Bansal, Vikas

Background/Objectives: Sodium glucose co-transporter 2 inhibitors (SGLT2is) have demonstrated a reduction in heart failure (HF) hospitalizations in HF patients and decreased recurrence of atrial fibrillation (AF), including in those who have undergone catheter ablation (CA). The effects of SGLT2i are likely due to suppression of the renin–angiotensin–aldosterone system, reduction in oxidative stress with subsequent improvement in myocardial efficiency, and attenuation of cardiac remodeling. We aim to present the effects of SGLT2i on AF recurrence in patients who have undergone CA for AF. Methods: This is a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective studies evaluating the effect of SGLT2i on AF recurrence following CA compared with non-SGLT2i. The primary outcome was the recurrence of AF by the final follow-up reported in each study. Secondary outcomes include AF recurrence by the first follow-up within 12 to 24 months and follow-up intervals (6, 12, 18, 24, and 36 to 42 months) post-ablation, multivariate risk of AF recurrence, and the effect on left atrial diameter (LAD) (less than 45 mm vs. greater than or equal to 45 mm). For risk of bias (ROB) analysis, the NIH ROB and Cochrane ROB2 tool were used. All statistical, heterogeneity, and sensitivity analyses were conducted using Cochrane Review Manager. A random-effect model was employed for all pooled statistical analyses. Results: A total of nine studies, two RCTs and seven retrospective studies, were included (N = 6874) for the primary outcome. Compared to non-SGLT2i (N = 3693), SGLT2i (N = 3181) significantly decreased AF recurrence by the final follow-up (OR = 0.62; 95% CI: 0.45–0.85; p = 0.008). For secondary outcomes, SGLT2i significantly reduced AF recurrence by the first follow-up within 12 to 24 months post-ablation (OR = 0.58; p = 0.0001) and by the different follow-up periods, 6-month (OR = 0.53; p = 0.02), 12-month (OR = 0.56; p = 0.0001), 18-month (OR = 0.55; p = 0.01), and 24-month (OR = 0.60; p = 0.12) follow-up periods. On the other hand, by 36 to 42 months, SGLT2i was associated with increased risk of AF recurrence (OR = 1.41; p = 0.004). Conclusions: We conclude that SGLT2i demonstrated a reduction in AF recurrence following CA, particularly by 12 to 18 months post-ablation.

INTRODUCTION A retrospective cohort study on patients aged < 18 years included in the Society of Critical Care Medicine: Viral Infection and Respiratory Illness Universal Study registry from March 2020 to April 2024 with an objective of calculating the prevalence of sepsis as defined by the Phoenix Sepsis Score (PSS) and to validate the PSS with respect to outcomes in children with COVID-19. METHODS Linear mixed-effects regression was used to examine the relationship between the PSS and hospital length of stay after controlling for confounding factors. The performance of the PSS was assessed using the receiver operating characteristic (ROC) and the precision-recall curve (PRC). Cross-validation was performed using leave-one-out cross-validation. RESULTS Out of 1731 patients (58 hospitals), 326 (18.8%) met criteria for sepsis and 167 (9.7%) for septic shock. The overall mortality was 1.4% (25/1731), with significant differences between nonseptic (10/1405, 0.7%) and both sepsis (15/326, 4.6%) and septic shock (9/167, 5.4%) groups. After adjusting for confounders, the septic group was associated with a longer hospital length of stay than the nonseptic group. One unit increase in the numeric PSS led to a 70% increase in risk of mortality (odds ratio 1.70; P < .001). The area under the ROC curve was 0.80 and the area under the PRC curve was 0.13. The threshold of ≥ 2 for detection of mortality had a sensitivity of 0.63, specificity of 0.82, and positive predictive value of 0.05. CONCLUSION Phoenix Sepsis Criteria retain its validity in identifying sepsis in children with COVID-19 and can be used in further epidemiological studies in this population

e20041 Background: Paraneoplastic syndromes (PNS) are caused by underlying malignancy but not due to metastasis, or treatment related side effects. Studies are lacking which target PNS seen in non small cell lung cancer (NSCLC) Methods: Systematic search of PubMed & Scopus was conducted to include all case reports & case series of adult NSCLC patients with PNS, published globally from inception upto July 7, 2024. Patient demographics, geographical distribution, NSCLC histology, clinical manifestations, diagnosis, treatment was extracted. Quality was assessed by JBI's critical appraisal checklist. Results: 138 publications (136 case reports, 2 case series) describing 142 patients published in 30 countries were included. Majority patients were male (69.7%) with mean age 57 years. Top publishing countries were USA (28.2%), Japan (13%), China (6.5%), Germany (5%), with publications (n=16) peak seen in 2020. Histological type of NSCLC with PNS was adenocarcinoma (39.8%), SCC (26.8%), unspecified histology (13%) & large cell (8.6%). Most common PNS seen in NSCLC were hypertrophic osteoarthropathy (7.2%), bilateral diffuse uveal melanocytic proliferation (5.7%), leukemoid reaction (4.3%) & limbic encephalitis (4.3%). Conclusions: Study provides bird’s eye view of all PNS found in NSCLC, aiding in timely diagnosis & treatment of NSCLC. Organ system PNS Cases Neurology Limbic encephalitisOpsoclonus myoclonus syndromeGBSSensorimotor peripheral neuropathyCerebellar degenerationEncephalomyelitisPerson in barrel syndromeMyoclonusPandysautonomiaNeuromyelitis opticaOpsoclonusAntiHu Ab neuropathyMononeuritis multiplexMorvan syndrome 63221111111111 Cardiology & haematology Leukemoid reactionLeukocytoclastic vasculitisHSPDICITPMyelofibrosisAcral vascular cyanosisHyper eosinophiliaHeart blockTrousseau syndromeHaemophilia ASVC syndromeChurg Strauss syndrome 6332211111111 Endocrinology SIADHCushing syndromeHypercalcemia of malignancyGynaecomastiaβ HCG secretionErectile dysfunction 433221 Rheumatology Hypertrophic osteoarthropathyPolyarthritisPolymyositisDermatomyositisMyasthenia gravisLambert Eaton syndromePolymyalgia rheumaticaSclerodermaRaynaud phenomenonAnti synthetase syndrome 10433311111 Dermatology Bazex syndromeBullous pemphigoidErythema gyratumLeser Trélat Tripe palmsErythrodermaIchthyosisAcanthosis nigricansRhinophymaGranuloma annularePityriasis rubria pilarisEczemaErythema induratumHyperhidrosis 42212111111111 Ophthalmology Bilateral diffuse uveal melanocytic proliferationCancer associated retinopathyCicatrizing conjunctivitisRetinal detachmentOrbital inflammationOcular flutterProptosis 8311111 Nephrology Nephrotic syndrome 3 Gastroenterology Pseudo achalasiaVerner Morrison syndromeGranulomatous visceral neuronopathy 111 Musculoskeletal Necrotizing myopathy 2

Background: Procalcitonin (PCT) is recognized as an inflammatory biomarker, often elevated in COVID-19 pneumonia alongside other biomarkers. Understanding its association with severe outcomes and comparing its predictive ability with other biomarkers is crucial for clinical management. Objectives: This retrospective multicenter observational study aimed to investigate the association between PCT levels and adverse outcomes in hospitalized COVID-19 patients. Additionally, it sought to compare the predictive performance of various biomarkers. Design: The study analyzed data from the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry, comprising COVID-19 patients hospitalized across multiple Mayo Clinic sites between March 2020 and June 2022. Methods: A total of 7851 adult COVID-19 patients were included. Patients were categorized into 6 groups based on the worst WHO ordinal scale. Multivariate models were constructed using peak biomarker levels within 72 hours of admission, adjusted for confounders. Results: Elevated PCT levels were independently associated with increased odds of adverse outcomes, including ICU admission (adjusted odds ratio [aOR] 1.32, 95%CI 1.27-1.38), IMV requirement (aOR 1.35, 95%CI: 1.28-1.42), and in-hospital mortality (aOR 1.30, 95%CI: 1.22-1.37). A 3.48-fold increase in IMV requirement and 3.55 times increase in in-hospital mortality were noted with peak PCT ⩾ 0.25 ng/ml. Similar associations were observed with other biomarkers like NLR (AUC 0.730), CRP, IL-6, LDH (AUC 0.800), and D-dimer (AUC 0.719). Models incorporating NLR, LDH, D-dimer, and PCT demonstrated the highest predictive accuracy, with a combined model exhibiting an area under the curve (AUC) of 0.826 (95%CI 0.803-0.849). Conclusions: Higher PCT levels were significantly linked to worse outcomes in COVID-19 patients, emphasizing its potential as a prognostic marker. Biomarker-based predictive models, particularly those including PCT, showed promising utility for risk assessment and clinical decision-making. Further prospective studies are warranted to validate these findings on a larger scale.

Introduction/Background: Patients admitted with sepsis are at risk of developing septic cardiomyopathy (SCM), which may elevate their risk of short-term mortality. However, the effect of SCM on long-term outcomes after sepsis is poorly understood. This study explores whether patients with sepsis and SCM have worse long-term outcomes compared to those without SCM. Research Questions/Hypothesis: What are the long-term major adverse cardiovascular events, including death, stroke, and myocardial infarction (MACE) 36 months after ICU discharge for septic patients with abnormal global left ventricular strain (LV GLS)? Methods: We conducted a retrospective study of 396 sepsis patients from August 2018 to September 2022, approved by the Mayo Clinic IRB. Patient demographics, comorbidities, echo parameters, and outcomes were collected. Due to the expected non-linear relation between LV GLS and Hazard Ratio (HR) of MACE we employed Cox regression analysis with Restricted Cubic Splines. Secondly, we divided the population into 2 groups, patients with and without normal LV GLS (between -23 and -16). The effect of non-normal LV GLS on MACE was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment, adjusting for diabetes, hypertension, BMI, history of stroke or myocardial infarction, chronic kidney disease, age, and sex. Results: Demographic variables did not differ significantly based on normal versus abnormal LV GLS. In the restricted cox regression with cubic spline models, we observed that patients with normal values had HR lower than one compared with patients without normal values (Figure 1). Secondly, we found that the HR of MACE in patients with normal LV GLS was significantly lower in the crude analysis (HR 0.66 [CI 95% 0.5, 0.86]; p<0.01) and in the analysis adjusted by IPWT (HR 0.7 [CI 95% 0.53, 0.92]; p=0.01). Conclusion: Sepsis patients with abnormal global left ventricular strain (LV GLS) have a higher risk of major adverse cardiovascular events (MACE) within 36 months post-ICU discharge compared to those with normal strain. LV GLS values outside the range of -23 to -16 are associated with increased risk. Monitoring LV GLS in sepsis patients is important for identifying those at elevated risk for long-term cardiovascular complications.

Background: Invasive management strategies for myocardial infarction (MI) and multivessel coronary artery disease (MV-CAD) include complete revascularization (successful revascularization of all coronary artery lesions or segments ≥1.5 mm in diameter with ≥50% diameter stenosis) and incomplete revascularization (including culprit-only revascularization). However, non-culprit lesion management strategy in elderly patients remains ambiguous due to a lack of representation of this cohort in randomized trials (RCTs) and higher cardiovascular complication risks. Methods: We performed a meta-analysis comparing clinical outcomes of elderly individuals (age ≥65 years) with MI and MV-CAD submitted to complete vs. incomplete (including culprit-only) percutaneous coronary intervention (PCI). The outcomes of interest were all-cause death, cardiovascular mortality, recurrent MI, and any revascularization. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model. Results: Thirteen studies (3 RCTs, 1 post hoc analysis of previous RCT, and 9 observational studies) with a total of 12,289 patients were included. Complete revascularization (CR) was performed in 5,232 patients, while 7,057 patients underwent incomplete revascularization (IR). The mean age was 80.46 years for CR and 80.73 years for IR and the mean durations of follow-ups ranged from 12-78 months. As compared to IR, the CR group was associated with significantly lower risk of all-cause mortality (OR 0.59, 95% CI 0.49 to 0.71, p<0.0001) (Figure 1), cardiovascular mortality (OR 0.56, 95% CI 0.40 to 0.77, p=0.0005), recurrent MI (OR 0.62, 95% CI .47 to 0.81, p=0.0005) (Figure 2), and any revascularization (OR 0.47, 95% CI 0.26 to 0.86, p=0.01). Conclusion: Among elderly patients with MI and MV-CAD, CR is associated with a lower risk of all-cause mortality, cardiovascular mortality, recurrent MI, and any revascularization.

Background: Ambiguity surrounds invasive management of non-ST-segment elevation myocardial infarction (NSTE-MI) in older adults (≥70 years), and the number of elderly patients undergoing invasive treatment in clinical practice remains relatively low. Data comparing the efficacy of invasive versus conservative medical management for NSTEMI in this population is conflicting due to the under-representation or exclusion of the older population from randomized controlled trials (RCTs). Methods: We performed a meta-analysis of RCTs to evaluate the long-term outcomes of invasive versus conservative medical strategies in older patients with NSTEMI. Random effects meta-analysis was conducted to estimate the odds ratio (OR) with 95% CI for the individual endpoints of all-cause mortality, cardiovascular (CV) mortality, recurrent myocardial infarction (MI), unplanned revascularization, and readmission for cardiovascular causes. Results: A total of nine RCTs with 4,336 patients (Invasive: 2,368; Control: 1,968) with median follow-ups ranging from 6-63.6 months were included. Compared with a conservative strategy, an invasive strategy was associated with a significantly decreased risk of recurrent MI (OR 0.62, 95% CI 0.47-0.81; p<0.001) (Figure 1) and unplanned revascularization (OR 0.38, 95% CI 0.25-0.56; p<0.001). There was no difference in all-cause mortality (OR 0.81, 95% CI 0.39-1.35; p=0.42) (Figure 2), CV mortality (OR 0.72, 95% CI 0.43-1.23; p=0.23), or readmission for cardiovascular causes (OR 1.21, 95% CI 0.63-2.33; p=0.57) between invasive and conservative management strategies. Conclusion: In older patients ≥70 years old with NSTE-MI, an invasive strategy reduced the risk of recurrent MI and revascularization when compared with conservative management. However invasive strategy did not offer any benefit in mortality or cardiac-cause related readmission over conservative management.