Prognostic value of layer-specific global longitudinal strain in patients undergoing coronary artery bypass grafting

Background Recent improvements in speckle tracking echocardiography have made sectionalized quantification of layer-specific global longitudinal strain (GLS) possible. Prior studies have reported prognostic value of GLS in several cardiac diseases, however, the use of layer-specific strain has not been investigated in patients undergoing coronary artery bypass grafting (CABG). Purpose To determine the prognostic value of layer-specific GLS for predicting all-cause mortality after CABG. Methods In this retrospective cohort study, consecutive patients undergoing isolated CABG between 2006 and 2011 were included. The patients were followed through nation-wide registries for the endpoint of all-cause mortality. Multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to assess the association between layer-specific GLS and all-cause mortality. Cumulative survival was stratified by clinical age and gender-dependent cut-off values for the layer-specific GLS, which was obtained from a large healthy population study. Results Of 641 patients included (mean age 67 years, 84% male), 70 (10.9%) died during follow-up (median 3.8 years [IQR: 2.7; 4.9 years]). Patients who died during follow-up were significantly older (71 years vs. 67 years, P = <0.001) and had a lower LVEF (46% vs. 51% P = <0.001). Endocardial GLS (GLSendo) (−14.2% vs. −16.3%, P<0.001), whole wall GLS (−12.1% vs. −13.9%, P<0.001), and epicardial GLS (GLSepi) (−10.6% vs. −12.2%, P<0.001) were all reduced in patients who died during follow-up, and patients with GLS below cut-off had a more than two-fold increased risk of all-cause mortality (Figure 1). The risk of dying increased linearly with decreasing absolute GLS for all layers (p<0.0002 for all layers), (Figure 2). In multivariable models, all layer-specific strain parameters remained significantly associated with all-cause mortality; GLSepi: HR=1.14 (1.05–1.23), p=0.002; GLS: HR=1.12 (1.04–1.20), p=0.002; GLSendo: HR=1.09 (1.03–1.16), p=0.003, per 1% absolute decrease. However, only GLSepi remained significantly associated with mortality when also adjusting for echocardiographic parameters (GLSepi: HR=1.12 (1.00–1.25), p=0.049, per 1% absolute decrease) and separately also after adjusting for the EuroScore II (GLSepi: HR=1.09 (1.00–1.18), p=0.043, per 1% absolute decrease). Conclusion Layer-specific GLS is an independent prognosticator of all-cause mortality after CABG. In multivariable models, GLSepi provided significant prognostic value after adjusting for echocardiographic parameters and EuroScore II. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Research grant from Herlev & Gentofte University Hospital's internal research funds. Figure 1. Kaplan-Meier survival estimates Figure 2. Incidence rate of all-cause mortality

Abstract P110: Intravenous Hydralazine Effect On Blood Pressure Following Severe Inpatient Hypertension Development

Background: BP elevations in the hospital are commonly treated with intravenous medications, specifically hydralazine. However, treatment guidelines are lacking. Our goal is to assess the effect of intravenous hydralazine on BP following severe inpatient HTN development. Methods: This is a cohort study of adults admitted for reasons other than HTN and developed severe HTN within a single healthcare system. We defined severe inpatient HTN as the first documentation of BP elevation (>180 systolic or >110 diastolic) at least 1 hour after admission. Pregnant women were excluded. Mixed-effects models with nonlinear time trend were used to assess and visualize the time-dependent effect of intravenous hydralazine on BP within 6 hours of BP elevation. Results: Of the 23,147 inpatients who developed severe HTN, 13,753 were untreated and 9,166 were treated of which 12% received intravenous hydralazine. Of the treated and untreated patients, 57 and 46% had a severe MAP reduction (drop ≥30%) (p-value<0.01). Risk factors for severe MAP drop include older age, history of drug and alcohol abuse, and higher BP on admission. Compared to inpatients with severe HTN who did not receive antihypertensives, those treated with intravenous hydralazine had a -12 [-14, -10], -19 [-22, -17], -8[-10, -7] mmHg greater reduction in MAP, SBP, and DBP after adjustment for demographic and clinical characteristics. Moreover, intravenous hydralazine resulted in acute BP reduction ( Figure 1 ). Conclusion: Severe MAP reduction is observed in both treated and untreated inpatients with severe HTN, however adjusted absolute decrease in MAP is greater in inpatients treated with intravenous hydralazine.

Cardiac mechanics and incident ischemic stroke: the Cardiovascular Health Study

Recent evidence indicates that our understanding of the relationship between cardiac function and ischemic stroke remains incomplete. The Cardiovascular Health Study enrolled community-dwelling adults ≥ 65 years old. We included participants with speckle-tracking data from digitized baseline study echocardiograms. Exposures were left atrial reservoir strain (primary), left ventricular longitudinal strain, left ventricular early diastolic strain rate, septal e’ velocity, and lateral e’ velocity. The primary outcome was incident ischemic stroke. Cox proportional hazards models were adjusted for demographics, image quality, and risk factors including left ventricular ejection fraction and incident atrial fibrillation. Among 4,000 participants in our analysis, lower (worse) left atrial reservoir strain was associated with incident ischemic stroke (HR per SD absolute decrease, 1.14; 95% CI 1.04–25). All secondary exposure variables were significantly associated with the outcome. Left atrial reservoir strain was associated with cardioembolic stroke (HR per SD absolute decrease, 1.42; 95% CI 1.21–1.67) and cardioembolic stroke related to incident atrial fibrillation (HR per SD absolute decrease, 1.60; 1.32–1.95). Myocardial dysfunction that can ultimately lead to stroke may be identifiable at an early stage. This highlights opportunities to identify cerebrovascular risk earlier and improve stroke prevention via therapies for early myocardial dysfunction.

Memo for a patient with ischemic heart disease

Angina pectoris is not an independent disease, but a syndrome that is a manifestation of ischemic heart disease (IHD). Ischemic artery disease occurs due to insufficient blood supply to the heart muscle and is an acute or chronic heart dysfunction resulting from a relative or absolute decrease in the supply of the myocardium with arterial blood. In more than 90% of cases, the anatomical basis of ischemic heart disease is the lesion of the coronary arteries of the heart. Angina pectoris is a kind of heart signal about oxygen deficiency. The signal is felt in the form of attacks of short-term sudden acute compressive, pressing, burning pains in the heart region. In some patients, the pain is accompanied by a state of general discomfort, a feeling of lack of air, and interruptions in the work of the heart.

Early Anakinra Treatment for COVID-19 Guided by Urokinase Plasminogen Receptor

Background In a previous open-label trial, early anakinra treatment guided by elevated soluble urokinase plasminogen activator receptor (suPAR) prevented progression of COVID-19 pneumonia into respiratory failure. Methods In the SAVE-MORE multicenter trial, 594 hospitalized patients with moderate and severe COVID-19 pneumonia and plasma suPAR 6 ng/ml or more and receiving standard-of-care were 1:2 randomized to subcutaneous treatment with placebo or 100 mg anakinra once daily for 10 days. The primary endpoint was the overall clinical status of the 11-point World Health Organization ordinal Clinical Performance Scale (WHO-CPS) at day 28. The changes of the WHO-CPS and of the sequential organ failure assessment (SOFA) score were the main secondary endpoints. Results Anakinra-treated patients were distributed to lower strata of WHO-CPS by day 28 (adjusted odds ratio-OR 0.36; 95%CI 0.26-0.50; P<0.001); anakinra protected from severe disease or death (6 or more points of WHO-CPS) (OR: 0.46; P: 0.01). The median absolute decrease of WHO-CPS in the placebo and anakinra groups from baseline was 3 and 4 points respectively at day 28 (OR 0.40; P<0.0001); and 2 and 3 points at day 14 (OR 0.63; P: 0.003); the absolute decrease of SOFA score was 0 and 1 points (OR 0.63; P: 0.004). 28-day mortality decreased (Hazard ratio: 0.45; P: 0.045). Hospital stay was shorter. Conclusions Early start of anakinra treatment guided by suPAR provides 2.78 times better improvement of overall clinical status in moderate and severe COVID-19 pneumonia. (Sponsored by the Hellenic Institute for the Study of Sepsis ClinicalTrials.gov identifier, NCT04680949)

Impact of COVID-19 on PM2.5 Pollution in Fastest-growing Megacity Dhaka, Bangladesh

Objective: The purpose of the research was to investigate and identify the impact of COVID-19 lockdown on fine particulate matter (PM2.5) pollution in Dhaka, Bangladesh by using ground-based observation data. Methods: The research assessed air quality during the COVID-19 pandemic for PM2.5 from 1 January 2017 to 1 August 2020. The research considered pollution in pre-COVID-19 (1 January-23 March), during COVID-19 (24 March-30 May), and post-COVID-19 (31 May-1 August) lockdown periods with current (2020) and historical (2017-2019) data. Results: PM2.5 pollution followed a similar yearly trend in year 2017-2020. The average concentration for PM2.5 was found 87.47 μg/m3 in the study period. Significant PM2.5 declines were observed in the current COVID-19 lockdown period compared to historical data: 11.31% reduction with an absolute decrease of 7.15 μg/m3. Conclusion: The findings of the research provide an overview of how the COVID-19 pandemic affects air pollution. The results will provide initial evidence regarding human behavioral changes and emission controls. This research will also suggest avenues for further study to link the findings with health outcomes.

Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system

BackgroundReports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes.MethodsFor this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted.ResultsA total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207).DiscussionEarly phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation.Level of evidenceLevel II (therapeutic/care management).

Agro-economic substantiation of the feasibility of green manured fallow in sugar beet crop rotations of the Central Chernozem Region

The aim of the study is to find out the feasibility of including green manured fallow in specialized sugar beet crop rotations by comparing necessary assessment indicators with their values in a traditional crop rotation with black fallow against the background of unequal fertilization levels. The study was based on the analysis of experimental data from a long-term stationary experiment, laid out simultaneously in all fields and variants on typical chernozem in triplicate. The results are as follows: within the same fertilization levels, no significant differences in the yield of winter wheat (sugar beet precursor) were revealed, and the yield of sugar beet in a crop rotation with green manured fallow was stably higher (no more than 5 to 7%), an increase in yield relative to the control fertilizer variant (6 tons of manure per hectare per year) against the background of a double rate of manure in combination with mineral fertilizers amounted to 21.7 to 23.4% for wheat and 14.3 to 15.6% for beets with an increase in the productivity of crop rotations (in natural and value terms) by 1.2 times, but an increase in costs by 1.3 times caused an absolute decrease in the level of profitability by 23 to 25%. Differences in the assessment indicators for specific fertilization variants increased over time due to an unequal degree of soil fertility reproduction, and therefore in the fifth cycle of the crop rotation with black fallow turned out to be 1.1 to 1.3 times greater than in the green manured rotation.

Specific features of the use of alogliptin in various groups of patients with type 2 diabetes mellitus: additional results of the ENTIRE study

BACKGROUND: Since the obtaining of data on the effect of Alogliptin towards the lipid profile, body weight and blood pressure (BP) of patients, the additional analysis of the results of the ENTIRE study, completed in the Russian Federation in 2018, was conducted. AIMS: Assess the dynamics of HbA1c, body weight, fats indices, blood pressure (BP), and characterize the profile of the patient who received the maximum clinical benefit on treatment of Alogliptin therapy in the ENTIRE study. MATERIALS AND METHODS: A prospective non-interventional observational study that included patients aged 18 years and older with first-onset type 2 diabetes mellitus (T2DM) or patients with T2DM who did not achieve their glycemic targets during the previous therapy. RESULTS: A decrease in glycated hemoglobin (HbA1c) by more than 0.5% was detected in 73.5% of patients. The most significant absolute decrease of HbA1c was noticed in patients with initially higher values. Younger patients with a shorter duration of T2DM showed the more often compensation of carbohydrate metabolism. The average loss of weight was -2.64.2 kg. 76.6% of patients showed the loss of weight. The most significant decrease in body weight was noticed in patients with a large initial body mass index and a shorter duration of the disease. 74.7% of patients showed a decrease of the level of low-density lipoproteins (LDL). The most significant absolute decrease in LDL was noticed in patients with initially higher values and more often in younger people with a shorter duration of T2DM. The average decrease in systolic blood pressure (BP) was 5.90.3 mm Hg; the average decrease in diastolic blood pressure (BP) was 2.70.2 mm Hg. 59% of patients showed decrease of blood pressure during the group analyzing. The most frequent BP reduction was observed in younger patients with shorter duration of T2DM. At the same time, a more significant absolute decrease in blood pressure was noticed in patients with initially higher indicators, and an increase, on the contrary, was observed in patients with initially lower indicators. CONCLUSIONS: The intensification of Alogliptin therapy allowed to achieve the compensation of carbohydrate metabolism, moderate decrease of body weight, blood pressure and LDL indices within the majority of patients with T2DM. The most frequent achievement of HbA1c targets was noticed in young patients with a shorter duration of T2DM.

Drug Enforcement Agency 2014 Hydrocodone Rescheduling Rule and Opioid Dispensing after Surgery

Background In 2014, the U.S. Drug Enforcement Agency reclassified hydrocodone from Schedule III to Schedule II of the Controlled Substances Act, resulting in new restrictions on refills. The authors hypothesized that hydrocodone rescheduling led to decreases in total opioid dispensing within 30 days of surgery and reduced new long-term opioid dispensing among surgical patients. Methods The authors studied privately insured, opioid-naïve adults undergoing 10 general or orthopedic surgeries between 2011 and 2015. The authors conducted a differences-in-differences analysis that compared overall opioid dispensing before versus after the rescheduling rule for patients treated by surgeons who frequently prescribed hydrocodone before rescheduling (i.e., patients who were functionally exposed to rescheduling’s impact) while adjusting for secular trends via a comparison group of patients treated by surgeons who rarely prescribed hydrocodone (i.e., unexposed patients). The primary outcome was any filled opioid prescription between 90 and 180 days after surgery; secondary outcomes included the 30-day refill rate and the amount of opioids dispensed initially and at 30 days postoperatively. Results The sample included 65,136 patients. The percentage of patients filling a prescription beyond 90 days was similar after versus before rescheduling (absolute risk difference, −1.1%; 95% CI, −2.3% to 0.1%; P = 0.084). The authors estimated the rescheduling rule to be associated with a 45.4-mg oral morphine equivalent increase (difference-in-differences estimate; 95% CI, 34.2–56.7 mg; P &lt; 0.001) in initial opioid dispensing, a 4.1% absolute decrease (95% CI, −5.5% to −2.7%; P &lt; 0.001) in refills within 30 days, and a 37.7-mg oral morphine equivalent increase (95% CI, 20.6–54.8 mg; P = 0.008) in opioids dispensed within 30 days. Conclusions Among patients treated by surgeons who frequently prescribed hydrocodone before the Drug Enforcement Agency 2014 hydrocodone rescheduling rule, rescheduling did not impact long-term opioid receipt, although it was associated with an increase in opioid dispensing within 30 days of surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New