Adherence to medications that are prescribed after myocardial infarction is poor. Eliminating out-of-pocket costs may increase adherence and improve outcomes.
We enrolled patients discharged after ...myocardial infarction and randomly assigned their insurance-plan sponsors to full prescription coverage (1494 plan sponsors with 2845 patients) or usual prescription coverage (1486 plan sponsors with 3010 patients) for all statins, beta-blockers, angiotensin-converting-enzyme inhibitors, or angiotensin-receptor blockers. The primary outcome was the first major vascular event or revascularization. Secondary outcomes were rates of medication adherence, total major vascular events or revascularization, the first major vascular event, and health expenditures.
Rates of adherence ranged from 35.9 to 49.0% in the usual-coverage group and were 4 to 6 percentage points higher in the full-coverage group (P<0.001 for all comparisons). There was no significant between-group difference in the primary outcome (17.6 per 100 person-years in the full-coverage group vs. 18.8 in the usual-coverage group; hazard ratio, 0.93; 95% confidence interval CI, 0.82 to 1.04; P=0.21). The rates of total major vascular events or revascularization were significantly reduced in the full-coverage group (21.5 vs. 23.3; hazard ratio, 0.89; 95% CI, 0.90 to 0.99; P=0.03), as was the rate of the first major vascular event (11.0 vs. 12.8; hazard ratio, 0.86; 95% CI, 0.74 to 0.99; P=0.03). The elimination of copayments did not increase total spending ($66,008 for the full-coverage group and $71,778 for the usual-coverage group; relative spending, 0.89; 95% CI, 0.50 to 1.56; P=0.68). Patient costs were reduced for drugs and other services (relative spending, 0.74; 95% CI, 0.68 to 0.80; P<0.001).
The elimination of copayments for drugs prescribed after myocardial infarction did not significantly reduce rates of the trial's primary outcome. Enhanced prescription coverage improved medication adherence and rates of first major vascular events and decreased patient spending without increasing overall health costs. (Funded by Aetna and the Commonwealth Fund; MI FREEE ClinicalTrials.gov number, NCT00566774.).
Purpose of Review
Non-ischaemic dilated cardiomyopathy (DCM) occurs in 1 in 2500 individuals in the general population and is associated with considerable morbidity and mortality. Studies involving ...large numbers of unselected DCM patients have led to consensus guidelines recommending implantable cardioverter-defibrillator (ICD) implantation for protection against sudden cardiac death (SCD) in those with LVEF ≤35%. The purpose of this article is to review the literature for other potential markers including serological, electrocardiographic, echocardiographic, cardiac magnetic resonance, ambulatory ECG and genetic data, to highlight other potential markers that may optimise risk stratification for SCD in this cohort and thereby allow a more personalized approach to ICD-implantation.
Recent Findings
Recent studies including the Danish study to assess the efficacy of ICDs in patients with non-ischemic systolic heart failure on mortality (DANISH) trial have questioned the benefits of ICD implantation in this group of patients with no changes in all-cause mortality. Recent pooled cohorts of patients with genetic DCM and in particular in those with Lamin A/C (LMNA) mutations have identified patients at increased risk of SCD and allowed the creation of algorithms to prognosticate SCD risk in mutation carriers. Furthermore, genetic testing has identified other DCM-causing genes including filamin C (
FLNC
) and
RBM20
which may be associated with higher rates of ventricular arrhythmia.
Summary
To date, risk-stratification for SCD has been hampered by the utilisation of heterogenous subsets of idiopathic DCM patients and by use of static risk models where predictions are based on a single time point with a lack of consideration of disease progression. The current focus of personalised risk-stratification for SCD is shifting towards better characterisation of underlying DCM aetiology and the development of multi-parametric risk-stratification models that incorporate time-dependent disease characteristics and novel biomarkers.
Abstract
Cardiovascular disease risk factor profiles and health behaviors are known to differ between women and men. Sex-based differences in ideal cardiovascular health were examined in the My ...Research Legacy study, which collected cardiovascular health and lifestyle data via Life’s Simple 7 survey and digital health devices. As the study overenrolled women (n = 1251) compared to men (n = 310), we hypothesized that heterogeneity among women would affect comparisons of ideal cardiovascular health. We identified 2 phenogroups of women in our study cohort by cluster analysis. The phenogroups differed significantly across all 7 cardiovascular health and behavior domains (all p < 0.01) with women in phenogroup 1 having a lower Life’s Simple 7 Health Score than those in phenogroup 2 (5.9 ± 1.3 vs. 7.6 ± 1.3, p < 0.01). Compared to men, women in phenogroup 1 had a higher burden of cardiovascular disease risk factors, exercised less, and had lower ideal cardiovascular health scores (p < 0.01). In contrast, women in phenogroup 2 had fewer cardiovascular risk factors but similar exercise habits and higher ideal cardiovascular health scores than men (p < 0.01). These findings suggest that heterogeneity among study participants should be examined when evaluating sex-based differences in ideal cardiovascular health.
Abstract
For et al., who catalogued Magellanic Stream (MS) clouds, suggested that there is substantial large-scale turbulence in the MS. Here we follow up with a series of FLASH simulations that ...model the hydrodynamic effects that clouds have on each other. The suite of simulations includes a range of cloud separation distances and densities. The ambient conditions are similar to those surrounding the MS but also relevant to the circumgalactic medium and intergalactic medium. Ten simulations are presented, eight of which model clustered clouds and two of which model isolated clouds. The isolated clouds are used as controls for comparison with the multicloud simulations. We find that if the clouds are initially near each other, then hydrodynamical drafting helps the trailing cloud to catch the leading cloud and mix together. We present the measured acceleration due to drafting and find that lower-density clouds in lower-density environments experience more acceleration due to drafting than their denser cohorts. We find that the clustering of clouds also increases the condensation of ambient material and affects longevity. We analyze the velocity dispersion of the clouds using a single component method and a multicomponent decomposition method. We find that the presence of a second cloud increases the velocity dispersion behind the trailing cloud at some times. We find that the velocity dispersion due to gas motion in our simulations is significantly less than the actual dispersion observed by For et al., indicating that the thermal component must dominate in the MS.
Biomembranes consisting of multiple lipids may involve phase separation phenomena leading to coexisting domains of different lipid compositions. The modeling of such biomembranes involves an elastic ...or bending energy together with a line energy associated with the phase interfaces. This leads to a free boundary problem for the phase interface on the unknown equilibrium surface which minimizes an energy functional subject to volume and area constraints. In this paper we propose a new computational tool for computing equilibria based on an
L
2 relaxation flow for the total energy in which the line energy is approximated by a surface Ginzburg–Landau phase field functional. The relaxation dynamics couple a nonlinear fourth order geometric evolution equation of Willmore flow type for the membrane with a surface Allen–Cahn equation describing the lateral decomposition. A novel system is derived involving second order elliptic operators where the field variables are the positions of material points of the surface, the mean curvature vector and the surface phase field function. The resulting variational formulation uses
H
1 spaces, and we employ triangulated surfaces and
H
1 conforming quadratic surface finite elements for approximating solutions. Together with a semi-implicit time discretization of the evolution equations an iterative scheme is obtained essentially requiring linear solvers only. Numerical experiments are presented which exhibit convergence and the power of this new method for two component geometric biomembranes by computing equilibria such as dumbbells, discocytes and starfishes with lateral phase separation.
Human milk is the best form of nutrition for preterm infants and has been associated with a lower incidence of necrotizing enterocolitis (NEC). Infants that develop NEC have a higher incidence of ...feeding intolerance and longer hospitalizations. The combination of a donor milk bank and donor milk-derived fortifier has changed feeding practices in neonatal intensive care units (NICU). The purpose of this study is to assess the benefits and cost of an exclusive human milk (EHM) diet in very low birth weight (VLBW) infants in a community level III NICU.
This is a retrospective study including preterm infants ⩽28 weeks and/or VLBW (⩽1500 g) who were enrolled from March 2009 until March 2014. Infants were grouped as follows: group H (entirely human milk based, born March 2012 to 2014), group B (bovine-based fortifier and maternal milk, born March 2009 to 2012), group M (mixed combination of maternal milk, bovine-based fortifier and formula, born March 2009 to 2012) and group F (formula fed infants, born March 2009 to 2012). Baseline characteristics among the four groups were similar.
The study included 293 infants between gestational ages 23 to 34 weeks and birth weights between 490 and 1700 g. Feeding intolerance occurred less often (P<0.0001), number of days to full feeds was lower (P<0.001), incidence of NEC was lower (P<0.011), and total hospitalization costs were lower by up to $106,968 per infant (P<0.004) in those fed an EHM diet compared with the other groups. Average weight gain per day was similar among the four groups (18.5 to 20.6 g per day).
Implementing an EHM diet in our VLBW infants has led to a significant decrease in the incidence of NEC. Other benefits of this diet include: decreased feeding intolerance, shorter time to full feeds, shorter length of stay, and lower hospital and physician charges for extremely premature and VLBW infants.
The type I interferon (IFN) response protects cells from viral infection by inducing hundreds of interferon-stimulated genes (ISGs), some of which encode direct antiviral effectors. Recent screening ...studies have begun to catalogue ISGs with antiviral activity against several RNA and DNA viruses. However, antiviral ISG specificity across multiple distinct classes of viruses remains largely unexplored. Here we used an ectopic expression assay to screen a library of more than 350 human ISGs for effects on 14 viruses representing 7 families and 11 genera. We show that 47 genes inhibit one or more viruses, and 25 genes enhance virus infectivity. Comparative analysis reveals that the screened ISGs target positive-sense single-stranded RNA viruses more effectively than negative-sense single-stranded RNA viruses. Gene clustering highlights the cytosolic DNA sensor cyclic GMP-AMP synthase (cGAS, also known as MB21D1) as a gene whose expression also broadly inhibits several RNA viruses. In vitro, lentiviral delivery of enzymatically active cGAS triggers a STING-dependent, IRF3-mediated antiviral program that functions independently of canonical IFN/STAT1 signalling. In vivo, genetic ablation of murine cGAS reveals its requirement in the antiviral response to two DNA viruses, and an unappreciated contribution to the innate control of an RNA virus. These studies uncover new paradigms for the preferential specificity of IFN-mediated antiviral pathways spanning several virus families.
This article examines sniffing in everyday conversations. It builds on prior conversation analytic research on respiratory conduct, which has shown how things like inbreaths, sighs, and laughter are ...delicately organized and consequential components of the social occasions into which they figure. Sniffing-the swift, audible, intake of breath through the nasal passage-is analyzed by reference to its sequential placement in talk. Using a collection of 70 cases of sniffs in naturally occurring conversations, two recurrent uses of sniffing are described. Sniffs placed before or during a turn-at-talk serve to delay turn progression. And sniffs placed in the postcompletion space of a turn can indicate its completion. This association between postcompletion sniffing and turn completion is further supported through a comparison with postcompletion inbreaths. By situating sniffing in its sequential contexts, the organization of breathing is shown to be bound up with the organization of speaking. Data are in American and British English.
PDF
