This study determined the effect of systolic and diastolic hypertension on a composite of myocardial infarction, ischemic stroke, or hemorrhagic stroke in 1.3 million adult outpatients. Systolic ...blood-pressure elevation affected outcomes more, but systolic and diastolic hypertension independently influenced cardiovascular risk.
Oxidative stress is caused by an imbalance between reactive oxygen species (ROS) production and the ability of an organism to eliminate these toxic intermediates. Mutations in PTEN-inducible kinase 1 ...(PINK1) link mitochondrial dysfunction, increased sensitivity to ROS, and apoptosis in Parkinson's disease. Whereas PINK1 has been linked to the regulation of oxidative stress, the exact mechanism by which this occurs has remained elusive. Oxidative stress with associated mitochondrial dysfunction leads to cardiac dysfunction and heart failure (HF). We hypothesized that loss of PINK1 in the heart would have deleterious consequences on mitochondrial function. Here, we observed that PINK1 protein levels are markedly reduced in end-stage human HF. We also report that PINK1 localizes exclusively to the mitochondria. PINK1â»/â» mice develop left ventricular dysfunction and evidence of pathological cardiac hypertrophy as early as 2 mo of age. Of note, PINK1â»/â» mice have greater levels of oxidative stress and impaired mitochondrial function. There were also higher degrees of fibrosis, cardiomyocyte apoptosis, and a reciprocal reduction in capillary density associated with this baseline cardiac phenotype. Collectively, our in vivo data demonstrate that PINK1 activity is crucial for postnatal myocardial development, through its role in maintaining mitochondrial function, and redox homeostasis in cardiomyocytes. In conclusion, PINK1 possesses a distinct, nonredundant function in the surveillance and maintenance of cardiac tissue homeostasis.
Patients with cryptogenic ischemic stroke may have undetected paroxysmal atrial fibrillation (PAF). We established the Stroke and Monitoring for PAF in Real Time (SMART) Registry to determine the ...yield of 30-day outpatient PAF monitoring in cryptogenic ischemic stroke.
The SMART Registry was a 3-year, prospective multicenter registry of 239 patients with cryptogenic ischemic stroke undergoing 30-day outpatient autotriggered PAF detection in Kaiser Permanente Northern California.
In intention-to-monitor analysis, PAF was detected in 29 of 239 patients (12.1%; 95% CI, 8.6%-16.9%). After retrospective chart review was performed, a new diagnosis of PAF was confirmed in 26 of 236 patients (11.0%; 95% CI, 7.6%-15.7%). The majority of detected PAF events were asymptomatic; only 6 of 98 recorded PAF events (6.1%) were patient-triggered or associated with symptoms.
-Approximately 1 in every 9 patients with cryptogenic ischemic stroke was found to have new PAF within 30 days. Routine monitoring in this population should be strongly considered.
Tremendous progress has been made over the last several decades in improving the pyrometallurgical processing routes of nonferrous metals, such as aluminum, copper, and lead. Advances in the ...numerical modeling of pyrometallurgical processes has aided in these improvements by providing a better understanding of the complex transport phenomena occurring in modern furnaces. However, there is a need for a comprehensive discussion of the numerical modeling of a primary and a secondary nonferrous pyrometallurgical furnaces. This review provides such a discussion by surveying recent attempts at capturing the physico-chemical phenomena occurring within these furnaces, including gas-phase combustion, melting/smelting, and multiphase heat- and mass-transfer with the molten phases.This work then identifies a complete set of approaches for simulating these types of furnaces and provides recommendations for applying high-resolution numerical tools towards full-furnace simulation. By identifying gaps in the current state of the art, this review offers suggestions for future developments in commercial codebases, outlining the path to fulfilling the promise of CFD-enabled pyrometallurgy.
Abstract Background Although aortic valve-sparing (AVS) operations are established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms, comparative ...long-term outcomes are lacking. Objectives This study sought to compare the results of patients undergoing AVS procedures with those undergoing CVG operations. Methods From 1990 to 2010, a total of 616 patients age <70 years and without aortic stenosis underwent elective aortic root surgery (AVS, n = 253; CVG with a bioprosthesis bio-CVG, n = 180; CVG with a mechanical prosthesis m-CVG, n = 183). A propensity score was used as a covariate to adjust for unbalanced variables in group comparisons. Mean age was 46 ± 14 years, 83.3% were male, and mean follow-up was 9.8 ± 5.3 years. Results Patients undergoing AVS had higher rates of Marfan syndrome and lower rates of bicuspid aortic valve than those undergoing bio-CVG or m-CVG procedures. In-hospital mortality (0.3%) and stroke rate (1.3%) were similar among groups. After adjusting for clinical covariates, both bio-CVG and m-CVG procedures were associated with increased long-term major adverse valve-related events compared with patients undergoing AVS (hazard ratio HR: 3.4, p = 0.005; and HR: 5.2, p < 0.001, respectively). They were also associated with increased cardiac mortality (HR: 7.0, p = 0.001; and HR: 6.4, p = 0.003). Furthermore, bio-CVG procedures were associated with increased risk of reoperations (HR: 6.9; p = 0.003), and m-CVG procedures were associated with increased risk of anticoagulant-related hemorrhage (HR: 5.6; p = 0.008) compared with AVS procedures. Conclusions This comparative study showed that AVS procedures were associated with reduced cardiac mortality and valve-related complications when compared with bio-CVG and m-CVG. AVS is the treatment of choice for young patients with aortic root aneurysm and normal or near-normal aortic cusps.
Abstract Objectives Prolonged mechanical ventilation after cardiac surgery imposes a significant burden on the patient in terms of morbidity as well as a financial burden on the hospital. We ...undertook a retrospective analysis of 2 prospectively collected databases developed in tertiary cardiac care centers to derive and validate a risk index predicting prolonged mechanical ventilation after cardiac surgery. Methods We studied a retrospective cohort of 32,045 patients undergoing cardiac surgery in 2 hospitals in Toronto, Canada. The development cohort consisted of 21,661 patients at Toronto General Hospital. Data Sunnybrook Health Sciences Centre, Toronto, Canada, with 10,384 patients, served as an institutional validation cohort. We operationally characterized prolonged mechanical ventilation as the duration from surgery completion to extubation exceeding 48 hours. Results Prolonged postoperative mechanical ventilation rates in the development and validation cohort were 6% and 7%, respectively. Multivariable regression in the development cohort showed that the following factors were strong predictors of prolonged mechanical ventilation after cardiac surgery: previous cardiac surgery, lower left ventricular ejection fraction, shock, surgery involving repair of congenital heart disease, and cardiopulmonary bypass time. The intraoperative multivariable model retained good discrimination in the validation cohort, achieving a c statistic of 0.787. Conclusions Prolonged mechanical ventilation after cardiac surgery can be accurately predicted by readily available pre- and intraoperative information.
BACKGROUND AND PURPOSE—Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its ...acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California’s Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates.
METHODS—The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge.
RESULTS—This study included 310 patients treated with alteplase in the pre–EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29).
CONCLUSIONS—Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDerivs License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made.
PDF
