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Background Patient admissions at a U.S. tertiary care hospital occur via the emergency department (ED), or transfer center. We aim to compare the clinical outcomes of patients admitted from the ED to admissions coordinated by the transfer center. Methods Admissions to Mayo Clinic Hospital, Rochester, MN, between July 2019 to June 2021 were identified in this retrospective study and categorized into two cohorts—transfer center and ED. The two cohorts were then matched for age, sex, admitting service, and Charlson Comorbidity Index. Univariate and multivariate analyses were performed to compare hospital length of stay (LOS), mortality, 30-day mortality, and 30-day readmissions between the two cohorts. Results 73,685 admissions were identified, of which 24,262 (33%) were transfer center admissions. In the matched cohorts (n = 19,093, each), in-hospital mortality (2.4% versus 1.9%), 30-day mortality (5.4% versus 3.9%), 30-day readmission (12.7% versus 7.2%), and LOS (6.4 days versus 5.1 days) were significantly higher (P < 0.001) among the admissions coordinated by transfer center. A higher palliative care consultation rate (9.4% versus 6.2%, P < 0.001), and a lower proportion of home discharges home (76.2% versus 82.5%, P < 0.001) among transfer center admissions was observed. Similar findings were noted in multivariate analysis, even when adjusting for LOS. Conclusions Transfer center admissions had higher in-hospital mortality, LOS, 30-day mortality, and 30-day readmission compared to ED admissions. This study also highlights new considerations for palliative care consultation before transfer acceptance, especially to avoid futile transfers. Additional studies analyzing factors behind the outcomes of transfer center admissions are required.

Abstract Background Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes. Methods We performed a retrospective pre–post study and year‐matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre–post study, we compared patients who received GC (2016–2022) with controls (2011–2015). In the cohort study (2016–2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in‐hospital, 30‐day, 90‐day), length of stay (LOS), discharge disposition, and hospital readmission rates (30‐day, 90‐day). Results We analyzed 1968 patients in the pre–post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in‐hospital mortality compared to controls (pre–post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30‐ and 90‐day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre–post study. Lower readmission rates (statistically non‐significant) were noted in the GC group across both studies. Conclusions GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.

Background: Recent case series and smaller registries from around the world have reported higher frequency of Takotsubo Cardiomyopathy (TTC) in females.The aim of this study was to look for gender difference and age - gender interactions for TTC across the nation. Methods: This was a cross sectional study using the Nationwide Inpatient Sample (NIS) 2007 database. TTC or Broken heart syndrome or Reversible left ventricular dysfunction following sudden emotional stress or Stress induced Cardiomyopathy or Transient left ventricular apical ballooning syndrome was defined as patients discharged with any ICD code of 429.83 ( http://www.cdc.gov/nchs/data/icd9/agendasept05.pdf ). Multivariate logistic regression with interaction variable between age and sex was performed. Results: There were 6229 estimated discharges in 2007 NIS. Of these, 5558 (89.2 %) were females and 671 (10.8%) were males. 11.1 % were between 18-50 years, 32% between 50-65 years,58% were more than 65 years. Overall females had significantly higher odds of developing TTC (OR, 7.5; 95% CI, 6.31-9.13). In age group > 55yrs, the odds of developing TTC was 9.5 times higher in females than in males, while in age 55yrs had 2.9 times higher odds of developing TTC while there was no such age difference in males. Conclusions: We conclude that women have 7.5 times higher odds of developing TTC than males. Females with age > 55 years have 2.9 times higher odds of developing TTC than females with age < 55 years. Further research needs to be done on hormonal influence and its effect on TTC.

AbstractIntroductionPercutaneous left atrial appendage occlusion (LAAO) is traditionally performed under general anesthesia with trans‐esophageal echocardiography guidance. Intracardiac echo (ICE)‐guided LAAO closure is increasing in clinical use. The ICE catheter is crossed into LA via interatrial septum (IAS) after the septum is dilated with LAAO delivery sheath. This step can be time‐consuming and requires significant ICE catheter manipulation, which increases the risk of cardiac perforation. Pre‐emptive septal balloon dilation can potentially help with ICE advancement in the LA. We sought to evaluate the effect of pre‐dilation of the IAS with an 8 mm balloon on the ease of crossing the ICE catheter, fluoroscopy time for crossing, and overall procedure time.MethodsThe Piedmont LAAO registry was used to identify consecutive patients who underwent LAAO. The initial 25 patients in whom balloon dilation of the IAS was performed served as the experimental cohort, and the 25 consecutive patients before that in whom balloon dilation was not performed served as controls. In the experimental group, after a trans‐septal puncture, the sheath was retracted to the right atrium with a guidewire still in the LA. An 8 × 40 mm Evercoss™ over the wire balloon was inflated across the IAS. The ICE catheter was then crossed into the LA using the fluoroscopic landmark of the guide wire and the ICE imaging. The sheath was then advanced along the ICE catheter via the transseptal puncture (TSP) and the procedure continued. Follow‐up compputed tomography imaging was obtained at 4–8 weeks.ResultsEach group consisted of 25 patients. There were no significant differences in baseline characteristics. All procedures were performed successfully under conscious sedation and ICE guidance. There was a significant reduction in the overall procedure time, fluoroscopy time, and time for transseptal puncture to ICE in LA. There was no difference in the size of the acute residual interatrial shunt, as measured via ICE, or the size and presence of iatrogenic ASD at follow‐up.ConclusionBalloon dilation of TSP is safe and is associated with increased efficiency in ICE‐guided LAAO procedures.

Background: Percutaneous left atrial appendage occlusion (LAAO) is traditionally performed under general anesthesia with trans-esophageal echocardiography guidance. Intracardiac echo (ICE) guided LAAO closure is increasing in clinical use. The ICE catheter is crossed into LA via interatrial septum (IAS) after the septum is dilated with LAAO delivery sheath. This step can be time-consuming and requires significant ICE catheter manipulation increasing the risk of cardiac perforation. Pre-emptive septal balloon dilation can potentially help with the advancement of ICE in LA. Objective: Evaluate the effect of pre-dilation of IAS with an 8 mm balloon on ease of crossing the ICE catheter, fluoroscopy time for crossing, and overall procedure time. Methods: The Piedmont LAAO registry was used to identify consecutive patients undergoing LAAO. The initial 25 patients where balloon dilation of IAS was performed served as the experimental cohort, and the 25 consecutive patients prior to that in whom balloon dilation was not performed, served as controls. For the experimental group, after a trans-septal puncture, the sheath was retracted to the right atrium with guide wire still in the LA. An 8x40 mm Evercoss™ over the wire balloon was inflated across the IAS. The ICE catheter was then crossed into the LA using the fluoroscopic landmark of the guide wire and the ICE imaging. The sheath was then advanced along the ICE catheter via the transseptal puncture (TSP) and the procedure continued. Follow up CT imaging was obtained in 4-8 weeks. Results: Each group included 25 patients. There were no significant differences in baseline characteristics. All procedures were performed successfully with the use of conscious sedation and ICE guidance. There was a significant reduction in overall procedure time, fluoroscopy time, and time for trans-septal puncture to ICE in LA. There was no difference in the size of the acute residual interatrial shunt as measured via ICE or size and presence of iatrogenic ASD at follow up. Conclusion: Balloon dilation of TSP is safe and associated with increased efficiencies in ICE guided LAAO procedures.

ImportanceEndovascular thrombectomy (EVT) is standard treatment for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO), but optimal post-EVT blood pressure (BP) control remains debated.ObjectiveTo assess the association of different systolic BP targets following EVT with functional outcomes, mortality, and complications in patients with AIS due to LVO.Data SourcesSystematic review and meta-analysis of databases (PubMed, Embase, Web of Science, Scopus, and Cochrane Library) to September 8, 2023.Study SelectionInclusion criteria consisted of randomized clinical trials examining post-EVT management of systolic BP in patients with AIS and LVO comparing intensive vs conventional targets. Nonrandomized studies, observational studies, noninterventional trials, meeting abstracts, duplicate studies, studies with overlapping data, and non–English language studies were excluded. Two authors independently applied these criteria through a blinded review, with discrepancies resolved through consensus. The risk of bias in the included studies was assessed using the revised tool for assessing risk of bias in randomized trials.Data Extraction and SynthesisThis study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Three authors extracted data regarding study characteristics, baseline patient data, and outcomes of interest. The pooled data were analyzed using a random-effects meta-analysis.Main Outcomes and MeasuresRates of functional independence, 90-day mortality, symptomatic intracranial hemorrhage, and hypotensive events.ResultsA total of 4 randomized clinical trials with 1571 initially enrolled patients were included in the analysis. Lower functional independence rates were observed in the intensive control group (relative risk [RR], 0.81 [95% CI, 0.67-0.98]). No significant differences were found in 90-day mortality (RR, 1.18 [95% CI, 0.92-1.52]), symptomatic intracranial hemorrhage (RR, 1.12 [95% CI, 0.75-1.67]), or hypotensive events (RR, 1.80 [95% CI, 0.37-8.76]). There was minimal heterogeneity among the studies included in the functional independence outcome (I2 = 13% and τ2 = 0.003), which was absent among other outcomes (I2 = 0 and τ2 = 0).Conclusions and RelevanceThese findings suggest that intensive post-EVT BP reduction does not yield benefits and may carry risks. While awaiting the results of additional ongoing trials, a conservative BP management strategy after endovascular recanalization is favored in daily practice.