Pulmonary hypertension (PH) is prevalent in patients with aortic stenosis (AS); however, previous studies have demonstrated inconsistent results regarding the association of PH with adverse outcomes ...after aortic valve replacement (AVR). The goal of this study was to evaluate the effects of preoperative PH on outcomes after AVR. We performed a regional prospective cohort study using the Northern New England Cardiovascular Disease Study Group database to identify 1,116 consecutive patients from 2005 to 2010 who underwent AVR ± coronary artery bypass grafting for severe AS with a preoperative assessment of pulmonary pressures by right-sided cardiac catheterization. PH was defined as a mean pulmonary artery pressure of ≥25 mm Hg, with severity based on the pulmonary artery systolic pressure—mild, 35 to 44 mm Hg; moderate, 45 to 59 mm Hg; and severe, ≥60 mm Hg. We found that PH was present in 536 patients (48%). Postoperative acute kidney injury, low-output heart failure, and in-hospital mortality increased with worsening severity of PH. In multivariate logistic regression, severe PH was independently associated with postoperative acute kidney injury (adjusted odds ratio 4.1, 95% confidence interval CI 1.7 to 10, p = 0.002) and in-hospital mortality (adjusted odds ratio 6.9, 95% CI 2.5 to 19.1, p <0.001). There was a significant association between PH and decreased 5-year survival (adjusted log-rank p value = 0.006), with severe PH being associated with the poorest survival (adjusted hazard ratio 2.4, 95% CI 1.3 to 4.2, p = 0.003). In conclusion, severe PH in patients with severe AS is associated with increased rates of in-hospital adverse events and decreased 5-year survival after AVR.
Aims. We present cosmological constraints from a joint analysis of type Ia supernova (SN Ia) observations obtained by the SDSS-II and SNLS collaborations. The dataset includes several low-redshift ...samples (z< 0.1), all three seasons from the SDSS-II (0.05 <z< 0.4), and three years from SNLS (0.2 <z< 1), and it totals 740 spectroscopically confirmed type Ia supernovae with high-quality light curves. Methods. We followed the methods and assumptions of the SNLS three-year data analysis except for the following important improvements: 1) the addition of the full SDSS-II spectroscopically-confirmed SN Ia sample in both the training of the SALT2 light-curve model and in the Hubble diagram analysis (374 SNe); 2) intercalibration of the SNLS and SDSS surveys and reduced systematic uncertainties in the photometric calibration, performed blindly with respect to the cosmology analysis; and 3) a thorough investigation of systematic errors associated with the SALT2 modeling of SN Ia light curves. Results. We produce recalibrated SN Ia light curves and associated distances for the SDSS-II and SNLS samples. The large SDSS-II sample provides an effective, independent, low-z anchor for the Hubble diagram and reduces the systematic error from calibration systematics in the low-z SN sample. For a flat ΛCDM cosmology, we find Ωm =0.295 ± 0.034 (stat+sys), a value consistent with the most recent cosmic microwave background (CMB) measurement from the Planck and WMAP experiments. Our result is 1.8σ (stat+sys) different than the previously published result of SNLS three-year data. The change is due primarily to improvements in the SNLS photometric calibration. When combined with CMB constraints, we measure a constant dark-energy equation of state parameter w =−1.018 ± 0.057 (stat+sys) for a flat universe. Adding baryon acoustic oscillation distance measurements gives similar constraints: w =−1.027 ± 0.055. Our supernova measurements provide the most stringent constraints to date on the nature of dark energy.
Background Whether delaying coronary artery bypass grafting (CABG) after myocardial infarction (MI) is associated with better outcomes or is an unnecessary use of health care resources is unclear. ...This study investigated the relationship between MI-to-CABG timing on in-hospital death. Methods From the Northern New England Cardiovascular Disease Study Group (NNE) Cardiac Surgery Registry we identified 3,060 isolated CABG patients with prior MI from 2008 to 2014. We compared in-hospital death by MI-to-CABG timing of less than 1 day, 1 to 2 days, 3 to 7 days, and 8 to 21 days. We adjusted for patient characteristics using logistic regression. Results Among patients with prior MI, CABG was performed within 1 day for 99 (3.2%), 1 to 2 days for 369 (12.1%), 3 to 7 days for 1,966 (64.3%), and 8 to 21 days for 626 (20.5%) patients. NNE-predicted mortality was similar for patients operated on within 1 day (1.8%), 1 to 2 days (1.8%), and 3 to 7 days (1.9%), but was higher for 8 to 21 days (2.4%) of MI. Crude in-hospital mortality was higher for those with MI-to-CABG time of less than 1 day (5.1%) compared with 1 to 2 days (1.6%), 3 to 7 days (1.6%), and 8 to 21 days (2.7%, p = 0.044). Adjusted in-hospital mortality remained high for less than 1 day (5.4%; 95% CI, 1.5% to 9.4%), and similar for 1 to 2 days (1.8%; 95% CI, 0.4% to 3.1%), 3 to 7 days (1.7%; 95% CI, 1.1% to 2.3%), and 8 to 21 days (2.3%; 95% CI, 1.2% to 3.3%) between MI and CABG. Conclusions Patients operated on 1 to 2 days and 3 to 7 days after MI had a similar mortality rate, suggesting it may be possible to reduce the MI-to-CABG interval for some patients without sacrificing outcomes. Patients operated on within 1 day after MI had a higher mortality rate.
Background Increasing numbers of the very elderly are undergoing coronary artery bypass graft surgery (CABG). Short-term results have been studied, but few data are available concerning long-term ...outcomes. Methods We conducted a cohort study of 54,397 consecutive patients undergoing primary, isolated CABG surgery between July 1, 1987, and June 30, 2006. Patient records were linked to the Social Security Administration’s Death Master File. Results During 390,871 person-years of follow-up, there were 17,352 deaths. There were 51,149 patients younger than 80 years, 2,661 patients aged 80 to 84 years, and 587 patients aged 85 or more years who underwent isolated CABG surgery. Crude in-hospital survival was 97.2% for those less than 80 years, 98.3% for those aged 80 to 84 years, and 87.6% for those aged 85 or more years. Patients aged 80 or more years were more likely to be female (46.9%), more likely to be emergency priority (10.2%), and more likely to have associated comorbidities than younger patients. Patients aged 85 or more years were more likely to have intraoperative and postoperative morbid events. Among patients younger than 80, median survival was 14.4 years with an annual incidence of death of 4.2%. Among patients 80 to 84 years old, median survival time was 7.4 years, with an annual incidence rate of death of 10.3%. Among patients aged 85 or more years, median survival was 5.8 years, and the annual incidence of death was 13.7%. Conclusions Although very elderly CABG patients have more comorbidities and more acute presentation than younger patients and their in-hospital mortality rate is high, their long-term survival is surprisingly good.
Within the coastal zone, waterfront development has caused severe loss of shallow-water habitats, such as salt marshes and seagrass beds. Although the effects of habitat degradation on community ...structure within intertidal marshes have been well studied, little is known about the impact of habitat degradation on, and the ecological value of, subtidal shallow-water habitats, despite the prevalence of these habitats in coastal ecosystems. In coastal habitats, bivalves are dominant benthic organisms that can comprise over 50% of benthic prey biomass and are indicative of benthic production. We quantified bivalve diversity, density, and biomass in deep and shallow (<1.5 m MLW) unstructured subtidal habitats in 2 tributaries of lower Chesapeake Bay (Elizabeth-Lafayette River system and York River). We also examined the effects of shoreline alteration in shallow habitats by contrasting the benthos of the subtidal areas adjacent to natural marsh, bulkhead, and rip-rap shorelines. Bivalve diversity, density, and biomass were significantly higher in shallow than in deep benthic habitats in both systems. Benthic abundance and diversity were higher in subtidal habitats adjacent to natural marsh than those adjacent to bulkhead shorelines; abundance and diversity were intermediate in rip-rap shorelines, and appeared to depend on landscape features. Predator density and diversity tended to be highest adjacent to natural marsh shorelines, and density of crabs was significantly higher in natural marsh than in bulkhead habitats. There is thus a crucial link between natural marshes, infaunal prey in subtidal habitats, and predator abundance. Consequently, the indirect effects of coastal habitat degradation upon secondary production in the shallow, subtidal habitats adjacent to salt marshes may be as great as or greater than direct habitat effects.
Objective A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality ...Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (<3 units red blood cells RBCs). Methods We examined 11,200 patients undergoing isolated nonemergent coronary artery bypass graft surgery across 56 medical centers in 4 IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intraoperative practices, and percentage of patients receiving RBC transfusions were collected. Region-specific transfusion rates were calculated after adjusting for pre- and intraoperative factors among region-specific centers. Results There were small but significant differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% of coronary artery bypass graft procedures (2826 out of 11,200). Significant variation in the number of RBC units used existed across regions (no units, 74.8% min-max, 70.0%-84.1%, 1 unit, 9.7% min-max, 5.1%-11.8%, 2 units, 15.5% min-max, 9.1%-18.2%; P < .001). Variation in overall transfusion rates remained after adjustment (9.1%-31.7%; P < .001). Conclusions Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.
Summary Background The timing of the initial spread of hepatitis C virus genotype 1a in North America is controversial. In particular, how and when hepatitis C virus reached extraordinary prevalence ...in specific demographic groups remains unclear. We quantified, using all available hepatitis C virus sequence data and phylodynamic methods, the timing of the spread of hepatitis C virus genotype 1a in North America. Methods We screened 45 316 publicly available sequences of hepatitis C virus genotype 1a for location and genotype, and then did phylogenetic analyses of available North American sequences from five hepatitis C virus genes ( E1, E2, NS2, NS4B, NS5B ), with an emphasis on including as many sequences with early collection dates as possible. We inferred the historical population dynamics of this epidemic for all five gene regions using Bayesian skyline plots. Findings Most of the spread of genotype 1a in North America occurred before 1965, and the hepatitis C virus epidemic has undergone relatively little expansion since then. The effective population size of the North American epidemic stabilised around 1960. These results were robust across all five gene regions analysed, although analyses of each gene separately show substantial variation in estimates of the timing of the early exponential growth, ranging roughly from 1940 for NS2 , to 1965 for NS4B. Interpretation The expansion of genotype 1a before 1965 suggests that nosocomial or iatrogenic factors rather than past sporadic behavioural risk (ie, experimentation with injection drug use, unsafe tattooing, high risk sex, travel to high endemic areas) were key contributors to the hepatitis C virus epidemic in North America. Our results might reduce stigmatisation around screening and diagnosis, potentially increasing rates of screening and treatment for hepatitis C virus. Funding The Canadian Institutes of Health Research, Michael Smith Foundation for Health Research, and BC Centre for Excellence in HIV/AIDS.
Background There is limited information comparing long-term survival after percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients aged 80 years and older. ...We studied the long-term survival of octogenarians with multivessel coronary artery disease undergoing PCI or CABG who might have been candidates for either procedure. Methods We identified 1693 patients, aged 80 to 89, with two-vessel disease (57.6%) or three-vessel disease (42.4%), without left main disease, undergoing a first, nonemergency revascularization from 1992 to 2001. Adjusted hazard ratios (HR) were calculated for CABG versus PCI. Because survival curves for these procedures crossed midway through year 1, results were analyzed separately for the first 6 months and 6 months to 8 years. Results PCI was performed in 54.6% of patients with two-vessel disease and 23.7% of those with three-vessel disease. More CABG patients were men (54.7% versus 43.3%). The CABG patients had more peripheral vascular disease (23.1% versus 15.2%) and congestive heart failure (24.5% versus 13.1%) but less renal failure (4.6% versus 9.1%) and fewer prior myocardial infarctions (48.7% versus 53.6%). In-hospital mortality was 3.0% for PCI and 5.9% for CABG ( p = 0.005). CABG was associated with poorer survival than PCI during the first 6 months (HR, 1.32; p = 0.135). Survival from 6 months to 8 years was significantly better with CABG for the group as a whole (HR, 0.72; p = 0.005) and for patients with two-vessel disease (HR, 0.68; p = 0.016), and there was a nonsignificant trend for those with three-vessel disease (HR, 0.75; p = 0.177). Conclusions Patients aged 80 years or older with multivessel disease must consider the trade-off between the increased early risks of CABG in return for improved long-term survival.
We report a detection of the baryon acoustic oscillation (BAO) feature in the three-dimensional correlation function of the transmitted flux fraction in the Lyα forest of high-redshift quasars. The ...study uses 48 640 quasars in the redshift range 2.1 ≤ z ≤ 3.5 from the Baryon Oscillation Spectroscopic Survey (BOSS) of the third generation of the Sloan Digital Sky Survey (SDSS-III). At a mean redshift z = 2.3, we measure the monopole and quadrupole components of the correlation function for separations in the range 20 h-1 Mpc < r < 200 h-1 Mpc. A peak in the correlation function is seen at a separation equal to (1.01 ± 0.03) times the distance expected for the BAO peak within a concordance ΛCDM cosmology. This first detection of the BAO peak at high redshift, when the universe was strongly matter dominated, results in constraints on the angular diameter distance DA and the expansion rate H at z = 2.3 that, combined with priors on H0 and the baryon density, require the existence of dark energy. Combined with constraints derived from cosmic microwave background observations, this result implies H(z = 2.3) = (224 ± 8) km s-1 Mpc-1, indicating that the time derivative of the cosmological scale parameter ȧ = H(z = 2.3)/(1 + z) is significantly greater than that measured with BAO at z ~ 0.5. This demonstrates that the expansion was decelerating in the range 0.7 < z < 2.3, as expected from the matter domination during this epoch. Combined with measurements of H0, one sees the pattern of deceleration followed by acceleration characteristic of a dark-energy dominated universe.
Appropriateness of Coronary Artery Bypass Graft Surgery Performed in Northern New England Gerald T. O'Connor, Elaine M. Olmstead, William C. Nugent, Bruce J. Leavitt, Robert A. Clough, Paul W. ...Weldner, David C. Charlesworth, Kristine Chaisson, Donato Sisto, Edward R. Nowicki, Richard P. Cochran, David J. Malenka, for the Northern New England Cardiovascular Disease Study Group The goal of this study was to assess the concordance between the American College of Cardiology (ACC) and the American Heart Association (AHA) 2004 Guideline Update for Coronary Artery Bypass Graft Surgery and actual clinical practice. We evaluated 4,684 consecutive isolated coronary artery bypass graft procedures performed in 2004 and 2005 in northern New England. The majority of procedures were class I (87.7%). Class II procedures totaled 10.9%. The remaining 1.4% of procedures were class III. We found that 98.6% of coronary artery bypass graft (CABG) procedures that could be classified were appropriate. In these data, actual clinical practice closely follows the 2004 ACC/AHA guidelines for CABG surgery.
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