A real-world assessment of the burden associated with hospitalizations in US patients with heart failure and left ventricular ejection fraction (LVEF) greater than 40%

Background and purpose

Heart failure (HF) is one of the leading causes of hospitalization among older adults and is associated with a large burden of disease for the individual, the patient's family, healthcare systems, and society. This study assessed the burden of hospitalizations in patients with HF with LVEF >40% in the United States (US).

Methods

This retrospective, non-interventional study identified adult patients with incident or prevalent HF in Optum® de-identified Electronic Health Record (EHR) dataset (2007–2018) between 01/01/2013 and 31/12/2017. Optum's longitudinal EHR repository is derived from dozens of healthcare provider organizations in the US, that include more than 700 Hospitals and 7000 Clinics; treating >95 million patients receiving care in the US. Patients were followed for up to 1 year or until last active date whichever occurred first. Comorbidities, all-cause hospitalizations (AcH) and primary cause HF hospitalizations (HFH) were analysed.

Results

120,606 patients with HF and LVEF >40% (54% female) with a mean (SD) age of 71 (13) yrs were included, representing 80,324.74 patient-yrs follow-up (days). Common comorbidities were hypertension (91.8%), ischemic heart disease (IHD, 71.4%), atrial fibrillation (AF, 54.8%), renal disease (54.1%), type 2 diabetes (T2D, 50.7%), obesity (44.6%) and anemia (39%). Comorbidities including IHD (72.9% vs. 68.4%), AF (56.4% vs. 51.6%) and T2D (51.1% vs. 49.9%) were more often recorded in patients with LVEF >40-≤60% than >60% cohort while hypertension (91.6% vs. 92.2%), renal disease (53.8% vs. 54.6%), obesity (43.9% vs. 46.1%) and anemia (38.1% vs. 40.9%) had significantly higher frequency in the LVEF >60% cohort. The annualized AcH rate for patients with LVEF>40% was 1.44 and annualized HFH rate was 0.24 with a median length of stay of 3 and 4 days, respectively. Annualized hospitalization rates were significantly higher for women than men (both AcH and HFH). AcH rates were significantly higher and HFH rates were significantly lower for patients with LVEF>60% compared with LVEF >40-≤60.

Conclusions

This study demonstrates that patients with HF and LVEF >40% experience significant burden from comorbidities and hospitalizations from any-cause and for HF. The hospitalization rates are higher in women (both AcH and HFH) or patients with LVEF >60% (AcH only). Further focus on reduction of hospitalizations and interdisciplinary management of patients with HF should be warranted.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

Stabilization of Stormwater Biofilters: Impacts of Wetting and Drying Phases and the Addition of Organic Matter to Filter Media

Ripening period refers to a phase of stabilization in sand filters in water treatment systems that follow a new installation or cleaning of the filter. Intermittent wetting and drying, a unique property of stormwater biofilters, would similarly be subjected to a phase of stabilization. Suspended solids are an important parameter that is often used to monitor the stabilization of sand filters in water treatment systems. Stormwater biofilters, however, contain organic material that is added to the filter layer to enhance nitrate removal, the dynamics of which is seldom analyzed in stabilization of stormwater biofilters. Therefore, in this study of stormwater biofiltration in addition to suspended solids (turbidity), organic matter (TOC, DOC, TN, and TKN) was also monitored as a parameter for stabilization of the stormwater biofilter. One Perspex bioretention column (94 mm internal diameter) was fabricated with filter layer that contained 8 % organic material and fed with tapwater with different antecedent dry days (0-40 day) at 100 mL/min. Samples were collected from the outflow at different time intervals between 2 and 150 min and were tested for total organic carbon, dissolved organic carbon, total nitrogen, total Kjeldhal nitrogen, and turbidity. The column was observed to experience two phases of stabilization, one at the beginning of each event that lasted for 30 min, while the other phase was observed across subsequent events that are related to the age of filter.

Simultaneous heart and kidney transplantation in patients with end-stage heart and renal failure

Combined simultaneous organ transplantation has become more common as selection criteria for transplantation have broadened. Broadening selection criteria is secondary to improved immunosuppression and surgical techniques. The kidney is the most common extrathoracic organ to be simultaneously transplanted with the heart. A series of 13 patients suffering from both end-stage heart and renal failure underwent 14 simultaneous heart and kidney transplantations at Temple University Hospital between 1990 and 1999. This is the largest series reported from a single center. Three patients died during the initial hospitalization for an in-hospital mortality of 21%. Of 10 patients who left the hospital, 1-year survival was 100% and 2-year survival 75%. One patient required retransplant for rejection within the first year. Overall mortality at 1 and 2 years was 25 and 41%, respectively. Four out of nine (44%) patients greater than 5 years post-transplant were alive. Of the 10 patients who left the hospital, 66% were alive at 5 years. One patient succumbed to primary nonfunction of the cardiac allograft, while the four other deaths were secondary to bacterial or fungal sepsis. The patient's racial backgrounds were equally divided between African-American and white. These results are similar to those reported in a United Network of Organ Sharing Database (UNOS) registry analysis of 84 simultaneous heart and kidney transplants that found 1- and 2-year survival to be 76 and 67%, respectively. Simultaneous heart and kidney transplantation continues to be a viable option for patients suffering from failure of these two organ systems, although the results do not match those of heart transplant alone.

Characterization of an insulin-like growth factor (IGF) receptor and the insulin-like effects of IGF-1 in the bony fish, Lates calcarifer

The present work is part of a broad phylogenetic study of the insulin superfamily of peptides in lower vertebrates. In the bony fish barramundi (Lates calcarifer), the presence of IGF receptors were investigated in the liver by means of competitive binding studies. The results suggested the presence of a type 1-like but no type 2-like IGF receptor. We also demonstrated insulin-like effects of intraperitoneally injected recombinant human (rh)-IGF-1 in barramundi with rh-IGF-1 and rh-insulin showing similar effects with respect to induction of hypoglycemia and stimulation of incorporation of [14C]-glucose into muscle glycogen.

CNTF induces raphe neuronal precursors to switch from a serotonergic to a cholinergic phenotype in vitro

Ciliary neurotrophic factor (CNTF) is a multifunctional cytokine that mediates survival and differentiation of neurons as well as many other cell types. In this study, CNTF and leukemia inhibitory factor (LIF) reduced the apparent number of primary serotonergic neurons in E14 raphe culture by 90% as determined by immunocytochemistry for serotonin (5HT). The reduction in 5HT cell number was not due to neuronal loss as removal of CNTF after 4 days in culture resulted in a partial restitution of the serotonergic phenotype. In the RN46A serotonergic cell line which is induced to become serotonergic by brain-derived neurotrophic factor (BDNF), the addition of CNTF suppressed tryptophan hydroxylase and 5HT synthesis and increased choline acetyl transferase (ChAT) expression by 6-fold and ChAT activity by 20- to 30-fold over 12 days. As with the primary neurons, removal and replacement of CNTF with BDNF after 4 days resulted in a partial restitution of 5HT expression. Moreover, other members of the CNTF-cytokine family that use gp130 and/or LIF receptor beta as their signal transducing receptors-LIF, oncostatin M, interleukin 6, and interleukin 11-had similar effects on increasing ChAT activity and reducing 5HT expression in RN46A cells. Analysis of 5HT levels showed no significant difference in the amount of serotonin between wild-type and CNTFR alpha knockout mice at birth, suggesting that the potential to switch phenotype mediated through CNTFR alpha is a latent property of neuroepithelial precursors in the raphe nucleus.

Adult orthotopic heart transplantation using undersized pediatric donor hearts. Technique and postoperative management

BACKGROUND

Because of the critical shortage of adult donor hearts, many recipients die awaiting transplantation of an organ of appropriate size. Undersized hearts (donor/recipient weight ratio < 0.7) have been used for heterotopic heart transplantation. We report on 6 moribund adult heart transplant candidates who were rescued with orthotopic heart transplantation of undersized pediatric hearts.

METHODS AND RESULTS

Recipients were hypotensive (mean blood pressure, 62.3 +/- 13.4 mm Hg), had high pulmonary artery pressures (mean pulmonary artery pressure, 42.4 +/- 6.3 mm Hg), and had mean cardiac indexes of 1.7 +/- 0.6 L.min-1.m-2. Four had pretransplant intra-aortic balloon pumps, and one was on a Thoratec left ventricular assist device complicated by fungemia. Since conventionally sized donors were unavailable (+/- 30% recipient weight), the patients were listed in a wider weight range (+/- 60%). Donor characteristics were age, 8.7 +/- 1.5 years; weight, 32.8 +/- 7.0 kg; and donor/recipient weight ratio, 0.44 +/- 0.2, with average ischemic time of 236.0 +/- 59.3 minutes. Technical considerations during transplantation included (1) opening the donor right atrium from the inferior vena cava to superior vena cava to facilitate size matching, (2) performing size-mismatched pulmonary artery and aortic anastomoses end to end, (3) infusing prostaglandin E1 12 ng.kg-1.min-1 to decrease pulmonary and systemic vascular resistance, (4) pacing donor and recipient atria synchronously to improve ventricular filling, (5) maintaining high heart rates up to 140 beats per minute (initially with isoproterenol or pacing, chronically with theophylline), (6) hyperventilating with sedation and paralysis as necessary, (7) reperfusing with triiodothyronine, and (8) minimizing afterload. All patients were discharged from the hospital. At 1 week, hemodynamics were normal and echocardiograms demonstrated left ventricular growth.

CONCLUSIONS

Hence, undersized pediatric hearts can be used successfully to salvage moribund patients and expand the potential donor pool for adult orthotopic heart transplantation.

Total IgG and IgG subclass specific antibody responses to insulin in diabetic patients

Abnormal antibody responses to insulin in diabetic patients have been associated with syndromes of insulin hypersensitivity and abnormal insulin pharmacokinetics. In this study, we evaluated total and IgG subclass antibody responses to insulin in 70 diabetic subjects on insulin distributed into five clinical groups, and in two control groups using ELISAs with CDC/WHO recommended monoclonal antibodies. As expected, levels of total IgG insulin antibody were greater in diabetic patients treated with insulin than in the control group of diabetic patients on oral agents or nondiabetic controls. Insulin antibody responses of the IgG2 subclass were negligible to absent in all groups. Adult diabetic patients on insulin without complications and those with insulin associated anaphylaxis had mean values of IgG1, IgG3, and IgG4 insulin antibodies no different from those of controls. Patients with local hypersensitivity had elevated IgG1 responses. Type I diabetic patients had elevated IgG3 responses. A group of Type II diabetic patients selected for high levels of total IgG insulin antibodies had elevated levels of IgG1, IgG3, and IgG4 antibody responses. Thus, the IgG subclass response to insulin primarily involves IgG subclasses 1, 3, and 4 and varies with the type of diabetes and complications of insulin therapy.

Evaluation of patients with local reactions to insulin with skin tests and in vitro techniques

To better understand the part played by IgE and IgG antibody in the production of dermal reactions to insulin and the usefulness of skin tests in the evaluation of these reactions, we studied 21 diabetic patients referred for evaluation of large local insulin reactions, 46 diabetic patients without local insulin reactions, and 22 healthy nondiabetic controls. Study subjects were skin tested with 15 different insulins, and the results were evaluated over 48 h. All control subjects and 41 of 46 diabetic patients without local reactions were skin-test negative to insulin. The 11% of diabetic patients who reacted had positive wheal-and-flare reactions at 20 min to animal-species insulin but negative skin tests to human insulin. Study revealed two subgroups of patients with histories of local reactions. Ten (48%) of these patients had negative skin tests to insulin. Five of this subgroup remained skin-test negative to quantities of less than or equal to 8 U insulin/skin test. Eleven (52%) of the patients formed a subgroup with positive insulin skin tests; most of these patients were skin-test positive to human insulin and to beef, pork, or both insulins as well. Although the group mean insulin-specific IgE values of this latter subgroup were significantly higher than those of any other study group, overlap of these individual IgE values did not allow separation of specific individuals with positive skin tests from those of patients on insulin without dermal reactions.(ABSTRACT TRUNCATED AT 250 WORDS)