bluuebunny/crossref_metadata_2025 huggingface dataset:
НОВІТНІ МЕТОДИ СТРИМУВАННЯ ІНФЕКЦІЙ, ЩО ПЕРЕДАЮТЬСЯ СТАТЕВИМ ШЛЯХОМ
Authors: Mavrov H. I. , Shcherbakova Yu. V. , Osinska T. V.
Published: April 2019

Кожен день більше 1 млн осіб заражаються на інфекції, що передаються статевим шляхом (ІПСШ), які становлять значну частину захворюваності людства, а також підвищують ризик придбання вірусу імунодефіциту людини (ВІЛ). Існуючі стратегії профілактики та запобігання ІПСШ, включаючи зміну поведінки, розповсюдження презервативів і своєчасну терапію, не привели до їх суттєвого скорочення, що вказує на необхідність пошуку нових стратегій.

Мета цього огляду – узагальнити нові біомедичні підходи до профілактики ІПСШ, включаючи багатоцільові технології, а також виявити наукові та організаційні перешкоди, які необхідно подолати.

Матеріали і методи. За період 1990-2018 рр. аналізувалися результати власних досліджень, статті, знайдені в базі даних PubMed, глобальні звіти UNAIDS (ЮНЕЙДС) – агентства об’єднаних націй з боротьби зі СНІДом, звіти окремих країн, матеріали Всесвітньої організації охорони здоров’я (ВООЗ).

Результати. Проведено систематичний аналіз клінічних досліджень жіночих презервативів, місцевих мікробіцидів на основі гелю, вагінальних кілець, таблеток, плівок та нановолокон. Проаналізовано стан хімічної профілактики генітального герпесу, трихомонозу. Наведено принципи багатоцільової технології профілактики (БТП) та перспективи досліджень.

Висновок. ВІЛ та інші ІПСШ є частиною глобальної кризи охорони здоров’я. В даний час розробляються нові БТП для захисту від ВІЛ й ІПСШ з урахуванням механізмів зараження та культурних і соціальних чинників.
НЕВРОЛОГІЧНІ УСКЛАДНЕННЯ КОРУ У ДІТЕЙ
Authors: Prokopiv O. V. , Lysheniuk S. A. , Prykuda N. M.
Published: April 2019

Мета роботи – вивчити клінічний перебіг неврологічних ускладнень кору у дітей, які перебували на стаціонарному лікуванні у Львівській обласній інфекційній клінічній лікарні (ЛОІКЛ) у 2018 р.

Пацієнти і методи. Спостереження проведено у 10 дітей з неврологічними ускладненнями кору віком від 3 до 16 років. Діагноз кору базувався на типових клінічних проявах хвороби, даних епідеміологічного анамнезу, результатах загальноприйнятих лабораторних та імунологічних досліджень.

Результати досліджень та їх обговорення. Упродовж 2018 р. на стаціонарному лікуванні у ЛОІКЛ перебувало 5 дітей з коровим енцефалітом, 3 – з менінгітом і 2 дітей з енцефаломієлітом. Переважали діти віком 3-6 років. Ураження нервової системи виникали на 6-14-у добу хвороби. Описано випадок корового енцефаломієліту у вакцинованого хлопчика віком 16 років, хворого на розсіяний склероз.

Висновки. З-поміж неврологічних ускладнень домінував енцефаліт, що розвинувся у дітей із середньотяжкою формою кору на 10-14-у добу хвороби. Ведучим початковим симптомом в усіх хворих були зорові галюцинації. Ураження нервової системи у вигляді енцефаломієліту є тяжким ускладненням, що характеризується тривалим перебігом. За умов своєчасного інтенсивного лікування можливе повне видужання з відновленням порушених функцій. На сьогодні необхідним є перманентне виконання комплексу планових профілактичних щеплень з метою запобігання кору, насамперед дотримання термінів схем вакцинації, з обов’язковим виконанням протиепідемічних заходів в осередку інфекції.
ОСОБЛИВОСТІ ПЕРЕБІГУ КОРУ В ЕПІДСЕЗОНІ 2017-2018 рр. – РОЗВИТОК АСОЦІЙОВАНОГО З ВІРУСОМ КОРУ УРАЖЕННЯ ПЕЧІНКИ
Authors: Smyrnova D. D. , Usachova O. V. , Firulina O. M.
Published: April 2019

Мета – вивчення зв’язку гепатоцитолітичного синдрому, виявленого у хворих на кір в епідемічному сезоні 2017-2018 рр., з вірусною етіологією основного захворювання.

Матеріали і методи. Ретроспективно були вивчені історії хвороби 100 пацієнтів із встановленим діагнозом кору, які перебували на лікуванні у ЗОІКЛ в період з вересня 2017 по березень 2018 рр. Всі пацієнти, за результатами підвищення активності ферменту аланінамінотрансферази (АЛТ), були розділені на дві групи: з підтвердженим цитолізом (Г1, n=54) та з нормальними показниками АЛТ (Г2, n=46).

Результати досліджень та їх обговорення. Загальна кількість ускладнень кору була вища у пацієнтів Г1 (88,8 %). Для цієї групи також була більш характерна гепатомегалія (59,3 %). За результатами загального аналізу крові пацієнтів були визначені непрямі ознаки, що свідчать про спрямованість імунної відповіді на вірус кору. За порівнянням відношення показників лімфоцитопенія/лімфоцитоз у Г1 була виявлена сповільнена противірусна імунна реакція, на відміну від Г2. Оцінка синдрому цитолізу проводилась у порівнянні АЛТ першого біохімічного аналізу на 1-2-у добу (АЛТ-1) та повторного тесту на 5-7-у добу госпіталізації (АЛТ-2) у пацієнтів Г1. Було встановлено, що цитоліз легкого ступеня важкості (АЛТ>в 1-2 рази) швидко знижувався у динаміці: АЛТ-1 72,2 % проти АЛТ-2 46,9 %, на відміну від ураження середнього (АЛТ>2,5-5 разів) та важкого (АЛТ>5-10 раз) ступеня, що зберігався без значних змін і на 7-й день госпіталізації.

Висновки. Сучасна особливість кору – ураження печінки, що реєструється у 54 % випадків. Розвиток реактивного гепатиту пов’язаний з прямою цитопатичною дією вірусу кору. Легкий ступінь підвищення АЛТ та його подальша нормалізація на 5-7-у добу вказують на сприятливий перебіг процесу та швидке відновлення функції органа. При розвитку реактивного гепатиту у хворих на кір сповільнюється швидкість імунної відповіді. Можливо, з цим пов’язана і більша кількість пацієнтів з бактерійними ускладненнями у Г1. Згідно з цими висновками, пацієнтів з кором та реактивним гепатитом слід відносити до групи ризику за розвитком бактерійних ускладнень.
ДЕЩО ПРО ЛЕКСИКУ ЛІКАРІВ
Authors: Kopcha V. S
Published: April 2019

Мета роботи – проаналізувати професійну лексику лікарів на підставу виявлення алогізмів.

Наведено роздуми автора про численні кліше в медичній документації, які не тільки не логічні, але й часто застарілі, подекуди смішні й неграмотні. Пропонуються замінники таких виразів або усунення їх з ужитку.
Alimentação e saúde: a fundamentação científica do guia alimentar para a população brasileira
Authors:   Universidade de São Paulo. Faculdade de Saúde Pública, Louzada Maria Laura da Costa , Canella Daniela Silva ,   Universidade de São Paulo. Faculdade de Saúde Pública, Jaime Patrícia Constante ,   Universidade de São Paulo. Faculdade de Saúde Pública, Monteiro Carlos Augusto ,   Universidade de São Paulo. Faculdade de Saúde Pública
Published: April 2019

O Guia Alimentar para a População Brasileira é um documento oficial do Ministério da Saúde que aborda os princípios e as recomendações de uma alimentação adequada e saudável para a população brasileira, configurando-se como um instrumento norteador de ações de educação alimentar e nutricional e indutor de programas e políticas de saúde no Sistema Único de Saúde (SUS) e em outros setores. Por sua linguagem simples e seu formato compacto, que procurou tornar o conteúdo acessível a toda a população, o Guia, no entanto, não se propôs a trazer uma descrição exaustiva das evidências utilizadas em sua elaboração, nem apresentar uma longa lista de referências no final do documento. Além disso, parte dessas evidências foi publicada posteriormente ao seu lançamento. Portanto, o objetivo do livro é apresentar a fundamentação científica que apoiou a elaboração do Guia Alimentar para a População Brasileira.
Vascular Smooth Muscle Cell Plasticity and Autophagy in Dissecting Aortic Aneurysms
Authors: Clément Marc , Chappell Joel , Raffort Juliette , Lareyre Fabien , Vandestienne Marie , Taylor Annabel L. , Finigan Alison , Harrison James , Bennett Martin R. , Bruneval Patrick , Taleb Soraya , Jørgensen Helle F. , Mallat Ziad
Published: April 2019

Objective—

Recent studies suggested the occurrence of phenotypic switching of vascular smooth muscle cells (VSMCs) during the development of aortic aneurysm (AA). However, lineage-tracing studies are still lacking, and the behavior of VSMCs during the formation of dissecting AA is poorly understood.

Approach and Results—

We used multicolor lineage tracing of VSMCs to track their fate after injury in murine models of Ang II (angiotensin II)–induced dissecting AA. We also addressed the direct impact of autophagy on the response of VSMCs to AA dissection. Finally, we studied the relevance of these processes to human AAs. Here, we show that a subset of medial VSMCs undergoes clonal expansion and that VSMC outgrowths are observed in the adventitia and borders of the false channel during Ang II–induced development of dissecting AA. The clonally expanded VSMCs undergo phenotypic switching with downregulation of VSMC differentiation markers and upregulation of phagocytic markers, indicative of functional changes. In particular, autophagy and endoplasmic reticulum stress responses are activated in the injured VSMCs. Loss of autophagy in VSMCs through deletion of autophagy protein 5 gene (
Atg5
) increases the susceptibility of VSMCs to death, enhances endoplasmic reticulum stress activation, and promotes IRE (inositol-requiring enzyme) 1α-dependent VSMC inflammation. These alterations culminate in increased severity of aortic disease and higher incidence of fatal AA dissection in mice with VSMC-restricted deletion of
Atg5
. We also report increased expression of autophagy and endoplasmic reticulum stress markers in VSMCs of human dissecting AAs.

Conclusions—

VSMCs undergo clonal expansion and phenotypic switching in Ang II–induced dissecting AAs in mice. We also identify a critical role for autophagy in regulating VSMC death and endoplasmic reticulum stress–dependent inflammation with important consequences for aortic wall homeostasis and repair.
Expandable Lattice Electrode Ablation Catheter
Authors: Barkagan Michael , Leshem Eran , Rottmann Markus , Sroubek Jakub , Shapira-Daniels Ayelet , Anter Elad
Published: April 2019

Background:

High-current short-duration radiofrequency energy delivery has potential advantages for cardiac ablation. However, this strategy is limited by high current density and narrow safety-to-efficacy window. The objective of this study was to examine a novel strategy for radiofrequency energy delivery using a new electrode design capable of delivering high power at a low current density to increase the therapeutic range of radiofrequency ablation.

Methods:

The Sphere9 is an expandable spheroid-shaped lattice electrode design with an effective surface area 10-fold larger than standard irrigated electrodes (lattice catheter). It incorporates 9 surface temperature sensors with ablation performed in a temperature-controlled mode. Phase I: in 6 thigh muscle preparations, 2 energy settings for atrial ablation were compared between the lattice and irrigated-tip catheters (low-energy: T
max
75°C/5 s versus 25 W/20 s; high-energy: T
max
75°C/7 s versus 30 W/20 s). Phase II: in 8 swine, right atrial lines were created in the posterior and lateral walls using low- and high-energy settings, respectively. Phase III: the safety, efficacy, and durability at 30 days were evaluated by electroanatomical mapping and histopathologic analysis.

Results:

In the thigh model, the lattice catheter resulted in wider lesions at both low- and high-energy settings (18.7±3.3 versus 12.2±1.7 mm,
P
<0.0001; 19.4±2.4 versus 12.3±1.7 mm,
P
<0.0001). Atrial lines created with the lattice were wider (posterior: 14.7±3.4 versus 9.2±4.0 mm,
P
<0.0001; lateral: 15.8±4.2 versus 5.7±4.2 mm,
P
<0.0001) and required 85% shorter ablation time (12.4 versus 79.8 s/cm-line). While current squared (I
2
) was higher with Sphere9 (7.0±0.04 versus 0.2±0.002 A
2
;
P
<0.0001), the current density was lower (9.6±0.9 versus 16.9±0.09 mA/mm
2
;
P
<0.0001). At 30 days, 100% of ablation lines created with the lattice catheter remained contiguous compared with only 14.3% lines created with a standard irrigated catheter. This was achieved without steam pops or collateral tissue damage.

Conclusions:

In this preclinical model, a novel, high-current low-density radiofrequency ablation strategy created contiguous and durable ablation lines in significantly less ablation time and a comparable safety profile.
Abstract 103: Clinical Process and Outcome Improvements Based on Within Site Communication: Insights from the Patient Navigator Acute Myocardial Infarction and Heart Failure Program
Authors: Albert Nancy M , Gluckman Ty J , McNamara Robert L , Fonarow Gregg C , Malik Adnan , Brindis Ralph G , Lu Di , Negi Smita , Rogers Susan , Mobayed Julie
Published: April 2019

Background:
Team communication about hospital quality efforts in acute myocardial infarction and heart failure (AMI-HF) may affect compliance with hospital transitional care metrics.

Methods:
At 2 years, hospitals (n=35) participating in the Patient Navigator Program completed surveys on 5 types of communication (sharing meeting minutes, regular team meetings or conference calls with team leaders, a shared checklist, and electronic medical record (EMR)-directed communication) supporting program implementation. Results were assessed for association with 3 outcomes (30-day unadjusted AMI-HF readmission and in-hospital risk adjusted AMI death) and 14 processes: left ventricular systolic dysfunction evaluation, prescription of renin-angiotensin system and beta-blocker medications; identifying HF cases pre-discharge; medication reconciliation documentation on admission, discharge and both times [AMI-HF); planned follow-up in 7 days [HF]; documentation of self-care education and when to call healthcare providers [AMI-HF] and documentation of medication instructions, timing, and changes [AMI-HF]). In STEMI and NSTEMI, performance composites, overall defect free care and referral to cardiac rehabilitation were assessed. Univariate analyses were completed.

Results:
There were no differences in process or outcome metrics for sharing meeting minutes, regular team meetings or conference calls with leaders or using a shared checklist. EMR-directed communication was associated with a greater likelihood of discharge medication reconciliation (100% vs 68.4%,
p
=.027) and prescribed medication documentation, 100% vs 66.7%,
p
=.024). Sites that used 2-5 vs 0-1 communication types were more likely to identify patients with HF pre-discharge (100% vs 60%,
p
=.018), perform discharge medication reconciliation (100% vs 66.7%,
p
=.021), complete education documentation (93.3% vs 58.8%,
p
=.041) and medication instruction documentation (100% vs 64.7%, p=.019); but they were less likely to improve STEMI performance composite scores (37.5% vs 76.5%,
p
=.036).

Conclusion:
Team communication via EMR and using 2+ communication methods promoted some process metric improvements. Some communication methods may have had low use and process and outcome metrics that were unchanged may have been underpowered to detect differences.
Abstract 107: The Impact of Out-of-Hospital Cardiac Arrest Patients on Hospital Quality Reporting of Percutaneous Coronary Intervention; Can Prediction Models Do Better?
Authors: Birs Antoinette S , Smith Bryn M , Kearney Kate , Rea Thomas , Maynard Chuck , McCabe James M
Published: April 2019

Objectives:
This study aimed to develop a mortality risk model for percutaneous coronary intervention (PCI) specific to the Out of Hospital Cardiac Arrest (OHCA) population and assess the influence of these patients on currently publicly reported PCI metrics in Washington state.

Methods:
Our study analyzed 331 out of hospital cardiac arrest patients who underwent PCI in Washington state over a 1-year period. Data was obtained over a 2-year period from the Clinical Outcomes Assessment Program (COAP), a PCI public reporting program for Washington hospitals and Cardiac Arrest Registry to Enhance Survival (CARES), a disease-based OHCA registry. Stepwise multivariate logistic regression was used for model development and bootstrapping was performed. Model performance was analyzed using c statistic and the Hosmer Lemeshow goodness of fit tests.

Results:
The OHCA model contains seven predictors of mortality: age, GFR, cardiogenic shock, emergency-salvage priority, witnessed arrest, arrest after 911 arrival, and initial shockable rhythm. The C statistics for mortality prediction of the new OHCA, CathPCI
®
and COAP PCI models were c=.85 (95% CI .81-.90), c=.82 (95% CI .77-.87) and c=.79 (95% CI .74-.84), respectively. Prediction of mortality in OHCA patients undergoing PCI had an overall difference of .029. No hospitals were reclassified in quality performance based on reversal of observed-to-expected mortality ratios when applying the new model to OHCA patients undergoing PCI.

Conclusions:
The new OHCA model predicting PCI mortality in the OHCA population demonstrated excellent discrimination using a combination of pre-hospital and baseline features. This improved on the currently utilized model’s sensitivity and specificity for predicted mortality in the OCHA cohort, but the impact of this population on hospitals’ overall performance for PCI mortality was minimal. Even small changes in metric performance have important implications for hospitals and patients in the era of public reporting.
Abstract 11: Comparative Effectiveness and Safety of Oral Anticoagulants across Baseline Kidney Function
Authors: Yao Xiaoxi , Inselman Jonathan W , Shah Nilay D , Ross Joseph S , Izem Rima , Graham David , Martin David , Thompson Aliza , Southworth Mary R , Siontis Konstantinos C , Ngufor Che G , Nath Karl , Desai Nihar R , Nallamothu Brahmajee , Saran Rajiv , Noseworthy Peter A
Published: April 2019

Background:
Stroke prevention using warfarin is challenging in AF patients with CKD, due to high bleeding risk and difficulties in the INR control. NOACs provide alternative options, but all have greater degrees of renal clearance. This study aimed to compare the outcomes of apixaban, dabigatran, rivaroxaban, and warfarin across the range of kidney function in patients with AF.

Methods:
Using a US administrative database including private insurance or Medicare Advantage patients with linked claims and laboratory data, we identified 34,569 new users of oral anticoagulants with AF and eGFR ≥15 between 10/1/2010-11/29/2017. Stabilized IPTW balanced four treatment groups on 66 baseline characteristics. The primary outcomes included stroke, major bleeding, and mortality. Weighted Cox proportional hazards models compared treatments in the overall population and in each eGFR subgroup, with mortality as a competing risk for stroke and major bleeding.

Results:
The proportion of patients using warfarin increased as the kidney function declined - 26.5%, 30.4%, 34.6%, 40.5%, and 55.0% of patients were prescribed warfarin in eGFR ≥90, 60-90, 45-60, 30-45, 15-30 groups, respectively. In comparison to warfarin, apixaban was associated with a lower risk of stroke, major bleeding, and mortality; dabigatran was associated with a similar risk of stroke, and a lower risk of major bleeding and mortality; rivaroxaban was associated with a lower risk of stroke, major bleeding, and mortality (Figure). When comparing one NOAC to another NOAC, apixaban and dabigatran were associated with a lower risk of major bleeding than rivaroxaban (HR 0.61 [0.51-0.73], p<0.001 for apixaban versus rivaroxaban; HR 0.67 [0.50-0.90], p=0.007 for dabigatran versus rivaroxaban); dabigatran was associated with a higher risk of stroke than apixaban (HR 1.65 [1.11-2.46], p=0.01); there was no difference in mortality. There was no significant interaction between treatment and eGFR categories for any outcome, but the number of patients with low eGFR was small.

Conclusions:
In practice, relative to warfarin, NOACs are progressively less commonly used with increasing degree of renal dysfunction. However, each NOAC was consistently associated with at least equivalent effectiveness and safety compared with warfarin across the range of kidney function.
Abstract 118: Impact of an Early HF Discharge Follow-up Intervention on 30-Day Outcomes in a Veterans Hospital
Authors: Dev Sandesh , Fawcett Janet , Wu Wen-Chih , Schwenke Dawn C
Published: April 2019

Objective:
Rehospitalizations occur in 25% of HF patients. We implemented an intervention to improve HF outcomes by focusing on early post-discharge follow-up. We conducted a pre- and post-intervention analysis to determine if the intervention was associated with improved 30-day HF composite outcome, defined as 30-day all-cause ED visit, all-cause rehospitalization, or death.

Methods:
In 2011, we created an intervention in which the discharge team was asked to refer all HF patients to HF clinic follow-up within 14 days. Patients were given an appointment prior to hospital discharge and received contact information for a HF nurse. In the post-intervention period, patients were seen by a NP or HF cardiologist, whereas in the pre-intervention period patients were seen by any cardiology provider. The study sample consisted of patients with a discharge diagnosis of HF hospitalized within 6 months before (‘pre-intervention’) or within 6 months after the intervention (‘post-intervention’) began. Clinical variables were collected including demographics, vital signs, lab values, and LVEF. We censored hospice patients. Descriptive statistics and incidence of individual and composite outcomes were calculated. Hospital utilization at outside hospitals was not available. We created a Cox proportional hazards model to evaluate the effect of the intervention on the 30-day composite outcome, adjusted for clinical predictors associated with the outcome (p<0.1).

Findings:
261 patients were studied (pre-intervention, n=142; post-intervention, n=119). Patients were male (99%), white (71%), with a mean age of 70 years. 65% of patients had LVEF ≤ 40%. Only BNP was different between the pre- and post-groups, respectively ((median 1212 [IQR, (613-2752)] vs. 990 [IQR, (426-1726]), p=.04)). 40% of intervention group was referred for cardiology follow-up within 7 days versus 12% of the pre-intervention group (p<.001), with medians of 6 days (IQR [5,9)] and14 days (IQR [8,20] p<.001), respectively. There was a trend towards lower unadjusted 30-day composite outcome incidence in the intervention group (p=.15). After adjustment for clinical predictors, the post-intervention period was associated with a reduced hazard of the 30-day composite endpoint (HR 0.56, 95%CI [0.33,0.94], p=.03).

Discussion:
The transitional HF care intervention was associated with a reduced risk of all-cause ED visit, all-cause rehospitalization, or death. This analysis confirms the importance of establishing a systematic follow-up program for all HF patients that bridges the transition from hospital to home.
Abstract 136: Enrollment of Black Individuals in Cardiovascular Clinical Trials: A Meta-Analysis
Authors: Jones Terrell , Madut Deng , Jackson Larry , Green Cynthia L , Thomas Kevin
Published: April 2019

Objectives:
Lack of racial and ethnic diversity in clinical trials (CT) limits the generalizability of results to individuals who have unique cultural, environmental and physiological factors that affect outcomes. Consequently, the NIH and FDA issued directives to include historically underrepresented racial and ethnic groups in research studies. We sought to determine the enrollment of black relative to non-black populations in cardiovascular clinical trials and whether racial enrollment varied across trial characteristics.

Methods:
Clinical trials were identified using PubMed, Embase, and Cochrane. Between 2000-2018, studies were included if they were English language, CT of cardiovascular disease or risk factors and race/ethnicity were reported. Trial characteristics were extracted from the primary manuscript or clinical trials.gov and included: study area, funding source, intervention type, location, sample size, and distribution of female participants. Summary statistics for each study included percentage of blacks enrolled with 95% CI. Meta-analysis of the proportion of black enrollment across relevant CT was conducted to analyze overall estimates of the effect compared to non-black enrollment using an inverse variance weighted random effects model. Additional meta-analyses compared candidate variables that could influence the likelihood of black enrollment. All analyses were performed with SAS version 9.4 (SAS Institute Inc., Cary NC).

Results:
We identified 2501 trials, 85 met inclusion criteria, comprising a total of 159,791 patients: 25,720 black and 134,071 non-black. The percentage of blacks 38.2% (95%CI: 33.0%-43.6%) enrolled was significantly less than non-blacks 61.8% (95%CI: 56.4%-67%). Enrollment differed significantly across study type with peripheral vascular disease enrolling the largest 59.9% (95%CI: 47.3%-71.4%) and cerebrovascular disease the least 25.1% (16.1%-37%). Industry only studies accounted for 41% (35 of 85) of total trials and were less likely 30.3% (95%CI: 22.7%-39.1%), than NIH 40.9% (95%CI: 34%-48.1%), joint NIH/Industry 46.8% (95%CI: 33.3%-60.7%), and non-NIH/Industry 76.6% (95%CI: 38.7%-94.4%) funded studies to enroll black patients. Pharmacotherapy studies 29.3% (23.3%-36.1%) enrolled fewer black patients than behavioral 43.8% (36.9%-51%) and device/other 48.2% (37.5%-59.1%) studies. Black enrollment decreased for non-US based studies, and as a function of decreasing female sex enrollment and increasing sample sizes of studies.

Conclusion:
CTs of cardiovascular disease and risk factors were significantly less likely to enroll blacks when compared to non-black patients. Trial characteristics such as study area, funding source, intervention type, study site location, sample size, female percentage, and mean age had statistically significant impacts on black patient accrual in cardiovascular CTs.
Abstract 140: Predictors of Patient Self-Advocacy (PSA) in Heart Failure (HF)
Authors: Kleman Carolyn
Published: April 2019

Objective:
Patients with heart failure self-manage by communicating with various providers. Knowing what impacts patient communication must inform how providers relate to these chronically ill patients. Patients are becoming more assertive. Providers and organizations are asking them to be more assertive. The American Heart Association literature, “Heart-to-heart: Talking to Your Doctor [Healthcare Provider]” (AHA, n.d.) stresses direct communication.and asking questions which is a form of self-advocacy (AHA, n.d.). Self-advocating, or speaking-up, involves gaining and using knowledge to assertively communicate and make decisions (Brashers, 1999). Investigating what influences PSA in patients with heart failure, who access providers and the system frequently, can help us better understand this evolving behavior. Without PSA interventions cannot be individualized or targeted in ways that patients feel are important and are therefore willing to adhere to. The purpose of this study was to examine the direct and indirect effects of PSA and its predictors of trust in nurses and social support on psychological distress and physical symptoms in patients with chronic heart failure. Seven hypotheses were tested relating to the indirect and direct relationships between variables.

Design:
A cross-sectional, path analysis design was used to test two models. The distal outcomes of psychological distress and physical symptoms were separated into two models. IRB approval was obtained. Surveys were collected from a convenience sample of 80 HF clinic out-patients. (This is the quantitative strand of a mixed methods study. The qualitative strand analysis will be complete at time of conference).

Population Studied:
Eighty adults from one out-patient clinic with a diagnosis of HF for 3+ months who have had at least two visits at the out-patient care clinic participated.

Findings:
Neither of the two models tested fit the study data as hypothesized. A respecified model was tested and fit the data well (chi square 9.452, df 6, p .105, RMSEA .085). Trust in nurses directly influenced PSA knowledge. Social support directly influenced PSA assertiveness. And social support directly influenced depressive symptoms.

Conclusions:
Nurses have a direct relational role in helping patients use knowledge to speak-up. Nurses have a role in helping patients access and take advantage of social support so that patient assertiveness can be enhanced.

Implications:
Trusting providers and social support is important to patient self-advocacy. Interventions designed to increase trust in provider, increase social support and social skills may have a positive impact on a patient’s level of self-advocacy. The outcomes of PSA in patients with heart failure need to be studied further.The outcomes of PSA in patients with heart failure need to be studied further.
Abstract 142: Feel the Burn, PCI Advances Increase Radiation Exposure of Patients
Authors: Lawson William E , Gulino Kathie , Wilbert Lisa , Jaffer Osman , Bonvento Michael , Parikh Puja , Pyo Robert
Published: April 2019

Objective:
Interventional cardiology success in revascularization and structural heart has an unseen cost. Complex, prolonged cases increase exposure of patients (Pts) and staff to ionizing radiation. The increased radiation has direct deterministic effects (air kerma; skin dose) and stochastic effects (air kerma x area product). Fluoro time is also monitored. Individual MD and overall lab perfomance exposure guidelines for the laboratory have been set [peak Skin dose < 5 Gray, Air kerma x Area product (DAP) < 200 Gray*cm
2
, fluoro time < 60 min).

Procedure:
Exposure for cath pts was tracked. MD, pt, anatomic, procedural variables associated with high exposures were identified and specific interventions to minimize radiation exposure identified.

Results:
Over a year period 17.2% of cases [237/1375] received high skin [6.0%; 83/1375] or DAP radiation [17.2%; 237/1375]. No pt sequelae were identified on follow-up for doses as high as 13.251 Gray, 775 Gy*cm2, fluoro time 119.9 min. Fluoro time was not a useful measure; it did not correlate with either skin dose or DAP, reflecting variable use of fluoro compared to cine, pt BMI, differing fluoro rates (ranging from 4 fps to 15 fps). Frequency of high radiation exposure by MD (with over 50 cases/year) ranged from 4.5% - 28.3% of interventions [Skin dose 1.1%-15.4% and DAP 4.5%-28.3%]. Pt risk factors included: morbid obesity, multivessel/multilesion interventions, lesion complexity [particularly calcified lesions and CTOs], complex structural heart procedures. MD factors included: highly angled views, # of cine runs [8.9% (122/1375) > 40 runs, 3.7% (51/1375) > 50 runs, 0.8% 14/1375) > 75 runs], staged procedures versus multivessel/ multilesion procedures, trainee staffing. Default radiation exposure settings of Xray equipment are now set at lower levels acceptable for imaging (MD can modify). MD feedback and interventions to decrease radiation exposure are ongoing, targeting: MD continued case awareness of displayed radiation dose with appropriate staging, use of lowest visually acceptable fluoro rates, shortening and minimizing cine runs where possible, store/map reference images, vary imaging angle and decrease where possible steep angulations, optimal collimation. The MDs who have adopted these practices have the lowest pt exposure rates [skin dose 1.4-5.1%, DAP 4.5-8.6% guideline tracked]. Opportunities for improvement are evident in current practice but also include improved tracking of pt medical treatment related exposure, upgrades in Xray equipment.

Conclusions:
Advances in equipment and MD experience have been offset by the increasing disease complexity of attempted interventions [including CTOs]. Pt factors and MD practice both contribute to optimal radiation safety [ALARA]. MD practice is a key modifiable variable to promote radiation safety, affecting exposure of pts and staff.
Abstract 144: Quality Assurance Measurement of St Jude/Abbott Tendril Pacemaker Leads in Veterans
Authors: Lee Samuel , Kanjerla Kiran , Steele Pamela , Lo Hsincheng , Raitt Merritt , Fletcher Ross , Moore Hans
Published: April 2019

Background:
St Jude/Abbott 1688TC and 2088TC Tendril Pacemaker Leads with a silicone-polyurethane copolymer insulation have been reported to have failure rates as high as 5.7% and 5.2%. The VA National Cardiac Surveillance Program (NCDSP) monitors 45,000 Veterans; many have St Jude/Abbott Leads.

Objective:
Examine the survival rate of the 1688TC and 2088TC Tendril Pacemaker Leads in the VA database as an ongoing QA measure.

Method:
Model and serial numbers, dates of implant, and out of service (OOS) dates among other variables are listed. Records of OOS leads were analyzed for the OOS reason, and the cause of lead failure: noise, fracture, malfunction, insulation breaks, dislodgement and significant changes in impedance and threshold.

Results:
There were 5,550 1688TC Tendril pacemaker leads implanted in 4,140 veterans, for an average of 83 (0-199) months; 185 (3.33%) leads were OOS at an average of 58 (0-152) months. Reasons for OOS were: failures in 69 (1.24%), system upgrades in 51 (0.92%), infections in 55 (0.99%), and other reasons in 10 (0.18%). Of 11,587 2088TC Tendril pacemaker leads implanted in 8,147 veterans for an average of 46 (0-108) months; 224 (1.93%) leads were OOS at an average of 29 (0-92) months. Lead failures occurred in 67 (0.58%), system upgrades in 85 (0.73%), infections in 64 (0.55%), and other reasons in 8 (0.07%). The graph shows the survival rate of the 1688TC and 2088TC Tendril pacemaker leads after implant (excluding upgrades, infections, and other reasons).

Conclusion:
At 108 months follow-up, both leads had comparable survival. Lead failure was found in 1.05% of the 1688TC and 0.58% of the St Jude/Abbott 2088TC Tendril pacemaker leads implanted in veterans, much lower than that in other published reports.
Abstract 149: Identifying the Psychosocial Needs of New Stroke Patients: A Retrospective Chart Review of Stroke Patients with Previous Psychiatric Diagnosis
Authors: Mayorga Lina , Rock Alisa
Published: April 2019

Introduction:
The patient experience for a newly diagnosed stroke patient can be psychologically devastating. Limited research exists on stroke patients with pre-existing psychiatric conditions, including implications on quality of life, outcomes, readmissions, compliance and utilization of resources. The majority of the research focuses on depression post stroke diagnosis or discharge. Stroke patients are known to be vulnerable to psychological issues after a stroke diagnosis. However, we are limited in understanding how the hospital experience is for new stroke patients with preexisting psychiatric illness including: whether or not sufficient support is being provided during their hospital admission; is the underlying psychiatric illness preventing them from meeting functional milestones; and are they prepared for discharge?

Methods:
The study design is a retrospective chart review of newly diagnosed stroke patients with a previous psychiatric diagnosis admitted between January to June 2018. Data on sociodemographic, disease, treatment, assessment and utilization of resources were collected in a retrospective chart tool. Psychiatric variables were collected from consultation and progress notes dictated by psychiatry, social work, care coordination and other care providers.

Results:
We reviewed forty-six charts that met the eligibility criteria. Gender was 56.5% female/43.5% male; average age 72 (age range 41-100) and average length of stay 9 days. Of these patients 39.1% had two or more psychiatric diagnoses. Common psychiatric diagnoses were anxiety (50%), depression (39.1%), “Other” was schizophrenia, bipolar disorder and delirium. Higher rates of substance use, distress, current family conflict and no social support or caregiver concerns were found in this subset of stroke patients.

Conclusion:
Data from this study provides a glance at the psychosocial issues new stroke patients with previous psychiatric history experience. Areas for further research in the realm of education, psychosocial support and distress screening are needed. Results can be used as a foundation for developing and/or refining hospital assessments and may assist those in planning services and resources needed for stroke survivors.
Abstract 156: Cost-Effectiveness Analysis of the Sentinel Cerebral Embolic Protection Device During Transcatheter Aortic Valve Replacement
Authors: Ferket Bart S , Morey Jacob R , Gelijns Annetine C , Moskowitz Alan J , Giustino Gennaro
Published: April 2019

Introduction:
Transcatheter aortic valve replacement (TAVR) has been established as a standard of care for patients with severe aortic stenosis deemed at prohibitive or high risk for surgery. However, stroke remains an unpredictable and devastating complication after TAVR. The Sentinel cerebral embolic protection (CEP) device has been shown to collect thrombus and debris in 99% of patients during TAVR and possibly lowers risk of clinically-overt periprocedural stroke.

Methods:
We performed a cost-effectiveness analysis comparing CEP vs no CEP using a Markov model with 3 health states (stroke-free, post-stroke, death) and simulated an average 83-year old high-risk TAVR patient cohort. Risk of stroke and mortality at 30 days with and without CEP (5.6 vs 9.0 and 1.3 vs 1.8%, respectively) were based on the SENTINEL trial. U.S. healthcare costs, utilities, and long-term survival following TAVR with or without stroke were based on the PARTNER and CoreValve US Pivotal trials. Sentinel device costs were based on the manufacturer’s cost estimate ($2,400). We performed a probabilistic sensitivity analysis accounting for parameter uncertainty and calculated lifetime costs and quality-adjusted life years (QALYs) at a discount rate of 3%.

Results:
CEP increased QALYs of 3.81 by 0.16 (95% CI -0.04 to 0.54) and costs of $232,623 by $7,517 (95% CI $103 to 28,161), yielding an incremental cost-effectiveness ratio of $48,269 per QALY gained. The likelihood that CEP would be considered cost-effective at commonly used thresholds of $50-150k/QALY ranged from 45 to 86% (
Figure
). Results were influenced by procedural stroke risk and efficacy of the device.

Conclusion:
Our results suggest CEP may be considered a cost-effective strategy during TAVR.
Abstract 166: Blood Pressure Variability and Cardiovascular Outcomes in Heart Failure with Preserved Ejection Fraction
Authors: Peri-Okonny Poghni A , Hejjaji Vittal , Malik Ali , Patel Krishna K , Khariton Yevgeniy , Tang Yuanyuan , Spertus John
Published: April 2019

Background:
High blood pressure variability (BPV), independent of mean blood pressure, is associated with increased cardiovascular events in patients with hypertension or chronic kidney disease. Heart failure with preserved ejection fraction (HFpEF) is often managed with aggressive blood pressure control, but the association of BPV with cardiovascular outcomes among patients with HFpEF has not been examined.

Methods:
We performed a
post hoc
analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. BPV was assessed for each patient as the standard deviation of all available systolic blood pressure measurements (SD-SBP) during follow up. A cox regression analysis, adjusting for demographic, clinical, and blood pressure medication and measurement characteristics (Figure), was performed to assess the independent association of BPV with all-cause death and a composite of cardiovascular death and heart failure hospitalization. BPV was modeled with a spline function with the median SD-SBP (9.95) chosen as reference, and as quartiles with the highest quartile (Q4) as reference

Results:
Among 3445 participants at baseline, mean age was 68.6, BMI was 32.1 and 51.5% were female. Over a median follow up of 3.4 years, average SD-SBP was 10.9 mmHg. BPV was associated with the risk of all-cause death [Hazard Ratio (95% CI) vs. Q4: Q1=0.85 (0.65, 1.2) p=0.2, Q2 = 0.75 (0.58, 0.96) p =0.03, Q3 = 0.74 (0.58, 0.93) p=0.01] and composite outcome of cardiovascular death or heart failure hospitalization [Q1 = 0.49 (0.39, 0.63) p < 0.01, Q2 = 0.63 (0.51, 0.77) p<0.01, Q3=0.69 (0.57, 0.83) p<0.01]. The risk of death and the composite outcome appeared to significantly increase as the SD-SBP increased above ~11 mmHg (Figure).

Conclusion:
In patients with HFpEF, the risk of all cause death and a composite of cardiovascular death and heart failure hospitalization significantly increased, as the SD-SBP increased beyond 11 mmHg. This association was independent of mean SBP. Whether reducing BPV is a potential therapeutic target in HFpEF requires further study.
Abstract 170: Worse Patency in Women After Endovascular Peripheral Vascular Intervention
Authors: Ramkumar Niveditta , Suckow Bjoern D , Mackenzie Todd A , Sedrakyan Art , Brown Jeremiah R , Goodney Philip P
Published: April 2019

Objectives:
Women are suspected to have worse outcomes after lower extremity revascularization. We sought to study how patency differed among men and women undergoing endovascular peripheral vascular intervention (PVI).

Methods:
We studied patients in the Vascular Quality Initiative who underwent a PVI (angioplasty, stent, or atherectomy) between January 2010 to October 2016. We excluded all reinterventions on a previously treated artery. The primary exposure was gender (men vs women) and our outcomes were reintervention or occlusion in each artery treated. We studied outcomes through 1-year post-procedure using Kaplan Meier survival analysis and Cox regression, stratified by artery treated. We adjusted for patient demographics and disease characteristics.

Results:
Our cohort included 106,073 eligible arteries treated in 58,247 patients across 66,045 procedures. Among these patients, the mean age was 68 years old, 15% were African-American, and 41% were women. Half (50%) of the arteries were treated with stents, 39% were treated with PTA alone, and 11% were treated with atherectomy. Follow-up data on patency was available in 64% of patients (n=37,442 patients, 67,292 arteries). Women experienced lower reintervention-free survival in the iliac (98.4% vs 98.8%, log rank p=0.01) and femoropopliteal (94.7% vs 95.6%, log rank p<0.001) vascular beds (
Figure
). After adjusted Cox regression, gender difference in the femoropopliteal arteries alone remained statistically significant, where women were 30% more likely to need reintervention to maintain artery patency than men (HR: 1.31, 95% CI: 1.18-1.44). Similarly, women experienced lower occlusion-free survival in iliac (95.0% vs 95.9%, log rank p<0.001) and femoropopliteal (88.5% vs 90.9%, log rank p<0.001) arteries. Again, after adjustment, the gender difference remained statistically significant only in the femoropopliteal arteries, where women were 33% more likely than men to have an artery occlude after intervention (HR: 1.33, 95% CI: 1.16-1.53).

Conclusions:
Women undergoing PVI in the femoropopliteal arteries are more likely to develop an occlusion or need a reintervention in the treated artery within 1-year after intervention. We need further research and improved follow-up data on patency to understand how and why these sex differences arise.
Abstract 171: User Beware: Understanding the Adjusted Estimates of Propensity Score Methods
Authors: Ramkumar Niveditta , Iribarne Alexander , Olmstead Elaine M , DiScipio Anthony , Malenka David J , Mackenzie Todd A
Published: April 2019

Background:
Propensity score methods are used in observational studies to compensate for the lack of random allocation by balancing measured baseline characteristics between treated and untreated patients. Yet default implementations of propensity score methods may lead to contradictory findings. Our goal was to illustrate differences in treatment effect estimates produced using propensity score methods such as matching and inverse probability weighting (IPW).

Methods:
We used data from a retrospective analysis of the Northern New England Cardiovascular Disease Study Group registry that studied reintervention after single internal mammary artery (SIMA) versus bilateral internal mammary artery (BIMA) conduit use in 41,481 coronary artery bypass grafting (CABG) procedures from 1992-2014.

Results:
The mean duration of follow-up was 13.2 (IQR: 7.4-17.7) years. In our standard multivariable Cox regression analysis, the adjusted HR for reintervention was 0.83 (95% confidence interval (CI): 0.75-0.92) in patients receiving BIMA compared to SIMA (Table). The 1:1 propensity matched analysis (HR=0.79, 95% CI: 0.69-0.91) and IPW estimate among the treated (HR=0.83, 95% CI: 0.75-0.92) show a similar protective treatment effect of BIMA use on reintervention. However, the IPW approach for the overall population effect unusually showed no difference between BIMA and SIMA on reintervention-free survival (HR=1.08, 95% CI: 0.94-1.24).

Conclusions and Relevance:
The adjusted HR for reintervention after BIMA versus SIMA use in CABG was remarkably different for the two IPW estimates. This difference is attributed to the population represented by the two IPW approaches- the IPW among the treated estimate represents the effect in the average study population, whereas the IPW in the treated represents the effect in the treated population alone. Determining how the study population is balanced (weighted to look like the overall study population versus treated group) is a large driver of treatment effect, and a key element of propensity score methods. Ultimately, the treatment effect estimate desired should drive the choice of propensity score adjustment method.
Abstract 172: Improving Heart Failure Outcome, a Team Based Approach
Authors: Saadat Mohsen , Mostamand Mariam
Published: April 2019

Description:
About 5.7 million adults in the United States have heart failure (HF), costing the nation an estimated $30.7 billion each year. In the first half of 2017, The Internal Medicine service at San Joaquin General Hospital (SJGH) notices an increase in admissions and emergency room visits for patients with HF. The department moved the HF clinic for cardiology to the primary care clinic and changed the format into a multidisciplinary clinic, to include a wider variety of providers, such as clinical pharmacist, physicians, health coaches, dietician, registered nurse manager and a case manager from the local health plan payer.

Project’s Aim:

• To reduce HF related hospital admissions and emergency room visits.

• To increase adherence to Guideline Directed Medical Therapy (GDMT)

• Increase access to care

• Encourage patient engagement and empowerment

Methods:
Patients with at least one visit to the HF clinic between 8/1/17 to 7/31/18, (n=107) were included in the study. During the same year period there were a total of 958 HF related ED visits and 621 HF related admissions.

Data was collected on the following measures:

• Difference in ED visits before and after a patient’s first visit to the clinic

• Difference in hospital admissions before and after a patient’s first visit to the clinic

• Difference in length of stay (LOS) before and after a patient’s first visit to the clinic

Finding and Conclusion:
Patients with at least one visit to the new HF clinic had:

• 40% reduction in ED visits (P=0.069)

• 63% reduction in admissions (P=0.0001)

• 54% reduction in LOS (P=0.0001)

Future Direction:

• Engaging the two local managed care plans to provide uber/lyft to appointments, pharmacy, and grocery stores

• Leveraging technology, such as: blue tooth wearables, telemedicine/e-consult to improve access

• Utilize available technology within electronic health record to enable virtual care management