Predicting 5-Year Clinical Outcomes After Transcatheter or Surgical Aortic Valve Replacement (a Risk Score from the SURTAVI Trial)

Risk prediction scores for long-term outcomes after transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) are lacking. This study aimed to develop preprocedural risk scores for 5-year clinical outcomes after TAVI or SAVR. This analysis included 1,660 patients at an intermediate surgical risk with severe aortic stenosis randomly assigned to TAVI (n = 864) or SAVR (n = 796) from the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial. The primary end point was a composite of all-cause mortality or disabling stroke at 5 years. The secondary end point was a composite of cardiovascular mortality or hospitalizations for valve disease or worsening heart failure at 5 years. Preprocedural multivariable predictors of clinical outcomes were used to calculate a simple risk score for both procedures. At 5 years, the primary end point occurred in 31.3% of the patients with TAVI and 30.8% of the patients with SAVR. Preprocedural predictors differed between TAVI and SAVR. Baseline anticoagulant use was a common predictor for events in both procedures, whereas male sex and a left ventricular ejection fraction <60% were significant predictors for events in patients with TAVI and SAVR, respectively. A total of 4 simple scoring systems were created based on these multivariable predictors. The C-statistics of all models were modest but performed better than the contemporary risk scores. In conclusion, preprocedural predictors of events differ between TAVI and SAVR, necessitating separate risk models. Despite the modest predictive value of the SURTAVI risk scores, they appeared superior to other contemporary scores. Further research is needed to strengthen and validate our risk scores, possibly by including biomarker and echocardiographic parameters.

Structural Valve Deterioration After Self-Expanding Transcatheter or Surgical Aortic Valve Implantation in Patients at Intermediate or High Risk

Importance

The frequency and clinical importance of structural valve deterioration (SVD) in patients undergoing self-expanding transcatheter aortic valve implantation (TAVI) or surgery is poorly understood.

Objective

To evaluate the 5-year incidence, clinical outcomes, and predictors of hemodynamic SVD in patients undergoing self-expanding TAVI or surgery.

Design, Setting, and Participants

This post hoc analysis pooled data from the CoreValve US High Risk Pivotal (n = 615) and SURTAVI (n = 1484) randomized clinical trials (RCTs); it was supplemented by the CoreValve Extreme Risk Pivotal trial (n = 485) and CoreValve Continued Access Study (n = 2178). Patients with severe aortic valve stenosis deemed to be at intermediate or increased risk of 30-day surgical mortality were included. Data were collected from December 2010 to June 2016, and data were analyzed from December 2021 to October 2022.

Interventions

Patients were randomized to self-expanding TAVI or surgery in the RCTs or underwent self-expanding TAVI for clinical indications in the nonrandomized studies.

Main Outcomes and Measures

The primary end point was the incidence of SVD through 5 years (from the RCTs). Factors associated with SVD and its association with clinical outcomes were evaluated for the pooled RCT and non-RCT population. SVD was defined as (1) an increase in mean gradient of 10 mm Hg or greater from discharge or at 30 days to last echocardiography with a final mean gradient of 20 mm Hg or greater or (2) new-onset moderate or severe intraprosthetic aortic regurgitation or an increase of 1 grade or more.

Results

Of 4762 included patients, 2605 (54.7%) were male, and the mean (SD) age was 82.1 (7.4) years. A total of 2099 RCT patients, including 1128 who received TAVI and 971 who received surgery, and 2663 non-RCT patients who received TAVI were included. The cumulative incidence of SVD treating death as a competing risk was lower in patients undergoing TAVI than surgery (TAVI, 2.20%; surgery, 4.38%; hazard ratio [HR], 0.46; 95% CI, 0.27-0.78; P = .004). This lower risk was most pronounced in patients with smaller annuli (23 mm diameter or smaller; TAVI, 1.32%; surgery, 5.84%; HR, 0.21; 95% CI, 0.06-0.73; P = .02). SVD was associated with increased 5-year all-cause mortality (HR, 2.03; 95% CI, 1.46-2.82; P < .001), cardiovascular mortality (HR, 1.86; 95% CI, 1.20-2.90; P = .006), and valve disease or worsening heart failure hospitalizations (HR, 2.17; 95% CI, 1.23-3.84; P = .008). Predictors of SVD were developed from multivariate analysis.

Conclusions and Relevance

This study found a lower rate of SVD in patients undergoing self-expanding TAVI vs surgery at 5 years. Doppler echocardiography was a valuable tool to detect SVD, which was associated with worse clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifiers: NCT01240902, NCT01586910, and NCT01531374.

Long-term safety of drug-coated devices for peripheral revascularisation

BACKGROUND

Meta-analyses of randomised trials of paclitaxel-coated peripheral devices found an association with worse long-term survival.

AIMS

We aimed to assess long-term mortality in patients treated with drug-coated versus non-drug-coated devices who are insured by Medicare Advantage (MA), an alternative to traditional Medicare that represents >30% of the Medicare eligible population. We analysed data from an MA administrative claims data source that includes both inpatient and outpatient femoropopliteal artery revascularisation procedures.

METHODS

Patients treated with or without drug-coated devices for femoropopliteal artery revascularisation from 4/2015-12/2017 were studied using Optum's De-identified Clinformatics Datamart Database. Mortality was assessed up to December 2019 using Kaplan-Meier cumulative mortality curves and Cox proportional hazard models. Inverse probability of treatment weighting was used to adjust for differences between groups.

RESULTS

Of 16,796 patients revascularised, 4,427 (26.4%) were treated with drug-coated devices: 3,600 (81.3%) balloons and 827 (18.7%) stents. The median follow-up was 2.66 years (IQR 2.02-3.52). Treatment with drug-coated devices was associated with similar long-term mortality to non-drug-coated devices (adjusted HR 1.03, 95% CI: 0.96-1.10; p=0.39). Results were comparable for patients treated with balloons alone (adjusted HR 1.00, 95% CI: 0.92-1.08; p=0.96) or stents (adjusted HR 1.02, 95% CI: 0.88-1.18; p=0.78). These findings did not differ based on treatment setting, disease severity, age, sex or comorbidity burden (interaction p>0.05 for all).

CONCLUSIONS

In this large cohort, there was no evidence of increased long-term mortality following treatment with drug-coated devices.

Developing a COVID-19 module for the European Social Survey

This short report describes the development of a COVID-19 module for Round 10 of the European Social Survey (ESS). The module is formed of 20 items, including 10 agreed with ESS National Coordinators and 10 developed by two academic teams following an external call for content. The majority of ESS participating countries will field the module for Round 10 fieldwork in 2020–2021. This report provides the rationale for the module, presents challenges of developing such a module for ESS, and gives an overview of the question development and testing process. The two external sub-modules—Government authority and legitimacy in the age of a pandemic and COVID-19 conspiracy beliefs and government rule compliance—are also introduced.

T1rho and T2rho MRI in the evaluation of Parkinson's disease

Prior work has shown that adiabatic T(1rho) and T(2rho) relaxation time constants may have sensitivity to cellular changes and the presence of iron, respectively, in Parkinson's disease (PD). Further understanding of these magnetic resonance imaging (MRI) methods and how they relate to measures of disease severity and progression in PD is needed. Using T(1rho) and T(2rho) on a 4T MRI scanner, we assessed the substantia nigra (SN) of nine non-demented moderately affected PD and ten gender- and age-matched control participants. When compared to controls, the SN of PD subjects had increased T(1rho) and reduced T(2rho). We also found a significant correlation between asymmetric motor features and asymmetry based on T(1rho). This study provides additional validation of T(1rho) and T(2rho) as a means to separate PD from control subjects, and T(1rho) may be a useful marker of asymmetry in PD.

Field estimation of the flock-level diagnostic specificity of an enzyme-linked immunosorbent assay for Avian metapneumovirus antibodies in turkeys

Routine serologic testing for Avian metapneumovirus (AMPV) infection of turkey flocks at slaughter is currently being used to monitor changes in the occurrence of AMPV infection in endemic areas and can also be used to detect the emergence of infection in currently unaffected areas. Because of the costs associated with false-positive results, particularly in areas that are free of AMPV infection, there is a need to obtain improved estimates of flock-level specificity (SP). The objective of this study was to estimate flock-level SP of a program to monitor AMPV infection in turkey flocks at processing using a standard enzyme-linked immunosorbent assay (ELISA). A study was carried out in which 37 AMPV-free flocks from 7 Midwest operations were followed serologically. Six percent, 3%, and 0.2% of total samples tested AMPV positive at 8 weeks, 12 weeks, and at processing, respectively. Overall, flock-level SP increased as the cutoff increased and as age increased. Flock-level SP at processing was 97%, if a cutoff of 1 was used (the flock was classified as positive if at least 1 sample tested positive), and 100%, if any other cutoff was used. Administration of antibiotics (P = 0.02) and vaccination for Bordetella avium (P = 0.08) were positively associated with the probability of (false) positive test results. These findings suggest possible cross-reactions with other infections and highlight the need to consider variable diagnostic performance depending on farm conditions.

Detection of neuronal loss using T(1rho) MRI assessment of (1)H(2)O spin dynamics in the aphakia mouse

The loss of dopaminergic (DA) neurons in the substantia nigra pars compacta (SNc) is well characterized in Parkinson's disease (PD). Recent developments in magnetic resonance imaging (MRI) techniques have provided the opportunity to evaluate for changes in cellular density. Longitudinal relaxation measurements in the rotating frame (T(1rho)) provide a unique magnetic resonance imaging contrast in vivo. Due to the specificity of T(1rho) to water-protein interactions, the T(1rho) MRI method has strong potential to be used as a non-invasive method for quantification of neuronal density in the brain. Recently introduced adiabatic T(1rho) magnetic resonance imaging mapping methods provide a tool to assess molecular motional regimes with high sensitivity due to utilization of an effective magnetic field sweep during adiabatic pulses. In this work, to investigate the sensitivity of T(1rho) to alterations in neuronal density, adiabatic T(1rho) MRI measurements were employed in vivo on Pitx3-homeobox gene-deficient aphakia mice in which the deficit of DA neurons in the SNc is well established. The theoretical analysis of T(1rho) maps in the different areas of the brain of aphakia mouse suggested variation of the (1)H(2)O rotational correlation times, tau(c). This suggests tau(c) to be a sensitive indicator for neuronal loss during neurological disorders. The results manifest significant dependencies of the T(1rho) relaxations on the cell densities in the SNc, suggesting T(1rho) MRI method as a candidate for detection of neuronal loss in neurological disorders.

Using the Bivariate Dale Model to jointly estimate predictors of frequency and quantity of alcohol use

OBJECTIVE

This study demonstrates the usefulness of the Bivariate Dale Model (BDM) as a method for estimating the relationship between risk factors and the quantity and frequency of alcohol use, as well as the degree of association between these highly correlated drinking measures.

METHOD

The BDM is used to evaluate childhood sexual abuse, along with age and gender, as risk factors for the quantity and frequency of beer consumption in a sample of driving-while-intoxicated (DWI) offenders (N = 1,964; 1,612 men). The BDM allows one to estimate the relative odds of drinking up to each level of ordinal-scaled quantity and frequency of alcohol use, as well as model the degree of association between quantity and frequency of alcohol consumption as a function of covariates.

RESULTS

Individuals who experienced childhood sexual abuse have increased risks of higher quantity and frequency of beer consumption. History of childhood sexual abuse has a greater effect on women, causing them to drink higher quantities of beer per drinking occasion.

CONCLUSIONS

The BDM is a useful method for evaluating predictors of the quantity-frequency of alcohol consumption. SAS macrocode for fitting the BDM model is provided.

Interference in spectrophotometric analysis of cerebrospinal fluid by haemolysis induced by transport through a pneumatic tube system

The hypothesis that sending blood-stained cerebrospinal fluid (CSF) through a pneumatic tube causes in vitro haemolysis has been tested. Spectrophotometric scanning of CSF supernatants demonstrated a significantly greater absorbance at 415 nm in those CSF samples that had been sent through the tube system compared to those that had not (P=0.0034). It is concluded that passage of blood-stained CSF down a pneumatic tube system causes in vitro haemolysis, accompanied by the release of oxyhaemoglobin from the lysed cells into the surrounding CSF. In view of this observation, it is recommended that CSF samples requiring spectrophotometric analysis, as part of the investigation of subarachnoid haemorrhage, should not be transported via a pneumatic tube system.

Comparison of neutrophil and monocyte function by microbicidal cell-kill assay in patients with cancer receiving granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, or no cytokine after cytotoxic chemotherapy: a phase II trial

Functional effects of recombinant human granulocyte colony-stimulating factor (rhG-CSF) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) were prospectively measured by harvesting blood samples from 51 oncology patients (21 who were receiving no cytokines, 14 receiving rhGM-CSF, and 16 who were receiving rhG-CSF) just before cytotoxic chemotherapy (baseline) immediately before the last cytokine dose (pre), 2 hours after the last cytokine dose (post), and 48 hours after the pre period (follow-up). Neutrophils and monocytes were separated and functional effects were measured by comparing cell-kill percentages, as determined by a microbial cell-kill assay against Staphylococcus aureus and Candida albicans. Optimal cell concentrations (2 x 10(6) monocytes/ml; 4 x 10(6) neutrophils/ml) and effector-to-cell ratios (1:50) were initially determined with blood samples harvested from 23 healthy volunteers. Results in oncology patients indicated that rhGM-CSF improved monocyte-killing activity against S. aureus at follow-up, compared with controls (p = 0.0094) and compared with monocytes from rhG-CSF-treated patients at the post period (p = 0.014). Cell-killing percentage of the rhGM-CSF-treated patients was also enhanced against C. albicans during the post period, compared with controls (p = 0.011) and rhG-CSF-treated patients (p = 0.067). Neutrophil activity was not altered by either cytokine. In conclusion, monocyte-induced microbial killing was enhanced in oncology patients receiving rhGM-CSF after cytotoxic chemotherapy, compared with patients receiving rhG-CSF or no cytokines. No differences in neutrophil activity were observed between patients receiving either cytokine.

Anti-CD40 antibody binding modulates human multiple myeloma clonogenicity in vitro

Ligand binding of the B-cell lineage antigen CD40 enhances growth and interleukin-6 (IL-6) secretion in human B cells (the CD40/IL-6 loop). IL-6 has an autocrine and paracrine role in human multiple myeloma (MM) cell growth. With the use of the CD40 monoclonal antibody (MoAb) G28-5, we examined CD40 expression and the effect of CD40 binding on MM clonogenic colony (MCC) formation to characterize the IL-6/CD40 loop activity in MM. CD40 was expressed on plasmacytoid cells in 21 of 28 plasma cell dyscrasia (PCD) bone marrow (BM) biopsies tested (10 of 14 MM, 2 of 2 Waldenstrom's macroglobulinemia [WM], 2 of 2 plasma cell leukemia [PCL], 6 of 8 monoclonal gammopathy of undetermined significance [MGUS], and 1 of 2 primary amyloidosis [AL]). G28-5 binding increased MCCs by 35% to 150% in 11 of 17 CD40+ PCD BM cultures, but did not affect MCC formation in CD40- specimens or normal BM colony forming units (CFU-GEMM, CFU-GM, BFU-E). Responsive cultures originated from BM of patients with MM (2 of 5 cases tested), WM (2 of 2), PCL (2 of 2), and MGUS (5 of 6). CD40-responsiveness was not significantly inhibited by the presence of an anti-IL-6 MoAb (2 of 2 MGUS cultures tested), and did not correlate with the capacity to respond to IL-6 stimulation (n = 17, P > .05) or a detectable level of endogenous IL-6 (n = 15, P > .05). Additional studies were performed with PCD cell lines to characterize the interrelationship of CD40 activation and IL-6 production. Fifty percent to greater than 95% of cells from the RPMI 8226 and ARH77 lines expressed CD40, whereas 6% of U266 cells were CD40+. For RPMI 8226, ARH-77, and U266 cells, the increased MCC formation after anti-CD40 stimulation was not affected by the presence of an anti-IL-6 neutralizing MoAb and was not accompanied by detectable IL-6 secretion. There was no apparent increase in IL-6 mRNA transcription following G28-5 treatment of U266 or RPMI 8226 cells. Our observations indicate that CD40 is expressed in a subset of human myeloma cells present in various PCDs. Cell-line studies suggest that the CD40+ myeloma cell may regulate MM clonogenic colony formation without activating the IL-6 pathway.

Strain redistribution in the canine femur resulting from hip implants of different stiffnesses

Bone remodeling adjacent to orthopedic implants has been attributed to bone strain changes. Although many animal studies have assessed bone remodeling near implants, the altered bone strains and even the strains in the intact bone prior to implantation have not been mapped extensively. Instead, bone changes are often correlated with implant stiffnesses. In this study, a benchtop loading system was developed using measurements from in vivo strain analysis to simulate physiologic loading of a canine femur. The effect on bone strains of three different stiffness canine hip implants with the same anatomic shape were compared by taking measurements from the proximal greyhound femur during loading. Peak compressive and tensile strains of the order of 200 to 400 microstrain were measured in the intact and implanted femora. The measurements indicate that during simulated in vivo loading, none of the implants substantially alter the normal strain state of the bone. If initial axial strains significantly affect the remodeling response of bone, the similarity of measurements with the different implants in place suggests that the same remodeling response would be expected to both the stiffest and least stiff implant, as has been noted in animal studies adjacent to the intermediate stiffness implant. It also suggests that this implant shape and initial bone implant interface condition can compensate for strain reductions expected near stiff straight-stemmed implants.

Successful childbirth by a patient with congenital factor XI deficiency and an acquired inhibitor

Acquired inhibitors in factor XI deficiency (FXI) are rare. The presence of an inhibitor during pregnancy poses a potential haemorrhagic risk to the fetus. We report an uncomplicated pregnancy and successful childbirth by a woman with congenital FXI deficiency and an acquired inhibitor, and discuss the persistence of residual FXI activity in the presence of an inhibitor.

Clinical service review--a framework

Continuous challenge of the way in which healthcare is delivered is one of the features which characterises the current environment for health authorities. As a consequence, managers face the pressure to review their services thoroughly and regularly. Part of the challenge to managers is to examine and define explicitly the role and function of services; to ensure that services are appropriate to the needs of the population; that they are effective in terms of outcome; that they are of high quality; and that they deploy resources in a cost-effective and efficient way. Tracy Hanson and Derek Mowbray show how this can be done.

Effect of sampling intervals and digesta markers on abomasal flow determinations

Four sampling schedules and three digesta markers were investigated with abomasally-cannulated steers. Nonammonia nitrogen flow through the abomasum was used as the criterion for comparison. A single diet, consisting of ground corn cobs and cane molasses and supplemented with soybean meal to 11.5% crude protein, was used. Each steer was fed hourly to maintain a constant digesta flow. Digesta markers used were: polyethylene glycol (PEG) and chromic oxide (Cr2O3), as external markers for the liquid fraction and the particulate fraction, respectively; and indigestible neutral detergent fiber (INDF) and indigestible acid detergent fiber (IADF), as internal markers for the particulate fraction. Treatments were sampling intervals of 24 hr, 48 hr, 48 hr (sampled twice) and 72 hours. Sampling interval did not alter digesta flow through the abomasum. Extending sampling intervals beyond 24 hr or taking more than one sample per day did not appear advantageous. IADF and Cr2O3 appear to be suitable markers for the particulate fraction. However, IADF is an integral part of the particulate fraction and meets the criteria of an ideal marker.

Elevated serum dopamine-beta-hydroxylase activity in rats with inherited diabetes insipidus

The activity of dopamine-beta-hydroxylase, the enzyme that catalyzes the conversion of dopamine to norepinephrine, was measured in the serum of a strain of Wistar rats homozygous and heterozygous for a genetic form of hypothalamic diabetes insipidus and in Wistar control rats. Serum dopamine-beta-hydroxylase activity and water intake was highest in the homozygous affected rats and lowest in normal controls. Treatment with pitressin tannate reduced serum enzyme activity and water intake in rats with diabetes insipidus to levels which did not differ from controls. Thus serum dopamine-beta-hydroxylase activity appeared to vary directly with changes in sympathetic nerve activity in response to intravascular volume depletion and repletion.