bluuebunny/crossref_metadata_2025 huggingface dataset:
Synthesis and Characterization of an Iron-Containing Fatty Acid-Based Ionomer
Authors: Stone David A. , Biswas Atanu , Liu Zengshe , Boddu Veera , Cheng H. N.
Published: April 2019

One of the desirable research goals today is to convert agro-based raw materials into low-cost functional polymers. Among the readily available natural raw materials are the fatty acids that can be obtained from the hydrolysis of plant oils or from the paper industry as byproducts. In this work, a novel iron-containing ionomer has been prepared through the reaction of fatty acids with steel dust or iron powder in the presence of carbon dioxide and water. Characterization has been achieved via 1H and 13C NMR, FT-IR, and size exclusion chromatography. The product has been shown to have an ionomeric structure, consisting of oligomers of fatty acid carboxylates (derived from Diels-Alder reaction) coupled with iron(II) and iron(III) ions (from the oxidation of iron). Because the fatty acid oligomers have low molecular weights, the ionomer easily dissolves in a solvent and can be made into different physical forms, such as liquid, solid, film, or foam.
Changes in Gastric Smooth Muscle Cell Contraction during Pregnancy: Effect of Estrogen
Authors: Al-Shboul Othman A. , Al-Rshoud Hanan J. , Al-Dwairi Ahmed N. , Alqudah Mohammad A. , Alfaqih Mahmoud A. , Mustafa Ayman G. , Jaafar Mohammad
Published: April 2019

It is well known that pregnancy is associated with frequent gastrointestinal (GI) disorders and symptoms. Moreover, previous reports have shown that estrogen, which changes in levels during pregnancy, participates in the regulation of GI motility and is involved in the pathogenesis of various functional disorders in the stomach. The aim of the current study was to explore the changes in the expression of estrogen receptors (ERs) and examine the effect of estrogen on nitric oxide- (NO-) cyclic guanosine monophosphate (cGMP) pathway and thus relaxation in gastric smooth muscle cells (GSMC) during pregnancy. Single GSMC from early-pregnant and late-pregnant Sprague-Dawley rats were used. Protein and mRNA expression levels of ERs were measured via specifically designed enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR), respectively. NO and cGMP levels were measured via specifically designed ELISA kits. Effect of estrogen on acetylcholine- (ACh-) induced contraction of single GSMC was measured via scanning micrometry in the presence or absence of the NO synthase inhibitor,N-nitro-L-arginine (L-NNA), or guanylyl cyclase inhibitor, 1H-[1,2,4]oxadiazolo[4,3,-a]quinoxalin-1-one (ODQ). Estrogen increased both NO and cGMP levels and their levels were greater in early compared to late pregnancy. Expression of ERs was greater in early compared to late pregnancy. ACh induced greater contraction of GSMC in late pregnancy compared to early pregnancy. Estrogen inhibited ACh-induced contraction in both periods of pregnancy. Importantly, pretreatment of GSMC with either L-NNA or ODQ abolished estrogen inhibitory action on muscle contraction. In conclusion, GSMC contractile behavior undergoes drastic changes in response to estrogen during pregnancy and this might explain some of the pregnancy-associated gastric disorders.
Increased Serum Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) Levels in FSGS: A Meta-Analysis
Authors: Lee Jiwon M. , Yang Jae Won , Kronbichler Andreas , Eisenhut Michael , Kim Gaeun , Lee Keum Hwa , Shin Jae Il
Published: April 2019

Introduction. The soluble urokinase-type plasminogen activator receptor (suPAR) has been found to be elevated in primary focal segmental glomerulosclerosis (pFSGS). However, its usefulness as a biomarker for FSGS remains controversial. We conducted a meta-analysis aiming at investigating the significance of suPAR in diagnosing pFSGS. Methods. Electronic databases (PubMed and EMBASE) were searched to identify studies comparing suPAR levels in FSGS patients and controls, from the earliest available date to May 1, 2018. A random-effects model with standardized mean difference (SMD) was used for meta-analyses. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale. Results. A total of 187 articles were screened, and the final analysis included 13 articles. In comparison to healthy controls, serum suPAR levels were significantly increased in pFSGS patients (SMD, 1.07, 95% confidence interval (CI) 0.65 to 1.48; participants=814; studies=9, I2=85%). Higher suPAR levels were also found in patients with pFSGS compared to those with minimal change disease (SMD 0.53, 95% CI 0.22 to 0.84). Of note, such a difference was not found in pediatric groups (SMD 0.42, 95% CI -0.13 to 0.96) while it was more evidently noted in adult patients (SMD 1.32, 95% CI 0.90 to 1.74). Serum suPAR levels did not differ between pFSGS patients in remission compared to those in active proteinuric state (SMD 0.29, 95% CI -0.30 to 0.88). Comparison with membranous nephropathy and IgA nephropathy showed no significant difference. Conclusions. Our meta-analysis demonstrated that, in comparison to both healthy controls and controls with minimal change disease, suPAR levels were significantly higher in adult patients with pFSGS. suPAR levels did not differ between pFSGS patients during the initial period of diagnosis and those in remission.
Chairside Restorations of Maxillary Anterior Teeth with CAD/CAM Porcelain Laminate Veneers Produced by Digital Workflow: A Case Report with a Step to Facilitate Restoration Design
Authors: Bayazıt Elif Öztürk , Karabıyık Murat
Published: April 2019

Since the introduction of porcelain laminate veneers in the early 1980s, the anterior esthetic rehabilitation with PLVs has been provided with a conventional restorative technique for many years. Recently, a new concept named digital workflow has been raised that will lead to the abandonment of conventional procedures during the fabrication of PLVs. Digital workflow is a new concept facilitating applications by adapting digital systems to clinical applications, including intra- and extraoral photographs, diagnostic wax-up, mock-up, intraoral camera, and use of the CAD/CAM device. The aim of this case report is to describe the clinical procedures of porcelain laminate veneers using digital workflow with a facilitating step in a single session and to evaluate the PLVs after one year of clinical service.
Antioxidative Property and Molecular Mechanisms Underlying Geniposide-Mediated Therapeutic Effects in Diabetes Mellitus and Cardiovascular Disease
Authors: Li Ning , Li Ling , Wu Haiming , Zhou Heng
Published: April 2019

Geniposide, an iridoid glucoside, is a major component in the fruit of Gardenia jasminoides Ellis (Gardenia fruits). Geniposide has been experimentally proved to possess multiple pharmacological actions involving antioxidative stress, anti-inflammatory, antiapoptosis, antiangiogenesis, antiendoplasmic reticulum stress (ERS), etc. In vitro and in vivo studies have further identified the value of geniposide in a spectrum of preclinical models of diabetes mellitus (DM) and cardiovascular disorders. The antioxidative property of geniposide should be attributed to the result of either the inhibition of numerous pathological processes or the activation of various proteins associated with cell survival or a combination of both. In this review, we will summarize the available knowledge on the antioxidative property and protective effects of geniposide in DM and cardiovascular disease in the literature and discuss antioxidant mechanisms as well as its potential applications in clinic.
An Energy Efficiency Study of Web-Based Communication in Android Phones
Authors: Ayala Inmaculada , Amor Mercedes , Fuentes Lidia
Published: April 2019

Currently, mobile devices are the most popular pervasive computing devices, and they are becoming the primary way for accessing Internet. Battery is a critical resource in such personal computing gadgets, network communications being one of the primary energy consuming activities in any mobile app. Indeed, as web-based communication is the most used explicitly or implicitly by mobile devices, HTTP-based traffic is the most power demanding one. So, mobile web developers should be aware of how much energy demands the different web-based communication alternatives. The goal of this paper is to measure and compare the energy consumption of three asynchronous HTTP-based methods in mobile devices in different browsers. Our experiments focus on three HTTP-based asynchronous communication models that allow a web server to push data to a client browser through a HTTP/1.1 interaction: Polling, Long Polling, and WebSockets. The resulted measurements are then analysed to get more accurate understanding of the impact of the selected method, and the mobile browser, in the energy consumption of the asynchronous HTTP-based communication. The utility of these experiments is to show developers what are the factors and settings that mostly influence the energy consumption when different web-based asynchronous communication methods are used, helping them to choose the most beneficial solution if possible. With this information, mobile web developers should be able to reduce the power consumption of the front-end of web applications for mobile devices, just selecting and configuring the best asynchronous method or mobile browser, improving the performance of HTTP-based communication in terms of energy demand.
Trapezoidal Type Fejér Inequalities Related to Harmonically Convex Functions and Application
Authors: Turhan Sercan
Published: April 2019

Some authors introduced the concepts of the harmonically arithmetic convex functions and establish some integral inequalities of Hermite Hadamard Fejér type related to the harmonically arithmetic convex functions. In this paper, a mapping M(t) is considered to get some preliminary results and a new trapezoidal form of Fejér inequality related to the harmonically arithmetic convex functions. By using a mapping M(t), the new theorems and corollaries are obtained. Taking advantage of these, applications were given for some real number averages.
Case Report of Gastrointestinal Bleeding in an Adult with Chronic Visceral Acid Sphingomyelinase Deficiency
Authors: Cassiman David , Libbrecht Louis , Meersseman Wouter , Wilmer Alexander
Published: April 2019

Introduction. Acid sphingomyelinase deficiency (ASMD, also known as Niemann-Pick Type A and Type B disease) is a rare, inherited metabolic disorder. Liver-related issues, including cirrhosis and variceal haemorrhage, are a leading cause of early mortality in individuals with chronic forms of ASMD. Due to the rarity of this lysosomal storage disorder, there can be a lack of awareness that adults with chronic ASMD disease are at significant risk of cirrhosis, portal hypertension, and variceal bleeding. This case highlights an unusual presentation of recurrent variceal bleeding in an adult with cirrhosis and portal hypertension due to chronic visceral ASMD. Case Presentation. A patient with severe splenomegaly was diagnosed with ASMD at age of 25. At age 64 they had multiple hospital admissions for hematochezia (originally diagnosed as ischemic colitis) accompanied by hypotension (blood pressure 91/45 mmHg), anemia (hemoglobin 8.5g/dL, ref 12-16; INR 1.4, ref ≤1.2), and mild renal insufficiency (creatinine 1.33mg/dL, ref 0.51-0.95). Colonoscopy did not reveal a source of bleeding. Computerized tomography scanning imaging showed diffuse venous collaterals and ascites. Arteriographies during subsequent episodes of bleeding were negative for active arterial intestinal bleeding. Recurrent gastrointestinal bleeding was found to originate from a varicose vein cluster connected to the right iliac vein and the superior mesenteric vein, located in the submucosa of a small intestinal loop. Multiple varices were secondary to portal hypertension in the context of cirrhosis. The patient died from recurrent variceal bleeding that exacerbated liver failure worsened by pneumonia and hypovolemic and septic shock. Conclusions. The variceal bleeding in this patient was atypical in that it originated from venous collaterals bleeding into the small intestine rather than the more typical gastroesophageal varices observed in ASMD. With long standing liver dysfunction and gradual development of portal hypertension, intestinal varices rather than occult intestinal bleeding due to ischemia should be considered in ASMD patients presenting with either hematochezia or hematemesis.
St. Gallen/Vienna 2019: A Brief Summary of the Consensus Discussion on the Optimal Primary Breast Cancer Treatment
Authors: Balic Marija , Thomssen Christoph , Würstlein Rachel , Gnant Michael , Harbeck Nadia
Published: April 2019

This year, the St. Gallen Consensus Conference on early breast cancer treatment standards took place for the third time in Vienna, Austria, which is where the next conference will also take place (next date: March 17–20, 2021!). Once again, more than 3,000 participants from over 100 countries came together, and, overall, the 2019 St. Gallen/Vienna conference was a great success. After 3 days of reviews conducted by a global faculty concerning the most important evidence published in the last 2 years, the Consensus votes’ challenge was to define the impact on routine everyday practice. This year, the conference’s main theme was the optimization of early breast cancer therapies by assessment of the magnitude of benefit, aiming at further refinement when compared to de-escalation and escalation, which were mainly the topic of the 2017 conference. Patient empowerment and the importance of shared decision-making were particularly emphasized. The traditional panel votes were moderated by Eric Winer from Harvard, and for the most part, they managed to clarify most of the critical questions. This brief report by Editors of Breast Care summarizes the results of the 2019 international panel votes with respect to locoregional and systemic treatment as a quick news update for our readers, but it expressly does not intend to replace the official St. Gallen Consensus publication that will follow shortly in Annals of Oncology.
ПЕРЕБІГ І НАСЛІДКИ ВАГІТНОСТІ У ВІЛ-ПОЗИТИВНИХ ЖІНОК З HCV-ІНФЕКЦІЄЮ
Authors: Matvisiv M. V.
Published: April 2019

Проблема HCV-інфекції у вагітних набуває особливої актуальності за умов епідемії ВІЛ/СНІДу в Україні. Оскільки спостерігається тенденція до зростання кількості вагітних, інфікованих ВІЛ та парентеральними гепатотропними вірусами, збільшується ризик їх вертикальної передачі [1].

Мета роботи – проаналізувати частоту і характер акушерсько-перинатальних ускладнень, внутрішньоутробне інфікування плода у ВІЛ-позитивних вагітних з різними формами HСV-інфекції.

Пацієнти і методи. Спостерігали за перебігом та наслідками вагітності у 30 ко-інфікованих вірусами гепатиту С та ВІЛ (HCV+ВІЛ) вагітних. Групою порівняння служили 102 вагітні, інфіковані НСV з негативним ВІЛ-статусом.

Для верифікації HСV-інфекції визначали серологічні маркери методом ІФА та вірусне навантаження методом ПЛР в кожному триместрі вагітності. Дітей обстежували на 3-й та 6-й місяці життя, а за необхідності – в 12, а на анти-НСV – у 18 місяців. При наявності клінічних показань (жовтяниця, гепатолієнальний синдром) діти обстежувалися раніше.

Результати досліджень та їх обговорення. Серед вагітних з ВІЛ-позитивним статусом реплікативні форми діагностували у 53,3 % жінок, а латентні – у 46,7 %. У вагітних з негативним ВІЛ-статусом реплікативні форми НСV-інфекції мали місце у 60,8 % жінок, а латентні – у 39,2 %.

Частота патологічних станів під час вагітності залежала від клінічної форми хвороби і ВІЛ-статусу матері та була вищою у жінок з позитивним ВІЛ-статусом і реплікативними формами НСV-інфекції, ніж з латентними (р˂0,05, р˂0,001).

Ускладнений перебіг пологів вірогідно частіше був у жінок з реплікативними формами і позитивним ВІЛ-статусом, ніж з негативним (р˂0,05). Такі ускладнення, як стрімкі пологи та розрив пологових шляхів, частіше діагностували у жінок без ВІЛ-інфекції (р˂0,05), що повʼязано із значно меншою частотою проведення їм кесарського розтину.

Частота репродуктивних втрат вища у ко-інфікованих ВІЛ, ніж у жінок без ВІЛ-інфекції і складала 23,3 % проти 4,9 % відповідно, а частота вродженої HСV-інфекції становила 13,3 % проти 1,9 %.

У жінок з латентними формами ХГС як з позитивним, так і з негативним ВІЛ-статусом не зареєстровано випадків народження інфікованих дітей.

Висновки. HCV-інфекція є причиною акушерських і перинатальних ускладнень, внутрішньоутробного інфікування плода. Частота акушерсько-перинатальних ускладнень вища у ко-інфікованих вагітних HCV+ВІЛ, ніж у жінок з моно-інфекцією. У жінок з ВІЛ-позитивним статусом частота репродуктивних втрат в 4,7 разу вища, а частота вродженої HСV-інфекції – в 7 разів.
ТЕРМОСЕМІОТИКА ХРОНІЧНОГО ТОНЗИЛІТУ
Authors: Andreichyn Iu. M. , Kopcha Yu. V. , Loyko I. I.
Published: April 2019

Мета дослідження – з’ясувати особливо­сті інфра­червоного випромінювання у підщелепній ділянці, на долонях, у проекції надколінків та у центрі плесна хворих на хронічний тонзиліт і зіставити отримані результати з відповідними показниками здорових людей.

Пацієнти і методи. Обстежено 32 здорових волонтерів з нормальною температурою тіла, які не мали патології мигдаликів, віком від 20 до 56 років, середній вік – (28,3±2,3) року. З них 19 чоловіків (59,4 %), і 13 жінок (40,6 %), середній вік з урахуванням статі виявився приблизно однаковим, у чоловіків – (30,2±3,3) року, у жінок – (26,4±3,6) року (Р>0,05).

Досліджувана група хворих на хронічний тонзиліт у стадії загострення складалась із 23 людей. З них у 9 встановлено компенсовану, а в 14 осіб – декомпенсовану форму запалення.

Для визначення особливостей інфрачервоного випромінювання використовували медичний тепловізор ТІ-120. Аналіз термограм виконували за допомогою програмного пакету «IRSee Software».

Статистичну обробку даних виконали на персональному комп’ютері за допомогою електронних таб­лиць «Microsoft Excel» і пакету прикладних програм «Statistica for Windows» v. 6.0, StatSoft Inc. (США).

Результати досліджень та їх обговорення. Встановили, що нормальними термографічними ознаками шкірних покривів є симетричність, гомогенність та ізотермія. Допустима фізіологічна термоасиметрія становить 0,3 °С з переважанням як у лівий, так і в правий бік. Суттєвих відмінностей між чоловіками і жінками немає.

При хронічному тонзиліті у фазі загострення термотопограма передньої частини шиї також засвідчувала помірний загальний «розігрів» шиї, симптом «коміра», де на тлі незначної гіпертермії виявлялися окремі, яскравіші вогнища світіння в проекції лімфатичних вузлів, в основному підщелепних (перепад температури – ∆Т=0,6 °С). Зазначене повною мірою стосувалося і центра долоней, розігрів яких був вищим, ніж у нормі (Р<0,05). Разом з тим, середні температурні показники проекції надколінків статистично вагомо перевищували значення здорових людей – (35,4±0,8) проти (32,5±0,6) °С (Р<0,01). Подібним чином змінювалася теплова картина центра плесен. Зокрема, при хронічному тонзиліті у фазі загострення встановили значний розігрів зазначеної ділянки порівняно зі здоровими людьми – (35,1±0,8) проти (28,4±0,5) °С (Р<0,05).

Висновки. При хронічному тонзиліті у фазі загострення встановлено помірний загальний розігрів шиї і центра долонь, розігрів яких був вищим, ніж у нормі. Водночас середні температурні показники проекції надколінків і центра плесен перевищували значення здорових людей (Р<0,05). Гіпертермію надколінків і центра плесен можна вважати характерною ознакою хронічного тонзиліту у фазі загострення. Ступінь компенсації хронічного запалення мигдаликів можна оцінити за рівнем перепаду температур над проекцією надколінків і нижньою частиною стегон та у центрі плесен і сусідніми ділянками.
What is the importance of vaccine hesitancy in the drop of vaccination coverage in Brazil?
Authors: Sato Ana Paula Sayuri
Published: April 2019

The successful Programa Nacional de Imunizações do Brasil (Brazilian National Immunization Program) has been experiencing a major challenge with regard to vaccination coverage for children, which has been dropping. Several aspects are related, but certainly vaccine hesitancy has been strengthening itself as one of the main concerns of Brazilian public administrators and researchers. Vaccine hesitancy is the delay in acceptance or refusal despite having the recommended vaccines available in health services, being a phenomenon that varies over time, over location and over types of vaccines. Hesitant individuals are between the two poles of total acceptance and refusal of vaccination. Vaccine hesitancy is nothing new in European and North-American countries, and even in Brazil, it has been studied even if under another name. The drop of vaccination coverage observed from 2016 on reiterates the relevance of the theme, which must be better understood through scientific research.
Abstract 101: The Development and Initial Validation of PROMIS-Plus-HF Profile Measure
Authors: Ahmad Faraz S , Kallen Michael A , Schifferdecker Karen E , Carluzzo Kathleen L , Yount Susan E , Gelow Jill M , McCullough Peter A , Kimmel Stephen E , Fisher Elliot S , Cella David
Published: April 2019

Background:
Bringing together generic and heart failure (HF)-specific items in a publicly-available, patient-reported outcome measure may facilitate better health status comparisons across groups and within individuals longitudinally in learning health systems and clinical research studies.

Methods and Results:
We performed a mixed-methods study to develop and validate the PROMIS
®
-Plus-HF profile measure, a HF-specific instrument based on the generic The Patient-Reported Outcomes Measurement Information System (PROMIS). We conducted eight focus groups with 61 HF patients and phone interviews with 10 HF clinicians. The measure was developed via an iterative process of reviewing existing PROMIS items and developing and testing new HF items. In 600-patient sample, we estimated reliability (internal consistency; test-retest, with n=100 participants). We conducted validity analyses using Pearson
r
and Spearman
rho
correlations with Kansas City Cardiomyopathy Questionnaire (KCCQ) subscores. In a longitudinal sample, we performed responsiveness testing (paired t-tests) with 75 HF patients receiving interventions with expected health status improvement. The PROMIS-Plus-HF measure comprises 86 items (64 existing; 22 new) across 18 domains. Internal consistency reliability (Cronbach’s alpha) coefficients ranged from 0.52-0.96, with alpha≥0.70 in 12/17 domains. Test-retest intraclass correlation coefficients were ≥0.90. Correlations with KCCQ subscores supported expected convergent (
r/rho
>0.60) and divergent validity (
r/rho
<0.30). In the longitudinal sample, 10/18 domains had improved (P<0.05) scores from baseline to follow-up.

Conclusions:
The PROMIS-Plus-HF profile measure—a complete assessment of physical, mental, and social health—exhibited good psychometric characteristics and may facilitate patient-centered care and research. Subsets of domains, or the entire measure, can be used, depending on the clinical or research purpose.
Abstract 105: Improving Compliance and Follow-Up for Chemotherapy-Induced Heart Failure in an Urban Underserved Tertiary Hospital
Authors: Al-Sadawi Mohammed , Singh Kurnvir , Capric Violeta , Mohiuddin Amena , Haddadin Michael , Shaikh Shakil , Bukharovich Inna
Published: April 2019

Background:
Chemotherapy-induced cardiomyopathy and heart failure are major complications of cancer therapy and can result in significant morbidity and mortality. Unfortunately, there is a high risk of poor compliance and loss to follow-up in underserved areas.

Objective:
Create a pathway to improve detection and management of chemotherapy-induced cardiotoxicity and heart failure in patients undergoing chemotherapy treatment in an urban underserved hospital.

Description:
The project is performed at Kings County Hospital, a major cancer treatment center in Brooklyn, NY. Our findings indicate that over the past five years, patients with chemotherapy-induced cardiomyopathy were lost to follow-up with outpatient cardiology services. Therefore, we developed and applied a new collaborative protocol for patients who were diagnosed with any cancer undergoing treatment complicated by cardiomyopathy. The protocol is as follows; Firstly, patients are sent for a multigated acquisition (MUGA) scan prior to beginning chemotherapy, and every three months thereafter over the course of their chemotherapy treatment. The reading physician then identifies all patients with a 10% or more reduction in ejection fraction between MUGA scans, and notifies the Heart Health Center at Kings County Hospital to contact the patient with an appointment with cardiology services. At the Heart Health Center, the patient is then counseled on guideline-recommended treatment for heart failure. Further follow up with the nurse practitioner is done for medication reconciliation, education regarding activity, weight monitoring, dietary intake, and warning symptoms for heart failure exacerbations. The patient will receive follow-up with a nutritionist for guideline directed dietary recommendations for heart failure and social work services to ensure appropriate social conditions and support. The oncology service will monitor if the patient has followed up with outpatient cardiology before continuing chemotherapy. If the patient was lost to follow up, oncology will notify the Heart Health Center and assist with providing the patient with an appointment.

Conclusions:
We aim to improve compliance for follow up and guideline directed management for chemotherapy-induced heart failure in an urban underserved tertiary hospital.
Abstract 106: Predicting Pulmonary Hypertension Readmission Using Machine Learning Models
Authors: Bhattacharya Priyanka T , Bhattacharya Shubhadeep T , Hameed Asif A , Chirinos Julio A , Gimotty Phyllis , Chatterjee Saurav , Giri Jay S , Kawut Steve M , Mazurek Jeremy A
Published: April 2019

Objectives:
Pulmonary hypertension (PH) is increasingly recognized but understudied. We sought to determine predictors of 30-day readmission after PH-related hospitalization using Driverless Artificial Intelligence (DAI) algorithm.

Methods:
We utilized the 2012-2014 Healthcare Cost and Utilization Project Nationwide Readmission Database (NRD) that accounts for weighted estimates of roughly 35 million discharges in the United States. Adult patients with primary ICD-9-CM diagnosis codes of 416.0 and 416.8 for primary and secondary PH with an index admission and any readmission within 30-days of the index event were identified. We assessed predictors of all cause 30-day readmission from clinical, hospital and 29 AHRQ comorbidity measures using predictive modeling to provide interpretable risk factors globally at population level and locally associated with each discharge. The risk prediction model was developed using DAI algorithm and results compared to models based on LIME GLM, Random Forest, and Decision Tree. Overall model performance was assessed using concordance statistic.

Results:
Data from patients with 14,659 admissions and 2797 30-day readmissions were used to train the model. After data processing, the final model included 3674 variables. The Random Forest model had the best performance with c-statistic of 0.70 and surrogate models compared at AUCs of 0.51(Decision Tree), 0.62 (LIME) and (DAI) 0.59. Global features that mainly important to the overall prediction of DAI model were deficiency anemia, APR-DRG severity risk, APR-DRG mortality risk, renal failure and CHF.

Conclusion:
Using predictive models with high predictive power, interpretable risk factors and prediction accuracy may enable health care systems to accurately target high-risk PH patients and prevent recurrent readmissions.
Abstract 111: External Validations of Clinical Predictive Models for Patients with Sudden Cardiac Arrest
Authors: Carrick Richard T , Lundquist Christine M , Brown Kristen , Park Jinny G , Janes William A , Kent David M , Wessler Benjamin S
Published: April 2019

Background:
Sudden cardiac arrest is associated with high morbidity and mortality. A number of clinical predictive models (CPMs) have been introduced to help with patient-specific prognostication of survival and neurologic outcomes. Here, we evaluate the performance of these CPMs with attention to key variables and models with rigorous validation.

Methods:
We performed a systematic review and citation search of cardiac arrest CPMs in the Tufts Predictive Analytics and Comparative Effectiveness (PACE) CPM Registry and identified external validations of these models through September 2018. We extracted information on CPM performance from both original reports and external validations. For external validations, we calculated the percent change in discrimination.

Results:
We identified 65 unique cardiac arrest CPMs (median n=611, IQR=781) published between 1981 and 2018. Thirty-eight of the 65 models (58%) reported a c-statistic (ROC AUC) (median=0.82, IQR=0.09). The median number of predictive variables was 4 (IQR=3), and the three most common variables were 1) initial cardiac rhythm (n=41 of 65; 63%), 2) age (n=33 of 65; 51%), and 3) witnessed arrest (n=24 of 65; 37%). We identified external validations for 26 of 65 (40%) CPMs. All validations (n=44) reported discrimination, but only 21 of 44 (48%) validations reported information regarding calibration. Of the CPMs that reported discrimination and were externally validated at least once (n=15), we noted a median percent change in discrimination of -1.9% (IQR = 11.3%). The three most rigorously validated cardiac arrest CPMs were 1) the OHCA score (n=5, median AUC=0.79), 2) the CAHP score (n=3, median AUC=0.85), and 3) the GO-FAR score (n=3, median AUC=0.82).

Conclusions:
While few cardiac arrest CPMs have been externally validated, those that have demonstrate stable discriminatory power.
Abstract 117: Improving Efficiency in a Cardiac Catheterization Laboratory
Authors: Denktas Ali E , Prasad Pooja , Kenyon Shannon , Petersen Laura A
Published: April 2019

Background:
The cardiac catheterization lab (CCL) can be a fast-paced and unpredictable setting, as the staff must balance inpatient, emergent, and outpatient cases, which can make the CCL susceptible to inefficiencies. The goal of this project is to improve the efficiency of the CCL by reducing unnecessary patient wait times.

Methods:
Lean and Six Sigma methods were used in this project. Outpatients were timed from the point that they entered the waiting area of the cardiology unit to be checked in to the point that they left the CCL after recovering from the procedure. This was a convenience sample; it does not represent all outpatients that entered the CCL during the collection period, and not all patients were consecutive. The major stages of the patient experience in the CCL were mapped to include value and non-value adding steps.

Results:
We collected data on 89 outpatients presenting to the Michael E. DeBakey VA Medical Center CCL for elective procedure between June 20, 2018 to October 30, 2018. In the current state, patients are asked to come at the same time the morning of their procedure. The first patient who arrived in the morning would wait an average of 58 minutes for their procedure (n=36), the second patient 110 minutes (n=26), the third 188 minutes (n=17), and the fourth patient 240 minutes (n=7). The process mapping revealed that the largest contributors to wait time were: waiting upon arrival to be checked in, (28.9% of total time 37.3/129), waiting before nurse prep (11.1%, 14.4/129), waiting in the holding area after nurse prep (52%, 67.1/129), and waiting during the procedure (7.9%, 10.2/129). Patient timings additionally revealed that turnover rate of rooms in the CCL was not heavily influenced by janitorial delays. Time spent cleaning the room after a procedure was less than 20% of the total turnover time (10.8/57.7), whereas the majority of the turnover time consisted of the room being unused.

Conclusion:
We found that patient arrival order determined total wait time, waiting in the holding area after nurse prep contributed most to total patient wait time, and janitorial delays did not heavily influence turnover rate. In our next step in this work, we will design a ranking system that allows clinicians to rate the likelihood that their patient will undergo an intervention to allow staggering of scheduling patients. Currently, all patients are asked to come at the same time in the morning, which leads to 4 hour wait times for the fourth patients that arrive. Instead, the CCL can use this ranking system to stagger patients throughout the morning so that more complex interventional cases are scheduled last and those corresponding patients come later in the morning/wait less throughout the day. The next steps of this project include implementing proposed recommendations with input and guidance from the CCL team and measuring patient wait times after interventions are implemented.
Abstract 125: Predictors of Positive Radionuclide Myocardial Perfusion Imaging Within 2-Years of a Normal Study: Results From The Veterans Health Administration
Authors: Fernandes Marcelo , Rivera Manuel , Grevious Salih , Vincent Louis , Clauss Stephanie , Marzouka George , Chakko Simon
Published: April 2019

Background:
Coronary atherosclerosis is a dynamic disease with sudden and unpredictable bouts of progression. According to the most recent appropriateness use criteria (AUC), repeat testing within 2-years of a normal MPI is rarely appropriate for asymptomatic patients or in those with stable symptoms. Nonetheless, numerous patients with or without symptoms undergo repeat testing. Predictors of reversible ischemia on MPI within 2-years of a normal study has not been evaluated.

Methods:
After IRB approval, records from veterans who underwent multiple MPI stress testing within 2-years of a negative MPI, between 2013 and 2016, at our VA Medical Center were accessed and variables of interest collected. A multivariate logistic regression analysis was performed to determine predictors of reversible ischemia on repeat MPI.

Results:
We identified a total of 239 veterans with repeat stress MPI within 2-years of a prior negative MPI. The median age was 65, with 35% (83 of 239) having a history of clinical ASCVD. The median interval between tests was 14 months [IQR, 10 to 18]. Nearly 17% (41 of 239) of repeat tests were positive. Multivariate regression analysis failed to find an association between reversible ischemia on repeat MPI and our variables of interest as displayed in Table 1.

Conclusion:
Our study was unable to find a relationship between any traditional risk factors for ASCVD, including new symptoms, and the development of reversible perfusion defects on MPI within 2-years of a normal study. Further studies are needed to help identify those patients who would most benefit from a repeat MPI.
Abstract 129: Implications of Incorrect Documentation and Coding of Troponin Elevation
Authors: Gopalakrishnan Lakshmi , Kumar Varun , Khosla Sandeep
Published: April 2019

Background:
Though clinicians provide appropriate care by clinically differentiating between acute myocardial infarction (AMI) and non-thrombotic cause of troponin elevation (NTTE), documentation and appropriate coding of the same can have implications on hospital level outcome metrics, accreditation and public reporting for quality of care. We aim to evaluate the implications of incorrect coding of NTTE.

Methods:
This is a single-center retrospective analysis of 465 patients discharged with a principle ICD-10 diagnosis code of I21.4 or I21.A1 between January 2017 to December 2018. All charts were reviewed, including admission notes, cardiology consult notes and discharge summaries relevant to obtain discharge medications restricted to dual antiplatelet therapy. Of the total 465 patients that were reviewed, NTTE were separated from patients with AMI based on The Fourth Universal Definition of Myocardial Infarction.

Results:
Of the total 465 patients who were coded as Non-ST Elevation MI (NSTEMI), 54.41% of patients were discharged on dual antiplatelet therapy (DAPT) which is below the 65% criteria for GWTG-CAD 2019 Mission Lifeline Recognition. However, 25.16% of these patients had NTTE and were incorrectly grouped under NSTEMI coding category. Upon exclusion of these patients, the DAPT measure improved to 72.7%.

Implication:
Reflex documentation and coding of all elevated troponin as NSTEMI could lead to incorrect and unintentional inclusion of NTTE into AMI metrics. This could contribute to penalties such as those associated with CMS’ Hospital Readmission Reduction Program and 30-day AMI Mortality Rate as many of these patients with NTTE often have other underlying comorbidities that could result in frequent hospitalizations and/or mortality. Losing out on national accreditation and hospital compare stars could negatively impact hospital inpatient volume and reimbursement.

Conclusion:
Educating clinicians about the appropriate documentation of NTTE as “troponin elevation secondary to…” and coding for the cause of troponin elevation could help in the true assessment and reflection of quality of care provided.
Abstract 132: Integrated Risk Factor Management in Patients with Coronary Artery Disease: Insights from the Angina Prevalence and Provider Evaluation of Angina Relief Study
Authors: Hejjaji Vittal , Gosch Kensey , Breeding Tracie , Jones Philip G , Spertus John A , Arnold Suzanne V
Published: April 2019

Introduction:
Effective management of cardiovascular risk factors is the foundation of secondary prevention in coronary artery disease (CAD). The physician under whose sphere these are managed can vary—most typically primary care physicians (PCP), cardiologists, or both—and the optimal management strategy for risk factor control in outpatients with CAD is unknown.

Methods:
Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study was a cross-sectional cohort study of outpatients with CAD (stable angina, PCI, CABG, or myocardial infarction) from 25 US cardiology practices and 155 providers. After each patient visit, providers noted who managed each risk factor. Blood pressure (BP), lipid levels, medications, and comorbidities were recorded from charts. We compared adherence to guideline-directed risk factor control between management strategies (PCP alone, cardiologist alone, or co-managed).

Results:
Among 1259 outpatients with CAD (mean age 71 y, 69% men), BP was managed by cardiologists alone in 66% of patients, co-managed in 29%, and PCP alone in 5%. Median BP was 128/72 mmHg, with 74% of patients at <140/90 and 46% at <130/80. Lipids were managed by cardiologists alone in 56%, co-managed in 28%, and PCP alone in 16%. Median LDL was 77 mg/dL, with 75% of patients at <100, 37% at <70, and 91% of patients on appropriate statin therapy. Patients managed by cardiologists alone tended to have higher rates of risk factor control for both BP and lipids (Table).

Conclusions:
Although co-management has shown benefit in some clinical situations, we found that risk factor control in patients with CAD tended to be poorer when care was shared between cardiologists and PCPs. Further research is needed to better define which conditions are best co-managed and how to more effectively co-manage patients in the fractured healthcare systems common in the US.
Abstract 134: Can Coronary Calcification Scores Be Approximated by Routine Clinical CT?
Authors: Horbal Steven R , Brown Edward , Ross Brian E , Holcombe Sven A , Wang Nicholas , Sullivan June A , Bidulescu Aurelian , Wang Stewart C
Published: April 2019

Introduction:
Coronary calcification scores (CAC) scores are established predictors of coronary atherosclerosis and are useful, independent measures of cardiovascular risk. More recently, medical image based phenotyping has gained traction in the medical literature for cardiovascular and other disease processes. CAC scores are limiting as they are only obtained when a physician suspects cardiovascular disease, are expensive, and only capture data relative to the heart. Routine clinical tomography (CT) scans can be processed using Analytic Morphomics to obtain quantified calcification in the descending aorta. Calcification of the descending aorta can be quantified through processing of routine clinical CT. We hypothesize that CT-based morphometric assessment of calcification in the descending aorta will be a useful approximation of the CAC score.

Methods:
Analysis was performed on 210 participants who had a CAC score within 30 days of a chest and/or abdominal CT. The scans were retrospectively obtained from the University of Michigan radiology database. Processing of CT images was performed with Analytic Morphomics, a semi-automated system for obtaining granular measurements of body composition recorded using a vertebral level coordinate system. The data capture included aortic segmentation and quantification of calcification. Aortic wall calcification percent was established at each vertebral level. Kendall’s correlations, averaged across 100 bootstrapped samples, establishes relationships of aortic wall calcification and CAC score.

Results:
A boxplot reporting Kendall’s correlation coefficients at each vertebral level are reported in Figure 1. Correlations among CAC and aortic calcification are stronger at lower vertebral levels. Correlations were significant (α<0.05) for most vertebral levels (excludes T7, T10, T11, T12).

Conclusion:
Providing a granular, segmented assessment of aortic calcification from routine CT scans may provide an approximate measure of CAC. This aortic calcification approach may identify patients at risk for cardiovascular events, who would not have otherwise been identified, or reduce unnecessary radiation exposure by ruling out the need for a CAC scan. This may reduce financial cost of healthcare and the emotional burden on patients and their families.
Abstract 135: Urban-Rural Differences in Coronary Heart Disease Mortality in the United States in 2010-2015
Authors: Singh Avinainder , Jiang Nona M , Blaha Michael , Blankstein Ron , Nasir Khurram
Published: April 2019

Background:
While there has been an overall decline in CHD (coronary heart disease) mortality rates in the U.S., recent studies show the decline is slower in rural areas, where in some cases mortality maybe rising. Our aimwas to characterize the age-adjusted death rates from CHD between urban and rural counties in the U.S. over a 5-year period 2010 to 2015.

Methods:
We collected county-level data pertaining to rurality of each U.S. county from the U.S. Census 2010 database. Counties were categorized by the U.S. Census into completely rural (100% of population living in rural areas), mostly rural (50-99.9% of population in rural areas), or mostly urban (<50% of population living in rural areas). Deaths attributed to CHD were captured from the Centers for Disease Control and Prevention’s WONDER database. Age-adjusted death rates/1,000,000 population with ICD10 I25.XX reported as underlying cause of death for each county were collected. A one-way between-groups ANOVA was conducted to assess regional differences in mortality from CHD.

Results:
Among 3140 counties evaluated, 40% were classified as completely urban, 38% as mostly rural and 22% as completely rural. The age-adjusted death rate for CHD was significantly higher in rural areas compared to completely urban areas - completely rural (mean 118.2 ± 38.26), mostly rural (mean 121.1 ± 36.7), and mostly urban (106.2 ± 32.4) counties; see
Figure
. There was a positive and significant correlation between % rurality and age-adjusted death rate (correlation coefficient 0.25; p<0.001).

Conclusions:
CHD mortality rates are higher in mostly rural and completely rural counties as compared with urban. These data highlight the continued need for optimizing health-care resources and provide opportunity to develop targeted programs to improve CHD mortality rates in areas of highest need.
Abstract 143: Spoke and Hub or Moat and Castle, Evolving Referral Patterns
Authors: Lawson William E , Wilbert Lisa , Maliszewski Mary , Niegelberg Eric , Seliem Ahmed , Chen On , Pyo Robert
Published: April 2019

Objective:
Stony Brook University Renaissance Medical School and University Hospital [UH] is a tertiary care hospital in Sufflolk County, NY, an area covering 912 square miles [86 miles in length and maximum width of 26 miles] and serving a population of 1.5 million. UH coordinates STEMI calls of the 94 voluntary ambulance services covering the county. The county geography has made coverage for emergent interventional procedures challenging. UH, until relatively recently had one of two cath labs (now 7) and the only CT surgical program (now 3) in the county. Independent cath labs (and 2 CTS programs) have been set up at Community hospitals to provide 7 x 24 interventional service, changes that may modify the traditional "Hub with Spokes" referral pattern for STEMI. Opposing this centrifugal force has been the increasing consolidation of health care hospital networks. We examined the effects of these changes on STEMI referrals and overall volume at UH and a Cath capable community hospital between 2014- 2017.

Procedure:
We examined the effects of changes in emergency cath lab availability on STEMI referrals and overall volume at UH and a Cath capable community hospital [BMH] between 2014- 2017.

Results:
In 2014 of 167 STEMI calls 76 [45.5%] were referred to UH and 49 [29.3%] BMH. 2015 had 209 calls, 109 [52.2%] were referred to UH and 53 [25.4%] BMH. 2016 had 205 calls, 89 [43.4%] referred to UH and 53 [25.9%] BMH. 2017 had 247 calls, 101 [40.9%] referred to UH and 47 [19.0%] BMH. Ambulance company patterns of referral remained relatively stable despite an increase in local hospital availability. 34 ambulance companies brought patients to UH and 17 to BMH in 2014; 28 brought pts to UH and 19 to BMH in 2017. Ambulance companies continued to serve multiple hospitals throughout the monitored period. Total volume at UH remained little effected by changing practice guidelines or referral patterns: 2014: 2194 cath and 1329 PCI [total 3523]; 2015: 2371 cath and 1502 PCI [total 3873]; 2016: 2336 cath and 1578 PCI [total 3914]; 2017: 2367 cath and 1516 PCI [total 3883]. At UH, private [reflecting community hospital referrals] and staff physician utilization of the Cath lab also remained relatively unchanged in the studied period.

Conclusions:
Increased availability of 24 x 7 cath lab availability has resulted in a modest relative decline in referrals, more pronounced at the community hospital. Despite this, overall volume and therefore demand remains preserved. The increasing development of hospital networks and hospital based emergency ambulance services has not yet had a major impact on services, changing our "Hub with Spokes" to a "Castle and Moat", but will continue to be closely observed.