bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Strabismus Muscle Surgery on Corneal Biomechanics
Authors: El Gendy Heba A. , Khalil Noha M. , Eissa Iman M. , Shousha Shireen MA.
Published: September 2018

Purpose. Studying the early effect of different extraocular muscle (EOM) surgeries on corneal biomechanics.Subjects and methods. This is a prospective, nonrandomized, interventional study, in which 42 eyes of 29 candidates for EOM surgery for strabismus correction at Cairo university hospitals, aged 14–37 years, were recruited. All participants had measuring of the visual acuity, refraction (spherical equivalent (SE)), assessment of the EOM motility and muscle balance, sensory evaluation, fundus examination, and assessing the ocular biomechanics using the Ocular response analyzer (ORA, Reichert, INC., Depew, NY) noting the corneal hysteresis (CH) and corneal resistance factor (CRF) preoperatively. Same patients were reassessed using ORA 4 weeks postoperatively following a different standard EOM surgery (recti weakening/strengthening and inferior oblique weakening either (graded recession) according to the surgical indication, and ∆CH and ∆CRF were calculated, each is the preoperative − the postoperative value.Results. ∆CH and ∆CRF = −0.78 ± 1.56 and −0.72 ± 2.15, respectively, and a highly significant difference was found between each of the pre- and postoperative CH and CRF (p<0.001). 18 eyes had single EOM surgery, while 24 had multiple (2 or 3) EOM surgery; ∆CH in the single group = −1.28 ± 1.5, and ∆CH in the multiple group = 0.4 ± 1.49 (p=0.07). 23 eyes had EOM weakening surgery, while 18 had combined weakening and strengthening EOM surgery: ∆CH in the weakening group = −1.24 ± 1.77 and ∆CH in combined group = −0.26 ± 1.07 (p=0.04). A nonsignificant difference was found for ∆CRF (p=0.53).Conclusion. A different EOM surgery has an early tendency for increase of the postoperative CH specially for muscle weakening procedures (recti recession/inferior oblique muscle weakening).
Successful Antimicrobial Treatment of Phlegmonous Gastritis: A Case Report and Literature Review
Authors: Iqbal Madiha , Saleem Rabia , Ahmed Salman , Jani Prachi , Alvarez Salvador , Tun Han W.
Published: September 2018

Phlegmonous gastritis is an uncommon acute bacterial infection of the stomach that carries a fatal prognosis in spite of the advent of antibiotics. A high index of suspicion is required in patients with risk factors. An immunocompromised state is identified as one of the most important risk factors. We hereby report a case of successful antimicrobial treatment of phlegmonous gastritis in a patient who was receiving intensive chemotherapy for acute myelogenous leukemia. We have also carried out a review of literature over the past ten years. Streptococcus pyogenes is identified as the most common causative organism, and patient presentation is usually nonspecific. Conservative treatment with prompt institution of antibiotics can lead to rapid resolution in the majority of patients.
Necrotizing Fasciitis Resulting from an Anastomotic Leak after Colorectal Resection
Authors: Nagib Anthony , Kiffin Chauniqua , Carrillo Eddy H. , Rosenthal Andrew A. , Solomon Rachele J. , Davare Dafney L.
Published: September 2018

One of the most feared complications in colorectal surgery is an anastomotic leak (AL) following a colorectal resection. While various recommendations have been proposed to prevent this potentially fatal complication, anastomotic leaks still occur. We present a case of an AL resulting in a complicated and fatal outcome. This case demonstrates the importance of high clinical suspicion, early recognition, and immediate management.
Human Neonatal Thymus Mesenchymal Stem Cells Promote Neovascularization and Cardiac Regeneration
Authors: Wang Shuyun , Huang Shan , Gong Lianghui , Yuan Zhize , Wong Joshua , Lee Jeffrey , Si Ming-Sing
Published: September 2018

Newborns with critical congenital heart disease are at significant risk of developing heart failure later in life. Because treatment options for end-stage heart disease in children are limited, regenerative therapies for these patients would be of significant benefit. During neonatal cardiac surgery, a portion of the thymus is removed and discarded. This discarded thymus tissue is a good source of MSCs that we have previously shown to be proangiogenic and to promote cardiac function in an in vitro model of heart tissue. The purpose of this study was to further evaluate the cardiac regenerative and protective properties of neonatal thymus (nt) MSCs. We found that ntMSCs expressed and secreted the proangiogenic and cardiac regenerative morphogen sonic hedgehog (Shh) in vitro more than patient-matched bone-derived MSCs. We also found that organoid culture of ntMSCs stimulated Shh expression. We then determined that ntMSCs were cytoprotective of neonatal rat cardiomyocytes exposed to H2O2. Finally, in a rat left coronary ligation model, we found that scaffoldless cell sheet made of ntMSCs applied to the LV epicardium immediately after left coronary ligation improved LV function, increased vascular density, decreased scar size, and decreased cardiomyocyte death four weeks after infarction. We conclude that ntMSCs have cardiac regenerative properties and warrant further consideration as a cell therapy for congenital heart disease patients with heart failure.
Uplift Behavior of Belled Short Piles in Weathered Sandstone
Authors: Yang Bai , Ma Jianlin , Chen Wenlong , Yang Yanxin
Published: September 2018

Field pull out test results of 500 kV double-circuit line of Luping-Fule are presented in this paper to investigate the uplift bearing behavior of rock-socketed belled short piles. A calculation model of rock-socketed belled short pile has been proposed. During the initial stage of loading test, uplift load is shared by even section and bell of the pile, and the bell continues to bear uplift load after the lateral resistance of even section pile reaches the limit. A different performance has been found on the case of long belled pile. At the ultimate state, the uplift resistance provided by bell accounts for about 54.9% and 34.7% of the total uplift capacity for the 6.0 m long and 7.0 m long piles, respectively. Increasing pile length has been found to noticeably increase the ultimate uplift bearing capacity, while it has less effect on the displacement of pile top. The uplift capacity of even section pile is associated with the shear strength of rock mass around the pile, and the test results demonstrate that the ultimate resistance can be equal to the shear strength. The calculation method proposed in this paper is proven to be able to accurately predict the ultimate uplift bearing capacity of the rock-socketed belled short piles.
The New Plastic Flow Machining Process for Producing Thin Sheets
Authors: Vu Viet Q. , Beygelzimer Yan , Kulagin Roman , Toth Laszlo S.
Published: September 2018

A new severe plastic deformation (SPD) process called plastic flow machining (PFM) was recently proposed to produce thin sheets with gradient structures. In the present paper, the role of the die geometry is investigated by studying the effects of the produced sheet thickness (h) on the material properties of commercial pure Aluminum (Al1050) processed by PFM. The obtained experimental results show that an increase of h in the range of 0.65 to 1.5 mm improved the formation efficiency of the sheet. Microstructures of the produced sheets show gradient structures with an average grain size varying from 0.8 to 3.81 µm across the sheet thickness. Both experiments and finite element (FE) simulations document that the degree of the gradient in the microstructure became more significant when h was increased. Sheets produced by PFM exhibited a better strength‐ductility balance than sheets obtained in other SPD processes. Tensile strength of 160–175 MPa and total ductility of 18–25% were obtained for the processed samples after PFM. A rise of h from 0.65 to 1.5 mm lowered the strength but enhanced the ductility of the produced sheet, which is due to the coarser microstructure at larger values of h.
Multicriteria Decision Model and Thermal Pretreatment of Hotel Food Waste for Robust Output to Biogas: Case Study from City of Jaipur, India
Authors: Gandhi Paras , Paritosh Kunwar , Pareek Nidhi , Mathur Sanjay , Lizasoain Javier , Gronauer Andreas , Bauer Alexander , Vivekanand Vivekanand
Published: September 2018

The anaerobic batch test (45 days at 37°C) was performed to describe the effect of thermal pretreatment at moderate temperatures (60, 80, and 100°C) over durations of 10 and 20 minutes on the enhancement of biogas production using hotel food waste from city of Jaipur, India. The results showed that the total cumulative biogas production with thermal pretreatment (100°C, 10 minutes) was 41% higher than the control. Also, this alternative gets first rank using multicriteria decision making model, VIKOR. This outcome was obtained due to the enhancement of degradation of organic compounds such as protein and volatile solids that occurred in the linear trend. Modified Gompertz and Logistic models were used to study the effect of different pretreatment parameters on lag time and biogas yield. Scanning electron microscopy and Fourier transform infrared spectroscopy were also employed to investigate the effect of thermal pretreatment on the physiochemical properties of food waste.
When a Seemingly Harmless Prescription Turns into Toxicity
Authors: Azmaiparashvili Zurab , Lo Kevin Bryan , Habib Nawal , Hsieh Annie
Published: September 2018

Valacyclovir neurotoxicity is commonly seen in the elderly and those with impaired renal function. Differential diagnosis can be challenging as a myriad of medical conditions, including herpes zoster virus associated encephalitis, may present in a similar fashion. We present a case of a 71-year-old male who presented with altered mental status in the setting of recent herpes zoster eruption. His condition was attributed to valacyclovir neurotoxicity, and initiation of appropriate supportive therapy was met with complete resolution of symptoms and normalization of cognitive function.
Mediastinal Myeloid Sarcoma with TP53 Mutation Preceding Acute Myeloid Leukemia with a PICALM-MLLT10 Fusion Gene
Authors: Naesens Leslie , Devos Helena , Nollet Friedel , Michaux Lucienne , Selleslag Dominik
Published: September 2018

Introduction: Myeloid sarcoma (MS), previously known as granulocytic sarcoma or chloroma, is a rare neoplastic condition defined as a tumor mass consisting of myeloblasts or immature myeloid cells occurring at an extramedullary site. Clinical presentation is diverse and determined by a tumor mass effect or local organ dysfunction. Case Report: We report the case of a 25-year-old previously healthy male with rapidly progressive shortness of breath. A chest CT scan demonstrated a heterogenous anterosuperior mediastinal mass with pleural and pericardial invasion. A diagnosis of MS with both myeloid and lymphoid characteristics was made by pathologic, morphologic, and immunophenotypic investigation. Next generation analysis revealed a pathogenic TP53 mutation (c.1035_1036insCT, p.Glu346Leufs*25). After 4 cycles of chemotherapy only a partial metabolic response and tumor size reduction was obtained. A pretransplant bone marrow biopsy revealed the progression of disease to acute myeloid leukemia. Cytogenetic analysis demonstrated a t(10; 11)(p12;q21). Fluorescence in situ hybridization confirmed the presence of a PICALM-MLLT10 fusion gene. Conclusion: MS with a mediastinal localization is rare and often misdiagnosed as malignant lymphoma. Acute leukemia harboring a PICALM-MLLT10 fusion gene is characterized by a mixed T cell and myeloid phenotype. The rearrangement is a rare recurrent translocation associated with specific clinical features, as illustrated in this case report.
LABA/LAMA Fixed Dose Combination in Chronic Obstructive Pulmonary Disease: The Impact on Health-Related Quality of Life
Authors: Labor Marina , Braido Fulvio , Bikov Andras , Lahousse Lies , Rogliani Paola , Baiardini Ilaria
Published: September 2018

Background: While fixed dose combinations (FDCs) of long-acting beta 2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) are increasingly tested on their efficacy in improving lung function, their effectiveness on Patient Reported Outcomes (PROs) such as Health Related Quality of Life (HRQoL) and Health Status (HS) deserve more attention. Objectives: To review current available evidence about the treatment effect of fixed LABA/LAMA FDCs on HRQoL. Methods: A systematic literature search for randomized controlled trials (RCTs) about the impact of LABA/LAMA FDCs versus placebo, LABA or LAMA or LABA/ICS on HRQoL in Chronic obstructive pulmonary disease (COPD) patients has been performed. Results: Twenty-eight RCTs (n = 32, 165 COPD patients) investigating the impact of fixed LABA/LAMA combinations on HRQoL were included. Using the St George’ s Respiratory Questionnaire, 27 out of 28 trials assessed HRQoL. LABA/LAMA FDCs significantly improved HRQoL versus placebo in 9 out of 11 trials, while change when compared to other LABA or LAMA monocomponents was significantly better in 11 out 24. In 5 out of 6 RCTs having LABA/ICS as comparators, LABA/LAMA FDC had a similar effect and only 1 showed significant improvement in HRQL compared to LABA/ICS FDC. Conclusion: LABA/LAMA FDCs may be helpful in improving HRQoL, but because of the heterogeneity of performed trials, strong conclusions cannot be drawn. Moreover, due to the different molecule properties, treatment schedule, and device characteristics of each FDC, a generalized judgment seems inappropriate. Pragmatic trials powered to detect real-life differences in HRQoL and head-to-head comparison are needed to guide clinical practice in terms of PROs.
Efficacy of Recombinant Human Soluble Thrombomodulin in Treating Disseminated Intravascular Coagulation Complicating Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Inoue Yasuyuki , Matsunawa Manabu , Sano Fumiaki , Miura Ikuo
Published: September 2018

The prognosis for patients who experience hemostatic complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is poor. However, no report has investigated disseminated intravascular coagulation (DIC) caused by the complications of allo-HSCT without infection. Recombinant human soluble thrombomodulin (rhTM) was used to treat 12 episodes of DIC (n = 10; group 1) caused by allo-HSCT complications such as acute graft-versus-host disease (aGVHD) or thrombotic microangiopathy (TMA), and the clinical outcomes were compared with those of historical controls (n = 9; group 2) treated for DIC without rhTM. In group 1, the mean DIC score was significantly improved after using rhTM. Fibrinogen degeneration product (FDP), C-reactive protein (CRP), and the inflammatory cytokine high-mobility group box 1 (HMGB1) were also significantly decreased. Serial changes from the baseline values of platelet counts and levels of FDP were significantly better in group 1 than in group 2. The recovery rate from DIC was significantly higher in group 1 than in group 2. These findings suggest that rhTM is effective against both DIC and systemic inflammatory complications after allo-HSCT.
Combined Pre- and Postoperative Lymphocyte Count Accurately Predicts Outcomes of Patients with Colorectal Cancer
Authors: Yamamoto Manabu , Saito Hiroaki , Uejima Chihiro , Tanio Akimitsu , Takaya Seigo , Ashida Keigo , Fujiwara Yoshiyuki
Published: September 2018

Background: Although preoperative lymphopenia is reportedly a prognostic factor in cancer patients, the association between postoperative lymphopenia and patient prognosis has not been widely studied. Methods: We enrolled 379 patients who underwent surgery for colorectal cancer (CRC) to analyze correlations among pre- and postoperative lymphocyte counts (LCs) and prognosis in patients with CRC. Results: Pre- and postoperative LCs were significantly correlated (r = 0.615, p < 0.0001). Based on results of receiver operating characteristic analysis, patients were subgrouped as preoperative LC ≥1,280 (pre-LCHigh, n = 234), preoperative LC < 1,280 (pre-LCLow, n = 145); and as postoperative LC ≥680 (post-LCHigh, n = 246), and postoperative LC < 680 (post-LCLow, n = 133). Five-year disease-specific survival rates significantly differed between pre-LCHigh (88.6%) and pre-LCLow (72.5%) groups (p < 0.0001); and also between the post-LCHigh (88.5%) and post-LCLow (71.1%) groups (p < 0.0001). Five-year disease-specific survival rates of patients who were both pre-LCLow and post-LCLow was significantly lower than those for patients who were either pre-LCHigh or post-LCHigh or pre-LCHigh/post-LCHigh (p = 0.0003). Multivariate analysis indicated that the combination of pre- and postoperative LC was an independent prognostic indicator. Conclusions: The combination of pre- and postoperative LC is a predictive factor for prognosis in CRC patients.
Removal of Bilirubin with a New Adsorbent System: In Vitro Kinetics
Authors: Gemelli Claudia , Cuoghi Aurora , Magnani Stefania , Atti Mauro , Ricci Davide , Siniscalchi Antonio , Mancini Elena , Faenza Stefano
Published: September 2018

Background/Aims: Many potentially toxic molecules accumulate in the blood during hepatic dysfunction. In clinical practice, it is very difficult to remove bilirubin, the most widely studied toxin, and particularly the unconjugated form, strongly albumin-bound. The aim of this in vitro study was to assess irreversible bilirubin adsorption as a protein-bound compound marker, using Cytosorb® (Cytosorbents Corp.), a new hemoadsorption device designed to remove cytokines. Methods: We performed 4 in vitro experiments, dynamic and static, with different albumin-bilirubin solutions. Results: All experiments showed the resin’s ability to break the albumin-bilirubin complex (Experiment 1, 2), leading to efficient bilirubin removal for 24 h (Removal Rate: 90% Experiment 3) with minimal albumin loss. No sign of bilirubin release from the charged resin was detected (Experiment 4). Conclusion: Cytosorb® seems a promising artificial liver support, thanks to its ability to adsorb bilirubin and its proven ability to modulate the cytokines involved in hepatic dysfunction.
Early Loss of Forkhead Transcription Factor, O Subgroup, Member 1 Protein in the Development of Pancreatic Ductal Adenocarcinoma
Authors: Al-Zoughbi Wael , Schauer Silvia , Pichler Martin , Hoefler Gerald
Published: September 2018

Objectives: Forkhead transcription factor, O subgroup, member 1 (FOXO1) is a regulatory protein that plays an essential role in cellular homeostasis. A biological function as a tumor suppressor has been proposed. Here, we examined FOXO1 expression in human pancreatic ductal adenocarcinoma (PDAC) and its precursor lesions. Methods: We immunohistochemically labeled tissue samples from 47 patients with PDAC for FOXO1 protein. In addition, we extracted data from the Cancer Genome Atlas and the Cancer Cell Line Encyclopedia and studied a potential association with well-established genetic variants. A publicly available microarray dataset of 102 PDAC samples was used to explore the influence of FOXO1 expression on patients’ clinical outcome. Results: Normal ductal epithelium universally expressed nuclear and cytoplasmic FOXO1. Reduced expression was observed in PanIN lesions and PDAC of all cases. Analysis of several datasets showed that the FOXO1 gene transcript levels do not correlate with KRAS, TP53, SMAD4, or CDKN2A mutation status, but positively correlate with patients’ outcomes. Conclusions: Loss of FOXO1 protein is identified as an early event during PDAC development and may be independent of the top 4 mutated cancer genes. Because of its strong expression in normal ductal cells, immunohistochemical detection of FOXO1 can function as a valuable test to establish the diagnosis of transformation and malignancy in pancreatic tissues.
High Enhancement Settings for White Light Observation Improves Colorectal Polyp Visibility in Color Difference Value and an Endoscopist’s Visibility
Authors: Yoshida Naohisa , Inoue ken , Yasuda Ritsu , Hirose Ryohei , Dohi Osamu , Naito Yuji , Murakami Takaaki , Inada Yutaka , Ogiso Kiyoshi , Morinaga Yukiko , Kishimoto Mitsuo , Konishi Eiichi , Itoh Yoshito
Published: September 2018

Background/Aims: Settings of structure and color enhancement (CE) change view of white light imaging and a preset low enhancement setting is used regularly. The aim of this study was to investigate whether higher enhancement settings increased colorectal lesions’ visibility with endoscopists’ visibility scoring and objective color difference (CD) value. Methods: From April 2015 to September 2015, we analyzed 27 pictures and 100 videos of colorectal lesions. Combinations of structure enhancement (B3, A3, A5) and CE (CE 0, 1, 3) were evaluated and CD values of 2 corresponding modes (high enhancement: A5 + CE3, preset low enhancement: A3 + CE0) were calculated using marketed software. In the video, these 2 modes were evaluated. All pictures and movies were graded by 4 endoscopists using visibility scores: score 4 (excellent) to score 1 (poor). Results: The scores of A3 + CE0 (2.74 ± 1.09) were significantly lower than those of all other higher enhancement settings such as B3 + CE1 (3.11 ± 1.08), A3 + CE1 (3.33 ± 0.91), and A5 + CE3 (3.56 ± 0.74; p < 0.001). The CD value of A5 + CE3 was significantly higher than A3 + CE0 (20.2 ± 6.9 vs. 12.9 ± 5.6, p < 0.001). In the video, the scores for A5 + CE3 were significantly higher than A3 + CE0 (3.27 ± 0.83 vs. 2.53 ± 1.05, p < 0.001). Conclusions: Higher enhancement settings increased visibility of colorectal lesions.
Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest
Authors: Rao Prashant , Khalpey Zain , Smith Richard , Burkhoff Daniel , Kociol Robb D.
Published: September 2018

Venoarterial extracorporeal membrane oxygenation (VA-ECMO)—also referred to as extracorporeal life support—is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange. The initiation of VA-ECMO has emerged as a salvage intervention in patients with cardiogenic shock, even cardiac arrest refractory to standard therapies. Analogous to veno-venous ECMO for acute respiratory failure, VA-ECMO provides circulatory support and allows time for other treatments to promote recovery or may be a bridge to a more durable mechanical solution in the setting of acute or acute on chronic cardiopulmonary failure. In this review, we provide a brief overview of VA-ECMO, the attendant physiological considerations of peripheral VA-ECMO, and its complications, namely that of left ventricular distention, bleeding, heightened systemic inflammatory response syndrome, thrombosis and thromboembolism, and extremity ischemia or necrosis.
Benefit From Reperfusion With Primary Percutaneous Coronary Intervention Beyond 12 Hours of Symptom Duration in Patients With ST-Segment–Elevation Myocardial Infarction
Authors: Nepper-Christensen Lars , Lønborg Jacob , Høfsten Dan E. , Ahtarovski Kiril A. , Bang Lia E. , Helqvist Steffen , Kyhl Kasper , Køber Lars , Kelbæk Henning , Vejlstrup Niels , Holmvang Lene , Engstrøm Thomas
Published: September 2018

Background:

Guidelines recommend primary percutaneous coronary intervention (PCI) in patients with ST-segment–elevation myocardial infarction (STEMI) presenting ≥12 hours of symptom onset in the presence of ongoing ischemia. However, data supporting this recommendation are limited. We evaluated the effect of primary PCI on reperfusion success, using cardiac magnetic resonance, in STEMI patients with signs of ongoing ischemia presenting 12 to 72 hours after symptom onset compared with STEMI patients presenting <12 hours.

Methods and Results:

We included 865 STEMI patients who underwent cardiac magnetic resonance just after index PCI and 3 months later. Despite equal area at risk (34±12% versus 33±12%;
P
=0.370), patients presenting late (n=58) had larger final infarct size (13% [interquartile range, 9–24] versus 11% [interquartile range, 4–19];
P
=0.037) and smaller myocardial salvage index (0.58 [interquartile range, 0.39–0.71] versus 0.65 [interquartile range, 0.49–0.84];
P
=0.021) compared with patients presenting <12 hours after symptom onset (n=807). However, 65% of late-presenting patients achieved substantial myocardial salvage ≥0.50, and area under the curve for symptom onset to PCI as predictor of a myocardial salvage index ≥0.50 was poor (0.58 [95% CI, 0.53–0.63];
P
<0.001). In addition, final infarct size, salvage index and left ventricular function correlated weakly with duration from symptom onset to primary PCI (
R
2
values <0.05).

Conclusions:

STEMI patients with signs of ongoing ischemia treated with primary PCI 12 to 72 hours after symptom onset had less myocardial salvage and developed larger infarcts. However, a large proportion achieved substantial myocardial salvage indicating a benefit from primary PCI in late-presenting patients.

Clinical Trial Registration:

URL:
https://www.clinicaltrials.gov
. Unique identifiers: NCT01435408 and NCT01960933.
Rates, Characteristics, and Outcomes of Patients Transferred to Specialized Stroke Centers for Advanced Care
Authors: Ali Syed F. , Fonarow Gregg , Liang Li , Xian Ying , Smith Eric E. , Bhatt Deepak L. , Schwamm Lee
Published: September 2018

Background

While many patients are transferred to specialized stroke centers for advanced acute ischemic stroke (AIS) care, few studies have characterized these patients. We sought to determine variation in the rates and differences in the baseline characteristics and clinical outcomes between AIS cases presenting directly to stroke centers’ front door versus Transfer-Ins from another hospital.

Methods and Results

We analyzed 970 390 AIS cases in the Get With The Guidelines–Stroke registry from January 2010 to March 2014 to compare hospitals with high Transfer-In rates (≥15%) versus those with low Transfer-In rates (<5%) and to compare the front-door versus Transfer-In patients admitted to those hospitals with high Transfer-In rates (high Transfer-In hospitals). Of 970 390 patients discharged from 1646 hospitals, 87% initially presented via the emergency department versus 13% were a Transfer-In from another hospital. High Transfer-In hospitals had a median 31% Transfer-In rate among all stroke discharges, were larger, had higher annual AIS volume and intravenous tPA (tissue-type plasminogen activator) rates, and were more often Midwest teaching hospitals and stroke centers. Compared with front-door, Transfer-In patients were younger, more often white, had higher median National Institutes of Health Stroke Scale scores, less often hypertension and previous stroke/transient ischemic attack, and higher in-hospital mortality (7.9% versus 4.9%; standardized difference, 12.4%). After multivariable adjustment, Transfer-In patients had higher in-hospital mortality and discharge modified Rankin scale.

Conclusions

There is significant regional variability in the transfer of patients with AIS. Because Transfer-In patients seem to have worse short-term outcomes, these patients have the potential to negatively influence institutional mortality rates and should be accounted for explicitly in hospital risk-profiling measures.
Impact of Patient Distance From Percutaneous Coronary Intervention Centers on Longitudinal Outcomes
Authors: Valle Javier A. , Glorioso Thomas J. , Maddox Thomas M. , Armstrong Ehrin J. , Waldo Stephen W. , Bradley Steven M. , Ho P. Michael
Published: September 2018

Background

In regional healthcare referral networks, specialty care is provided at a few sites within the network, with patients referred there for management. This model may increase access to specialized care but also increases the distance that patients travel to receive such care, with unknown effects on longitudinal outcomes. The Veterans Administration uses such regional models for percutaneous coronary intervention (PCI). The impact of patient distance from specialty centers on longitudinal outcomes after receipt of specialized care is understudied and may carry implications for care delivery models.

Methods and Results

We identified 31 483 patients undergoing PCI at 64 Veterans Administration sites between 2008 to 2012, and assessed the relationship between quintile (Qn) of patient distance from PCI center and all-cause death or myocardial infarction within a year of PCI. Secondary analyses investigated interactions between patient distance and PCI presentation, urgency, and Medicare eligibility on the primary outcome. Median distance to PCI site was 48 miles (interquartile range, 17–110). After adjustment, increasing distance from PCI center was not associated with higher risk of 1-year death or myocardial infarction (with Qn1 as reference, Qn2: odds ratio, 1.02 [95% simultaneous CI, 0.84–1.25]; Qn3: 1.06 [95% simultaneous CI, 0.87–1.30]; Qn4: 0.92 [95% simultaneous CI, 0.75–1.14]; Qn5: 0.97 [95% simultaneous CI, 0.78–1.20]). Stratifying the cohort by acute coronary syndrome presentation, urgency of PCI, and by eligibility for Medicare did not find an association between distance and outcome.

Conclusions

In this cohort of US veterans, 50% traveled 48 miles or longer to undergo PCI, and 25% traveled >110 miles. Despite this wide range of distances traveled, there was no association between patient distance to PCI center and subsequent outcomes of death or myocardial infarction at 1 year. These findings suggest that regional referral networks may represent viable models for PCI care delivery.
Is Anticoagulation Beneficial in Pulmonary Arterial Hypertension?
Authors: Khan Muhammad Shahzeb , Usman Muhammad Shariq , Siddiqi Tariq Jamal , Khan Safi U. , Murad M. Hassan , Mookadam Farouk , Figueredo Vincent M. , Krasuski Richard A. , Benza Raymond L. , Rich Jonathan D.
Published: September 2018

Background

Data about anticoagulation in pulmonary arterial hypertension (PAH) patients are inconsistent. The objective of this study was to examine the impact of adjunctive oral anticoagulants in patients with PAH through meta-analysis, and to further assess whether response differs by PAH subtype.

Methods and Results

Cochrane CENTRAL, Medline, and Scopus databases were searched for randomized or nonrandomized studies that assessed the association between anticoagulation and outcomes in patients with PAH. Hazard ratios (HRs) for mortality were pooled using the random effects model. Subgroup analyses were performed for type of PAH and study design. Twelve nonrandomized studies, at moderate risk of bias, were included. These consisted of 2512 patients (1342 receiving anticoagulation and 1170 controls). Anticoagulation significantly reduced mortality in the overall PAH cohort (HR, 0.73 [0.57, 0.93];
P
=0.001;
I
2
=64%). On subgroup analysis, a significant mortality reduction was seen in idiopathic PAH patients (HR, 0.73 [0.56, 0.95];
P
=0.02;
I
2
=46%), whereas no significant difference was observed in connective tissue disease–related PAH (HR, 1.16 [0.58, 2.32];
P
=0.67;
I
2
=71%). Sensitivity analysis specific to scleroderma-associated PAH demonstrated a significant increase in mortality with anticoagulant use (HR, 1.58 [1.08, 2.31];
P
=0.02;
I
2
=9%).

Conclusions

This meta-analysis shows that use of anticoagulation may improve survival in idiopathic PAH patients, while increasing mortality when used in scleroderma-associated-PAH patients. Currently, no randomized clinical trials have been published, and until randomized data are available, anticoagulant use in PAH should be tailored to PAH subtype.
Ventricular Arrhythmias in Cardiac Sarcoidosis
Authors: Okada David R. , Smith John , Derakhshan Arsalan , Gowani Zain , Misra Satish , Berger Ronald D. , Calkins Hugh , Tandri Harikrishna , Chrispin Jonathan
Published: September 2018

The diagnosis of cardiac sarcoidosis (CS), especially in cases where there is limited or no extracardiac involvement, is challenging. Patients with CS are at increased risk of ventricular arrhythmias and sudden cardiac death. Several techniques for risk stratification for sudden cardiac death have been proposed in this population, including advanced cardiac imaging and electrophysiology study. Clinical ventricular arrhythmias in patients with CS may be treated with immunosuppressant therapy, antiarrhythmic drugs, catheter ablation, or implantable cardioverter-defibrillator placement. This article will provide an update on techniques for diagnosing CS, risk stratifying patients with CS for sudden cardiac death, and treating patients with CS with ventricular arrhythmias, focusing on evidence that has become available since publication of the 2014 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Management of Arrhythmias Associated With Cardiac Sarcoidosis.
An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association
Authors: Mason Peter J. , Shah Binita , Tamis-Holland Jacqueline E. , Bittl John A. , Cohen Mauricio G. , Safirstein Jordan , Drachman Douglas E. , Valle Javier A. , Rhodes Denise , Gilchrist Ian C. ,   On behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; and Council on Genomic and Precision Medicine
Published: September 2018

Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome–related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a “radial-first” strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.
How Do Home and Clinic Blood Pressure Readings Compare in Pregnancy?
Authors: Tucker Katherine L. , Bankhead Clare , Hodgkinson James , Roberts Nia , Stevens Richard , Heneghan Carl , Rey Évelyne , Lo Chern , Chandiramani Manju , Taylor Rennae S. , North Robyn A. , Khalil Asma , Marko Kathryn , Waugh Jason , Brown Mark , Crawford Carole , Taylor Kathryn S. , Mackillop Lucy , McManus Richard J.
Published: September 2018

Hypertensive disorders during pregnancy result in substantial maternal morbidity and are a leading cause of maternal deaths worldwide. Self-monitoring of blood pressure (BP) might improve the detection and management of hypertensive disorders of pregnancy, but few data are available, including regarding appropriate thresholds. This systematic review and individual patient data analysis aimed to assess the current evidence on differences between clinic and self-monitored BP through pregnancy. MEDLINE and 10 other electronic databases were searched for articles published up to and including July 2016 using a strategy designed to capture all the literature on self-monitoring of BP during pregnancy. Investigators of included studies were contacted requesting individual patient data: self-monitored and clinic BP and demographic data. Twenty-one studies that utilized self-monitoring of BP during pregnancy were identified. Individual patient data from self-monitored and clinic readings were available from 7 plus 1 unpublished articles (8 studies; n=758) and 2 further studies published summary data. Analysis revealed a mean self-monitoring clinic difference of ≤1.2 mm Hg systolic BP throughout pregnancy although there was significant heterogeneity (difference in means, I
2
>80% throughout pregnancy). Although the overall population difference was small, levels of white coat hypertension were high, particularly toward the end of pregnancy. The available literature includes no evidence of a systematic difference between self and clinic readings, suggesting that appropriate treatment and diagnostic thresholds for self-monitoring during pregnancy would be equivalent to standard clinic thresholds.
Randomized Crossover Trial of the Impact of Morning or Evening Dosing of Antihypertensive Agents on 24-Hour Ambulatory Blood Pressure
Authors: Poulter Neil R. , Savopoulos Christos , Anjum Aisha , Apostolopoulou Martha , Chapman Neil , Cross Mary , Falaschetti Emanuela , Fotiadis Spiros , James Rebecca M. , Kanellos Ilias , Szigeti Matyas , Thom Simon , Sever Peter , Thompson David , Hatzitolios Apostolos I.
Published: September 2018

Some data suggest that nocturnal dosing of antihypertensive agents may reduce cardiovascular outcomes more than daytime dosing. This trial was designed to evaluate whether ambulatory blood pressure monitoring levels differ by timing of drug dosing. Patients aged 18 to 80 years with reasonably controlled hypertension (≤150/≤90 mm Hg) on stable therapy of ≥1 antihypertensive agent were recruited from 2 centers in London and Thessaloniki. Patients were randomized to receive usual therapy either in the morning (6
am
–11
am
) or evening (6
pm
–11
pm
) for 12 weeks when participants crossed over to the alternative timing for a further 12 weeks. Clinic blood pressures and a 24-hour recording were taken at baseline, 12, and 24 weeks and routine blood tests were taken at baseline. The study had 80% power to detect 3 mm Hg difference in mean 24-hour systolic blood pressure (α=0.05) by time of dosing. A 2-level hierarchical regression model adjusted for center, period, and sequence was used. Of 103 recruited patients (mean age, 62; 44% female), 95 patients (92%) completed all three 24-hour recordings. Mean 24-hour systolic and diastolic blood pressures did not differ between daytime and evening dosing. Similarly, morning and evening dosing had no differential impact on mean daytime (7
am
–10
pm
) and nighttime (10
pm
–7
am
) blood pressure levels nor on clinic levels. Stratification by age (≤65/≥65 years) or sex did not affect results. In summary, among hypertensive patients with reasonably well-controlled blood pressure, the timing of antihypertensive drug administration (morning or evening) did not affect mean 24-hour or clinic blood pressure levels.

Clinical Trial Registration—

URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01669928.
Blood Pressure Variability, Arterial Stiffness, and Arterial Remodeling
Authors: Zhou Tan Lai , Henry Ronald M.A. , Stehouwer Coen D.A. , van Sloten Thomas T. , Reesink Koen D. , Kroon Abraham A.
Published: September 2018

Greater very short- to midterm blood pressure variability (BPV) has been associated with an increased cardiovascular disease risk, especially stroke. However, this link remains incompletely understood. We hypothesized that increased arterial stiffness and maladaptive carotid arterial remodeling may underlie this association. We, therefore, investigated the association between very short- to midterm systolic BPV, aortic and carotid stiffness and carotid arterial remodeling using cross-sectional data from The Maastricht Study (aged 60±8 years; 53% men). Aortic (carotid-femoral pulse wave velocity, n=1671) and carotid stiffness (ultrasonography, n=1690) were assessed. A composite index of systolic BPV was derived by standardizing and averaging systolic within-visit, 24-hour, and 7-day BPV. We performed linear regression analyses with adjustment for age, sex, glucose metabolism status, mean arterial pressure, and cardiovascular risk factors. A 1-SD greater systolic BPV was statistically significantly associated with 0.10 m/s (95% CI, 0.01–0.20) greater carotid-femoral pulse wave velocity, but not with carotid distensibility (−0.033×10
−3
/kPa [−0.255 to 0.190]). In addition, a 1-SD greater systolic BPV was statistically significantly associated with greater carotid circumferential wall tension (0.84 dyne/cm [0.51–1.17]), circumferential wall stress (0.79 kPa [0.031–1.27]), and intima-media thickness (8.6 µm [1.0–16.3]). These results are indicative of maladaptive carotid remodeling, as circumferential wall tension and stress were not normalized despite greater intima-media thickness. In conclusion, greater very short- to midterm BPV is associated with greater aortic stiffness and maladaptive carotid arterial remodeling, but not with carotid stiffness. These findings may explain, at least partially, the increased BPV-associated cardiovascular disease risk, in particular stroke.
CRHR2 (Corticotropin-Releasing Hormone Receptor 2) in the Nucleus of the Solitary Tract Contributes to Intermittent Hypoxia-Induced Hypertension
Authors: Wang Lei A. , Nguyen Dianna H. , Mifflin Steve W.
Published: September 2018

This study tested the hypothesis that CRHRs (corticotropin-releasing hormone receptors) in the nucleus of the solitary tract (NTS) contribute to the hypertension induced by intermittent hypoxia (IH) exposure in rats. Initial studies using in situ hybridization revealed low mRNA level of CRHR1 (CRH type 1 receptor) but high mRNA level of CRHR2 (CRH type 2 receptor) in the NTS. Calcium imaging studies on NTS slice preparations using Fura-2-acetoxymethyl ester demonstrated that CRH induced a transient increase of intracellular calcium level. The CRH-induced calcium response was reproduced in the presence of TTX (tetrodotoxin) but was abolished by depletion of extracellular calcium or by the L-type calcium channel blocker Nifedipine. The CRH-induced calcium influx was attenuated by the CRHR2 antagonist K41498 but not by the CRHR1 antagonist NBI-35 965. Calcium influx can be induced by the CRHR2 agonist Urocortin II but not by the CRHR1 agonist Stressin 1. IH exposure did not affect CRHR1 mRNA level but significantly decreased CRHR2 mRNA level and the CRH-induced calcium influx in the NTS. Further in vivo studies showed that intra-fourth ventricle infusion of K41498 did not affect the basal blood pressure but significantly attenuated the IH-induced hypertension; intra-fourth ventricle infusion of Urocortin II significantly increased basal blood pressure and exacerbated the IH-induced hypertension. Collectively, these results suggest that CRHR2 in the NTS contributes to the IH-induced hypertension; downregulation of CRHR2 and CRHR2-mediated calcium influx in the NTS may serve as an adaptive response to protect against the IH-induced hypertension.
Prognostic Value of Masked Uncontrolled Hypertension
Authors: Pierdomenico Sante D. , Pierdomenico Anna M. , Coccina Francesca , Clement Denis L. , De Buyzere Marc L. , De Bacquer Dirk A. , Ben-Dov Iddo Z. , Vongpatanasin Wanpen , Banegas José R. , Ruilope Luis M. , Thijs Lutgarde , Staessen Jan A.
Published: September 2018

The prognostic relevance of masked uncontrolled hypertension (MUCH) is incompletely clear, and its global impact on cardiovascular outcomes and mortality has not been assessed. The aim of this study was to perform a meta-analysis on the prognostic value of MUCH. We searched for articles assessing outcome in patients with MUCH compared with those with controlled hypertension (CH) and reporting adjusted hazard ratio and 95% CI. We identified 6 studies using ambulatory blood pressure monitoring (12 610 patients with 933 events) and 5 using home blood pressure measurement (17 742 patients with 394 events). The global population included 30 352 patients who experienced 1327 events. Selected studies had cardiovascular outcomes and all-cause mortality as primary outcome, and the main result is a composite of these events. The overall adjusted hazard ratio was 1.80 (95% CI, 1.57–2.06) for MUCH versus CH. Subgroup meta-analysis showed that adjusted hazard ratio was 1.83 (95% CI, 1.52–2.21) in studies using ambulatory blood pressure monitoring and 1.75 (95% CI, 1.38–2.20) in those using home blood pressure measurement. Risk was significantly higher in MUCH than in CH independently of follow-up length and types of studied events. MUCH was at significantly higher risk than CH in all ethnic groups, but the highest hazard ratio was found in studies, including black patients. Risk of cardiovascular events and all-cause mortality is significantly higher in patients with MUCH than in those with CH. MUCH detected by ambulatory or home blood pressure measurement seems to convey similar prognostic information.
Prediction of Ambulatory Hypertension Based on Clinic Blood Pressure Percentile in Adolescents
Authors: Hamdani Gilad , Flynn Joseph T. , Becker Richard C. , Daniels Stephen R. , Falkner Bonita , Hanevold Coral D. , Ingelfinger Julie R. , Lande Marc B. , Martin Lisa J. , Meyers Kevin E. , Mitsnefes Mark , Rosner Bernard , Samuels Joshua A. , Urbina Elaine M.
Published: September 2018

Ambulatory blood pressure (BP) monitoring provides a more precise measure of BP status than clinic BP and is currently recommended in the evaluation of high BP in children and adolescents. However, ambulatory BP monitoring may not always be available. Our aim was to determine the clinic BP percentile most likely to predict ambulatory hypertension. We evaluated clinic and ambulatory BP in 247 adolescents (median age, 15.7 years; 63% white; 54% male). Clinic BP percentile (based on the fourth report and the 2017 American Academy of Pediatrics clinical practice guidelines) and ambulatory BP status (normal versus hypertension) were determined by age-, sex-, and height-specific cut points. Sensitivity and specificity of different clinic BP percentiles and cutoffs to predict ambulatory hypertension were calculated. Forty (16%) and 67 (27%) patients had systolic hypertension based on the fourth report and the 2017 guidelines, respectively, whereas 38 (15%) had wake ambulatory systolic hypertension. The prevalence of ambulatory wake systolic hypertension increased across clinic systolic BP percentiles, from 3% when clinic systolic BP was <50th percentile to 41% when ≥95th percentile. The 2017 guidelines’ 85th systolic percentile had similar sensitivity (86.8%) and better specificity (57.4% versus 48.1%) than elevated BP (≥90th percentile or ≥120 mm Hg) to diagnose ambulatory hypertension. When evaluating adolescents for hypertension, 2017 guidelines’ clinic systolic 85th percentile may be the optimal threshold at which to perform ambulatory BP monitoring.
Office and Ambulatory Heart Rate as Predictors of Age-Related Kidney Function Decline
Authors: Eriksen Bjørn O. , Småbrekke Silje , Jenssen Trond G. , Mathisen Ulla D. , Norvik Jon V. , Schei Jørgen , Schirmer Henrik , Solbu Marit D. , Stefansson Vidar T.N. , Melsom Toralf
Published: September 2018

The decline in glomerular filtration rate (GFR) associated with aging is one of the most important predisposing causes of kidney failure in old age. Identifying persons at risk for accelerated GFR decline is an essential first step in the development of preventive measures to preserve kidney function in the elderly. Heart rate (HR) has not yet been studied as a risk factor for GFR decline in the general population. In the RENIS-T6 (Renal Iohexol-Clearance Survey in Tromsø 6), we measured baseline ambulatory HR and GFR as iohexol clearance in a representative, middle-aged cohort of 1627 persons without self-reported diabetes mellitus, cardiovascular disease, or kidney disease. In the RENIS-FU (RENIS Follow-Up Study), we repeated the GFR measurements and calculated the rate of GFR decline in 81% of the participants after a median follow-up of 5.6 years. The unadjusted mean rate of GFR decline was 0.96 mL/min per year. In multivariable-adjusted linear mixed models, 10 bpm higher ambulatory 24-hour and daytime HRs and office HR were associated with steeper GFR decline rates of 0.20 to 0.21 mL/min per year (
P
≤0.01). The odds ratio for predicting a rate of GFR decline twice that of the population mean in a fully adjusted model was 1.24 (
P
=0.01) for ambulatory 24-hour HR. Office HR was also an independent predictor of a steeper rate of GFR decline. HR may be a useful biomarker to identify persons at risk of accelerated GFR decline.