Comparative Effectiveness of CABG versus PCI in Patients with Ischemic Heart Disease: insights from SWEDEHEART Registry

Background

Several studies have compared CABG to PCI as revascularization treatment in patients with ischemic heart disease (IHD). However, it remains unclear which revascularization strategy carries survival benefits in the long-term.

Methods

We used data from the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry for all hospital admissions at 13 cardiac care centers within Västra Götaland County in Sweden (∼20% of all SWEDEHEART data). The database contains >1000 clinical variables documenting the entire process of acute coronary hospital care. All patients hospitalized for stable angina or NSTE-ACS during the period 2000–2018 were included in the analysis. We used a propensity score-adjusted Cox proportional-hazards regression with hospitals as random-effect variables. We adjusted for patients' demographics, socio-economic status, traditional risk factors, comorbidities, the severity of coronary artery disease, left ventricular function, calendar year and medication at discharge. For sensitivity analysis, we used the instrumental variable estimator for the Cox proportional-hazards model (with treating hospital as a treatment-preference instrument) to simultaneously deal with the problems of unmeasured confounding and censoring of the outcome. The primary outcome was all-cause mortality.

Results

In total, 11,896 patients were included in the study. Of these, 3,129 (26.3%) were women. 20.4% had diabetes and 10.4% had a previous myocardial infarction. The mean age was 66.7±10.7, and 42.9% were >70 years old. 61.5% had three-vessel and/or left main disease. Median follow-up time was 5.7 years (range 1 day-18.2 years). Revascularization therapy after coronary angiography was PCI in 9449 (79.4%) and CABG in 2,447 (20.6%) patients. CABG patients were more likely to have diabetes, left main/multivessel disease and heart failure. The number of revascularized patients with PCI increased by 6.4% per calendar year (P<0.001). There were 2,481 (20.9%) deaths. CABG was associated with a lower risk of death compared to PCI (HR 0.81; 95% CI 0.69–0.95; P=0.011. We found no evidence for treatment heterogeneity between the revascularization strategy and age, gender, diabetes, heart failure and indication for revascularization (all P-interaction >0.05). Results from the sensitivity analysis support the conclusions from the primary model.

Conclusions

In hospitalized patients due to IHD, revascularization with CABG was associated with superior long-term survival compared to PCI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Heart and Lung Foundation, ALF Västra Götaland, Swedish Scientific Council

Long-term survival in patients with coronary artery disease undergoing percutaneous coronary intervention with or without intracoronary pressure wire guidance: a report from SCAAR

Background

Intracoronary pressure wire measurements of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) provide decision-making guidance during percutaneous coronary intervention (PCI). However, limited data exist on the impact of FFR/iFR on long-term clinical outcomes in patients with stable angina, unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), or STEMI.

Methods

We used data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) on all patients in Sweden undergoing PCI (with or without FFR/iFR guidance) for stable angina, UA/NSTEMI, or STEMI between January 2005 and March 2018. The primary endpoint was all-cause mortality and the secondary endpoints were stent thrombosis or restenosis and periprocedural complications. The primary model was multilevel Cox proportional-hazards regression using an instrumental variable (IV) to adjust for known and unknown confounders with treating hospital as a treatment-preference instrument. The following variables were entered into Cox proportional-hazards regression in addition to the IV: age, sex, diabetes, indication for PCI, severity of coronary disease, smoking status, hypertension, hyperlipidemia, previous myocardial infarction, previous PCI, previous coronary artery bypass graft, type of stent.

Results

In total, 151,001 patients underwent PCI: 31,514 (20.9%) for stable angina, 74,982 (49.6%) for UA/NSTEMI, and 44,505 (29.5%) for STEMI. Of these, FFR/iFR guidance was used in 11,433 patients (7.6%): 5029 (44.0%) with stable angina, 5989 (52.4%) with UA/NSTEMI, and 415 (3.6%) with STEMI; iFR was used in 1156 (10.1%) of these patients. After a median follow-up of 1784 (range 1–4824) days, the FFR/iFR group had lower adjusted risk estimates for all-cause mortality [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.69–0.91; P=0.001] and stent thrombosis and restenosis (HR 0.13; 95% CI 0.09–0.19; P<0.001). The number of periprocedural complications did not differ significantly between the groups (odds ratio 0.69; 95% CI 0.30–1.55; P=0.368). There was no interaction between FFR/iFR and indication for PCI. We found no difference between FFR and iFR (HR 1.12; 95% CI 0.90–1.59; P=0.216).

Conclusions

In this observational study, the use of FFR/IFR was associated with a lower risk of long-term mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI. Our study supports the current European and American guidelines for the use of FFR/iFR during PCI and shows that intracoronary pressure wire guidance has prognostic benefit in patients with stable angina as well as in patients with the acute coronary syndrome.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Heart and Lung Foundation, ALF Västra Götaland, Swedish Scientific Council

Enhanced thermal conduction by surface phonon-polaritons

Improving heat dissipation in increasingly miniature microelectronic devices is a serious challenge, as the thermal conduction in nanostructures is markedly reduced by increasingly frequent scattering of phonons on the surface. However, the surface could become an additional heat dissipation channel if phonons couple with photons forming hybrid surface quasiparticles called surface phonon-polaritons (SPhPs). Here, we experimentally demonstrate the formation of SPhPs on the surface of SiN nanomembranes and subsequent enhancement of heat conduction. Our measurements show that the in-plane thermal conductivity of membranes thinner than 50 nm doubles up as the temperature rises from 300 to 800 kelvin, while thicker membranes show a monotonic decrease. Our theoretical analysis shows that these thickness and temperature dependencies are fingerprints of SPhP contribution to heat conduction. The demonstrated thermal transport by SPhPs can be useful as a previously unidentified channel of heat dissipation in a variety of fields including microelectronics and silicon photonics.

A self-initiated cue-reward learning procedure for neural recording in rodents

BACKGROUND

Single-unit recording in Pavlovian conditioning tasks requires the use of within-subject designs as well as sampling a considerable number of trials per trial type and session, which increases the total trial count. Pavlovian conditioning, on the other hand, requires a long average intertrial interval (ITI) relative to cue duration for cue-specific learning to occur. These requirements combined can make the session duration unfeasibly long.

NEW METHOD

To circumvent this issue, we developed a self-initiated variant of the Pavlovian magazine-approach procedure in rodents. Unlike the standard procedure, where the animals passively receive the trials, the self-initiated procedure grants animals agency to self-administer and self-pace trials from a predetermined, pseudorandomized list. Critically, whereas in the standard procedure the typical ITI is in the order of minutes, our procedure uses a much shorter ITI (10 s).

RESULTS

Despite such a short ITI, discrimination learning in the self-initiated procedure is comparable to that observed in the standard procedure with a typical ITI, and superior to that observed in the standard procedure with an equally short ITI.

COMPARISON WITH EXISTING METHOD(S)

The self-initiated procedure permits delivering 100 trials in a ∼1-h session, almost doubling the number of trials safely attainable over that period with the standard procedure.

CONCLUSIONS

The self-initiated procedure enhances the collection of neural correlates of cue-reward learning while producing good discrimination performance. Other advantages for neural recording studies include ensuring that at the start of each trial the animal is engaged, attentive and in the same location within the conditioning chamber.

Heat transfer in rough nanofilms and nanowires using full band ab initio Monte Carlo simulation

The Boltzmann transport equation is one of the most relevant frameworks to study the heat transport at the nanoscale, beyond the diffusive regime and up to the micrometer-scale. In the general case of 3D devices, the particle Monte Carlo approach of phonon transport is particularly powerful and convenient, and requires reasonable computational resources. In this work, we propose an original and versatile particle Monte Carlo approach parametrized by using ab initio data. Both the phonon dispersion and the phonon-phonon scattering rates have been computed by DFT calculation in the entire 3D Brillouin zone. To treat the phonon transport at rough interfaces, a combination of specular and diffuse reflections has been implemented in phase space. Thermal transport has been investigated in nanowires and thin films made of cubic and hexagonal Silicon, including edge roughness, in terms of effective thermal conductivity, phonon band contributions and heat flux orientation. It is shown that the effective thermal conductivity in quasi-ballistic regime obtained from our Monte Carlo simulation cannot be accurately fitted by simple semi-analytical Matthiessen-like models and that spectral approaches are mandatory to get good results. Our full band approach shows that some phonon branches exhibiting a negative group velocity in some parts of the Brillouin zone may contribute negatively to the total thermal flux. Besides, the thermal flux clearly appears to be oriented along directions of high density of states. The resulting anisotropy of the heat flux is discussed together with the influence of rough interfaces.

Spectral mapping of heat transfer mechanisms at liquid-solid interfaces

Thermal transport through liquid-solid interfaces plays an important role in many chemical and biological processes, and better understanding of liquid-solid energy transfer is expected to enable improving the efficiency of thermally driven applications. We determine the spectral distribution of thermal current at liquid-solid interfaces from nonequilibrium molecular dynamics, delivering a detailed picture of the contributions of different vibrational modes to liquid-solid energy transfer. Our results show that surface modes located at the Brillouin zone edge and polarized along the liquid-solid surface normal play a crucial role in liquid-solid energy transfer. Strong liquid-solid adhesion allows also for the coupling of in-plane polarized modes in the solid with the liquid, enhancing the heat-transfer rate and enabling efficient energy transfer up to the cutoff frequency of the solid. Our results provide fundamental understanding of the energy-transfer mechanisms in liquid-solid systems and enable detailed investigations of energy transfer between, e.g., water and organic molecules.

Tunable thermal conductivity of thin films of polycrystalline AlN by structural inhomogeneity and interfacial oxidation

The effect of local oxidation and grain morphology evolution on the thermal conductivity of polycrystalline aluminum nitrides (AlN) films deposited on single-crystalline silicon substrates is experimentally and theoretically investigated.

Informational needs of patients with metastatic breast cancer: what questions do they ask, and are physicians answering them?

In the setting of breast oncology consultations, we sought to understand communication patterns between patients with advanced breast cancer and their oncologists during visits with Decision Support Services. This is a descriptive study analyzing themes and their frequencies of premeditated question lists of patients with metastatic breast cancer. We identified topics physicians most commonly discussed among themes previously found, documenting questions patients with metastatic breast cancer prepare for physician consultations and oncologists' response. Inclusion criteria were as follows: diagnosis of metastatic breast cancer, completion of a question list before meeting with an oncologist, and receipt of a summary of the consultation. We identified 59 women with metastatic breast cancer who received both documents. We reviewed the question lists and consultation summaries of these patients. Of the 59 patients whose documents we reviewed, patients most often asked about prognosis (38), symptom management (31), clinical trials (43), and quality of life (38). Physicians answered questions about prognosis infrequently (37% of the time); other questions that were answered more than commonly are the following: symptom management (81%), clinical trials (79%), and quality of life (66%). Breast cancer patients have many questions regarding their disease, its treatment, and symptoms, which were facilitated in this setting by Decision Support Services. Question lists may be insufficient to bridge the divide between physicians and patient information needs in the setting of metastatic breast cancer, particularly regarding prognosis. Patients may need additional assistance defining question lists, and physicians may benefit from training in communication, particularly regarding discussions of prognosis and end of life.

Making better doctors: a survey of premedical interns working as health coaches

We operate a decision support program in a medical center in San Francisco. In this program, postbaccalaureate, premedical interns deliver decision and communication, aids to patients. We asked whether working in this program helped these premedical interns develop key physician competencies. To measure physician competencies, we adopted the standards of the Accreditation Committee on Graduate Medical Education (ACGME), which accredits residency programs in the USA. The ACGME competencies are patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice. We developed a survey for our program alumni to rate themselves on a scale from 0 (none) to 100 (perfect) on each competency, before and after their time in our program. The survey also solicited free-text comments regarding each competency. In June 2012, we e-mailed all 47 alumni a link to our online survey and then analyzed responses received by July 15, 2012. We visually explored the distributions of ratings and compared medians. We selected the most specific and concrete comments from the qualitative responses. Respondents (21/47 or 45%) reported that their participation in Decision Services increased their competencies across the board. Qualitative comments suggest that this is because students accompanied patients on their clinic journeys (seeing multiple facets of the systems of care) while also actively facilitating patient physician communication. Providing decision support can improve self-ratings of crucial physician competencies. Educators should consider deploying premedical and medical students as decision support coaches to increase competencies through experiential learning.

Physician behaviors surrounding the implementation of decision and communication AIDS in a breast cancer clinic: a qualitative analysis of staff intern perceptions

The aim of this paper is to examine how physician behavior facilitated or impeded our implementation of decision and communication aids in a breast cancer clinic. Staff interns provided decision and communication aids to patients and wrote up case notes for each patient they served. We used grounded theory to code our staff interns' case notes. We then identified barriers and facilitators to our program's implementation from each category we generated in the coding. Facilitators included physicians reading patient questions and then bringing the staff interns to the consultation. Barriers included physicians forgetting to bring the staff interns to the appointments and discouraging interns from speaking during the consultation. Physicians vary in their cooperation with our program. Our next steps will be to inquire directly with physicians about how to adapt our program design. We will also seek to position the staff interns as mentees to increase physician commitment to our program.

Age-related changes of cerebral autoregulation: new insights with quantitative T2'-mapping and pulsed arterial spin-labeling MR imaging

BACKGROUND AND PURPOSE

Cerebral perfusion and O(2) metabolism are affected by physiologic age-related changes. High-resolution motion-corrected quantitative T2'-imaging and PASL were used to evaluate differences in deoxygenated hemoglobin and CBF of the gray matter between young and elderly healthy subjects. Further combined T2'-imaging and PASL were investigated breathing room air and 100% O(2) to evaluate age-related changes in cerebral autoregulation.

MATERIALS AND METHODS

Twenty-two healthy volunteers 60-88 years of age were studied. Two scans of high-resolution motion-corrected T2'-imaging and PASL-MR imaging were obtained while subjects were either breathing room air or breathing 100% O(2). Manual and automated regions of interest were placed in the cerebral GM to extract values from the corresponding maps. Results were compared with those of a group of young healthy subjects previously scanned with the identical protocol as that used in the present study.

RESULTS

There was a significant decrease of cortical CBF (P < .001) and cortical T2' values (P < .001) between young and elderly healthy subjects. In both groups, T2' remained unchanged under hyperoxia compared with normoxia. Only in the younger but not in the elderly group could a significant (P = .02) hyperoxic-induced decrease of the CBF be shown.

CONCLUSIONS

T2'-mapping and PASL in the cerebral cortex of healthy subjects revealed a significant decrease of deoxygenated hemoglobin and of CBF with age. The constant deoxyHb level breathing 100% O(2) compared with normoxia in young and elderly GM suggests an age-appropriate cerebral autoregulation. At the younger age, hyperoxic-induced CBF decrease may protect the brain from hyperoxemia.

Ballistic thermal conductance of a lab-in-a-TEM made Si nanojunction

The thermal conductance of a single silicon nanojunction was measured based on a Lab-in-a-TEM (microelectromechanical systems in a transmission electron microscope) technique and was found to be at least 2 orders of magnitude larger than the ones of long nanowires in the 380-460 K temperature range. The predominance of ballistic phonon transport appears as the best hypothesis to retrieve quantitative predictions despite the geometrical irregularity of the junction. The measurement is based on a MEMS structure including an electrostatic actuator that allows producing nanojunctions with the accuracy based on the resolution of a transmission electron microscope. The thermal conductance is measured by two integrated resistors that are simultaneously heating and measuring the local temperatures at the nearest of the nanojunction. The considerable thermal conductance of short nanojunctions constitutes a new key element in the design of nanosystems and in the understanding of the damaging of mechanical micronanocontacts. This conducting behavior is also paving the way for the development of nanoscale cooling devices as well as of the recent phononic information technology.

Turning carbon nanotubes from exceptional heat conductors into insulators

Thermal conductivity (kappa) of isolated carbon nanotubes (CNTs) is higher than the kappa of diamond; however, in this Letter we show that the kappa of a packed bed of three-dimensional random networks of single and multiwall CNTs is smaller than that of thermally insulating amorphous polymers. The thermoelectric power (Sigma) of the random network of CNTs was also measured. The Sigma of a single wall nanotube network is very similar to that of isolated nanotubes and, in contrast with kappa, Sigma shows a strong dependence on the tube diameter.

Thermodiffusion in model nanofluids by molecular dynamics simulations

In this work, a new algorithm is proposed to compute single particle (infinite dilution) thermodiffusion using nonequilibrium molecular dynamics simulations through the estimation of the thermophoretic force that applies on a solute particle. This scheme is shown to provide consistent results for model nanofluids in the liquid state (spherical nonmetallic nanoparticles+Lennard-Jones fluid) where it appears that thermodiffusion amplitude, as well as thermal conductivity, decreases with nanoparticle concentration. Then, by changing the nature of the nanoparticle (size, mass, and internal stiffness) and that of the solvent (quality and viscosity), various trends are exhibited. In all cases, the single particle thermodiffusion is positive, i.e., the nanoparticle tends to migrate toward the cold area. The single particle thermal diffusion coefficient is shown to be independent of the size of the nanoparticle (diameter of 0.8-4 nm), whereas it increases with the quality of the solvent and is inversely proportional to the viscosity of the fluid. In addition, this coefficient is shown to be independent of the mass of the nanoparticle and to increase with the stiffness of the nanoparticle internal bonds. Besides, for these configurations, the mass diffusion coefficient behavior appears to be consistent with a Stokes-Einstein-like law.

Niedermolekulares Heparin bei Frühgeborenen mit hereditären Risikofaktoren und venösen Thrombosen

We describe the use of low molecular weight heparin to treat venous thrombosis in two very low-birth-weight pre-term infants (GA: 30 and 27 weeks) both with genetic and acquired prothrombotic risk factors. Initially both infants were treated with unfractionated heparin. Since in one infant no effect on the thrombus size was observed and in the other infant there was an increase in size, the anticoagulation therapy was switched to subcutaneously injected low molecular heparin (Enoxaparin). During enoxaparin therapy the anti-Xa-level was carefully monitored and dosages were adjusted accordingly. Partial resolution of the thrombosis was achieved in both infants during enoxaparin therapy. No clot extension or recurrence of thrombosis occurred. An accidental overdose of Enoxaparin (100 times the required dosage) was administered to one infant without any consequences. Our data suggest that the use of low molecular weight heparin (Enoxaparin) for treatment of venous thrombosis in our two preterm infants was practical, safe and effective.

Interventional magnetic resonance imaging: an alternative to image guidance with ionising radiation

At present, interventional procedures, such as stent placement, are performed under X-ray image guidance. Unfortunately with X-ray imaging, both patient and interventionalist are exposed to ionising radiation. Furthermore, X-ray imaging is lacking soft tissue contrast and is not capable of true 3-D displays of either interventional device or tissue morphology. Magnetic resonance imaging (MRI) offers excellent soft tissue contrast, 3-D acquisition techniques, as well as rapid image acquisition and reconstruction. Despite these advantages, MR-guided interventions are challenging owing to the limited access to the patient, strong magnetic and radio-frequency fields that require special interventional devices, inferior image frame rates and spatial resolution, and high MRI scanner noise. For MR-guided intravascular interventions, where access to the target organ is achieved through catheters, dedicated hardware and automated image slice positioning techniques have been developed. We illustrate that MR-guided renal embolisations can be performed in closed-bore high-field MR scanners.

Microscopic nature of the pygmy dipole resonance: the stable Ca isotopes

The electric dipole strength distribution in 44Ca has been measured up to 10 MeV in high resolution photon scattering experiments for the first time. The data obtained have been compared to earlier measurements on (40,48)Ca in order to view the evolution of the electric pygmy dipole resonance (PDR). Calculations that were performed within the framework of the microscopic extended theory of finite Fermi systems, which adds contributions of the quasiparticle-phonon coupling to random phase approximation calculations, give a qualitative agreement with the experimental data for all three isotopes. We have shown that it is necessary to include this coupling to describe the PDR.

Nature of low-energy dipole strength in nuclei: the case of a resonance at particle threshold in 208Pb

A high-resolution (gamma,gamma') study of the electric dipole response in 208Pb at the S-DALINAC reveals a resonance structure centered around the neutron emission threshold. Microscopic quasiparticle phonon model calculations in realistic model spaces including the coupling to complex configurations are able to describe the data in great detail. The resonance is shown to result from surface density oscillations of the neutron skin relative to an approximately isospin-saturated core. It also forms an integral part of a toroidal E1 mode representing an example of vortex collective motion in nuclei.

Measurement of the dipole and electric quadrupole strength distributions up to 10 MeV in the doubly magic nuclei 40Ca and 48Ca

The doubly magic nuclei 40Ca and 48Ca have been studied in high resolution photon scattering experiments. We have derived absolute dipole and quadrupole excitation strengths up to 10 MeV. Evidence was found for a two-phonon quadrupole-octupole state in 48Ca. At higher energies in contrast to 40Ca, a concentration of dipole strength is observed in 48Ca which is discussed in terms of a pygmy resonance originating from the large neutron excess.