The Evolving Management of Aortic Valve Disease: Trends in the Utilization and Cost of SAVR, TAVR, and Medical Therapy

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding usage and cost of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease. From the Nationwide Readmissions Database, we determined utilization and cost trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted 2012-2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. From 2012 through 2016, there was a 48.1% increase in the number of patients hospitalized for aortic valve disease annually. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016; TAVR increased from 2.6% to 12.5%; and MT decreased from 75.5% to 69.0%. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21-4.97) with TAVR increasing at the expense of both SAVR and MT. The average 6-month inpatient costs were $59,743 for SAVR,$64,395 for TAVR, and $23,460 for MT. TAVR IA costs decreased over time to become similar to SAVR costs by 2016. The TAVR increase was distributed inequitably, with certain patients more likely to receive TAVR and certain hospitals more likely to provide TAVR. Aggregate costs were higher for TAVR than SAVR and were significantly more expensive than MT alone. With the expected expansion of indications, equitable and affordable access to TAVR must be addressed to minimize disparities and to optimize patient outcomes

Leadership Perspectives on the Financial Sustainability of Non-Orthodox Jewish Day Schools in Toronto

The purpose of this study was to better understand how Jewish school leaders in Toronto understand non-Orthodox Jewish day school financial sustainability. A review of literature included: (a) a multidisciplinary understanding of “sustainability”, (b) a history of Jewish education in North America, (c) challenges and potential solutions to financial sustainability of Jewish day schools in North America, and (d) the evolution of the school leader and its impact on financial sustainability. This multi-site case study used a questionnaire, completed by 23 school leaders, and one-on-one interviews with all eight heads of school of the non-Orthodox Jewish day schools in Toronto to collect data. Both data collection instruments addressed the guiding research questions: (a) To what degree do Jewish day school leaders believe addressing sustainability to be a leadership priority? (b) What are the various approaches to addressing sustainability reported by Jewish day school leaders? (c) What do leaders of Jewish day schools believe to be the factors and conditions that increase and inhibit their capacity to focus on school sustainability? The study included the following findings: (1) Financial stability is one of the most important issues for leaders in non-Orthodox Jewish day schools, but they are unable to focus on sustainability to the degree necessary due to their many other responsibilities; (2) The majority of non-Orthodox Jewish day school leaders do not believe they have achieved long-term financial sustainability, or will do so in the near future; (3) Known financial sustainability strategies were not being utilized to the degree desired by school leaders. The endowment strategy was identified as the most underutilized strategy; (4) A collaborative approach between schools to address the problem of financial sustainability is not currently being applied; (5) School leaders identified criteria to assess the impact of financial sustainability strategies; (6) Lack of overall available time, most notably efforts on enrollment, prevent leaders from focusing more on financial sustainability; (7) The use of financial sustainability practices are contingent on the manner in which leaders choose to spend their time and other resources. These findings led to eight recommendations for Jewish day school leaders to help support the financial sustainability of their institutions. Future research was also suggested

The Impact of United States Antitrust Law on the Balance of Trade

This Article explores the underlying propositions that the United States antitrust agencies have created a barrier to the export of United States industrial goods or have impeded their domestic manufacture with respect to this nation\u27s major trading partners. We conclude that neither proposition is well supported by solid evidence, although improved cooperation among Government and business and a less litigious climate are desirable in this area as well as all other industry-government relations. This Article first considers the impact of antitrust enforcement on the export or overseas distribution stage of United States domestic producers and then turns to the effect of United States policy on domestic versus overseas production... In theory, United States antitrust policy could harm the United States balance of trade by discouraging either the domestic production or overseas distribution of United States manufacturers. Undoubtedly, in the past United States agency actions have impeded the growth and development of domestic producers because of an unfounded hostility to growth and sometimes resultant increases in industrial concentration. However, this attitude has diminished in recent years. Moreover, there is clearly no evidence that price-fixing or other traditional violations of United States antitrust laws will render United States firms more efficient and competitive internationally. Exemptions to the laws against coordination and collusion for export operations of United States manufacturers have been available for years, though domestic firms have displayed little interest in them. A further extension of these exemptions recently has become available as a result of the Export Trading Company Act. If this Article\u27s conclusions about the impact of United States Government antitrust policies are correct, one should expect to see little improvement in the United States balance of trade as a result of this legislation

Outcomes of viral myocarditis in patients with and without COVID-19: a nationwide analysis from the United States

UNLABELLED: Cardiovascular complications contribute to 40% of coronavirus disease 2019 (COVID-19) related deaths. The viral myocarditis associated with COVID-19 accounts for significant morbidity and mortality. How COVID-19 myocarditis compares to other viral myocardites is unknown. METHODS: The authors conducted a retrospective cohort study using the National Inpatient Sample database to identify adult patients hospitalized for viral myocarditis in 2020 and to compare outcomes between those with and without COVID-19. The primary study outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, length of stay, and total costs. RESULTS: The study population included 15 390 patients with viral myocarditis, of whom 5540 (36%) had COVID-19. After adjustment for baseline characteristics, patients with COVID-19 had higher odds of in-hospital mortality [adjusted odds ratio (aOR) 3.46, 95% CI 2.57-4.67], cardiovascular complications (aOR 1.46, 95% CI 1.14-1.87) including cardiac arrest (aOR 2.07, 95% CI 1.36-3.14), myocardial infarction (aOR 2.97, 95% CI 2.10-4.20), venous thromboembolism (aOR 2.01, 95% CI 1.25-3.22), neurologic complications (aOR 1.82, 95% CI 1.10-2.84), renal complications (aOR 1.72, 95% CI 1.38-2.13), and hematologic complications (aOR 1.32, 95% CI 1.10-1.74), but lower odds of acute heart failure (aOR 0.60, 95% CI 0.44-0.80). The odds of pericarditis, pericardial effusion/tamponade, cardiogenic shock, and the need for vasopressors or mechanical circulatory support were similar. Patients with COVID-19 had longer length of stay (7 days vs. 4 days, P\u3c0.01) and higher total costs ($21,308 vs.$14,089, P\u3c0.01). CONCLUSIONS: Among patients with viral myocarditis, COVID-19 is associated with higher in-hospital mortality and cardiovascular, neurologic, renal, and hematologic complications compared to non-COVID-19 viruses

Post-injection delirium/sedation syndrome in patients with schizophrenia treated with olanzapine long-acting injection, I: analysis of cases

<p>Abstract</p> <p>Background</p> <p>An advance in the treatment of schizophrenia is the development of long-acting intramuscular formulations of antipsychotics, such as olanzapine long-acting injection (LAI). During clinical trials, a post-injection syndrome characterized by signs of delirium and/or excessive sedation was identified in a small percentage of patients following injection with olanzapine LAI.</p> <p>Methods</p> <p>Safety data from all completed and ongoing trials of olanzapine LAI were reviewed for possible cases of this post-injection syndrome. Descriptive analyses were conducted to characterize incidence, clinical presentation, and outcome. Regression analyses were conducted to assess possible risk factors.</p> <p>Results</p> <p>Based on approximately 45,000 olanzapine LAI injections given to 2054 patients in clinical trials through 14 October 2008, post-injection delirium/sedation syndrome occurred in approximately 0.07% of injections or 1.4% of patients (30 cases in 29 patients). Symptomatology was consistent with olanzapine overdose (e.g., sedation, confusion, slurred speech, altered gait, or unconsciousness). However, no clinically significant decreases in vital signs were observed. Symptom onset ranged from immediate to 3 to 5 hours post injection, with a median onset time of 25 minutes post injection. All patients recovered within 1.5 to 72 hours, and the majority continued to receive further olanzapine LAI injections following the event. No clear risk factors were identified.</p> <p>Conclusions</p> <p>Post-injection delirium/sedation syndrome can be readily identified based on symptom presentation, progression, and temporal relationship to the injection, and is consistent with olanzapine overdose following probable accidental intravascular injection of a portion of the olanzapine LAI dose. Although there is no specific antidote for olanzapine overdose, patients can be treated symptomatically as needed. Special precautions include use of proper injection technique and a post-injection observation period.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov ID; URL: <url>http://http//www.clinicaltrials.gov/</url>: NCT00094640, NCT00088478, NCT00088491, NCT00088465, and NCT00320489.</p