Fighting Depression at Christmas

Depression is a hard thing to understand and an even harder thing to explain. But you don’t have to ‘get it’ to help your loved ones this holiday season. Posting about factors that contribute to depression from In All Things - an online hub committed to the claim that the life, death, and resurrection of Jesus Christ has implications for the entire world. http://inallthings.org/fighting-depression-at-christmas

Implications of myocardial dysfunction before and after aortic valve intervention

BACKGROUND Postoperative heart failure in the setting of aortic valve surgery results in poor long-term survival. We hypothesized that there could be a myocardial factor that is not addressed by risk scores currently available. We speculated that this myocardial factor could be diastolic dysfunction. By evaluating postoperative heart failure, the EuroSCORE, the NT-proBNP level, and diastolic function, we might achieve a deeper understanding of the outcome for individuals with postoperative heart failure. METHODS This research project was built upon four cohort studies. The first two studies (I and II) were retrospective in nature, and studies III and IV were prospective, observational, and longitudinal. All work was based on data from clinical and national databases. In Study I, we compared the outcome of patients with or without postoperative heart failure, evaluated according to the preoperative risk score. In Study II, we explored the effect of underlying heart disease on the preoperative level of NT-proBNP and the relationships between NT-proBNP and severe postoperative heart failure and short-term mortality. In Study III, we described the dynamics of NT-proBNP, from a preoperative evaluation to a six-month follow-up, in patients that underwent one of two different procedures: a surgical aortic valve replacement and a transcatheter implantation. We related both pre- and postprocedural NT-proBNP levels to one-year mortality. In Study IV, we evaluated diastolic function in patients that underwent surgical aortic valve replacement and its influence on outcome. We also evaluated NT-proBNP levels and postoperative heart failure as predictors of long-term mortality. RESULTS Study I This study included 397 patients that underwent isolated surgical aortic valve replacements. Of these, 45 patients (11%) were treated for postoperative heart failure. With an average follow-up of 8.1 years (range 5.2-11.2), among patients at low risk (EuroSCORE≤7), the crude five-year survival rates were 58% in patients with postoperative heart failure and 89% in those without postoperative heart failure (p<0.001). Among patients with postoperative heart failure, those classified as low risk had the same poor long-term prognosis as those classified as high risk (EuroSCORE>7). In the high risk group, survival rates were similar between patients with or without postoperative heart failure (57% vs. 64%; p=0.60). Study II This study included a cohort of 2978 patients with coronary artery disease, aortic stenosis, and mitral regurgitation. Preoperative NTproBNP levels were found to be 1.7-fold higher in patients with aortic stenosis than in patients with coronary artery disease and 1.4-fold higher in patients with mitral regurgitation than in patients with coronary disease. The power of preoperative NT-proBNP for predicting severe postoperative heart conditions was good among patients with coronary heart disease and patients with mitral regurgitation, but not as good among patients with aortic stenosis. NT-proBNP also showed good discriminating power for short-term mortality among patients with coronary artery disease. Moreover, NT-proBNP was found to be an independent predictor for both severe postoperative heart failure and short-term mortality in patients with coronary artery disease. Study III This study included 462 patients that underwent preoperative evaluations for aortic valve disease. Aortic valve interventions elicited a rise in NT-proBNP that was more pronounced in patients undergoing surgical aortic valve replacement compared to patients undergoing transcatheter valve implantation. No deterioration in NT-proBNP was observed during the waiting time before the intervention, despite a median duration of four months. At six months after the intervention, NT-proBNP levels had decreased to or below the preoperative levels in all groups. Among patients that received surgical aortic valve replacements, pre-and early postoperative NT-proBNP levels showed good discriminatory power for oneyear mortality. This discriminatory power was not observed among patients that had undergone a transcatheter procedure; those patients had higher levels of both pre- and postoperative NT-proBNP compared to patients that had undergone surgery. Study IV We evaluated 273 patients that underwent aortic valve surgery. High left ventricular filling pressure was present in 22% (n=54) of patients at the time of surgery. At six months after surgery, diastolic function deteriorated in 24/193 (12%) patients and improved in 27/54 (50%) patients. Diastolic dysfunction was not found to be associated with long-term mortality. However, both postoperative heart failure and preoperative NTproBNP levels were associated with increases in long-term mortality. In a multivariable Cox analysis, NT-proBNP remained predictive of long-term mortality. CONCLUSION Postoperative heart failure contributed to long-term mortality, even in patients considered to be at low risk preoperatively. Our results suggested that pressure overload, followed by a volume overload led to a NTproBNP response that was more pronounced than the ischemia response. Elevated levels of NT-proBNP were associated with both short- and long-term mortality. In these studies, we could not corroborate the notion that high left ventricular filling pressure was associated with long-term mortality

The Combined Impact of Postoperative Heart Failure and EuroSCORE on Long-Term Outcome after Surgery for Aortic Stenosis

Background and aim of the study: Although the EuroSCORE was developed for predicting operative mortality after cardiac surgery, it has also been shown to predict long-term mortality. It has been reported that postoperative heart failure (PHF) in association with surgery, albeit comparatively benign in the short term, has a profound impact on five-year survival after surgery for aortic stenosis (AS). The study aim was to determine the combined impact of EuroSCORE and PHF on long-term survival after isolated aortic valve replacement (AVR) for AS. Methods: A total of 397 patients (48% females; average age 70 +/- 10 years) who underwent AVR for AS at the authors' institution between 1995 and 2000 was studied. The cohort was subdivided according to the additive EuroSCORE into a high-risk group (EuroSCORE >7) and a low-risk group (EuroSCORE Results: The average follow up was 8.1 years (range: 5.2-11.2 years). Forty-five patients (11%) were treated for procedure-associated PHF. Patients with or without PHF and a high-risk EuroSCORE had crude five-year survivals of 57% and 64%, respectively (p = 0.6), whereas those with or without PHF but with a low-risk EuroSCORE had crude five-year survivals of 58% and 89%, respectively (p = 0.0003). Conclusion: Both PHF and a high EuroSCORE were associated with poor long-term survival. The role of PHF per se for the long-term prognosis was illustrated by the fact that the negative impact on long-term survival was almost as profound in patients of the low-risk group as of the high-risk group

Evaluation of the Valve Academic Research Consortium-2 Criteria for Myocardial Infarction in Transcatheter Aortic Valve Implantation: A Prospective Observational Study

Objective To evaluate the relevance of the individual components of the Valve Academic Research Consortium (VARC)-2 criteria for periprocedural myocardial infarction (MI) in transcatheter aortic valve implantation (TAVI). The association between biomarkers and adverse procedural outcome has been established. However, the additive prognostic importance of signs and symptoms are more uncertain. Methods A total of 125 consecutive TAVI patients were prospectively included in this study. Biomarkers for MI were analyzed and signs and symptoms according to VARC-2 criteria were collected from clinical records. Results The criteria of elevated biomarkers and of signs or symptoms were found in 27 (22%) and 32 (26%) of the patients, respectively. According to VARC-2 definition, 12 (10%) had MI. VARC-2 definition of MI, Troponin T (TnT) greater than 600 ng/L, and presence of signs or symptoms correlated with 6 months mortality, prolonged ICU stay, elevation of N-terminal prohormone brain natriuretic peptide, and renal impairment. No signs or symptoms were found in 7 (44%) of the patients who fulfilled the criterion of elevated TnT greater than 600 ng/L. In the group with positive TnT criterion, there were no significant differences between those with and without signs or symptoms in respect to levels of TnT (1014 [585-1720] ng/L versus 704 [515-905] ng/L, p = 0.17) or creatine kinase-MB (36 [25-52] mu g/L versus 29 [25-39] mu g/L, p = 0.32). In the multivariate Cox regression analysis, TnT greater than 600 ng/L was the only significant independent variable associated with 6-months postprocedural mortality. Conclusions Myocardial injury in TAVI, measured with biomarkers, correlates well with adverse procedural outcome. In this study it is also the strongest predictor for early postprocedural mortality. The additional requirement of signs or symptoms for the diagnosis of MI results in omission of a considerable number of clinically significant MI.Funding Agencies|Medical Research Council of Southeast Sweden [FORSS-12657, FORSS-23891, FORSS-159851, FORSS-311341]; ALF founding, County Council of Ostergotland, Sweden</p

N.B.: When citing this work, cite the original article. Original Publication:

Transcatheter versus surgical treatment fo

Transcatheter versus surgical treatment for aortic stenosis : Patient selection and early outcome

Objectives. To describe short-term clinical and echocardiography outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). To explore patient selection criteria for treatment with TAVI. Design. TAVI patients (n = 45) were matched to SAVR patients (n = 45) with respect to age within +/- 10 years, sex and systolic left ventricular function. Results. TAVI patients were older, 82 +/- 8 versus 78 +/- 5 years (p = 0.005) and they had higher logEuroSCORE, 16 +/- 11% versus 8 +/- 4% (p andlt; 0.001). There were no significant differences in 30 days mortality, stroke and myocardial infarction. TAVI patients received less erythrocyte (53% vs. 78%, p = 0.03) and thrombocyte (7% vs. 27%, p = 0.02) transfusions. Postoperative atrial fibrillation was less common (18% vs. 60%, p andlt; 0.001) in the TAVI group. Paravalvular regurgitation was more common in TAVI patients (87% vs. 0%, p andlt; 0.001) and 27% had access site complications. Aortic transvalvular velocity was 2.3 +/- 0.4 m/s versus 2.6 +/- 0.5 m/s (p = 0.002) and mean valve pressure gradient was 12 +/- 4 mmHg versus 15 +/- 5 mmHg (p = 0.01) in the TAVI and SAVR groups, respectively. Twenty-nine (64%) of the TAVI patients had logEuroSCORE andlt; 15%. Conclusions. Both TAVI and SAVR have good short term clinical outcome with excellent hemodynamic result. In clinical practice, factors other than high logEuroSCORE play an important role in patient selection for TAVI.Funding Agencies|Swedish Heart and Lung Foundation||Medical Research Council of Southeast Sweden (FORSS)||ALF||County Council of Ostergotland||</p

Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery

Objective The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality. Methods A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures. Results Preoperative NT-proBNP was 1.67 times (pamp;lt;0.0001) and 1.41 times (pamp;lt;0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders. NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95% CI 0.73 +/- 0.85, pamp;lt;0.0001), MR (AUC = 0.80, 95% CI 0.72 +/- 0.87, pamp;lt;0.0001) and AS (AUC = 0.66, 95% CI 0.51 +/- 0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95% CI 0.71 +/- 0.85, pamp;lt;0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD. Conclusions Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.Funding Agencies|Region Ostergotland [LIO-443891]</p

Baseline patient characteristics and procedural data according to the cumulative all-cause mortality at 6-months follow-up.

<p>Data are presented as numbers (%), mean ± SD or median (25th to 75th percentile). COPD = chronic obstructive pulmonary disease; ECC = extracorporeal circulation; LVEF = Left ventricular ejection fraction; MI = myocardial injury; NYHA = New York Heart Association class; NT-proBNP = N-terminal prohormone brain natriuretic peptide; PCI = percutaneous coronary intervention; PAP = pulmonary artery pressure; CK-MB = creatine kinase-muscle, brain isotype; TnT = Troponin T.</p><p>Baseline patient characteristics and procedural data according to the cumulative all-cause mortality at 6-months follow-up.</p

Procurement procedures - open competition problems of organization of public procurement

Darbā apskatīts šī brīža Publisko iepirkumu likuma regulējums attiecībā uz atklāta konkursa, kā viena no iepirkuma procedūras veidiem, piemērošanu un organizēšanu, kā arī izstrādātais jaunais publisko iepirkumu likumprojekts, kurā plānots iestrādāt Eiropas Parlamenta un Padomes 2014.gada 26.februāra Direktīvā 2014/24/ES par publisko iepirkumu un ar ko atceļ Direktīvu 2004/18/EK (turpmāk tekstā – Direktīva 2014/24/ES) noteikto. Tiek pētīts tiesiskais regulējums, kā arī raksturotas praksē pastāvošās problēmas, piedāvājot risinājumus šo problēmu novēršanai. Darbs sastāv no trīs nodaļām, kuras ir strukturētas apakšnodaļās. Vispirms autore apskatījusi atklāta konkursa nošķiršanu no citām iepirkuma procedūrām, piemērošanas tiesiskais regulējums un tā plānošanas nepieciešamību. Secīgi autore apskatījusi iepirkuma komisijas izveides kārtību un darbību, organizējot atklātu konkursu. Darba noslēgumā autore izpētījusi atklāta konkursa organizēšanas procesu. Darba izstrādes mērķis ir vērst uzmanību uz problēmām, kas saistās ar atklāta konkursa organizēšanu, kas kavē kvalitatīva un pasūtītāja vajadzībām atbilstoša atklāta konkursa organizēšanu iepirkuma līguma noslēgšanai un kvalitatīva pakalpojuma saņemšanai, piedāvājot priekšlikumus šo problēmu mazināšanai vai risināšanai. Darba pamatā ir izmantoti publisko iepirkumu regulējošie normatīvie akti, tiesu prakse, Iepirkumu uzraudzības biroja lēmumi, publikācijas, kā arī interneta resursi. Darba izstrādes gaitā autore ir nonākusi pie vairākiem problēmjautājumiem un no tiem izrietošiem secinājumiem. Darba noslēgumā ir norādīti secinājumi, kā arī priekšlikumi atklātu konkursu organizēšanas problēmu novēršanai vai mazināšanai.In this work is viewed current Public Procurement Law framework for the open competition, as one of the types of procurement procedure, its application and organization, as well as the new public procurement bill, which is planned to incorporate in the European Parliament Council of 26 February 2014 Directive 2014/24/EU public procurement and repealing Directive 2004/18/EC (hereinafter - Directive 2014/24 /EU). Will be also studied legislation, as well as the described existing problems in practice, offering solutions to these problems. The work consists of three chapters, which are structured in sections. First of all, the author looked at the open competition separation from other procurement procedures, application of legislation and the need for its planning. Sequentially, the author examined the procurement commission procedures establishment and functioning, while organizing an open competition. In the final phase, the author studied the open tendering process. The aim is to draw attention to the problems associated with the organization of an open competition, hindering qualitative and customer-needed proper conclusion of an open competition procurement agreement and receiving of qualitative service, offering proposals to solve or alleviate these problems. This work is based on the use of Public Procurement Law, practice of jurisprudence, decisions of the Procurement Monitoring Bureau (IUB), publications, as well as internet resources. During the process of developing this work, the author has come to a number of issues and resulting conclusions. Final section presents conclusions, as well as proposals for preventing or reducing the problems in the organization of an open competition