Due to the aging and increasingly complex nature of our patients, frailty has become a high-priority theme in cardiovascular medicine. Despite the recognition of frailty as a pivotal element in the ...evaluation of older adults with cardiovascular disease (CVD), there has yet to be a road map to facilitate its adoption in routine clinical practice. Thus, we sought to synthesize the existing body of evidence and offer a perspective on how to integrate frailty into clinical practice. Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of frailty—slow walking speed, weakness, inactivity, exhaustion, and shrinking—as measured by physical performance tests and questionnaires. The prevalence of frailty ranges from 10% to 60%, depending on the CVD burden, as well as the tool and cutoff chosen to define frailty. Epidemiological studies have consistently demonstrated that frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. Frailty contributes valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients. Interventions designed to improve outcomes in frail elders with CVD such as multidisciplinary cardiac rehabilitation are being actively tested. Ultimately, frailty should not be viewed as a reason to withhold care but rather as a means of delivering it in a more patient-centered fashion.
Woodland caribou ( Rangifer tarandus caribou (Gmelin, 1788)) use older forests that provide abundant terrestrial lichen forage and refuge from predators. However, forest structural characteristics ...vary widely, differing in forage availability but also, perhaps, in the ability of caribou to move freely to access forage or to escape predation. We conducted a multivariate analysis of habitat in two geographically and biophysically distinct regions to identify the independent effects of various attributes, including forest understorey stand density, defined as standing and downed biomass, on caribou habitat selection. We developed Bayesian network models to predict the probability of habitat selection based on a set of remotely sensed habitat inputs. Caribou in the Bistcho range (northwestern Alberta) selected non-forest/sparsely forested areas, while caribou in the Trout Lake region (northwestern Ontario) selected primarily forested habitats, nevertheless consistent with selection for reduced predation risk in both cases. Caribou also selected forest stands with lower understorey stand density in both regions, consistent with selection for stands that would allow greater ease of movement. The high-resolution satellite data resolved habitat characteristics more consistently and in greater detail than standard forest cover datasets that are most often used for these analyses, and led us to conclude that habitat management may require different treatments in different parts of the species’ range to address what are nevertheless common pathways to decline.
Transcatheter aortic valve replacement (TAVR) is an effective treatment for severe symptomatic aortic stenosis (AS) in patients who are inoperable or at high risk for surgery. However, the ...intermediate- to long-term mortality is high, emphasizing the importance of patient selection. We, therefore, sought to evaluate the prognostic value of frailty in older recipients of TAVR, hypothesizing that frail patients would experience a higher mortality rate and a higher likelihood of poor outcome 1 year after TAVR. This substudy of the Placement of Aortic Transcatheter Valves trial was conducted at 3 high-enrolling sites where frailty was assessed systematically before TAVR. In total, 244 patients received TAVR at the participating sites. Frailty was assessed using a composite of 4 markers (serum albumin, dominant handgrip strength, gait speed, and Katz activity of daily living survey), which were combined into a frailty score. The cohort was dichotomized at median frailty score. Outcomes measures were the time to death from any cause for >1 year of follow-up and poor outcome at 1 year. Poor outcome was defined as (1) death, (2) Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS) score <60, or (3) decrease of ≥10 points in the KCCQ-OS score from baseline to 1 year. At 1 year, the Kaplan-Meier–estimated all-cause mortality rate was 32.7% in the frail group and 15.9% in the nonfrail group (log-rank p = 0.004). At 1 year, poor outcome occurred in 50.0% of the frail group and 31.5% of the nonfrail group (p = 0.02). In conclusion, frailty was associated with increased mortality and a higher rate of poor outcome 1 year after TAVR.
Recent research has shown promising results for the detection of aortic stenosis (AS) using cardio-mechanical signals. However, they are limited by two main factors: lacking physical explanations for ...decision-making on the existence of AS, and the need for auxiliary signals. The main goal of this paper is to address these shortcomings through a wearable inertial measurement unit (IMU), where the physical causes of AS are determined from IMU readings. To this end, we develop a framework based on seismo-cardiogram (SCG) and gyro-cardiogram (GCG) morphologies, where highly-optimized algorithms are designed to extract features deemed potentially relevant to AS. Extracted features are then analyzed through machine learning techniques for AS diagnosis. It is demonstrated that AS could be detected with 95.49-100.00% confidence. Based on the ablation study on the feature space, the GCG time-domain feature space holds higher consistency, i.e., 95.19-100.00%, with the presence of AS than HRV parameters with a low contribution of 66.00-80.00%. Furthermore, the robustness of the proposed method is evaluated by conducting analyses on the classification of the AS severity level. These analyses are resulted in a high confidence of 92.29%, demonstrating the reliability of the proposed framework. Additionally, game theory-based approaches are employed to rank the top features, among which GCG time-domain features are found to be highly consistent with both the occurrence and severity level of AS. The proposed framework contributes to reliable, low-cost wearable cardiac monitoring due to accurate performance and usage of solitary inertial sensors.
Objectives: The primary objective of the study was to assess whether the Availability, Responsiveness and Continuity (ARC) organizational intervention improved youth outcomes in community based ...mental health programs. The second objective was to assess whether programs with more improved organizational social contexts following the 18-month ARC intervention had better youth outcomes than programs with less improved social contexts. Method: Eighteen community mental health programs that serve youth between the ages of 5 and 18 were randomly assigned to ARC or control conditions. Clinicians (n = 154) in the participating programs completed the Organizational Social Context (OSC) measure at baseline and following the 18-month ARC organizational intervention. Caregivers of 393 youth who were served by the 18 programs (9 in ARC and 9 in control) completed the Shortform Assessment for Children (SAC) once a month for six months beginning at intake. Results: Hierarchical linear models (HLM) analyses indicated that youth outcomes were significantly better in the programs that completed the 18 month ARC intervention. HLM analyses also showed that youth outcomes were best in the programs with the most improved organizational social contexts following the 18 month ARC intervention. Conclusions: Youth outcomes in community mental health programs can be improved with the ARC organizational intervention and outcomes are best in programs that make the most improvements in organizational social context. The relationships linking ARC, organizational social context, and youth outcomes suggest that service improvement efforts will be more successful if those efforts include strategies to improve the organizational social contexts in which the services are embedded. (Contains 3 figures.)
This paper describes an open-access database for seismo-cardiogram (SCG) and gyro-cardiogram (GCG) signals. The archive comprises SCG and GCG recordings sourced from and processed at multiple sites ...worldwide, including Columbia University Medical Center and Stevens Institute of Technology in the United States, as well as Southeast University, Nanjing Medical University, and the first affiliated hospital of Nanjing Medical University in China. It includes electrocardiogram (ECG), SCG, and GCG recordings collected from 100 patients with various conditions of valvular heart diseases such as aortic and mitral stenosis. The recordings were collected from clinical environments with the same types of wearable sensor patch. Besides the raw recordings of ECG, SCG, and GCG signals, a set of hand-corrected fiducial point annotations is provided by manually checking the results of the annotated algorithm. The database also includes relevant echocardiogram parameters associated with each subject such as ejection fraction, valve area, and mean gradient pressure.
Acute kidney injury (AKI) is associated with a poor prognosis after transcatheter aortic valve replacement (TAVR). A paucity of data exists regarding the incidence and effect of AKI after TAVR using ...the new recommended Valve Academic Research Consortium criteria. At Columbia University Medical Center, 218 TAVR procedures (64.2% transfemoral, 35.8% transapical) were performed from 2008 to July 2011. The creatinine level was evaluated daily until discharge. Using the Valve Academic Research Consortium definitions, the 30-day and 1-year outcomes were compared between patients with significant AKI (AKI stage 2 or 3) and those without significant AKI (AKI stage 0 or 1). Significant AKI occurred in 18 patients (8.3%). Of these 18 patients, 10 (55.6%) had AKI stage 3 and 9 (50%) required dialysis. AKI was associated with a lower baseline mean transvalvular gradient (37.6 ± 11.4 vs 45.6 ± 14.8 mm Hg for no AKI, p = 0.03). After TAVR, the AKI group had a greater hemoglobin decrease (3.6 ± 2.0 vs 2.4 ± 1.3 g/dl, p = 0.01), greater white blood cell elevation at 72 hours (21.09 ± 12.99 vs 13.18 ± 4.82 × 103 /μl, p = 0.001), a more severe platelet decrease (118 ± 40 vs 75 ± 43 × 103 /μl, p <0.0001), and longer hospitalization (10.7 ± 6.4 vs 7.7 ± 8.5 days, p <0.001). One stroke (5.6%) occurred in the AKI group compared with 3 (1.5%) in the group without AKI (p = 0.29). The 30-day and 1-year rates of death were significantly greater in the AKI group than in the no-AKI group (44.4% vs 3.0%, hazard ratio 18.1, 95% confidence interval 6.25 to 52.20, p <0.0001; and 55.6% vs 16.0%, hazard ratio 6.32, 95% confidence interval 3.06 to 13.10, p <0.0001, respectively). Periprocedural life-threatening bleeding was the strongest predictor of AKI after TAVR. In conclusion, the occurrence of AKI, as defined by the Valve Academic Research Consortium criteria, is associated with periprocedural complications and a poor prognosis after TAVR.
Abstract Background A hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) prioritizing and combining all available crossing techniques was developed to optimize ...procedural efficacy, efficiency, and safety, but there is limited published data on its outcomes. Methods We examined the procedural techniques and outcomes of 1036 consecutive CTO PCIs performed using a hybrid approach between 2012 and 2015 at 11 US centers. Results Mean age was 65 ± 10 years and 86% of the patients were men, with a high prevalence of diabetes mellitus (43%) and prior coronary artery bypass graft surgery (34%). Most target CTOs were located in the right coronary artery (59%), followed by the left anterior descending artery (23%) and the circumflex (19%). Dual injection was used in 71%. Technical success was achieved in 91% and a major procedural complication occurred in 1.7% of cases. The final successful crossing technique was antegrade wire escalation in 46%, antegrade dissection/re-entry in 26%, and retrograde in 28%. The initial crossing strategy was successful in 58% of the lesions, whereas 39% required an additional approach. Overall, antegrade wire escalation was used in 71%, antegrade dissection/re-entry in 36%, and the retrograde approach in 42% of procedures. Median contrast volume, fluoroscopy time, and air kerma radiation dose were 260 (200–360) ml, 44 (27–72) min, and 3.4 (2.0–5.4) Gray, respectively. Conclusion Application of a hybrid approach to CTO crossing resulted in high success and low complication rates across a varied group of operators and hospital practice structures, supporting its expanding use in CTO PCI.
Using massively parallel sequencing by synthesis methods, we have surveyed the polyA+ transcripts from four stages of the nematode Caenorhabditis elegans to an unprecedented depth. Using novel ...statistical approaches, we evaluated the coverage of annotated features of the genome and of candidate processed transcripts, including splice junctions, trans-spliced leader sequences, and polyadenylation tracts. The data provide experimental support for >85% of the annotated protein-coding transcripts in WormBase (WS170) and confirm additional details of processing. For example, the total number of confirmed splice junctions was raised from 70,911 to over 98,000. The data also suggest thousands of modifications to WormBase annotations and identify new spliced junctions and genes not part of any WormBase annotation, including at least 80 putative genes not found in any of three predicted gene sets. The quantitative nature of the data also suggests that mRNA levels may be measured by this approach with unparalleled precision. Although most sequences align with protein-coding genes, a small fraction falls in introns and intergenic regions. One notable region on the X chromosome encodes a noncoding transcript of >10 kb localized to somatic nuclei.
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