Performance of stent thrombosis and bleeding risk scores in out-of-hospital cardiac arrest due to acute coronary syndromes

BackgroundPatients with out-of-hospital cardiac arrest (OHCA) due to acute coronary syndromes (ACS) who undergo percutaneous coronary intervention (PCI) are at high risk of bleeding and thrombosis. While predictive bleeding and stent thrombosis risk scores have been established, their performance in patients with OHCA has not been evaluated.MethodsAll consecutive patients admitted for OHCA due to ACS who underwent PCI between January 2007 and December 2019 were included. The ACTION and CRUSADE bleeding risk scores and the Dangas score for early stent thrombosis risk were calculated for each patient. A C-statistic analysis was performed to assess the performance of these scores.ResultsAmong 386 included patients, 82 patients (21.2%) experienced severe bleeding and 30 patients (7.8%) experienced stent thrombosis. The predictive performance of the ACTION and CRUSADE bleeding risk scores for major bleeding was poor, with areas under the curve (AUCs) of 0.596 and 0.548, respectively. Likewise, the predictive performance of the Dangas stent thrombosis risk score was poor (AUC 0.513). Using multivariable analysis, prolonged low-flow (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.05; P = 0.025), reduced haematocrit or fibrinogen at admission (OR 0.93, 95% CI 0.88–0.98; P = 0.010 and OR 0.61; 95% CI 0.41–0.89; P = 0.012, respectively) and the use of glycoprotein IIb/IIIa inhibitors (OR 2.10, 95% CI 1.18–3.73; P = 0.011) were independent risk factors for major bleeding.ConclusionThe classic bleeding and stent thrombosis risk scores have poor performance in a population of patients with ACS complicated by OHCA. Other predictive factors might be more pertinent to determine major bleeding and stent thrombosis risks in this specific population.     

Improvement of Risk Prediction After Transcatheter Aortic Valve Replacement by Combining Frailty With Conventional Risk Scores

Objectives

This study sought to evaluate whether frailty improves mortality prediction in combination with the conventional scores.

Clinical importance of "breakthrough" bacteremia

Fifty-one episodes of bacteremia and a single episode of fungemia occurred during treatment with seemingly adequate doses of appropriate antibiotics. Clinical findings in these "breakthrough" bacteremias and fungemia were compared with those in 448 non-breakthrough episodes. Breakthrough was more likely to be caused by facultative or aerobic gram-negative rods (e.g., Enterobacteriaceae and Pseudomonas species) than by anaerobes. Of the underlying conditions examined, immunosuppressive doses of glucocorticosteroids, diabetes mellitus, and moderate renal failure were significantly more frequent in patients with breakthrough. A significant association was also observed between an intra-abdominal primary focus of infection (abscesses, biliary tract or bowel infections) and the occurrence of breakthrough. Mortality in breakthrough bacteremia was 61 percent compared with 40 percent in non-breakthrough episodes. The phenomenon of breakthrough bacteremia shows the potential limitations of antibiotic therapy alone.     

Racial Differences in the Incidence and Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to compare the incidence and prognostic significance of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) according to racial groups.BackgroundPPM after TAVR may be of more concern in Asian populations considering their relatively small annular and valve sizes compared with Western populations.MethodsTP-TAVR (Transpacific TAVR Registry) was an international multicenter cohort study of patients with severe aortic stenosis who underwent TAVR in the United States and South Korea from January 2015 to November 2019. PPM was defined as moderate (0.65-0.85 cm²/m²) or severe (<0.65 cm²/m²) at the indexed effective orifice area. The primary outcome was a composite of death, stroke, or rehospitalization at 1 year.ResultsAmong 1,101 eligible patients (533 Asian and 569 non-Asian), the incidence of PPM was significantly lower in the Asian population (33.6%; moderate, 26.5%; severe, 7.1%) than in the non-Asian population (54.5%; moderate, 29.8%; severe, 24.7%). The 1-year rate of the primary outcome was similar between the PPM and non-PPM groups (27.5% vs 28.1%; P = 0.69); this pattern was consistent between Asian (25.4% vs 25.2%; P = 0.31) and non-Asian (28.7% vs 32.1%; P = 0.97) patients. After multivariable adjustment, the risk for the primary outcome did not significantly differ between the PPM and non-PPM groups in the overall population (HR: 0.95; 95% CI: 0.74-1.21), in Asian patients (HR: 1.07; 95% CI: 0.74-1.55), and in non-Asian patients (HR: 0.86; 95% CI: 0.63-1.19).ConclusionsIn this study of patients with severe aortic stenosis who underwent TAVR, the incidence of PPM was significantly lower in Asian patients than in non-Asian patients. The 1-year risk for the primary composite outcome was similar between the PPM and non-PPM groups regardless of racial group. (Transpacific TAVR Registry [TP-TAVR]; NCT03826264)     

Predictors and Clinical Impact of Prosthesis-Patient Mismatch After Self-Expandable TAVR in Small Annuli

ObjectivesThe aim of this study was to define predictors of prosthesis-patient mismatch (PPM) and its impact on mortality after transcatheter aortic valve replacement (TAVR) with self-expandable valves (SEVs) in patients with small annuli.BackgroundTAVR seems to reduce the risk for PPM compared with surgical aortic valve replacement, especially in patients with small aortic annuli. Nevertheless, predictors and impact of PPM in this population have not been clarified yet.MethodsPredictors of PPM and all-cause mortality were investigated using multivariable logistic regression analysis from the cohort of the TAVI-SMALL (International Multicenter Registry to Evaluate the Performance of Self-Expandable Valves in Small Aortic Annuli) registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm² on computed tomography) treated with transcatheter SEVs: 445 patients with (n = 129) and without (n = 316) PPM were enrolled.ResultsIntra-annular valves conferred increased risk for PPM (odds ratio [OR]: 2.36; 95% confidence interval [CI]: 1.16 to 4.81), while post-dilation (OR: 0.46; 95% CI: 0.25–0.84) and valve oversizing (OR: 0.53; 95% CI: 0.28–1.00) seemed to protect against PPM occurrence. At a median follow-up of 354 days, patients with severe PPM, but not those with moderate PPM, had a higher all-cause mortality rate compared with those without PPM (log-rank p = 0.008). Multivariable Cox regression confirmed severe PPM as an independent predictor of all-cause mortality (hazard ratio: 4.27; 95% CI: 1.34 to 13.6).ConclusionsAmong patients with aortic stenosis and small aortic annuli undergoing transcatheter SEV implantation, use of intra-annular valves yielded higher risk for PPM; conversely, post-dilation and valve oversizing protected against PPM occurrence. Severe PPM was independently associated with all-cause mortality.     

Fine and gross motor skills predict later psychosocial maladaptation and academic achievement

BackgroundDifficulties in fine and gross motor skills are often overlooked as developmental problems, although approximately 6–13% of all school-age children have poor motor coordination. Understanding motor coordination is important from the perspective of school adaptation. This longitudinal cohort study aimed to determine whether fine and gross motor skills in preschool children predict later academic achievement and psychosocial maladaptation.Methods & ProceduresParticipants were 2,501 children from nursery and elementary schools (5–13 years old). The motor skills of preschool children were assessed by their nursery teacher immediately before entering elementary school. The Strengths and Difficulties Questionnaire and a standardized Japanese test were administered annually throughout elementary school.ResultsEarly motor difficulties in preschool children had significant effects on their academic achievement and psychosocial maladaptation up until the sixth grade. Gross motor difficulties in preschool were associated with the later peer problems and worsened emotional symptoms.ConclusionsMotor skills in preschool children are useful as a predictor of later psychosocial maladaptation and academic achievement.     

希望和大学生学业成就的关系自尊水平的调节作用

目的 调查希望、乐观与大学生学业成就的关系,以及自尊水平对此关系的调节作用.方法 对330名大学生进行了问卷调查,并利用层次回归的方法对数据进行分析.结果 希望的动力维度和大学生的学业成就相关显著（R =0.32,P＜0.01）;且在控制了相关的人口学变量之后,希望对学业成就的主效应仍然非常显著（R2 =0.073,P＜0.01）;自尊水平在希望预测大学生学业成就时的调节效应显著.结论 希望能显著的正向预测大学生的学业成就,乐观和学业成就相关不显著,这也说明了希望和乐观是两个独立的概念;自尊水平在希望预测大学生学业成就时起着调节的作用,希望对大学生学业成就的影响主要表现在中等自尊水平和低自尊水平的个体上.     

Recent trends in National Institutes of Health funding for surgery: 2003 to 2013

Background

The purpose of this study is to compare the compositions of federally funded surgical research between 2003 and 2013, and to assess differences in funding trends between surgery and other medical specialties.

Data Sources

The National Institutes of Health (NIH) Research Portfolio Online Reporting Tool database was queried for grants within core surgical disciplines during 2003 and 2013. Funding was categorized by award type, methodology, and discipline. Application success rates for surgery and 5 nonsurgical departments were trended over time.

Conclusions

Inflation-adjusted NIH funding for surgical research decreased 19% from $270M in 2003 to $219M in 2013, with a shift from R-awards to U-awards. Proportional funding to outcomes research almost tripled, while translational research diminished. Nonsurgical departments have increased NIH application volume over the last 10 years; however, surgery’s application volume has been stagnant. To preserve surgery’s role in innovative research, new efforts are needed to incentivize an increase in application volume.     

Academic advising and student support: Help-seeking behaviors among Saudi dental undergraduate students

Objective

The purpose of this study was to assess the use of and satisfaction with the academic-advising and student-support systems available to undergraduate students in the College of Dentistry at the University of Dammam. In addition, the study aimed to also identify factors that explained the help-seeking behavior of students which they used to solve academic issues.

Materials and methods

Students enrolled in the five-year Bachelor of Dental Surgery (BDS) program in 2012–13 and 2013–14 first-year students were invited to respond to a self-administered questionnaire.

Results

The results showed that 66.2% of students had discussed academic issues with their advisor at least once, with a frequency ranging from zero to six times. Most students reported that their advisors were readily available, listened intently to their needs and questions, and helped them solve their problems. However, only 7.6% of students relied primarily on advisors for help with academic issues, whereas 51% depended first on colleagues and 13.8% did not seek help and relied on themselves. In total, 17.2% of students were very or somewhat satisfied with the academic advising system. Males had lower odds of discussing issues with their advisors, and the odds were higher with advisors who were more available (OR = 0.25 and 3.74, respectively). Alerting students to important dates in the academic calendar significantly increased the odds that a student would depend primarily on academic advisors for advice related to academic issues (OR = 6.53).

Conclusions

Few students were satisfied with the academic support system. We need to train advisors to help them develop their skills and knowledge and to enable them to provide the support needed by the students.     

A comparison of treatment and outcomes of perihilar cholangiocarcinoma between Eastern and Western centers

Background

Perihilar cholangiocarcinoma (PHC) often requires extensive surgery which is associated with substantial morbidity and mortality. This study aimed to compare an Eastern and Western PHC cohort in terms of patient characteristics, treatment strategies and outcomes including a propensity score matched analysis.