Evaluating the Clinical Effectiveness and Safety of Semaglutide in Individuals with Uncontrolled Type 2 Diabetes. Real-World Evidence from Saudi Arabia: The Observational, Multicenter, 15-Month EVOLUTION Study

INTRODUCTION

This study aimed to assess the safety and effectiveness of semaglutide, administered either by weekly subcutaneous (SC) injection or orally, in real-life practice in Saudi Arabia in individuals with type 2 diabetes mellitus (T2DM).

METHODS

A retrospective chart review study was conducted at 18 Saudi Arabia centers. An accredited centralized institutional review board approved the study. Medical records were included for individuals of any age ≥ 18 years with uncontrolled T2DM. The primary outcome measure was the laboratory glycated hemoglobin (HbA1c) level. Secondary measures included fasting blood glucose (FBG), weight, and hypoglycemia. All variables were checked after 6 and 12 months of semaglutide initiation.

RESULTS

The analysis of this study included 1223 patients with uncontrolled T2DM (HbA1c > 7%). The mean (SD) baseline HbA1c was 10.02% (1.17). HbA1c was reduced by an average of 3.02% (0.84) and 3.17% (0.84) at 6 and 12 months, respectively. Results of a repeated measure analysis of variance (ANOVA) indicated significant differences in HbA1c (p value < 0.001). HbA1c levels at 6 and 12 months were significantly lower, 7.00% (0.70) and 6.85% (0.69), than at baseline, 10.02% (1.17). About 193 patients (56.4%) of the 295 patients having HbA1c < 9% achieved HbA1c of 5.7% or less. The frequency of hypoglycemia events was 4.60 (1.10) in the 3 months before semaglutide was initiated. The frequency of hypoglycemia events in the last 3 months was 2.30 (0.80) events and 0.80 (0.50) events at 6-month and 12-month follow-up visits, respectively. The percent reduction in body mass index (BMI) was an average of 13.07% (1.53) and 19.89% (4.07) at 6 and 12 months, respectively. Lipid profile and blood pressure were improved at 6 and 12 months.

CONCLUSION

Semaglutide, administered either by SC injection or orally, provided substantial glycemic and weight-loss benefits in adults with T2DM.

Anxiolytic potential of resveratrol and rufinamide combination by modulating GABA-ergic transmission: insights from experiments, molecular docking and dynamics simulations

Resveratrol is a polyphenolic phytocompound known to possess anxiolytic-like effects but its impact on central gammaaminobutyric acid (GABA) modulation has never been explored. The purpose of this study was to analyze the anxiolytic-like effects of resveratrol alone and in combination with rufinamide, an antiepileptic drug which has never been studied for its anxiolytic potential. The BALB/c mice were tested in a battery of behavior testing after administration of resveratrol (50 mg/kg) and rufinamide (50 mg/kg) alone and in combination. Moreover, molecular docking studies were also carried out to understand the interaction of resveratrol and rufinamide with GABA aminotransferase, GABA receptor and GABA-A transporter type 1. Resveratrol alone exerted notable anxiolytic-like effects and improved outcomes in few experiments but rufinamide alone did not yield any beneficial outcomes. However, the animal co-administered with resveratrol and rufinamide behaved exceptionally well (p<0.05) and preferred open, illuminated and exposed areas of open field, light/dark and elevated plus maze. Further, these animals showed reduced anxiety towards anxiogenic stimuli i.e. holes and marbles in hole board and marble bury tests, respectively. Resveratrol and rufinamide showed moderate to strong binding affinities with GABA proteins, indicating the potential to treat anxiety-like neurological disorders. Moreover, resveratrol and rufinamide were analyzed using molecular docking to determine their interaction with GABA receptors, transporters, and transaminase. The results suggest that their anxiolytic-like effects may be due to inhibiting GABA reuptake transporter 1 protein, leading to increased synaptic levels of GABA neurotransmitter, as seen in stable molecular dynamics results with the 7SK2 GABA transporter protein.

Awareness of healthcare providers on environment-friendly practices in operating rooms in selected hospitals in Riyadh, Saudi Arabia

Climate change will have a great impact on humanity in upcoming years and will affect the health of all living creatures. Hospitals play a significant role in climate change due to their substantial waste production and they are considered a profound pollution source, with the Operating Theater as a main contributor. This study was aimed to examine the level of knowledge among healthcare professionals in Saudi Arabia concerning the proper implementation of operating room (OR) environmental procedures and efficient management of hospital waste. This is a cross sectional study performed across 3 hospitals in Riyadh, Saudi Arabia. The hospitals included are Prince Sultan military hospital, National guard hospital and King Salman hospital. The study included all the staff and health workers in OR (operating room), excluding all staff and health workers not in OR. The study took place between September 1 and November 1, 2022. None of the study participants mentioned that their institute or hospital fully engaged in Greenhealth Greening the OR initiative. Almost 1 to 3rd of the study participants (38.1%) mentioned that endorsement and participation in the practice of Greenhealth Greening the OR initiative was not implemented at all, and 45% of the participants were completely unaware of such an initiative. The study's findings suggest that healthcare providers in Saudi Arabia are not fully aware of environmentally friendly practices. Further, the current initiatives undertaken by the hospital administration fall short in attaining environmentally sustainable benchmarks.

Clean Energy Based Multigeneration System for Sustainable Cities: Thermodynamic, and Stability Analyses

This paper concerns the development and analysis of multigeneration systems based on hybrid sources such as biomass and wind. Industry requires different types of sources to provide several outputs, so the goal of this research was to fulfill the industrial requirement with optimization. The multigeneration cycle supplies enough power to satiate energy demands, i.e., power, cooling, hydrogen, air conditioning, freshwater, hot water, and heating. For this, the multigeneration cycle was modeled in the Engineering Equation Solver (EES) and Simulink to obtain optimized results for the industry. Energy and exergy for the multigeneration cycle were determined to assess the performance of the cycle and to investigate the optimized results for the overall system. This study shows that for configuration selection and design, different thermodynamic, economic, and environmental aspects should be considered. Based on the results, the selection of the best location for this multigeneration system was made. Power output from the wind turbine was around 7 MW and from biogas 0.6 MW. The overall exergy efficiency of the multigeneration system was found to be 0.1401.

Transcriptomic Responses of Mycoplasma bovis Upon Treatments of trans-Cinnamaldehyde, Carvacrol, and Eugenol

Mycoplasma bovis (M. bovis) is an insidious, wall-less primary bacterial pathogen that causes bovine pneumonia, mid-ear infection, mastitis, and arthritis. The economic losses caused by M. bovis due to culling, diminished milk production, and feed conversion are underestimated because of poor diagnosis/recognition. Treatment with common antibiotics targeting the cell wall is ineffective. Plant-derived antimicrobials (PDAs) such as food-grade trans-cinnamaldehyde (TC), eugenol (EU), and carvacrol (CAR) are inexpensive and generally regarded as safe for humans and animals yet possess strong anti-bacterial properties. In preliminary studies, we found that all three PDAs inhibited the growth of M. bovis in vitro. Through RNA sequencing, we report here that CAR affected the expression of 153 genes which included the downregulation of energy generation-related proteins, pentose phosphate pathway, and upregulation of ribosomes and translation-related proteins. Few differentially expressed genes were found when M. bovis was treated with TC, EU, or when the three PDAs were double or triple combined. Our results suggest that, as opposed to the effect of CAR, the growth-inhibitory effects of TC and EU at levels tested may be exerted through mechanisms other than gene expression regulations.

Neuropharmacological investigation, ultra-high performance liquid chromatography analysis, and in silico studies of Phyla nodiflora

The increasing burden of neurological disorders is becoming a worldwide health challenge and researchers are continuously struggling to cure them by utilizing the miraculous medicinal properties of plants. The crude methanolic extract of whole herb of Phyla nodiflora (Pn.Cr) was subjected to phytochemical, antioxidant and neuropharmacological assessment. The Pn.Cr was initially exposed to the in vitro examination for phytocomposition through ultra-high performance liquid chromatography (UHPLC). The Sprague Dawley rats were chronically administered with various doses (100, 200 and 300 mg/kg) of Pn.Cr for one month with subsequent exposure to neurobehavioral and biochemical experimentation. The Pn.Cr exhibited a dose-dependent anxiolytic effect (P < 0.05 in comparison to control) as rats preferred central, illuminated and open arm zones in open field (OFT), light/dark (L/D) and elevated plus maze (EPM) tests. Likewise, scopolamine-induced amnesia was noticeably reversed with P < 0.05 by Pn.Cr as animals showed improved spontaneous alternation, discrimination index and shorter escape latencies in Y-maze, novel object recognition (NOR) and Morris water maze (MWM) tests. Subsequently, in vivo enzymatic assays depicted the reduced acetylcholinesterase and malondialdehyde levels. The levels of oxidative stress combating enzymes (glutathione peroxidase and superoxide dismutase) were increased in a dose-dependent style. The UHPLC detected 22 phytocompounds were further investigated in silico studied to predict the interaction of blood-brain barrier (BBB) crossing phytocompounds with human acetylcholinesterase. The four BBB crossing phytocompounds belonging to flavonoids, chalcones and alkaloids showed possible interaction with the target enzyme. We found that the phytocompounds owned by Pn.Cr might be playing multiple roles in modulation of different pathways to hinder the pathophysiology of neurological disorders including anxiety and Alzheimer's disease.

Contemporary trends in the management of aortic stenosis in the USA

AIMS

To assess the contemporary trends in aortic stenosis (AS) interventions in the USA before and after the introduction of transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We utilized the National-Inpatient-Sample to assess temporal trends in the incidence, cost, and outcomes of AS interventions between 1 January 2003 and 31 December 2016. During the study's period, AS interventions increased from 96 to 137 per 100 000 individuals > 60 years old, P < 0.001. In-hospital expenditure on AS interventions increased from $2.28 billion in 2003 to $4.33 in 2016 P < 0.001. Among patients who underwent aortic valve replacement, the proportion of TAVI increased from 11.9% in 2012 to 43.2% in 2016 (P < 0.001). Males and Hispanics had lower proportions of TAVI compared with females and White patients. Adjusted in-hospital mortality of isolated SAVR decreased from 5.4% in 2003 to 3.3% in 2016 (P < 0.001), whereas adjusted in-hospital mortality of TAVI decreased from 4.7% in 2012 to 2.2% in 2016, P < 0.001. The incidence of new dialysis, permanent pacemaker implantation, and blood transfusion decreased after both TAVI and SAVR between 2012 and 2016. However, the rate of post-operative stroke did not significantly decrease. Length of stay and cost of hospitalization decreased after both SAVR and TAVI, although the later remained higher with TAVI. Rates of non-home discharge decreased over time after TAVI but remained stable after isolated SAVR.

CONCLUSION

This nationwide survey documents the increasing incidence of AS interventions, the rising cost of modern AS care, and the paradigm shift in aortic valve replacement practice in the USA.

Differences in the characteristics and outcomes of isolated tricuspid and mitral valve surgery for valvular regurgitation

BACKGROUND

Isolated tricuspid valve (TV) surgery is associated with markedly worse outcomes than isolated mitral valve (MV) surgery. We hypothesized that this is related to late referral of patients with isolated TV disease.

METHODS

Adult patients who underwent isolated TV or MV surgery in 2016-2017 were identified in the National-Readmission-Database. We compared the outcomes of isolated TV and MV surgery before and after adjustment for surrogates of late referral.

RESULTS

A total of 21,446 patients who had isolated MV (n = 19,933), or TV surgery (n = 1153) were included. Patients in the TV group were younger (55.7 ± 16.6 vs. 63.4 ± 12.3 years), had lower socioeconomic status, but higher prevalence of surrogates for late referral [acute HF 41.0% vs. 22.0%, advanced liver disease 16.8% vs. 2.6%, non-elective surgery status 44.3% vs. 23.5%, need for peri-operative mechanical circulatory support 27.7% vs. 4.7%, and unplanned admissions in the 90 days before surgery 31.0% vs. 18.8%, (P < 0.001 for all)]. Surgery was performed on day 0/1 of the admission in 80% of patients in the MV group and 52% in the TV group, P < 0.001. Repair rate was 63.5% in the TV group and 56.3% in the MV group (P < 0.001). In-hospital mortality was 3-folds higher after TV surgery (8.7% vs. 2.5%; OR = 3.41, 95%CI 2.73-4.25, p < 0.001). However, this difference became non-significant after adjusting for baseline characteristics including surrogates for late referral (OR = 1.24, 95%CI 0.85-1.82, p = 0.27).

CONCLUSION

The poor outcomes of isolated TV surgery compared with isolated MV surgery may be largely explained by the late referral for intervention in patients with isolated TR.

Bed Surge Capacity in Saudi Hospitals During the COVID-19 Pandemic

OBJECTIVES

To assess the hospital beds and intensive care unit (ICU) beds with a ventilator surge capacity of the health system in Kingdom of Saudi Arabia (KSA) during the coronavirus disease (COVID-19) pandemic.

METHODS

This study used relevant data from the National Health Emergency Operation Center to estimate general hospital and ICU bed surge capacity and tipping points under 3 distinct transmission scenarios.

RESULTS

The study results reveal that hospitals in the KSA need to be supplied with additional 4372 hospital beds to care for COVID-19 positive cases if the pandemic continues over a 6 months' period. At the same time, it requires additional 2192 or 1461 hospital beds if the pandemic persists over a 12- or 18-month period, respectively, to manage hospitalized COVID-19 overloads. The health system surge capacity would suffer from a shortage of 1600, 797, and 540 ICU beds under the 3 transmission scenarios to absorb critical and intensive care COVID-19 cases.

CONCLUSION

Our findings highlight the urgent need for additional hospital and ICU beds in the face of critical COVID-19 cases in KSA. The study recommends further assessment measures to the health system surge capacity to keep the Saudi health system prepared during the COVID-19 pandemic.

Predictors of Use and Outcomes of Mechanical Valve Replacement in the United States (2008-2017)

Background

Contemporary nationwide data on the use, predictors, and outcomes of mechanical valve replacement in patients less than 70 years of age are limited.

Methods and Results

We identified hospitalizations for aortic valve replacement (AVR) or mitral valve replacement (MVR) in the Nationwide Inpatient Sample between January 1, 2008, and December 31, 2017. The study's end points included predictors of mechanical valve replacement and risk‐adjusted in‐hospital mortality. Among 253 100 hospitalizations for AVR, the use rate of mechanical prosthesis decreased from 45.3% in 2008 to 17.0% in 2017. Among 284 962 hospitalizations for MVR, mechanical prosthesis use decreased from 59.5% in 2008 to 29.2% in 2017 (P for trend<0.001). In multilogistic regression analyses, female sex, prior sternotomy, prior defibrillator, and South/West geographic location were predictive of mechanical valve use. The presence of bicuspid valve was a negative predictor of mechanical AVR (odds ratio [OR], 0.68; 95% CI, 0.66–0.69; P<0.001), whereas mitral stenosis was associated with higher mechanical MVR (OR, 1.28; 95% CI, 1.22–1.33; P<0.001). Unadjusted in‐hospital mortality decreased over time with AVR but not with MVR, regardless of prosthesis choice. Using years 2008 and 2009 as a reference, risk‐adjusted mortality also decreased over time with AVR but did not decrease after MVR.

Conclusions

There is a substantial decline in the use of mechanical valve replacement among patients aged ≤70 years in the United States. Long‐term durability data on bioprosthetic valve replacement are needed to better define the future role of mechanical valves in this age group.

Association of Transcatheter Mitral Valve Repair Availability With Outcomes of Mitral Valve Surgery

Background

Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery.

Methods and Results

We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P<0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30‐day readmission rates. After propensity matching, mortality remained higher at non‐TMVr centers (5.5% versus 4.0%, P<0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non‐TMVr centers in multiple risk‐adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non‐TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14–1.73; P=0.002).

Conclusions

Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.

Evaluation of the mode of failure of abutments supporting implant-supported fixed partial dentures via different retention techniques

Objective

The objective was to in-vitro evaluate the mode of failure of abutments supporting fixed partial dentures (FPDs) via different retention techniques.

Materials and Methods

Thirty-six implants with diameter and length of 4.5 and 13 mm, respectively, were used to prepare 18 samples of FPDs. Based on the variations on abutment's design, the FPDs were divided into three groups: Group A is cement-based retention; Group B is screw-based retention; and Group C is multiunit screw-based retention. Using a chewing simulator, cyclic loads of 1,250,000 load cycles with the load of 70N were applied on all samples to simulate 5 years of human functional chewing. The samples were loaded until failure using an electromechanical test machine. Sample-size estimation was done and fracture-load values were recorded as means and corresponding standard deviations; and group comparisons were done using one-way analysis of variance and Tukey's post hoc tests. A P value below 0.01 was nominated as an indicator of statistical significance.

Results

In total, 36 samples (12 implant-abutment connections per group) were assessed. Abutment bending was observed in 6 (50%), 6 (50%) and 6 (50%) samples in groups A, B and C, respectively. De-attachment of the FPD form the abutment occurred in 5 (41.7%) and 5 (41.7%) samples in groups A and C, respectively. Screw fracture and fracture of FPD at the connector side occurred in 1 (8.3%) and 1 (8.3%) sample in groups A and C, correspondingly. Failure of the FPD was more often encountered in groups A (100%) and C (100%), compared to group B (50%).

Conclusion

All abutments underwent failures under cyclic loading with abutment bending being the most common failure mode. Cement- and multi-screw-supported abutments fail more often than screw-supported abutments.

Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction

OBJECTIVE

To assess the impact of female sex on the incidence, management, and outcomes of myocardial infarction (MI) in different age groups.

METHODS

Patients admitted with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI), between January 1, 2003, and December 31, 2015, were identified in the National Inpatient Sample. We compared STEMI and NSTEMI rates, management patterns, and in-hospital morbidity and mortality in men and women stratified into 4 age groups (<45, 45 to 64, 65 to 84, and ≥85 years of age).

RESULTS

A total of 6,720,639 weighted hospitalizations for MI (79.8% NSTEMI, and 20.2% STEMI) were included. The incidence rate of hospitalizations for MI was lower in women than men across all age groups. Women were less likely than men to undergo coronary angiography, revascularization, or to use circulatory-support devices. These differences were consistent across all age groups. Adjusted odds of death for women (vs men) varied by age: odds ratio (95% confidence interval) 1.08 (0.97 to 1.20), 1.05 (1.02 to 1.08), 0.92 (0.91 to 0.94), and 0.86 (0.85 to 0.88) for NSTEMI, and 1.15 (1.04 to 1.27), 1.22 (1.18 to 1.26), 1.09 (1.06 to 1.11), and 0.97 (0.94 to 0.99), for STEMI, in age groups (<45, 45 to 64, 65 to 84, and ≥85), respectively. The magnitude of differences in complications between men and women was higher in younger and middle-age patients.

CONCLUSION

Compared with men, women have lower incidence of MI and less likelihood of undergoing invasive treatment regardless of age. However, post-MI outcomes are age specific. The negative impact of female sex on most outcomes was most pronounced in young and middle-aged women.

Association of chronic kidney disease with in-hospital outcomes of endovascular stroke interventions

BACKGROUND

Data on the differential impact of chronic kidney disease (CKD) on the outcomes of endovascular stroke interventions (ESI) for acute ischemic stroke (AIS) are limited.

METHODS

Adult patients who underwent ESI for AIS between October 1st, 2015 and September 30th, 2019, were identified in a national multicenter database. The primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints included intracranial hemorrhage, mechanical ventilation, pneumonia, myocardial infarction, blood transfusion, length of stay, and cost. A multilevel mixed-effects regression model was used to derive adjusted outcomes.

RESULTS

A total of 22,193 AIS patients who underwent ESI at 99 centers were included. Among those, 18,881 (85%) had no CKD, and 3312 (15%) had CKD. Patients with CKD were older and had a higher prevalence of key comorbidities. After multivariable risk adjustment, patients with CKD had significantly higher in-hospital mortality (Odds Ratio [OR] 1.55 [95% Confidence Interval] [CI] 1.40-1.73, p < 0.01), and poor functional outcomes (OR 1.38, 95%CI 1.26-1.50, p < 0.01). Major complications, including mechanical ventilation, pneumonia, blood transfusion, and myocardial infarction, were more common among CKD patients, who also had longer hospitalizations and accrued higher cost.

CONCLUSION

The presence of CKD in patients with AIS treated with ESI is an independent predictor of in-hospital mortality and poor functional outcomes at discharge.

Determinants of Morbidity and Mortality Associated With Isolated Tricuspid Valve Surgery

Background

Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown.

Methods and Results

Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016–2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In‐hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7–35 days), and median cost was $87 223 ($43 122–$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in‐hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74–8.25 [P<0.001]). This was also consistent in a second model incorporating unplanned hospitalizations in the 90 days before surgery as a surrogate for late referral (OR, 5.50; 95% CI, 2.28–10.71 [P<0.001]).

Conclusions

The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.

Time course evaluation of lacosamide alone and in polypharmacy on behavioral manifestations and oxidative stress in lithium-pilocarpine-induced model

The lithium-pilocarpine model in rats is commonly used to study the characteristic events of acute status epilepticus (SE), epileptogenesis and temporal lobe epilepsy (TLE). Here we investigated the impact of lacosamide alone and in combination with other drugs (pregabalin, piracetam and scopolamine) on spontaneous recurrent seizures (SRSs) and behavioral parameters during the time frame of 6 weeks after SE. In addition, the level of oxidative stress in the hippocampus was accessed by real-time microdialysis study (8-isoprostanes) and antioxidants enzymes in the homogenate. Results revealed severe behavioral deficits with the control epileptic group and animals displayed hyperexcitability, aggression apprehension and memory insufficiency. Pharmacological manipulation for 6 weeks with lacosamide (L) - 80 mg/kg; in polypharmacy with pregabalin (L/P) - 50/50 mg/kg and piracetam (L/Pi) - 50/140 mg/kg significantly (P < 0.05) ameliorated the anxiety-related behavior (open filed, elevated plus maze, light/dark tests), depression (forced swim test) and improved spatial/reference memory (Morris water maze). There were low incidences of seizures in L, L/P and L/Pi groups revealing disease-modifying effects of employed drugs. Furthermore, the chronic use of scopolamine (L/P/S; 50/50/2 mg/kg) as polypharmacy with the concept of antagonizing the cholinergic inputs in the epileptogenic phase aberrated the behavioral situation further worse. Treatments with L/P and L/Pi significantly attenuated (P < 0.05) the oxidative stress by reducing 8-isoprostanes and malondialdehyde (MDA) levels. Furthermore, superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels in the L/P group were significantly (P < 0.05) improved. Overall, our findings support the use of a combination of drugs (L/P and L/Pi) in lithium-pilocarpine model which remarkably ameliorated SRSs, reduced anxiety-related behaviors, retention of spatial/reference memory and lowered oxidative stress in a time-course evaluation 6 weeks post- SE insult.

Temporal Trends in Resource Use, Cost, and Outcomes of Transcatheter Aortic Valve Replacement in the United States

OBJECTIVE

To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States.

METHODS

We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR.

RESULTS

A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P<.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P<.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P<.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P<.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P<.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017.

CONCLUSION

This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Temporal Trends in the Incidence and Outcomes of Pacemaker Implantation After Transcatheter Aortic Valve Replacement in the United States (2012-2017)

Background

Nationwide studies documenting temporal trends in permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) are limited.

Methods and Results

We selected patients who underwent TAVR between 2012 and 2017 in the National Readmission Database. The primary end point was the 6‐year trend in post‐TAVR PPMI at index hospitalization and at 30, 90, and 180 days after discharge. The secondary end point was the association between PPMI and in‐hospital mortality, stroke, cost, length of stay, and disposition. Among the 89 202 patients who underwent TAVR, 77 405 (86.8%) with no prior pacemaker or defibrillator were included. Patients who required PPMI had a higher prevalence of atrial fibrillation (43.6% versus 38.7%, P<0.001) and conduction abnormalities (28.4% versus 15.3%, P<0.001). The incidence of PPMI during index admission increased from 8.7% in 2012 to 13.2% in 2015, and then decreased to 9.6% in 2017. The incidence of inpatient PPMI within 30 days after discharge increased from 0.5% in 2012 to 1.25% in 2017 (P_trend<0.001). Inpatient PPMI beyond 30 days remained rare (<0.5%) during the study period. After risk adjustment, PPMI was not associated with in‐hospital mortality or stroke but was associated with increased nonhome discharge, longer hospitalization, and higher cost. The incremental expenditure associated with post‐TAVR PPMI during index admission increased from $9.6 million to $72.2 million between 2012 and 2017.

Conclusions

After an upward trend, rates of PPMI after TAVR in the United States stabilized at ~10% in 2016 to 2017, but there was a notable increase in PPMI within 30 days after the index admission. PPMI was not associated with increased in‐hospital morbidity or mortality but led to longer hospitalization, higher cost, and more nonhome discharges.

Clinical Outcomes of On-Site Versus Off-Site Endovascular Stroke Interventions

OBJECTIVES

The aim of this study was to assess whether offering local endovascular stroke therapy (EST) rather than transferring patients off-site to receive EST would improve outcomes.

BACKGROUND

There are limited data to determine whether offering EST on-site rather than transferring patients to receive EST off-site improves clinical outcomes.

METHODS

A large academic consortium database was queried to identify patients with acute ischemic stroke who received EST between October 2015 and September 2019. Primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints were major complications, length of stay, and cost. Baseline characteristics were adjusted for using propensity score matching and multivariate risk adjustment.

RESULTS

A total of 22,193 patients with acute ischemic stroke who underwent EST (50.8% on-site, 49.2% off-site) were included. Mean ages were 67.9 ± 15.5 years and 68.4 ± 15.5 years, respectively (p = 0.03). In the propensity score matching analysis, mortality and poor functional outcomes were higher in the off-site EST group (14.7% vs. 11.2% and 40.7% vs. 35.9%, respectively; p < 0.001). In the risk-adjusted analyses with different models, in-hospital mortality and poor functional outcomes remained significantly higher in the off-site EST group. In the most comprehensive model (adjusting for age, sex, demographics, risk factors, tissue plasminogen activator use, and institutional EST volume), in-hospital mortality and poor functional outcomes were significantly higher in the off-site EST group, with odds ratios of 1.38 (95% confidence interval: 1.26 to 1.51) and 1.26 (95% confidence interval: 1.18 to 1.34), respectively (p < 0.001). The incidence of intracranial hemorrhage and mechanical ventilation was higher in the off-site group, but cost was higher in the on-site group in both the propensity score matching and risk-adjusted analyses.

CONCLUSIONS

In contemporary U.S. practice, patients with acute ischemic stroke treated with EST on-site had lower in-hospital mortality and better functional outcomes compared with those transferred off-site for EST.

Hospital screening for obstructive sleep apnea in patients admitted to a rural, tertiary care academic hospital with heart failure

BACKGROUND

Rural communities represent a vulnerable population that would significantly benefit from hospital-based OSA screening given these areas tend to have significant health-care disparities and poor health outcomes. Although inpatient screening has been studied at urban hospitals, no study to date has assessed this approach in rural populations.

METHODS

This study utilized the Electronic Medical Record (EMR) to generate a list of potential candidates by employing inclusion/exclusion criteria as screening. Subjects identified were then approached and offered information regarding the study. Screening for OSA entailed a tiered approach utilizing the sleep apnea clinical score (SAC) and portable sleep testing. Individuals identified as high risk (SAC ≥ 15) for OSA underwent evaluation with a portable sleep testing system while hospitalized. All participants with an apnea-hypopnea index (AHI) ≥5 events/h confirmed by a sleep medicine physician were considered screen positive for OSA. If approved/available, subjects screening positive for OSA were provided with an auto-titrating continuous positive airway pressure (PAP). Patient characteristics were analyzed using descriptive statistics. Categorical data were described using contingency tables, including counts and percentages. Continuously scaled measures were summarized by median with range. This study was registered with ClinicalTrials.gov. Identifier: NCT03056443.

RESULTS

Nine hundred and fifty-eight potential subjects were identified. The three most common reasons for exclusion included previous OSA diagnosis or exposure to PAP therapy (n = 357), advanced illness (n = 380), and declined participation by the individual (n = 68). The remaining 31 subjects underwent further evaluation for obstructive sleep apnea. Twenty-three subjects had a high sleep apnea clinic score. Per our study protocol, 13 subjects who screened positive for OSA were initiated on APAP therapy. Conclusion: Our study provides important insight into the burden of sleep-disordered breathing (SDB) and unique challenges of hospital-based OSA screening/treatment in a rural setting. Our study identified barriers to successful screening in a rural population that may be well addressed by adapting previous research in hospital sleep medicine.

Mortality and morbidity in patients with atrial fibrillation and liver cirrhosis

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice. However, the outcomes associated with AF in hospitalized patients with liver cirrhosis are unknown.

AIM

To determine the outcomes of hospitalized patients with liver cirrhosis and AF.

METHODS

In this study, we examined morbidity and mortality of patients with concomitant AF and liver cirrhosis from the National Inpatient Sample database, the largest publicly available inpatient healthcare database in the United States.

RESULTS

A total of 696937 patients with liver cirrhosis were included, 45745 of whom had concomitant AF (6.6%). Liver cirrhosis patients with AF had higher rates of in-hospital mortality (12.6% vs 10.3%, P < 0.001), clinical stroke (1.6% vs 1.1%, P < 0.001), and acute kidney injury (28.2% vs 25.1%, P < 0.001), and less gastrointestinal bleeding (4.4% vs 5.1%, P < 0.001) and blood transfusion (22.5% vs 23.8%, P < 0.001) compared with those who did not have the arrhythmia. In addition, they had a longer length of stay (8 ± 10 d vs 7 ± 8 d, P < 0.001) and higher hospitalization costs (20720 ± 33210 $ vs 16272 ± 24166 $, P < 0.001).

CONCLUSION

In subjects with liver cirrhosis, AF is associated with higher rates of inpatient mortality, stroke, and acute kidney injury compared to those who do not have the cardiac arrhythmia.

Complete mitochondrial genome of the water vole, Microtus richardsoni (Cricetidae, Rodentia)

Water voles (Microtus richardsoni) are sensitive species distributed in the mountains of Canada (Alberta, British Columbia), and the United States of America (Idaho, Montana, Oregon, Utah, Washington, and Wyoming). We assembled the complete circular M. richardsoni mitogenome, which is 16,285 bp in length and encodes 13 protein-coding genes, 22 tRNA genes, and two rRNA genes. We estimated the phylogenetic tree of M. richardsoni and 24 related arvicoline species with two outgroup species: Phodopus roborovskii and Cricetus cricetus.

Observed versus Expected Ischemic and Bleeding Events Following Left Atrial Appendage Occlusion

Data on the efficacy of left atrial appendage occlusion (LAAO) in clinical practice are limited. We performed a systematic review and meta-analysis of observational studies that reported observed versus expected rates of ischemic strokes and/or major bleeding following LAAO. Our primary end points were the pooled relative risk reduction (RRR) in ischemic stroke and major bleeding with corresponding 95% confidence intervals compared with what was expected by the CHA2DS2-VASc and HASBLED scores, respectively. Twenty-nine studies including 11,071 patients (age 74.0 ± 8.7 years, 60% males) met the inclusion criteria. The mean CHA2DS2-VASc score was 4.22 ± 1.48, and the mean HASBLED score was 3.04 ± 1.16. During 19,567 patient-year follow-up, 290 of 11,071 patients (2.62%) suffered an acute ischemic stroke. This represented a 73.6% (95% confidence interval 68.9-78.2%) RRR in ischemic strokes compared with what was expected based on the CHA2DS2-VASc score. A total of 26 studies reported observed versus expected major bleeding (10,056 patients; age 74.0 ± 8.7, 60% males). During 16,967 patient-year follow-up, 404 of 10,056 patients (4.0%) suffered a major bleeding event. This represented a 55% (95% confidence interval 44.2% to -65.9%) RRR in major bleeding compared with what was expected based on the HASBLED score. These estimates were consistent across subgroups stratified according to age, CHADS2VASc, HASBLED scores and type of LAAO device used. In conclusion, LAAO is associated with a favorable observed/expected ratio with regards to ischemic stroke and major bleeding in clinical practice. Future clinical trials remain essential to further assess the efficacy of LAAO via a direct comparison with oral anticoagulation.

Incidence, Characteristics, and Outcomes of Acute Myocardial Infarction among Patients Admitted with Acute Exacerbation of Chronic Obstructive Lung Disease

The frequency, characteristics and outcomes of acute myocardial infarction (AMI) during exacerbation of chronic obstructive pulmonary disease (COPD) are unknown. Adult patients hospitalized with a principle diagnosis of acute COPD exacerbation were identified using retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2003 to 2016. Patients were stratified into 2-groups with and without a secondary diagnosis of AMI. The study's endpoints were in-hospital morbidity, mortality, and resource utilization. We also assessed the impact of invasive management strategy on the same end-points. We included 6 894 712 hospitalizations, of which 56 515 (0.82%) were complicated with AMIs. Patients with AMI were older, and had higher prevalence of known coronary disease (48.9% vs. 27.4%), atrial fibrillation (23.3% vs. 15.2%), heart failure (47.8% vs. 26.2%), and anemia (20.7% vs. 14.8%) (p < 0.001). Rates of oxygen dependence were similar (16.3% vs. 16.1%, p = 0.24). In 56 486 propensity-matched pairs of patients with and without AMI, mortality was higher in the AMI group (12.1% vs. 2.1%, p < 0.001). Rates of major morbidities, non-home discharge, and cost were all higher in the AMI group. A minority (18.1%) of patients with AMI underwent invasive assessment, and those had lower in-hospital mortality before (4.9% vs. 13.8%) and after (5.0% vs. 10.0%) propensity-score matching (p < 0.001). This lower mortality persisted in a sensitivity analysis accounting for immortal time bias. AMI complicates ∼1% of patients admitted with acute COPD exacerbation, and those have worse outcomes than those without AMI. Invasive management for secondary AMI during acute COPD exacerbation may be associated with improved outcomes but is utilized in <20% of patients.

Clinical and Economic Burden of Hospitalizations for Infective Endocarditis in the United States

OBJECTIVE

To assess contemporary trends in the incidence, characteristics, and outcomes of hospital admissions for infective endocarditis (IE) in the United States.

PATIENTS AND METHODS

Patients ≥18 years admitted with IE between January 1, 2003, and December 31, 2016, were identified in the National Inpatient Sample. We assessed the annual incidence, clinical characteristics, morbidity, mortality, and cost of IE-related hospitalizations.

RESULTS

The incidence of IE-related hospitalizations increased from 34,488 (15.9; 95% confidence interval [CI], 15.73, 16.06) per 100,000 adults) in 2003 to 54,405 (21.8; 95% CI, 21.60-21.97) per 100,000 adults) in 2016 (P<.001). The prevalence of patients below 30 years of age, and those who inject drugs, increased from 7.3% to 14.5% and from 4.8% to 15.1%, respectively (P<.001). The annual volume of valve surgery for IE increased from 4049 in 2003 to 6460 in 2016 (P<.001), but the ratio of valve surgery to IE-hospitalizations did not decrease (11.7% in 2003; 11.8% in 2016). There was also a temporal increase in risk-adjusted rates of stroke (8.0% to 13.2%), septic shock (5.4% to 16.3%), and mechanical ventilation (7.7% to 16.5%; P<.001). However, risk-adjusted mortality decreased from 14.4% to 9.8% (P<.001). Median length-of-stay and mean inflation-adjusted cost decreased from 11 to 10 days and from $45,810±$61,787 to $43,020±$55,244, respectively, (P<.001). Nonetheless, the expenditure on IE hospitalizations increased ($1.58 billion in 2003 to $2.34 billion in 2016; P<.001).

CONCLUSIONS

There is a substantial recent rise in endocarditis hospitalizations in the United States. Although the adjusted in-hospital mortality of endocarditis and the cost of admission decreased over time, the overall expenditure on in-hospital care for endocarditis increased.

Early Experience With Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement in the United States

This survey study evaluates the early post–US Food and Drug Administration approval experience with an embolic protection device used during transcatheter aortic valve replacement procedures.

Temporal Trends and Predictors of Pancreatitis Patients Who Leave Against Medical Advice: A Nationwide Analysis

Background

Acute pancreatitis is the leading gastrointestinal cause of hospital admissions. Our study aims to determine the trends and predictors of discharge against medical advice (AMA).

Methods

We utilized the Nationwide Inpatient Sample (2003 - 2016) to identify patients admitted with pancreatitis. We compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression.

Results

A total of 7,158,894 patients were admitted with pancreatitis. Of those, 199,351 left AMA. Discharge AMA increased over time from 2.3% to 3.2%. Patients who left AMA were more likely to be younger, male, black, and a lower socioeconomic status (SES). They had a greater prevalence of depression, cirrhosis, smoking, drug abuse, and human immunodeficiency virus (HIV) infection. Alcohol use was the most likely etiology of pancreatitis among those leaving AMA. In a multivariate regression, patients more likely to leave AMA included: age 18 - 44, male, and black. Patients with a history of depression, drug abuse, and HIV infection were also more likely to be discharged AMA.

Conclusions

Discharges AMA increased over time. Predictors of AMA include patients who are younger, male, black, lower socioeconomic status, and have a history of depression, HIV infection, alcohol and drug use. Future studies are necessary to examine the reasons for discharge AMA among this population.

Cardiovascular Outcomes and Rehospitalization Rates in Homeless Patients Admitted With Acute Myocardial Infarction

OBJECTIVE

To study the in-hospital outcomes and 30-day readmission data in homeless patients admitted with acute myocardial infarction (AMI).

METHODS

Adult patients (>18 years of age) who were admitted with AMI between January 1, 2015, and December 31, 2016, were identified in the National Readmission Database. Patients were classified into homeless or non-homeless. Baseline characteristics, rates of invasive assessment and revascularization, mortality, 30-day readmission rates, and reasons for readmission were compared between the 2 cohorts.

RESULTS

A total of 3938 of 1,100,241 (0.4%) index hospitalizations for AMI involved homeless patients. Compared with non-homeless patients, homeless patients were younger (mean age, 57±10 years vs 68±14 years; P<.001) and had a lower prevalence of atherosclerotic risk factors (hypertension, hyperlipidemia, and diabetes) but a higher prevalence of anxiety, depression, and substance abuse. Homeless patients were less likely to undergo coronary angiography (38.1% vs 54%; P<.001), percutaneous coronary intervention (24.1% vs 38.7%; P<.001), or coronary artery bypass grafting (4.9% vs 6.7%; P<.001). Among patients who underwent percutaneous coronary intervention, bare-metal stent use was higher in homeless patients (34.6% vs 12.1%; P<.001). After propensity score matching, homeless patients had similar mortality but higher rates of acute kidney injury, discharge to an intermediate care facility or against medical advice, and longer hospitalizations. Thirty-day readmission rates were significantly higher in homeless patients (22.5% vs 10%; P<.001). Homeless patients had more readmissions for psychiatric causes (18.0% vs 2.0%; P<.001).

CONCLUSION

Considerable differences in cardiovascular risk profile, in-hospital care, and rehospitalization rates were observed in the homeless compared with non-homeless cohort with AMI. Measures to remove the health care barriers and disparities are needed.

Statistical Mitogenome Assembly with RepeaTs

By using next-generation sequencing technologies, it is possible to quickly and inexpensively generate large numbers of relatively short reads from both the nuclear and mitochondrial DNA (mtDNA) contained in a biological sample. Unfortunately, assembling such whole-genome sequencing (WGS) data with standard de novo assemblers often fails to generate high-quality mitochondrial genome sequences due to the large difference in copy number (and hence sequencing depth) between the mitochondrial and nuclear genomes. Assembly of complete mitochondrial genome sequences is further complicated by the fact that many de novo assemblers are not designed for circular genomes and by the presence of repeats in the mitochondrial genomes of some species. In this article, we describe the Statistical Mitogenome Assembly with RepeaTs (SMART) pipeline for automated assembly of mitochondrial genomes from WGS data. SMART uses an efficient coverage-based filter to first select a subset of reads enriched in mtDNA sequences. Contigs produced by an initial assembly step are filtered using the Basic Local Alignment Search Tool searches against a comprehensive mitochondrial genome database and are used as "baits" for an alignment-based filter that produces the set of reads used in a second de novo assembly and scaffolding step. In the presence of repeats, the possible paths through the assembly graph are evaluated using a maximum likelihood model. Additionally, the assembly process is repeated for a user-specified number of times on resampled subsets of reads to select for annotation of the reconstructed sequences with highest bootstrap support. Experiments on WGS data sets from a variety of species show that the SMART pipeline produces complete circular mitochondrial genome sequences with a higher success rate than current state-of-the-art tools, particularly for low-coverage WGS data sets.

Increasing Rates of Infective Endocarditis in Patients with Inflammatory Bowel Disease

Introduction and aim Infective endocarditis (IE) cases are on the rise in the United States. The incidence of IE in patients with inflammatory bowel disease (IBD) has not been reported. Utilizing a national level database, we sought to estimate the incidence of IE in IBD-related hospitalizations and to determine its outcomes.  Methods Discharge records from the National Inpatient Sample were analyzed, and the International Classification of Diseases, ninth revision, Clinical Modification codes (ICD-9-CM) was used to identify adult patients with IBD (Crohn's disease or ulcerative colitis) and IE between 2003 and 2014. Trends in the incidence of IE were recorded and multivariable regression was used to determine the impact of IE on IBD-hospitalizations. Results The incidence of IE in patients with IBD rose from 14.5 cases per 10,000 admissions in 2003 to 21.7 in 2014. After multivariable adjustment, both patient groups with CD (odds ratio [OR] 3.5, 95% confidence interval [CI] 3.0-4.1) and UC (OR 2.9, 95% CI 2.5-3.5) admitted with IE were found to be at greater risk for in-hospital mortality compared to non-IE admissions. Patients with IBD admitted with IE were found to have greater mean length of stay (13 days vs. six days, p<0.0001) and higher average hospital charges ($36,869.85 vs. $13,324.01, p <0.0001) compared to non-IE admissions.  Conclusions Infective endocarditis is a growing complication in patients with IBD and is associated with increased mortality and utilization of healthcare resources. Further studies addressing the association between IE and IBD are needed.