Impact of surgical left atrial appendage closure during coronary bypass on clinical outcomes and readmissions

Background

Whether surgical left atrial appendage closure (sLAAC) during coronary artery bypass (CABG)surgery improves post-operative outcome including stroke and atrial fibrillation (AF) occurrence is largely unknown.

Objective

To analyze the impact of concomitant sLAAC during CABG in terms of outcomes and readmissions over the following year.

Methods

We analyzed the Nationwide Readmissions Database (2016–2019) using ICD-10 codes to identify hospitalizations for CABG. Patients were subcategorized based on whether sLAAC was performed or not. Among patients who survived their index admission, we employed propensity matching (1:3) to adjust for age, sex, comorbidities, CHA2DS2-VASc scores, previous AF history, heart failure and hospital characteristics. Primary outcomes included unplanned AF and stroke-related readmissions at 1 year.

Results

A total of 58,311 patients with CABG and sLAAC were identified with 175,940 propensity matched controls. Patients undergoing sLAAC were older with higher CHA2DS2-VASc scores and comorbidity burdens. Confounders were well balanced following propensity matching. Over a mean follow-up of 152 days, sLAAC was associated with higher risk of readmission due to AF at one year (HR 1.71 [1.49–1.96] p<0.001). This association is independent of previous AF history. Lower rates of stroke-related readmission was associated with perfomance of sLAAC (HR 0.80 (0.65–0.97) p=0.026), however the association was not observed when accounting for AF history.

Conclusion

CABG with concomitant sLAAC is maybe associated with lower stroke risk at the cost of higher risk of AF readmissions.

Funding Acknowledgement

Type of funding sources: None.

Increasing use of ablation in the management of atrial fibrillation in heart failure: insights from a national database on 10 year trends in the United States

Background

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice, even more so among patients with heart failure (HF). Results of the recent CABANA and CASTLE-AF trials indicate significant improvements in ejection fraction, HF readmissions as well as overall mortality with the incorporation of rhythm control strategies in HF patients. These findings challenge existing notions of equivalency of rate vs rhythm control strategies. In this study, we analyzed the impact of this evidence on treatment practices and the short term outcomes of ablation in this patient cohort.

Methods

We conducted a retrospective study using the AHRQ-HCUP National Readmission Database for the years 2005–2014. ICD 9 diagnosis codes were used to identify all adult patients (≥18 years) undergoing AF ablation procedures as well as a sub-cohort of patients with existing HF. Trends in the use of ablation procedures, patient characteristics as well as details of short term procedural outcomes were studied. Multivariate regression analysis was utilized to adjust for confounders. Complications were defined as per the Agency for healthcare research and quality guidelines. Independent risk factors for in-hospital mortality were identified using proportional hazards model.

Results

Our results indicate a trend of rising rates of AF ablation procedures overall with a peak in 2011 at 20,046 and gradual downtrend thereafter (10,195 in 2005 to 11735 in 2014). Our data revealed a consistent rise in ablation procedures among heart failure patients during the same period (832 to 2245). A definite reduction in peri-procedural mortality is noted (0.24% in 2005 to 0.17% in 2014, p=0.2) – an improvement that is maximally apparent in the heart failure group (2.49% to 0.4%, p=0.07). Overall complication rates however are significantly increased overall with a proportional rise noted among HF patients.

Conclusions

Our data from a nationally representative registry indicates an increasing utilization of ablation as a therapeutic modality in the management of atrial fibrillation in HF. Future prospective studies are required to assess the positive impact of these changes in clinical practice as offset by their associated complications.

10 year AF ablation trends in HF

Funding Acknowledgement

Type of funding source: None

A genome-wide association study identifies novel genetic loci associated with pulmonary embolism

Background

Pulmonary embolism (PE) is a life-threatening cardiovascular condition. Studies showed that PE patients were associated with disorders of lipid metabolism and had higher triglyceride and lower HDL-C levels compared with healthy. We conducted the genome-wide association study to identify novel loci contributing to PE.

Methods

We conducted a large-scale GWAS of PE in 5,466 PE cases and 461,219 controls of European ancestry from the UK Biobank (466,685 participants total). We used genome-wide summary statistics to test for enrichment of functional annotations using ENRICHR. Example pathways included in Enrichr for testing include membership of genes in pathway databases such as the Kyoto Encyclopedia of Genes and Genomes (KEGG), Wikipathway, PANTHER, BioCarta or NCI-Nature pathways. We analyzed the pathways using combined score and p-values which were well validated by comparing to several methods. For pathway analyses, we considered a nominal P-value threshold of 0.05.

Results

We identified genome-wide significant genetic associations in 63 independent genetic loci for PE (P<5.0x10–7). Our findings for top pathways highlight that lipid metabolism (LIPC, LCAT, NPC2), caffeine metabolism (NAT2), and sudden cardiac death (ABCG8) related genetic loci play an important role in PE alongside genes already associated with coagulation-thrombosis pathway (VWF, THPO, PTPN11, INPP5D, UROS, HMBS) (all p-values p-values <0.05).

Conclusion

Our findings uncovered unexpected novel factors of PE etiology, suggesting novel mechanistic concepts of PE pathophysiology.

Funding Acknowledgement

Type of funding source: None

Impact of outflow tract obstruction in the management of atrial fibrillation in hypertrophic cardiomyopathy: insights from the national readmission database

Background

Atrial fibrillation (AF) is commonly encountered in patients with Hypertrophic Cardiomyopathy (HCM). Presence of AF in this high risk population is detrimental due to its effect on hemodynamics, diastolic function and potential induction of ventricular tachyarrhythmias. For these reasons a rhythm control strategy is highly desirable, and yet catheter ablation of AF is consistently inefficacious with poorer overall outcomes. We hypothesize that in HCM presence of outflow tract obstruction by virtue of its effect on left atrial hemodynamics, altered circulatory flow patterns in the pulmonary veins, and stretch related triggered activities would create an arrhythmogenic substrate, and have significant impact on the outcomes of catheter ablation of AF. In this study, we aimed to evaluate AF ablation outcomes based on the presence or absence of outflow tract obstructions in patients with HCM.

Methods

We conducted a retrospective study using the AHRQ-HCUP National Readmission Database for the years 2016–17. All adults (≥18 years) with HCM undergoing AF ablation procedures were identified using ICD-9 codes. The cohort was divided into two groups; Obstructive HCM (Group A) and Non-Obstructive HCM (Group B)

Multivariate regression analysis was utilized to adjust for confounders. Independent risk factors for in-hospital mortality were identified using a proportional hazards model. Complications were defined as per the Agency for Health Care Research and Quality guideline.

Results

From a total of 71,451,419 patients in the NRD registry, 97 patients with HCM were identified and formed the study cohort. When divided based on the presence or absence of outflow tract obstruction, there were 25 patients with Obstructive HCM and 72 patients with Non-obstructive HCM.

Both groups were similar in clinical characteristics including CHADVASc scores and Charlson Comobidity indices as outlined in Table 1. Procedural outcome analysis revealed higher 30-day cardiac readmissions in the Obstructive HCM group compared to Non-obstructive HCM (25.2% vs 7.97%, p=0.049). The Obstructive HCM group had higher rates of atrial arrhythmias, 57.97%, compared to 32.44% in the non-obstructive HCM group, and heart failure exacerbations, 41.27% vs 25.82%. However, both indices did not reach statistical significance. The procedural complications rates tended to be higher in the non-obstructive HCM group, 10.8% vs. 5.6% in the Obstructive HCM group (p=0.54).

Conclusions

Presence of an obstructive component to HCM is associated with significantly increased short term cardiac readmissions predominantly driven by recurrent atrial arrhythmias and heart failure. These findings suggest negative influence of altered cardiac hemodynamics related to outflow tract obstruction on atrial arrhythmias. The arrhythmogenic substrate of HCM may therefore be different and less amenable to catheter ablation.

HCM ablation outcomes

Funding Acknowledgement

Type of funding source: None

Gender differences in spontaneous coronary artery dissection: a nationwide analysis

Background

Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndromes in young otherwise healthy patients with a striking predilection for the female gender. Unfortunately, SCAD can result in significant morbidities and mortality. The pathological mechanism has not been fully clarified yet but hormonal changes might represent a sufficiently convincing explanation for some patients with SCAD. We hypothesized that gender difference in mortality in SCAD patients.

Methods

Data for this retrospective cohort study were extracted from the Nationwide Inpatient Sample for 2014 using the 9th revision of the International Classification of Diseases (ICD) 414.12 (spontaneous coronary artery dissection). Demographics, in-hospital mortality, conventional risk factors (diabetes, hypertension, hyperlipidemia, alcohol and tobacco abuse), acute critical illnesses like sepsis, septic shock, stroke, acute respiratory insufficiency, acute renal failure, and chronic conditions (anxiety, depression, malignancy and metastatic diseases) were studied. Univariate and multivariate logistic regression modeling were performed to determine predictors associated with the development of inpatient mortality in SCAD patients. All analyses were conducted using R 3.4.0 and STATA/MP 14.2. All p-values were two-sided, and statistical significance was determined at the level of p<0.05.

Result

A total of 270 SCAD patients were identified. Of those SCAD patients, no fibromuscular dysplasia (FMD) or pregnancy were identified. Patients were predominantly women (71%) and the mean age was 53 years. Overall in-hospital mortality was 5.6%, with 6.6% in male and 5.3% in female. Ethnicity, gender, stroke, acute renal failure, anxiety and depression did not predict mortality, length of stay, annual income, total hospital charge (all p>0.05). Multivariate analysis revealed no gender difference in SCAD patients and no independent predictors of mortality were identified.

Conclusions

This large nationwide study reveals that SCAD may be underdiagnosed but underutilization of work up such as FMD. SCAD is thought to be hormone related likely associated with female gender. Our results showed that no gender difference in mortality. Further large prospective studies are needed to determine gender difference in mortality and other predictors in mortality.

Funding Acknowledgement

Type of funding source: None

Impact of age on the obesity paradox in acute coronary syndrome: a nationwide analysis

Background

The obesity paradox – indicating improved short term mortality in obese individuals has been widely explored in a number of cardiovascular conditions. However, its validity in an elderly population and the possible physiological impact of aging on this phenomenon in Acute Coronary syndrome (ACS) remain unclear. In this study, we aim to determine the relationship between obesity and in-hospital mortality, morbidity, and health care resource utilization in this cohort of patients.

Methods

A retrospective study was conducted using the AHRQ-HCUP National Inpatient Sample for the year 2014. Elderly adults (≥65 years) with a principal diagnosis of ACS and a secondary diagnosis of obesity were identified using ICD-9 diagnosis codes as described in the literature. The primary outcome of in-hospital mortality and secondary outcomes like length of hospital stay (LOS), and total hospitalization costs were analyzed. Propensity score (PS) using the next neighbor method without replacement with 1:1 matching was utilized to adjust for confounders. Independent risk factors for mortality were identified using a multivariate logistic regression model.

Results

In total, 1,137,108 hospital admissions with a primary diagnosis of ACS were identified, of which 7.46% were obese. In-hospital morality during the index admission was lower among obese patients with ACS compared to non-obese patients (4.62 vs 6.87%, p<0.001) with significantly lower 30-day readmission rates as well (p<0.001). However, in-hospital mortality rates during readmission were statistically equivalent between the obese and non-obese groups (5.6 vs 8.3%, p=0.72). LOS during the index admission was longer for obese patients (6.39 vs 5.36 days, p=0.65) but equivalent to non-obese patients during subsequent readmissions (p=0.12). The total cost of these admissions was significantly more in the obese cohort as well (p<0.001).

Conclusion

In this study, obese elderly patients admitted with ACS were found to have significantly reduced in-hospital mortality and 30-day readmission rates when compared to non-obese patients - reinforcing the obesity paradox independent of patient age.

Funding Acknowledgement

Type of funding source: None

Impact of chronic sequential LV-RV pacing with cardiac resynchronization therapy for patients with narrower (<130 ms) QRS complexes following evaluation of acute myocardial strain characteristics

Background

Prior studies have shown acute improvement in myocardial strain patterns (SP) and strain rates (SR), left ventricular ejection fraction (LVEF), and long-term clinical improvement by Cardiac Resynchronization Therapy (CRT) preferential LV pacing. This relationship has not been studied in patients (pts) with narrower QRS.

Objectives

We aimed to evaluate myocardial speckle tracking SP and SR at different VV intervals in pts with narrow (<130 ms) and wide (>130 ms) QRS.

Methods

We assessed LVEF and speckle tracking myocardial SP and SR as per the American Society of Echocardiography (ASE) Dyssynchrony Writing Group methods in pts with CRT in acute settings at VV0, VV60 and LV-only pacing. For SP assessment, we used Bull's eye format display of the LV segments, and scores for SR, 2 = early stretch, late peak, 1= early stretch, early peak, and 0 = single peak at aortic closure.

Results

Total cohort of 271 pts; age 69.2±10.3 yrs (mean ± SD), male - 60%, divided into 2 groups; Gp A (QRS <130 ms, n=69) and Gp B (QRS >130 ms, n=202). QRS width and LVEF in Gp A and B were 120.1±12.3 ms and 152.1±12.9 ms, and 22.3±9.4% and 23.3±10.2% respectively. With VV0 increase in LVEF, 67±6.0% from baseline 22.3±9.4% was seen in Gp A compared to 43±6.5% from 23.3±10.2% in Gp B (p<0.01). With VV60 and LV-only pacing further rise in LVEF to 100.0±7.1% and 112.0±7.2% in Gp A and 80.2±8.0% and 93±8.1% in Gp B was seen. (Figure 1). Strain scores at different VV timings in both groups are shown in Table 1.

Conclusions

In pts with CRT, different VV timings show differences in acute myocardial speckle tracking SP and SR, and LVEF. These changes are markedly favorable with LV-only and sequential LV-RV pacing even in pts with narrower QRS. Our findings support chronic sequential LV-RV pacing programming in CRT pts with narrow QRS.

Figure 1

Funding Acknowledgement

Type of funding source: None

Predictors of sudden cardiac arrest in adolescents with mitral valve prolapse: an analysis of the nationwide inpatient sample

Background

Mitral valve prolapse (MVP) is the most commonly encountered valvular pathology seen in 2–3% of the general population. Though traditionally regarded as a benign pathology, recent literature suggests that sudden cardiac death is significantly more common in these patients with estimates of 0.2–0.4%/year. The exact underlying mechanism of these higher rates of SCD remain poorly understood. In this study, we aim to identify predictors of sudden cardiac arrest (SCA) in an adolescent population.

Methods

We conducted a retrospective study using the AHRQ-HCUP National Inpatient Sample 2016-2017 for the years 2016-17. All patients (≤18 years) admitted with Mitral valve prolapse were identified using ICD-10 codes and further sub stratified based on presence or absence of sudden cardiac arrest (SCA). Baseline characteristics were obtained and multivariate regression analysis was utilized to identify potential predictors of SCA. Independent risk factors for in-hospital mortality were identified using a proportional hazards model. Complications were defined as per the Agency for Health Care Research and Quality guideline.

Results

We screened a total of 71,473,874 admissions in the NIS database to identify a total of 1,372 adolescent patients admitted with MVP in the years 2016–17. These patients were then sub-categorized based on presence or absence of SCA during the hospitalization. Our findings revealed that patients with SCA were generally slightly older (15y vs 13y, p=0.036, OR-1.1, p=0.007) and more likely female (83.3% vs 13%, p=0.227, OR – 3.55, p=0.57)). Interestingly, patients in the SCA cohort were noted to have almost 4 fold higher rates of Mitral regurgitation (66.6% vs 18.35%, p=0.008, OR-8.89, p=0.005) as well as family history of SCD (16.7% vs 4.1%, p=0.145, OR-4.65, p=0.14).

Conclusions

Presence of Mitral regurgitation and a family history of sudden cardiac death are associated with significantly higher rates of SCA in adolescent patients with mitral valve prolapse.

Predictors of SCA in Adolescent MVP

Funding Acknowledgement

Type of funding source: None

A nationwide 16-year study of the trends, burden and impact of atrial fibrillation in cardiac amyloidosis

Background

Cardiac amyloidosis (CA) remains an underdiagnosed entity. Atrial fibrillation (AF) is common in patients with CA, likely owing to direct amyloid deposition in the left atrium. However, the prevalence of AF in CA and its association with in-hospital outcomes has not been studied in large populations.

Purpose

Our aim was to study the trends, baseline characteristics, and clinical impact of AF in patients with CA in the United States using the Healthcare Cost and Utilization Project (HCUP) National) Inpatient Sample (NIS) from 1999 to 2014.

Methods

We queried the NIS and identified CA using ICD-9-CM codes 277.39 and 425.7. AF in CA patients was identified using the ICD-9-CM code of 427.31. Statistical Analysis System (SAS) 9.4 was used for analysis of data.

Results

There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States, of which 37,070 (25.4%) had AF. The prevalence of AF remained consistent from 27.5% in 1999 to 27.4% in 2014.

The mean age of patients with AF was 72.9±28.2 years and for patients without AF was 67±31.9 years (p<0.0001). The majority of the patients with AF were male (60.3%) and the study group was predominantly white (62.8% in patients with AF and 56.4% in patients without AF). CA patients with AF suffered more from thyroid-related disease (22.5% vs 16.1%), heart failure (62.9% vs 36.5%) and renal failure (34.7% vs 30.5%) and less from hypertension (29.3% vs 34.0%) and diabetes mellitus (23.2% vs 25.2%) (p<0.0001). There was no significant difference in the Charlson comorbidity score between the groups.

Inpatient mortality was significantly higher in CA patients with AF (10.4% vs 6.5%, p<0.001). However, in-patient mortality has been decreasing over the years from 10.3% in 1999 to 7.6% in 2014. Furthermore, cardiogenic shock was significantly higher in CA patients with AF (2.1% vs 1.2%, p<0.001), yet the use of mechanical circulatory support was not significantly different between the groups (0.42% vs 0.35%, p=0.375). Pacemaker implantation was also noted to be higher in CA patients with AF compared to patients without AF (2.8% vs 1.2%, p<0.0001).

There was no significant difference between CA patients with and without AF in mean cost of hospitalization ($58222±10752 vs $57695±545, p=0.081) or length of stay (7.9±0.1 vs 7.7±0.1 days, p=0.7089).

Conclusion

CA with atrial fibrillation is a well-recognized entity, and our large scale retrospective analysis found significant association with worse in-hospital outcomes and cardiogenic shock. Interestingly, trend of in-patient mortality in CA has been decreasing over the years, likely owing to improved imaging modalities for diagnosis. Optimal management of AF in CA is imperative to improve outcomes in this population.

Funding Acknowledgement

Type of funding source: None

Breast cancer patients have lower in-hospital mortality after acute coronary syndrome, a 5 year nationwide analysis

Background

Breast cancer and cardiovascular disease (CVD) share common risk factors, and breast cancer therapies are well known to cause cardiotoxicity. Prior studies highlighted the higher burden coronary artery disease and the importance to further assess its consequences on breast cancer patients.

Purpose

We sought to evaluate the revascularization rate and in-hospital short-term outcomes of breast cancer patients following acute coronary syndrome (ACS) compared to the general female population.

Methods

We reviewed the Nationwide Inpatient Sample from 2010 to 2014 to identify female patients with principal diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina). Two subgroups were identified, women with a history of breast cancer and women without, and were propensity matched.

Multivariate regression analyses were performed to evaluate the impact of breast cancer on primary outcome (in-hospital mortality) and secondary outcomes: occurrence of shock, acute kidney injury (AKI), mechanical ventilation (MV), and length of stay (LOS). We also compared the rate of cardiac procedures. Statistical significance of odd ratios (OR) is defined with p-value<0.05 and reported 95% confidence intervals (CI).

Results

We identified a total of 245,563 female patients with primary diagnosis of ACS, among them 10,625 (4.3%) had a history of breast cancer. The comorbidity of breast cancer was associated with statistically significant lower rates of mortality (OR 0.83, CI 0.74–0.94), shock (OR 0.87, CI 0.77–0.99), AKI (OR 0.90, CI 0.82–0.98), MV (OR 0.81, CI 0.71–0.92) and relative 5.4% decrease in LOS (CI: −7.8%, −3.0%). The cardiac procedural rates were similar for left heart catheterization (OR 0.96, CI 0.90–1.02), for percutaneous coronary intervention (OR 0.95, CI 0.89–1.02) and for CABG (OR 0.88, CI 0.78–1.00) compared to control group.

Conclusion

Breast cancer patients received a comparable catheterization and revascularization procedure rate and exhibited a statistically significant lower morbidity and mortality rates during hospitalization after an ACS event compared to the general female population.

Funding Acknowledgement

Type of funding source: None

10-year trend analysis of atrioventricular node ablation in patient with atrial fibrillation: 2005–2014 United State hospitalization

Introduction

Atrial fibrillation (AF) ablation and Atrioventricular Node (AVN) ablation are both important non-pharmacological therapy of AF. In spite of increased availability of AF ablation data, that of AVN ablation per se is limited.

Method

AF ablation was identified using ICD-9 procedure code with principle diagnosis of AF from United States National Inpatient Sample database 2005–2014. From procedure and diagnosis codes of pacemaker insertion followed by ablation, the cohort who underwent AVN ablation was identified. Patients hospitalization with any diagnosis of other type of arrythmia or epicardial ablation were excluded. Complications were defined as per the Agency for Health Care Research and Quality guideline.

Results

Total AF ablation was noted to increase from 2005- 2011, and declined steadily from 2011–2014. In contrast, the number of AVN ablations increased from 4505 cases to 5175 (Figure 1). AVN ablation were mainly performed in elderly patient (mean age 72), and increasingly in patient with higher Charlson Commobidity index (0.9 to 1.7)and higher CHA2DS2-VASc score (2.8 to 3.7) (Table 1). An increasing trend in procedure complications but no significant change in mortalitywere observed with AVN ablation. Progressive increase in the length of stay and the hospitalization cost were also observed over the years with AVN ablation.

Conclusion

AVN ablation is being performed at a steady volume, and increasingly in patients with multiple comorbidities. This trend although was not associated with increased mortality, it was associated with increased hospital complications.

Funding Acknowledgement

Type of funding source: None

Prognostic role of positron emission tomography in patients with known or suspected cardiac sarcoidosis. a systematic review and meta-analysis

Background

Sarcoidosis is a chronic inflammatory disorder of unclear etiology, characterized by the presence of non-caseating granulomas. Cardiac involvement occurs in upto 27 percent of patients, manifesting as atrioventricular blocks, ventricular arrhythmia or sudden cardiac death. Current guidelines cite insufficient evidence for the prognostic utility of positron emission tomography (PET) in patients with cardiac sarcoidosis. Thus, we performed a systematic review and meta-analysis of published studies to ascertain the prognostic significance of PET imaging in patients with suspected or diagnosed cardiac sarcoidosis.

Purpose

To review current literature and determine if PET has prognostic utility in patients with known or suspected cardiac sarcoidosis

Methods

We performed a comprehensive literature search of electronic databases (Embase, Medline and Web of Science) using MeSH terms and keywords for sarcoidosis and PET from inception through December 2019. Studies were eligible if they included patients with known and/or suspected cardiac sarcoidosis undergoing evaluation by PET with or without perfusion imaging and reported clinical events of interest. An abnormal PET study was defined as the presence of focal or focal-on-diffuse uptake of 18- fluorodeoxyglucose (18-FDG) by visual analysis. In studies with perfusion imaging, patients with only perfusion defects were excluded. The primary outcome of interest was a composite of major adverse cardiac events (MACE), including sustained ventricular tachycardia, sudden cardiac death. Secondary analysis studied association of MACE with focal right ventricular (RV) uptake in patients with an abnormal PET study. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Heterogeneity of results among the studies was assessed using the Higgins I2 value.

Results

Out of a total of 1645 citations, 40 were selected for full-text review. Five studies were included in the final analysis with a total of 465 patients. mean follow-up was 2.3 years. Three of the five studies also reported frequency of abnormal RV uptake of 18-FDG. Patients with abnormal 18-FDG uptake on visual assessment had higher odds of MACE (OR 3.12, CI 1.9–5.01, p<0.00001), compared to known or suspected cardiac sarcoid patients with normal PET studies. Heterogeneity among studies was low (I2 = 0). In patients with an abnormal PET study, abnormal focal RV uptake of 18-FDG was associated with higher odds of MACE (OR 5.24, CI 1.1–25.1, p=0.04), with moderate heterogeneity among studies (I2=41).

Conclusion

In patients undergoing PET imaging for known or suspected cardiac sarcoidosis, abnormal metabolism on visual analysis is associated with increased risk of MACE. Furthermore, focal RV uptake further increases the risk of MACE in patients with abnormal PET imaging. Thus, PET imaging can serve as a tool to risk stratify patients with known or suspected cardiac sarcoidosis.

Forrest Plots

Funding Acknowledgement

Type of funding source: None

A nationwide analysis of 16 year trends in cardiac transplantation for acute myocarditis

Background

Orthotopic heart transplant (OHT) is indicated in 1–8% of patients with myocarditis. However, national trends in the utilization of transplantation and outcomes in myocarditis across the United States are not well established.

Purpose

Our objective was to study the trends and baseline characteristic of myocarditis patients undergoing heart transplant in the United States using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) from 1999 to 2014.

Methods

Using NIS data, we identified patients older than 18 years with myocarditis using codes ICD9 codes of 422.0 and 422.9. Among these patients, we identified those who underwent cardiac transplantation using ICD9 procedure codes 37.5 and 33.6. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

We identified a total of 62,264 hospitalizations for myocarditis from 1999–2014. 430 (0.69%) myocarditis patients underwent OHT which consisted of 0.82% of all 29990 cardiac transplants identified in the same period. The trends in OHT for myocarditis is as shown in Figure 1.

The mean age was 32.9±2.4 years and 51.1% (n=219) were females. 235 (54.6%) were Caucasians and 60 (13.9%) were Hispanic. Majority of the transplants were performed at medium (16%) and large sized hospitals (80.4%). Cardiac transplants were mainly done at teaching hospitals (98.9%). Further, with regards to the geographical distribution of transplant procedure, most were done in the West (37.2%) followed by South (25.3%), Northeast (21.4%) and Mid-west (16%) of the United States. Private insurance was the major payor source which covered 245 (58%) patients followed by Medicaid covering 112 (26%) patients.

A total of 26 (6%) myocarditis patients died during the same hospitalization for OHT. In terms of discharge following OHT in myocarditis 85.8% (n=369) were discharged home and 8.1% (n=35) to short term hospitalization. The average length of stay for OHT for myocarditis was 64.3±6.3 days. Also, the mean cost of hospitalization for heart transplant in myocarditis when adjusted for inflation was 789,566±93,108 dollars.

In-patient mortality following OHT was not significantly different in large sized hospital compared to small and medium sized hospitals (7.6% vs 5.7%, p=0.54). However, the cost of hospitalization was significantly lesser in small and medium sized hospitals (588,363±154,349 vs 826,864±106,110 dollars, p<0.0001).

Conclusions

Only a small percentage of OHT is done for myocarditis with high proportion done in female when compared to OHT for other etiologies. Further studies need to be done to compare long term outcomes of heart transplant in myocarditis.

Funding Acknowledgement

Type of funding source: None

Treatment of neurodegenerative disorders through the blood-brain barrier using nanocarriers

Neurodegenerative diseases refer to disorders of the central nervous system (CNS) that are caused by neuronal degradations, dysfunctions, or death. Alzheimer's disease, Parkinson's disease, and Huntington's disease (APHD) are regarded as the three major neurodegenerative diseases. There is a vast body of literature on the causes and treatments of these neurodegenerative diseases. However, the main obstacle in developing an effective treatment strategy is the permeability of the treatment components at the blood-brain barrier (BBB). Several strategies have been developed to improve this obstruction. For example, nanomaterials facilitate drug delivery to the BBB due to their size. They have been used widely in nanomedicine and as nanoprobes for diagnosis purposes among others in neuroscience. Nanomaterials in different forms, such as nanoparticles, nanoemulsions, solid lipid nanoparticles (SLN), and liposomes, have been used to treat neurodegenerative diseases. This review will cover the basic concepts and applications of nanomaterials in the therapy of APHD.

Development of QSAR for antimicrobial activity of substituted benzimidazoles

QSAR analysis has been done to correlate antimicrobial activity of substituted benzimidazole derivatives with their physicochemical parameters. Developed QSAR models have been cross validated using leave one out (LOO) method. Statistical parameters like probable error of the coefficient of correlation (PE), least square error (LSE), Friedman's lack of fit measure (LOF), standard error of prediction (SEP) and quality value (Q) were also used to cross validate the models. QSAR studies established the importance of WAP, Mlog P and UI in describing the antimicrobial activities of substituted benzimidazole derivatives.

Carbohydrate-functionalized nanovaccines preserve HIV-1 antigen stability and activate antigen presenting cells

The functionalization of polymeric nanoparticles with ligands that target specific receptors on immune cells offers the opportunity to tailor adjuvant properties by conferring pathogen mimicking attributes to the particles. Polyanhydride nanoparticles are promising vaccine adjuvants with desirable characteristics such as immunomodulation, sustained antigen release, activation of antigen presenting cells (APCs), and stabilization of protein antigens. These capabilities can be exploited to design nanovaccines against viral pathogens, such as HIV-1, due to the important role of dendritic cells (DCs) and macrophages in viral spread. In this work, an optimized process was developed for carbohydrate functionalization of HIV-1 antigen-loaded polyanhydride nanoparticles. The carbohydrate-functionalized nanoparticles preserved antigenic properties upon release and also enabled sustained antigen release kinetics. Particle internalization was observed to be chemistry-dependent with positively charged nanoparticles being taken up more efficiently by DCs. Up-regulation of the activation makers CD40 and CD206 was demonstrated with carboxymethyl-α-d-mannopyranosyl-(1,2)-d-mannopyranoside functionalized nanoparticles. The secretion of the cytokines IL-6 and TNF-α was shown to be chemistry-dependent upon stimulation with carbohydrate-functionalized nanoparticles. These results offer important new insights upon the interactions between carbohydrate-functionalized nanoparticles and APCs and provide foundational information for the rational design of targeted nanovaccines against HIV-1.

Synthesis, antimicrobial and anticancer evaluation of N'-(substituted benzylidene)-2-(benzo[d]oxazol-3(2H)-yl)acetohydrazide derivatives

A series of N'-(substituted benzylidene)-2-(benzo[d]oxazol-3(2H)-yl)acetohydrazide derivatives was synthesized and evaluated for its in vitro antimicrobial and anticancer activities. Antimicrobial activity results revealed that compound 12 was found to be the most potent antimicrobial agent. Results of anticancer study indicated that the synthesized compounds exhibited average anticancer potential. Compound 7 (IC 50 =3.12 µM) and compound 16 (IC 50 =2.88 µM) were found to be most potent against breast cancer (MCF7) cell lines. In conclusion, compound 12 and 16 have the potential to be selected as lead compound for the developing of novel antimicrobial and anticancer agents respectively.

Synthesis, SAR Study and Evaluation of Mannich and Schiff Bases of Pyrazol-5(4H)-one Moiety Containing 3-(Hydrazinyl)-2-phenylquinazolin-4(3H)-one

In the present investigation, a series of 12 Mannich bases (QP1-12) and 5 Schiff bases (QSP1-5) of pyrazol-5(4H)-one moiety containing 3-(hydrazinyl)-2-phenylquinazolin-4(3H)-one has been synthesized and characterized by physicochemical as well as spectral means. The synthesized Mannich and Schiff bases were screened for their preliminary antimicrobial activity against Gram-positive and Gram-negative bacterial as well as fungal strains by the determination of zone of inhibition. Mannich bases (QP1-12) were found to be more potent antibacterial agents against Gram-positive bacteria, whereas Schiff bases (QSP1-5) were more potent against Gram-negative bacteria and fungi. Minimum inhibitory concentration result demonstrated that Mannich base compound (QP7) having ortho -OH and para -COOH group showed some improvement in antibacterial activity (minimum inhibitory concentration of 48.88×10⁻³ μM/ml) among the tested Gram-positive organisms and it also exhibit minimum inhibitory concentration of value of 12.22×10⁻³ μM/ml for Klebsiella pneumoniae. The antitubercular activity of synthesized compounds against Mycobacterium tuberculosis (H₃₇Rv) was determined using microplate alamar blue assay. Compound QP11 showed appreciable antitubercular activity (minimum inhibitory concentration of 6.49×10⁻³ μM/ml) which was more active than the standard drugs, ethambutol (minimum inhibitory concentration of 7.60×10⁻³ μM/ml) and ciprofloxacin (9.4×10⁻³ μM/ml). Compounds QP11, QP9, QSP1, QSP2, and QSP5 have good selective index and may be selected as a lead compound for the development of novel antitubercular agents.

Synthesis, antimicrobial evaluation and QSAR studies of p-hydroxy benzoic acid derivatives

In the present study, a series of p-hydroxy benzoic acid derivatives (1-29) was synthesized and tested for its antimicrobial potential. Results of antimicrobial studies indicated that in general, Schiff bases were found to be more active as compared to esters and compound 14 was found to be most potent antimicrobial agent (pMICam=1.50 µM/ml). QSAR study was performed in order to understand the relationship between antimicrobial activity and changes in the molecular structures which indicated that antimicrobial activity of the synthesized compounds was governed by valence first order molecular connectivity index (1χv), Kier's alpha first order shape index (κα1), Kier's first order shape index (κ1) and Balaban topological index (J).

Amphiphilic polyanhydride nanoparticles stabilize Bacillus anthracis protective antigen

Advancements toward an improved vaccine against Bacillus anthracis, the causative agent of anthrax, have focused on formulations composed of the protective antigen (PA) adsorbed to aluminum hydroxide. However, due to the labile nature of PA, antigen stability is a primary concern for vaccine development. Thus, there is a need for a delivery system capable of preserving the immunogenicity of PA through all the steps of vaccine fabrication, storage, and administration. In this work, we demonstrate that biodegradable amphiphilic polyanhydride nanoparticles, which have previously been shown to provide controlled antigen delivery, antigen stability, immune modulation, and protection in a single dose against a pathogenic challenge, can stabilize and release functional PA. These nanoparticles demonstrated polymer hydrophobicity-dependent preservation of the biological function of PA upon encapsulation, storage (over extended times and elevated temperatures), and release. Specifically, fabrication of amphiphilic polyanhydride nanoparticles composed of 1,6-bis(p-carboxyphenoxy)hexane and 1,8-bis(p-carboxyphenoxy)-3,6-dioxaoctane best preserved PA functionality. These studies demonstrate the versatility and superiority of amphiphilic nanoparticles as vaccine delivery vehicles suitable for long-term storage.

In vitro antimicrobial activity of methanolic leaf extract of Psidium guajava L

AIM

This study was designed to examine the chemical composition and in vitro antimicrobial potential of methanolic extract of Psidium guajava Linn (Myrtaceae).

MATERIALS AND METHODS

The inhibitory effect of methanolic extract of P. guajava was tested against three bacterial and two fungal strains by using the paper disc diffusion method.

RESULTS

The methanolic extract exhibited antibacterial activity against E. coli with minimum inhibitory concentration, 0.78 μg/ml, minimum bactericidal concentration of 50 μg/ml, and appreciable antifungal activity with minimum inhibitory concentration of 12.5 μg/ml. Preliminary phytochemical analysis of methanolic extract revealed the presence of antimicrobial compounds such as flavonoids, steroids, and tannins, which may contribute for the antimicrobial action of P. guajava.

CONCLUSION

The extract was found to be bacteriostatic and fungistatic in action.

Rainfall and temperature distinguish between Karnal bunt positive and negative years in wheat fields in Texas

Karnal bunt of wheat, caused by the fungus Tilletia indica, is an internationally regulated disease. Since its first detection in central Texas in 1997, regions in which the disease was detected have been under strict federal quarantine regulations resulting in significant economic losses. A study was conducted to determine the effect of weather factors on incidence of the disease since its first detection in Texas. Weather variables (temperature and rainfall amount and frequency) were collected and used as predictors in discriminant analysis for classifying bunt-positive and -negative fields using incidence data for 1997 and 2000 to 2003 in San Saba County. Rainfall amount and frequency were obtained from radar (Doppler radar) measurements. The three weather variables correctly classified 100% of the cases into bunt-positive or -negative fields during the specific period overlapping the stage of wheat susceptibility (boot to soft dough) in the region. A linear discriminant-function model then was developed for use in classification of new weather variables into the bunt occurrence groups (+ or -). The model was evaluated using weather data for 2004 to 2006 for San Saba area (central Texas), and data for 2001 and 2002 for Olney area (north-central Texas). The model correctly predicted bunt occurrence in all cases except for the year 2004. The model was also evaluated for site-specific prediction of the disease using radar rainfall data and in most cases provided similar results as the regional level evaluation. The humid thermal index (HTI) model (widely used for assessing risk of Karnal bunt) agreed with our model in all cases in the regional level evaluation, including the year 2004 for the San Saba area, except for the Olney area where it incorrectly predicted weather conditions in 2001 as unfavorable. The current model has a potential to be used in a spray advisory program in regulated wheat fields.

Assessment of Regional Site-Specific Sorghum Ergot Severity Potential Using Radar-Rainfall Measurement

Sorghum ergot, caused by Claviceps africana, generally requires cool weather and humid conditions for optimum infection. Rainfall reportedly is not required for infection as long as relative humidity is high. However, occurrence of high humidity in the Texas Panhandle during the summer is usually associated with rain showers, and ergot incidence in the region has been observed to be associated with rain events. These events are often irregular and can vary within a small area both in incidence and intensity. Existing ground weather stations are too far apart to provide accurate representation of localized rainfall events. Radar-based precipitation measurements have a resolution of 4 × 4 km out to 230 km from the radar location. In the present study, radar rainfall measurements were used to assess regional site-specific sorghum ergot potential in the Texas Panhandle. The results have a potential for development of a web-based ergot risk assessment system in which growers can enter the GPS locations of their fields and determine whether management actions are necessary.

Mathematical models describing polymer dissolution: consequences for drug delivery

Polymer dissolution is an important phenomenon in polymer science and engineering that has found applications in areas like microlithography, controlled drug delivery, and plastics recycling. This review focuses on the modeling efforts to understand the physics of the drug release process from dissolving polymers. A brief review of the experimentally observed dissolution behavior is presented, thus motivating the modeling of the mechanism of dissolution. The main modeling contributions have been classified into two broad approaches - phenomenological models and Fickian equations, and anomalous transport models and scaling law-based approaches. The underlying principles and the important features of each approach are discussed. Details of the important models and their corresponding predictions are provided. Experimental results seem to be qualitatively consistent with the present picture.

Microphase separation in bioerodible copolymers for drug delivery

This research examines the microstructure of bioerodible polyanhydrides with an eye towards precise design of drug delivery devices. Our main hypothesis is that the bioerodible copolymer poly(1,6-bis-p-carboxyphenoxyhexane-co-sebacic anhydride) (CPH : SA) undergoes micro-phase separation at certain copolymer compositions due to differences in relative hydrophobicity of the co-monomers, resulting in thermodynamic partitioning of drugs incorporated into these copolymers. We investigate the thermal properties, degree of crystallinity, and surface microstructure of several compositions of CPH : SA using differential scanning calorimetry (DSC), wide-angle X-ray diffraction (WAXD), and atomic force microscopy (AFM). We observe that the degree of crystallinity decreases, while the crystal lamellar thickness increases with CPH content. Phase-imaging using AFM indicates the presence of micro-domains in 20 : 80 and 80 : 20 CPH : SA, while poly(SA) and 50 : 50 CPH : SA show no micro-phase separation. Finally, drug-polymer interactions are studied by loading the polymers with different amounts of brilliant blue (hydrophilic) and p-nitroaniline (hydrophobic). DSC and WAXD analysis shows that loading hydrophobic drugs into relatively hydrophobic polymers (poly(SA)) lowers melting point that becomes more pronounced with increased drug loading.

The inference of antigen selection on Ig genes

Analysis of somatic mutations in V regions of Ig genes is important for understanding various biological processes. It is customary to estimate Ag selection on Ig genes by assessment of replacement (R) as opposed to silent (S) mutations in the complementary-determining regions and S as opposed to R mutations in the framework regions. In the past such an evaluation was performed using a binomial distribution model equation, which is inappropriate for Ig genes in which mutations have four different distribution possibilities (R and S mutations in the complementary-determining region and/or framework regions of the gene). In the present work, we propose a multinomial distribution model for assessment of Ag selection. Side-by-side application of multinomial and binomial models on 86 previously established Ig sequences disclosed 8 discrepancies, leading to opposite statistical conclusions about Ag selection. We suggest the use of the multinomial model for all future analysis of Ag selection.

Bone mineral acquisition in healthy Asian, Hispanic, black, and Caucasian youth: a longitudinal study

Ethnic and gender differences in bone mineral acquisition were examined in a longitudinal study of 423 healthy Asian, black, Hispanic, and white males and females (aged 9-25 yr). Bone mass of the spine, femoral neck, total hip, and whole body was measured annually for up to 4 yr by dual energy x-ray absorptiometry. Age-adjusted mean bone mineral curves for areal (BMD) and volumetric (BMAD) bone mineral density were compared for the 4 ethnic groups. Consistent differences in areal and volumetric bone density were observed only between black and nonblack subjects. Among females, blacks had greater mean levels of BMD and BMAD at all skeletal sites. Differences among Asians, Hispanics, and white females were significant for femoral neck BMD, whole body BMD, and whole body bone mineral content/height ratio, for which Asians had significantly lower values; femoral neck BMAD in Asian and white females was lower than that in Hispanics. Like the females, black males had consistently greater mean values than nonblacks for all BMD and BMAD measurements. A few differences were also observed among nonblack male subjects. Whites had greater mean total hip BMD, whole body BMD, and whole body bone mineral content/height ratio than Asian and Hispanic males; Hispanics had lower spine BMD than white and Asian males. The tempo of gains in BMD varied by gender and skeletal site. In females, total hip, spine, and whole body BMD reached a plateau at 14.1, 15.7, and 16.4 yr, respectively. For males, gains in BMD leveled off at 15.7 yr for total hip and at age 17.6 yr for spine and whole body. Black and Asian females and Asian males tended to reach a plateau in BMD earlier than the other ethnic groups. The use of gender- and ethnic-specific standards is recommended when interpreting pediatric bone densitometry data.

Self-diffusion and molecular mobility in PVA-based dissolution-controlled systems for drug delivery

Nuclear magnetic resonance (NMR) microscopy has been used to monitor the hydration of poly(vinyl alcohol) (PVA) samples of varying molecular weight. One-dimensional profiles weighted to predominantly show the variation of water concentration were acquired every 3 min during the first 30 min of hydration and subsequently at 1 and 2 h. Diffusion-weighted profiles obtained after 30 min and 1 and 2 h were used to calculate the spatial variation of the water self-diffusion coefficient. The resulting data provide supporting evidence for the hypothesis that phenomena such as reptation are important near the glassy/rubbery interface of polymers during dissolution, while the diffusion gradually changes to Zimm type near the rubbery/solvent interface.

Novel Phosphoinositides in Barley Aleurone Cells (Additional Evidence for the Presence of Phosphatidyl-scyllo-Inositol)

A novel isomer of phosphatidylinositol that differs in the structure of the head group was detected in barley (Hordeum vulgare cv Himalaya) seeds. In this paper we describe our efforts to elucidate the structure of the novel isomer. Evidence from a variety of techniques, including chemical modification of in vivo 32Pi- and myo-[3H]inositol-labeled compounds, gas chromatography-mass spectrometry analysis, in vivo incorporation of scyllo-[3H]inositol, and enzymatic studies that suggest that the structure is phosphatidylscyllo-inositol (scyllo-PI), is presented. The use of microwave energy to significantly enhance the slow rate of hydrolysis of phosphoinositides is described. The presence of scyllo-PI can be easily overlooked by the methods commonly employed; therefore, experimental considerations important for the detection of scyllo-PI are discussed.

Molecular analysis of drug delivery systems controlled by dissolution of the polymer carrier

Dissolution-controlled drug delivery systems are characterized by a phase erosion of the polymer carrier that is associated with fast or slow dissolution of the macromolecular chains. The molecular nature of the dissolution phenomenon was examined by analyzing the water transport process and the subsequent polymer chain disentanglement that is usually characterized by a snake-like motion of the chain (reptation). The results indicate that the polymer molecular weight, water, polymer and drug diffusion coefficients, equilibrium water concentration in the polymer, and water-polymer interaction parameter can control the mechanism and rate of drug release. A new model for this process was developed, and its predictions are compared with experimental studies of drug delivery from poly(vinyl alcohol)-based systems.

Characterization of scyllo-inositol-containing phosphatidylinositol in plant cells

The structure of in vivo [3H]myo-inositol-labeled phosphatidylinositols in barley seeds were investigated by chemical degradation. In this report we present data that suggests the presence of scyllo-inositol-containing phosphatidylinositol in addition to the commonly occurring myo-inositol-containing phosphatidylinositol.