The Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial aimed to assess the impact of ablation on morbidity and mortality. This observational study was conducted ...in parallel to CABANA to assess trial generalizability.
Using a large US administrative database, we identified 183 760 patients with atrial fibrillation (AF) treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 August 2009 and 30 April 2016 (CABANA enrolment period). Propensity score weighting was used to balance patients treated with ablation (N = 12 032) or medical therapy alone (N = 171 728) on 90 dimensions. Ablation was associated with a reduction in the composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.70-0.81; P < 0.001. The majority of patients (73.8%) were potentially trial eligible; among whom the risk reduction associated with ablation was greatest (HR 0.70, 95% CI 0.63-0.77; P < 0.001). Among the 3.8% of patients who failed to meet the inclusion criterion, i.e. patients under 65 years without stroke risk factors, the event rates were low and there was no significant relationship with ablation (HR 0.67, 95% CI 0.29-1.56; P = 0.35). Among the 22.4% patients who met at least one of the trial exclusion criteria, there was a lesser but statistically significant reduction associated with ablation (HR 0.85, 95% CI 0.75-0.95; P = 0.01).
In routine clinical care, ablation was associated with a reduction in the primary CABANA composite endpoint of all-cause mortality, stroke, major bleeding, and cardiac arrest, particularly in patients who were eligible for the trial.
Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to ...clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.
Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.
We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.
Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.
clinical trials.gov NCT00949611.
An energy-efficient Magnéli phase Ti4O7 reactive electrochemical membrane (REM) was applied for the oxidation of perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS). Approximately ...5-log removal of these compounds was achieved in a single pass through the REM with residence times of ∼11 s at 3.3 V/SHE for PFOA and 3.6 V/SHE for PFOS. The permeate concentrations of PFOA and PFOS were <86 and 35 ng L–1, from initial concentrations of 4.14 and 5 mg L–1, respectively. The highest removal rates were 3415 ± 203 μmol m–2 h–1 for PFOA and 2436 ± 106 μmol m–2 h–1 for PFOS at a permeate flux of 720 L m–2 h–1 (residence times of ∼3.8 s). The levels of energy consumption (per log removal) to remove PFOA and PFOS to below the detection limits were 5.1 and 6.7 kWh m–3, respectively. These values are the lowest reported for electrochemical oxidation and approximately an order of magnitude lower than those reported for other technologies (i.e., ultrasonication, photocatalysis, vacuum ultraviolet photolysis, and microwave–hydrothermal decomposition), demonstrating the promise of the REM technology for water treatment applications.
Carbonyl sulfide (COS) and carbon disulfide (CS2) are volatile sulfur compounds that are critical precursors to sulfate aerosols, which enable climate cooling. COS and CS2 stem from the indirect ...photolysis of organic sulfur precursors in natural waters, but currently the chemistry behind how this occurs remains unclear. This study evaluated how different organic sulfur precursors, water quality constituents, which can form important reactive intermediates (RIs), and temperature affected COS and CS2 formation. Nine natural waters ranging in salinity were spiked with cysteine, cystine, dimethylsulfide (DMS), or methionine and exposed to simulated sunlight over varying times and water quality conditions. Results indicated that COS and CS2 formation increased up to 11× and 4×, respectively, after 12 h of sunlight, while diurnal cycling exhibited varied effects. COS and CS2 formation was also strongly affected by the DOC concentration, organic sulfur precursor type, O2 concentration, and temperature, while salinity differences and CO addition did not play a significant role. Overall, important factors in forming COS and CS2 were identified, which may ultimately impact their atmospheric concentrations.
Improving the quality of physicians' recommendations for human papillomavirus (HPV) vaccination is critical to addressing low coverage. Thus, we sought to describe HPV vaccine communication practices ...among primary care physicians.
Pediatricians and family physicians (n = 776) completed our national online survey in 2014. We assessed the quality of their HPV vaccine recommendations on strength of endorsement (i.e., saying the vaccine is important), timeliness (recommending it by ages 11-12), consistency (recommending it routinely vs. using a risk-based approach), and urgency (recommending same-day vaccination).
A sizeable minority of physicians reported that they do not strongly endorse HPV vaccine (27%) or deliver timely recommendations for girls (26%) or boys (39%). Many physicians (59%) used a risk-based approach to recommending HPV vaccine, and only half (51%) usually recommended same-day vaccination. Overall recommendation quality was lower among physicians who were uncomfortable talking about HPV vaccine or who believed parents did not value it. Quality was higher among physicians who began discussions by saying the child was due for HPV vaccine versus giving information or eliciting questions.
Many physicians in our national sample reported recommending HPV vaccine inconsistently, behind schedule, or without urgency. These practices likely contribute to under-immunization among adolescents, and may convey ambivalence to parents.
As one of the first studies to assess multiple aspects of recommendation quality, these findings can inform the many state and national initiatives that aim to improve communication about HPV vaccine so as to address the persistent underuse of a powerful tool for cancer prevention.
Randomized gossip algorithms Boyd, S.; Ghosh, A.; Prabhakar, B. ...
IEEE transactions on information theory,
06/2006, Letnik:
52, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Motivated by applications to sensor, peer-to-peer, and ad hoc networks, we study distributed algorithms, also known as gossip algorithms, for exchanging information and for computing in an ...arbitrarily connected network of nodes. The topology of such networks changes continuously as new nodes join and old nodes leave the network. Algorithms for such networks need to be robust against changes in topology. Additionally, nodes in sensor networks operate under limited computational, communication, and energy resources. These constraints have motivated the design of "gossip" algorithms: schemes which distribute the computational burden and in which a node communicates with a randomly chosen neighbor. We analyze the averaging problem under the gossip constraint for an arbitrary network graph, and find that the averaging time of a gossip algorithm depends on the second largest eigenvalue of a doubly stochastic matrix characterizing the algorithm. Designing the fastest gossip algorithm corresponds to minimizing this eigenvalue, which is a semidefinite program (SDP). In general, SDPs cannot be solved in a distributed fashion; however, exploiting problem structure, we propose a distributed subgradient method that solves the optimization problem over the network. The relation of averaging time to the second largest eigenvalue naturally relates it to the mixing time of a random walk with transition probabilities derived from the gossip algorithm. We use this connection to study the performance and scaling of gossip algorithms on two popular networks: Wireless Sensor Networks, which are modeled as Geometric Random Graphs, and the Internet graph under the so-called Preferential Connectivity (PC) model.
Although randomized clinical trials are considered to be the criterion standard for generating clinical evidence, the use of real-world evidence to evaluate the efficacy and safety of medical ...interventions is gaining interest. Whether observational data can be used to address the same clinical questions being answered by traditional clinical trials is still unclear.
To identify the number of clinical trials published in high-impact journals in 2017 that could be feasibly replicated using observational data from insurance claims and/or electronic health records (EHRs).
In this cross-sectional analysis, PubMed was searched to identify all US-based clinical trials, regardless of randomization, published between January 1, 2017, and December 31, 2017, in the top 7 highest-impact general medical journals of 2017. Trials were excluded if they did not involve human participants, did not use end points that represented clinical outcomes among patients, were not characterized as clinical trials, and had no recruitment sites in the United States.
The primary outcomes were the number and percentage of trials for which the intervention, indication, trial inclusion and exclusion criteria, and primary end points could be ascertained from insurance claims and/or EHR data.
Of the 220 US-based trials analyzed, 33 (15.0%) could be replicated using observational data because their intervention, indication, inclusion and exclusion criteria, and primary end points could be routinely ascertained from insurance claims and/or EHR data. Of the 220 trials, 86 (39.1%) had an intervention that could be ascertained from insurance claims and/or EHR data. Among the 86 trials, 62 (72.1%) had an indication that could be ascertained. Forty-five (72.6%) of 62 trials had at least 80% of inclusion and exclusion criteria data that could be ascertained. Of these 45 studies, 33 (73.3%) had at least 1 primary end point that could be ascertained.
This study found that only 15% of the US-based clinical trials published in high-impact journals in 2017 could be feasibly replicated through analysis of administrative claims or EHR data. This finding suggests the potential for real-world evidence to complement clinical trials, both by examining the concordance between randomized experiments and observational studies and by comparing the generalizability of the trial population with the real-world population of interest.
Why does poor-quality sleep lead to atherosclerosis? In a diverse sample of over 1,600 individuals, we describe a pathway wherein sleep fragmentation raises inflammatory-related white blood cell ...counts (neutrophils and monocytes), thereby increasing atherosclerosis severity, even when other common risk factors have been accounted for. Improving sleep quality may thus represent one preventive strategy for lowering inflammatory status and thus atherosclerosis risk, reinforcing public health policies focused on sleep health.
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