Decade Long Trends (2001-2011) in Duration of Pre-Hospital Delay Among Elderly Patients Hospitalized for an Acute Myocardial Infarction

BACKGROUND: Early intervention with medical and/or coronary revascularization treatment approaches remains the cornerstone of the management of patients hospitalized with acute myocardial infarction (AMI). However, several patient groups, especially the elderly, are known to delay seeking prompt medical care after onset of AMI-associated symptoms. Current trends, and factors associated with prolonged prehospital delay among elderly patients hospitalized with AMI, are incompletely understood. METHODS AND RESULTS: Data from a population-based study of patients hospitalized at all 11 medical centers in central Massachusetts with a confirmed AMI on a biennial basis between 2001 and 2011 were analyzed. Information about duration of prehospital delay after onset of acute coronary symptoms was abstracted from hospital medical records. In patients 65 years and older, the overall median duration of prehospital delay was 2.0 hours, with corresponding median delays of 2.0, 2.1, and 2.0 hours in those aged 65 to 74 years, 75 to 84 years, and in patients 85 years and older, respectively. There were no significant changes over time in median delay times in each of the age strata examined in both crude and multivariable adjusted analyses. A limited number of patient characteristics were associated with prolonged delay in this patient population. CONCLUSIONS: The results of this community-wide study demonstrate that delay in seeking prompt medical care continues to be a significant problem among elderly patients hospitalized with AMI. The lack of improvement in the timeliness of patients\u27 care-seeking behavior during the years under study remains of considerable clinical and public health concern

Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all-cause mortality in the 14 171 participants in the intention-to-treat population. The median age was 73 years, and the mean CHADS(2) score was 3.5. Over 1.9 years of median follow-up, 1214 (8.6%) patients died. Kaplan-Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all-cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33-1.70, P= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation

Objective To evaluate whether a structured exercise programme improved functional and health related quality of life outcomes compared with usual care for women at high risk of upper limb disability after breast cancer surgery. Design Multicentre, pragmatic, superiority, randomised controlled trial with economic evaluation. Setting 17 UK National Health Service cancer centres. Participants 392 women undergoing breast cancer surgery, at risk of postoperative upper limb morbidity, randomised (1:1) to usual care with structured exercise (n=196) or usual care alone (n=196). Interventions Usual care (information leaflets) only or usual care plus a physiotherapy led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7-10 days postoperatively, with two further appointments at one and three months. Main outcome measures Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, analysed by intention to treat. Secondary outcomes included DASH subscales, pain, complications, health related quality of life, and resource use, from a health and personal social services perspective. Results Between 26 January 2016 and 31 July 2017, 951 patients were screened and 392 (mean age 58.1 years) were randomly allocated, with 382 (97%) eligible for intention to treat analysis. 181 (95%) of 191 participants allocated to exercise attended at least one appointment. Upper limb function improved after exercise compared with usual care (mean DASH 16.3 (SD 17.6) for exercise (n=132); 23.7 (22.9) usual care (n=138); adjusted mean difference 7.81, 95% confidence interval 3.17 to 12.44; P=0.001). Secondary outcomes favoured exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale −0.68, −1.23 to −0.12; P=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4) −2.02, −3.11 to −0.93; P=0.001). No increase in complications, lymphoedema, or adverse events was noted in participants allocated to exercise. Exercise accrued lower costs per patient (on average −£387 (€457; $533) (95% confidence interval −£2491 to £1718; 2015 pricing) and was cost effective compared with usual care. Conclusions The PROSPER exercise programme was clinically effective and cost effective and reduced upper limb disability one year after breast cancer treatment in patients at risk of treatment related postoperative complications

Subrank and Optimal Reduction of Scalar Multiplications to Generic Tensors

Since the seminal works of Strassen and Valiant it has been a central theme in algebraic complexity theory to understand the relative complexity of algebraic problems, that is, to understand which algebraic problems (be it bilinear maps like matrix multiplication in Strassen’s work, or the determinant and permanent polynomials in Valiant’s) can be reduced to each other (under the appropriate notion of reduction). In this paper we work in the setting of bilinear maps and with the usual notion of reduction that allows applying linear maps to the inputs and output of a bilinear map in order to compute another bilinear map. As our main result we determine precisely how many independent scalar multiplications can be reduced to a given bilinear map (this number is called the subrank, and extends the concept of matrix diagonalization to tensors), for essentially all (i.e. generic) bilinear maps. Namely, we prove for a generic bilinear map T : V × V → V where dim(V ) = n that θ(√n) independent scalar multiplications can be reduced to T. Our result significantly improves on the previous upper bound from the work of Strassen (1991) and Bürgisser (1990) which was n^{2/3+o(1} . Our result is very precise and tight up to an additive constant. Our full result is much more general and applies not only to bilinear maps and 3-tensors but also to k-tensors, for which we find that the generic subrank is θ(n^{1/(k−1}). Moreover, as an application we prove that the subrank is not additive under the direct sum. The subrank plays a central role in several areas of complexity theory (matrix multiplication algorithms, barrier results) and combinatorics (e.g., the cap set problem and sunflower problem). As a consequence of our result we obtain several large separations between the subrank and tensor methods that have received much interest recently, notably the slice rank (Tao, 2016), analytic rank (Gowers–Wolf, 2011; Lovett, 2018; Bhrushundi–Harsha–Hatami–Kopparty–Kumar, 2020), geometric rank (Kopparty–Moshkovitz–Zuiddam, 2020), and G-stable rank (Derksen, 2020). Our proofs of the lower bounds rely on a new technical result about an optimal decomposition of tensor space into structured subspaces, which we think may be of independent interest

Variation in Expression and Protein Localization of the PIN Family of Auxin Efflux Facilitator Proteins in Flavonoid Mutants with Altered Auxin Transport in Arabidopsis thaliana

Aglycone flavonols are thought to modulate auxin transport in Arabidopsis thaliana via an as yet undefined mechanism. Biochemical studies suggest that flavonoids interact with regulatory proteins rather than directly with the PIN auxin efflux facilitator proteins. Auxin transport is enhanced in the absence of flavonoids (transparent testa4 [tt4]) and reduced in the presence of excess flavonols (tt7 and tt3). Steady state PIN mRNA levels in roots inversely correlate with auxin movement in tt mutants. PIN gene transcription and protein localization in flavonoid-deficient mutants appear to be modulated by developmental cues and are auxin responsive. Modulation of PIN gene expression and protein distribution by localized auxin accumulations occurs in the wild type as well. Flavonoids inhibit auxin transport primarily at the shoot apex and root tip and appear to modulate vesicular cycling of PIN1 at the root tip. In some auxin-accumulating tissues, flavonoid increases and changes in flavonoid speciation are subsequent to auxin accumulation