Contemporary Management of Severe Symptomatic Aortic Stenosis

There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians

Assessing the Wraparound Process During Family Planning Meetings

Research and evaluation of the wraparound process has typically focused on outcomes, service providers, and costs. While many of these studies describe a process that is consistent with the wraparound approach, few studies have reported attempts to monitor or measure the treatment fidelity of the wraparound process. The purpose of this study was to assess the fidelity of the wraparound process in a community-based system of care using the Wraparound Observation Form-Second Version. Results from 112 family planning meetings indicated some strengths and weaknesses within the current system. Families and professionals were frequently involved in the planning and implementation of the wraparound process. However, informal supports and natural family supports were not present in a majority of the meetings. Given the significant number of youth served in wraparound programs, the benefits of using the Wraparound Observation Form-Second Version as an instrument to monitor the fidelity of the wraparound approach should not be ignored