Concomitant Valvular Procedures During LVAD Implantation and Outcomes: An Analysis of the MOMENTUM 3 Trial Portfolio

Purpose: Correction of valvular pathology is often undertaken in patients undergoing LVAD implantation but impact on outcomes is uncertain. We compared clinical outcomes with HeartMate 3 (HM3) LVAD implantation in those with concurrent valve procedures (VP) to those with an isolated LVAD implant within the MOMENTUM3 trial portfolio, including the Pivotal Trial (n=515, NCT02224755) and Continued Access Protocol/ CAP (n=1685, NCT02892955). Methods: The study included 2200 HM3 implanted patients. Among 820 concurrent procedures (including VP, CABG, RVAD, LAA closure), 466 (21.8%) were VPs (HM3+VP), including 81 aortic, 61 mitral, 163 tricuspid, and 85 patients with multiple VPs. Short and Long-term outcomes including peri-operative complications and healthcare resource use, major adverse events and survival were analyzed. Results: Patients undergoing HM3+VP were older (63[54-70] vs. 62[52-68] yrs), with a sicker INTERMACS profile (1-2:41% vs.31%) and higher central venous pressure (11[8-16] vs. 9[6-14] mmHg) compared to HM3 alone (all p\u3c0.05). The cardiopulmonary bypass time (124[97-158] vs.76[59-96] mins); ICU (8.5 [5-16] vs. 7 [5-13]) and hospital length of stay (20 [15-30] vs. 18 [14-24] days) were longer in HM3+VP (all p\u3c0.0001). A significantly higher incidence of stroke (4.9% vs. 2.4%), bleeding (33.9% vs. 23.8%) and right heart failure (41.5% vs. 29.6%) was noted in HM3+VP for 0-30 days post-implant (all p\u3c0.01), but 30-day survival was similar between groups (96.7% vs. 96.1%). There was no difference in 2-year survival in HM3+VP vs HM3 alone patients (HR[95%CI]:0.93 [0.71-1.21];p=0.60). Analysis of individual VPs showed no significant differences in survival compared to HM3 alone (Figure). Conclusion: Concurrent VPs are commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, but short and long-term survival are not impacted adversely when compared with those that undergo an isolated LVAD procedure

Competition and Vertical/Agglomeration Effects in Media Mergers: Bagging Bundle Benefits

Existing frameworks (such as used by the New Zealand Commerce Commission in its recent evaluation of the proposed merger between Sky Television and Vodafone) require, as a first step, the definition of the relevant markets affected by the merger or vertical integration activity. Historic precedents in the telecommunications sector have tended towards finding that vertical agglomeration effects when network operators integrate downstream into the provision of applications and services to end-consumers are harmful to competition. Such Structure-Conduct-Performance methods of evaluating mergers and other aspects of market performance are problematic when the firm(s) concerned supply many different products, both together in various different bundle forms and separately as individual components. Defining the markets for (merger) analysis on the basis of only one of the components in a possible bundle that the (merged) firm may supply risks overlooking the complex interactions that occur on the demand side when consumers make their purchase decisions. This is especially likely to be an issue in the supply of internet applications and content bundled with broadband internet access. Consumers have heterogeneous preferences for different applications and content (hereafter ‘content’), and will purchase (or access) many different content types. Even though ownership of rights to distribute one content may confer a degree of market power in for the owner-provider over those consumers with very strong preferences for this content over all others, it is not axiomatic that the firm will be able to exert this power over consumers whose preferences are more evenly distributed. The more variety there is in the content bundles available, and the more heterogeneous are consumers’ preferences across the various content types, the greater is the number of possible markets in which interaction is likely to occur and the more problematic it becomes to identify the relevant markets for analysis of mergers and antitrust cases. We propose that classic merger and antitrust analysis based on econometric cost-benefit analysis can be augmented by using simulation and numerical analysis of a range of bundle offers expected to be relevant in decision-making. We develop a simple model and use it to demonstrate how this approach could have informed the recent New Zealand Commerce Commission decision about the proposed Sky-Vodafone merger by offering some quantitative estimates of total and consumer welfare and provider profits under the proposed factual (with bundling) and counterfactual (individual component sales) cases. The approach may also inform other analyses, such as the assessment of the effects of two-sided markets and firm pricing decisions

Potential severe asthma hidden in UK primary care

Funding: ISAR is conducted by Observational & Pragmatic Research Institution (OPRI), and co-funded by OPC Global and AstraZeneca. This research study was co-funded by AstraZeneca and Optimum Patient Care Global Limited, including access to the Optimum Patient Care Research Database (OPCRD).Peer reviewedPublisher PD

Cardiovascular actions of the hypotensive agent, N, N-diallylmelamine (U-7720)

Diallylmelamine is an effective hypotensive agent in hypertensive dogs and rats, having a duration of action exceeding twenty-four hours from a single oral dose. It has limited efficacy in normotensive rats. Hypotensive activity of gradual onset is preceded by a latent period of up to two hours and becomes maximal six hours or more after dosing. This agent does not depress cardiac output or sympathetic vasoconstrictor activity. It is suggested that its hypotensive activity results from a direct effect upon vascular smooth muscle.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46303/1/210_2004_Article_BF00245728.pd

Ki-67 as prognostic marker in early breast cancer: a meta-analysis of published studies involving 12 155 patients

The Ki-67 antigen is used to evaluate the proliferative activity of breast cancer (BC); however, Ki-67's role as a prognostic marker in BC is still undefined. In order to better define the prognostic value of Ki-67/MIB-1, we performed a meta-analysis of studies that evaluated the impact of Ki-67/MIB-1 on disease-free survival (DFS) and/or on overall survival (OS) in early BC. Sixty-eight studies were identified and 46 studies including 12 155 patients were evaluable for our meta-analysis; 38 studies were evaluable for the aggregation of results for DFS, and 35 studies for OS. Patients were considered to present positive tumours for the expression of Ki-67/MIB-1 according to the cut-off points defined by the authors. Ki-67/MIB-1 positivity is associated with higher probability of relapse in all patients (HR=1.93 (95% confidence interval (CI): 1.74–2.14); P<0.001), in node-negative patients (HR=2.31 (95% CI: 1.83–2.92); P<0.001) and in node-positive patients (HR=1.59 (95% CI: 1.35–1.87); P<0.001). Furthermore, Ki-67/MIB-1 positivity is associated with worse survival in all patients (HR=1.95 (95% CI: 1.70–2.24; P<0.001)), node-negative patients (HR=2.54 (95% CI: 1.65–3.91); P<0.001) and node-positive patients (HR=2.33 (95% CI: 1.83–2.95); P<0.001). Our meta-analysis suggests that Ki-67/MIB-1 positivity confers a higher risk of relapse and a worse survival in patients with early BC

Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial.

AIMS: To report the longer term outcomes following either a strategy of endovascular repair first or open repair of ruptured abdominal aortic aneurysm, which are necessary for both patient and clinical decision-making. METHODS AND RESULTS: This pragmatic multicentre (29 UK and 1 Canada) trial randomized 613 patients with a clinical diagnosis of ruptured aneurysm; 316 to an endovascular first strategy (if aortic morphology is suitable, open repair if not) and 297 to open repair. The principal 1-year outcome was mortality; secondary outcomes were re-interventions, hospital discharge, health-related quality-of-life (QoL) (EQ-5D), costs, Quality-Adjusted-Life-Years (QALYs), and cost-effectiveness [incremental net benefit (INB)]. At 1 year, all-cause mortality was 41.1% for the endovascular strategy group and 45.1% for the open repair group, odds ratio 0.85 [95% confidence interval (CI) 0.62, 1.17], P = 0.325, with similar re-intervention rates in each group. The endovascular strategy group and open repair groups had average total hospital stays of 17 and 26 days, respectively, P < 0.001. Patients surviving rupture had higher average EQ-5D utility scores in the endovascular strategy vs. open repair groups, mean differences 0.087 (95% CI 0.017, 0.158), 0.068 (95% CI -0.004, 0.140) at 3 and 12 months, respectively. There were indications that QALYs were higher and costs lower for the endovascular first strategy, combining to give an INB of £3877 (95% CI £253, £7408) or €4356 (95% CI €284, €8323). CONCLUSION: An endovascular first strategy for management of ruptured aneurysms does not offer a survival benefit over 1 year but offers patients faster discharge with better QoL and is cost-effective. CLINICAL TRIAL REGISTRATION: ISRCTN 48334791