Abstract Objective To evaluate the use of sarcopenia as a frailty assessment tool for patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve ...replacement (TAVR). Methods The study cohort comprised 295 patients who underwent either SAVR (n = 156) or TAVR (n = 139). The mean preoperative Society of Thoracic Surgeons mortality risk score was 4.7%. Preoperative computed tomography (CT) scans were used to calculate gender-standardized total psoas area (TPA), as a validated measure of sarcopenia. Results For the entire cohort, independent predictors of a composite measure of 30-day death, stroke, renal failure, prolonged ventilation, and deep wound infection included preoperative STS major morbidity and mortality risk score (odds ratio OR, 91.1; P = .02) and TPA (OR, 0.5; P = .024). Two-year survival was 85.7% in patients with sarcopenia, compared with 93.8% in patients without sarcopenia ( P = .02). Independent predictors of late survival included TPA (hazard ratio, 0.47; P = .02). Male sex (OR, 0.52; P = .04) and TPA (OR, 0.6; P = .001) were predictive of high resource utilization. A separate analysis by treatment group found that TPA predicted high resource utilization after SAVR (OR, 0.4; P < .001), but not after TAVR ( P = .66). Conclusions CT scan–derived measurement of TPA as an objective frailty assessment tool predicts early morbidity and mortality, high resource utilization, and late survival after treatment for aortic stenosis. The correlation observed between sarcopenia and resource utilization after SAVR versus TAVR suggests that this simple and reproducible risk assessment tool also may help identify those patients who will derive optimal benefit from catheter-based therapy.
Background
The risk of contrast‐induced acute kidney injury (CI‐AKI) increases in a nonlinear fashion with increasing volume of contrast media. Prior studies recommend limiting contrast volume to ...less than three times the estimated creatinine clearance (CC). Recently, a number of operators have reported successful percutaneous coronary intervention (PCI) using even lower volumes of contrast.
Objectives
To evaluate the prevalence and outcomes associated with ultra‐low contrast volume among patients undergoing PCI.
Methods
We assessed the prevalence and outcomes associated with use of ultra‐low contrast volume among 75 393 patients undergoing PCI in Michigan between July 2014 and June 2017 in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry. Ultra‐low contrast volume was defined as contrast volume less than or equal to the patient's estimated CC. Patients receiving dialysis at the time of the procedure were excluded.
Results
Ultra‐low contrast volume was used in 13% of procedures with the majority of these patients being at low risk of renal complications. Compared with patients who received a contrast volume between one and three times the CC, use of ultra‐low volume of contrast was associated with a significantly lower incidence of AKI (aOR 0.682, 95% CI 0.566–0.821, P < 0.001) and a lower incidence of need for dialysis (aOR = 0.341, 95% CI 0.165–0.704, P = 0.003). These benefits were most evident in the patients with a high baseline predicted risk of AKI.
Conclusions
A small but clinically significant number of patients are treated with ultra‐low contrast volume. Ultra‐low contrast volume use is associated with a significant reduction in the incidence of AKI or need for dialysis. It may be prudent to consider this new threshold when performing PCI on patients who are at an increased risk of AKI.
Structural valve degeneration (SVD) is a major flaw of bioprostheses. An apparent increase in the SVD rate has been observed among patients who received the Trifecta bioprosthesis (Abbott Vascular, ...Santa Clara, CA).
This study retrospectively reviewed 1058 consecutive patients who underwent aortic valve placement with a stented bioprosthesis between January 2011 and December 2015. Patients were grouped into a Trifecta group (508 48.0% patients with Trifecta bioprostheses) and a non-Trifecta group (550 52.0% patients with other bioprostheses).
Patients in the Trifecta group were older (69.7 years vs 64.6 years; P = .001), were more likely female (40.4% vs 28.0%; P = .001), more often had aortic stenosis (85.1% vs 77.1%; P = .001), and received smaller valves (23.0 mm vs 25.0 mm; P < .001) than patients in the non-Trifecta group. SVD occurred in 28 patients (Trifecta, n = 22; non-Trifecta, n = 6) within 7 years. Aortic regurgitation or mixed stenosis/regurgitation was observed as the mode of failure in more than 50% of the Trifecta group, whereas none in non-Trifecta group. The cumulative incidence of SVD was higher in the Trifecta group both in the entire cohort (13.3% vs 4.6%; P = .010) and in the younger cohort (age ≤ 65 years; 27.9% vs 6.9%; P = .004), with a notable increase between 5 and 7 years. Multivariable competing risks regression in the Trifecta group revealed younger age (hazard ratio, 0.56 per 10-point decrease; 95% confidence interval, 0.44 to 0.72; P < .001) to be the sole contributor to SVD.
The SVD rate of the Trifecta bioprosthesis has been greater than expected, compared with other bioprostheses, particularly in younger patients. In view of the large number of Trifecta bioprostheses implanted worldwide, further investigation involving other institutions is warranted.
•Increase in proportion with 8years of schooling lowered number of pregnancies.•Education increased use of contraceptives and awareness of the ovulation cycle.•There is weak evidence that mothers ...schooling caused a decline in child mortality.•No evidence that women’s education changed attitudes toward gender inequality.
We use Turkey’s 1997 Education Law that increased compulsory schooling from 5 to 8years to study the effect of education on women’s fertility and empowerment. Using an instrumental variables methodology, we find that a 10 percentage-point increase in the proportion of ever-married women with eight-years of schooling lowered pregnancies by 0.13 per woman; increased the proportion paying an antenatal-visit during the first trimester by 6 percentage points; using contraceptives by eight points and with knowledge of the ovulation cycle by five points. There is weak evidence that schooling decreased child mortality; no evidence that it changed attitudes toward gender inequality.
Amotivation is a central feature of psychosis that can lead to underperformance on a variety of tasks, including neurocognitive testing; however, there is some evidence that neurocognitive ...impairments resulting from low effort can be ameliorated with the use of monetary reinforcement. While cross-sectional data has also shown that amotivation is associated with social cognitive performance, limited research has examined the directionality of this relationship, and whether monetary reinforcement can similarly reduce these impairments. In the present study, 35 patients with early psychosis and 35 community controls were randomized to either a reward condition in which they received monetary reinforcement for every correct response on a theory of mind (ToM) task, or a non-reward condition in which no feedback was provided. A significant group by condition interaction emerged after adjusting for premorbid intelligence and global neurocognition, F(1, 63) = 7.76, p = .007. Post-hoc analyses revealed that performance on the ToM task was similar across conditions for controls, whereas early psychosis patients in the reward condition had clinically and statistically significant differences in ToM performance compared to patients in the non-reward condition. These results suggest that social cognitive task performance may underrepresent actual ability in the early stages of psychosis. Future research is needed to discriminate the relative effects of monetary reinforcement, corrective feedback, and/or a combination of these factors to better understand performance differences between conditions, which appeared to be unique to early psychosis patients.
Abstract Background ACS verification is believed to provide benefits for trauma patients but is associated with direct costs. Study Design One-year retrospective review of the NTDB for 2012. Patients ...separated into three age groups; Pediatric (PEDS) 0-14, Adult 15-65, and elderly (ELD), >65. We analyzed 2 injury severity cohorts, ISS 9-74 (ALL) and ISS 25-74 (MAJ). Multiple logistic regression to determine significance of ACS verification on mortality and major complications, controlling for age, ISS, shock, GCS, gender, age, co-morbidities and mechanism. Patients excluded with an ISS < 8 or equal to 75, DOA, ED transfers and burns. Results There were 392,997 patients, 262,644 in ACS, 130,353 non-ACS centers. PEDS 3.8%, adults 64.5%, ELD 31.7%. For ALL adults, no differences observed for either primary outcome in ACS vs non-ACS centers (p=.128, .061, for mortality, complications). For ALL PEDS and ELD, complications were more likely in non-ACS centers: p = .003, OR = 2.61 (CI 1.36-5.0) and p < .0001, OR = 3.17 (CI 2.21-4.56). For MAJ trauma death was more likely in adults in ACS vs non-ACS centers p = .013, OR = .82 (CI .71-.96). Complications for MAJ trauma were more likely in all age groups in non ACS centers adult: p = .028, OR = 1.48 (CI 1.04-2.1); ELD: p < .0001, OR = 2.49 (CI 1.7-3.7); PEDS: p < .0001, OR 4.29 (CI 2.13-8.69). Length of stay was increased for all patients with complications (p < .0001) Conclusions Measurable benefits in complications observed in all age groups with MAJ trauma and in PEDS and ELD for ALL injury severity in ACS vs non-ACS trauma centers.
Objective To investigate the effects of Müllerian-inhibiting substance (MIS) on cytochrome P450 aromatase (CYP19) gene expression in cultured human granulosa lutein cells (GLC). Design In vitro ...primary cell culture study. Setting Academic research laboratory and hospital-based fertility center. Patient(s) Eight normo-ovulatory patients undergoing IVF procedures due to male factor or tubal infertility. Intervention(s) Serum and follicular fluid (FF) collected and stored at −80°C until assayed. Granulosa lutein cells were harvested from follicular aspirates obtained during oocyte retrieval and cultured for 7 days with media in the presence or absence of MIS (10 ng/mL) or FSH 0.2 IU/mL. Main Outcome Measure(s) Serum and FF levels of E2 and MIS, and E2 production by GLC in culture. Levels of CYP19 mRNA in cultured GLC were determined by quantitative polymerase chain reaction (PCR) and CYP19 protein by Western blot. Statistical comparison used ANOVA and post hoc Tukey tests. Result(s) Follicle-stimulating hormone significantly increased E2 production in cultured GLC compared with control. The increase in E2 production is associated with higher levels of CYP19 mRNA and protein in GLC. The presence of MIS significantly inhibited FSH-induced E2 production, with concomitant reduction in CYP19mRNA and protein levels. Conclusion(s) Müllerian-inhibiting substance inhibits FSH augmentation of CYP19 enzyme activity and CYP19 gene expression in GLC. These findings may help to explain the association of high MIS levels and low FF E2 levels reported in women with polycystic ovary syndrome (PCOS).
Background The traditional definition of contrast-induced nephropathy (CIN) has been an absolute rise of serum creatinine (Cr) of ≥0.5 mg/dL, although most recent clinical trials have included a ≥25% ...increase from baseline Cr. The clinical implication of this definition change remains unknown. Methods and Results We compared the association of the two definitions with risk of death or need for dialysis among 58,957 patients undergoing percutaneous coronary intervention in 2007 to 2008 in a large collaborative registry. Patients with a preexisting history of renal failure requiring dialysis were excluded. Contrast-induced nephropathy as defined by a rise in Cr ≥0.5 mg/dL (CINTraditional ) developed in 1,601, whereas CIN defined either as Cr ≥0.5 mg/dL or ≥25% increase in baseline Cr (CINNew ) developed in 4,308 patients. Patients meeting the definition of CINNew but not CINTraditional were classified as CINIncremental (n = 2,707). Compared with CINNew , CINTraditional was more commonly seen in patients with abnormal renal function, which was more likely to develop in patients with normal renal function at baseline. Compared with CINIncremental , patients meeting the definition of CINTraditional were more likely to die (16.7% vs 1.7%) and require in-hospital dialysis (9.8% vs 0%). Conclusions Our data suggest that the traditional definition of CIN (a rise in Cr of ≥0.5 mg/dL) in patients undergoing PCI is superior to ≥25% increase in Cr at identifying patients at greater risk for adverse renal and cardiac events.
Difficulties in emotion regulation (ER) can negatively impact the clinical course and outcomes of a range of psychiatric conditions, including psychosis spectrum disorders. Individuals with psychosis ...may exhibit poorer ER abilities, which have been associated with increased severity and distress of psychotic symptoms. A paucity of research has investigated the clinical correlates of ER in psychosis and the influence of these difficulties on indices of recovery, such as daily functioning and quality of life. In the present study, 59 outpatients presenting for Cognitive Behaviour Therapy for psychosis (CBTp) in a large psychiatric hospital completed an intake assessment of clinician-rated and self-reported measures prior to treatment. Poor ER abilities were positively correlated with positive symptoms (overall and delusions), social anxiety, depression, and self-reflectiveness and negatively correlated with quality of life and personal recovery. Multiple regression analyses showed ER was a significant predictor of quality of life but not daily functioning, which was predicted most by cognition and psychiatric symptoms. Overall, findings support the clinical utility of assessing emotion dysregulation in psychosis and provide a more nuanced understanding of how such challenges differentially influence recovery in psychosis, which can further inform treatment planning and intervention.
Abstract Objectives This study evaluated the safety and effectiveness of self-expanding transcatheter aortic valve replacement (TAVR) in patients with surgical valve failure (SVF). Background ...Self-expanding TAVR is superior to medical therapy for patients with severe native aortic valve stenosis at increased surgical risk. Methods The CoreValve U.S. Expanded Use Study was a prospective, nonrandomized study that enrolled 233 patients with symptomatic SVF who were deemed unsuitable for reoperation. Patients were treated with self-expanding TAVR and evaluated for 30-day and 1-year outcomes after the procedure. An independent core laboratory was used to evaluate serial echocardiograms for valve hemodynamics and aortic regurgitation. Results SVF occurred through stenosis (56.4%), regurgitation (22.0%), or a combination (21.6%). A total of 227 patients underwent attempted TAVR and successful TAVR was achieved in 225 (99.1%) patients. Patients were elderly (76.7 ± 10.8 years), had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 9.0 ± 6.7%, and were severely symptomatic (86.8% New York Heart Association functional class III or IV). The all-cause mortality rate was 2.2% at 30 days and 14.6% at 1 year; major stroke rate was 0.4% at 30 days and 1.8% at 1 year. Moderate aortic regurgitation occurred in 3.5% of patients at 30 days and 7.4% of patients at 1 year, with no severe aortic regurgitation. The rate of new permanent pacemaker implantation was 8.1% at 30 days and 11.0% at 1 year. The mean valve gradient was 17.0 ± 8.8 mm Hg at 30 days and 16.6 ± 8.9 mm Hg at 1 year. Factors significantly associated with higher discharge mean aortic gradients were surgical valve size, stenosis as modality of SVF, and presence of surgical valve prosthesis patient mismatch (all p < 0.001). Conclusions Self-expanding TAVR in patients with SVF at increased risk for surgery was associated with a low 1-year mortality and major stroke rate, significantly improved aortic valve hemodynamics, and low rates of moderate and no severe residual aortic regurgitation, with improved quality of life.
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