bluuebunny/crossref_metadata_2025 huggingface dataset:
Pan‐Cancer Analysis of the Prognostic and Immunological Role of HSF1: A Potential Target for Survival and Immunotherapy
Authors: Chen Fei , Fan Yumei , Cao Pengxiu , Liu Bing , Hou Jiajie , Zhang Bo , Tan Ke
Published: June 2021

Emerging evidence revealed the significant roles of heat shock factor 1 (HSF1) in cancer initiation, development, and progression, but there is no pan‐cancer analysis of HSF1. The present study first comprehensively investigated the expression profiles and prognostic significance of HSF1 and the relationship of HSF1 with clinicopathological parameters and immune cell infiltration using bioinformatic techniques. HSF1 is significantly upregulated in various common cancers, and it is associated with prognosis. Pan‐cancer Cox regression analysis indicated that the high expression of HSF1 was associated with poor overall survival (OS), disease‐specific survival (DSS), and progression‐free interval (PFI) in cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC), head and neck squamous cell carcinoma (HNSC), and kidney renal papillary cell carcinoma (KIRP) patients. The methylation of HSF1 DNA was decreased in most cancers and negatively correlated with the HSF1 expression. Increased phosphorylation of S303, S307, and S363 in HSF1 was observed in some cancers. HSF1 remarkably correlated with the levels of infiltrating cells and immune checkpoint genes. Our pan‐cancer analysis provides a deep understanding of the functions of HSF1 in oncogenesis and metastasis in different cancers.
Bipartite Synchronization of Heterogeneous Signed Networks with Distributed Impulsive Control
Authors: Feng Guizhen , Ding Jian , Cao Jinde , Cao Qingqing
Published: June 2021

This study investigates the bipartite synchronization of heterogeneous signed networks with distributed impulsive control. Leader‐follower bipartite synchronization within a nonzero error bound is analyzed when the average impulsive interval is Ta < ∞ or Ta = ∞. Some sufficient conditions to achieve the bipartite quasi‐synchronization are presented, and the synchronization error level is estimated by the specific mathematical expression. The correctness of the theoretical results is verified by numerical examples.
Multiobjective Multicast DSR Algorithm for Routing in Mobile Networks with Cost, Delay, and Hop Count
Authors: El-Sayed Hamdy H. , Younes A. , Alghamdi Fahad A.
Published: June 2021

Tremendous evaluation of wireless mobile communication needs more efficient algorithms for communication systems. The use of conventional single‐objective optimization algorithms may be unsuitable for real applications, because they act to the detriment of the rest of the performance parameters like lifetime network, delay, cost, and hop count; for this reason, multiobjective is needed. This paper presents performance evaluation and compares between the Multicast MDSR and MAODV with MACO. The proposed MDSR is concerned with change of the route discovery phase, where the route selection is based on the shortest path of route reply packets on the route with calculating the number of hop counts. Also, this article compares our MDSR modification with the evaluation algorithm based on Ant Colony Optimization (ACO), which finds the best path and multicast tree optimizes total weight (cost, delay, and hop count) of the multicast tree using multiobjective. Experimental results proved that the proposed MDSR algorithm is more efficient than MAODV and MACO in the total weight (cost, delay, and hop count), respectively. Moreover, the MACO outperforms MAODV for multicast routing problem.
O Sonho de Balzac: Comédia Humana ou Bíblia Mundana?
Authors: Mello Lucius de
Published: June 2021

Este artigo analisa o diálogo intertextual entre a Bíblia e uma pequena galeria dos romances e histórias que constituem A Comédia Humana de Honoré de Balzac. Com base em ensaios recentes de críticos franceses, apontamos que Balzac teria usado a estrutura da narrativa bíblica e algumas de suas histórias e personagens como referência, modelo e inspiração para elaborar o seu grande projeto literário. Sob a pluma e a ironia balzaquianas, Paris é vista como uma terra prometida ao contrário, “a sucursal do inferno”, e A Comédia Humana pode ser lida como uma Bíblia Mundana.
Abstract 001: Clinical Course After Elective Percutaneous Coronary Intervention in China: A Report From China PEACE Prospective Study of Percutaneous Coronary Interventions
Authors: Lu Yuan , Zhang Haibo , Wang Yongfei , Welsh John , Liu Jiamin , Guan Wenchi , Li Jing , Li Xi , Zheng Xin , Spertus John A , Masoudi Frederick A , Krumholz Harlan M , Jiang Lixin
Published: June 2021

Introduction:
Despite remarkable growth in the use of percutaneous coronary intervention (PCI) in China over the past 30 years, little is known about the impact of PCI on patient’s health status. This study aims to describe the change in angina symptom and angina-related quality of life during the first year of recovery among Chinese patients undergoing elective PCI.

Methods:
We studied 2,252 patients undergoing elective PCI to 34 hospitals from December 2012 to August 2014 in the China PEACE Prospective Study of Percutaneous Coronary Intervention. Angina frequency and angina-related quality of life were assessed with the Seattle Angina Questionnaire (SAQ) at the time of hospitalization and 1 year later. Scores ranged from 0 to 100 points, with higher scores indicating fewer symptoms and better quality of life. We categorized both 1-year scores and changes in scores to facilitate clinical interpretability. We considered a clinically poor outcome at 1 year to be an angina frequency score ≤ 60 (daily/weekly angina) or quality of life score ≤ 50 (poor/fair quality of life). A 1-year change in score ≥ 5 was improvement, a change between -5 and 5 was interpreted as no change, and ≤ -5 was interpreted as being significantly worse at 1 year than before the PCI.

Results:
The average age of the cohort was 62.3 years (±10.0) and 33.4% were women. The response rate was about 74% and non-responders had similar characteristics compared with responders. At baseline, the mean angina frequency score (61.4±30.4) and quality of life score (55.7±23.9) were markedly low. 53.5% of patients had severe angina symptoms and 47.9% had poor quality of life. Over the year of recovery, a majority of patients experienced a clinically important improvement in angina (74.8%), 18.2% had no change, and 7.0% had worse symptoms. Similarly, 59.7% had significantly improved quality of life, 13.4% had no change, and 26.9% had worse quality of life. At 1 year after PCI, 6.2% of patients still had poor angina symptom and 26.4% had poor quality of life.

Conclusion:
Angina symptoms had greatly improved among most of the Chinese patients over the year following elective PCI, although the improvement in quality of life was relatively small. Future research is needed to characterize patients who have no improvement or have recession in angina symptoms and quality of life after PCI.
Abstract 009: The Impact of Participation in a Telestroke Network on In-hospital Mortality in Georgia
Authors: Zhang Donglan , Ido Moges S , Shi Lu , Green Dale
Published: June 2021

Objectives:
Telestroke is the application of telemedicine to stroke care. We estimated the effect of participation in a telestroke network on in-hospital mortality in the state of Georgia, and explored its impact on mitigating the difference in mortality for patients admitted in nighttime compared to those admitted in daytime.

Methods:
We selected patients with ischemic stroke from 15 non-teaching hospitals in the Georgia’s Paul Coverdell Acute Stroke Registry from 2005 to 2016. We applied a quasi-experimental study design by classifying patients from 4 hospitals that participated in a telestroke network in 2009 as the treatment group, and patients from 11 hospitals that were not covered by the telestroke network as the comparison group. All selected hospitals are located in non-Metropolitan Areas. We compared mortality between treatment and comparison groups in 2005 - 2008 (pre-participation period for treatment group) and in 2009 - 2016 (post-participation period for treatment group), and estimated difference in in-hospital mortality attributable to participation in a telestroke network by applying a difference-in-differences approach, while adjusting for patients’ age, sex, race/ethnicity, insurance coverage, arrival mode, ambulatory status prior to the current stroke, stroke severity, medical history of atrial fibrillation/flutter and hospital admission time.

Results:
The mortality among ischemic stroke patients decreased in all selected hospitals over the last decade. Participation in a telestroke network significantly decreased in-hospital mortality by 3.2% (p-value= 0.003). There was a positive association between nighttime admission and in-hospital mortality in the entire patient sample. After controlling for the effect of participation in a telestroke network, the nighttime effect on mortality still remained significant (odds ratio=1.25, 95% confidence interval: 1.10 - 1.42).

Conclusions:
Acute ischemic stroke patients admitted in hospitals participating in a telestroke program had a more pronounced reduction in in-hospital mortality. However, telestroke coverage did not alter the effect of nighttime admission on in-hospital mortality.
Abstract 010: Characteristics of Patients and Hospitals Utilizing Advanced Providers for Post-myocardial Infarction Outpatient Care
Authors: Rymer Jennifer , Chen Anita Y , Thomas Laine , Stafford Judith , Enriquez Jonathan , Goyal Abhinav , Peterson Eric , Wang Tracy Y
Published: June 2021

Background:
Physician shortages and reimbursement changes have led to greater utilization of advanced practice providers (APP). National patterns of APP utilization for post-myocardial infarction (MI) patients are unknown.

Methods:
We examined 29477 Medicare patients ≥65 years discharged alive after an MI at 364 US hospitals in the ACTION Registry-GWTG from 2007-2010. Using NPI data from Medicare claims, we determined whether a patient had an outpatient visit with an APP within 90 days after discharge. We compared characteristics of patients seen by an APP vs. a physician only, stratified by % hospital APP use.

Results:
Within 90 days of discharge, 11% of MI patients were seen by an APP. Patients seen by APPs were more likely to be female (49% vs. 45%), have diabetes (37% vs. 33%) or heart failure (20% vs. 16%), and discharged to a nursing facility (21% vs. 13%, p<0.01 for all) than patients seen by a physician only. The number of outpatient visits within 90 days of discharge was higher for APP patients (median 6 vs. 5, p<0.01). Among hospitals, the median % of patients discharged to APP follow-up was 9.1%. APP follow-up was used more by non-teaching than teaching hospitals (29% vs. 25%, p<0.01). Whether higher risk patients are referred to APP care did not differ much among hospitals that more or less frequently used an APP post-discharge (Figure).

Conclusions:
Current US practice reveals APPs are utilized to provide closer follow-up to more complex MI patients after discharge. APP referral patterns do not substantially vary by how frequently a hospital utilizes APPs.
Abstract 018: Prior Authorization for Diagnostic Catheterization: The Value of Reviewers When There is Clinical Ambiguity
Authors: Powell Adam C , Price Stephen E , Nguyen Khoa , Smith Gary L , Long James W , Deshmukh Uday U
Published: June 2021

Background:
There are many clinical situations in which evidence-based guidelines cannot definitively determine the appropriateness of diagnostic catheterization. One specialty benefits management company has taken a two-step approach towards handling this ambiguity: first evaluating the appropriateness of orders using a rule-based decision support system, and then having reviewers provide additional input through the review process of a nondenial prior authorization program. When reviewers did not find a clear case for appropriateness, ordering physicians were engaged in a discussion with a peer physician. This program evaluation reports on the outcomes of diagnostic catheterization orders analyzed through this two-step process.

Methods:
Data from 2015 elective diagnostic catheterization orders submitted by one health insurer’s Medicare Advantage plans were used for this program evaluation. The rates at which the rule-based system suggested orders were inadequately justified, potentially nonindicated, and potentially appropriate are presented. Rates of approval after review and information gathering by the review process are presented for the three groups of orders. Chi-squared tests were conducted to examine whether the classification of the orders by the rule-based system and the review system were independent of the plan type (HMO or PPO), the specialty of the ordering physician (cardiologist or noncardiologist), or state of residence of the patient (FL, KY, LA, OH, TX, or other).

Results:
There were 3,808 orders for elective diagnostic catheterization, and inadequate initial justification was provided for 699 (18.4%) of the orders. After inquiry through the review process, 509 (72.8%) of these orders were approved. Among the 344 (9.0%) orders deemed potentially nonindicated by the rule-based system, the review process approved 298 (86.7%). Of the 2,765 (72.6%) orders deemed potentially appropriate by the rule-based system, the review process approved 99.1% (2,740/2,765). Chi-squared tests did not show a significant association between plan type (p=0.18) or physician specialty (p=0.89) and the classification of the order by the rule-based system. However, there was a significant association between the classification of the order by the rule-based system and state of residence of the patient (p<0.001). There was not a significant association between the outcome of the review process and the health plan type (p=0.10), the provider’s specialty (p=0.57), or the state of residence of the patient (p=0.73).

Conclusions:
Rule-based decision support can be combined with a review process featuring peer discussion to determine whether care is appropriate when guidelines are ambiguous. Orders which are poorly justified are often supportable after gathering information on the patient’s presentation. There may be state-based variation in the appropriateness of orders.
Abstract 023: Mission Lifeline Regional Reports Impact Performance in Two Major Metropolitan EMS Regions
Authors: Kiser Robin Y , Miller Art , O’Neill Kathleen , Woods Gwendolyn , Scharnott Michelle
Published: June 2021

The American Heart Association launched Mission: Lifeline (M:L) in 2007 with a goal of reducing system barriers to prompt treatment for heart attacks, beginning with the 911 call and continuing through hospital treatment. M:L also encourages regional collaboration and measurement of heart attack systems of care. Regional reports allow hospitals to see blinded comparisons to other hospitals in their region as well as regional, state and national benchmarks. We compared two major metropolitan areas.Data analysis and measurement using Mission: Lifeline (M:L) regional reports created from data in the ACTION Registry-Get With The Guidelines (ARG) national registry, was initiated in Chicago and St. Louis. Measures impacting systems of care, operations and outcomes were shared with hospitals and EMS. Regional reports include de-identified hospital data and state and national benchmarks.Data was shared at regional meetings and opportunities for performance improvement were identified. We reviewed First Medical Contact (FMC) to Percutaneous Coronary Intervention (PCI)and other system measures quarterly from 2010-2015. In order to facilitate regional improvement, system level M:L reports are generated quarterly. This allows hospitals to see blinded comparisons to other hospitals in their region as well as regional, state and national benchmarks.The FMC to PCI and other system measures were examined as indicators of process improvement in Chicago and St. Louis to determine if data sharing activities would impact systems improvement. One obstacle was getting hospitals to meet the data entry deadlines so their data was included in the regional reports. American Heart Association (AHA) staff worked with hospitals to help facilitate this.Data sharing in two EMS major metropolitan regions encouraged collaboration and performance improvement impacting FMC to PCI times and other measures. We saw a marked decrease in FMC to PCI in the first 6 quarters while regions were meeting regularly and initiating PI efforts. When state initiatives in Missouri took priority and the region was not actively meeting, we saw a rise in this measure.
Abstract 024: Public Access Defibrillation State Law Assessment: Do Current Laws Align With Best Available Evidence?
Authors: Kunka Andrew
Published: June 2021

I. Introduction:
Cardiac arrest (CA) is a leading cause of death in the U.S. An estimated 70-90% of people experiencing out-of-hospital CA die before reaching the hospital. Applying cardiopulmonary resuscitation (CPR) and using an automated external defibrillator (AED) within minutes of CA can dramatically raise survival rates. Public Access Defibrillation (PAD) laws can facilitate rapid AED application by lay bystanders. This study assesses whether existing state laws align with best available evidence for PAD implementation to assist decision makers in strengthening existing PAD policies.

II. Methods:
Two analysts applied CDC’s Quality and Impact of Component (QuIC) Evidence Assessment to appraise the strength of evidence bases for 9 PAD program “policy components,” defined as discrete requirements, provisions, or other elements within a public health policy. Analysts utilized subject matter experts (SME), PubMed, and grey literature to collect evidence and identify 9 policy components. Analysts independently coded evidence across 8 dimensions of evidence quality and public health impact. Resulting scores were used to rank the policy component evidence bases into 3 categories; best, promising or emerging.

To identify policy components found in state law, two legal researchers reviewed PAD peer-reviewed and grey literature and analyzed 10 states’ laws using Westlaw. The results were used to construct variables for a legal dataset. Researchers coded and categorized the components in statutes and regulations for all 50 states and Washington, D.C, in effect as of December 31, 2015. Researchers conducted descriptive analysis of the legal dataset and examined correlations with the QuIC policy component results.

III. Results:
Fifty jurisdictions had PAD laws in effect as of December 31, 2015, authorizing at least one of the 9 evidence-informed PAD policy components (maximum: 8; median: 6). The QuIC assessment categorized 3 components “best”, 4 “promising” and 2 “emerging.” The most common components found in law were PAD use training (best), EMS coordination (best) and lay bystander limited liability (emerging). No state authorized all 9 components. However, 3 states authorized 8 components and 12 states authorized all 3 best components. Two states authorized only lay bystander limited liability (emerging).

IV. Implications:
There is strong evidence of potential public health impact for targeted AED placement, user training, and EMS PAD coordination, yet two thirds of states have not enacted all three policy components. The Institute of Medicine recommends developing policy strategies and addressing legal barriers to bystander CPR and defibrillation to improve CA outcomes. Studies directly evaluating the role of PAD law in cardiac arrest response and associated health outcomes are needed to determine the best policy approaches to meet state needs and contexts.
Abstract 049: Smart Rx
Authors: Gandhi Shaan-Chirag C , Zern Emily K , Majmudar Maulik D
Published: June 2021

Introduction:
Chronic cardiac conditions, such as heart failure (HF) and atrial fibrillation (AF), have complex pathophysiology that can often pose challenges when treating comorbid conditions, especially with respect to drug-disease interactions. Although much is known scientifically about these interactions, integrating such evidence into clinical practice with the intent of avoiding negative health outcomes and avoiding excess healthcare costs has proved challenging. Here, we present: (1) a novel software platform that enables real-time assessment of incidence of drug-disease interactions among patients with CHF taking medications for other comorbid indications in a large cohort; and (2) development of a natural language processing (NLP)-driven software platform for performing such quality improvement assessments through automated searches of the electronic health record (EHR) of patients with any cardiac disease.

Methods and Results:
An NLP-driven search tool (Figure 1A) was developed based upon the Queriable Patient Inference Dossier (QPID) created by the Laboratory of Computer Science at the Massachusetts General Hospital (MGH) that incorporates an automated assessment of chronic cardiac diseases and of medications that have been identified as absolutely or relatively contraindicated in patients with specific cardiac diseases. The tool, which can be customized to assess for medications or other factors important in cardiovascular care, was used to perform an automated cross-sectional study of medications prescribed to 2,500 patients with CHF currently under care at the MGH. All records were manually reviewed by two independent observers, with a Cohen’s κ of greater than 0.8. Nearly 60% of patients were prescribed agents in the past three months that are known to cause major or moderate adverse events, with three drugs (citalopram, doxazosin and ibuprofen), accounting for over 80% of the contraindicated agents (Figure 1B).

Conclusion:
Use of prescription drugs known to cause major or moderate adverse events among patients with HF is quite common. An automated software platform for rapid real-time assessment of drug disease interactions can help identify gaps in care and help improve the quality of care among patients with cardiovascular disease and multiple comorbidities.
Abstract 054: Mortality Decline After Ischemic Stroke-the Medicare Cohort From 2009 to 2013
Authors: Man Shumei , Schold Jesse D , Uchino Ken
Published: June 2021

Objectives:
After a declined in mortality by 25.4% from 1996 to 2005, stroke became the fifth leading cause of death in men and the second leading cause of death in women. Stroke mortality decline in the past was mainly attributed to the improvement of stroke prevention. Stroke system of care has gone through evolutional changes in the past decade in both acute stroke treatment, preventing complications, identifying stroke etiology and stroke prevention. This study is to examine whether there was greater decline of mortality after ischemic stroke hospitalization from 2009 and 2013.

Methods:
We examined the one-year mortality in Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 and December 31, 2013 with a primary discharge diagnosis of ischemic stroke. The data of the patient information were obtained from the Medicare Provider Analysis and Review (MEDPAR) file. The list and characteristics of hospitals were obtained from the American Hospital Association Annual Survey Database. All statistical analyses were performed using SAS Version 9.4 software.

Results:
A total of 1165,960 Medicare Beneficiaries was hospitalized for ischemic stroke between 2009 and 2013. The one-year mortality showed a steady declined by 17.6 % over the five years period. The one-year mortality declined by 17.4% in female, 17.8% in male, 17.0% in black,17.6 % in white, 22.6% in Hispanic, and 20.3% in Asian. Among the ten-year age group, people aged 65 to 74 years had the greatest decline in mortality, 22.5%, followed by 19.2% decline in the group 75 to 84 years, and 14.7% in the group 85 years and over.

Conclusion:
The one-year mortality among Medicare beneficiaries after ischemic stroke hospitalization showed a dramatic decline from 2009 to 2013. Further study is needed to determine whether this is attributable to the change of stroke system of care in the past decade.
Abstract 066: Perioperative Stroke as a Predictor of Mortality and Morbidity in Patients Undergoing CABG
Authors: Mehta Amol
Published: June 2021

Background:
Perioperative stroke is a devastating neurological complication of Coronary Artery Bypass Grafting surgery (CABG). It results in significantly increased rates of mortality and morbidity and presents a significant financial burden to our healthcare system. It has not, however, been studied in a large population based sample. We aim to investigate the role of perioperative stroke as an independent risk factor for in-hospital mortality and morbidity following CABG, and to review trends in the early outcomes of CABG from the years 1999-2011.

Hypothesis:
Perioperative stroke is an independent risk factor for in-hospital mortality and morbidity following CABG.

Methods:
Data from the 1999-2011 Nationwide Inpatient Sample was analyzed. We identified patients who underwent CABG using ICD-9 and CCS codes, excluding patients undergoing concomitant heart and or vascular procedures, and also excluding patients below the age of 18 and above the age of 100.

Results:
Analysis on our sample of 668,627 patients yielded an overall rate of perioperative stroke, mortality, and morbidity of 1.87%, 2.13%, and 49.07%, respectively. Along with age, risk category, gender, and other postoperative outcomes, perioperative stroke was found to be a strong predictor of mortality and morbidity, leading to more than a 5-fold risk of death and morbidity.

Conclusions:
Perioperative stroke remains a serious adverse outcome of CABG and is an independent predictor of mortality and morbidity. While rates of stroke and mortality are decreasing, morbidity continues to trend upwards. This study emphasizes the importance of prevention and early intervention in patients at risk for perioperative stroke.
Abstract 067: Predictors of High-sensitivity C-reactive Protein Elevation Among Patients With Myocardial Infarction: Insights From VIRGO and TRIUMPH
Authors: Qintar Mohammed , Sharma Puza P , Tang Yuanyuan , Jones Philip , Pokharel Yashashwi , Dreyer Rachel , Spertus John
Published: June 2021

Background:
Elevated hs-CRP is associated with worse cardiovascular outcomes in patients with acute myocardial infarction (AMI), but little is known about predictors of elevated hs-CRP after AMI.

Methods:
TRIUMPH and VIRGO are prospective AMI registries that assessed hs-CRP levels 30 days after AMI. TRIUMPH assessed hs-CRP levels at 6 months. Multivariable regression analysis was conducted to examine predictors of elevated hs-CRP [≥2.0 mg/L] at 30 days and at 6 months after an AMI (TRIUMPH only).

Results:
Of 3410 patients in both registries, 58.6% had elevated hs-CRP 30 days post AMI. Patients with elevated hs-CRP were more likely to be female, black, obese, smokers, to have had higher LDL-C at the time of their AMI, with more peripheral vascular disease and history of heart failure, and were less likely to have had a prior PCI (Table). In TRIUMPH, baseline hs-CRP ≥2 mg/L (n=1301) was significantly associated with elevated hs-CRP at 6 months (p<0.001). Patients with elevated hs-CRP at 6 months (n=407) were more likely to be black, obese, smokers, have peripheral vascular disease and have higher baseline hs-CRP.

Conclusions:
hs-CRP remains elevated in a large proportion of patients following AMI. We identified several predictors of elevated hs-CRP at 1 and 6 months post AMI. Further studies are needed to validate the findings and understand the utility of routine screening of hs-CRP in post AMI patients.
Abstract 077: Hospitalized Heart Failure Epidemiology: Active Surveillance to Enhance Inpatient Cardiology Consultation Rates
Authors: Youmans Quentin , Kansal Preeti , Alphs Jackson Hannah , Fortman Robin , Navarro Daniel , Abecassis Michael , Noskin Gary , Anderson Allen , Davidson Charles , Yancy Clyde , Mutharasan R Kannan
Published: June 2021

Background:
Co-management of hospitalized heart failure (HHF) patients by hospitalists and cardiologists may enhance care quality. Aided by an enterprise data warehouse (EDW) screen for HHF patients, we implemented a house surveillance model of heart failure consultation, whereby cardiology consultation and multidisciplinary heart failure intervention was offered for patients meeting criteria.

Objective:
To analyze the impact of house surveillance for HHF on cardiology consultation rates for patients coding into heart failure diagnosis-related groups (DRGs) on medicine units.

Methods:
An EDW screen for HHF was deployed, and services with HHF patients were offered cardiology consultation. The intervention was deployed 7/2015; chart review for patients 6 months pre- and post-intervention was conducted to ascertain consultation rate.

Results:
There were 386 patient discharges from a non-cardiac service with a heart failure DRG. In the six months prior to intervention, 40% of patients had cardiology consultation. This figure rose to 69% post-intervention, a highly statistically significant result.

Conclusions:
EDW-enabled active surveillance for HHF increases cardiology consultation rate, allowing for multidisciplinary intervention, co-management, and potentially improved outcomes for HHF patients.
Abstract 080: Validity of Performance Measures for Heart Failure
Authors: Patel Jay M , Heidenreich Paul A
Published: June 2021

Background:
Numerous quality metrics for heart failure care now exist based on process (from clinical guidelines) or outcome (readmission and mortality). It is unclear, however, how valid these measures are at serving as indicators of hospital quality for patients with heart failure (HF). We sought to determine validity by comparing convergent validity (correlation among measures) and reliability (correlation over time).

Methods:
We gathered data on several HF performance measures from the Veterans Affairs Health Care System from 2008-2013. Process data are collected through chart review of a random sample of facilities. There are between 114 and 119 facilities that have at least one patient that is a treatment candidate each year. There are a mean 72 patients per facility per year included. For each facility and each year, we determined, among ideal candidates, use of ACE-inhibitor (ACEi), any beta-blocker (BB), recommended beta-blocker (rBB) (carvedilol, metoprolol succinate, bisoprolol), mineralocorticoid receptor antagonist (MRA), hydralazine/isosorbide dinitrate in African Americans, as well as rates of 30-day readmission, 30-day mortality, and 1-year mortality. We measured validity in 2 ways: determining correlations between measures, assuming that if a measure is associated with overall “quality” that it should be correlated with the other measures, and year-to-year reliability, assuming that if a measure has a good signal/noise ratio then there should be a strong correlation from one year to the next.

Results:
Data were available for 55,735 hospitalizations for HF from 2008-2013. In determining correlations between performance measures, we found a statistically significant correlation between ACEi and rBB (R=0.25, p<0.001), ACE inhibitors and any BB (R=0.20, p<0.001), ACEi and 30-day mortality (R=-0.08, p<0.05), ACEi and 1-year mortality (R=-0.12, p<0.01), rBB and MRA (R=0.12, p<0.01), rBB and 30-day mortality (R=-0.11, p<0.01), rBB and 1-year mortality (R=-0.18, p<0.001), any BB and MRA (R=0.12, p<0.01), any BB and 30-day mortality (-0.08, p<0.05), and any BB and 1-year mortality (R=-0.13, p<0.001). Additionally, both rBB and any BB showed statistically significant year-to-year reliability (R=0.57, p<0.0001 and R=0.48, p<0.0001 respectively). MRA, 30-day mortality, and 1-year mortality also had similar reliability (R=0.50, R=0.42, R=0.41, respectively, p<0.0001), but not ACEi (R=0.04, p=0.71). Readmission within 30 days and hydralazine/nitrate were not reliable year-to-year nor did they correlate with any of the above performance measures.

Conclusion:
BB, ACEi and MRA use rates showed evidence of validity as measures of HF quality through correlation with each other, mortality and/or year to year reliability. In contrast, 30-day readmission was poorly correlated with process of care and mortality and had poor reliability.
Abstract 082: Health and the Patient-Doctor Interaction in a Behavioral Framework
Authors: Stefanescu Schmidt Ada C , Bhatt Ami , Sunstein Cass
Published: June 2021

Introduction:
Cognitive errors are commonly made by patients during medical visits, traditionally thought to be due to gaps in communication and a complicated subject matter; use of diagrams and post-visit summaries has had a modest effect in improving in patient understanding and recall. We hypothesize that those cognitive errors can also be understood by using the behavioral economics framework of “System 1” mindset, in which patients are reliant on intuition and vulnerable to heuristics, as opposed to “System 2” mindset, which is reflective, slow and detailed-oriented, and that patient-reported outcome measures (PROMs) can shift patients to a “System 2” mindset.

Methods:
In this pilot, patients from a tertiary center adult congenital heart disease clinic were given Frederick’s Cognitive Reflection Test (CRT; score of 0 to 3, with low scores associated with System 1 mindset) prior to a routine clinical visit. They were randomly assigned to complete the PROMIS and Kansas City Cardiomyopathy Questionnaire either before or after the CRT. The primary endpoint was the mean CRT score in all patients; the secondary endpoint was a comparison of the effect of PROMs. Kruskal-Wallis test was used to compare ordinal variables.

Results:
Patients (N=47) had a mean age of 48, 93% were native English speakers and all had completed high school (93% at least started college). The median CRT score was 0 (IQR 0-1; 74% had a score of 0), and the mean score was 0.45 (SD 0.85), which is lower than any previously published results in control populations (mean scores 0.57 to 2.18 in 35 studies with 3428 respondents). CRT scores were numerically but not statistically higher in the group who completed the PROMs first (32% vs 20% had a score >0, mean 0.5 vs. 0.4, p=0.46). Patients randomized to PROMs first reported more often that they remembered to ask the physician the questions they had (94.7% vs. 86.7%) and were less nervous during the visit (15.8% vs. 46.7%).

Conclusions:
The finding that patients are in an intuitive state of mind prior to routine clinic visits, reliant on heuristics and vulnerable to biases, offers an important new framework in which to devise interventions to improve patient participation in their medical visits, recall of information, and decision-making. PROM are a promising candidate for intervention that will be further studied.
Abstract 083: In-hospital Outcomes in Acute Myocardial Infarction Patients Who Receive Morphine
Authors: McCarthy Cian P , Bhambhani Vijeta , Pomerantsev Eugene , Wasfy Jason H
Published: June 2021

Background:
Morphine is commonly used for analgesia in the setting of chest discomfort associated with acute coronary syndromes (ACS). However, a retrospective analysis in non-ST elevation acute coronary syndrome (NSTE-ACS) patients suggesting increased mortality with morphine administration and further studies suggesting morphine may delay and inhibit the absorption of the oral anti-platelet agents has placed its utility in ACS under closer scrutiny. In a large single center retrospective study, we analyzed the association between morphine and in-hospital outcomes in ST elevation myocardial infarction (STEMI) and NST-ACS patients undergoing coronary angiogram +/- percutaneous coronary intervention (PCI).

Methods:
All STEMI and NSTE-ACS patients undergoing PCI between January 2009 and July 2016 in Massachusetts General Hospital were included in our study. Following institutional board review approval, baseline patient characteristics (demographics, risk factors and medical history) was obtained. In-hospital outcomes included mortality, post-procedure cardiogenic shock, length of hospital stay and infarct size as measured by troponin level.

Results:
Overall, 3027 patients were examined. Of those, 1287/3027 (42.52%) had STEMI, of which 359/1287 patients received morphine (27.89%). STEMI patients who received morphine were younger, had a higher prevalence of prior MI, PCI, and angina, were more likely to be on oxygen therapy, and had a longer time to PCI. 1740/3027 (57.48%) of study patients had NST-ACS, of which 424 (24.37%) received morphine. NSTE-ACS patients who received morphine were younger, had a higher prevalence of cerebrovascular disease, peripheral vascular disease, prior PCI, MI, congestive heart failure and valvular surgery. In unadjusted outcomes, STEMI patients who received morphine had a lower in-hospital mortality [4.18% versus 7.54%, odds ratio (OR): 0.53, p=0.03] and smaller infarct size (mean troponin level 0.75 ng/ml versus 1.29 ng/ml, p=0.02). There was no significant difference in post procedure cardiogenic shock or length of hospital stay (p= 0.26 and p=0.29 respectively). After adjusting for basic characteristics no outcomes remained significant in the STEMI cohort. In the NST-ACS cohort, patients who received morphine had a longer hospital stay (mean 6.58 days versus 4.78 days, p<0.0001) and larger infarct size (mean troponin 1.16 ng/ml versus 0.90 ng/ml, p= 0.05). There was no statistical difference in in-hospital mortality or cardiogenic shock (p=0.17 and p=0.80 respectively). After adjusting for basic characteristics, length of hospital stay (p <0.0001) and infarct size (p=0.02) remained significant.

Conclusion:
In a large retrospective study, morphine was associated with larger infarct size and a longer hospital admission in NSTE-ACS patients but had no effect on outcomes in STEMI patients.
Abstract 087: Impact of High Intensity Statin on Biologic and Clinical Markers of the Metabolic Syndrome in Women
Authors: Velarde Gladys P , Garcia Emilio , Sherazi Saadia , Choudhary Naila , Kraemer Dale
Published: June 2021

Background:
The metabolic syndrome (MBS) increases the risk of cardiovascular disease in both men and women. This risk is higher in women. The role of statins in the treatment of MBS remains uncertain.

Objectives:
To evaluate the ability of high dose atorvastatin to modify components of MBS

Methods:
Age matched women with MBS (n =88, mean age 52.4 ± 9.2 years), recruited from the Women’s Heart Clinic at the University of Rochester and who met the study inclusion criteria were randomly assigned to either 80 mg of atorvastatin or matching placebo (44 in each arm) in a double blinded fashion. The duration of treatment was 12 weeks. Statistical analysis was performed using Students t-test using SAS 9.3 (Cary, NC).

Results:
At 6 weeks after randomization, there was significant reduction in the mean LDL, triglycerides, CRP, and Apo-B (p <0.0001, 0.0006, 0.01 and <0.0001) respectively in the atorvastatin arm. There was no difference in fasting blood glucose (FBG), serum HDL, serum Leptin, Apo-A1, and platelet activity (p value NS). A trend towards a decrease in waist circumference (WC) in the atorvastatin arm (p 0.05), while no impact in systolic blood pressure (p 0.92) was seen. These differences persisted at 12 weeks after randomization.

Conclusion:
High dose atorvastatin has an early and significant impact on biomarkers in women with MBS and is not associated with a rise in FBG. The use of statins for primary prevention in this group of patients should be further explored

Table:
Lipogenic, Inflammatory Markers at 6 weeks Post Randomization.
Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients
Authors: Fette Caitlin , Krallman Rachel , McMahon Colin , Montgomery Daniel , Wang Jennifer , Erjavac Benjamin , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: June 2021

Background:
Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE.

Methods:
Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients.

Results:
Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees.

Conclusions:
Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.
Abstract 104: Statin Advisor: A Model to Predict Low-Density Lipoprotein Responsiveness
Authors: Samani Saira , Murata Allison , Murata Glen , Charlton Gerald
Published: June 2021

Background:
For patients with ASCVD, reduction of LDL-C levels to a goal of <100mg/dl ranges from 36-74%. This broad success rate reflects inconsistency in clinical practice and biologic variability in response to statins, and suggests that a significant proportion of ASCVD patients may not obtain the full therapeutic benefit of statin therapy. Contributing to this problem is the fact that there are no specific guidelines for managing ASCVD patients who do not have an adequate LDL-C response to statin therapy.

Methods:
All ASCVD patients who had ever been prescribed a statin in the Veterans Affairs Corporate Data Warehouse were analyzed. Of 268 possible statin up-titrations or within intensity-transitions for patients not at LDL-C goal, 41 statin transitions with at last 2000 patients were included, representing a total of 1.16 million patients. The transitions were randomly divided into a derivation sample (60%) and a validation sample (40%). Logistic regression models were developed to predict the likelihood of specific statin transitions achieving a goal LDL-C level of <100mg/dl. Predictor variables included demographics, BMI, medication possession ratio, prior LDL-C, and if the patient was on medications with statin interactions. These models were then validated, and predicted probability of achieving LDL-C <100mg/dl were categorized as low (<30%), intermediate (30-70%), or high (>70%).

Results:
Table below.

Conclusion:
These models were able to accurately identify groups of patients who would have a low (19.4%; 19,548 / 100,730), intermediate (49.8%; 165,356 / 331,801), or high (72.6%; 21,301 / 29,350) likelihood of achieving goal LDL-C, by a specific statin transition. Any statin transition had only a 44.6% (206,205 / 461,881) probability of achieving LDL-C <100 mg/dl. Use of these models may aide practitioners at the frontline to determine which statin transition would most likely achieve LDL-C <100 mg/dl, based on specific patient characteristics. Based on these data, there is a potential to eliminate over 20% (100,730 / 461,881) of transitions which would be unlikely to result in achieving LDL-C goal, thus potentially reducing time to goal and wasteful utilization resources.
Abstract 128: Vascular Assessment in Patients With Non-healing Foot Wounds
Authors: Koshy Thomas P , Bhattatiry Mitu , Das Sandeep , Kumbhani Dharam
Published: June 2021

Background:
Chronic lower extremity wounds have become a major challenge to healthcare systems and are a significant source of morbidity and mortality. Assessment of lower extremity perfusion is strongly recommended for non-healing lower extremity wounds. However, there is wide variation in treatment practices and the frequency of vascular assessment in an outpatient setting remains unknown.

Methods:
Our retrospective cohort included all adult patients seen in Parkland Hospital’s outpatient foot wound clinic over a six month time period (2/2014-6/2014). Charts were reviewed to collect demographic characteristics, wound characteristics, common vascular risk factors, vascular assessment and subsequent interventions. Peripheral arterial disease was defined as an ankle-brachial index (ABI<0.9) or non-compressible (ABI>1.4). Wounds were characterized as non-healing if there was no evidence of improvement after 3 months of follow up. Statistical analysis was then performed on patients with non-healing wounds and no previous history of peripheral vascular disease.

Results:
Our retrospective cohort included a total of 438 patients that were followed for a median of 2.1 years. The population was 70% male with a median age of 56 and a median BMI of 30. The majority of patients were Hispanic (45%) and there was high prevalence of hypertension (82%), hyperlipidemia (59%), diabetes (87%), tobacco use (51%), peripheral vascular disease (36%) and coronary artery disease (19%). Follow up data was missing in 39 patients. Among all patients seen in the foot wound clinic, an ABI was performed in 185 (42%) patients. At 3 months, 170 patients (38%) had evidence of a non-healing wound. After excluding patients with a known history of PVD, an ABI was performed in 27% patients (27 of 99) with non-healing wounds. Those patients undergoing ABIs were older (56 vs 50, p=0.006), had lower BMI (30 vs 34, p=0.04) and higher prevalence of CKD (40% vs 15%, p=0.007). After adjusting for common risk factors both age and CKD were remained statistically significant (p=0.004 and p=0.001, respectively). Among the ABIs performed, 15% (4 of 27) were found to have PAD, 48% (13 of 27) were normal and 37% (10 of 27) had non-compressible disease. Patients with PAD were also more likely to undergo peripheral angiography with intervention compared to patients with (50% vs 7%, p=0.02) and remained statistically significant after adjusting for traditional risk factors (p=0.001)

Discussion:
Although the foot wound population has a high rate of vascular risk factors, a vascular assessment was performed in the minority of patients. Patients who underwent vascular assessment and were found to have evidence of ischemia were more likely to undergo subsequent revascularization.