Impact of Transforming Interface Geometry on Edge States in Valley Photonic Crystals

We investigate how altering the interface geometry from a zigzag to a glide plane interface between two topologically distinct valley Hall emulating photonic crystals (VPC), profoundly affects edge states. We experimentally observe a transition from gapless to gapped edge states, accompanied by the occurrence of slow light within the Brillouin zone, rather than at its edge. We numerically simulate the propagation and measure the transmittance of the modified edge states through a specially designed valley-conserving defect. The robustness to backscattering gradually decreases, suggesting a disruption of valley-dependent transport. We demonstrate the significance of interface geometry to gapless edge states in a VPC.

Is Quadriceps-Strengthening Exercises (QSE) in Medial-Compartment Knee Osteoarthritis with Neutral and Varus Malalignment a Paradox? - A Risk-Appraisal of Strength-Training on Disease Progression

Introduction

The present inquiry seeks to investigate whether the current regimens of QSEs (Quadriceps-Strengthening Exercises) aggravate the disease while mitigating symptoms.

Materials and methods

A comparative study was conducted on 32 patients with medial compartment osteoarthritis of knees. While the neutral group of 16 patients was constituted of those with an anatomical-lateral-femoro-tibial-angle (aFTA) 176-180º, varus group comprised an equal number of patients with an aFTA >180º. A home-based 12-week strength-training program involving weekly visits to hospital for supervised sessions was administered. The outcome measures were visual-analog-scale (VAS), medial patello-femoral joint tenderness (MPFJT), time-up-and-go-test (TUGT), stair-climb test, step test, WOMAC, IKDC scores, aFTA, hip-knee-ankle (HKA) angle, lateral-tibio-femoral-joint-separation (LTFJS), and horizontal-distance-from-centre-of-knee-to-Mikulicz-line.

Results

There was a significant increase in quadriceps strength (p<0.01) in both groups. Values for neutral group with VAS score (p=0.01), MPFJT (p=0.01), TUGT (p=0.01), timing of the stair climb test (p=0.01), WOMAC (p<0.01), and IKDC (p=0.03) were better compared to varus group with VAS score (p=0.13), MPFJT (p=0.03), TUGT (p=0.90), timing of stair climb test (p=0.68), WOMAC (p<0.02), and IKDC (p=0.05). Varus group also showed an increase in aFTA and LTFJS in 12 patients, increase in HKA in 11, and increase in horizontal distance from the centre of knee to the Mikulicz line in 7 patients.

Conclusion

The present study brings to the fore the paradoxical role played by QSEs in management of medial knee OA. While there is a radiological progression of the disease in both neutral and varus mal-aligned knees more so in the latter than the former.

Cost-effectiveness of a real-time spatiotemporal mapping surveillance system for meticillin-resistant Staphylococcus aureus prevention

OBJECTIVES

An infection surveillance system based on a hospital's digital twin [4D-Disease Outbreak Surveillance System (4D-DOSS)] is being developed in Singapore. It offers near-real-time infection surveillance and mapping capabilities. This early economic modelling study was conducted, using meticillin-resistant Staphylococcus aureus (MRSA) as the pathogen of interest, to assess the potential cost-effectiveness of 4D-DOSS.

METHODS

A Markov model that simulates the likelihood of MRSA colonization and infection was developed to evaluate the cost-effectiveness of adopting 4D-DOSS for MRSA surveillance from the hospital perspective, compared with current practice. The cycle duration was 1 day, and the model horizon was 30 days. Probabilistic sensitivity analysis was conducted, and the probability of cost-effectiveness was reported. Scenario analyses and a value of information analysis were performed.

RESULTS

In the base-case scenario, with 10-year implementation/maintenance costs of 4D-DOSS of $0, there was 68.6% chance that 4D-DOSS would be cost-effective. In a more pessimistic but plausible scenario where the effectiveness of 4D-DOSS in reducing MRSA transmission was one-quarter of the base-case scenario with 10-year implementation/maintenance costs of $1 million, there was 47.7% chance that adoption of 4D-DOSS would be cost-effective. The value of information analysis showed that uncertainty in MRSA costs made the greatest contribution to model uncertainty.

CONCLUSIONS

This early-stage modelling study revealed the circumstances for which 4D-DOSS is likely to be cost-effective at the current willingness-to-pay threshold, and identified the parameters for which further research will be worthwhile to reduce model uncertainty. Inclusion of other drug-resistant organisms will provide a more thorough assessment of the cost-effectiveness of 4D-DOSS.

Curriculum-based Faculty Training in Networking: Knowledge and Self-efficacy Outcomes

Although the advantages of developmental networks are well-known, most faculty do not know how to participate in such networks actively. Additionally, institutions face challenges in teaching faculty the best practices of networking. This deficiency constitutes a critical gap in the literature, which may slow career advancement for faculty, particularly from underrepresented groups. The study's purpose was to examine the effectiveness of a curriculum-based faculty training in developmental networks, utilizing the Extension for Community Health Outcomes (ECHO) platform. In this pre-post study, 33 faculty members participated in the intervention utilizing eight modules involving four competencies. Each module followed a standard format, including a short didactic, two facilitated case study discussions based on real-life scenarios, and self-reading of selected literature. Outcomes included (i) change in knowledge scores obtained from two questions per module and (ii) self-efficacy scores measured on a scale of 0-100. Paired student's t-test and mixed model regression analyses were used. A significant increase in knowledge score was documented using mixed model regression for 4 of the eight modules (mean change score 0.4-0.8, p≤0.03 for all analyses). The proportion of faculty participants reporting correct knowledge items for all modules increased from 49.8% (pre) to 64.3% (post), which was statistically significant (p<0.001). Significant increases in paired self-efficacy scores were reported for each of the eight modules (mean change score 17-37, p<0.05 for all analyses). This study highlights the importance of curriculum-based training in networking. Participants showed a significant increase in pre-post networking self-efficacy and knowledge scores. Our ECHO-based curriculum, facilitator training, and manual enable easy implementation in other institutions, ensuring scalability and adaptability. Our analysis provides the evidence basis for examining the impact of a developmental network intervention in enhancing individual career networks.

Temporal trends and outcomes of patients with chronic limb-threatening ischemia with and without history of coronary artery disease: insights from the us national inpatient sample database

BACKGROUND

The burden and prognostic significance of coronary artery disease (CAD) in adults with peripheral artery disease and chronic limb-threatening ischemia (CLTI) is unknown.

METHODS

Temporal trends in prevalence of significant CAD (history of myocardial infarction or coronary revascularizations) in hospitalizations for CLTI were determined using the 2000 to 2018 National Inpatient Sample (NIS) database. A multivariable regression analysis of outcomes was performed based on presence or absence of CAD.

RESULTS

Among 13 575 099 hospitalizations for CLTI (41% female, 69% white, mean age 69 years), 23% had concomitant CAD, of which 11% underwent lower extremity arterial revascularization (43.6% endovascular and 56.4% surgical). The prevalence of concomitant CAD with CLTI increased from 15.3% in 2000 to 23.1% in 2018. Furthermore, the frequency of endovascular revascularization in adults with CAD and CLTI increased from 15.1% to 48.3%, while there was a decreasing trend of surgical revascularization, from 84.9% to 51.7%. After multivariate adjustments, CLTI with CAD was associated with increased risk of in-hospital mortality (OR, 1.40; 95% CI, 1.32-1.47; P less than .0001) and bleeding requiring transfusion (OR, 1.10; 95% CI, 1.06-1.12; P less than .0001) compared with patients with CLTI without CAD. As compared with surgical revascularization, endovascular revascularization was associated with lower risk of in-hospital mortality in both patients with CLTI with CAD (OR, 0.69; 95% CI, 0.63-0.76; P less than .001) and CLTI without CAD (OR, 0.71; 95% CI, 0.67-0.76; P less than .001).

CONCLUSIONS

Prevalence of CAD has increased in adults presenting with CLTI and is associated with poor outcomes, warranting the need for effective interventions and secondary prevention in this high-risk population.

Mortality in Patients Hospitalized With Acute Myocardial Infarction Without Standard Modifiable Risk Factors: The ARIC Study Community Surveillance

Background Prevention strategies targeting standard modifiable cardiovascular risk factors (SMuRFs; diabetes, hypertension, smoking, hypercholesterolemia) are critical to improving cardiovascular disease outcomes. However, acute myocardial infarction (AMI) among individuals who lack 1 or more SMuRFs is not uncommon. Moreover, the clinical characteristics and prognosis of SMuRFless individuals are not well characterized. Methods and Results We analyzed AMI hospitalizations from 2000 to 2014 captured by the ARIC (Atherosclerosis Risk in Community) study community surveillance. AMI was classified by physician review using a validated algorithm. Clinical data, medications, and procedures were abstracted from the medical record. Main study outcomes included short- and long-term mortality within 28 days and 1 year of AMI hospitalization. Between 2000 and 2014, a total of 742 (3.6%) of 20 569 patients with AMI were identified with no documented SMuRFs. Patients without SMuRFs were less likely to receive aspirin, nonaspirin antiplatelet therapy, or beta blockers and less often underwent angiography and revascularization. Compared with those with one or more SMuRFs, patients without SMuRFs had significantly higher 28-day (odds ratio, 3.23 [95% CI, 1.78-5.88]) and 1-year (hazard ratio, 2.09 [95% CI, 1.29-3.37]) adjusted mortality. When examined across 5-year intervals from 2000 to 2014, the incidence of 28-day mortality significantly increased for patients without SMuRFs (7% to 15% to 27%), whereas it declined for those with 1 or more SMuRFs (7% to 5% to 5%). Conclusions Individuals without SMuRFs presenting with AMI have an increased risk of all-cause mortality with an overall lower prescription rate for guideline-directed medical therapy. These findings highlight the need for evidence-based pharmacotherapy during hospitalization and the need to discover new markers and mechanisms for early risk identification in this population.

Clinical Profiles, Outcomes, and Sex Differences of Patients With STEMI: Findings From the NORIN-STEMI Registry

Background

Low- and middle-income countries account for most of the global burden of coronary artery disease. There is a paucity of data regarding epidemiology and outcomes for ST-segment elevation myocardial infarction (STEMI) patients in these regions.

Objectives

The authors studied the contemporary characteristics, practice patterns, outcomes, and sex differences in patients with STEMI in India.

Methods

NORIN-STEMI (North India ST-Segment Elevation Myocardial Infarction Registry) is an investigator-initiated prospective cohort study of patients presenting with STEMI at tertiary medical centers in North India.

Results

Of 3,635 participants, 16% were female patients, one-third were <50 years of age, 53% had a history of smoking, 29% hypertension, and 24% diabetes. The median time from symptom onset to coronary angiography was 71 hours; the majority (93%) presented first to a non-percutaneous coronary intervention (PCI)-capable facility. Almost all received aspirin, statin, P2Y₁₂ inhibitors, and heparin on presentation; 66% were treated with PCI (98% femoral access) and 13% received fibrinolytics. The left ventricular ejection fraction was <40% in 46% of patients. The 30-day and 1-year mortality rates were 9% and 11%, respectively. Compared with male patients, female patients were less likely to receive PCI (62% vs 73%; P < 0.0001) and had a more than 2-fold greater 1-year mortality (22% vs 9%; adjusted HR: 2.1; 95% CI: 1.7-2.7; P < 0.001).

Conclusions

In this contemporary registry of patients with STEMI in India, female patients were less likely to receive PCI after STEMI and had a higher 1-year mortality compared with male patients. These findings have important public health implications, and further efforts are required to reduce these gaps.

Impact of Diabetes on Outcomes in Patients Hospitalized With Acute Myocardial Infarction: Insights From the Atherosclerosis Risk in Communities Study Community Surveillance

Background Diabetes is associated with increased risk of acute myocardial infarction (AMI). The demographic trends, clinical presentation, management, and outcomes of patients with diabetes who are hospitalized with AMI have not been recently reported. Methods and Results The ARIC (Atherosclerosis Risk in Communities) study conducted hospital surveillance of AMI in 4 US communities. AMI was classified by physician review using a validated algorithm. Medications and procedures were abstracted from the medical record. From 2000 to 2014, 21 094 weighted hospitalizations for AMI were sampled. The prevalence of diabetes steadily increased, from 35% to 41% to 43% (P-trend<0.0001) across 2000 to 2004, 2005 to 2009, and 2010 to 2014, respectively. Patients with diabetes were older (61 versus 59 years of age), more often Black (44% versus 31%), and more commonly women (42% versus 34%). The burden of cardiovascular comorbidities was higher with diabetes and increased temporally. Patients with diabetes less often presented with ST-segment elevation (9% versus 17%) or acute chest pain (72% versus 80%), and had higher mean GRACE (Global Registry of Acute Coronary Syndrome) score (123 versus 109), Thrombolysis in Myocardial Ischemia (TIMI) score (4.3 versus 4.0), and Killip class (1.9 versus 1.5). Patients with diabetes had a lower adjusted probability of receiving aspirin (relative probability, 0.95 [95% CI, 0.91-0.99]), nonaspirin antiplatelets (0.93 [95% CI, 0.86-0.99]), coronary angiography (0.85 [95% CI, 0.78-0.92]), and coronary revascularization (0.85 [95% CI, 0.76-0.92]). Diabetes was associated with a 52% higher hazard of all-cause 1-year mortality (hazard ratio, 1.52 [95% CI, 1.23-1.89]). Conclusions Diabetes is associated with higher risk of death in patients hospitalized with AMI, highlighting the need for adherence to evidence-based therapies in this high-risk population.

Epidemiology and Outcomes of Aortic Stenosis in Acute Decompensated Heart Failure: The ARIC Study

BACKGROUND

Few studies characterize the epidemiology and outcomes of aortic stenosis (AS) in acute decompensated heart failure (ADHF). This study investigates the significance of AS in contemporary patients who have experienced an ADHF hospitalization.

METHODS

The ARIC study (Atherosclerosis Risk in Communities) surveilled ADHF hospitalizations for residents ≥55 years of age in 4 US communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF). Demographic differences in AS burden and the association of varying AS severities with mortality were estimated using multivariable logistic regression.

RESULTS

From 2005 through 2014, there were 3597 (weighted n=16 692) ADHF hospitalizations of which 48.6% had an LVEF <50% and 51.4% an LVEF ≥50%. AS prevalence was 12.1% and 18.7% in those with an LVEF <50% and ≥50%, respectively. AS was less likely in Black than White patients regardless of LVEF: LVEF <50% (odds ratio [OR], 0.34 [95% CI, 0.28-0.42]); LVEF ≥50% (OR, 0.51 [95% CI, 0.44-0.59]). Higher AS severity was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.16 [95% CI, 1.04-1.28]); LVEF ≥50% (OR, 1.40 [95% CI, 1.28-1.54]). Sensitivity analyses excluding severe AS patients detected that mild/moderate AS was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.23 [95% CI, 1.02-1.47]); LVEF ≥50% (OR, 1.31 [95% CI, 1.14-1.51]).

CONCLUSIONS

Among patients who have experienced an ADHF hospitalization, AS is prevalent and portends poor mortality outcomes. Notably, mild/moderate AS is independently associated with 1-year mortality in this high-risk population.

Production and characterization of sustainable vermimanure derived from poultry litter and rice straw using tiger worm Eisenia fetida

Poultry litter (PL) and rice straw (RS), commonly available waste materials, pose severe threat to environment, if not properly managed. As viable waste treatment method, vermi-transformation of PL into enriched vermimanure was done using RS and cow dung (CD) with different feedstocks (FS) combinations like FS0_{(CD without earthworm),} FS1_(CD), FS2_{(1CD: 1RS)}, FS3_{(1CD: 1PL)} and FS4_{(1CD: 1RS: 1PL)} for 110 days. Increased growth performance (P < 0.05) of Eisenia fetida, macronutrient levels, and a consistently lower carbon-to-nitrogen ratio (C/N) emphasize the importance of RS and PL in the vermimanuring process. Several analytical techniques have revealed the presence of functional groups, nitrate (NO₃^-), phosphate (PO₄^3-), and potassium ions (K⁺) as well as the high porosity of the matured vermimanures. Therefore, using earthworms, the feedstock FS4_{(1CD: 1RS: 1PL)} could be successfully biotransformed into sustainable manure lowering the usage of chemical fertilizers and rice straw burning.

Trends in Veno-Arterial Extracorporeal Life Support With and Without an Impella or Intra-Aortic Balloon Pump for Cardiogenic Shock

Background Mechanical circulatory support devices, such as the intra-aortic balloon pump (IABP) and Impella, are often used in patients on veno-arterial extracorporeal life support (VA-ECLS) with cardiogenic shock despite limited supporting clinical trial data. Methods and Results Hospitalizations for cardiogenic shock from 2016 to 2018 were identified from the National Inpatient Sample. Trends in the use of VA-ECLS with and without an IABP or Impella were assessed semiannually. Multivariable logistic regression and general linear regression evaluated the association of Impella and IABP use with in-hospital outcomes. Overall, 12 035 hospitalizations with cardiogenic shock and VA-ECLS were identified, of which 3115 (26%) also received an IABP and 1880 (16%) an Impella. Use of an Impella with VA-ECLS substantially increased from 10% to 18% over this period (P<0.001), whereas an IABP modestly increased from 25% to 26% (P<0.001). In-hospital mortality decreased 54% to 48% for VA-ECLS only, 61% to 58% for VA-ECLS with an Impella, and 54% to 49% for VA-ECLS with an IABP (P<0.001 each). Most (57%) IABPs or Impellas were placed on the same day as VA-ECLS. After adjustment, there were no differences in in-hospital mortality or length of stay with the addition of an IABP or Impella compared with VA-ECLS alone. Conclusions From 2016 to 2018 in the United States, use of an Impella and IABP with VA-ECLS significantly increased. More than half of Impellas and IABPs were placed on the same day as VA-ECLS, and the use of a second mechanical circulatory support device did not impact in-hospital mortality. Further studies are needed to decipher the optimal timing and patient selection for this growing practice.

Prognostic significance of obstructive coronary artery disease in patients admitted with acute decompensated heart failure: the ARIC study community surveillance

AIMS

We aimed to investigate the impact of obstructive coronary artery disease (CAD) in patients with acute decompensated heart failure (ADHF), and examine potential differences in prognostic utility for heart failure with reduced (HFrEF) versus preserved ejection fraction (HFpEF).

METHODS AND RESULTS

The Atherosclerosis Risk in Communities study conducted hospital surveillance of ADHF from 2005 to 2014. Obstructive CAD was defined as ≥50% or ≥75% stenosis, respectively, for the left main and other major epicardial arteries. Adjusted associations between obstructive CAD and 30-, 60-, and 90-day mortality were analysed. A total of 934 (4146 weighted) patients admitted with ADHF (mean age 72 years, 46% women, 30% Black, 30% HFpEF) had available angiography (61% performed in hospital). Obstructive CAD was more prevalent with HFrEF than HFpEF, whether at the left main (15% vs. 11%), left anterior descending (LAD) (48% vs. 30%), left circumflex (37% vs. 32%), right coronary (42% vs. 32%), or multiple coronary arteries (45% vs. 33%). In-hospital revascularization was performed in 25% and 22% of patients with HFrEF and HFpEF, respectively. Obstructive CAD was associated with higher adjusted mortality, particularly with left main or LAD involvement, and had a more pronounced association with 90-day mortality in HFrEF (odds ratio [OR] 2.77; 95% confidence interval [CI] 1.53-5.02) than HFpEF (OR 0.94; 95% CI 0.36-2.41) (p-interaction = 0.05).

CONCLUSION

Patients hospitalized with ADHF and coexisting obstructive CAD have higher short-term mortality, warranting the need for effective interventions and secondary prevention.

Healthcare use by children in North West London 2015-2019 by deprivation and integrated care access

Background

England has a health system offering universal coverage, but disparities in healthcare use are increasing. Between 2007-2017, children living in more deprived areas had higher rates of unplanned care (Emergency Department (ED) attendance and hospital admissions), whereas children from less deprived areas had higher rates of planned care (General Practitioner (GP) contact and outpatient appointments). More detailed research to find solutions for this divergent pattern is required.

Aim

To assess the rates of GP contact, outpatient appointments, hospital admissions and ED attendance in North West London, by Index of Multiple Deprivation (IMD) decile of home postcode and access to an integrated care service providing linked care between multiple child health professionals ‘Connecting Care for Children (CC4C)', for children aged 0-18 years between 2015-2019.

Methods

Retrospective analysis of a de-identified database of integrated care records for 495,357 children.

Results

Children from the most deprived decile had higher rates of emergency admissions (0.070 per child per year vs. overall mean 0.040), elective admissions (0.076 vs. 0.032), ED attendances (0.754 vs. 0.358) and outpatient appointments (1.702 vs. 0.756) between 01.01.2015- 31.12.2019. Children from the least deprived decile had the second highest rates of outpatient appointments (0.911 vs. 0.756) and GP contact (8.192 vs. 5.390) between 01.01.2015- 31.12.2019. Children with access to the CC4C service, despite being from more deprived backgrounds, had lower rates of emergency admissions (0.028 vs. 0.037) compared to patients with access to usual care. P values &lt;0.001 in all cases.

Conclusions

Greater deprivation was linked to higher rates of emergency admissions, but this was partially mitigated by access to more integrated healthcare models. Children from the least deprived decile continued to have disproportionately higher use of planned care.

Key messages

• Despite universal health coverage, children from more deprived areas continue to have disproportionately higher use of unplanned care.

• Further research is required to explore whether integrated care solutions can reduce the burden on unplanned health services and inequalities in access to care.

Implication and utility of DAS-28 squeeze in rheumatoid arthritis: an Indian experience

The purpose of this study was to compare and correlate disease activity score including 28 joints counts (DAS-28) Squeeze with DAS-28 and clinical disease activity index (CDAI) to assess disease activity (DA) in rheumatoid arthritis (RA) patients. A total of 100 RA patients were included in the study. All subjects were evaluated for disease activity using the DAS-28 Squeeze, DAS-28, and CDAI. Spearman’s rho (ρ) was calculated to determine the correlation between DAS-28 Squeeze, DAS-28, and CDAI. Cross-tabulation was performed to compare and calculate the kappa coefficient for the link between two indices. For each scale, Cronbach’s alpha was also calculated to test dependability. The average age of the study group was 43.9±11.3. The mean scores on the DAS-28 Squeeze, DAS-28, and CDAI were, respectively, 3.58±1.06, 5.06±1.56, and 22.81±14.92. p=0.001 indicated a significant correlation between DAS-28 Squeeze and DAS-28 (ρ=0.986) and CDAI (ρ=0.939) for DAS-28 Squeeze. There was a considerable correlation between all three measures at various DA levels. Cronbach’s alpha for DAS-28 Squeeze, DAS-28, and CDAI were respectively 0.716, 0.663, and 0.734. DAS-28 Squeeze exhibited a substantial positive association with DAS-28 and CDAI for assessing disease activity and appears to be a more useful and reliable method than DAS-28 and CDAI for monitoring disease activity in RA patients.

Prevalence and determinants of isolated systolic and isolated diastolic hypertension in India: Insights from the national family health survey (NFHS)- 4

Background

Isolated Systolic Hypertension (ISH) and Isolated Diastolic Hypertension (IDH) are often the ignored forms of hypertension and are determinants of future cardiac and neurological events and contribute to mortality. However, the nationally representative estimates of both these forms of hypertension remain unknown from India.

Aim

To estimate the ISH and IDH from a nationally representative survey of India.

Material and Methods

The present study used data from 7,23,181 people (15-54 years), recorded during the fourth round (2015-2016) of the National Family Health Survey (NFHS), India. The prevalence of ISH and IDH was calculated for state comparison, while multilevel logistic regression analysis was done to assess the correlates of both types of hypertension.

Results

The prevalence of ISH and IDH was found to be 1.2% (95% CI 1.0-1.4) and 5.7% (95% CI 5.2-6.2), respectively. The prevalence of both ISH and IDH increased with age, with a more significant increase in systolic pressure towards the higher age. Northeastern states of India (Assam, Meghalaya, and Arunachal Pradesh) had the highest prevalence of both forms of hypertension. On multilevel logistic regression, male gender, increasing age groups (highest odds ratio (OR) being in 45-49 year age group), alcohol, and diabetes positively predicted both ISH and IDH. Urban residence, literacy, and tobacco were positive predictors of IDH, whereas urban residence, smoking, and literacy negatively predicted ISH.

Conclusion

ISH and IDH have a significant presence among the population of India. This data provides insights to formulate strategies at the primary and primordial prevention levels.

Trends in Percutaneous Balloon Mitral Valvuloplasty Complications for Mitral Stenosis in the United States (the National Inpatient Sample [2008 to 2018])

The epidemiology of mitral stenosis (MS) continues to evolve in the United States. Although the incidence of rheumatic MS has decreased in high-income countries, there is a paucity of data surrounding trends in percutaneous balloon mitral valvuloplasty (PBMV), the current first-line management strategy. This study aimed to identify contemporary trends in PBMV in the United States. Hospitalizations for adults (≥18 years) with MS who underwent PBMV were identified from the National Inpatient Sample from 2008 to 2018. Baseline co-morbidities and outcomes over the study period were determined using Poisson regression. There were 3,980 weighted PBMV cases, 70% of which were women. PBMV hospitalizations decreased from 603 in 2008 to 210 in 2018 (p <0.001). From 2008 to 2018, the age at hospitalization was unchanged in both female and male patients. In contrast, the Charlson Co-morbidity Index increased in both. Baseline heart failure (39% to 64%), hypertension (38% to 43%), and diabetes mellitus (17% to 26%) all substantially increased over the study period. In-hospital mortality occurred in 2% of female and 5% of male patients and was unchanged from 2008 to 2018. Vascular complications (12%) and acute kidney injury (10%) were the most frequent postprocedural complications during the 11-year study period. A composite of mortality or any postprocedural complication did not vary by gender (odds ratio 1.23, 95% confidence interval 0.88 to 1.72). In conclusion, the use of PBMV significantly decreased from 2008 to 2018, and patients with MS who underwent PBMV over this period had an increased burden of co-morbidities, elevated postprocedural complication rate, and no change in in-hospital mortality.

Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock

Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], I² = 0%, p = 0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], I² = 0%, p <0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], I² = 0%, p <0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], I² = 11%, p <0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], I² = 0%, p = 0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

Prevalence and prognostic implications of reduced left ventricular ejection fraction among patients with STEMI in India

AIMS

To describe clinical characteristics and outcomes for those with STEMI and reduced left ventricular ejection fraction (LVEF) in low-income and middle-income countries (LMICs).

METHODS AND RESULTS

Adults presenting with STEMI to two government-owned tertiary care centres in Delhi, India were prospectively enrolled in the North India ST-elevation myocardial infarction (NORIN-STEMI) registry. LVEF was evaluated at presentation and clinical characteristics were compared across LVEF categories. Overall, 3597 patients were included, of whom 468 (13%) had LVEF >50%, 1482 (41%) had mildly reduced LVEF (40-49%), 1357 (38%) had moderately reduced LVEF (30-39%), and 290 (8%) had severely reduced LVEF (<30%). Presentation delay >24 h, prior MI, and hyperlipidaemia were associated with decreasing LVEF category. Although most patients with reduced LVEF were discharged on appropriate guideline-directed therapies, adherence at 1 year was low (ACE inhibitor/ARB 91% to 41%, beta blocker 98% to 78%, aldosterone receptor antagonist 69% to 6%). After multivariable adjustment, a Cox regression model showed moderately reduced LVEF (HR 1.77, 95% CI 1.20, 2.60) and severely reduced LVEF (HR 3.63, 95% CI 2.41, 5.48) were associated with increased risk of all-cause mortality compared with LVEF ≥50%.

CONCLUSIONS

On presentation for STEMI, almost 90% of NORIN-STEMI participants had at least mildly reduced LVEF and almost half had LVEF <40%. Patients with LVEF <40% had significantly higher risk of mortality at 1 year, and adherence to guideline-directed therapies at 1 year was poor. Systematic initiatives to improve access to timely revascularization and guideline-directed therapies are essential in advancing STEMI care in LMICs.

Prevalence and Prognostic Significance of Polyvascular Disease in Patients Hospitalized With Acute Decompensated Heart Failure: The ARIC Study

BACKGROUND

Polyvascular disease is associated with increased mortality rates and decreased quality of life. Whether its prevalence or associated outcomes differ for patients hospitalized with heart failure with reduced vs preserved ejection fraction (HFrEF vs HFpEF, respectively) is uncertain.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of acute decompensated heart failure (ADHF) from 2005-2014. Polyvascular disease (coexisting disease in ≥ 2 arterial beds) was identified based on the finding of prevalent coronary artery disease, peripheral artery disease or cerebrovascular disease. Mortality risks associated with polyvascular disease were analyzed separately for HFpEF and HFrEF, with adjustment for potential confounders. All analyses were weighted by the inverse of the sampling probability.

RESULTS

Of 24,937 weighted (5460 unweighted) hospitalizations due to ADHF (52% female, 32% Black, mean age 75 years), polyvascular disease was prevalent in 22% with HFrEF and in 17% with HFpEF. One-year mortality risks increased sequentially with 0, 1 and ≥ 2 arterial bed involvement, both for patients with HFrEF (29%-32%-38%; P trend = 0.0006) and for those with HFpEF (26%-32%-37%; P trend < 0.0001). After adjustments, polyvascular disease was associated with a 26% higher mortality hazard for patients with HFrEF (HR = 1.26; 95% CI: 1.07-1.50) and a 29% higher hazard for patients with HFpEF (HR = 1.29; 95% CI: 1.03-1.62), with no interaction by HF type (P interaction = 0.9).

CONCLUSION

Patients hospitalized with ADHF and coexisting polyvascular disease have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward polyvascular disease, with implementation of secondary prevention strategies to improve the prognosis of this high-risk population.

SUMMARY

Polyvascular disease is known to be associated with myocardial infarction, stroke or cardiovascular death and is a major risk factor for decreased quality of life. This study sought to evaluate the relationship between polyvascular disease and mortality in patients hospitalized with acute decompensated heart failure (ADHF), and to understand whether the associations differ based on ejection fraction. Patients hospitalized with ADHF and coexisting polyvascular disease had an increased risk of death, irrespective of heart failure type, implying the need for increased clinical attention directed toward polyvascular disease, along with implementation of secondary prevention strategies to improve prognosis.

TWEET

Patients hospitalized with acute HF and coexisting polyvascular disease face an increased risk of death, irrespective of HF type.

Contemporary Trends and Comparison of Racial Differences in Hospitalizations of Adults With Congenital Heart Disease

As advancements in care improve longevity in patients with congenital heart disease (CHD), it is crucial to further characterize this rapidly growing adult population. It is also essential that equitable care is offered across demographic groups. Hospitalizations for adults with CHD in the National Inpatient Sample were identified to describe trends in overall and cause-specific rates of admission per 1,000 adults with CHD from 2000 to 2018. Primary admission causes were then analyzed and stratified by race. An aggregate rate of left-ventricular assist device placements and heart transplants was calculated for each group and trended over the years. A total of 1,562,001 weighted hospitalizations were identified. Overall, annual rates of hospital admissions increased from 39 per 1,000 adults with CHD in 2000 to 74 per 1,000 in 2018, as did rates of cardiovascular admissions (16 of 1,000 to 34 of 1,000, p <0.001 for both). Transient ischemic attack/stroke (2.5 of 1,000 to 10.7 of 1,000), coronary artery disease (4.1 of 1,000 to 5.6 of 1,000), arrhythmias (2.8 of 1,000 to 4.6 of 1,000), and heart failure (2.8 of 1,000 to 5.0 of 1,000) were the most common cardiovascular primary causes of admission (other than CHD itself), and each significantly increased over time (p <0.001 for each). Mean age at all-cause and primary heart failure hospitalization increased for all races but remained 7 to 9 years younger for Black and Hispanic adults than White adults. In conclusion, hospitalization rates of adults with CHD in the United States increased from 2000 to 2018, largely driven by an increase in adults ≥55 years. Although the age at hospitalization increased overall, Black and Hispanic patients were substantially younger at presentation for advanced heart failure. Anticoagulation guidelines in this population may need revisiting as transient ischemic attack/stroke hospitalizations were frequent.

Breakdown of Spin-to-Helicity Locking at the Nanoscale in Topological Photonic Crystal Edge States

We measure the local near-field spin in topological edge state waveguides that emulate the quantum spin Hall effect. We reveal a highly structured spin density distribution that is not linked to a unique pseudospin value. From experimental near-field real-space maps and numerical calculations, we confirm that this local structure is essential in understanding the properties of optical edge states and light-matter interactions. The global spin is reduced by a factor of 30 in the near field and, for certain frequencies, flipped compared to the pseudospin measured in the far field. We experimentally reveal the influence of higher-order Bloch harmonics in spin inhomogeneity, leading to a breakdown in the coupling between local helicity and global spin.

INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

Airway Complications After Lung Transplant for Post Coronaviral Disease (COVID-19) Acute Respiratory Distress Syndrome (ARDS) Related End Stage Lung Disease: Single Centre Experience

Purpose

Severe COVID-19 ARDS related end stage lung fibrosis with irreversible changes is a newer indication for lung transplantation with acceptable survival rate. Airway complication post lung transplant is a major source of morbidity and mortality with incidence as high as 25 to 49 percent. Patients with end stage COVID-19 fibrosis are likely to be clinically deconditioned with long duration of extracorporeal oxygenator (ECMO) support, high burden of sepsis and prolonged respiratory support which may affect the airways post lung transplantation.

Methods

This is a retrospective observational study after obtaining institutional ethical clearance. We reviewed electronic medical data of patients who underwent lung transplantation for post COVID-19 ARDS related fibrosis. We evaluated the incidence and type of airway complications and the various therapeutic interventions applied for its management.

Results

Between May 2020 and September 2021 our centre performed 23 bilateral lung transplants for end stage COVID-19 ARDS related fibrosis. 22 patients were on ECMO support with mean duration of 50.9 days before transplantation. All patients underwent lung transplantation with central Veno-Arterial ECMO support with mean organ ischaemia time of 360±154 minutes. The incidence of airway complication in our study group was 56%. We observed anastomotic narrowing in 3(13%), distal airway narrowing in 4(17%) and sloughing/coating of anastomotic site in 5(22%) patients. Nonspecific inflammatory polypi around the bronchial anastomotic site were noticed in 4(17%) and mild airway anastomotic dehiscence in 2 subjects. 8(34%) patients required serial bronchoscopy and balloon dilatation; 2 among them mandated additional cautery usage. 2 cases underwent polypectomy, further 4 subjects needed bronchial stent placement. 5 (21%) recipients were discharged with Tracheostomy while rest were successfully decannulated in the ward.

Conclusion

We observed a high incidence of airway complications in post lung transplant for COVID-19 ARDS related fibrosis. Early detection, timely management and serial follow up is of paramount importance in this subset of patients.

P2Y12 inhibitor versus aspirin monotherapy for secondary prevention of cardiovascular events: meta-analysis of randomized trials

Aim

To compare the efficacy and safety of P2Y₁₂ inhibitor or aspirin monotherapy for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD).

Methods and results

Medline, Embase, and Cochrane Central databases were searched to identify randomized trials comparing monotherapy with a P2Y₁₂ inhibitor versus aspirin for secondary prevention in patients with ASCVD (cardiovascular, cerebrovascular, or peripheral artery disease). The primary outcome was major adverse cardiac events (MACE). Secondary outcomes were myocardial infarction (MI), stroke, all-cause mortality, and major bleeding. A random-effects model was used to calculate risk ratios (RR) and the corresponding 95% confidence interval (CI) and heterogeneity among studies was assessed using the Higgins I² value. A total of 9 eligible trials (5 with clopidogrel and 4 with ticagrelor) with 61 623 patients were included in our analyses. Monotherapy with P2Y₁₂ inhibitors significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84-0.95, I² = 0%) and MI by 19% (0.81, 95% CI 0.71-0.92, I2 = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke (0.85, 95% CI 0.73-1.01), or all-cause mortality (1.01, 95% CI 0.92-1.11). There was also no significant difference in the risk of major bleeding with P2Y₁₂ inhibitor monotherapy compared with aspirin (0.94, 95% CI 0.72-1.22, I² = 42.6%). Results were consistent irrespective of the P2Y₁₂ inhibitor used.

Conclusion

P2Y₁₂ inhibitor monotherapy for secondary prevention is associated with a significant reduction in atherothrombotic events compared with aspirin alone without an increased risk of major bleeding.

Five-year trends in cause-specific readmissions and cost burden of mitral transcatheter edge-to-edge repair

OBJECTIVES

The study aimed to evaluate cost trends associated with mitral valve transcatheter edge-to-edge repair (TEER).

BACKGROUND

TEER is a treatment option for patients at prohibitive surgical risk with moderate to severe mitral valve regurgitation and NYHA class III or IV symptoms. The 30-day costs and causes of readmission following TEER have not been well studied.

METHODS

Patients undergoing mitral TEER in the United States from 2014 to 2018 were identified in the Nationwide Readmission Database. Patient characteristics, cause-specific readmission, and costs of the index hospitalization and readmissions were analyzed. Costs were trended over years using general linear regression.

RESULTS

A total of 10,196 patients underwent mitral TEER during the study period. Thirty-day readmissions were stable over time at around 16%. The mean length of stay following TEER decreased from 7 days in 2014 to 5 days in 2018. There was a significant decline in the cost of the index hospitalization of $1311 per year, and a significant decline in the total 30-day cost of $1588 per year (p < 0.001). This was strictly due to a reduction in the cost of the index hospitalization without a change in readmission costs over time (p = 0.23). Infectious causes of readmissions significantly decreased while total cardiovascular readmissions, including heart failure, remained constant.

CONCLUSION

The decreasing 30-day cost burden of TEER is primarily driven by the shorter index length of stay, as experience in TEER has grown and, length of stay has declined. However, cardiovascular readmissions, and consequently readmission costs, have remained steady.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND

The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.

METHODS

We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.

RESULTS

A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).

CONCLUSION

Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.