Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.
The goal of this study was to investigate the incidence, ...predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.
Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.
Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).
After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting CABG Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation ...during mitral valve surgery (MVS).
Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered).
Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P < .02).
Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ...ischemic mitral regurgitation (IMR).
Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.
NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio adjOR, 1.52; 95% confidence interval CI, 1.35-1.72; P < .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P < .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.
NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.
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The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to ...coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.
We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.
In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 2370 to 28,888), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 −3866 to 56,826) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.
The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
The CTSN (Cardiothoracic Surgical Trials Network) recently
reported no difference in left ventricular end-systolic volume index or in survival
at 2 years between patients with severe ischemic mitral ...regurgitation (MR)
randomized to mitral valve repair or replacement. However, replacement provided
more durable correction of MR and fewer cardiovascular readmissions. Yet, costeffectiveness
outcomes have not been addressed.
We conducted a cost-effectiveness analysis of the
surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair;
n=125 for replacement). Patient-level data on readmissions, survival, qualityof-
life, and US hospital costs were used to estimate costs and quality-adjusted
life years per patient over the trial duration and a 10-year time horizon. We
performed microsimulation for extrapolation of outcomes beyond the 2 years
of trial data. Bootstrap and deterministic sensitivity analyses were done to
address parameter uncertainty. In-hospital cost estimates were $78 216 for
replacement versus $72 761 for repair (difference: $5455; 95% uncertainty
interval UI: −7784–21 193) while 2-year costs were $97 427 versus $96 261
(difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted
life years at 2 years were 1.18 for replacement versus 1.23 for repair
(difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits
of reduction in cardiovascular readmission rates with replacement increased,
and survival minimally improved compared with repair. At 5 years, cumulative
costs and quality-adjusted life years showed no difference on average, but
by 10 years, there was a small, uncertain benefit for replacement: $118 023
versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and qualityadjusted
life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08).
After 10 years, the incremental cost-effectiveness of replacement continued
to improve.
Our cost-effectiveness analysis predicts potential savings in cost
and gains in quality-adjusted survival at 10 years when mitral valve replacement
is compared with repair for severe ischemic MR. These projected benefits,
however, were small and subject to variability. Efforts to further delineate
predictors of long-term outcomes in patients with severe ischemic MR are
needed to optimize surgical decisions for individual patients, which should yield
more cost-effective care.
URL: https://www.clinicaltrials.gov. Unique
identifier: NCT00807040.
Abstract Maintenance of weight loss remains a challenge for most individuals. Thus, practical and effective weight-loss maintenance (WTLM) strategies are needed. A two-group 12-month WTLM ...intervention trial was conducted from June 2007 to February 2010 to determine the feasibility and effectiveness of a WTLM intervention for older adults using daily self-monitoring of body weight, step count, fruit/vegetable (F/V) intake, and water consumption. Forty weight-reduced individuals (mean weight lost=6.7±0.6 kg; body mass index calculated as kg/m2 29.2±1.1), age 63±1 years, who had previously participated in a 12-week randomized controlled weight-loss intervention trial, were instructed to record daily body weight, step count, and F/V intake (WEV defined as weight, exercise, and F/V). Experimental group (WEV+) participants were also instructed to consume 16 fl oz of water before each main meal (ie, three times daily), and to record daily water intake. Outcome measures included weight change, diet/physical activity behaviors, theoretical constructs related to health behaviors, and other clinical measures. Statistical analyses included growth curve analyses and repeated measures analysis of variance. Over 12 months, there was a linear decrease in weight (β=−0.32, P <0.001) and a quadratic trend (β=0.02, P <0.01) over time, but no group difference (β=−0.23, P =0.08). Analysis of the 365 days of self-reported body weight for each participant determined that weight loss was greater over the study period in the WEV+ group than in the WEV group, corresponding to weight changes of −0.67 kg and 1.00 kg, respectively, and an 87% greater weight loss (β=−0.01, P <0.01). Overall compliance to daily tracking was 76%±5%. Daily self-monitoring of weight, physical activity, and F/V consumption is a feasible and effective approach for maintaining weight loss for 12 months, and daily self-monitoring of increased water consumption may provide additional WTLM benefits.
In 2020, the Journal of the Medical Library Association (JMLA) launched an initiative aimed at providing more equitable opportunities for authors, reviewers, and editorial team members. This ...editorial provides an update on the steps we have taken thus far to empower authors, increase the diversity of our editorial team, and make equity-minded recommendations to the Medical Library Association.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Sports that emphasize low body weight for optimal performance, such as ballet, are associated with an increased prevalence of the female athlete triad (FT). Previous research in this area that ...involves dancers has been limited; the majority of studies have been performed on adolescents
training in classical ballet, and not professional adult dancers. The purpose of this study is to compare the physical and behavioral characteristics of female elite ballet dancers to sedentary, recreationally active non-dancing controls, with regard to characteristics of the FT and energetic
efficiency. Women aged 18 to 35 years were recruited as participants. The dancers (N = 15) and non-dancing controls (N = 15) were pair-matched via age (dancers: 24.3 ± 1.3 years; controls: 23.7 ± 0.9 years), body mass index (dancers: 18.9 ± 0.2; controls: 19.4 ±
0.2 kg/m 2 ), and fat-free mass (dancers: 44.3 ± 0.8; controls: 44.1 ± 0.9 kg). Assessments included habitual dietary intake using 4-day food records, self-reported physical activity, psychometric measures of eating behaviors, health and menstrual history, body composition and
bone density (dual energy x-ray absorptiometry), and resting metabolic rate (RMR) assessed by indirect calorimetry. Characteristics of the FT, specifically menstrual irregularities (6 of 15 dancers reported irregular or no menses; 1 of 15 controls reported irregular menses) and low energy
availability, were more prevalent in dancers than in pair-matched controls. Despite having a similar fat-free mass (FFM), dancers had a significantly lower absolute RMR (dancers: 1367 ± 27; controls: 1454 ± 34 kcal/d; p ≤ 0.05) and significantly lower RMR relative to FFM (dancers:
30.9 ± 0.6; controls: 33.1 ± 0.8 kcal/kg fat-free mass/d; p ≤ 0.05). Energy intake between dancers (1577 ± 89 kcal/d) and pair-matched controls (2075 ± 163 kcal/d) also differed significantly (p ≤ 0.01). Six of the 15 dancers met the criteria for the FT (including
low bone mineral density, menstrual irregularities, and eating pathology accompanied by low energy availability) and, therefore, represent a population of individuals afflicted with this disorder. These findings provide insight as to the metabolic impact of chronic energy restriction, and
suggest that alterations in RMR (i.e., energetic efficiency) may be an indicator of low energy availability. Future larger-scale studies are warranted to address this possibility. Interventions aimed at increasing energy availability in elite female ballet dancers may be needed to promote
optimal health status.
Intimal hyperplasia that results from therapeutic revascularization is an important etiologic factor in the failure of these procedures (i.e., restenosis). Drugs which donate nitric oxide have been ...shown to inhibit the proliferation of vascular smooth muscle cells in vitro. We tested the hypothesis that administration of L-arginine (0.5 g/kg/day), the precursor of nitric oxide, would inhibit development of intimal hyperplasia following balloon catheter-induced injury. L-arginine administration from 2 days prior to and 2 weeks following catheter-induced injury to the rabbit thoracic aorta attenuated the development of intimal hyperplasia by 39% as compared with untreated controls. This effect was due to decreased intimal area. The effect of L-arginine was inhibited by co-administration of an inhibitor of nitric oxide synthase, NG-nitro-L-arginine methyl ester (0.5 g/kg/day). These data demonstrate that L-arginine attenuates intimal hyperplasia and suggest that the mechanism for this effect is the conversion of L-arginine to nitric oxide.
This study applied an early screening approach to determine the risk status of children in five urban schools and monitor their patterns of reading growth over 3 years. A majority of students were ...from culturally diverse and low-SES backgrounds.Two validated instruments were used for determining (a) academic risk (the Dynamic Indicators of Basic Early Literacy Skills DIBELS; Good et al., 1998) and (b) behavioral risk (Systematic Screening for Behavior Disorders SSBD; Walker & Severson, 1992, or Early Screening Project; Walker, Severson, & Feil, 1995). DIBELS data for 383 students were used to determine the characteristics and effectiveness of reading curriculum reforms for students in kindergarten through second grade. Results indicated that students with a single risk factor (academic or behavioral) progressed more slowly than the general population in the participating schools.The students with behavioral risks, however, made better progress, becoming more fluent readers than the students with academic risks. Students with both academic and behavioral risks made the least progress. The Reading Mastery curriculum (Reading Mastery, 1995) produced better growth in reading fluency than did Success for All (Success for All, 1999) or the literature-based curriculum. It also produced better growth for students with academic, behavioral, or both risk factors.The Success for All curriculum produced less growth compared to the Reading Mastery curriculum but was superior to the literature-based curriculum. Implications are discussed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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