statistics for all outcomes stratified by assigned randomized factor and used chi-square tests to evaluate between-group differences. RESULTS:1031 PCPs (42.7% women, mean age 52.1 ± 12.1 years) completed the case. At initial presentation, 63.9% of participants correctly identified SLE as a differential diagnosis. An initial diagnosis of SLE significantly differed by the race and sex of the case (p < 0.001), with the highest proportion of correct diagnoses occurring for Black female cases (72.2%) and lowest for White male cases (55.3%). Median review time for correct initial diagnoses was longest for White male cases (175 s). After participants reviewed lab results, the overall proportion assigning a final diagnosis of SLE (63.9%) remained unchanged from the initial diagnosis. CONCLUSION:A patient's race and sex may influence diagnostic accuracy and clinical decision-making for SLE in primary care. The observed variation in diagnostic accuracy, which aligns with the descriptive epidemiology of SLE, highlights the need for targeted interventions to ensure equitable diagnostic processes.

Cataracts are the leading cause of blindness worldwide. Obesity, a key component of metabolic syndrome (MetS), may represent a modifiable risk factor for cataracts. However, the evidence regarding the association between MetS or its components and cataracts remains controversial. Therefore, our meta-analysis aims to clarify the relationship between MetS or its components and cataracts. A search was conducted until February 2024 via the MEDLINE, EMBASE, and Cochrane databases. The primary endpoint included the association between MetS or its components, including body mass index (BMI), diabetes mellitus (DM), hypertension (HT), and dyslipidemia (DLP), and cataracts. Secondary endpoints included the association between levels of blood pressure, blood sugar, and lipid profiles and cataracts. A total of 27 studies were included with a total of 1,010,014 patients (134,498 with cataracts and 875,516 without cataracts). Of these, there were 2 prospective cohort studies, 6 case-control studies, and 19 cross-sectional studies. The prevalence of cataracts was 13.3%. MetS was significantly associated with cataracts with an odds ratio (OR) of 1.60 (95% confidence interval [CI]: 1.44-1.77, I2 = 93%). Among MetS components, high BMI and being diagnosed with DM, HT, and DLP were associated with cataracts with ORs of 1.45 (95% CI: 1.33-1.58, I2 = 80%), 1.77 (95% CI: 1.69-1.85, I2 = 51%), 1.23 (95% CI: 1.19-1.28, I2 = 62%), and 1.38 (95% CI: 1.30-1.46, I2 = 0%). Among the metabolic parameters, high total cholesterol, high triglycerides, low high-density lipoprotein cholesterol, and high low-density lipoprotein cholesterol were associated with cataracts with ORs of 1.25 (95% CI: 1.04-1.49, I2 = 48%), 1.05 (95% CI: 1.04-1.06, I2 = 68%), 1.07 (95% CI: 1.01-1.13, I2 = 0%), and 1.30 (95% CI: 1.10-1.53, I2 = 71%), respectively. MetS, obesity, DM, HT, and DLP are associated with cataracts. Prevention or treatment of MetS or its components likely represent a modifiable risk factor in cataract development.