Association of inferior vena cava filter placement for venous thromboembolic disease and a contraindication to anticoagulation with 30-day mortality

Importance: Despite the absence of data from randomized clinical trials, professional societies recommend inferior vena cava (IVC) filters for patients with venous thromboembolic disease (VTE) and a contraindication to anticoagulation therapy. Prior observational studies of IVC filters have suggested a mortality benefit associated with IVC filter insertion but have often failed to adjust for immortal time bias, which is the time before IVC filter insertion, during which death can only occur in the control group. Objective: To determine the association of IVC filter placement with 30-day mortality after adjustment for immortal time bias. Design, Setting, and Participants: This comparative effectiveness, retrospective cohort study used a population-based sample of hospitalized patients with VTE and a contraindication to anticoagulation using the State Inpatient Database and the State Emergency Department Database, part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, from hospitals in California (January 1, 2005, to December 31, 2011), Florida (January 1, 2005, to December 31, 2013), and New York (January 1, 2005, to December 31, 2012). Data analysis was conducted from September 15, 2015, to March 14, 2018. Exposure: Inferior vena cava filter placement. Main Outcomes and Measures: Multivariable Cox proportional hazard models were constructed with IVC filters as a time-dependent variable that adjusts for immortal time bias. The Cox model was further adjusted using the propensity score as an adjustment variable. Results: Of 126 030 patients with VTE, 61 281 (48.6%) were male and the mean (SD) age was 66.9 (16.6) years. In this cohort, 45 771 (36.3%) were treated with an IVC filter, whereas 80 259 (63.7%) did not receive a filter. In the Cox model with IVC filter status analyzed as a time-dependent variable to account for immortal time bias, IVC filter placement was associated with a significantly increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P \u3c .001). When the propensity score was included in the Cox model, IVC filter placement remained associated with an increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P \u3c .001). Conclusions and Relevance: After adjustment for immortal time bias, IVC filter placement was associated with increased 30-day mortality in patients with VTE and a contraindication to anticoagulation. Randomized clinical trials are needed to determine the efficacy of IVC filter placement in patients with VTE and a contraindication to anticoagulation

Increased hazard of myocardial infarction with insulin‐provision therapy in actively smoking patients with diabetes mellitus and stable ischemic heart disease: The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial

Background In the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial, randomization of diabetic patients with stable ischemic heart disease to insulin provision ( IP ) therapy, as opposed to insulin sensitization ( IS ) therapy, resulted in biochemical evidence of impaired fibrinolysis but no increase in adverse clinical outcomes. We hypothesized that the prothrombotic effect of IP therapy in combination with the hypercoagulable state induced by active smoking would result in an increased risk of myocardial infarction ( MI ). Methods and Results We analyzed BARI 2D patients who were active smokers randomized to IP or IS therapy. The primary end point was fatal or nonfatal MI . PAI ‐1 (plasminogen activator inhibitor 1) activity was analyzed at 1, 3, and 5 years. Of 295 active smokers, MI occurred in 15.4% randomized to IP and in 6.8% randomized to IS over the 5.3 years ( P =0.023). IP therapy was associated with a 3.2‐fold increase in the hazard of MI compared with IS therapy (hazard ratio: 3.23; 95% confidence interval, 1.43–7.28; P =0.005). Baseline PAI ‐1 activity (19.0 versus 17.5 Au/mL, P =0.70) was similar in actively smoking patients randomized to IP or IS therapy. However, IP therapy resulted in significantly increased PAI ‐1 activity at 1 year (23.0 versus 16.0 Au/mL, P =0.001), 3 years (24.0 versus 18.0 Au/mL, P =0.049), and 5 years (29.0 versus 15.0 Au/mL, P =0.004) compared with IS therapy. Conclusions Among diabetic patients with stable ischemic heart disease who were actively smoking, IP therapy was independently associated with a significantly increased hazard of MI . This finding may be explained by higher PAI ‐1 activity in active smokers treated with IP therapy. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 00006305. </jats:sec

The association of preoperative cardiac stress testing with 30-day death and myocardial infarction among patients undergoing kidney transplantation

BACKGROUND:Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI. METHODS:Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation. RESULTS:In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79-1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89-1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71-1.32; P = 0.84). CONCLUSION:Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation

A constrained scheme for Einstein equations based on Dirac gauge and spherical coordinates

We propose a new formulation for 3+1 numerical relativity, based on a constrained scheme and a generalization of Dirac gauge to spherical coordinates. This is made possible thanks to the introduction of a flat 3-metric on the spatial hypersurfaces t=const, which corresponds to the asymptotic structure of the physical 3-metric induced by the spacetime metric. Thanks to the joint use of Dirac gauge, maximal slicing and spherical components of tensor fields, the ten Einstein equations are reduced to a system of five quasi-linear elliptic equations (including the Hamiltonian and momentum constraints) coupled to two quasi-linear scalar wave equations. The remaining three degrees of freedom are fixed by the Dirac gauge. Indeed this gauge allows a direct computation of the spherical components of the conformal metric from the two scalar potentials which obey the wave equations. We present some numerical evolution of 3-D gravitational wave spacetimes which demonstrates the stability of the proposed scheme.Comment: Difference w.r.t. v1: Major revision: improved presentation of the tensor wave equation and addition of the first results from a numerical implementation; w.r.t. v2: Minor changes: improved conclusion and figures; w.r.t. v3: Minors changes, 1 figure added; 25 pages, 13 figures, REVTeX, accepted for publication in Phys. Rev.

Association of alcohol consumption after development of heart failure with survival among older adults in the Cardiovascular Health Study

Importance: More than 1 million older adults develop heart failure annually. The association of alcohol consumption with survival among these individuals after diagnosis is unknown. Objective: To determine whether alcohol use is associated with increased survival among older adults with incident heart failure. Design, Setting, and Participants: This prospective cohort study included 5888 community-dwelling adults aged 65 years or older who were recruited to participate in the Cardiovascular Health Study between June 12, 1989, and June 1993, from 4 US sites. Of the total participants, 393 individuals had a new diagnosis of heart failure within the first 9 years of follow-up through June 2013. The study analysis was performed between January 19, 2016, and September 22, 2016. Exposures: Alcohol consumption was divided into 4 categories: abstainers (never drinkers), former drinkers, 7 or fewer alcoholic drinks per week, and more than 7 drinks per week. Primary Outcomes and Measures: Participant survival after the diagnosis of incident heart failure. Results: Among the 393 adults diagnosed with incident heart failure, 213 (54.2%) were female, 339 (86.3%) were white, and the mean (SD) age was 78.7 (6.0) years. Alcohol consumption after diagnosis was reported in 129 (32.8%) of the participants. Across alcohol consumption categories of long-term abstainers, former drinkers, consumers of 1-7 drinks weekly and consumers of more than 7 drinks weekly, the percentage of men (32.1%, 49.0%, 58.0%, and 82.4%, respectively; P \u3c .001 for trend), white individuals (78.0%, 92.7%, 92.0%, and 94.1%, respectively, P \u3c. 001 for trend), and high-income participants (22.0%, 43.8%, 47.3%, and 64.7%, respectively; P \u3c .001 for trend) increased with increasing alcohol consumption. Across the 4 categories, participants who consumed more alcohol had more years of education (mean, 12 years [interquartile range (IQR), 8.0-10.0 years], 12 years [IQR, 11.0-14.0 years], 13 years [IQR, 12.0-15.0 years], and 13 years [IQR, 12.0-14.0 years]; P \u3c .001 for trend). Diabetes was less common across the alcohol consumption categories (32.1%, 26.0%, 22.3%, and 5.9%, respectively; P = .01 for trend). Across alcohol consumption categories, there were fewer never smokers (58.3%, 44.8%, 35.7%, and 29.4%, respectively; P \u3c .001 for trend) and more former smokers (34.5%, 38.5%, 50.0%, and 52.9%, respectively; P = .006 for trend). After controlling for other factors, consumption of 7 or fewer alcoholic drinks per week was associated with additional mean survival of 383 days (95% CI, 17-748 days; P = .04) compared with abstinence from alcohol. Although the robustness was limited by the small number of individuals who consumed more than 7 drinks per week, a significant inverted U-shaped association between alcohol consumption and survival was observed. Multivariable model estimates of mean time from heart failure diagnosis to death were 2640 days (95% CI, 1967-3313 days) for never drinkers, 3046 days (95% CI, 2372-3719 days) for consumers of 0 to 7 drinks per week, and 2806 (95% CI, 1879-3734 days) for consumers of more than 7 drinks per week (P = .02). Consumption of 10 drinks per week was associated with the longest survival, a mean of 3381 days (95% CI, 2806-3956 days) after heart failure diagnosis. Conclusions and Relevance: These findings suggest that limited alcohol consumption among older adults with incident heart failure is associated with survival benefit compared with long-term abstinence. These findings suggest that older adults who develop heart failure may not need to abstain from moderate levels of alcohol consumption

Analysis of arterial sub-trees affected by Pulmonary Emboli

©2004 SPIE--The International Society for Optical Engineering. One print or electronic copy may be made for personal use only. Systematic reproduction and distribution, duplication of any material in this paper for a fee or for commercial purposes, or modification of the content of the paper are prohibited. The electronic version of this article is the complete one and can be found online at: http://dx.doi.org/10.1117/12.535993DOI: 10.1117/12.535993Presented at Medical imaging 2004. Image processing : 16-19 February 2004, San Diego, California, USA.Although Pulmonary Embolism (PE) is one of the most common causes of unexpected death in the U.S., it may also be one of the most preventable. Images acquired from 16-slice Computed Tomography (CT) machines of contrast-injected patients provide sufficient resolution for the localization and analysis of emboli located in segmental and sub-segmental arteries. After a PE is found, it is difficult to assess the local characteristics of the affected arterial tree without automation. We propose a method to compute characteristics of the local arterial tree given the location of a PE. The computed information localizes the portion of the arterial tree that is affected by the embolism. Our method is based on the segmentation of the arteries and veins followed by a localized tree computation at the given site. The method determines bifurcation points and the remaining arterial tree. A preliminary segmentation method is also demonstrated to locally eliminate over-segmentation of the arterial tree. The final result can then be used assess the affected lung volume and arterial supply. Initial tests revealed a good ability to compute local tree characteristics of selected sites

PET imaging of in vivo caspase-3/7 activity following myocardial ischemia-reperfusion injury with the radiolabeled isatin sulfonamide analogue [(18)F]WC-4-116

The utility of [(18)F]WC-4-116, a PET tracer for imaging caspase-3 activation, was evaluated in an animal model of myocardial apoptosis. [(18)F]WC-4-116 was injected into rats at 3 hours after a 30 min period of ischemia induced by temporary occlusion of the left anterior descending coronary artery in Sprague-Dawley rats. [(18)F]WC-4-116 uptake was quantified by 1) autoradiography, 2) microPET imaging studies, and 3) post-PET biodistribution studies. MicroPET imaging also assessed uptake of the non-caspase-3-targeted tracer [(18)F]ICMT-18 at 3 hours postischemia. Enzyme assays and Western blotting assessed caspase-3 activation in both at-risk and not-at-risk regions. Caspase-3 enzyme activity increased in the at-risk but not in the not-at-risk myocardium. Quantitative autoradiographic analysis of [(18)F]WC-4-116 demonstrated nearly 2-fold higher uptake in the ischemia-reperfusion (IR) versus sham animals. [(18)F]WC-4-116 microPET imaging studies demonstrated that the IR animals was similarly elevated in relation to sham. [(18)F]ICMT-18 uptake did not increase in at-risk myocardium despite evidence of caspase-3 activation. Biodistribution studies with [(18)F]WC-4-116 confirmed the microPET findings. These data indicate that the caspase-3-PET tracer [(18)F]WC-4-116 can noninvasively image in vivo caspase activity during myocardial apoptosis and may be useful for clinical imaging in humans

Slope of the anterior mitral valve leaflet: A new measurement of left ventricular unloading for left ventricular assist devices and systolic dysfunction

Left ventricular assist device (LVAD)-supported patients are evaluated routinely with use of transthoracic echocardiography. Values of left ventricular unloading in this unique patient population are needed to evaluate LVAD function and assist in patient follow-up. We introduce a new M-mode measurement, the slope of the anterior mitral valve leaflet (SLAM), and compare its efficacy with that of other standard echocardiographically evaluated values for left ventricular loading, including E/e′ and pulmonary artery systolic pressures. Average SLAM values were determined retrospectively for cohorts of random, non-LVAD patients with moderately to severely impaired left ventricular ejection fraction (LVEF) (<0.35, n=60). In addition, pre- and post-LVAD implantation echocardiographic images of 81 patients were reviewed. The average SLAM in patients with an LVEF <0.35 was 11.6 cm/s (95% confidence interval, 10.4–12.8); SLAM had a moderately strong correlation with E/e′ in these patients. Implantation of LVADs significantly increased the SLAM from 7.3 ± 2.44 to 14.7 ± 5.01 cm/s (n=42, P <0.0001). The LVAD-supported patients readmitted for exacerbation of congestive heart failure exhibited decreased SLAM from 12 ± 3.93 to 7.3 ± 3.5 cm/s (n=6, P=0.041). In addition, a cutpoint of 10 cm/s distinguished random patients with LVEF <0.35 from those in end-stage congestive heart failure (pre-LVAD) with an 88% sensitivity and a 55% specificity. Evaluating ventricular unloading in LVAD patients remains challenging. Our novel M-mode value correlates with echocardiographic values of left ventricular filling in patients with moderate-to-severe systolic function and dynamically improves with the ventricular unloading of an LVAD

Supersymmetric Pair Correlation Function of Wilson Loops

We give a path integral derivation of the annulus diagram in a supersymmetric theory of open and closed strings with Dbranes. We compute the pair correlation function of Wilson loops in the generic weakly coupled supersymmetric flat spacetime background with Dbranes. We obtain a -u^4/r^9 potential between heavy nonrelativistic sources in a supersymmetric gauge theory at short distances.Comment: 18 pages, Revte