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Background The epidemiology and pathophysiology of heart failure (HF) differ in women and men. Whether these differences extend to the subgroup of patients with advanced HF is not well defined. Methods and Results This is a retrospective cohort study of all adult Olmsted County, Minnesota residents with advanced HF (European Society of Cardiology criteria) from 2007 to 2017. Differences in survival and hospitalization risks in women and men following advanced HF development were examined using Cox proportional hazard regression and Andersen‐Gill models, respectively. Of 936 individuals with advanced HF, 417 (44.6%) were women and 519 (55.4%) were men (self‐reported sex). Time from development of HF to advanced HF was similar in women and men (median 3.2 versus 3.6 years). Women were older at diagnosis (mean age 79 versus 75 years), less often had coronary disease and hyperlipidemia, but more often had hypertension and depression ( P <0.05 for each). Advanced HF with preserved ejection fraction was more prevalent in women than men (60% versus 30%, p<0.001). There were no differences in adjusted risks of all‐cause mortality (hazard ratio [HR], 0.89 [95% CI, 0.77–1.03]), cardiovascular mortality (HR, 0.85 [95% CI, 0.70–1.02]), all‐cause hospitalizations (HR, 1.04 [95% CI, 0.90–1.20]), or HF hospitalizations (HR, 0.91 [95% CI, 0.75–1.11]) between women and men. However, adjusted cardiovascular mortality was lower in women versus men with advanced HF with reduced ejection fraction (HR, 0.72 [95% CI, 0.56–0.93]). Conclusions Women more often present with advanced HF with preserved ejection fraction and men with atherosclerotic disease and advanced HF with reduced ejection fraction. Despite these differences, survival and hospitalization risks are largely comparable in women and men with advanced HF.

Background. Four-factor prothrombin complex concentrate (PCC) is a plasma product that contains factors II, VII, IX, X, protein C, and protein S. PCC can be used off-label to treat coagulopathy during orthotopic liver transplantation (OLT). However, its use comes with safety concerns regarding thrombosis. The purpose of our study is to determine the safety of PCC in OLT. Methods. We conducted a retrospective cohort study of patients who received 4-factor PCC during OLT at our institution from January 1, 2018, to May 1, 2022, with a 1:1 match of 83 patients who received PCC and 83 patients who did not. We evaluated 30-d mortality, 1-y mortality, prevalence of thrombotic complications (portal vein thrombosis, deep venous thrombosis, myocardial infarction, and pulmonary embolus), and postoperative intensive care (ICU) length of stay (LOS). Results. There was no significant difference in 30-d mortality (odds ratio [OR] 5; 95% confidence interval [CI], 0.58-42.8; P = 0.14), 1-y mortality (OR 3; 95% CI, 0.61-14.86; P = 0.18), or ICU LOS (OR –13.8; 95% CI, –39.2 to 11.6; P = 0.29). There was no increased incidence of thrombotic complications among patients receiving PCC 90 d after surgery, including portal vein thrombosis (OR 1.5; 95% CI, 0.42-5.32; P = 0.53), pulmonary embolus (OR 1; 95% CI, 0.14-7.1; P = 0.99), deep venous thrombosis (OR 0.67; 95% CI, 0.11-3.99; P = 0.66), and myocardial infarction (OR 1.67; 95% CI, 0.4-6.97; P = 0.48). Conclusions. Although there was a statistically insignificant increase in mortality after PCC administration during OLT, we did not see a significant increase in perioperative complications, including thrombotic events and increased ICU LOS.

AbstractPurposeBy assessing longitudinal associations between COVID‐19 census burdens and hospital characteristics, such as bed size and critical access status, we can explore whether pandemic‐era hospital quality benchmarking requires risk‐adjustment or stratification for hospital‐level characteristics.MethodsWe used hospital‐level data from the US Department of Health and Human Services including weekly total hospital and COVID‐19 censuses from August 2020 to August 2023 and the 2021 American Hospital Association survey. We calculated weekly percentages of total adult hospital beds containing COVID‐19 patients. We then calculated the number of weeks each hospital spent at Extreme (≥20% of beds occupied by COVID‐19 patients), High (10%–19%), Moderate (5%–9%), and Low (<5%) COVID‐19 stress. We assessed longitudinal hospital‐level COVID‐19 stress, stratified by 15 hospital characteristics including joint commission accreditation, bed size, teaching status, critical access hospital status, and core‐based statistical area (CBSA) rurality.FindingsAmong n = 2582 US hospitals, the median(IQR) weekly percentage of hospital capacity occupied by COVID‐19 patients was 6.7%(3.6%–13.0%). 80,268/213,383 (38%) hospital‐weeks experienced Low COVID‐19 census stress, 28% Moderate stress, 22% High stress, and 12% Extreme stress. COVID‐19 census burdens were similar across most hospital characteristics, but were significantly greater for critical access hospitals.ConclusionsUS hospitals experienced similar COVID‐19 census burdens across multiple institutional characteristics. Evidence‐based inclusion of pandemic‐era outcomes in hospital quality reporting may not require significant hospital‐level risk‐adjustment or stratification, with the exception of rural or critical access hospitals, which experienced differentially greater COVID‐19 census burdens and may merit hospital‐level risk‐adjustment considerations.

Background: The 2010 AHA Guidelines state rescuers should perform chest compressions (CCs) of at least 2 inches in depth for adult cardiac arrest patients. Although the pediatric guidelines recommend adjustment of CC depth based upon anteroposterior chest dimension, there is no such recommendation for adults. Purpose: To determine 1) whether prehospital providers intuitively vary CC depth in adults according to patient size and 2) whether implementation of real-time audiovisual CPR feedback (RTAVF) impacts weight/CC depth variation. Methods: CC quality data were prospectively collected prior to (9/08-4/10; Pre-feedback) and after (5/10-12/10; Post-feedback) implementation of an RTAVF system (ZOLL Medical, Chelmsford MA) from 3 EMS agencies. The RTAVF includes a visual display of absolute CC depth and gives audio prompts when depth is outside of the Guideline-recommended range. Among 363 cases of adult, non-traumatic out-of-hospital cardiac arrest (OHCA), body weight was estimated by EMS in 249 patients (study group; 66%). CPR quality data were available for all cases via code review software. Results: 168 Pre-feedback and 81 Post-feedback study group cases (mean 64±16 years, 68% male). Mean estimated body weight was 201 lbs (quartiles 161, 231; range 70-451) and was not different between groups. CC depth increased significantly with RTAVF use (Pre-feedback = 1.77, 95% confidence interval [CI]:1.71-1.83 in.; Post-feedback = 2.10, CI: 2.04-2.15 in.; p<0.001). CC depth did not vary significantly by patient gender or age (p>0.4). Multivariate linear regression (r 2 =0.23, p<0.001 for model) revealed a significant increase in CC depth with estimated weight in both periods (0.07in/50lbs, p<0.001) after controlling for the presence of RTAVF. RTAVF was not an effect-modifier of the relationship between estimated weight and CC depth (p-value for interaction term=0.4). Conclusion: Although not specifically recommended in the 2010 AHA Guidelines for adults, rescuers may instinctively and/or intentionally adjust CC depth according to patient size. In this setting, weight/CC depth adjustments occurred both without and with real-time feedback. Follow-up studies are needed to determine the potential effect of size-adjusted CC depth on patient outcome.

BACKGROUND: For sudden collapse from out-of-hospital cardiac arrest (OHCA) in adults, bystander chest compression-only CPR (COCPR) results in equivalent or better survival compared with conventional CPR with rescue breathing. However, patients who arrest from a non-cardiac cause may also receive COCPR even though rescue breathing might benefit them. We sought to determine whether lay rescuers appropriately provided COCPR or conventional CPR depending on the suspected etiology of OHCA. METHODS: Analysis of a statewide, Utstein-style registry of adult OHCA during a large-scale campaign endorsing COCPR for adults who suddenly collapse. The relationship between bystander CPR (both COCPR and conventional CPR), presumed arrest etiology, and survival to hospital discharge were evaluated. Means and 95% confidence intervals (CI) were calculated. FINDINGS: A total of 7,652 adult OHCAs not witnessed by EMS were analyzed from 10/04 to 09/10. After exclusion of non-lay bystanders and arrests in medical facilities, presumed cardiac etiology and non-cardiac etiology OHCA totaled 4,913 and 1,202, respectively. The presumed specific non-cardiac etiologies were non-cardiopulmonary (e.g. overdose, suicide, subarachnoid hemorrhage) (57%), trauma (27%), and respiratory (16%). All-rhythm survival was 7.0% (CI: 6.3 - 7.8) for cardiac etiologies and 3.3% (CI: 2.3 - 4.3) for non-cardiac (p<0.001). Bystander CPR was provided for 33% (CI: 31.4 - 34.1) of victims with presumed cardiac causes versus 28% (CI: 25.6 - 30.7) for non-cardiac causes (p=0.002). Presumed respiratory causes of OHCA had a much lower proportion of COCPR (8.3%, CI: 4.4 - 12.2) than cardiac causes (18.0%, CI: 16.9 - 19.1, p<0.001). Survival for non-cardiac cases was: 4.4% (CI 0.9 - 7.8) for conventional CPR, 3.5% (CI: 0.9 - 6.0) for COCPR, and 3.1% (CI: 2.0 - 4.3) for no CPR (p = 0.66). CONCLUSIONS: In the setting of a large-scale, statewide public health campaign endorsing lay rescuer COCPR for adults who suddenly collapse and are not breathing normally, bystanders were much less likely to perform COCPR on OHCA victims who might benefit from rescue breathing. Furthermore, when COCPR was performed on presumed non-cardiac cause arrest victims, there was no demonstrable negative impact on survival.

Abstract Introduction/Aims Biomarkers have shown promise in amyotrophic lateral sclerosis (ALS) research, but the quest for reliable biomarkers remains active. This study evaluates the effect of debamestrocel on cerebrospinal fluid (CSF) biomarkers, an exploratory endpoint. Methods A total of 196 participants randomly received debamestrocel or placebo. Seven CSF samples were to be collected from all participants. Forty‐five biomarkers were analyzed in the overall study and by two subgroups characterized by the ALS Functional Rating Scale‐Revised (ALSFRS‐R). A prespecified model was employed to predict clinical outcomes leveraging biomarkers and disease characteristics. Causal inference was used to analyze relationships between neurofilament light chain (NfL) and ALSFRS‐R. Results We observed significant changes with debamestrocel in 64% of the biomarkers studied, spanning pathways implicated in ALS pathology (63% neuroinflammation, 50% neurodegeneration, and 89% neuroprotection). Biomarker changes with debamestrocel show biological activity in trial participants, including those with advanced ALS. CSF biomarkers were predictive of clinical outcomes in debamestrocel‐treated participants (baseline NfL, baseline latency‐associated peptide/transforming growth factor beta1 [LAP/TGFβ1], change galectin‐1, all p < .01), with baseline NfL and LAP/TGFβ1 remaining ( p < .05) when disease characteristics ( p < .005) were incorporated. Change from baseline to the last measurement showed debamestrocel‐driven reductions in NfL were associated with less decline in ALSFRS‐R. Debamestrocel significantly reduced NfL from baseline compared with placebo (11% vs. 1.6%, p = .037). Discussion Following debamestrocel treatment, many biomarkers showed increases (anti‐inflammatory/neuroprotective) or decreases (inflammatory/neurodegenerative) suggesting a possible treatment effect. Neuroinflammatory and neuroprotective biomarkers were predictive of clinical response, suggesting a potential multimodal mechanism of action. These results offer preliminary insights that need to be confirmed.

Abstract On June 1, 2020, NYC Health + Hospitals, in partnership with the NYC Department of Health and Mental Hygiene, other city agencies, and a large network of community partners, launched the New York City Test & Trace (T2) COVID-19 response program to identify and isolate cases, reduce transmission through contact tracing, and provide support to residents during isolation or quarantine periods. In this paper, we describe lessons learned with respect to planning and implemention of case notification and contact tracing. Our findings are based on extensive document review and analysis of 74 key informant interviews with T2 leadership and frontline staff, cases, and contacts conducted between January and September 2022. Interviews elicited respondent background, history of program development, program leadership and structure, goals of the program, program evolution, staffing, data systems, elements of community engagement, trust with community, program reach, timeliness, equity, general barriers and challenges, general facilitators and best practices, and recommendations/improvement for the program. Facilitators and barriers revealed in the interviews primarily revolved around hiring and managing staff, data and technology, and quality of interactions with the public. Based on these facilitators and barriers, we identify suggestions to support effective planning and response for future case notification and contact tracing programs, including recommendations for planning during latent periods, case management and data systems, and processes for outreach to cases and contacts.

ImportancePreventing diabetes complications requires monitoring and control of hyperglycemia and cardiovascular risk factors. Switching to high-deductible health plans (HDHPs) has been shown to hinder aspects of diabetes care; however, the association of HDHP enrollment with microvascular and macrovascular diabetes complications is unknown.ObjectiveTo examine the association between an employer-required switch to an HDHP and incident complications of diabetes.Design, Setting, and ParticipantsThis retrospective cohort study used deidentified administrative claims data for US adults with diabetes enrolled in employer-sponsored health plans between January 1, 2010, and December 31, 2019. Data analysis was performed from May 26, 2022, to January 2, 2024.ExposuresAdults with a baseline year of non-HDHP enrollment who had to switch to an HDHP because their employer offered no non-HDHP alternative in that year were compared with adults who were continuously enrolled in a non-HDHP.Main Outcomes and MeasuresMixed-effects logistic regression models examined the association between switching to an HDHP and, individually, the odds of myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy, and blindness. Models were adjusted for demographics, comorbidities, and medications, with inverse propensity score weighting used to account for potential selection bias.ResultsThe study included 42 326 adults who switched to an HDHP (mean [SD] age, 52 [10] years; 19 752 [46.7%] female) and 202 729 adults who did not switch (mean [SD] age, 53 [10] years; 89 828 [44.3%] female). Those who switched to an HDHP had greater odds of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% CI, 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment).Conclusions and RelevanceThis study found that an employer-driven switch to an HDHP was associated with increased odds of experiencing all diabetes complications. These findings reinforce the potential harm associated with HDHPs for people with diabetes and the importance of affordable and accessible chronic disease management, which is hindered by high out-of-pocket costs incurred by HDHPs.