bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 29: Cost-effectiveness of Inpatient Case Management for Heart Failure Patients
Authors: Gopalakrishnan Lakshmi , Kabbani Loay , Brown Sarah , Goodman Rachel , Montoya Ana , Hutton David W
Published: May 2020

Background:
Prior studies have demonstrated that approximately 5.7 million Americans suffer from heart failure (HF). The direct costs of HF have been estimated at $39.3 billion, and the annual cost of unplanned readmissions is approximately $17.4 billion. Many interventions have been implemented in order to decrease healthcare costs and burden of this disease. Case management (CM) is an intervention that has been utilized in inpatient and outpatient settings. The purpose of this study was to analyze the cost-effectiveness of using CM in addition to usual care in a tertiary hospital that has a large HF population to decrease the 30-day readmission rate.

Objectives:
We hypothesize that the addition of CM to provide transitional care services to HF patients will decrease 30-day readmission rate, consequently decreasing healthcare utilization costs and improving patient’s quality of life (QoL).

Methods:
We conducted a cost-effectiveness analysis using a decision analytic model that incorporated Markov processes to evaluate the use of CM for HF patients. We compared two different management strategies following index HF hospitalization: ‘usual care’ versus ‘usual care plus CM’. Our analysis was conducted from a societal perspective with estimated key cost parameters based on established Diagnosis-related Groups (DRGs) and the Healthcare Cost and Utilization Project (HCUP). Lastly, patients’ quality adjusted life years (QALYs) were measured by days spent out of the hospital.

Results:
In our analysis, ’usual care plus CM’ resulted in cost savings of $696.58 per patient when compared to ‘usual care’ alone for an ACO based health system with large HF patient volume. In addition, ‘usual care plus CM’ was associated with shorter inpatient stay (decrease in 0.35 inpatient days), and a slight increase in QALYs by 0.003.

Conclusion:
Our study demonstrated that ACO-based health system’s investment in CM in addition to usual care decrease the cost per discharge of complex HF patients.
Abstract 291: Changes In Prescribing Patterns Before And After Price Reduction In Pcsk9 Inhibitors
Authors: Smith Alexander , Johnson Drew , Karalis Dean
Published: May 2020

Introduction:
Atherosclerotic cardiovascular disease (ASCVD) is one of the leading causes of morbidity and mortality worldwide. There have been many advances in the lipid management of these patients from statin therapy to the more recent PCSK9 inhibitors. PCSK9 inhibitors (PCSK9i) have been shown to reduce cardiovascular events in patients with ASCVD. Despite their efficacy, there have been challenges to physicians adopting widespread use of PCSK9i, particularly cost. Our goal is to evaluate PCSK9i utilization in a real world setting before and after reduction in costs of PCSK9i.

Methods:
We retrospectively reviewed a large metropolitan outpatient cardiology practice EMR database to evaluate the demographics of their patient population as well as individual prescriber habits to determine their utilization of PCSK-9i before and after the price reduction in March 2016. All data were compared using χ
2
and student t-test via IBM SPSS version 25.

Results:
Patients were included if they had a diagnosis of ASCVD and had been seen once between January and December 2019. Among eligible patients, despite reduction in cost, only 4.1% (1059 of 25749) were prescribed a PCSK9i. Compliance with PSCK9i from 2015 to 2019 improved from 20% (9 of 45) to 68% (215 of 316). The percentage of patients with insurance approval for a PCSK9i via commercial carriers increased by over 10% after the 2016 price decrease (31.0% [155 of 500] to 41.3% [231 of 559], P<0.001). Data can be seen in Table 1.

Conclusions:
In a large metropolitan cardiology practice, of over 25,000 patients eligible for a PCSK9i, only 4.1% were actively prescribed. Although compliance increased over threefold over the study period, there are still clear barriers to prescribing and compliance with PCSK9i. Despite the cost reduction, women and older patients were less likely to be treated with a PCSK9i. Additional barriers exist for prescribing for eligible patients, particularly in older women.
Abstract 306: Guideline-based Strategies for Improving Control of High Blood Pressure: The 2019 Acc/Aha Performance and Quality Measures for Adults With High Blood Pressure
Authors: Casey Donald E
Published: May 2020

Despite a 27% reduction in all-cause mortality from targeting a systolic blood pressure of < 120 mm Hg, as compared with < 140 mm Hg, existing quality measures from the NCQA for controlling HBP (for hypertensive adults 18-59 years of age whose blood pressure was < 140/90 mm Hg) have not changed substantially over the past several years for a variety of insured populations, including commercial, Medicaid, Medicare Fee for Service and Medicare Advantage. Re-examining both the targets and processes of managing HBP are thus warranted to help support the use of the latest evidence in optimizing the quality of care and outcomes for patients with HBP. The recently published 2019 ACC/AHA Clinical Performance and Quality Measures for Adults with High Blood Pressure are designed to promote improvements in diagnosis and control of high blood pressure, including a new emphasis on “structural” quality measures that focus on a comprehensive system of care as outlined in the 2017 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. The purpose of this presentation will be to provide a detailed overview of this new measure set as a “Blueprint for Change” necessary to overcome current health system inertia and ensure the achievement of better quality of care for people with High Blood Pressure.
Abstract 318: Heart Failure and Osteoporosis- an Evidence Based Approach
Authors: Kapoor Anmol , Singh Amanpreet , Singh Armandeep
Published: May 2020

Background:
Heart disease occurs when there is reduced blood flow to the heart. It refers to a range of conditions that affect the heart. These conditions include ischemic heart disease (which can lead to acute myocardial infarction), angina, arrhythmia, atrial fibrillation, and heart failure, among others. Currently, there are 600,000 Canadians living with heart failure (HF) with 50,000 Canadians being diagnosed every year with HF. Community-based heart failure clinics have been proven to reduce hospitalizations, but Alberta has only one. The CHARM (Community Heart Failure Assessment, Rehabilitation and Management) clinic at Advanced Cardiology, Calgary, Alberta is a community based, charity funded clinic providing outpatient care, which is physician-directed but RN managed. We intended to investigate whether there was any relationship between patients with heart failure and their pre-disposition to osteoporosis and vice versa.

Methods:
We performed an observational case series with a retrospective chart review of 600 CHARM clinic patients who have been diagnosed with Heart Failure till June 2019. The primary endpoint was to look at CHARM clinic's prevalence of HF, patients who ever had Bone Mineral Density (BMD) done and if there was an intertwining relationship by comparing co-existence of heart failure with osteoporosis.

Results:
•Total # of pts above 65 years of age from a pool of 356 clinic pts = 169•Total # of pts above 65 years of age who had BMD done before June 2019 = 60•Total # of pts above 65 years of age who have Not had BMD done before June 2019 =108•Percentage of patients above 65 years of age who had BMD done before June 2019 = 35%•Percentage of patients above 65 years of age who have not had BMD done before June 2019 = 65%We also compared our finding with studies from Raymond b. Et al and Ezekowitz and it was found that out of 623 patients with Heart failure, 12% had moderate to severe vertebral compression fracture, 55% of those people have multiple fractures. It was seen that CHF patients with osteoporosis were the features that they were mostly female, Caucasian, smoker, obese, hypertensive, COPD, and patients with prevalence of diabetes.

Conclusion:
It was noticed from our clinic data that 65% of the patients with CHF did not have a BMD done (till June2019) and there by the presence of osteoporosis could have gone undiagnosed. What complicates CHF and osteoporosis is the age factor (mostly elderly), shared risk factors(factors include advanced age, hypovitaminosis D, renal disease and diabetes mellitus), medication use like (loop diuretics) and common pathogenic mechanisms(activation of the renin-angiotensin-aldosterone system) affect both HF and osteoporosis. It is to be noted that CHF is a major risk factor for mortality following fracture as the patient becomes immobile and it is important to carefully assess osteoporosis and take measures to reduce the risk of osteoporotic fractures.
Abstract 323: Assessment of Coronary Artery Calcium on Routine Non-gated Chest Computed Tomography to Risk Stratify Patients Presenting With Chest Pain
Authors: Vautier Richard , Lee Dae Hyun , Ayoubi Yasmin , Hernandez Burgos Paula , Hawk Fahad , Chen Allan
Published: May 2020

Background:
Coronary artery calcium (CAC) scoring is an important tool for cardiovascular risk stratification. CAC scoring in both asymptomatic and symptomatic, low-intermediate risk patients has also shown prognostic utility and has a high negative predictive value for obstructive coronary artery disease (CAD). Patients who present with chest pain frequently undergo non-gated chest computed tomography (CT) to evaluate for non-cardiac etiologies. In fact, several studies have demonstrated that a CAC score from a non-gated chest CT correlates well with a dedicated calcium-scoring CT. However, the predictive value on CAD through assessing the presence (CAC>0) or the absence of calcium (CAC=0) detected on non-gated chest CT in patients presenting with chest pain is unknown.

Methods:
Low-intermediate risk patients (n=92) presenting to the emergency department with chest pain who underwent non-gated chest CT and were subsequently evaluated with either a cardiac stress test or invasive coronary angiography were included. Dichotomous CAC was assessed in a blinded fashion and classified as CAC=0 or CAC>0. Obstructive CAD was defined as either: ischemia on stress testing or any coronary artery stenosis greater than 70% (left main coronary artery stenosis greater than 50%) on invasive coronary angiography.

Results:
CAC=0 on non-gated chest CT was found in 59.2% (n=42). Patients with CAC=0 had a significantly lower age and TIMI score compared to patients with a CAC>0. (p<0.01 ) Patients with a CAC>0 were found to more likely have obstructive CAD on subsequent testing: cardiac stress test (Likelihood ratio[LR]:6.42, p=0.022); and invasive angiography (LR:12.46, p=0.002). There were no patients with a CAC=0 that were found to have obstructive CAD on invasive coronary angiography, resulting in a 100% sensitivity and 100% negative predictive value.

Conclusion:
Patient who presents with chest pain frequently undergo evaluation with a non-gated chest CT to assess non-cardiac etiologies. Exclusion of CAC on non-gated chest CT may be useful as an adjunct for further risk stratification to avoid potential adverse events and cost associated with further testing.
Abstract 328: Heart Failure Quality Improvement at the Las Vegas VA
Authors: Javaid Awad
Published: May 2020

Background:
Recently there has been a push to prevent patients admitted with acute decompensated heart failure from being readmitted to the hospital within 30 days. At the VA Southern Nevada Healthcare System, we found that congestive heart failure was the most common cause of hospital admission from January 2017 to June 2018, as well as the diagnosis with the highest 30-day readmission rate to the hospital.

Objective:
The goal of this project was to research the cause of heart failure readmissions at the VA Southern Nevada Healthcare System and recommend solutions to reduce the readmission rate.

Methods:
We obtained a list of all patients at the VA who were documented as being readmitted within 30 days for heart failure from January 2017 to June 2018. We compared each patient’s hospital management to recommendations from the American Heart Association’s (AHA) “Get with the Guidelines” heart failure quality improvement program, which lays out a specific set of evidence-based benchmarks that should be achieved for patients with heart failure before hospital discharge.

Results:
We identified 36 patients and analyzed their hospital courses for compliance with AHA quality improvement measures. There were ten patients who did not receive pharmacologic guideline directed medical therapy for heart failure on discharge, who were not found to have any contraindications. There were eight patients who did not have a transthoracic echocardiogram performed in the previous six months who may have benefitted from repeat left ventricular function assessment. Importantly, 16 patients were not seen at a follow up appointment within one month of discharge from the hospital.

Conclusion:
We presented our findings to the Chief of Medicine, nursing staff, and residents at the VA Southern Nevada Healthcare System and worked with the Systems Redesign staff to determine how to improve adherence to guidelines and obtain close follow up for patients. An acute care transition clinic was created for patients at high risk for readmission on discharge, and a cardiology nurse practitioner was asked to make follow up appointments for all patients before discharge. We also created a heart failure order set in the electronic medical record, so that providers will be more likely to follow AHA recommendations from the beginning of each admission. We plan to conduct a follow up study to determine whether 30-day readmission rates improve after our recommended measures are instituted. Our objective is to reduce 30-day readmission rates and improve patient morbidity and mortality.ve patient morbidity and mortality.
Abstract 329: Cholecystalgia: an Atypical Presenting Symptom of Congestive Heart Failure
Authors: Gilbert Brittany , Harter Stephanie , Saunders Elizabeth
Published: May 2020

Acute acalculous cholecystitis is defined as acute inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction. Imaging studies typically show a distended acalculous gallbladder with thickened walls. Heart failure is well known to cause congestive hepatopathy and can be associated with isolated gallbladder edema which is often difficult to differentiate from acalculous cholecystitis. We present a case of cholecystalgia secondary to isolated gallbladder edema without hepatic congestion in a patient with non-ischemic cardiomyopathy mimicking the presentation of acalculous cholecystitis. A 46-year-old female with a past medical history of recently diagnosed non-ischemic cardiomyopathy during a prior hospitalization. Echocardiogram showed biventricular heart failure with EF of 15 to 20% with severe left and right ventricular dilatation and global hypokinesis. Left heart catherization showed no angiographic evidence of coronary artery disease and right heart catheterization demonstrated pulmonary hypertension secondary to left heart disease. She left against medical advice and was non-compliant with her medications. Approximately one month later, she presented with shortness of breath and orthopnea. On physical examination, jugular venous distention, S3 gallop, diffuse crackles and anasarca were noted. Labs showed BNP of 12,735. Chest CT revealed cardiomegaly and diffuse interstitial edema with bilateral pleural effusions and no signs of pulmonary embolus. Metoprolol and bumetanide were initiated for management of her acutely decompensated congestive heart failure. Several days after admission, she developed severe sharp RUQ pain associated with nausea and vomiting. She was tachypneic, diaphoretic with severe tenderness in the RUQ. Abdominal ultrasound revealed no signs of congestive hepatopathy but revealed a diffuse, edematous thickening of the gallbladder wall without evidence of stones. Hepatobiliary scintigraphy revealed preserved gallbladder function with an EF of 88%. The remainder of her care was focused on optimization of the patient’s congestive heart failure with complete resolution of her symptoms. Acute decompensation of congestive heart failure can result in an increase in pulmonary or systemic venous pressure, which may result in vascular congestion. The vascular distention can lead to isolated distention of the gallbladder wall that can mimic symptoms of acalculous cholecystitis. In such patient’s cholecystectomy or percutaneous cholecystostomy is not warranted. Radiographic evidence and symptoms usually resolve with optimization of congestive heart failure treatment. This case details the under-recognized presentation of secondary cholecystalgia in a patient with acute RUQ pain and underlying congestive heart failure.
Abstract 337: Gender Differences and Outcome After Isolated Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis
Authors: Deo Salil V , Chang Carolyn , Neudecker Mandy , Raza Sajjad , Altarabsheh Salah , Cmolik Brian L
Published: May 2020

Background:
Coronary artery bypass grafting (CABG) is among the most common surgical procedures performed in developed nations. In spite of this, studies have reported gender differences in clinical outcome exist in outcome after CABG. As data is limited to observational studies, we performed a systematic review to compare CABG outcome between women and men.

Methods:
We queried databases (1
st
January 2000 - 20
th
January 2020) to identify original studies comparing CABG outcome between genders. Our aims were (1) to study differences in risk factors (2) to compare early mortality, stroke, wound infection, acute kidney injury rates and long-term survival. We pooled risk ratios (RR) with inverse variance weighting and a random effects model for early end-points. Long-term survival was compared using incident risk ratios (IRR). All results are presented with their 95% confidence interval.

Results:
We identified 24 observational studies (1,647,035 women and 3,642,057 men) from 13 countries for inclusion. At time of CABG, women were older (66 vs 64 years; p < 0.01) and had a higher incidence of diabetes mellitus (32% vs 24%; p < 0.01), congestive heart failure (12% vs 8%; p < 0.01) and emergent surgery (13% vs 9%). More men had left ventricular dysfunction (12% vs 10%; p < 0.01) and prior myocardial infarction (40% vs 37%). Women received fewer grafts (mean difference -0.22; p < 0.01) and arterial conduits (OR 0.51, CI 0.41 - 0.63; p < 0.01). Early mortality (4% vs 2.5%, OR 1.5, CI 1.4 - 1.7) and stroke rates (OR 1.9, CI 1.3 - 1.7) were higher in women. Sternal wound infection (4.7% vs 2%) was also higher in women (OR 1.8, CI 1.1 - 1.8, p = 0.001). Acute kidney injury (OR 1.1, p = 0.09) and long-term survival (IRR 0.9, CI 0.8 - 1.2, p = 0.9) are comparable.

Conclusion:
Our meta-analysis demonstrates that women and men have significant differences in presentation and outcome after CABG. While women have worse post-operative outcomes, long-term survival is comparable.
Abstract 343: Trends and Predictors of Use of Angiotensin Receptor Blocker and Neprilysin Inhibitor in Patients With Heart Failure
Authors: Shore Supriya , Basu Tanima , Kamdar Neil , Brady Patrick , Hummel Scott L , Chopra Vineet I , Nallamothu Brahmajee K
Published: May 2020

Objective:
Current guidelines recommend use of combination therapy with angiotensin receptor blocker and neprilysin inhibitor (ARNI) (i.e., Entresto
®
) in patients with heart failure (HF) with reduced ejection fraction as a class 1 recommendation. Contemporary data on real-world use of these agents is lacking.

Methods:
This is a retrospective cohort study of individuals enrolled in Clinformatics® Data Mart Database (OptumInsight, Eden Prairie, MN from January 1, 2016 to December 31, 2018. We included all individuals ≥ 18 years, with two outpatient encounters or one inpatient encounter with a principal ICD 10 diagnosis for HFand 6 months of continuous enrollment. To further identify patients with reduced ejection fraction, we only included individuals who received prescriptions for beta-blockers and angiotensin converting enzyme inhibitors/ angiotensin receptor blockers. Comorbidities were identified using Elixhauser comorbidity index.. Multivariate logistic regression model was used to identify predictors of ARNI use.

Results:
A total of 154,777 patients were included in our cohort. Overall, 5,834 patients (3.8%) received an ARNI prescription. Use of ARNI increased from 1.4% in 2016 to 3.9% in 2018 (p<0.01). Compared to patients receiving angiotensin converting enzyme inhibitors/angiotensin receptor blockers, patients receiving ARNI were younger (mean age 69.4 ± 11.1 vs. 72.9 ± 11.0 years;), more likely to be male (69.3% vs. 54.4%) and have commercial insurance (22.1% vs. 16.7%) with a higher comorbidity burden. Predictors of ARNI use after multivariable adjustment included age<65 years (OR 1.4; 95% CI 1.3-1.5), Male sex (OR 1.8; 95% CI 1.7 - 1.9) and black race (OR 1.2; 95% CI 1.1 - 1.2). Other predictors of ARNI use are shown in Figure 1. Patients receiving care through a cardiologist compared to a primary care physician were more likely to receive an ARNI (OR 1.8; 95% 1.7 - 1.9). Out of pocket cost for ARNI ranged from $0 to $1006 per month (median $44; IQR $9-$60).

Conclusion:
Rates of ARNI use remain low among patients with heart failure with racial and gender disparities. Heart Failure patients receiving care with a cardiologist were more likely to receive ARNI. Out of pocket cost for this medication remains high and may be a significant barrier to its use.
Abstract 351: Size Matters: Saving the Penumbra
Authors: Curley Tom , Reese Kristy , Stone Casey
Published: May 2020

Background:
New Hanover Regional Medical Center (NHRMC) is a DNV-GL certified Comprehensive Stroke Center with its primary service area encompassing the seven-county region of Southeastern North Carolina. As the stroke hub of our region, the organization recognized the need to create a highly functional stroke center to provide optimal care to our community.In 2017, we began our comprehensive journey to include endovascular treatment of patients with large vessel occlusions. Based on the success of the Code Stroke response, which decreased door to needle times, Code ELVO (Emergent Large Vessel Occlusion) was layered in resulting in a seamless process.

Objectives:
The team completed a value-stream analysis by examining each step in the process. The stroke team care goals were to:•Increase the percentage of eligible stroke patients who received treatment with alteplase•Decrease the median time to treatment below the AHA/ASA “Get With the Guidelines” standards•Achieve Door to recanalization below the AHA/ASA “Get With the Guidelines” standards•Improve stroke systems of care in the region.

Methods:
1. Use of Lean problem solving and PDSA methodology to identify opportunities for improvement and implement countermeasures 2. Creation of interdisciplinary team for oversight and continuous process improvements 3. Code Stroke/Code ELVO processes were developed and are continuously evaluated for improvement 4. Weekly Stroke Huddle: Representatives from the interdisciplinary stroke team gather to review cases, identify opportunities for improvement, and celebrate successes. 5. Stroke Steering Committee: Interdisciplinary committee that meets monthly to review Code Stroke, Code ELVO, and acute cerebrovascular data including quality metrics, treatments and mortality.

Results:
The number of patients who were treated with alteplase significantly increased 5-fold (547%), from 30 patients per year (2014) to 194 patients (2019). During this period, median alteplase treatment times were reduced by 51%, from 63 minutes (2014) to 31 minutes (2019). The percentage of patients who received alteplase in 45 minutes or less at NHRMC was 76% from 2016 - October 2019, compared to 44% nationally participating in the AHA/ASA Get with the Guideline Stroke registry. Risk adjusted mortality rate during the same period was 4.9% for NHRMC, 5.6% for all hospitals. Bleeding complications from alteplase were 3.2% for NHRMC, 4.1% nationally. The number of patients who were treated with mechanical thrombectomy significantly increased by 61% from 53 patients in 2017 to 137 patients in 2019. During this period, median door to recanalization times were reduced by 5%, from 80 minutes (2017) to 76 minutes (2019). During this period, we expanded to 24/7 coverage, extended the treatment window, and added a cerebrovascular neurosurgeon to the team.
Abstract 366: A Combined Community Health Worker and Text Messaging-based Intervention for Smoking Cessation in India
Authors: Hejjaji Vittal , Khetan Aditya , Hughes Joel W , Gupta Prashant , Jones Philip , Ahmed Asma , Madan Mohan Sri K , Josephson Richard A
Published: May 2020

Background:
Home-based Community Health Worker (CHW) led care is a mode of health promotion. We sought to evaluate the effectiveness of a CHW-led smoking cessation intervention, supplemented by text messages in a semi-urban region of India.

Methods:
We conducted a cluster randomized controlled trial (4/2018- 8/2019) in adult smokers residing in the eastern part of India. Participants in the intervention arm were offered CHW-led home visits that were focused on counseling. In addition, participants could choose to receive text messages. Both CHW counseling and test messages were adapted to the participant’s stage of change. The control group received brief education only. Our primary outcome was self-reported smoking cessation at the end of 12 months, verified by exhaled carbon monoxide levels. CHWs were interviewed at the end of the study.

Results:
A total of 234 (mean age 43±12.3, male 96.2%) participants were enrolled; 151 (64%) in the intervention arm and 83 (35.4%) in the control arm. At 12-months, 30 (19.8%) participants in the intervention arm and 12 (14.4%) in the control arm quit smoking (absolute risk difference=5.4%; OR 1.46,
p
= 0.71). There was large cluster-level heterogeneity in intervention uptake (figure). Highlights from the CHW interviews are described in the figure.

Conclusion:
CHW-led home-based counseling, supplemented by regular text messages, led to a slight increase in quit rates, especially among those exposed to a higher dose of the intervention. However, the difference in cessation rates was not statistically significant. Future studies should consider testing mobile application-based multimedia messaging options, as an enhanced supplement to CHW based counseling.
Abstract 369: Secondary Risk Reduction in Patients With Type 2 Diabetes and Cardiovascular Disease: Experience From a Cardiometabolic Center of Excellence
Authors: Thomas Merrill , Magwire Melissa , O'Keefe James H , Nassif Michael , Kosiborod Mikhail N
Published: May 2020

Background:
Optimal guideline-directed medical therapy is delivered to only 6.9% of patients with type 2 diabetes (T2D) and cardiovascular disease (CVD) nationally, despite guideline recommendations emphasizing aggressive comprehensive secondary risk reduction. While there are many potential explanations, lack of effective clinical care delivery models is a key contributor. The Haverty Cardiometabolic Center of Excellence at Saint Luke’s Mid America Heart Institute was designed to address this unmet need, by delivering a patient-centric, collaborative model of care which focuses on aggressive and comprehensive secondary risk reduction in patients with T2D and CVD. Patients are managed by a multidisciplinary team comprised of preventative cardiologists, advanced practice providers and nurses cross-trained in T2D and CVD management, certified diabetes educator, dietician, pharmacist, and other professionals, in close coordination with endocrinologists and primary care clinicians. We aimed to determine whether patients receiving care in the Center had experienced better intermediate outcomes with similar patients receiving routine care in conventional settings.

Methods:
We analyzed data from the initial 60 patients seen in the Center who had at least one follow-up visit, and propensity matched them 1:3 to similar patients with T2D and CVD treated in conventional care settings. Propensity model included age, sex, baseline weight, HbA1c, systolic blood pressure (SBP), history of CVD, and duration between visits. Linear mixed models with a random effect for matched groups was used to compare between-group differences for changes in weight, LDL-C, and HbA1c.

Results:
At baseline, patients in the Center weighed 241.3 lbs ± 51.0 and had HbA1c 7.4 ± 1.4 and LDL 68.0 ± 27.0 as compared to 245.5 lbs ± 55.3, HbA1c 7.5 ± 1.5, and LDL 79.1 ± 37.1 in controls. Average duration between follow up visits was 138.3 days ± 52.5 in patients seen in the Center and 138.9 days ± 54.7 in controls. Patients seen in the Center had greater degree of weight loss (12.3 lbs vs 3.8 lbs, p <0.001) and reduction in HbA1c (0.5 vs 0.0%, p = 0.04) and LDL-C (-8.4 vs +4.0 mg/dL, p = 0.04) as compared with controls. Patients receiving care at the Center were more likely to be treated with an SGLT-2i (70.0% [42/60] vs 22.8% [41/180], p<0.001) and/or a GLP-1RA (91.7% [55/60] vs 15.6% [28/180], p<0.001) than those in the standard of care cohort.

Conclusion:
Patients with T2D and CVD, seen in a specialized, comprehensive Cardiometabolic Center experienced higher use of guideline-directed medical therapies and greater reduction in multiple CVD risk factors within ~4 months, as compared to those seen in the conventional setting. Although longer follow up is needed, these preliminary data suggest that such novel clinical care delivery models may improve the implementation of clinical practice guidelines.
Abstract 373: Meta-analysis of Clinical Outcomes Comparing Use of Transesophageal Echocardiography versus No Transesophageal Echocardiogram During Transcatheter Aortic Valve Replacement
Authors: Okereke Ifeanyichukwu M , Fatima Urooj , Khan Muhammad Usman , Khalid Mazhar , Opoku-Asare Isaac
Published: May 2020

Background:
Transesophageal echocardiography (TEE) is routinely used for intraoperative guidance for TAVR procedures. TAVR is also done with minimal imaging or no TEE guidance (minimal imaging approach). The clinical benefits of intraprocedure TEE during TAVR compared to minimal imaging approach has not been well established.

Aim:
To perform a meta-analysis of available trials comparing effectiveness of intraprocedural TEE versus minimal imaging approach during TAVR procedure.

Hypothesis:
TAVR with intraprocedural TEE is associated with better clinical outcomes compared with minimalist imaging approach.

Methods:
8 retrospective observational studies were identified via a comprehensive literature search that incorporated Embase, MEDLINE, and CENTRAL. Each selected study reported on the comparison between TAVR performed with TEE guidance or with no TEE (minimalist strategy) during the procedure. Studies were screened for risk of bias using a quality assessment tool. Outcomes studied included all-cause mortality, cardiovascular mortality, paravalvular leak as defined by the original trial, readmission within 30 days, stroke, myocardial infarction (MI) , and acute kidney injury (AKI). For each outcome, estimates were pooled and reported as a risk ratio with 95% confidence interval (CI).

Results:
A total of 2057 patients were divided into TEE (n=1115) vs. non-TEE (n=942) cohorts. No significant difference was seen between TEE vs non-TEE groups in reducing cardiovascular mortality (RR=2.06 [95%CI: 0.91- 4.67], p=0.08 ), all cause mortality (RR= 0.63 [95% CI: 0.21- 1.90], p=0.41), readmission within 30 days (RR=0.49 [95% CI: 0.06-4.41], p=0.53), stroke (RR=0.97 [95% CI: 0.27- 3.47], p=0.96), MI (RR=0.92 [95%CI: 0.26- 3.29], p=0.90), and AKI (RR=1.24 [95% CI: 0.16-9.35], p=0.83). A significant increase in paravalvular leak was observed within the non-TEE group (RR=1.19 [95% CI: 1.01-1.39], p=0.04) in comparison to the TEE group.

Conclusion:
TEE guidance during TAVR is associated with reduced paravalvular leak when compared with minimal imaging approach. No other clinical difference was observed between the two approaches. Further studies are needed to validate these findings.
Abstract 380: S.T.A.T. ECGs: Supporting Technicians in Acquiring Timely ECGs
Authors: Levy Andrew E , Ozkaynak Mustafa , Barnard Juliana , Pincus Sharon , Ho Michael
Published: May 2020

Introduction/Background:
A quality improvement project at the University of Colorado Hospital (UCH) was initiated to better understand perceived delays in the completion of STAT priority electrocardiograms (ECGs). The project team obtained ECG acquisition time data from the electronic health record in order to describe delays and evaluate potential solutions.

Methods:
Analysis of 25,159 completed, time-stamped inpatient ECGs completed at UCH between 1/1/2018 and 10/30/2018 were completed. Descriptive statistics for ECG volume, ECG completion delays and total AHT staffing levels were calculated and correlations between ECG characteristics and delays were examined. Between February and April 2019, a trained qualitative researcher completed interviews and observations with UCH staff involved in ECG completion, focusing on work processes and the workplace environment. Based on these initial quantitative and qualitative analyses, a simulation model was developed to evaluate changes in 1) technician shifts and staffing ratios; 2) the proportion of STAT orders; and 3) nurse training to help perform ECGs.

Results:
ECGs were ordered with a STAT priority in 40% of cases and, among individual providers, use of the STAT priority varied from 7% to 95%. ECG completion was delayed (>15 minutes) for 35% of STAT ECGs, compared to less than 10% of non-stat ECGs. In qualitative interviews, technicians described a “cascade” effect to delays resulting from a compounding effect of a series of late ECGs and supported by the quantitative observation that delays are strongly correlated with STAT ECG volume. Technicians also described spikes in ECG ordering during hours in which staffing levels are low and for non-emergency reasons (such as discharge), a finding again supported by quantitative analysis. Results of discrete event simulation suggest: adding technician staffing hours during the day outperforms reducing the proportion of STAT ECGs; short shifts (4-8 hours) may be a cost effective way to add personnel; ECG training for Cardiology nurses, who expressed a desire to help with ECG completion, could additionally offload technicians and reduce delays; the negative effect of technician “attrition” - e.g. a technician calls in sick and is not replaced - is more powerful than the positive effect of any intervention. That technicians described a hectic and unforgiving work environment suggests workplace interventions to manage the volume of ECGs per technician may improve satisfaction and avoid technician attrition.

Conclusions:
In light of the above findings, UCH operations leadership trained charge nurses on Cardiology units to perform STAT ECGs and are evaluating processes by which technician breaks are more structured, a feedback process is more formalized and staffing hours are more reflective of hourly fluctuations in ECG volume. Results of these interventions will be the subject of future analyses.
Abstract 397: Shared Decision Making In Cardiology: Measures Of Shared Decision Making In Patients With Severe Aortic Stenosis Considering Valve Replacement
Authors: Valentine KD , Marques Felisha , Selberg Alexandra , Flannery Laura , Langer Nathaniel , Elmariah Sammy , Sepucha Karen
Published: May 2020

Objective:
To identify the degree to which shared decision making (SDM) is occurring for patients with severe aortic stenosis (AS) considering aortic valve replacement (AVR) as measured by the Shared Decision Making Process (SDMP) measure.

Methods:
Patient eligibility was ascertained via the electronic medical record. Eligible patients were between 18-85, spoke English, were diagnosed with severe AS, either had no prior AVR or had AVR more than 6 months prior, and were at low to intermediate risk for surgical AVR (SAVR). Patients were ineligible if they had a concomitant disease of the aorta or another heart valve that required intervention. Eligible patients were approached in either the Interventional Cardiology or Cardiac Surgery clinic after the respective visit and asked to complete the Shared Decision Making Process (SDMP) Measure, which includes 6 questions with a total score ranging from 0-4. The questions focus on if options were presented (yes/no), preferences elicited (yes/no), and if the pros and cons of transcatheter AVR (TAVR) and SAVR were discussed (“a lot”, “some”, “a little”, or “not at all”). A higher score indicates greater shared decision making occurred.

Results:
Of 60 enrolled patients, 59 (98%) returned their survey. Most patients were recruited after the visit with an interventional cardiologist (68%, 40 of 59). The average age was 72 years (SD=7 years), all patients were white, 67.8% (40 of 59) were men, and 82.1% (46 of 56) had more than a high school education. There was a trend toward patients reporting higher SDMP scores if patients were recruited in the cardiac surgery clinic (M=3.0, SD=0.7) when compared to those recruited in the interventional cardiology clinic (M=2.6, SD=1.1; t(57)=1.4, p=.164, d=.39). Nearly all (96.6%, 57 of 59) patients stated they were presented with different options to treat their AS and 88.1% (52 of 59) reported discussing the pros of TAVR while 78.0% (46 of 59) discussed SAVR “some” or “a lot.” Conversely, fewer patients stated they discussed the cons of TAVR (57.6%, 34 of 59) or SAVR (49.2%, 29 of 59) “some” or “a lot.” Most patients stated they were asked what they wanted to do to treat their AS (64.4%, 38 of 59).

Conclusions:
One third of patients did not recall being asked for their preference—a key component of shared decision making conversations. Given the importance of patients being well informed in this preference sensitive decision context, future work should seek to understand both how this multidisciplinary approach may benefit patients, and how to ensure the downsides of options and patient preferences are discussed during the visit.
Antithrombotic Treatment of Embolic Stroke of Undetermined Source
Authors: Diener Hans-Christoph , Sacco Ralph L. , Easton J. Donald , Granger Christopher B. , Bar Michal , Bernstein Richard A. , Brainin Michael , Brueckmann Martina , Cronin Lisa , Donnan Geoffrey , Gdovinová Zuzana , Grauer Claudia , Kleine Eva , Kleinig Timothy J. , Lyrer Philippe , Martins Sheila , Meyerhoff Juliane , Milling Truman , Pfeilschifter Waltraud , Poli Sven , Reif Michal , Rose David Z. , Šaňák Daniel , Schäbitz Wolf-Rüdiger
Published: May 2020

Background and Purpose—

The RE-SPECT ESUS trial (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) tested the hypothesis that dabigatran would be superior to aspirin for the prevention of recurrent stroke in patients with embolic stroke of undetermined source. This exploratory subgroup analysis investigates the impact of age, renal function (both predefined), and dabigatran dose (post hoc) on the rates of recurrent stroke and major bleeding.

Methods—

RE-SPECT ESUS was a multicenter, randomized, double-blind trial of dabigatran 150 or 110 mg (for patients aged ≥75 years and/or with creatinine clearance 30 to <50 mL/minute) twice daily compared with aspirin 100 mg once daily. The primary outcome was recurrent stroke.

Results—

The trial, which enrolled 5390 patients from December 2014 to January 2018, did not demonstrate superiority of dabigatran versus aspirin for prevention of recurrent stroke in patients with embolic stroke of undetermined source. However, among the population qualifying for the lower dabigatran dose, the rate of recurrent stroke was reduced with dabigatran versus aspirin (7.4% versus 13.0%; hazard ratio, 0.57 [95% CI, 0.39–0.82]; interaction
P
=0.01). This was driven mainly by the subgroup aged ≥75 years (7.8% versus 12.4%; hazard ratio, 0.63 [95% CI, 0.43–0.94]; interaction
P
=0.10). Stroke rates tended to be lower with dabigatran versus aspirin with declining renal function. Risks for major bleeding were similar between treatments, irrespective of renal function, but with a trend for lower bleeding rates with dabigatran versus aspirin in older patients.

Conclusions—

In subgroup analyses of RE-SPECT ESUS, dabigatran reduced the rate of recurrent stroke compared with aspirin in patients qualifying for the lower dose of dabigatran. These results are hypothesis-generating. Aspirin remains the standard antithrombotic treatment for patients with embolic stroke of undetermined source.

Registration—

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02239120.
Neglecting Nonhuman Animals: A Content Analysis of Introductory Criminal Justice and Criminology Textbooks
Authors: Girgen Jen
Published: May 2020

As illustrated by the fact that all states now have felony anti-cruelty laws and the FBI has begun tracking some forms of nonhuman animal abuse in its National Incident-Based Reporting System, there is growing recognition by lawmakers and criminal justice professionals that the abuse of animals should be taken seriously and properly addressed by the criminal justice system. This article assesses 19 popular introductory criminal justice and criminology textbooks to determine whether these texts share this sentiment by giving attention to this offense. Results indicate that animal abuse is given no, or only minimal, attention in most of these textbooks, and when it is included, it tends to be framed more as an environmental problem than one of violence or morality. The article concludes with a call to textbook authors and publishers to better include animal abuse within their texts and offers suggestions for how to accomplish this.
Brokers on the Ward
Authors: Zaman Shahaduz , van der Geest Sjaak
Published: May 2020

This paper is based on an ethnographic study conducted in a public hospital in Bangladesh. The study shows how the social dynamics necessary to deal with the structural realities of the hospital give this cosmopolitan institution a local character. In this paper, we describe this local character by focusing on the lower-level hospital staff, such as ward boys, cleaners, and gatemen. Social inequality and exclusion are rampant in Bangladeshi public hospitals. Doctors and nurses are unwilling to communicate with patients and their relatives, while the latter are unable to approach the former for specific help or information. Our research, shows how low-level support workers fill the void between the two “factions” and act as brokers transporting information and activities between these factions. By doing so they do not only make a crucial contribution to the functioning of the ward, but also gain considerable influence in spite of their low position.
Macro-level Differences in Participation in Sharing Economy
Authors: Konieczny Piotr
Published: May 2020

Different countries embrace the sharing economy with differing enthusiasm and effects due to factors ranging from the development level to government policies and society’s cultural values. This research measures the participation of Asian countries in this phenomena through their contributions to a global sharing economy platform—Wikipedia. This study uses language as a proxy for each country, which allows for a macro-scale comparison of factors related to participation in sharing economy. The study finds that in addition to expected factors related to the global digital divide and the country’s development level, other factors such as country’s size, dominant language, and cultural factors also play a significant role. Lower development levels, multi-ethnic (multi-language) and smaller populations can be a severe impediment to the development of the sharing economy. Government policy (China) or unique Internet structure (South Korea) can create significant outliers. Contributing to the sharing economy is also more common in countries located near the self-expression and rational-secular ends of the Inglehart-Welzel model, and the uncertainty avoidance, masculinity, and long-term orientation dimensions of the Hofstede model.
Biology and origin of isolated north-easternmost populations of the common wall lizard, Podarcis muralis
Authors: Kolenda Krzysztof , Skawiński Tomasz , Majtyka Tomasz , Majtyka Monika , Kuśmierek Natalia , Starzecka Agata , Jablonski Daniel
Published: May 2020

The common wall lizard, Podarcis muralis, is a widely distributed European lizard which has been often introduced across the continent, including north of the continuous species range. Three such populations were recently discovered in the Strzelin Hills in Poland, but no information is available about their origin. We studied the morphological variation, demographic structure and ecology of these populations, as well as their possible origin based on cytochrome b mtDNA sequences. Between 2011 and 2019, the lizards were annually active from the first half of March to mid-October. Males attained significantly larger snout-vent length than females and had relatively larger heads. Almost half of all captured individuals exhibited at least one pileus scale anomaly. Analysis of colour polymorphism revealed the occurrence of three morphs: white, white-red and red. The oldest lizards reached the age of 8 years. These parameters of Polish populations do not deviate from those of other populations from similar latitudes. Molecular analysis revealed that they belong to the most common haplotype of Central European haplogroup I of the Central Balkan clade. This haplotype is widely distributed across the Czech Republic and Slovakia; however, genetic data do not allow determination of the exact origin of the Polish population. Human-mediated introduction from the closest localities, the Czech Republic or Slovakia, is probable but the relict status cannot at present be excluded.
Synergism of citral from Cymbopogon citratus essential oil and undecan-2-one against Meloidogyne incognita
Authors: Barros Aline F. , Campos Vicente P. , de Paula Letícia L. , de Oliveira Denilson F. , Silva Geraldo H.
Published: May 2020

The nematicidal activity of the essential oil of Cymbopogon citratus and its main components were studied. During in vitro assays with Meloidogyne incognita second-stage juveniles (J2), the oil showed an LC50 of 166 μg ml−1. In vivo assays that exposed J2 to the LC50 oil concentration significantly reduced galls and eggs on tomato roots. According to gas chromatography-mass spectrometry analyses, the main components of the essential oil were geranial (42.7%) and neral (33.0%). The combination of these two isomers, known as citral, had an enhanced nematicidal activity at low concentrations as shown by in vitro tests through a synergistic interaction with undecan-2-one. In assays with tomato plants inoculated with M. incognita J2, the combination of citral (600 μg ml−1) and undecan-2-one (300 μg ml−1) showed a high reduction in the number of galls (63.4%) and eggs (56.3%) in relation to Tween 80® control. The citral/undecan-2-one combination showed a synergistic nematicidal activity against M. incognita during in vitro and in vivo assays.