Combination Of Mortality Research Articles

Impacto de la natriuresis en el empeoramiento de la función renal durante un episodio de insuficiencia cardiaca aguda

Introduction and objectives: Worsening renal function (WRF) is a frequent complication in acute heart failure (AHF) with a controversial prognostic value. We aimed to study the usefulness of natriuresis to evaluate WRF.Methods: We conducted an observational, prospective, multicenter study of patients with AHF who underwent a furosemide stress test. The patients were classified according to whether WRF was present or absent and according to the median natriuretic response. The main endpoint was the combination of mortality, rehospitalization due to HF, and heart transplant at 6 months of follow-up.Results: One hundred and fifty-six patients were enrolled, and WRF occurred in 60 (38,5%). The patients were divided into 4 groups: a) 47 (30,1%) no WRF/low UNa (UNa ≤ 109 mEq/L); b) 49 (31,4%) no WRF/high UNa (UNa > 109 mEq/L); c) 31 (19,9%) WRF/low UNa and d) 29 (18,6%) WRF/high UNa. The parameters of the WRF/low UNa group showed higher clinical severity and worse diuretic and decongestive response. The development of WRF was associated with a higher risk of the combined event (HR, 1.88; 95%CI, 1.01-3.50; P = 0,046). When stratified by natriuretic response, WRF was associated with an increased risk of adverse events in patients with low natriuresis (HR, 2.28; 95%CI, 1.15-4.53; P = 0,019), but not in those with high natriuresis (HR, 1.18; 95%CI, 0.26-5.29; P = 0,826).Conclusions: Natriuresis could be a useful biomarker for interpreting and prognosticating WRF in AHF. WRF is associated with a higher risk of adverse events only in the context of low natriuresis.

Impact of natriuresis on worsening renal function during episodes of acute heart failure

Introduction and objectivesWorsening renal function (WRF) is a frequent complication in acute heart failure (AHF) with a controversial prognostic value. We aimed to study the usefulness of natriuresis to evaluate WRF. MethodsWe conducted an observational, prospective, multicenter study of patients with AHF who underwent a furosemide stress test. The patients were classified according to whether WRF was present or absent and according to the median natriuretic response. The main endpoint was the combination of mortality, rehospitalization due to HF, and heart transplant at 6 months of follow-up. ResultsOne hundred and fifty-six patients were enrolled, and WRF occurred in 60 (38.5%). The patients were divided into 4 groups: a) 47 (30.1%) no WRF/low UNa (UNa ≤ 109 mEq/L); b) 49 (31.4%) no WRF/high UNa (UNa >109 mEq/L); c) 31 (19.9%) WRF/low UNa and d) 29 (18.6%) WRF/high UNa. The parameters of the WRF/low UNa group showed higher clinical severity and worse diuretic and decongestive response. The development of WRF was associated with a higher risk of the combined event (HR, 1.88; 95%CI, 1.01-3.50; P=.046). When stratified by natriuretic response, WRF was associated with an increased risk of adverse events in patients with low natriuresis (HR, 2.28; 95%CI, 1.15-4.53; P=.019), but not in those with high natriuresis (HR, 1.18; 95%CI, 0.26-5.29; P=.826). ConclusionsNatriuresis could be a useful biomarker for interpreting and prognosticating WRF in AHF. WRF is associated with a higher risk of adverse events only in the context of low natriuresis.

Prognostic impact of vasopressor test in transcatheter edge-to-edge repair of secondary mitral regurgitation: The PETIT study.

Vasopressor test (VPT) might be useful in patients with functional mitral regurgitation (MR) and left ventricular dysfunction (MITRA-FR-like patients) during transcatheter edge-to-edge repair (TEER). We aimed to evaluate the prognostic impact of VPT. MR treated with TEER were included in a multicenter prospective registry. VPT was used intraprocedurally in patients with left ventricular dysfunction and/or hypotension. The 1-year echocardiographic and clinical outcomes were compared according to the use of VPT. The primary endpoint was a combination of mortality + heart failure (HF) readmission at 1-year. A total of 1115 patients were included, mean age was 72.8 ± 10.5 years and 30.4% were women. VPT was performed in 128 subjects (11.5%), more often in critically ill patients with biventricular dysfunction. Postprocedurally the VPT group had greater rate of MR ≥ 2+ (46.9% vs. 31.7%, p = 0.003) despite greater number of devices (≥2 clips, 52% vs. 40.6 p = 0.008) and device repositioning or new clip in 12.5%. At 1-year, the primary endpoint occurred more often in the VPT group (27.3% vs. 16.9%, p = 0.002) as well as all-cause mortality (21.9% vs. 8.1%, p ≤ 0.001) but no differences existed in HF readmission rate (14.8% vs. 13.2%, p = 0.610), cardiovascular mortality (4.4% vs. 3.9%, p = 0.713) or residual MR ≥ 2+ (51.1% vs 51.7%, p = 0.371). Dynamic evaluation of MR during TEER procedure through VPT was performed in patients with worse baseline risk who also presented higher all-cause mortality at 1-year follow-up. However, 1-year residual MR, cardiovascular mortality and HF readmission rate remained comparable suggesting that VPT might help in the management of MITRA-FR-like patients.

Impact of ESC Guidelines implementation on lipid lowering strategy in a tertiary hospital cohort of STEMI patients: Can we aspire to do better than the EUROASPIRE V registry?

Abstract Background Treatment with LDL-C-lowering-drug therapy (LLT) is essential in the management of patients who have suffered an acute coronary syndrome. The latest 2019 ESC/EAS Guidelines for the management of dyslipidaemias recommend an LDL-C target of <55mg/dL and 50% reduction in these very high risk patients. However, the impact of these recommendations on contemporary LLT prescription is uncertain. Purpose To analyse the impact of the publication of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias on the prescription of LLT in our centre in patients who have suffered a ST elevation myocardial infarct (STEMI) and its impact on the achievement of treatment objectives and major adverse cardiovascular events (MACEs) in the first year of treatment. Methods All patients who suffered a STEMI at our centre in 2018 and 2021 were retrospectively registered. We compared baseline characteristics, ESC Guidelines objectives achievement at first follow-up visit and MACE in the first 1 year of treatment in both groups. The 2016 ESC Guidelines objective was defined as an LDL-C <70mg/dL and the 2019 ESC Guidelines objective was defined as an LDL-C <55 mg/dL. MACEs were defined as a combination of mortality, acute coronary syndrome, stroke, peripheral ischemia and need for revascularization. Those patients whose follow-up time until LDL-C after discharge was greater than 1 year were excluded from the final analysis. Results Of a total 726 STEMI patients, 520 patients were included in the final analysis. 239 in 2018 and 281 in 2021. No significant differences were found in baseline characteristics. LDL-C at admission was 115.7±39.3 mg/dL in 2018 and 110.6±38.6 mg/dL in 2021 (p 0.11). The prescription of ezetimibe in association with a high potency statin at discharge was significantly higher in 2021 (125 patients; 33.6%) compared to 2018 (17 patients; 5.07%) (p<0.001) and it was independently associated with the presence of prior lipid-lowering treatment (p < 0.011) and higher LDL-C at admission (p < 0.001). In 2018 there were 105 patients (50.24%) with LDL-C <70mg/dL and 52 patients (24.88%) with LDL-C <55mg/dL. This was significantly lower than in 2021, with 178 patients (66.67%) with LDL-C <70mg/dL and 112 patients (41.95%) with LDL-C <55mg/dL (p<0.001). MACEs after 1 year of treatment occurred in 27 patients (8.88%) in 2018 and in 31 patients (9.06%) in 2021 (p 0.935). Conclusions The adoption of the 2019 ESC/EAS Dyslipidaemia Guidelines recommendations has fostered a change in the LLT strategy in our centre leading to a greater number of patients reaching the LDL-C goal. Unfortunately, nearly 60% of them still have an LDL-C >55 mg/dL. This should prompt us to seek structured clinical pathways in order to improve our results.Figure 1

Association between preoperative blood pressure and outcomes in cardiac surgery: results of a prospectively planned cohort study.

It is unknown whether unwitnessed BP (UBP) measurement or ambulatory BP (ABP) monitoring improves the prediction of adverse events estimated by risk scores. We intended to study associations between preoperative BP measured through these two methods and the incidence of adverse outcomes in patients undergoing cardiac surgery. We included a cohort of 167 patients undergoing elective or urgent cardiac surgeries. Preoperative BP was measured by UBP and 24-hour ABP. Primary outcome was the combination of mortality from any cause, nonfatal myocardial infarction, nonfatal stroke, new hospital admission, and dialysis occurring within 30 days after surgery. The associations between preoperative BP and surgical outcomes were tested using the chi-square test and Analysis of Variance. A generalized linear model with a logistic link function and a robust estimator was used to adjust for the EuroScore-II risk estimation. The incidence of the primary outcome increased in parallel with the quartiles of the 24-hour ABP in participants submitted to CABG: 10% in the first quartile, 13% in the second, 37% in the third, and 53% in the fourth quartile (P for trend<0.01). Quartiles of overnight ABP were also significantly associated with postoperative complications in patients undergoing CABG (P=0.04). The risks in CABG patients were independent of the EuroScore-II. There was no association between BP and outcomes in patients submitted to other surgeries. High preoperative BP measured by ABP monitoring is a risk factor for postoperative complications in patients submitted to CABG.

Prioritising Cochrane reviews to be updated with health equity focus

BackgroundThe prioritisation of updating published systematic reviews of interventions is vital to prevent research waste and ensure relevance to stakeholders. The consideration of health equity in reviews is also important to ensure interventions will not exacerbate the existing inequities of the disadvantaged if universally implemented. This study aimed to pilot a priority setting exercise based on systematic reviews of interventions published in the Cochrane Library, to identify and prioritise reviews to be updated with a focus on health equity.MethodsWe conducted a priority setting exercise with a group of 13 international stakeholders. We identified Cochrane reviews of interventions that showed a reduction in mortality, had at least one Summary of Findings table and that focused on one of 42 conditions with a high global burden of disease from the 2019 WHO Global Burden of Disease report. This included 21 conditions used as indicators of success of the United Nations Universal Health Coverage in attaining the Sustainable Development Goals. Stakeholders prioritised reviews that were relevant to disadvantaged populations, or to characteristics of potential disadvantage within the general population.ResultsAfter searching for Cochrane reviews of interventions within 42 conditions, we identified 359 reviews that assessed mortality and included at least one Summary of Findings table. These pertained to 29 of the 42 conditions; 13 priority conditions had no reviews with the outcome mortality. Reducing the list to only reviews showing a clinically important reduction in mortality left 33 reviews. Stakeholders ranked these reviews in order of priority to be updated with a focus on health equity.ConclusionsThis project developed and implemented a methodology to set priorities for updating systematic reviews spanning multiple health topics with a health equity focus. It prioritised reviews that reduce overall mortality, are relevant to disadvantaged populations, and focus on conditions with a high global burden of disease. This approach to the prioritisation of systematic reviews of interventions that reduce mortality provides a template that can be extended to reducing morbidity, and the combination of mortality and morbidity as represented in Disability-Adjusted Life Years and Quality-Adjusted Life Years.

A Systematic Review of SARS-CoV-2-Associated Hepatic Dysfunction and the Impact on the Clinical Outcome of COVID-19.

Coronavirus disease 2019 (COVID-19) has rapidly spread across the globe since December 2019. The spectrum of clinical manifestations of COVID-19 ranges from mild to life-threatening forms. Alteration of hepatic function in COVID-19 is multifactorial. The objective of this systematic review is to assess the relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced hepatic dysfunction and the clinical outcome in patients infected with COVID-19. We methodically explored several electronic databases (PubMed, PubMed Central, MEDLINE, and Google Scholar) in April 2022 using focused words and terms of medical subject headings for appropriate studies. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting our systematic review. Hepatic dysfunction was identified as elevation of liver function tests (LFTs) above the upper limit of normal. The clinical outcome was described as a combination of mortality, intensive care unit (ICU) transfer, and the need for mechanical ventilation (MV). The initial search yielded a total of 7187 studies. After elimination of duplicates, exclusion of studies based on irrelevant titles and abstracts, comprehensive analysis of full-text formats, and evaluation of quality, a total of 16 studies were eligible to be included in our systematic review. In the 16 selected studies, there were 23,962 patients. The SARS-CoV-2 virus can negatively affect several organ systems by interacting with specific receptors widely expressed in the human body. A multifactorial etiology of hepatic dysfunction is observed in COVID-19. SARS-CoV-2 infection is associated with abnormal LFTs. Significantly higher mortality, ICU admissions, and requirement for MV are associated with LFT alterations. For this reason, patients infected with COVID-19 must have their hepatic function closely monitored.

Trends of Healthy Life Expectancy of the Elderly in China in 1994-2015: Revisiting From the Perspective of Morbidity Transition.

Research on healthy life expectancy (HLE) in China has been fueled by a spate of new data sources and studies, yet no consensus is reached on the pattern of HLE changes and the underlying mechanism. This study examined the change of HLE in China over 20 years with long term national data. Health status, measured by activities of daily living, is combined with mortality to calculate the disability-free life expectancy by the Sullivan method. The results show that the HLE rose slower than life expectancy (LE) in 1994–2004, indicating morbidity expansion. However, in 2010–2015, the proportion of HLE to LE increased, manifesting morbidity compression. A counterfactual analysis further shows that health improvement has been increasingly important in increasing HLE in 2010–2015, despite the dominance of mortality decline. The findings suggest that morbidity can transition between compression, expansion and dynamic equilibrium over a long period due to different combinations of mortality and health improvements. Given the limited data in this study, whether and how morbidity transitions unfold in the future remains open and requires further research.

Mortality Prediction of the CHA2DS2-VASc Score, the HAS-BLED Score, and Their Combination in Anticoagulated Patients with Atrial Fibrillation.

Background and Objectives: Atrial fibrillation (AF) is associated with increased mortality, predictors of which are poorly characterized. We investigated the predictive power of the commonly used CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65–75 years, sex category [female]), the HAS-BLED score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [age ≥ 65 years], drugs/alcohol concomitantly), and their combination for mortality in AF patients. Methods: The PREvention oF thromboembolic events—European Registry in Atrial Fibrillation (PREFER in AF) was a prospective registry including AF patients across seven European countries. We used logistic regression to analyze the relationship between the CHA2DS2-VASc and HAS-BLED scores and outcomes, including mortality, at one year. We evaluated the performance of logistic regression models by discrimination measures (C-index and DeLong test) and calibration measures (Hosmer and Lemeshow goodness-of-fit and integrated discrimination improvement (IDI), with bootstrap techniques for internal validation. Results: In 5209 AF patients with complete information on both scores, average one-year mortality was 3.1%. We found strong gradients between stroke/systemic embolic events (SSE), major bleeding and—specifically—mortality for both CHA2DS2-VASc and HAS-BLED scores, with a similar C-statistic for event prediction. The predictive power of the models with both scores combined, removing overlapping components, was significantly enhanced (p < 0.01) compared to models including either CHA2DS2-VASc or HAS-BLED alone: for mortality, C-statistic: 0.740, compared to 0.707 for CHA2DS2-VASc or 0.646 for HAS-BLED alone. IDI analyses supported the significant improvement for the combined score model compared to separate score models for all outcomes. Conclusions: Both the CHA2DS2-VASc and the HAS-BLED scores predict mortality similarly in patients with AF, and a combination of their components increases prediction significantly. Such combination may be useful for investigational and—possibly—also clinical purposes.

Low Breeding-Site Fidelity Suggests Dispersal of Cerulean Warblers

Site fidelity can have significant impacts on population dynamics and may be influenced by both demographic and environmental characteristics, including age, sex, and habitat quality. We examined breeding-site fidelity of Setophaga cerulea (Cerulean Warbler), a small Nearctic–Neotropical migrant that is listed as endangered in Indiana and in decline throughout its range. Our research was part of a long-term demographic study in the research units of the Hardwood Ecosystem Experiment, southern Indiana. From 2013 to 2018, we banded 128 Cerulean Warblers, 10.2% of which returned the year following initial capture and banding. We did not find significant differences in return rates between adult males (n = 92) and adult females (n = 19; P = 0.69), novice (second-year, n = 20) and experienced (after-second-year, n = 91; P = 1) birds, or successful (n = 40) and unsuccessful breeders (n = 26; P = 0.39). We have yet to detect a bird banded as a hatch-year subsequently return the following season as a second-year (n = 0/17). Our return rates are likely affected by a combination of mortality between breeding seasons, our ability to detect returning birds, and dispersal between breeding seasons. We encourage other researchers to publish rates of Cerulean Warbler site fidelity across its range for comparison of populations and habitats to determine source/sink dynamics.

Effects of surgical septal myectomy on survival in patients with hypertrophic obstructive cardiomyopathy.

Objective:The purpose of this study was to determine the effects of surgical resection of muscle layer on the long-term survival of patients with hypertrophic obstructive cardiomyopathy (HOCM).Methods:The original study cohort consisted of 552 patients with hypertrophic cardiomyopathy (HCM), including 380 patients with HOCM and 172 patients with nonobstructive HCM. All these patients had a definite diagnosis in our center from October 1, 2009, to December 31, 2012. They were divided into three groups, viz., HOCM with myectomy group (n=194), nonoperated HOCM group (n=186), and nonobstructive HCM group (n=172). Median follow-up duration was 57.57±13.71 months, and the primary end point was a combination of mortality from all causes.Results:In this survival study, we compared the prognoses of patients with HOCM after myectomy, patients with nonoperated HOCM, and patients with nonobstructive HCM. Among the three groups, the myectomy group showed a lower rate of reaching the all-cause mortality with statistically indistinguishable overall survival compared with patients with nonobstructive HCM (p=0.514). Among patients with left ventricular outflow tract (LVOT) obstruction, the overall survival in the myectomy group was noticeably better than that in the nonoperated HOCM group (log-rank p<0.001). Parameters that showed a significant univariate correlation with survival included age, previous atrial fibrillation (AF), NT-proBNP, Cr, myectomy, and LV ejection fraction. When these variables were entered in the multivariate model, the only independent predictors of survival were myotomy [hazard ratio (HR): 0.109; 95% CI: 0.013–0.877, p<0.037], age (HR: 1.047; 95% CI: 1.007–1.088, p=0.021), and previous AF (HR: 2.659; 95% CI: 1.022–6.919, p=0.021).Conclusion:Patients with HOCM undergoing myectomy appeared to suffer from a lower risk of reaching the all-cause mortality and demonstrated statistically indistinguishable overall survival compared with patients with nonobstructive HCM. Multivariate analysis clearly demonstrated myectomy as a powerful, independent factor of survival, confirming that the differences in long-term survival recorded in this study may be due to surgical improvement in the LVOT gradient.

Can smartphones kill Trout? Mortality of memorable-sized Bull Trout (Salvelinus confluentus) after photo-releases

Mortality associated with catch-and-release (C&R) fisheries is typically estimated as a single value associated with fish that are immediately released after capture. However, with the widespread use of smartphones by anglers, memorable or rare fish may be subjected to prolonged handling time for photographs and measurements, resulting in increased air exposure and subsequent increased potential for post-release mortality. In situations of overfishing, large fish become rarer and their memorable status may increase. This may create a depensatory cycle of additional handling and mortality. The combination of mortality from prolonged handling, immediate release, and illegal harvest is a cumulative C&R-related cryptic mortality that may have population-level effects in high-effort sport fisheries. We investigated the potential post-release mortality of memorable-sized (average length of 60 cm) bull trout after simulating prolonged handling (involving photographing and measuring) and immediate release in a controlled angling study at a remote Albertan lake during summer. We found that handling time and air exposure of large bull trout subjected to photography and measurement was long (112 s) and associated post-release mortality was high (10 dead / 30 fish; 33 % after 24 h observation). Immediate release mortality was also high (3 dead / 20 fish; 15 %). These levels of mortality, combined with high angler effort, can potentially lead to population-scale declines at C&R fisheries. The complexity and difficulty of population-scale and field-level measurements of cryptic mortality suggest that adaptive management experiments in reductions in angling effort and improved fish handling may be effective in increasing understanding of sustainable angling.

Efficacy and Safety of Tafamidis Doses in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT)

Introduction Tafamidis was shown to be an effective treatment for transthyretin amyloid cardiomyopathy (ATTR-CM) in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT). Hypothesis While ATTR-ACT was not designed for a definitive assessment by dose, further analysis may assist determination of the optimal dose. Methods In ATTR-ACT, adult patients with ATTR-CM (variant or wild-type) were randomized (2:1:2) to tafamidis 80 mg, tafamidis 20 mg, or placebo for 30 months, with pooled tafamidis (80mg and 20mg) compared with placebo. In this analysis, tafamidis 80 mg and 20 mg are presented separately. Efficacy outcomes included the hierarchical combination of all-cause mortality and frequency of cardiovascular-related hospitalisations, all-cause mortality, and change in NT-proBNP. Results The combination of all-cause mortality and cardiovascular-related hospitalizations over 30 months vs placebo was significantly reduced with both tafamidis 80 mg (P=0.003) and 20 mg (P=0.005). All-cause mortality was significantly reduced with tafamidis 80 mg (Cox-proportional hazard model [95% CI], 0.690 [0.487, 0.979], P=0.0378), and there was a trend towards reduction with tafamidis 20 mg (0.715 [0.450-1.137], P=0.1564), compared with placebo. The increase in NT-proBNP was reduced with tafamidis 80 mg, compared with both 20 mg (P=0.0468) and placebo (P Conclusions Tafamidis 80 mg and tafamidis 20 mg effectively reduced the combination of mortality and cardiovascular-related hospitalizations. Given the lack of dose-related safety concerns, and the NT-proBNP and survival data, tafamidis 80 mg is the preferred dose.

The usefulness of C-reactive protein and procalcitonin to predict prognosis in septic shock patients: A multicenter prospective registry-based observational study

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184–2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

Clinical Use of Digitalis: A State of the Art Review.

The history of digitalis is rich and interesting, with the first use usually attributed to William Withering and his study on the foxglove published in 1785. However, some knowledge of plants with digitalis-like effects used for congestive heart failure (CHF) was in evidence as early as Roman times. The active components of the foxglove (Digitalis purpurea and Digitalis lanata) are classified as cardiac glycosides or cardiotonic steroids and include the well-known digitalis leaf, digitoxin, and digoxin; ouabain is a rapid-acting glycoside usually obtained from Strophanthus gratus. These drugs are potent inhibitors of cellular membrane sodium-potassium adenosine triphosphatase (Na+/K+-ATPase). For most of the twentieth century, digitalis and its derivatives, especially digoxin, were the available standard of care for CHF. However, as the century closed, many doubts, especially regarding safety, were raised about their use as other treatments for CHF, such as decreasing the preload of the left ventricle, were developed. Careful attention is needed to maintain the serum digoxin level at ≤ 1.0ng/ml because of the very narrow therapeutic window of the medication. Evidence for benefit exists for CHF with reduced ejection fraction (EF), also referred to as heart failure with reduced EF (HFrEF), especially when considering the combination of mortality, morbidity, and decreased hospitalizations. However, the major support for using digoxin is in atrial fibrillation (AF) with a rapid ventricular response when a rate control approach is planned. The strongest support of all for digoxin is for its use in rate control in AF in the presence of a marginal blood pressure, since all other rate control medications contribute to additional hypotension. In summary, these days, digoxin appears to be of most use in HFrEF and in AF with rapid ventricular response for rate control, especially when associated with hypotension. The valuable history of the foxglove continues; it has been modified but not relegated to the garden or the medical history book, as some would advocate.

Development of a richer measure of health outcomes incorporating the impacts of income inequality, ethnic diversity, and ICT development on health

BackgroundIn the literature, measuring health outcomes usually entails examining one dependent variable using cross-sectional data. Using a combination of mortality and morbidity variables, this study developed a new, richer measure of health outcome. Using the health outcome index, this study investigated the impacts of income inequality, levels of ethnic diversity and information and communication technology (ICT) development on health using panel data.MethodsPartial least squares regression based on a structural equation model is used to construct a health outcome index for 30 OECD countries over the period of 2004 to 2015 using SmartPLS software. Then, panel corrected standard errors estimation and pooled ordinary least square regression with Driscoll and Kraay standard errors approaches were used to investigate the key determinants of health outcomes. Both methods are efficient when the panel data is heteroscedastic and the errors are cross-sectional dependent.ResultsIncome inequality, level of ethnic diversity and development in ICT access and use have an adverse effect on health outcomes, however, development in ICT skills has a significant positive impact. Moreover, OECD countries with a higher percentage of publicly funded healthcare showed better public health compared to countries where the percentage is smaller. Finally, rising incomes, development of technologies and tertiary education are key determinants for improving health outcomes.ConclusionsThe results indicate that countries with higher levels of income inequality and more ethnically diverse populations have lower levels of health outcomes. Policymakers also need to recognise the adverse effect of ICT use on public health and the benefits of public healthcare expenditure.

Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial: Study Rationale and Design

The Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation (CABANA,NCT00911508)(1) trial is testing the hypothesis that the treatment strategy of percutaneous left atrial catheter ablation for the purpose of eliminating atrial fibrillation (AF) is superior to current state-of-the-art pharmacologic therapy. This international 140-center clinical trial was designed to randomize 2200 patients to a strategy of catheter ablation versus state-of-the-art rate or rhythm control drug therapy. Inclusion criteria include: 1) age> 65, or ≤65 with≥ 1 risk factor for stroke, 2) documented AF warranting treatment, and 3) eligibility for both catheter ablation and≥ 2 anti-arrhythmic or≥ 2 rate control drugs. Patients were followed every 3 to 6 months (median 4 years) and underwent repeat trans-telephonic monitoring, Holter monitoring, and CT/MR in a subgroup of patient studies to assess the impact of treatment on AF recurrence and atrial structure.With 1100 patients in each treatment arm, CABANA is projected to have 90% power for detecting a 30% relative reduction in the primary composite endpoint of total mortality, disabling stroke, serious bleeding, or cardiac arrest. Secondary endpoints include total mortality; mortality or cardiovascular hospitalization; a combination of mortality, stroke, hospitalization for heart failure or acute coronary artery events; cardiovascular death alone; and heart failure death, as well as AF recurrence, quality of life, and cost effectiveness. At a time when AF incidence is rising rapidly, CABANA will provide critical evidence with which to guide therapy and shape health care policy related to AF for years to come.

Copeptin for risk stratification in non-traumatic headache in the emergency setting: a prospective multicenter observational cohort study

BackgroundIn the emergency setting, non-traumatic headache is a benign symptom in 80% of cases, but serious underlying conditions need to be ruled out.Copeptin improves risk stratification in several acute diseases. Herein, we investigated the value of copeptin to discriminate between serious secondary headache and benign headache forms in the emergency setting.MethodsPatients presenting with acute non-traumatic headache were prospectively enrolled into an observational cohort study. Copeptin was measured upon presentation to the emergency department. Primary endpoint was serious secondary headache defined by a neurologic cause requiring immediate treatment of the underlying disease. Secondary endpoint was the combination of mortality and hospitalization within 3 months. Two board-certified neurologist blinded to copeptin levels verified the endpoints after a structured 3-month-telephone interview.ResultsOf the 391 patients included, 75 (19%) had a serious secondary headache. Copeptin was associated with serious secondary headache (OR 2.03, 95%CI 1.52–2.70, p < 0.0001). Area under the curve (AUC) for copeptin to identify the primary endpoint was 0.70 (0.63–0.76). After adjusting for age > 50, focal-neurological abnormalities, and thunderclap onset of symptoms, copeptin remained an independent predictive factor for serious secondary headache (OR 1.74, 95%CI 1.26–2.39, p = 0.001). Moreover, copeptin improved the AUC of the multivariate logistic clinical model (p-LR-test < 0.001).Even though copeptin values were higher in patients reaching the secondary endpoint, this association was not significant in multivariate logistic regression.ConclusionsCopeptin was independently associated with serious secondary headache as compared to benign headaches forms. Copeptin may be a promising novel blood biomarker that should be further validated to rule out serious secondary headache in the emergency department.Trial registrationStudy Registration on 08/02/2010 as NCT01174901 at clinicaltrials.gov.

Mid-term outcomes of surgical repair for anomalous origin of the left coronary artery from the pulmonary artery: In infants, children and adults.

Background:Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital malformation. We sought to evaluate in-hospital and mid-term outcomes of patients with a diagnosis of ALCAPA who underwent surgical repair.Objectives:The objective of this study is to evaluate the mid-term outcomes of surgical repair of ALCAPA at our center and to analyze the surgical techniques used.Materials and Methods:In a retrospective study, we analyzed early and mid-term clinical and echocardiographic data to determine the outcomes of patients who underwent surgical repair of ALCAPA in our institution between 2005 and 2015.Results:Twenty-one patients underwent surgical repair for ALCAPA using aortic reimplantation (n = 10, 47.6%), ostial closure (n = 8, 38.1%), or ligation (n = 3, 14.3%). The median age of patients was 24 months (range 22 days to 51 years). There were 2 (9.5%) in-hospital mortalities in infants undergoing the reimplantation technique. All patients were followed up for a median of 21 months (range 1–60 months). No patients required reoperation, and there was no mortality from discharge to mid-term follow-up. Severe early postoperative mitral regurgitation (MR) was associated with composite end-point, defined as a combination of mortality after surgery, moderate to severe MR, and moderate to severe left ventricular dysfunction at late follow-up (P = 0.019) while mitral valve repair was not (P = 0.469).Conclusion:The surgical management of ALCAPA can be associated with good in-hospital and mid-term outcomes regardless of the age, at which the patient has been operated.

Influence of water depth on growth and mortality of Chlamys varia (Linnaeus, 1758): implications for cage culture in Mali Ston Bay, Croatia

This study investigated growth and mortalities of juvenile variegated scallops Chlamys varia (Linnaeus, 1758) grown in suspension at Mali Ston Bay in the Adriatic Sea. Juveniles collected from the previous year’s natural breeding, mean length of 14.58 mm, were placed in cages at three depths (1, 3 and 5 m), for 21 months. We compared results on shell heights at the end of growth period in relation to seawater temperature and salinity. Shell lengths averaged 45.30 ± 4.10 mm (range 39–54 mm) at 1 m depths, 42.48 ± 2.40 mm (39–48 mm) at 3 m, and 41.90 ± 4.25 mm (37–50 mm) at 5 m. Average monthly growth of shell height throughout the experimental period was 1.7 (1 m), 1.6 (3 m) and 1.7 mm (5 m). Total mortality throughout the experimental period was 25.0 % (1 m), 16.6 % (3 m) and 71.4 % (5 m). Furthermore, we estimate von Bertalanffy growth parameters from growth increment models, where extensions of the von Bertalanffy model that allow growth rate to vary with changing body size and with periodic (seasonal) changes in the growth parameter K are presented. The goal of this research was to evaluate the potential for commercial aquaculture of C. varia (growth rate, degree of survival and quality of the soft tissue) caged at different depths. Based on a combination of mortality and growth rate, we found that the most suitable depth for culture was at 1 m, but culture at all three depths is viable and the main issue is being the source of mortality at 5 m, seasonally. We conclude that Mali Ston Bay has good potential for variegated scallop mariculture.