bluuebunny/crossref_metadata_2025 huggingface dataset:
Cognitive function in men with non-motor features of Parkinson’s disease
Authors: Flores-Torres Mario H , Hughes Katherine C , Molsberry Samantha , Gao Xiang , Kang Jae H , Schwarzschild Michael A , Ascherio Alberto
Published: June 2021

Objective

Subtle cognitive deficits can occur during the prodromal phase of Parkinson’s disease (PD), commonly in conjunction with hyposmia. However, little is known about the association between cognitive function and other features suggestive of prodromal PD. We evaluated the association of non-motor prodromal PD features, including hyposmia, constipation and probable REM sleep behaviour disorder (pRBD), with objective measures of cognitive function and self-reported cognitive decline.

Methods

The study population comprised 804 men who responded to a telephone cognitive interview in 2016–2017. Participants included 680 individuals with hyposmia, of whom 45 had confirmed PD, and 124 men without hyposmia. Among these men, we evaluated objective cognitive function and subjective cognitive decline to determine whether the presence of non-motor features of prodromal PD was associated with cognitive functioning. Analyses were adjusted for age, physical activity, body mass index, smoking status and coffee consumption.

Results

Individuals with non-motor features of prodromal PD had worse objective and subjective cognitive performance relative to men without non-motor features. Cognitive impairment was particularly prevalent among individuals with concurrent hyposmia, pRBD and constipation (multivariate-adjusted OR=3.80; 95% CI 1.52 to 9.47 for objective poor cognitive function; OR=8.71; 95% CI 3.18 to 23.83 for subjective cognitive decline). As expected, both objective (OR=7.91) and subjective (OR=17.42) cognitive impairment were also more common among men with confirmed PD.

Conclusions

Our study suggests that cognition is commonly affected in individuals with non-motor prodromal PD features, particularly when multiple of these features are present.
Quantum interference of spontaneous-emission channels near the surface of Bi2Se3
Authors: Karaoulanis Dimitrios , Yannopapas Vassilios
Published: June 2021

We show that the quantum interference between two spontaneous emission channels can be significantly enhanced when a three-level V-type atom is placed near the surface of the topological insulator [Formula: see text]. The enhancement of quantum interference is a result of the strong dependence of the spontaneous emission rate on the orientation of an atomic dipole relative to surface of the [Formula: see text] at the frequencies of polaritonic-type excitations.
Multimodal Video Indexing (MVI): A New Method Based on Machine Learning and Semi-Automatic Annotation on Large Video Collections
Authors: Hamroun Mohamed , Tamine Karim , Crespin Benoît
Published: June 2021

Indexing video by the concept is one of the most appropriate solutions for such problems. It is based on an association between a concept and its corresponding visual sound, or textual features. This kind of association is not a trivial task. It requires knowledge about the concept and its context. In this paper, we investigate a new concept detection approach to improve the performance of content-based multimedia documents retrieval systems. To achieve this goal, we are going to tackle the problem from different plans and make four contributions at various stages of the indexing process. We propose a new method for multimodal indexation based on (i) a new weakly supervised semi-automatic method based on the genetic algorithm (ii) the detection of concepts from the text in the videos (iii) the enrichment of the basic concepts thanks to the usage of our method DCM. Subsequently, the semantic and enriched concepts allow a better multimodal indexation and the construction of an ontology. Finally, the different contributions are tested and evaluated on a large dataset (TRECVID 2015).
Dynamics and optimal control in transmission of tungiasis diseases
Authors: Lv Wei , Liu Lu , Zhuang Shi-Jia
Published: June 2021

This paper aims to model the transmission of tungiasis disease and assess the optimal control schemes to stop its occurrence. Based on the development stage of fleas and propagation process of diseases, we propose a human-flea model without control, in which the susceptible-infected in latent stage-infectious populations and the egg-larva-pupa-adult stage of fleas are all in involved. In the light of the Lyapunov function method, we prove global stability of equilibria. The model is extended by reformulating it as an optimal control problem, with the use of four time-dependent controls, to assess the impact of individual protection, treatment and two flea control strategies (killing adult fleas and reduction of eggs and larvae). By using Pontryagin’s maximum principle, we characterize the optimal control. Using the data of human and flea in Brazil and Nigeri, numerical simulations are performed. The numerical results show that enhancing the protection and treatment of people and increasing the killing efficacy of flea adults would contribute to prevent and control the spread of the disease appreciably.
A year in lockdown
Authors: Feldmann Anja , Gasser Oliver , Lichtblau Franziska , Pujol Enric , Poese Ingmar , Dietzel Christoph , Wagner Daniel , Wichtlhuber Matthias , Tapiador Juan , Vallina-Rodriguez Narseo , Hohlfeld Oliver , Smaragdakis Georgios
Published: June 2021

In March 2020, the World Health Organization declared the Corona Virus 2019 (COVID-19) outbreak a global pandemic. As a result, billions of people were either encouraged or forced by their governments to stay home to reduce the spread of the virus. This caused many to turn to the Internet for work, education, social interaction, and entertainment. With the Internet demand rising at an unprecedented rate, the question of whether the Internet could sustain this additional load emerged. To answer this question, this paper will review the impact of the first year of the COVID-19 pandemic on Internet traffic in order to analyze its performance. In order to keep our study broad, we collect and analyze Internet traffic data from multiple locations at the core and edge of the Internet. From this, we characterize how traffic and application demands change, to describe the "new normal," and explain how the Internet reacted during these unprecedented times.
Hypokalemic Periodic Paralysis Precipitated by Thyrotoxicosis and Renal Tubular Acidosis
Authors: Jackson Ian , Addasi Yazan , Ahmed Moeed , Ramadan Bashar , Kalian Karson , Addasi Noor , Nayfeh Ali , Taylor Jocelyn , Bashir Khalid , Krajicek Bryan
Published: June 2021

Background. Hypokalemic periodic paralysis is a rare neuromuscular disorder characterized by transient episodes of flaccid paralysis due to a defect in muscle ion channels. Most cases are hereditary, but it can be acquired. We present a case of acquired hypokalemic periodic paralysis associated with hyperthyroidism and renal tubular acidosis. Clinical Case. A 38-year-old female with a history of Graves’ disease presented to the emergency department with generalized weakness and associated nausea, vomiting, and weight loss. Examination was significant for diffuse weakness in all extremities. Labs showed hypokalemia, hyperthyroidism, and nonanion gap metabolic acidosis with a positive urine anion gap. She was treated for hypokalemic periodic paralysis and renal tubular acidosis. Potassium replacement, propranolol, methimazole, and sodium bicarbonate were initiated. Her potassium gradually corrected with resolution of her symptoms. Further investigation revealed a history of dry eyes, dry mouth, and recurrent dental carries. She had positive ANA, SS-A, and SS-B antibodies. She was diagnosed with Sjögren’s syndrome, which may have been associated with her Graves’ disease and thus contributed to both her RTA and hyperthyroidism. Conclusion. Early recognition and treatment of thyrotoxic periodic paralysis are important to prevent cardiac complications. Management includes potassium replacement with careful monitoring to prevent rebound hyperkalemia. The definitive treatment is to achieve euthyroid status.
Intraoperative Transesophageal Echocardiography to Monitor for Pulmonary Emboli in a Pediatric Patient Undergoing Undifferentiated Embryonal Sarcoma of the Liver Resection
Authors: Salik Irim , Lamper Nicolas , Mehta Bhupen , Chan Kar-Mei
Published: June 2021

A minimally invasive monitoring technique, intraoperative transesophageal echocardiography (TEE), has been utilized to provide real-time data on volume status and ventricular function in patients undergoing liver transplantation. In this case, TEE was utilized in an 8-year-old female undergoing undifferentiated embryonal sarcoma of the liver resection to monitor for pulmonary emboli, particularly a saddle embolus. In addition to visualization of cardiac structures, TEE can also be utilized to monitor the liver, lungs, spleen, and kidneys. Monitoring for echocardiographic findings of pulmonary embolism in this high-risk patient was an integral part of effective intraoperative management.
Customer Knowledge Enabled Innovation: Analyzing Pricing‐Promotion Coordination Mechanism
Authors: Zhao Guanbing , Qiu Yangyang , Imran Muhammad , Manan Fazal
Published: June 2021

Pricing and promotion are two important decisions during the market launch of new consumer electronics products. Nowadays, the pricing and promotion of consumer electronic products are often not made separately but at the same time. This study focuses on the pricing‐promotion coordination mechanism of a secondary supply chain of new consumer electronics products (which consists of a manufacturer and a seller). Price and the degree of promotion together affect the demand for products. Manufacturers give sellers a sales target. Manufacturers and sellers set prices and promotions separately, introduce repurchase penalty joint contracts, and establish supply chain profit models to compare and analyze optimal pricing, promotion efforts, and maximum profit of supply chains under different decision‐making situations. We prove that the repurchase penalty joint contract can coordinate the supply chain under the assumptions of a single‐period game and a multiperiod repeated game. The results show that under the repurchase penalty joint contract, when manufacturers and sellers choose high prices and high promotions at the same time, the supply chain of new consumer electronics products has the largest profit. Finally, numerical experiments are conducted to study the influence of parameters on optimal decision‐making and supply chain profits.
An Update on the Pathogenic Role of Macrophages in Adult-Onset Still’s Disease and Its Implication in Clinical Manifestations and Novel Therapeutics
Authors: Chen Po-Ku , Chen Der-Yuan
Published: June 2021

Increasing evidence indicates a pivotal role of macrophages in innate immunity, which contributes to the pathogenesis of adult-onset Still’s disease (AOSD). Despite the available reviews that summarized the pathogenic role of proinflammatory cytokines in AOSD, a systematic approach focusing on the crucial role of macrophages in this disease is still lacking. This review summarizes the updated functions of macrophages in AOSD and their implication in clinical manifestations and therapeutics. We searched the MEDLINE database using the PubMed interface and reviewed the English-language literature as of 31 March 2021, from 1971 to 2021. We focus on the existing evidence on the pathogenic role of macrophages in AOSD and its implication in clinical characteristics and novel therapeutics. AOSD is an autoinflammatory disease mainly driven by the innate immune response. Among the innate immune responses, macrophage activation is a hallmark of AOSD pathogenesis. The pattern recognition receptors (PRRs) on macrophages recognize pathogen-associated molecular patterns and damage-associated molecular patterns and subsequently cause overproduction of proinflammatory cytokines and recruit adaptive immunity. Some biomarkers, such as ferritin and gasdermin D, reflecting macrophage activation were elevated and correlated with AOSD activity. Given that macrophage activation with the overproduction of proinflammatory cytokines plays a pathogenic role in AOSD, these inflammatory mediators would be the therapeutic targets. Accordingly, the inhibitors to interleukin- (IL-) 1, IL-6, and IL-18 have been shown to be effective in AOSD treatment. Gaining insights into the pathogenic role of macrophages in AOSD can aid in identifying disease biomarkers and therapeutic agents for this disease.
Disparities between Asian and Non-Asian Thrombolyzed Acute Ischemic Stroke Patients in the Enhanced Control of Hypertension and Thrombolysis Stroke Trial
Authors: Chen Chen , Wang Xia , Chen Xiaoying , Ouyang Menglu , Sun Lingli , Arima Hisatomi , Robinson Thompson , Lindley Richard I. , Chalmers John , Li Gang , Song Lili , Anderson Craig S. ,   for the ENCHANTED Investigators
Published: June 2021

Background and Purpose: As outcomes for acute ischemic stroke (AIS) vary according to clinical profile and management approaches, we aimed to determine disparities in clinical outcomes between Asian and non-Asian participants of the international, Enhanced Control of Hypertension and Thrombolysis Stroke study (ENCHANTED). Methods: ENCHANTED was a multicenter, prospective, partial-factorial, randomized, open trial of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) alteplase, and intensive (target systolic blood pressure [SBP] 130–140 mm Hg) or guideline-recommended (<180 mm Hg) BP management, in thrombolysis-eligible AIS patients. Logistic regression models were used to examine the associations with outcomes of death or disability (modified Rankin scale [mRS] scores 2–6), major disability (mRS 3–5), death, and intracranial hemorrhage (ICH), with adjustment prognostic factors, alteplase dose, and mean SBP over 1–24 h. Results: Among 4,551 thrombolyzed AIS patients (mean age 66.7 years, 37.8% female), there were 65.4% Asians who were younger, fewer female, and with less atrial fibrillation, hypercholesterolemia, premorbid symptoms, and concomitant antihypertensive, antithrombotic and statin treatment, and more prior stroke, compared to non-Asians. Frequencies of hypertension, coronary artery disease, and diabetes mellitus were comparable between groups. Asian patients were less likely to be admitted to an acute stroke unit and receive early mobilization by a therapist or rehabilitation but more likely to receive intensive care. There were no significant differences between Asians and non-Asians in functional outcome (defined by mRS scores 2–6 or 3–5; adjusted odds ratio [OR] 1.00, 95% confidence interval [CI] 0.85–1.19 [p = 0.958] and OR 0.95, 95% CI 0.80–1.13 [p = 0.572], respectively), or death (OR 1.25, 95% CI 0.95–1.65; p = 0.116), despite Asians having greater odds of ICH (OR 1.51, 95% CI 1.23–1.86; p = 0.0001) and neurological deterioration within 24 h (OR 1.58, 95% CI 1.18–2.12; p = 0.002). Conclusions: Within the context of an international clinical trial of thrombolyzed AIS patients, demography, risk factors, management, and odds of early neurological deterioration and ICH, all differ between Asian and non-Asian participants. However, patterns of functional recovery are similar between these major regional groups.
METHOD OF SPECIFIC SITUATIONS ANALYSIS (CASE METHOD) AS A PEDAGOGICAL TECHNOLOGY
Authors: Prokop I. A. , Savaryn T. V.
Published: June 2021

The article focuses on the issue of using case method as an interactive way of training in the medical education. History as well as classification and types of case demonstration, alongside with the steps of case study implementation, interactivity and feasibility for the use of the method in training medical students at Latin and English classes are considered.

The use of case study at the practical classes has been found to contribute to the development of students’ communication skills and ability to apply knowledge creatively. Besides, it develops group work skills as well skills in problem statement, search for the ways of addressing the problem, information collection and analysis, and rationale for one’s standpoint. Furthermore, it is an active training method that strengthens motivation and interest in studying a subject on the whole. A student gets accustomed to teamwork, as well as to stand his (her) ground and listen to different opinions. This is the moment the exchange of knowledge occurs. Case discussion provides combination of practical and theoretical aspects of a subject as well as clear understanding of what the previously gained knowledge is needed for.
The structure and significance of the Spiritual Universe of the Okinawan Cult Center
Authors: Mori Koichi
Published: June 2021

Este artigo examinará as características e os significados, tanto no nível coletivo como no nível individual, do universo espiritual dos deuses e dos espíritos possessivos no centro espiritual criado por Maria Nobuko (no texto ela será referida apenas como Maria), uma mulher que emigrou para o Brasil de Okinawa durante o período pré-guerra. E também discutirá a questão da identidade religiosa e étnica da fundadora desse centro e seus seguidores, 90% dos quais são okinawanos e seus descendentes.
Do estudo acadêmico da bíblia hebraica
Authors: Chwarts Suzana
Published: June 2021

Este artigo apresenta uma retrospectiva sintetizada da trajetória dos estudos acadêmicos da Bíblia Hebraica, ressaltando a heterogeneidade das abordagens empregadas no processo de compreensão e interpretação do relato bíblico.
Abstract 131: Methods Behind Thrombus Size Variability in Murine IVC Ligation Model Revealed: Insights From MRI
Authors: Palmer Olivia R , Diaz Jose A , Greve Joan M
Published: June 2021

Objectives:
Animal models are key tools for studying deep vein thrombosis (VT). Variation in thrombus size is a current concern that limits the ability to detect small differences between experimental groups. Our objective is to understand the mechanism of this variation. We hypothesized that thrombus size variability results from altered flow dynamics involving venous branches. Using MRI, we investigated the path of blood flow in the murine IVC ligation model.

Methods:
VT was induced in 11-15 week-old C57BL/6 mice (n=9) via IVC ligation with either interruption of all venous branches (IB), or all branches left open (OB). Mice were imaged by MRI 2 days post ligation to examine IVC patency and/or presence of thrombus. Venous flow was saturated to determine venous branching phenotype and flow direction, which was compared to pre-surgical MRI. Then, axial slices were acquired from the renal to iliac vessels to quantify thrombus volume. Finally, thrombus weight (TW) was quantified at harvest.

Results:
MRI: Thrombus volumes were larger in IB mice compared to OB mice (38.0 ± 4.6 mm
3
IB vs. 11.3 ± 8.3 mm
3
OB), with greater variability in OB mice (variation coefficient 12% IB vs. 73% OB). Open branches had great impact on reducing TW due to reversed flow direction, increasing thrombus size variability. IB mice showed flow compensation through the vertebral veins and collateral vessels.

At harvest:
TWs confirmed MRI findings (34.5 ± 3.8 mg IB vs. 15.7 ± 9.8 mg OB; variation coefficient 11% IB vs. 62% OB). The pattern of 2 back branches was observed in all mice, and 1 right branch was the most common phenotype. The OB mouse with the highest TW had 2 side branches, whereas the other OB mice had 1 right branch only.

Conclusion:
Thrombus size variability increased when branches were not interrupted. Blood flow dynamics detected by MRI were critical for understanding the “flow escape phenomenon” from the IVC that occurs through branches when they are left open. This study supports that the anatomical branching pattern affects blood flow in the IVC. Non-invasive MRI brings to light the important role of venous branches inducing thrombus variability in VT models.
Abstract 377: Predictors of Recovery in Out-Of-Hospital Post-Arrest Patients With Mild to Moderate Early Cerebral Edema
Authors: Fuller Zachary , Faro John , Callaway Clifton W , Elmer Jonathan
Published: June 2021

Introduction:
Some patients develop cerebral edema after cardiac arrest. Those with mild-to-moderate edema may or may not recover. Whether modifiable processes of care can improve outcomes in these patients is unknown.

Methods:
We conducted a retrospective cohort study of adults resuscitated from out-of-hospital arrest (OHCA) at a single center from 2010-2018. We included those with mild-to-moderate cerebral edema, defined as gray to white matter attenuation ratio (GWR) 1.2-1.4 on CT imaging obtained within 24h. We excluded patients who were awake, arrests due to trauma or neurological catastrophe, those with no CT imaging within 24h, and those who died or had limitations of care within 6 hours. We used Pittsburgh Cardiac Arrest Category (PCAC) to adjust for illness severity and considered as additional predictors the following values in the first 24 hours of admission: GWR, lab values affecting serum osmolality (sodium, glucose, blood urea nitrogen (BUN)), total osmolality, change in osmolality from 0 to 24 hours, cardiac etiology of arrest, targeted temperature to 33C (vs 36C), average mean arterial pressure (MAP) and sedative medications used. Our primary outcome was awakening from coma. We used unadjusted and adjusted logistical regression for analysis.

Results:
Of 1500 total OHCAs, 513 met inclusion criteria. Mean (SD) age was 58 (16) years, most (62%, 317 of 513) were male, and 35% (179 of 513) arrested from ventricular tachycardia or fibrillation. In adjusted models, higher mean glucose (OR 0.89 95% CI 0.83-0.96, p=0.002) and increasing serum osmolality (OR 0.90, 95% CI 0.82-0.98, p=0.018) were negatively associated with awakening, as was increased PCAC. Other predictors including BUN, MAP, target temperature and sedative choice were not associated with outcome in adjusted models. Associations were consistent in the subgroups with moderate (GWR 1.2 to <1.3) and mild (GWR 1.3-1.4) edema.

Conclusions:
Illness severity, but not modifiable processes of care, were associated with recovery among post-arrest patients with mild-to-moderate cerebral edema.
Abstract 002: Patient Provider Communication and Patient-centered Outcomes Among Patients With Atherosclerotic Cardiovascular Disease in United States: Medical Expenditure Panel Survey 2010-2013
Authors: Okunrintemi Victor , Spatz Erica , Salami Joseph , Warraich Haider , Virani Salim , Blaha Michael , Blankstein Ron , Krumholz Harlan , Nasir Khurram
Published: June 2021

Background:
With recent enactment of Accountable Care Act, consumer reported patient-provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey (CAHPS) in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative adult US population with established atherosclerotic cardiovascular disease (ASCVD).

Methods:
The study population consisted of a nationally representative sample of 8223 individuals (age ≥ 18 years) representing 21.6 million with established ASCVD (self-reported or ICD-9 diagnosis) reporting a usual source of care in the 2010-2013 pooled Medical Expenditure Panel Survey (MEPS) cohort. Participants responded to questions from CAHPS that assess satisfaction with PPC (four-point response scale:
never, sometimes, usually, always
)
:(1)

“How often providers show respect for what you had to say”

(2)

“How often health care providers listened carefully to you”

(3)

“How often health care providers explained things so you understood”

(4)

“How often health providers spent enough time with you”

We developed a
weighted PPC composite score, categorized as 1 (

never

/

sometimes

), 2 (

usually

), and 3 (

always

). Outcomes of interest were 1) patient reported outcomes (PRO):
SF-12 physical/mental health status, 2) quality of care measures: statin and ASA use, 3) health-care resource utilization (HRU): Emergency room visits & hospital stays, 4) total annual and out of pocket healthcare expenditures (HCE).

Results:
As shown in the table, those with ASCVD reporting ineffective (never/sometimes) vs. effective PCC (always) were over 2-fold more likely to report poor PRO, 34% & 22% less likely to report statin and ASA use respectively, had a significantly greater HRU (OR≥ 2 ER visit: 1.40 [95% CI:1.09-1.80], OR≥ 2 hospitalization: 1.35 [95% CI:1.02-1.77], as well as an estimated $1,294 ($121-2468) higher annual HCE.

Conclusion:
This study reveals a strong relationship between patient-physician communication among those with established ASCVD with patient-reported outcomes, utilization of evidence based therapies, healthcare resource utilization and expenditures.
Abstract 005: A Comparison of Methods for Identifying Hospital Performance Outliers in Cardiac Surgery
Authors: Wu Xiaoting , Zhang Min , Prager Richard L , Likosky Donald S
Published: June 2021

Introduction:
A number of statistical approaches have been advocated and implemented to estimate adjusted hospital outcomes for public reporting or reimbursement. Nonetheless, the ability of these methods to identify hospital performance outliers in support of quality improvement has not yet been fully investigated.

Methods:
We leveraged data from patients undergoing coronary artery bypass grafting surgery between 2012-2015 at 33 hospitals participating in a statewide quality collaborative. We applied 5 different statistical approaches (1: indirect standardization with standard logistic regression models, 2: indirect standardization with fixed effect models, 3: indirect standardization with random effect models, 4: direct standardization with fixed effect models, 5: direct standardization with random effect models) to estimate hospital post-operative pneumonia rates adjusting for patients’ risk. Unlike the standard logistic regression models, both fixed effect and random effect models accounted for hospital effect. We applied each method to each year, and subsequently compared methods in their ability to identify hospital performance outliers.

Results:
Pneumonia rates ranged from 0 % to 24 %. The standard logistic regression models for 2013-2015 had c-statistics of 0.73-0.75, fixed effect models had c-statistics of 0.81-0.83, and random effect models had c-statistics of 0.80-0.83. Each method differed in its ability to identify performance outliers (Figure 1). In direct standardization, random effect models stabilized the hospital rates by moving the estimated rates toward the average rate, fixed effect models produced larger standard errors of hospital effect (particularly for hospitals with low case volumes). In indirect standardization, the three models showed high agreement on their derived observed: expected ratio (intraclass correlation =0.95). Indirect standardization with fixed effect or random effect models, identified similar hospital performance outliers in each year.

Conclusion:
The five statistical approaches varied in their ability to identify performance outliers. Given its higher sensitivity to outlier hospitals, indirect standardization methods with fixed or random effect models, may be best suited to support quality improvement activities.
Abstract 006: Association Between Percutaneous Coronary Intervention Outcomes and Physician Education and Board Certification in New York State 2010-2012
Authors: Khatana Sameed Ahmed M , Fiorilli Paul N , Groeneveld Peter W , Giri Jay S
Published: June 2021

Objectives:
Patients have few objective predictors of quality in their choice of physician. We studied whether physician education variables and board certification status were associated with 30 day mortality rates after percutaneous coronary interventions (PCI) in New York State.

Methods:
Using the New York State PCI registry we obtained 30 day risk adjusted mortality rates after PCI procedures for all interventional cardiologists practicing between 2010-2012. Educational and certification variables were obtained using publicly available sources. Mortality rates were adjusted using a hierarchical Poisson shrinkage estimator. Hierarchical regression modeling was used to assess associations between mortality rates and education and certification markers (graduation from American vs. foreign medical school, years since medical school graduation, board certification in interventional cardiology and maintenance of certification for board certified physicians in 2016) with and without adjustment for caseload. Excluding correlated covariates, a regression model including caseload, board certification and US graduates was also constructed.

Results:
A total of 346 interventional cardiologists performed an average of 427.41 ± 402.52 cases with 3.90 ± 3.51 deaths. The average shrinkage estimator adjusted mortality rate was 1.00 ± 0.16. Only interventional cardiology board certification (75.8% of providers) was associated with lower mortality rate in univariate analysis (β = -0.06; p = 0.03). No other variables had a significant association with the outcomes. After adjusting for caseload, the association with board certification became non-significant. In the multivariate regression model including the above noted covariates, the association between caseload and the outcome remained significant (β = -0.001; p <.01).

Conclusion:
Risk-adjusted mortality rate after PCI is not associated with any education or certification markers, including board certification in interventional cardiology or maintenance of certification, after adjustment for caseload. Caseload was the only predictor of mortality rate in multivariate modeling.
Abstract 007: Titration From Low/moderate to High Intensity Statins Following Myocardial Infarction Among Patients With Diabetes
Authors: Muntner Paul , Colantonio Lisandro D , Brown Todd M , Carson April P , Dai Yu Ling , Farkouh Michael E , Monda Keri , Taylor Ben , Zhao Hong , Rosenson Robert S
Published: June 2021

Background:
High intensity statins have been shown to lower the risk of major cardiovascular events after a myocardial infarction (MI). Recent studies report that most people with diabetes who experience a coronary heart disease event are already taking a statin, but little is known about the percentage who are titrated to a high intensity statin following hospital discharge for a MI.

Methods:
We compared the percentage of patients with versus without diabetes who titrated from a low/moderate to a high intensity statin within 30 days following hospital discharge for MI in 2014. The analyses included 3,629 patients with diabetes and 3,502 patients without diabetes. All patients were 66 to 74 years of age, had government insurance through Medicare, and filled a low/moderate intensity statin without any high intensity statin fills within 365 days prior to having a MI. Also, all patients filled a statin within 30 days following hospital discharge. Statin fills were identified through pharmacy claims; high intensity statins included atorvastatin 40 or 80 mg and rosuvastatin 20 or 40 mg.

Results:
Titration from low/moderate to high intensity statins following hospital discharge for MI occurred among 37.7% and 43.7% of beneficiaries with and without diabetes, respectively. After adjustment for demographics, low socioeconomic status and comorbidities, having diabetes was not associated with titrating to a high intensity statin following hospital discharge (risk ratio [RR]: 1.03; 95% CI 0.96-1.10). Among those with diabetes, African Americans compared with whites (RR 1.16; 95% CI 1.02-1.32) and men compared with women (RR 1.14; 95% CI 1.05-1.25) were more likely to titrate from a low/moderate statin to a high intensity statin. Also, titration to a high intensity statin was less common among those with a history of heart failure (RR 0.79; 95% CI 0.69-0.90), those who had seen a cardiologist in the year prior to their MI (RR 0.90; 0.81-1.00), and those who had filled a non-statin lipid-lowering medication within 30 days following hospital discharge (RR 0.50; 95% CI 0.38-0.64). Titration to a high intensity statin was more common among those with diabetes filling a beta blocker (RR 1.15; 95% CI 1.02-1.28) or antiplatelet agent (RR 1.13; 95% CI 1.04-1.24) and attending cardiac rehabilitation (RR 1.22; 95% CI 1.09-1.36) within 30 days following hospital discharge. Only 9.0% of patients with diabetes whose first statin fill following hospital discharge was for a low/moderate-intensity dose filled a high intensity statin within the next 6 months.

Conclusions:
Most patients with diabetes do not titrate to a high intensity statin following hospital discharge for MI, potentially leaving substantial residual risk for recurrent MI. Further research into the under treatment of patients with diabetes is needed.
Abstract 012: Differences in Quantitative Coronary Angiographic (QCA) Characteristics of Coronary Artery Disease Between Human Immunodeficiency Virus (HIV) Patients Pre-treated With versus Without Statins on Admission
Authors: Meelu Omar A , Theodoropoulos Kleanthis , Sartori Samantha
Published: June 2021

Background:
Whereas statins are well-known to contribute to atheromatic plaque stability and regression of atherosclerosis burden, possible interactions with anti-retroviral therapy have led to sub-prescription in this cohort. However, exactly how statins affect the angiographic phenotype, coronary lesion characteristics and clinical outcomes in HIV patients undergoing PCI has not yet been investigated.

Aim:
To assess and describe the angiographic features and burden of Coronary Artery Disease (CAD) between HIV patients pre-treated with statins as compared to statin naïve patients undergoing Percutaneous Coronary Intervention (PCI).

Methods:
This is a retrospective, single-center study comparing pre-treated with statin to statin-naïve HIV patients who underwent PCI between 2003-2011. Quantitative coronary angiography (QCA) was performed for all treated lesions at baseline and following PCI in both groups. 1- Year clinical outcomes post-PCI were also analyzed and compared.

Results:
Statin pre-treated patients (n=47, 51%) had more frequently hyperlipidemia (95% vs. 50%, p<0.001), had higher weight (86 kg vs. 77kg, p=0.04), were more likely to have known coronary disease (17% vs. 4%, p=0.04) and presented more frequently with acute coronary syndrome (57.4% vs. 37%, p=0.04) as compared to those without pretreatment. Both groups had similar grade of stenosis and extent of CAD as measured by presence of multi-vessel disease as well as SYNTAX score; however statin pre-treated patients were more likely to have moderate/heavy calcified lesions and treated with drug eluting stents as compared to statin naïve patients. Residual syntax score post-PCI was significantly higher in the statin pre-treated group (4.65 +/- 7.4 vs. 1.9 +/- 3.8, p= 0.03). Major adverse cardiac event (MACE) rates at 1 year were significantly lower in the statin pre-treatment group.

Conclusion:
While statin pre-treatment HIV patients were more likely to present with ACS and had worse cardiovascular risk profile, detailed coronary angiographic analysis reveals no significant differences in CAD burden and lesion characteristics. Statin use is associated with more favorable clinical outcomes at 1 year post-PCI suggesting the beneficial effects of statins in atherosclerosis progression in HIV patients.
Abstract 019: Real-World Use of Sacubitril/ Valsartan in Heart Failure in the First Year Following FDA Approval
Authors: Sangaralingham Lindsey R , Sangaralingham S. J , Van Houten Holly K , Shah Nilay D , Adigun Rosalyn O , Dunlay Shannon M
Published: June 2021

Background:
In July 2015, the FDA approved the use of sacubitril/ valsartan in patients with heart failure (HF) and reduced ejection fraction. It was shown in a large clinical trial to reduce the risk of both hospitalization and death compared with enalapril, and has since received a class I recommendation for use in the 2016 ACC/ AHA HF guidelines. However, the use of sacubitril/ valsartan in a clinical practice has not been described. We aimed to assess the uptake and cost of sacubitril/ valsartan in its first year following FDA approval.

Methods:
Using a large U.S. insurance database, we identified privately insured and Medicare Advantage (MA) patients who filled a first prescription for sacubitril/ valsartan between July 1, 2015 and July 31, 2016. We restricted to persons with medical and pharmacy enrollment for 6 months prior to first fill. For reference, we identified all individuals with a diagnosis of HF on a billing claim (ICD9 428.X or ICD-10 I50.X) in the same time period.

Results:
There were 314,410 individuals with a diagnosis of HF in the study period. In total, 972 filled a new prescription for sacubitril/ valsartan, and the number of new users steadily increased over time (Figure). The mean age of sacubitril/ valsartan users was 68.1±12.3 years, 32.5% were women, 61.1% were white, and 77% were enrolled in MA plans. Most prescribing clinicians were cardiologists (82.5%). A majority of prescription costs were covered by the health plan (mean $324.05, median $335.38, interquartile range [IQR] $266.56-$370.10). Out-of-pocket (OOP) costs per 30-day prescription filled were variable (mean $101.53, median $45.00, IQR $7.40-$97.49), and were similar in beneficiaries enrolled in MA and commercial plans. By comparison, median OOP costs were $2-4 for lisinopril, losartan, carvedilol, and spironolactone per 30-day prescription.

Discussion:
These finding suggest that the uptake of sacubitril/ valsartan has been slow in the first year after FDA approval. While the majority of prescription costs are covered by the health plan, OOP costs are still much higher than other guideline-recommended HF medications. Further studies are needed to determine if uptake of sacubril/ valsartan continues to rise and if the higher prescription cost is associated with lower downstream costs of hospitalization and mortality benefit.
Abstract 032: Is Bigger Data Better? Predicting Readmissions in Acute Myocardial Infarction on Admission versus Discharge With Electronic Health Record Data
Authors: Nguyen Oanh K , Makam Anil N , Clark Christopher , Zhang Song , Das Sandeep R , Halm Ethan A
Published: June 2021

Background:
Readmissions after hospitalization for acute myocardial infarction (AMI) are common, but the few available risk prediction models have poor predictive ability. Including more data from hospitalization may improve risk prediction.

Objectives:
To assess if an AMI-specific electronic health record (EHR) readmission risk prediction model derived and validated from data through the entire hospital course (‘full stay’ model) outperforms a model using data available only from the first day of hospitalization (‘first day’ model).

Methods:
EHR data from AMI hospitalizations from 6 diverse hospitals in north Texas from 2009-2010 were used to derive a model predicting all-cause non-elective 30-day readmissions which was then validated using five-fold cross-validation.

Results:
Of 826 consecutive index AMI admissions, 13% were followed by a 30-day readmission. History of diabetes (AOR 2.41, 95% CI 1.37-4.24), SBP <100 mmHg on admission (AOR 2.18, 95% CI 1.68-2.82), elevated Cr (≥2 mg/dL) on admission (AOR 2.56, 95% CI 2.52-6.08), elevated BNP on admission (AOR 6.36, 95% CI 1.65-24.47) and lack of PCI within 24 hours of admission (AOR 1.31, 95% CI 1.02-1.69) were significant predictors of readmission. Our ‘first-day’ AMI readmissions model based on these predictors had good discrimination (
Table
). Adding three other variables from the hospital course - use of IV diuretics (AOR 1.58, 95% CI 1.07-2.31), anemia (hematocrit ≤ 33%) on discharge (AOR 2.04, 95% CI 1.20-3.46), and discharge to post-acute care (AOR 1.50, 95% CI 0.90-2.50) - improved discrimination of the ‘full stay’ AMI model but only modestly improved net reclassification and calibration.

Conclusions:
A ‘full-stay’ AMI-specific EHR readmission model modestly outperformed a ‘first-day’ EHR model, a multi-condition EHR model, and the CMS AMI model. Surprisingly, incorporating more hospitalization data improved discrimination of the full-stay AMI model but did
not
meaningfully improve reclassification compared to the first-day model. Readmissions in AMI may be accurately predicted on the first day of hospitalization; waiting until later in hospitalization does not markedly improve risk prediction.
Abstract 033: Understanding Diagnostic Factors Predicting Negative Coronary Angiography in Patients With Suspected Ischemic Heart Disease: Can We Prevent the Cost of Unnecessary Procedures?
Authors: Gaddipati Vamsi , Elsayed Adel , Kip Kevin , Diwadkar Sachin , Chae Sanders , Berlowitz Michael
Published: June 2021

Background:
Low risk patients with suspected coronary ischemic syndrome (CIS) undergo hospital procedures despite unclear benefit. False negative evaluations can contribute to unnecessary testing that increases cost. This analysis stratified the likelihood of non-obstructive disease at time of coronary angiography (CA) to determine predictors of a negative study and assessed subsequent costs resulting from negative CA.

Methods:
564 coronary angiograms were performed during 2013 at a single institution. Patients with ST-segment elevation myocardial infarction, cardiac arrest, multiple angiograms, or a clear non-CIS indication for CA (i.e. pre valve surgery) were excluded. 171 patients were included for retrospective chart review and categorized by age, race, gender, body mass index, blood pressure, chest pain quality, biomarker elevation, electrocardiographic findings, and clinical features that include hypertension, lipid status, diabetes, chronic kidney disease, psychiatric disease and substance abuse. These data were then analyzed by univariate assessment and logistic regression models for the multivariate predictors of factors associated with negative CA. Cost analysis was performed using a consumer based average cost database and direct hospital laboratory expense data.

Results:
Of the 171 patients studied, nearly half (47%) did not have obstructive coronary artery disease. The adjusted odds of negative CA were significantly elevated, in order of predictability, with the absence of chest pain (odds ratio (OR) 7.28, p = 0.0004), atypical chest pain (OR 7.13, p < 0.0001), African American race (OR 4.87, p = 0.0033), no diabetes (OR 4.25, p = 0.0026), female gender (OR 3.70, p = 0.0038), normal Troponin-I level (OR 3.16, p = 0.0208), no hyperlipidemia (OR 2.96, p = 0.0107), and low troponin level 0.033 - 0.1 ng/mL (OR 2.96, p = 0.0025). The total cost of negative CA was $749,088, or $9,363 per patient. Total avoidable direct catheterization laboratory expense was $251,000, or $3,137 per patient.

Conclusion:
In the evaluation of CIS, a large number of patients that undergo CA have no evidence of obstructive disease. Further study of characteristics that predict the absence of obstructive disease would help reduce the frequency and substantial cost of unnecessary invasive procedures.
Abstract 035: A Clinician’s Transfusion Trigger Predicts Variation in Red Blood Cell Transfusions During Cardiac Surgery
Authors: Loh Joyce W , Zahuranec Darin B , Paone Gaetano , Kramer Robert S , DeLucia Alphonse , Behr Warren D , Zhang Min , Engoren Milo C , Prager Richard L , Likosky Donald S ,   Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
Published: June 2021

Introduction:
Variation in red blood cell (RBC) transfusions persists across providers, and is thought, in part, to be attributed to a lack of consensus regarding thresholds to support transfusion decision-making. We developed standardized clinical vignettes to assess differences in inclinations to transfuse RBCs among surgeons, anesthesiologists and perfusionists in the setting of coronary artery bypass grafting (CABG) surgery.

Methods:
We surveyed operating room transfusion decision-makers across all 33 non-federal cardiac surgery programs in the state of Michigan. Respondents were asked for their transfusion threshold (hematocrit “trigger”). Ten clinical vignettes were developed to elicit a provider’s inclination to transfuse (on a 6-point Likert Scale) in situations having moderate (Class IIa) or weak (Class IIb) evidence to support a transfusion. Hierarchical generalized linear models were used to estimate the effect of provider type and hematocrit trigger on the inclination to transfuse across clinical vignettes.

Results:
There was a 45% (186 of 413) response rate. Of the respondents, 75.3% (140 of 186) reported having a hematocrit trigger, with a mean of 20.4 (SD 2.2). For every 1-unit increase in a hematocrit trigger, the inclination to transfuse increased by 0.19 points on the Likert scale (p<0.001). Inclination to transfuse differed by provider type: anesthesiologists vs. perfusionists (difference: 0.71, p<0.001); surgeons vs. perfusionists (difference: -0.11, p=0.51). After accounting for a provider’s transfusion trigger, the magnitude and significance of the effect diminished for anesthesiologists (difference: 0.30, p=0.06), while strengthening for surgeons (difference: -0.29, p=0.05) (
Figure
). Twenty-seven percent of the variation in a provider’s inclination to transfuse was accounted for by the transfusion trigger, while 15% of the variation was explained by the provider type.

Conclusion:
In our statewide survey of intra-operative transfusion decision-makers, a provider’s hematocrit trigger was the strongest predictor of variation in blood transfusions. Reducing variation in provider hematocrit triggers may serve as an effective

blood management target, especially in clinical situations less well supported by evidence.