Sex-Based Differences in the Epidemiology, Clinical Characteristics, and Outcomes Associated with Worsening Heart Failure Events in a Learning Health System

BACKGROUND

Differences in demographics, risk factors, and clinical characteristics may contribute to variation in men and women in terms of prevalence, clinical setting, and outcomes associated with worsening heart failure (WHF) events.

OBJECTIVES

To describe sex-based differences in the epidemiology, clinical characteristics, and outcomes associated with WHF events across clinical settings.

METHODS

We examined adults diagnosed with HF from 2010-2019 within a large, integrated healthcare delivery system. Electronic health record data were accessed for hospitalizations, emergency department (ED) visits/observation stays, and outpatient encounters. WHF was identified using validated natural language processing algorithms and defined as ≥1 symptom, ≥2 objective findings (including ≥1 sign), and ≥1 change in HF-related therapy. Incidence rates and associated outcomes for WHF were compared across care setting by sex.

RESULTS

We identified 1,122,368 unique clinical encounters with a diagnosis code for HF, with 124,479 meeting WHF criteria. These WHF encounters existed among 102,116 patients, of which 48,543 (47.5%) were women and 53,573 (52.5%) were men. Women experiencing WHF were older and more likely to have HF with preserved ejection fraction compared to men. The clinical settings of WHF were similar among women and men: hospitalizations (36.8% vs. 37.7%), ED visits or observation stays (11.8% vs. 13.4%), and outpatient encounters (4.4% vs. 4.9%). Women had lower odds of 30-day mortality following an index hospitalization (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.83-0.93) or ED visit/observation stay (aOR 0.86, 95% 0.75-0.98) for WHF.

CONCLUSION

Women and men contribute similarly to WHF events across diverse clinical settings despite marked differences in age and left ventricular ejection fraction.

Temporal trends in the prevalence and severity of aortic stenosis within a contemporary and diverse community-based cohort

BACKGROUND

Data on the epidemiology of aortic stenosis (AS) are primarily derived from single center experiences and administrative claims data that do not delineate by degree of disease severity.

METHODS

An observational cohort study of adults with echocardiographic AS was conducted January 1st, 2013-December 31st, 2019 at an integrated health system. The presence/grade of AS was based on physician interpretation of echocardiograms.

RESULTS

A total of 66,992 echocardiogram reports for 37,228 individuals were identified. The mean ± standard deviation (SD) age was 77.5 ± 10.5, 50.5% (N = 18,816) were women, and 67.2% (N = 25,016) were non-Hispanic whites. The age-standardized AS prevalence increased from 589 (95% Confidence Interval [CI] 580-598) to 754 (95% CI 744-764) cases per 100,000 during the study period. The age-standardized AS prevalences were similar in magnitude among non-Hispanic whites (820, 95% CI 806-834), non-Hispanic blacks (728, 95% CI 687-769), and Hispanics (789, 95% CI 759-819) and substantially lower for Asian/Pacific Islanders (511, 95% CI 489-533). Finally, the distribution of AS by degree of severity remained relatively unchanged over time.

CONCLUSIONS AND RELEVANCE

The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable.

Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System

Background

Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR.

Methods

We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed.

Results

Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR.

Conclusions

Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.

The anticoagulation length of therapy and risk of new adverse events in venous thromboembolism (ALTERNATIVE) study: Design and survey results

The Anticoagulation Length of Therapy and Risk of New Adverse Events In Venous Thromboembolism (ALTERNATIVE) study was designed to compare the benefits and harms of different treatment options for extended treatment of venous thromboembolism (VTE). In this paper, we describe the study cohort, survey data collection, and preliminary results. We identified 39,605 adult patients (age ≥ 18 years) from two large integrated health care delivery systems who were diagnosed with incident VTE and received initial anticoagulation therapy of 3 months or longer. A subset of the cohort (12,737) was invited to participate in a survey. Surveys were completed in English, Spanish or Mandarin via a mailed questionnaire, an online secure web link, or telephone. The survey domains included demographics, personal medical history, anticoagulant treatment history, anticoagulant treatment satisfaction, health-related quality of life and health literacy. A total of 5,017 patients participated in the survey for an overall response rate of 39.4%. The mean (SD) age of the survey respondents was 63.0 (14.5) years and self-reported race was 76.0% White/European, 11.1% Black/African American, and 3.8% Asian/Pacific Islander and 14.0% reported Hispanic ethnicity. Sixty percent of respondents completed the web survey, while 29.0% completed the mail-in paper survey, and 11.0% completed the survey via telephone. The ALTERNATIVE Study will address knowledge gaps by comparing several treatment alternatives for the extended management of VTE so that this information could be used by patients and clinicians to make more informed, patient-centered treatment choices.

Contemporary Burden and Correlates of Symptomatic Paroxysmal Supraventricular Tachycardia

BACKGROUND

Contemporary data about symptomatic paroxysmal supraventricular tachycardia (PSVT) epidemiology are limited. We characterized prevalence and correlates of symptomatic PSVT within a large healthcare delivery system and estimated national PSVT burden.

METHODS AND RESULTS

We identified adults with an encounter for potential PSVT between 2010 and 2015 in Kaiser Permanente Northern California, excluding those with prior known atrial fibrillation or atrial flutter. We adjudicated medical records, ECGs, and other monitoring data to estimate positive predictive values for targeted International Classification of Diseases (ICD), 9th and 10th Revisions codes in inpatient, emergency department, and outpatient settings. Combinations of diagnosis codes and settings were used to calculate PSVT prevalence, and PSVT correlates were identified using multivariable regression. We estimated national rates by applying prevalence estimates in Kaiser Permanente to 2010 US Census data. The highest positive predictive values included codes for "PSVT" in the emergency department (82%), "unspecified cardiac dysrhythmia" in the emergency department (27%), "anomalous atrioventricular excitation" as a primary inpatient diagnosis (33%), and "unspecified paroxysmal tachycardia" as a primary inpatient diagnosis (23%). Prevalence of symptomatic PSVT was 140 per 100 000 (95% confidence interval, 100-179) and was higher for individuals who were older, women, white or black, or who had valvular heart disease, heart failure, diabetes mellitus, lung disease, or prior bleeding. We estimate the national prevalence of symptomatic PSVT to be 168 per 100 000 (95% confidence interval, 120-215).

CONCLUSIONS

Selected diagnostic codes in inpatient and emergency department settings may be useful to identify symptomatic PSVT episodes. We project that at least 0.168% of US adults experience symptomatic PSVT, and certain characteristics can identify people at higher risk.

Photostimulation of Japanese quail

To adapt commercial poultry production to a new scenario of energy savings and to develop specific practices for quail production aimed at reducing costs while maintaining or improving productivity, four experiments were conducted. In the first experiment, birds were allocated to four treatments (photoperiod duration): T1: 14 L:10 D; T2: 15 L:9 D; T3: 16 L:8 D; and T4: 17 L:7 D. In the second experiment, birds were subjected to four levels of brightness: T1: 5 lux; T2: 10 lux; T3:15 lux; and T4: 22 lux (control). In the third experiment, four types of lamps were evaluated: T1: compact fluorescent lamp (color temperature: 6,500 K); T2: compact fluorescent lamp (color temperature: 2,700 K); T3: incandescent lamp; and T4: yellow LED. In the last experiment, four lighting programs were compared: T1: continuous program (control), in which there was a single photoperiod of 15 h; the other treatments consisted of intermittent lighting programs, as follows: T2: 1 h of light provided 1 h after dusk; T3: 1 h of light provided 2 h before dawn; T4: half an hour of light provided 1 h after dusk and half an hour of light provided 1.5 h before dawn. In each experiment, 1,296 Japanese quail were evaluated for four 28-d cycles, totaling 112 experimental days. A completely randomized experimental design of 4 treatments with 12 replicates of 27 birds each was applied in all trials. Performance and egg quality were evaluated in each experiment. Higher egg production and adequate egg quality, as well as energy savings, can be obtained with Japanese quail using compact fluorescent lamps or LEDs and a photoperiod of 15 h/d supplied using an intermittent lighting program, with 1 h of artificial light 2 h before dawn at a brightness of 5 lux.

The mouse pubic symphysis as a remodeling system: morphometrical analysis of proliferation and cell death during pregnancy, partus and postpartum

Marked changes in mice pubic symphysis occur by the end of pregnancy. Tissue remodeling involves a dynamic balance between cell proliferation and programmed cell death as well as changes in the extracellular matrix components. Therefore, it is important to consider both of these cellular behaviors when investigating the mechanism that regulates interpubic tissue remodeling, growth during late pregnancy and partus ensuring involution during the postpartum period. Proliferating and programmed death cells were identified by immunohistochemistry (proliferating cell nuclear antigen and TUNEL detection, respectively) and the rates at which these processes occurred were determined by morphometric analysis. The results demonstrated that cellular proliferation was intense during the period of ligament formation, from D15 to D18, thereafter abruptly declining on D19. From parturition (D19) onwards, an ever-increasing decline in the cellular proliferation levels could be observed. The quantitative analyses of cellular death showed opposite results when compared to cellular proliferation. During early pregnancy the cycle of cellular renovation was clearly proliferative and during late mouse pregnancy the cycle was directed by programmed cellular death. Although the high levels of cellular death during postpartum involution could be shown by the TUNEL-positive cells, we were unable to observed picnotic nucleus at the light microscopy.

Genes and hypertension

The combination of investigation of rare Mendelian forms of hypertension, candidate gene studies, comparative mapping and genome-wide screening in both animal models and man has led to significant progress in determining new mechanisms of blood pressure control. In this review, the newly discovered blood pressure/cardiovascular genes, WNK kinases and angiotensin converting enzyme 2 and the development of a new anti-hypertensive agent PST2238 are discussed. Major genes causing essential hypertension have yet to be discovered, however, there are now over 20 published genome-wide screens for blood pressure controlling genes. Several regions demonstrate suggestive linkage to the trait and there is some overlap of regions between the different studies. It is hoped that new blood pressure genes will ultimately be discovered using this method. Pharmacogenetic studies in hypertension have only been initiated recently, some are described in this paper. Small studies upon single candidate genes, suggest that the contribution of genetics to the inter-individual variation in blood pressure response to anti-hypertensive therapy, is small, approximately 3-5%. Recently micro-arrays with multiple polymorphisms in multiple genes have been used. After accounting for the additive affects of multiple blood pressure loci, an individual's genetic profile appeared to explain up to 50% of the variation in blood pressure response to therapy. Knowledge of the genetic variants that cause hypertension and influence response to anti-hypertensive therapy will ultimately provide a greater understanding of the molecular mechanisms underlying blood pressure control.

Efeito da Duração do Período de Jejum Pré-Abate Sobre Rendimento de Carcaça e a Qualidade da Carne do Peito de Frangos de Corte

O objetivo de estudo foi o de avaliar o efeito do jejum de ração e água antes do abate sobre o rendimento de carcaça e cortes, perda de peso vivo, conteúdo do papo, intestino e moela, matéria seca das fezes, bem como volume globular médio e proteína total plasmática do soro. Foram utilizados 600 pintos machos da linhagem Ross, criados até 42 dias de idade, quando foram submetidos a três períodos de jejum (zero, quatro ou oito horas). A duração do período de jejum afetou (p<0,05) a perda de peso vivo, o rendimento de carcaça, carne de pernas, pés, conteúdo do papo e intestino. Aumentando-se o período de jejum até 4 horas, aumentou-se a perda de peso vivo e o rendimento de carcaça e patas, mas diminuiu-se o rendimento de pernas e o conteúdo do papo e do intestino. Não houve efeito (p>0,05) do período de jejum sobre as demais variáveis estudadas.

Alimentação de Codornas com Milho Moído e Ração de Postura no Período Pós-jejum Durante a Muda Forçada e Seus Efeitos Sobre o Desempenho

O experimento foi realizado com o objetivo de avaliar o desempenho de codornas poedeiras alimentadas por diferentes períodos com milho moído ou ração de postura durante sete dias após três dias de jejum, método de muda utilizado. Após esse período, as aves foram alimentadas com ração de postura durante as 20 semanas do período experimental. Utilizou-se um delineamento inteiramente ao acaso com três tratamentos (ração de postura por sete dias, ração de postura por três dias e milho moído por quatro dias e milho moído por sete dias), e quatro repetições de 24 aves por parcela. Os resultados mostraram que aves alimentadas apenas com ração de postura nos sete primeiros dias após o jejum apresentaram maior produção de ovos nas seis primeiras semanas do período de produção pós-muda. Porém, não foi constatado efeito de tratamento sobre a produção de ovos, peso dos ovos, consumo de ração e conversão alimentar durante as 20 semanas do período experimental.

Efeito do Nível de Lisina da Dieta e do Sexo Sobre o Desempenho e Rendimento de Carcaça de Frangos de Corte

O experimento foi conduzido nas instalações da Faculdade de Medicina Veterinária e Zootecnia, UNESP, Campus de Botucatu, utilizando-se dois mil pintos de um dia de idade, da linhagem Ross, distribuídos em um delineamento inteiramente casualisado em esquema fatorial 2 x 2 (sexos x níveis de lisina) e criados até 49 dias de idade. As aves foram alimentadas com dietas: inicial (0-21 dias), crescimento (22-42 dias) e acabamento (43-49 dias), contendo 100% dos níveis de lisina recomendados pelo NRC (1994), ou 110% nas rações inicial e de crescimento e 120% na ração de acabamento. Os frangos foram abatidos aos 28, 35, 42 e 49 dias de idade quando os rendimentos de carcaça e de peito foram determinados. Os níveis de lisina não afetaram (p>0,05) o ganho de peso, conversão alimentar e o rendimento de carcaça, mas os níveis altos resultaram em menores porcentagens de gordura abdominal quando comparados aos níveis baixos de lisina, nas fêmeas. A inclusão de lisina na dieta não melhorou o rendimento de carcaça e de peito aos 28, 35, 42 e 49 dias de idade (p>0,05). Portanto, pode-se concluir que o aumento dos níveis de lisina acima do recomendado pelo NRC (1994) não apresentou influência sobre as características avaliadas.

Efeito dos Níveis de Cantaxantina na Dieta Sobre o Desempenho e Qualidade dos Ovos de Poedeiras Comerciais

O experimento teve como objetivo estudar os efeitos de níveis de cantaxantina sobre o desempenho e a coloração das gemas dos ovos de galinhas poedeiras. Foram utilizadas 384 galinhas da linhagem Hisex Brown, em um delineamento em blocos ao acaso, contendo seis tratamentos (0, 12, 24, 36, 48 e 60 ppm de cantaxantina), com oito repetições de oito aves por parcela. O período experimental foi de 56 dias. A coleta de ovos foi realizada diariamente e a análise de coloração dos ovos foi efetuada com o abanico colorimétrico da Roche. Durante os 14 dias do período inicial do experimento, a melhor coloração das gemas foi obtida com a adição de 60 ppm de cantaxantina, atingindo-se a cor plateau de 14,3 do leque colorimétrico Roche aos 5,43 dias de inclusão do pigmentante. Considerando-se o período experimental total, os níveis de cantaxantina utilizados melhoraram de forma quadrática a coloração das gemas, sem influenciar os parâmetros produtivos e demais características de qualidade dos ovos de poedeiras comerciais.

Efeito da Suplementação de Metionina Sobre o Desempenho e a Avaliação de Carcaças de Frangos de Corte

Um experimento foi conduzido para avaliar os efeitos da suplementação de metionina em dietas de crescimento (22 a 42 dias de idade) sobre o desempenho, rendimento e composição química da carcaça de frangos de corte. Foram utilizados 2000 frangos de corte da linhagem comercial Ross, sexados, distribuídos em um delineamento ao acaso, em esquema fatorial 2 x 5 (sexo e níveis de metionina) com quatro repetições de 50 aves cada. As dietas foram formuladas para conter 100% ,110%, 120%, 130% e 140% dos níveis de metionina recomendados pelo NRC (1994). Aos 42 dias de idade, as aves foram abatidas para avaliar a quantidade de gordura abdominal, bem como o rendimento e a composição química da carcaça. Ao aumentar o nível de metionina da dieta, não houve efeito (p> 0,05) sobre o ganho de peso, consumo de ração, conversão alimentar, mortalidade, gordura abdominal, e rendimento de carcaça, bem como, umidade, proteína, gordura e cinzas do peito e pernas. Não foi verificado efeito (p>0,05) de interação entre nível de metionina e sexo, mas as fêmeas apresentaram maior percentual de gordura abdominal (p<0,05) que os machos. Como o nível de metionina não afetou o desempenho, rendimento e composição química da carcaça, concluiu-se que a recomendação sugerida pelo NRC (1994) de 0,38% para frangos de corte no período de 22 a 42 dias de idade está adequada.

Efeito da Densidade de Criação e do Sexo Sobre o Empenamento, Incidência de Lesões na Carcaça e Qualidade da Carne de Peito de Frangos de Corte

O experimento foi conduzido nas instalações experimentais da Faculdade de Medicina Veterinária e Zootecnia - UNESP, Campus de Botucatu, SP, Brasil, com o objetivo de avaliar o efeito da densidade de criação e do sexo sobre o empenamento, incidência de lesões na carcaça e a qualidade de carne de peito de frangos de corte. Foram utilizados 1950 pintos de corte sexados, da linhagem Ross, distribuídos em um delineamento inteiramente casualizado, com esquema fatorial com 3 densidades (10, 13 e 16 aves/m²) e dois sexos com 5 repetições, sendo que uma foi destinada exclusivamente para reserva, criados até os 42 dias de idade. Aos 28, 35 e 42 dias foram amostradas 3 aves por repetição para a determinação do empenamento através da porcentagem de penas e 10 aves para a determinação do escore de empenamento. Também aos 42 dias de idade todas as aves foram identificadas na pata com anilhas numeradas e submetidas à avaliação da incidência de lesões na pele. Foram escolhidas ao acaso 5 aves por repetição para a determinação da qualidade da carne de peito. Pode-se concluir que o aumento na densidade de criação promoveu uma diminuição na velocidade de empenamento e, conseqüentemente, uma maior incidência de lesões na carcaça. O comprimento, a largura e a espessura do peito foram menores para as aves criadas na maior densidade, e a perda de peso por cozimento foi maior para as aves criadas na maior densidade.

Alterações Morfólogicas de Codornas Poedeiras Submetidas a Muda Forçada

Objetivou-se avaliar as alterações físicas, produção de ovos e mortalidade de codornas poedeiras submetidas a muda forçada, durante um período de jejum. Utilizou-se um delineamento inteiramente ao acaso, com quatro tratamentos (0, 1, 2, e 3) dias de jejum, com três repetições de 36 aves por parcela. No início e ao final do período de jejum 2 aves por parcela foram abatidas, pesadas individualmente e sacrificadas para retirada e avaliação do ovário, oviduto, e fígado. Os resultados mostraram que no período de jejum de três dias houve uma redução de 25,64% no peso vivo, a produção de ovos caiu a 2,81% e a mortalidade foi de 4,60%.

Nuclear DNA content analysis by static cytometry in cervical intraepithelial lesions using retrospective series of previously stained PAP smears

AIMS

To evaluate the nuclear DNA content in cytological smears of uterine cervix previously stained with Papanicolaou method, focusing the potential of the method in retrospective series.

METHODS

Consecutive cases of Pap smears examined at the Adolfo Lutz Institute, a Public Health Laboratory of São Paulo State were selected. The diagnosis were: CIN 1 (n=20), CIN 2 (n=24), CIN 3 (n=20). Slides were previously stained with Papanicolaou method. The stain was removed with 5% hydrochloric alcohol-acid solution and the slides were stained with Thionin-Feulgen using a Becton & Dickinson kit. Ploidy evaluation was performed using the DNA Quantitative Measurement software 3.0 (version 8.1) from Becton & Dickinson and the CAS 200 system of image analysis. Cell ploidy was evaluated after analysis of atypical nuclei found in the selected cases. The DNA index was obtained using histograms for interpretation.

MAIN RESULTS

CIN 1 cases showed the following DNA profile: 55% of diploid, 5% of tetraploid and 40% of aneuploid. CIN 2 cases showed 45.8% of diploid, 8.3% of tetraploid and 45.8% of aneuploid cells. CIN 3 cases showed 10% diploid, 15% of tetraploid and 75% of aneuploid cells.

CONCLUSION

DNA analysis was useful to distinguish CIN 3 to CIN 1 and 2, but did not discriminate CIN 1 and 2 in these series. Aneuploidy was strongly associated to the CIN 3 cases.

PCR with Paracoccidioides brasiliensis specific primers: potential use in ecological studies

The precise microenvironment of Paracoccidioides brasiliensis has not yet been discovered perhaps because the methods used are not sensitive enough. We applied to this purpose the polymerase chain reaction (PCR) using three sets of specific primers corresponding to two P. brasiliensis genes. This fungus as well as several other fungi, were grown and their DNA obtained by mechanical disruption and a phenol chloroform isoamylalcohol-based purification method. The DNA served for a PCR reaction that employed specific primers from two P. brasiliensis genes that codify for antigenic proteins, namely, the 27 kDa and the 43 kDa. The lowest detection range for the 27 kDa gene was 3 pg. The amplification for both genes was positive only with DNA from P. brasiliensis; additionally, the mRNA for the 27 kDa gene was present only in P. brasiliensis, as indicated by the Northern analysis. The standardization of PCR technology permitted the amplification of P. brasiliensis DNA in artificially contaminated soils and in tissues of armadillos naturally infected with the fungus. These results indicate that PCR technology could play an important role in the search for P. brasiliensis' habitat and could also be used in other ecological studies.