tbuckley/cabot-search huggingface dataset:
Delirium in Older Patients With COVID-19 Presenting to the Emergency Department
Authors: Maura Kennedy, Benjamin K. I. Helfand, Ray Yun Gou, Sarah L. Gartaganis, Margaret Webb, J. Michelle Moccia, Stacey N. Bruursema, Belinda Dokic, Brigid McCulloch, Hope Ring, Justin D. Margolin, Ellen Zhang, Robert Anderson, Rhonda L. Babine, Tammy Hshieh, Ambrose H. Wong, R. Andrew Taylor, Kathleen Davenport, Brittni Teresi, Tamara G. Fong, Sharon K. Inouye
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described. <h3>Objective</h3> To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes. <h3>Design, Setting, and Participants</h3> This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020. <h3>Exposure</h3> COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases). <h3>Main Outcomes and Measures</h3> The primary outcome was delirium as identified from the medical record according to a validated record review approach. <h3>Results</h3> A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55). <h3>Conclusions and Relevance</h3> In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.
Abstract 13148: Clinical Importance of Left Atrial Infiltration in Cardiac Transthyretin Amyloidosis
Authors: Francesco Bandera, Raffaele Martone, Liza Chacko, Sharmananthan Ganesananthan, Thirusha Lane, Ana Martinez-Naharro, Carol Wheland, Cristina Quarta, Dorota Rowczenio, Markella Ponticos, Janet A Gilbertson, Helen Lachmann, Ashutosh Wechelakar, James Brown, Daniel Knight, Moon James, Aviva Petrie, Francesco Cappelli, Marco Guazzi, Luciano Potena, Ornella Leone, Philip N Hawkins, Julian D Gillmore, Marianna Fontana
Journal: Circulation (2020)

Introduction: The clinical significance of left atrial (LA) involvement and dysfunction in ATTR amyloidosis cardiomyopathy (ATTR-CM) has not been characterized. We sought to study: 1) LA pathology in heart specimens from ATTR-CM patients 2) LA stiffness and mechanics using echocardiographic speckle tracking (EST) in cardiac ATTR-CM 3) the association between parameters of atrial function and mortality. Methods: Congo red staining and immunohistochemistry was performed to assess amyloid in the atria from 5 ATTR-CM heart specimens. 2D EST was used to assess LA reservoir, conduit, contractile function and stiffness in 906 ATTR-CM patients (551 wt ATTR; 93 T60A ATTR; 241 V122I ATTR; and 21 other gene variants). Results: There was extensive ATTR amyloid infiltration in the 5 atria, with loss of normal architecture, infiltration and remodelling of vessels, capillary disruption and subendocardial fibrosis. EST demonstrated increased atrial stiffness [median (25th-75th quartile) 1.83 (1.15-2.92)] that remained independently associated with reduced survival, after adjusting for known prognostic variables (lnLA stiff: HR= 1.26, CI 1.07-1.57; p=.009). There was substantial impairment of the three phasic functional atrial components [reservoir 8.86(5.94-12.97)%; conduit 6.5(4.53-9.28)%; and contraction 4.0(2.29-6.56)%]. Atrial contractile function was absent in 21.6% of patients whose ECG showed sinus rhythm (SR)-atrial electro-mechanical dissociation (AEMD). AEMD was associated with a poorer prognosis compared to SR patients who had effective mechanical contraction (p &lt;.0001). AEMD conferred a similar prognosis to patients in AF. Conclusions: The phenotype of ATTR-CM includes clinically significant infiltration of the atrial walls characterized by progressive loss of function and increased stiffness, a strong independent predictor of mortality. AEMD emerged as a distinctive functional phenotype identifying patients in SR with poor prognosis.
Abstract 16954: Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Cardiovascular Prevention Treatments in Patients With Coronary Artery Disease Insights From the Bridge Cardiovascular Prevention Cluster Randomized Trial
Authors: M. Julia Machline Carrion, Rafael M Soares, Helio P Penna Guimaraes, Renato H Nakagawa, Lucas P Damiani, Francisco A Fonseca, Maria C Izar, Octavio M Pontes-neto, Celso Amodeo, Pedro G Barros, Airton T Stein, Leopoldo S Piegas, Renato D Lopes, Otavio B Berwanger
Journal: Circulation (2020)

Introduction: Moving toward evidence-based care protocols is key to reduce the burden of cardiovascular diseases. Hypothesis: We assessed the hypothesis that a multifaceted intervention could improve the adherence to evidence-based therapies for coronary artery disease patients. Methods: The BRIDGE Cardiovascular Prevention study was a cluster randomized trial including 1,619 patients with ischemic stroke, coronary artery disease or peripheral artery disease from 40 outpatient clinics in Brazil. Clusters were randomized to receive a multifaceted quality improvement intervention or to routine practice. The intervention included reminders, care algorithms, training of a case manager, audit and feedback reports, and distribution of educational materials to health care providers. The primary endpoint was the adherence to combined use of statins, antiplatelets and ACEi or ARBs, using an “all or none” approach at 12 months in patients without contra-indications. Results: Among the 1619 patients enrolled in the original sample, 1327 (81.9%) were coronary artery disease patients. The mean age was 65.7 (SD=10.4) and 880 (66.3 %) were men. There was a significant difference in the combined prescription of evidence-based therapies between the intervention and the control groups (75.4% versus 61.8 % respectively, Odds Ratio, 2.33 [95% CI, 1.29 - 4.21], p&lt;0.01). Patients in the intervention group were more likely to receive statins (94.4% vs. 84.7%; Odds Ratio 4.15 [95% CI, 1.62 - 10.61], p&lt;0.01) and antiplatelet (95.3% vs. 89.0%; Odds Ratio 3.32 [95% CI, 1.45 - 7.58], p&lt;0.01). There was no significant difference in the occurrence of major cardiovascular events (non-fatal myocardial infarction, non-fatal stroke and mortality) between groups (2.34 % vs. 3.08%; Hazard Ratio 0.76 [95%CI, 0.39-1.49, p=0.42]. For patients with myocardial infarction the combined prescription of evidence-based therapies was increased in the intervention group as compared to the control group (75.6% versus 62.3 % respectively, Odds Ratio, 2.12 [95% CI, 0.99 - 4.54], p=0.02). Conclusions: Among coronary artery disease patients treated in Brazil, a quality improvement intervention resulted in improved prescription of evidence-based therapies for cardiovascular prevention.
Abstract 15042: Heart Rhythm Classification From an Optimal Lead Subset of the 12-lead Electrocardiogram by Deep Learning
Authors: Changxin Lai, Shijie Zhou, Natalia Trayanova
Journal: Circulation (2020)

Introduction: Deep learning (DL) has achieved promising performance on common heart rhythms classification using 12-lead electrocardiogram (ECG). However, two major concerns hinder the DL’s application - lack of interpretability and overfitting caused by using the full 12-lead ECG as input. Objective: We proposed a hybrid DL model with enhanced interpretability to detect 9 common types of heart rhythms from an optimal ECG lead subset, and to quantitively analyze the overfitting. Methods: We used a multicenter dataset of 6,877 annotated 12-lead ECG recordings. The proposed model (Fig. 1A) consists of a feature extraction and a decision-making. The feature extraction used 12 separate neural networks to extract features from each lead. The features were then fed into a random-forest classifier in the decision-making step to classify heart-rhythm types. The classifier was used to interpret the correlations between the heart rhythms and the ECG leads, to find an optimal subset of ECG leads, and to analyze whether using 12-lead ECG added unnecessary complexity to the model and undermined its generalizability. Results: The proposed model detected the correlations between the heart-rhythm types and the ECG leads (Fig. 1B), and identified an optimal ECG lead subset (leads II, aVR, V1, V4). The optimal subset was, in comparison with using 12-lead ECG, significantly better (F1 =0.776 vs. F1 = 0.767, P=0.02) on the validation set for classifying the 9 common heart rhythms. There was no statistical difference on the test set. No overfitting caused by 12-lead ECG was detected in this study. Conclusion: The hybrid DL model based on an optimal 4-lead ECG can interpret rhythm types without significant loss of accuracy in comparison with the 12-lead ECG.
Abstract 19806: Left Atrial Remodeling in Hypertrophic Cardiomyopathy and Markers for Atrial Fibrillation: Assessment by Cardiovascular Magnetic Resonance Imaging
Authors: Robert Schwartz, Tammy Haas, Joseph Browning, John Lesser, Ross Garberich, Martin Maron, Daniel Burkhoff, Barry Maron
Journal: Circulation (2012)

Introduction. Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), and an important determinant of clinical deterioration due primarily to heart failure and embolic stroke Hypothesis. Left atrial (LA) structural and functional parameters were assessed with high resolution cardiovascular magnetic resonance imaging (CMR) to provide imaging markers associated with the risk for developing AF in HCM patients. Methods. We studied 438 consecutive HCM patients (age 47 17 years) with CMR, including 57 with a history of paroxysmal AF, 13 in persistent AF, 368 without AF history, as well as 244 normal controls. The LA chamber was assessed for absolute and indexed end-diastolic volume (LAEDV) and end-systolic volume (LAESV), and % ejection fraction (LAEF). Results. Absolute LAEDV was significantly greater in HCM patients with AF (157 ± 73 ml) than in patients without AF (109 ± 39 ml), or normal controls (80 ± 24 ml; p &lt; 0.001). LAEF was lower in HCM with AF (34 ± 17%) than in HCM without AF (46 ± 12%) or controls (55 ± 9%; p &lt; 0.001), and decreased progressively from control values to HCM without AF to HCM with paroxysmal AF (37 ±16 ml), and to those patients with persistent/chronic AF (18 ±13%; p &lt; 0.001). A multivariate model showed LAEF (&lt; 40%) and LAEDV (&gt; 125 ml), as well as age (&gt; 46 years) each to be independently associated with occurrence of AF. Combining these 3 CMR variables most accurately discriminated the susceptibility to AF with the area under ROC curve = 0.805, and the accuracy = 82%. Conclusions. In HCM, % LAEF, as assessed by CMR, is a novel marker associated with AF, and in conjunction with increased LAEDV and older age.
SP0005 Risk factors for osteoarthritis
Authors: M Doherty
Journal: Annals of the Rheumatic Diseases (2001)

<h3></h3> Osteoarthritis (OA) is not a disease or a single condition. Diverse observations suggest that it may reflect the repair process of synovial joints. Sites commonly targeted by symptomatic OA include finger joints, knees and hips. These sites have different risk factors for development of structural OA. Different risk factors may relate to structural progression and outcome. Risk factors for pain and disability (such as muscle weakness and adverse psychosocial factors for the knee) may also differ from those relating to structural change. Risk factors for development of structural OA are divisible into general constitutional factors and local, predominantly biomechanical factors. Important constitutional factors include heredity and ageing (all sites); Caucasian ethnicity (hip); female gender (hands, knees); and obesity (knees). Overt trauma can predispose to OA, but so may specific repetitive activities relating to occupational and recreational usage (eg football, knee bending while load carrying – knee OA; farming – hip OA). Possible negative associations include osteoporosis (hip &gt;knee) and smoking (knee &gt;hip). The role of poor nutrition (especially low antioxidants and vitamin D) in development and progression of knee and hip OA merits further study. The genetic study of OA promises important insights into pathogenesis. A strong genetic contribution to OA of the hand, knee and hip has been shown using strategies such as: classic twin study; estimation of the relative risk of OA in siblings of OA patients; and segregation analysis of clustering of OA within families. Through candidate and genome wide association studies of affected sibling pairs, genetic associations are now being identified on several chromosomes (notably 2q, 11 and 16) and it is hoped that predisposing genes will shortly be identified. Inheritance is likely to be polygenic and to involve common polymorphisms, each with a relatively low attribution to OA. The next stage will be gene-gene and gene-environmental interaction studies to determine how individual genes and constitutional or environmental factors interrelate to cause OA and to modify its progress.
GRADE approach to drawing conclusions from a network meta-analysis using a minimally contextualised framework
Authors: Romina Brignardello-Petersen, Ivan D Florez, Ariel Izcovich, Nancy Santesso, Glen Hazlewood, Waleed Alhazanni, Juan José Yepes-Nuñez, George Tomlinson, Holger J Schünemann, Gordon H Guyatt
Journal: BMJ (2020)

This article describes GRADE (grading of recommendations assessment, development and evaluation) guidance on how to draw conclusions from a network meta-analysis of interventions that includes individual randomised controlled trials addressing a single outcome. The guidance uses a minimally contextualised approach that avoids value judgments regarding the magnitude of intervention effects. The framework is based on two principles: interventions should be grouped in categories, from the most to the least effective or harmful; and the judgments that place interventions in such categories should simultaneously consider the estimates of effect, the certainty of the evidence, and the rankings. The framework includes five steps, which we describe and illustrate using an example. The framework is simple, methodologically sound, and flexible, allowing for modifications to resolve situations in which additional complexity or value judgments might be appropriate.
Abstract 14696: The Effectiveness of a Unique Community Health System in Detecting Familial Hypercholesterolemia in Kagawa, Japan
Authors: Mizobuchi Asako, Keiji Matsunaga, Hayato Tada, Tsuyoshi Sasaki, Yoshihiro Asano, Shigeru Ito, Ichiro Yokota, Jun Kunikata, Takashi Iwase, Masa-aki Kawashiri, Takashi Kusaka, Tetsuo Minamino
Journal: Circulation (2020)

Introduction: Familial hypercholesterolemia (FH) is an autosomal hereditary disease found in patients who have elevated low-density lipoprotein cholesterol (LDL-C) levels from birth. Early detection and treatment of FH during childhood potentially reduces the risk of premature cardiovascular events. In Kagawa prefecture, a unique community health system, involving three steps, has been conducted to prevent lifestyle-related diseases for 10-year-old children. This system includes universal lipid screening, selection by pediatricians, and next-generation sequencing (NGS) of FH-related genes in the hospitals. The aim of this study is to investigate whether this system can be effective in detection of FH. Methods: In Kagawa prefecture, the universal lipid screening of children at 10 years of age is performed annually at school, covering over 90% of the target group. After excluding secondary hypercholesterolemia, pediatric clinics introduced children with LDL-C levels &gt;140 mg/dL to four hospitals to perform NGS to detect FH. Results: In 2017, 279 children (3.7%) showed elevated LDL-C &gt;140mg/dL among 7,647 ones who received the screening. We performed NGS for 46 children after excluding secondary hypercholesterolemia by pediatricians (LDL-C 186.0±50.3 mg/dL; M/F 27/19) and 26 children (57%) had FH genetic mutations (23 LDL-R, 3 PCSK9). The children with LDL-C &gt;180mg/dL are recommended to receive statin therapy according to the guideline from the Japanese Atherosclerosis Society (JAS). Children with LDL-C levels ≥180 mg/dL have 74% of positive genetic mutations, and even those with 140-180 mg/dl LDL-C levels have as much as 44%, respectively (Table). Conclusions: The unique community health system in Kagawa can efficiently detect FH of children. Further investigation will be required for the effective prevention of future atherosclerotic cardiovascular diseases.
Abstract 14556: Is There a Relationship Between Lipoprotein (a) and Proprotein Convertase Subtilisin /keksin Type 9 and Cardiovascular Events After Acute Myocardial Infarction?
Authors: Albert GALYAVICH, Alsu Gimadeeva
Journal: Circulation (2020)

Introduction: Lipoprotein (a) (Lp(a)) has atherogenic effects. Proprotein convertase subtilisin /keksin type 9 (PCSK9) involved in the degradation of LDL-C receptors, increasing LDL-C blood level. Hypothesis: Identify the relationship between Lp(a) and PCSK9 blood levels and major cardiovascular events (unstable angina, myocardial infarction, cardiovascular death) after acute myocardial infarction. Methods: The study included 119 patients with acute myocardial infarction (97 men and 22 women aged 50-70 years). Blood samples were taken on the 2nd day of myocardial infarction. The Lp(a) blood level was determined by immunoturbidimetry (RANDOX), the PCSK9 blood level was determined by ELISA (BioVendor). Primary combined endpoint included hospitalization due to myocardial infarction and unstable angina and cardiovascular death. Patient follow-up was 52 weeks. Statistical analysis methods included Mann-Whitney test and non-parametric correlation by Spearman. Results: In 36 (30.2%) patients with acute myocardial infarction the Lp(a) blood levels were higher than 30 mg/dL. In 83 (69.7%) patients the Lp(a) blood level were below 30 mg/dL. Mean values of Lp(a) blood level was 29.26 ± 2.79 (men 27.71 ± 2.82 mg/dL, women 36.07 ± 8.54 mg/dL, p = 0.797). Mean PCSK9 blood level was 479.7 ± 15.4 ng/ml (males 465.6 ± 16.2ng/ml, females 534.9 ± 38.9 ng/ml, p = 0.122). There was no significant correlation of Lp(a) blood level with total cholesterol, LDL-C, triglycerids and PCSK9 blood levels. No significant correlation was found between Lp(a) and PCSK9 blood levels and cardiovascular events within 12 months. In the group of smoking patients (n = 22) there was found negative correlation between PCSK9 and HDL-C blood levels (-0.45, p = 0.039). Conclusions: Due to the fact that there is no relationship between Lp(a) and PCSK9 blood levels and subsequent cardiovascular events within 52 weeks, the effectiveness of the use of PCSK9 inhibitors after acute myocardial infarction is doubtful.
Abstract 16780: Disease Severity Assessed by Thromboelastography in a Minority Population With COVID-19
Authors: Kevin Bliden, Amit Rout, Rahul Chaudhary, Jaime Barnes, Udaya Tantry, Paul A Gurbel
Journal: Circulation (2020)

Background: Thromboelastography (TEG®) is used across a wide range of clinical settings to identify patients at risk for thrombosis and coagulopathic bleeding and may be a useful diagnostic tool to guide antithrombotic treatment in patients with COVID-19. Hypothesis: TEG® identifies symptom progression in COVID -19 patients, particularly in the high-risk minority population known to have worse clinical outcomes. Methods: Whole blood from African American and Hispanic hospitalized COVID positive (n=22) and negative outpatients (n=24) was analyzed using point-of-care TEG®6s (Haemonetics, Corp). TEG® parameters including clot initiation (R), fibrin clot strength (FCS), platelet-fibrin clot strength (PFCS) and clot lysis (LY30) were compared across disease severity groups (table). Routine labs including D-Dimer, C-reactive protein (CRP), ferritin, and procalcitonin were also collected. Results: Ninety- five percent of COVID positive patients had at least one co-morbidity with the incidence of hypertension (73%), diabetes (55%), and obesity (45%) being the most frequent. R time was more rapid, and FCS and PFCS was significantly higher in COVID positive as compared to negative groups (p&lt;0.03). A stepwise increase in FCS and PFCS was observed with worsening respiratory function (table). Similarly, D-Dimer, CRP, ferritin, and procalcitonin levels were highest in patients receiving ventilator support. No differences were observed in clot lysis between the groups despite elevated D-Dimer levels. Conclusion: We have demonstrated that TEG®6s can identify a prothrombotic phenotype characterized by rapid clot initiation and increased fibrin and platelet-fibrin clot strength in a minority population with COVID-19. Future studies are warranted implementing the TEG6s® in clinical trials to personalize antithrombotic therapy in COVID-19 and improve outcomes.
Oral insulin delivery1Abbreviations: GI, gastrointestinal; IDDM, insulin-dependent diabetes mellitus; IU, international units; NIDDM, non-insulin-dependent diabetes mellitus; PIN, phase inversion nanoencapsulation; ZOT, zona occludens toxin.1
Authors: Gerardo P Carino, Edith Mathiowitz
Journal: Advanced Drug Delivery Reviews (1999)