Ríos, José

Introduction: Language barriers represent an often-overlooked determinant of health equity. This study evaluates the impact of limited English proficiency (LEP) on major adverse cardiac events (MACE) and mortality in patients undergoing cardiovascular surgery. We hypothesized that patients with LEP have a higher incidence of adverse outcomes compared to English proficient patients. Methods: We conducted a retrospective cohort study using Cosmos, a longitudinal national electronic health record dataset. Patients were classified as having LEP if their record indicated a preferred language other than English. Adult patients aged 18-95 years who underwent coronary artery bypass grafting, valvular surgery, or thoracic aorta surgery in the United States (January 2016 - February 2025) were included. Exclusion criteria were missing language data, first in-person encounter <1 year prior to surgery, history of metastatic cancer or dialysis, and nursing home residence within 90 days of surgery. The primary outcome was MACE, a composite of stroke, revascularization, and hospitalization for myocardial infarction or heart failure. The secondary outcome was all-cause mortality. The cumulative incidence of MACE was estimated via a competing risk framework, while the cumulative incidence of mortality was estimated with the Kaplan-Meier method. Multivariate Cox proportional hazard regressions were fitted for all outcomes. Results: The cohort included 12,706 LEP patients (28.8% female) and 393,612 English-proficient patients (33.2% female). Differences in baseline characteristics included age, race, and comorbidity burden. The unadjusted cumulative incidence of MACE was higher in LEP patients, but all-cause mortality was lower (Figure 1). Over the follow-up period, the incidence rate of MACE for English proficient patients vs LEP was 185 vs 219 per 1000 patient years and 39 vs 36 per 1000 patient years for mortality. The adjusted hazard ratio for MACE was 0.97 (95% CI: 0.94 - 1.01, p = 0.19) and 0.89 (95% CI: 0.83 - 0.95, p <0.001) for mortality. Conclusions: LEP was associated with higher unadjusted cumulative incidence of MACE and lower mortality, but only the association with mortality persisted after regression analysis. Our findings highlight the need for further research into the impact of language proficiency on outcomes after cardiac surgery and the potential benefit of targeted interventions to address language-related disparities.

ImportanceThere are no useful treatments to prevent the development of severe complications of liver cirrhosis. Simvastatin and rifaximin have shown beneficial effects in liver cirrhosis.ObjectiveTo assess whether simvastatin combined with rifaximin improves outcomes in patients with decompensated cirrhosis.Design, Setting, and ParticipantsDouble-blind, placebo-controlled, phase 3 trial conducted among patients with decompensated cirrhosis in 14 European hospitals between January 2019 and December 2022. The last date of follow-up was December 2022.InterventionsPatients were randomly assigned to receive simvastatin, 20 mg/d, plus rifaximin, 1200 mg/d (n = 117), or identical-appearing placebo (n = 120) for 12 months in addition to standard therapy, stratified according to Child-Pugh class B or C.Main Outcomes and MeasuresThe primary end point was incidence of severe complications of liver cirrhosis associated with organ failure meeting criteria for acute-on-chronic liver failure. Secondary outcomes included transplant or death and a composite end point of complications of cirrhosis (ascites, hepatic encephalopathy, variceal bleeding, acute kidney injury, and infection).ResultsAmong the 237 participants randomized (Child-Pugh class B: n = 194; Child-Pugh class C: n = 43), 72% were male and the mean age was 57 years. There were no differences between the 2 groups in terms of development of acute-on-chronic liver failure (21 [17.9%] vs 17 [14.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 1.23; 95% CI, 0.65-2.34; P = .52); transplant or death (22 [18.8%] vs 29 [24.2%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.75; 95% CI, 0.43-1.32; P = .32); or development of complications of cirrhosis (50 [42.7%] vs 55 [45.8%] patients in the treatment and placebo groups, respectively; hazard ratio, 0.93; 95% CI, 0.63-1.36; P = .70). Incidence of adverse events was similar in both groups (426 vs 419; P = .59), but 3 patients in the treatment group (2.6%) developed rhabdomyolysis.Conclusions and RelevanceThe addition of simvastatin plus rifaximin to standard therapy does not improve outcomes in patients with decompensated liver cirrhosis.Trial RegistrationClinicalTrials.gov Identifier: NCT03780673