Isolated Comminuted Fracture Of The Cricoid Cartilage and Narrowing Of The Airway After A Traumatic Blunt Injury Of The Neck
This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma.
KEY FINDINGS: This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma. The patient was clinically stable and treated conservatively with oxygen therapy and silence therapy (complete silence).
BACKGROUND: Blunt trauma to the anterior of the neck may compromise the vital structures like major blood vessels, trachea, larynx, pharynx, thyroid, spine, esophagus, and the cricoid. Laryngeal trauma is rare and accounts for 1% of all neck blunt traumas. Cricoid trauma is also very rare and accounts for half of the laryngeal traumas, and the diagnosis is frequently missed.
DETAILS: A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook, was referred to the Shahid Beheshti Hospital. The patient complained of dysphonia (hoarseness) and dyspnea. The CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord.
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Source: Mehrabi, S., Hosseinpour, R., and Barhaghtalab, M. J. (2022). Isolated Comminuted Fracture Of The Cricoid Cartilage and Narrowing Of The Airway After A Traumatic Blunt Injury Of The Neck: A Case Report. Int J Emerg Med. 2022; 15:55. Published: November, 2022. DOI: 10.1186/s12245-022-00459-9.
Effect of Empagliflozin on the Mechanisms Driving Erythropoiesis and Iron Mobilization in Patients With Heart Failure
The erythropoietin-erythroferrone-TfR1-hepcidin axis is activated in patients with heart failure as the disease advances and is further heightened by SGLT2 inhibitors, in parallel with their effect to enhance erythropoiesis and iron mobilization and use. These changes have important implications for understanding the mechanism of action of SGLT2 inhibitors and for monitoring the response to treatment.
KEY FINDINGS: The erythropoietin-erythroferrone-TfR1-hepcidin axis is activated in patients with heart failure as the disease advances and is further heightened by SGLT2 inhibitors, in parallel with their effect to enhance erythropoiesis and iron mobilization and use. These changes have important implications for understanding the mechanism of action of SGLT2 inhibitors and for monitoring the response to treatment.
BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibitors stimulate erythropoiesis, but the mechanisms and clinical relevance of the effect of SGLT2 inhibitors on systemic iron metabolism in patients with heart failure is not well understood. The authors sought to characterize a comprehensive suite of iron metabolism biomarkers—particularly the erythroblast signaling molecule, erythroferrone—in patients with heart failure before and after short- and long-term treatment with empagliflozin in patients with heart failure and a reduced or preserved ejection fraction.
DETAILS: Authors measured serum iron metabolism biomarkers at baseline, 12 weeks, and 52 weeks in 1,139 patients who were treated with placebo or empagliflozin in the EMPEROR (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure) program, and characterized the inter-relationships of these biomarkers with clinical status and with the effect of empagliflozin on erythropoiesis and heart failure outcomes. Correlations among iron biomarkers indicated the presence of a functional erythropoietin-erythroferrone-transferrin-receptor-protein-1 (TfR1)-hepcidin axis. As heart failure advanced, patients showed higher levels of erythropoietin, erythroferrone, and TfR1 (P trend <0.01), and levels of these proteins predicted a heightened risk of cardiovascular death or heart failure hospitalization (all P < 0.01). Compared with placebo, at 12 weeks, empagliflozin increased hemoglobin by 0.6 to 0.9 g/dL (P < 0.001), an effect that was accompanied by further activation of the erythropoietin-erythroferrone-TfR1 axis and increased iron use. Empagliflozin increased serum levels of erythroferrone by >40% (along with increases in erythropoietin and TfR1), while simultaneously decreasing hepcidin levels and reducing serum iron concentrations and transferrin saturation (all P < 0.01). When treated with empagliflozin, patients with evidence of iron deficiency at baseline showed attenuation of the erythrocytic response (P trend = 0.04) but no diminution of the heart failure benefits.
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Source: Ferreira, J. P., Anker, S. D., Butler, J., et al. (20245). Effect of Empagliflozin on the Mechanisms Driving Erythropoiesis and Iron Mobilization in Patients With Heart Failure: The EMPEROR Program. J Am Coll Cardiol.. 2025; 85(18): 1757-1770. Published: May, 2025. DOI: 10.1016/j.jacc.2025.03.503.
Adverse Pregnancy Outcomes and Long-Term Risk of Heart Failure in Women
In this large national cohort, women who experienced any of 5 major adverse pregnancy outcomes had increased risk for HF up to 46 years later. Women with adverse pregnancy outcomes need early preventive actions and long-term clinical care to reduce the risk of HF.
KEY FINDINGS: In this large national cohort, women who experienced any of 5 major adverse pregnancy outcomes had increased risk for HF up to 46 years later. Women with adverse pregnancy outcomes need early preventive actions and long-term clinical care to reduce the risk of HF.
BACKGROUND: Adverse pregnancy outcomes, such as preterm delivery and hypertensive disorders of pregnancy, may be associated with higher future risks of heart failure (HF). However, the comparative effects of different adverse pregnancy outcomes on long-term risk of HF, and their potential causality, are unclear. The authors sought to examine 5 major adverse pregnancy outcomes in relation to long-term risk of HF in a large population-based cohort.
DETAILS: A national cohort study was conducted of all 2,201,638 women with a singleton delivery in Sweden in 1973-2015, followed up for HF identified from nationwide outpatient and inpatient diagnoses through 2018. Cox regression was used to compute HRs for HF associated with preterm delivery, small for gestational age, preeclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, while adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors. In 48 million person-years of follow-up, 667,774 women (30%) experienced an adverse pregnancy outcome, and 19,922 women (0.9%) were diagnosed with HF (median age, 61 years). All 5 adverse pregnancy outcomes were independently associated with long-term increased risk of HF. With up to 46 years of follow-up after delivery, adjusted HRs for HF associated with specific adverse pregnancy outcomes were: gestational diabetes, 2.19 (95% CI: 1.95-2.45); preterm delivery, 1.68 (95% CI: 1.61-1.75); other hypertensive disorders, 1.68 (95% CI: 1.48-1.90); preeclampsia, 1.59 (95% CI: 1.53-1.66); and small for gestational age, 1.35 (95% CI: 1.31-1.40). All HRs remained significantly elevated (1.3- to 3.0-fold) even 30 to 46 years after delivery. These findings were only partially explained by shared familial factors. Women with multiple adverse pregnancy outcomes had further increases in risk (eg, up to 46 years after delivery, adjusted HRs associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.51 [95% CI: 1.47-1.56], 2.31 [95% CI: 2.19-2.45], and 3.18 [95% CI: 2.85-3.56], respectively).
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Source: Crump, C., Crump, J., and Crump, K. (20245). Adverse Pregnancy Outcomes and Long-Term Risk of Heart Failure in Women: National Cohort and Co-Sibling Study. J Am Coll Cardiol HF.. 2025; 3(4): 589–598. Published: April, 2025. DOI: 10.1016/j.jchf.2024.11.004.
Impact of a Sleep-Promoting Schedule on Sleep Quality in the Intensive Care Unit
An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.
KEY FINDINGS: Adherence to a sleep-promoting schedule reduced patient sleep interruptions between midnight and 4 am by as much as two-thirds while increasing patients' overall self-perceived sleep quality by 6.7 percentage points. An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.
BACKGROUND: Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of illness and is especially high in intensive care unit patients. Sleep deprivation can prolong the intensive care unit stay, contribute to emotional and physiological distress, and even increase the patient's risk of death.
DETAILS: Critical care nurses in a 28-bed medical intensive care unit reported that patients often complained of sleep disruption or exhibited emotional and physical distress resulting from sleep deprivation. An analysis of the gap between recommended evidence-based best practice and current practices in the unit revealed numerous opportunities to improve patients' sleep. The aim of this evidence-based quality improvement project was to increase interprofessional adherence to an existing sleep-promoting schedule to reduce avoidable interruptions and improve patient sleep quality. To promote sleep, staff member interactions with patients between midnight and 4 am were minimized, if appropriate. Documented patient encounters and call bell initiation were evaluated as process measures. Patients' self-perceived sleep quality, an outcome measure, was evaluated using the Richards-Campbell Sleep Questionnaire.
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Source: Long, K., Hundt, B., Wiencek, C., et al. (2025). Impact of a Sleep-Promoting Schedule on Sleep Quality in the Intensive Care Unit. Crit Care Nurse. 2025; 45(2): 33-40. Published: April, 2025. DOI: 10.4037/ccn2025288.
Allopurinol Use and Risk of Acute Coronary Syndrome in Gout Patients
In patients with gout and without CHD, long-term allopurinol use protects against first-ever ACS compared with non-users. In contrast, allopurinol initiators, possibly having more systemic inflammation, had a higher risk of first-ever ACS compared with long-term users.
Summary
A Population-Based Cohort Study in Sweden
[Posted 3/Mar/2025]
AUDIENCE: Cardiology, Emergency Medicine, Rheumatology
KEY FINDINGS: In patients with gout and without CHD, long-term allopurinol use protects against first-ever ACS compared with non-users. In contrast, allopurinol initiators, possibly having more systemic inflammation, had a higher risk of first-ever ACS compared with long-term users.
BACKGROUND: Purpose of this study is to investigate the impact of allopurinol use on the risk of first-ever acute coronary syndrome (ACS) event in patients with gout.
DETAILS: Using national and regional register data, we included all patients with a gout diagnosis at primary or specialised care in Western Sweden in the period 2007-2017 (n=18,862; 67% male patients). Patients with a prior history of coronary heart disease (CHD) were excluded. Follow-up started at the first gout diagnosis and ended at the first-ever ACS event, death or study end. The main outcome was the risk of first-ever ACS in: (1) allopurinol users versus non-users, by defining three categories of allopurinol exposure: exposed to 100 mg, >100 mg and no exposure (reference) and (2) allopurinol initiators (within 125 days) versus long-term users (reference). Multivariable logistic regression analysis was used to calculate ORs and 95% CIs. In analysis 1 (n=18,862), 15.3% (n=2892) were exposed to 100 mg, 9.1% (n=1717) to >100 mg and 75.6% (n=14,253) were not exposed. Allopurinol users were older and had more comorbidities compared with non-users. Allopurinol exposure (100 mg and >100 mg) was associated with significantly lower odds of first-ever ACS (OR 0.77; 95% CI 0.63 to 0.94, and OR 0.61; 95% CI 0.47 to 0.81, respectively). In Analysis 2, allopurinol initiators (n=489) had significantly higher odds of first-ever ACS compared with long-term users (n=2916) (OR 1.68; 95% CI 1.03 to 2.75).
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Source: Drivelegka, P., Jacobsson, L., Sandstrom, T. Z., et al. (2025). Allopurinol Use and Risk of Acute Coronary Syndrome in Gout Patients: A Population-Based Cohort Study in Sweden. BMJ Open. 2025; 15(2): e092522. Published: February 27, 2025. DOI: 10.1136/bmjopen-2024-092522.
Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism
PEERLESS met its primary end point in favor of LBMT compared with CDT in treatment of intermediate-risk pulmonary embolism. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with CDT, with no difference in mortality or bleeding.
Summary
Primary Results of the PEERLESS Randomized Controlled Trial
[Posted 4/Feb/2025]
AUDIENCE: Cardiology, Emergency Medicine
KEY FINDINGS: PEERLESS met its primary end point in favor of LBMT compared with CDT in treatment of intermediate-risk pulmonary embolism. LBMT had lower rates of clinical deterioration and/or bailout and postprocedural intensive care unit use compared with CDT, with no difference in mortality or bleeding.
BACKGROUND: There are a lack of randomized controlled trial data comparing outcomes of different catheter-based interventions for intermediate-risk pulmonary embolism.
DETAILS: PEERLESS is a prospective, multicenter, randomized controlled trial that enrolled 550 patients with intermediate-risk pulmonary embolism with right ventricular dilatation and additional clinical risk factors randomized 1:1 to treatment with large-bore mechanical thrombectomy (LBMT) or catheter-directed thrombolysis (CDT). The primary end point was a hierarchal win ratio composite of the following (assessed at the sooner of hospital discharge or 7 days after the procedure): (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) postprocedural intensive care unit admission and length of stay. Assessments at the 24-hour visit included respiratory rate, modified Medical Research Council dyspnea score, New York Heart Association classification, right ventricle/left ventricle ratio reduction, and right ventricular function. End points through 30 days included total hospital stay, all-cause readmission, and all-cause mortality. The primary end point occurred significantly less frequently with LBMT compared with CDT (win ratio, 5.01 [95% CI, 3.68-6.97]; P<0.001). There were significantly fewer episodes of clinical deterioration and/or bailout (1.8% versus 5.4%; P=0.04) with LBMT compared with CDT and less postprocedural intensive care unit use (P<0.001), including admissions (41.6% versus 98.6%) and stays >24 hours (19.3% versus 64.5%). There were no significant differences in mortality, intracranial hemorrhage, or major bleeding between strategies or in a secondary win ratio end point including the first 4 components (win ratio, 1.34 [95% CI, 0.78-2.35]; P=0.30). At the 24-hour visit, respiratory rate was lower for patients treated with LBMT (18.3±3.3 versus 20.1±5.1; P<0.001), and fewer had moderate to severe modified Medical Research Council dyspnea scores (13.5% versus 26.4%; P<0.001), New York Heart Association classifications (16.3% versus 27.4%; P=0.002), and right ventricular dysfunction (42.1% versus 57.9%; P=0.004). Right ventricle/left ventricle ratio reduction was similar (0.32±0.24 versus 0.30±0.26; P=0.55). Patients treated with LBMT had shorter total hospital stays (4.5±2.8 overnights versus 5.3±3.9 overnights; P=0.002) and fewer all-cause readmissions (3.2% versus 7.9%; P=0.03), whereas 30-day mortality was similar (0.4% versus 0.8%; P=0.62).
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Source: Jaber, W. A., Gonsalves, C. F., Stortecky, S., et al. (2024). Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial. Circulation. 2025; 151(5). Published: February 4, 2025. DOI: 10.1161/CIRCULATIONAHA.124.07236.
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