The potential for big data analytics to improve cardiovascular quality of care and patient outcomes is tremendous. However, the application of big data in health care is at a nascent stage, and the ...evidence to date demonstrating that big data analytics will improve care and outcomes is scant. This Review provides an overview of the data sources and methods that comprise big data analytics, and describes eight areas of application of big data analytics to improve cardiovascular care, including predictive modelling for risk and resource use, population management, drug and medical device safety surveillance, disease and treatment heterogeneity, precision medicine and clinical decision support, quality of care and performance measurement, and public health and research applications. We also delineate the important challenges for big data applications in cardiovascular care, including the need for evidence of effectiveness and safety, the methodological issues such as data quality and validation, and the critical importance of clinical integration and proof of clinical utility. If big data analytics are shown to improve quality of care and patient outcomes, and can be successfully implemented in cardiovascular practice, big data will fulfil its potential as an important component of a learning health-care system.
In contrast to its productive coastal margins, the open-ocean Gulf of Mexico (GoM) is notable for highly stratified surface waters with extremely low nutrient and chlorophyll concentrations. Field ...campaigns in 2017 and 2018 identified low rates of turbulent mixing, which combined with oligotrophic nutrient conditions, give very low estimates for diffusive flux of nitrate into the euphotic zone (< 1 µmol N m
d
). Estimates of local N
-fixation are similarly low. In comparison, measured export rates of sinking particulate organic nitrogen (PON) from the euphotic zone are 2 - 3 orders of magnitude higher (i.e. 462 - 1144 µmol N m
d
). We reconcile these disparate findings with regional scale dynamics inferred independently from remote-sensing products and a regional biogeochemical model and find that laterally-sourced organic matter is sufficient to support >90% of open-ocean nitrogen export in the GoM. Results show that lateral transport needs to be closely considered in studies of biogeochemical balances, particularly for basins enclosed by productive coasts.
Abstract
There is growing evidence that older adults exposed to natural disasters are at disproportionate risk for adverse health events such as all-cause mortality, injury, hospital admissions, ...stroke, displacement, cardiopulmonary distress, stress-related mental health problems, and exacerbation of chronic illnesses. Typically, analyses of the health consequences of natural disasters focus only on the populations impacted for the duration and immediate aftermath of the disaster. With few exceptions, the long-term effects of natural disasters on older adult health have not been examined. This article describes the potential consequences of exposure to natural disasters that contribute to cancer and disruption of cancer care treatment systems for older adults. It is argued that exposures to floods and wildfires in particular present an underestimated threat to the onset and/or progression of cancer and cancer care management in older adults. We propose that these impacts should be examined not only from an emergency preparedness perspective during the event but also from a public health focus that prospectively assesses risks for cancer and other health disparities. Recommendations for comprehensive longitudinal risk assessment and emergency preparedness models that address the full impact of natural disasters on the health and well-being of vulnerable, at risk, older adults are offered.
OBJECTIVE:To determine whether black patients have higher odds of readmission than white patients after major surgery, and to ascertain whether these disparities are related to where black patients ...receive care.
BACKGROUND:Racial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in readmissions after a surgical procedure, an area which is becoming a prime focus for clinical leaders and policymakers.
METHODS:Using national Medicare data from 2007 to 2010, we examined 30-day readmissions for patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if black patients had higher readmission rates than white patients, and if so, whether this effect was mediated by the hospitals at which patients received care, or by poverty.
RESULTS:Black patients had higher readmission rates than white patients (14.8% vs 12.8%, odds ratio OR 1.19; 95% confidence interval CI, 1.16–1.22; P < 0.001). Patients undergoing major surgery at minority-serving hospitals also had higher readmission rates (14.3% vs 12.8%, OR 1.14, 95% CI 1.09–1.19; P < 0.001). In multivariate analyses, black patients at minority-serving hospitals had the highest overall odds of readmissions (OR 1.34). White patients at minority-serving hospitals (OR 1.15) and black patients at non–minority-serving hospitals (OR 1.20) also had higher odds of readmission than the reference group of white patients at non–minority-serving hospitals. Racial disparities were mediated in part by poverty.
CONCLUSIONS:Among Medicare beneficiaries, black patients were more likely to be readmitted after hospitalization for surgical procedures. Since racial disparities in readmission rates are mediated both by patientsʼ race and the hospital at which care is delivered, efforts at reducing disparities should focus not only on race-based measures but also on improving outcomes of care at minority-serving hospitals.
This analysis of Medicare data suggests that 13% of patients are readmitted to the hospital within 30 days after major surgery. Readmission rates vary across hospitals and correlate with surgical ...volume and surgical mortality, two measures of surgical quality.
Reducing hospital-readmission rates is a priority for both policymakers and clinical leaders. The focus on readmissions has been driven by a belief that reducing the frequency with which patients return to the hospital can both improve care and lower costs. To date, much of the focus has been on readmissions after hospitalization for medical conditions, in which discharge planning and care coordination are often suboptimal.
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The Centers for Medicare and Medicaid Services (CMS) plans to include surgical procedures as it expands its readmissions penalty program.
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Using medical-readmission rates as a measure of hospital quality is controversial. Although hospitals vary . . .
OBJECTIVES: To provide pooled data on the prevalence of malnutrition in elderly people as evaluated using the Mini Nutritional Assessment (MNA).
DESIGN: Retrospective pooled analysis of previously ...published datasets.
SETTING: Hospital, rehabilitation, nursing home, community.
PARTICIPANTS: Four thousand five hundred seven people (75.2% female) with a mean age of 82.3.
MEASUREMENTS: The prevalence of malnutrition in the combined database and in the four settings was examined.
RESULTS: Twenty‐four data sets with information on full MNA classification from researchers from 12 countries were submitted. In the combined database, the prevalence of malnutrition was 22.8%, with considerable differences between the settings (rehabilitation, 50.5%; hospital, 38.7%; nursing home, 13.8%; community, 5.8%). In the combined database, the “at risk” group had a prevalence of 46.2%. Consequently, approximately two‐thirds of study participants were at nutritional risk or malnourished.
CONCLUSION: The MNA has gained worldwide acceptance and shows a high prevalence of malnutrition in different settings, except for the community. Because of its specific geriatric focus, the MNA should be recommended as the basis for nutritional evaluation in older people.
An assessment of the production, distribution and fate of highly branched isoprenoid (HBI) biomarkers produced by sea ice and pelagic diatoms is necessary to interpret their detection and proportions ...in the northern Bering and Chukchi Seas. HBIs measured in surface sediments collected from 2012 to 2017 were used to determine the distribution and seasonality of the biomarkers relative to sea ice patterns. A northward gradient of increasing ice algae deposition was observed with localized occurrences of elevated IP25 (sympagic HBI) concentrations from 68-70°N and consistently strong sympagic signatures from 71-72.5°N. A declining sympagic signature was observed from 2012 to 2017 in the northeast Chukchi Sea, coincident with declining sea ice concentrations. HBI fluxes were investigated on the northeast Chukchi shelf with a moored sediment trap deployed from August 2015 to July 2016. Fluxes of sea ice exclusive diatoms (Nitzschia frigida and Melosira arctica) and HBI-producing taxa (Pleurosigma, Haslea and Rhizosolenia spp.) were measured to confirm HBI sources and ice associations. IP25 was detected year-round, increasing in March 2016 (10 ng m-2 d-1) and reaching a maximum in July 2016 (1331 ng m-2 d-1). Snowmelt triggered the release of sea ice algae into the water column in May 2016, while under-ice pelagic production contributed to the diatom export in June and July 2016. Sea ice diatom fluxes were strongly correlated with the IP25 flux, however associations between pelagic diatoms and HBI fluxes were inconclusive. Bioturbation likely facilitates sustained burial of sympagic organic matter on the shelf despite the occurrence of pelagic diatom blooms. These results suggest that sympagic diatoms may sustain the food web through winter on the northeast Chukchi shelf. The reduced relative proportions of sympagic HBIs in the northern Bering Sea are likely driven by sea ice persistence in the region.
The property of self-imaging combined with the polarization birefringence of the angled multimode waveguide is used to design a silicon nitride (SiN) polarization splitter (PS) at λ ∼ 1550 nm. The ...demonstrated PS on a 450 nm thick SiN device layer (with 2.5 µm cladding oxide) has a footprint of 80 µm×13 µm and exhibits nearly wavelength independent performance over the C+L bands. Also, the device can be configured as a polarization combiner (PC) in reverse direction with similar bandwidth and performance. The measured crosstalk (CT) and insertion loss (IL) are respectively <−18 dB (<−20 dB) and ∼0.7 dB (∼0.8 dB) for TE (TM) polarization over the measurement wavelength range of 1525 nm ≤ λ ≤ 1625 nm. The measured device parameter variations suggest some tolerance to fabrication variations. Such a device is a good candidate for a photonics integrated chip (PIC) foundry-compatible, SiN PS.
BACKGROUND—Pulmonary hypertension (PH) is associated with increased morbidity across the cardiopulmonary disease spectrum. Based primarily on expert consensus opinion, PH is defined by a mean ...pulmonary artery pressure (mPAP) ≥25 mm Hg. Although mPAP levels below this threshold are common among populations at risk for PH, the relevance of mPAP <25 mm Hg to clinical outcome is unknown.
METHODS AND RESULTS—We analyzed retrospectively all US veterans undergoing right heart catheterization (2007–2012) in the Veterans Affairs healthcare system (n=21 727; 908-day median follow-up). Cox proportional hazards models were used to evaluate the association between mPAP and outcomes of all-cause mortality and hospitalization, adjusted for clinical covariates. When treating mPAP as a continuous variable, the mortality hazard increased beginning at 19 mm Hg (hazard ratio HR=1.183; 95% confidence interval CI, 1.004–1.393) relative to 10 mm Hg. Therefore, patients were stratified into 3 groups(1) referent (≤18 mm Hg; n=4 207); (2) borderline PH (19–24 mm Hg; n=5 030); and (3) PH (≥25 mm Hg; n=12 490). The adjusted mortality hazard was increased for borderline PH (HR=1.23; 95% CI, 1.12–1.36; P<0.0001) and PH (HR=2.16; 95% CI, 1.96–2.38; P<0.0001) compared with the referent group. The adjusted hazard for hospitalization was also increased in borderline PH (HR=1.07; 95% CI, 1.01–1.12; P=0.0149) and PH (HR=1.15; 95% CI, 1.09–1.22; P<0.0001). The borderline PH cohort remained at increased risk for mortality after excluding the following high-risk subgroups(1) patients with pulmonary artery wedge pressure >15 mm Hg; (2) pulmonary vascular resistance ≥3.0 Wood units; or (3) inpatient status at the time of right heart catheterization.
CONCLUSIONS—These data illustrate a continuum of risk according to mPAP level and that borderline PH is associated with increased mortality and hospitalization. Future investigations are needed to test the generalizability of our findings to other populations and study the effect of treatment on outcome in borderline PH.
Hypofractionated radiotherapy delivers larger daily doses of radiation and may increase the biologically effective dose delivered to the prostate. We conducted a randomized trial testing the ...hypothesis that dose-escalated, moderately hypofractionated intensity-modulated radiation therapy (HIMRT) improves prostate cancer control compared with conventionally fractionated IMRT (CIMRT) for men with localized prostate cancer.
Men were randomly assigned to 75.6 Gy in 1.8-Gy fractions delivered over 8.4 weeks (CIMRT) or 72 Gy in 2.4 Gy fractions delivered over 6 weeks (HIMRT, biologically equivalent to 85 Gy in 1.8-Gy fractions assuming prostate cancer α-to-β ratio of 1.5). Failure was defined as prostate-specific antigen (PSA) failure (nadir plus 2 ng/mL) or initiation of salvage therapy. Modified Radiation Therapy Oncology Group criteria were used to grade late (≥ 90 days after completion of radiotherapy) GI and genitourinary toxicity.
Most of the 206 men (72%) had cT1, Gleason score 6 or 7 (99%), and PSA level ≤ 10 ng/mL (90%) disease. Androgen deprivation therapy was received by 24%. With a median follow-up of 8.5 years, men treated with HIMRT experienced fewer treatment failures (n = 10) than men treated with CIMRT (n = 21; P = .036). The 8-year failure rate was 10.7% (95% CI, 5.8% to 19.1%) with HIMRT and 15.4% (95% CI, 9.1% to 25.4%) with CIMRT. There was no difference in overall survival ( P = .39). There was a nonsignificant increase in late grade 2 or 3 GI toxicity with HIMRT (8-year 5.0% v 12.6%; P = .08). However, GI toxicity was only 8.6% when rectal volume receiving 65 Gy of HIMRT was ≤ 15%. Late genitourinary toxicity was similar ( P = .84). There was no grade 4 toxicity.
The results of this randomized trial demonstrate superior cancer control for men with localized prostate cancer who receive dose-escalated moderately hypofractionation radiotherapy while shortening treatment duration.
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