Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well ...developed to be evaluated by the formal American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines process. Often the topic is the subject of ongoing investigation. ...the reader should view the CECD as the best attempt of the ACCF and the cosponsors to inform and guide clinical practice in areas where rigorous evidence may not be available or the evidence to date is not widely accepted. Either aspirin (81 to 325 mg), extended-release dipyridamole plus aspirin, or clopidogrel can be used.\n Safian None Medtronic Boston Scientific Cordis ev3 None None None None None Dr. Michael A. Sloan * Terumo Medical Corp. NINDS Abbott Boston Scientific Guidant Cordis None Boehringer-Ingelheim Bristol-Myers Squibb/Sanofi None None None Dr. Christopher J. White None None None None None None None Appendix 1 ACCF/SCAI/SVMB/SIR/ASITN Writing Committee to Develop a Clinical Expert Consensus Document on Carotid Stenting--Author Relationships With Industry This table represents the relationships of committee members with industry that were reported orally at the initial writing committee meeting and updated in conjunction with all meetings and conference calls of the writing committee during the document development process. Name Representation Consultant Research Grant Scientific Advisory Board Speakers' Bureau Steering Committee Stock Holder Other Dr. Robert M. Bersin * Official Reviewer--SCAI Cordis Corp. Guidant Corp. Cordis Corp. Boston Scientific ev3 Guidant Sanofi-Aventis Medicines Co. Cordis Corp. Boston Scientific Boston Scientific ev3 Sanofi-Aventis Medicines Co. None * Cordis * Cordis--Spouse's Employer, Proctor/ Trainer Dr. Michael J. Cowley * Official Reviewer--SCAI None None None None None None None Dr. David R. Holmes, Jr. * Official Reviewer-- ACCF Board of Trustees None None None None None None None Dr. Stuart A. Winston * Official Reviewer-- ACCF Board of Trustees None Guidant Medtronic Biotronic None None None None None Dr. Seemant Chaturvedi * Content Reviewer Boehringer Ingelheim Bristol-Myers Squibb/Sanofi Boehringer Ingelheim Pfizer None Boehringer Ingelheim Bristol-Myers Squibb/Sanofi None None None Dr. Leslie Sung Hee Cho * Content Reviewer--ACCF PVD Committee None None None None None None None Dr. Michael R. Jaff * Content Reviewer None None None None None None None Dr. Elizabeth Ratchford * Content Reviewer * Vasogen, Inc. None None None None Merck None Dr. Keith Calligaro * Organizational Reviewer--SVS None None None None None None None Dr. Colin P. Derdeyn * Organizational Reviewer--ASITN None None None None None None None Dr. Anthony Furlan * Organizational Reviewer--AAN None None None None None None None Dr. Scott Kinlay * Organizational Reviewer--SVMB None None None None None None None Dr. Gary M. Nesbit * Organizational Reviewer--ASITN None None None None None None None Dr. Bruce A. Perler * Organizational Reviewer--SVS None None None None None None None Dr. Rodney Raabe * Organizational Reviewer--SIR * Guidant None None Guidant Cordis Genotech None None Cook (Royalty from product) Trainer for Physicians for Carotid Stenting Dr. Lawrence Wechsler * Organizational Reviewer--AAN Astra-Zeneca NMT Medical Boston Scientific Bristol-Myers Squibb None Bristol-Myers Squibb * NMT Medical None None Dr. Mark H. Wholey * Organizational Reviewer--SIR Medrad Mallinckrodt Edwards * Bristol-Myers Squibb Medrad Edwards Mallinckrodt Edwards None None None Appendix 2 Peer Reviewer Relationships With Industry--ACCF/SCAI/SVMB/SIR/ASITN Writing Committee to Develop A Clinical Expert Consensus Document on Carotid Stenting This table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic.
Pentadic cartography is a useful way to examine the motivational vocabularies of discourses and to provide alternative vocabularies for negotiating rhetorical terrains. Pentadic cartographers have ...used Kenneth Burke's principles to examine and critique the motivational vocabularies of texts as their vocabularies compete against one another. This article expands the application of pentadic cartography by exploring maps as "overlays" or when two pentadic vocabularies do not necessarily compete but can complement one another. This study examines two potential competing mappings present in former Secretary of Health and Human Services Kathleen Sibelius's (2012) speech outlining a new global health strategy, as well as an overlay map that negotiates domestic and global health. Each mapping is assessed for its abilities to open and to close the universe of discourse. The possibility of overlays as a supplement to pentadic cartography is outlined.
This article employs critical realism to reflect on two views of the body found within Marxism. It is argued that the first view-that of the body as simple prerequisite-found within the 1844 ...Manuscripts should be rejected due to a latent idealism and residual dualisms that render the body under-theorised, ontologically primitive and in limbo. It is then argued that the second view-that of the thinking body-introduced within The German Ideology would be strengthened further by using critical realism in an underlabouring role to reconceptualise the body-in-general as emergent so as to recognise more fully the paradoxical situation in which humans both are and have bodies. This conceptualisation would help both to aid the perception or actuality of a reductionist position and to acknowledge fully the stratified nature of human beings. In so doing, it is argued that, once there is a move back towards the concrete, such a theory of the body is able to inform more insightful analyses of the ways in which the body is (re)produced in a society in which biological space, as well as geographical and social spaces, is being infiltrated and colonised by a capitalist logic.
Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction ...(STEMI) patients within the time limit of first contact to device ≤ 120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process.
We studied 14,518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times > 60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤ 120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤ 120 minutes was achieved in 65% of patients (n = 9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥ 75% of transfer STEMI patients with ≤ 120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay.
More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤ 120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.
Objectives The aim of this study was to determine the relative utility of anatomic and ischemic burden of coronary artery disease for predicting outcomes. Background Both anatomic burden and ischemic ...burden of coronary artery disease determine patient prognosis and influence myocardial revascularization decisions. When both measures are available, their relative utility for prognostication and management choice is controversial. Methods A total of 621 patients enrolled in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial with baseline quantitative nuclear single-photon emission computed tomography (SPECT) and quantitative coronary angiography were studied. Several multiple regression models were constructed to determine independent predictors of the endpoint of death, myocardial infarction (MI) (excluding periprocedural MI) and non–ST-segment elevation acute coronary syndromes (NSTE-ACS). Ischemic burden during stress SPECT, anatomic burden derived from angiography, left ventricular ejection fraction, and assignment to either optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) or OMT alone were analyzed. Results In nonadjusted and adjusted regression models, anatomic burden and left ventricular ejection fraction were consistent predictors of death, MI, and NSTE-ACS, whereas ischemic burden and treatment assignment were not. There was a marginal (p = 0.03) effect of the interaction term of anatomic and ischemic burden for the prediction of clinical outcome, but separately or in combination, neither anatomy nor ischemia interacted with therapeutic strategy to predict outcome. Conclusions In a cohort of patients treated with OMT, anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not. Importantly, neither determination, even in combination, identified a patient profile benefiting preferentially from an invasive therapeutic strategy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation COURAGE; NCT00007657 )
Objective. To determine if 1) patients have distinct affective reaction patterns to medication information, and 2) whether there is an association between affective reaction patterns and willingness ...to take medication. Methods. We measured affect in real time as subjects listened to a description of benefits and side effects for a hypothetical new medication. Subjects moved a dial on a handheld response system to indicate how they were feeling from “Very Good” to “Very Bad”. Patterns of reactions were identified using a cluster-analytic statistical approach for multiple time series. Subjects subsequently rated their willingness to take the medication on a 7-point Likert scale. Associations between subjects’ willingness ratings and affect patterns were analyzed. Additional analyses were performed to explore the role of race/ethnicity regarding these associations. Results. Clusters of affective reactions emerged that could be classified into 4 patterns: “Moderate” positive reactions to benefits and negative reactions to side effects (n = 186), “Pronounced” positive reactions to benefits and negative reactions to side effects (n = 110), feeling consistently “Good” (n = 58), and feeling consistently close to “Neutral” (n = 33). Mean (standard error) willingness to take the medication was greater among subjects feeling consistently Good 4.72 (0.20) compared with those in the Moderate 3.76 (0.11), Pronounced 3.68 (0.14), and Neutral 3.62 (0.26) groups. Black subjects with a Pronounced pattern were less willing to take the medication compared with both Hispanic (P = 0.0270) and White subjects (P = 0.0001) with a Pronounced pattern. Conclusion. Patients’ affective reactions to information were clustered into specific patterns. Reactions varied by race/ethnicity and were associated with treatment willingness. Ultimately, a better understanding of how patients react to information may help providers develop improved methods of communication.
Objectives To ascertain attitudes of prospective patients relevant to the delivery of race-based pharmacogenomics.
Methods Written anonymous survey and qualitative responses in two sets of reactance ...format focus groups over-sampled for minority groups in urban, suburban, and rural communities conducted from February through April, 2002 N = 104 and August through November, 2002 N = 120.
Results Participants do not associate “races” exclusively with continental clusters. They have incomplete knowledge of their recent ancestors (39.6% do not know all their biological grandparents). They would be highly suspicious of race-labeled drugs; with 47.5% saying they would be very suspicious of their safety and 40.6% indicating they would be very suspicious of their efficacy. A substantial minority of African-American participants (13.2%) would prefer to take the drugs designated for European Americans. Effect of discussion of race-based medicine on racial attitudes is ambiguous.
Conclusions Patient knowledge of ancestry and suspicion of race-designated drugs constitute substantial barriers that need to be incorporated in judging the likely effectiveness of race-based pharmacogenomics.
The Gulf of Maine North Atlantic Time Series (GNATS) has been run since 1998, across the Gulf of Maine (GoM), between Maine and Nova Scotia. GNATS goals are to provide ocean color satellite ...validation and to examine change in this coastal ecosystem. We have sampled hydrographical, biological, chemical, biogeochemical, and bio‐optical variables. After 2008, warm water intrusions (likely North Atlantic Slope Water NASW) were observed in the eastern GoM at 50–180 m depths. Shallow waters (<50 m) significantly warmed in winter, summer, and fall but cooled during spring. Surface salinity and density of the GoM also significantly increased over the 20 years. Phytoplankton standing stock and primary production showed highly‐significant decreases during the period. Concentrations of phosphate increased, silicate decreased, residual nitrate N*; nitrate‐silicate increased, and the ratio of dissolved inorganic nitrogen:phosphate decreased, suggesting increasing nitrogen limitation. Dissolved organic carbon (DOC) and its optical indices generally increased over two decades, suggesting changes to the DOC cycle. Surface seawater carbonate chemistry showed winter periods where the aragonite saturation (Ωar) dropped below 1.6 gulf‐wide due to upward winter mixing of cool, corrosive water. However, associated with increased average GoM temperatures, Ωar has significantly increased. These results reinforce the hypothesis that the observed decrease in surface GoM primary production resulted from a switch from Labrador Sea Water to NASW entering the GoM. A multifactor analysis shows that decreasing GoM primary production is most significantly correlated to decreases in chlorophyll and particulate organic carbon plus increases in N* and temperature.
Plain Language Summary
A 20‐year coastal time series, the Gulf of Maine North Atlantic Time Series, has included regular oceanographic measurements across the Gulf of Maine (GoM), one of the fastest warming ocean water bodies on Earth. Physical, chemical, biological, biogeochemical, and bio‐optical measurements demonstrate: (a) unexpected, statistically‐significant surface cooling in spring months along with surface warming in all other seasons, (b) deep warm water in the GoM after 2008, likely associated with intrusions of warm, saline N. Atlantic Slope water, (c) declines in phytoplankton primary production over 20 years, most significantly associated with chlorophyll, particulate organic carbon, temperature, and residual nitrate (the excess of nitrate over silicate), (d) deep mixing events in winter bring corrosive water to the surface, making it more likely to dissolve carbonates of shell formers and (e) dissolved organic carbon and its colored constituents progressively increased in the GoM, yet this does not correlate significantly with the drop in primary production. These results link the control of GoM productivity to waters originating outside of the GoM in the Northwest Atlantic.
Key Points
A 20‐year Gulf of Maine (GoM) time series shows surface cooling in spring months but warming in all other seasons
Primary production declined over 20 years, mostly associated with changes in chlorophyll, particulate organic carbon, temperature, and residual nitrate (nitrate‐silicate)
Deep intrusions of warm, saline North Atlantic Slope Water occurred post‐2008 into the GoM
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