Outpatient management of patients with peripheral artery disease by cardiologists or surgeons: influence on the prognosis and prevalence of surgical interventions

Highlights. The study shows for the first time that during the three-year follow-up of patients with diseases of the arteries of the lower extremities in the observation groups of a general surgeon and a cardiologist, adverse events (myocardial infarction, stroke, amputation, disability) and deaths occurred more often in a surgeon than a cardiologist. The study proves the correctness and real benefit of such an approach with the involvement of a cardiologist to the outpatient stage of management of a complex cohort of patients with atherosclerosis of the vessels of the lower extremities.Aim. To study the effect the outpatient observation of patients with peripheral arteries disease (PAD) by cardiologists and surgeons has on timing and prevalence of reconstructive surgery and the prognosis of patients. Methods We analyzed the data on 585 PAD patients who underwent outpatient observation from 2010 to 2017, dividing them into 2 groups. The first group (131 patients) managed by an surgeon; the second (454 patients) managed by a cardiologist. Since the groups were not comparable in terms of the initial parameters, the comparability of patients in the groups (observation by a surgeon or by a cardiologist) was achieved using pseudorandomization. The follow-up period was three years; we assessed the incidence of deaths, adverse events, and the prevalence of reconstructive operations.Results. During a three-year follow-up the 1st group, compared with the 2nd, had more deaths in general (p<0.001), death from cardiac causes (p = 0.045), from stroke (p><0.001), as well as the total number of adverse events (p><0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients. Conclusion Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries. Keywords Peripheral atherosclerosis • Outpatient follow-up • Optimal drug therapy • Reconstructive surgery>˂ 0.001), death from cardiac causes (p = 0.045), from stroke (p˂ 0.001), as well as the total number of adverse events (p˂ 0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients.Conclusion. Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries.Highlights. The study shows for the first time that during the three-year follow-up of patients with diseases of the arteries of the lower extremities in the observation groups of a general surgeon and a cardiologist, adverse events (myocardial infarction, stroke, amputation, disability) and deaths occurred more often in a surgeon than a cardiologist. The study proves the correctness and real benefit of such an approach with the involvement of a cardiologist to the outpatient stage of management of a complex cohort of patients with atherosclerosis of the vessels of the lower extremities.Aim. To study the effect the outpatient observation of patients with peripheral arteries disease (PAD) by cardiologists and surgeons has on timing and prevalence of reconstructive surgery and the prognosis of patients. Methods We analyzed the data on 585 PAD patients who underwent outpatient observation from 2010 to 2017, dividing them into 2 groups. The first group (131 patients) managed by an surgeon; the second (454 patients) managed by a cardiologist. Since the groups were not comparable in terms of the initial parameters, the comparability of patients in the groups (observation by a surgeon or by a cardiologist) was achieved using pseudorandomization. The follow-up period was three years; we assessed the incidence of deaths, adverse events, and the prevalence of reconstructive operations.Results. During a three-year follow-up the 1st group, compared with the 2nd, had more deaths in general (p<0.001), death from cardiac causes (p = 0.045), from stroke (p><0.001), as well as the total number of adverse events (p><0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients. Conclusion Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries. Keywords Peripheral atherosclerosis • Outpatient follow-up • Optimal drug therapy • Reconstructive surgery>˂ 0.001), death from cardiac causes (p = 0.045), from stroke (p˂ 0.001), as well as the total number of adverse events (p˂ 0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients.Conclusion. Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries

Population exposure to hazardous air quality due to the 2015 fires in Equatorial Asia.

Vegetation and peatland fires cause poor air quality and thousands of premature deaths across densely populated regions in Equatorial Asia. Strong El-Niño and positive Indian Ocean Dipole conditions are associated with an increase in the frequency and intensity of wildfires in Indonesia and Borneo, enhancing population exposure to hazardous concentrations of smoke and air pollutants. Here we investigate the impact on air quality and population exposure of wildfires in Equatorial Asia during Fall 2015, which were the largest over the past two decades. We performed high-resolution simulations using the Weather Research and Forecasting model with Chemistry based on a new fire emission product. The model captures the spatio-temporal variability of extreme pollution episodes relative to space- and ground-based observations and allows for identification of pollution sources and transport over Equatorial Asia. We calculate that high particulate matter concentrations from fires during Fall 2015 were responsible for persistent exposure of 69 million people to unhealthy air quality conditions. Short-term exposure to this pollution may have caused 11,880 (6,153-17,270) excess mortalities. Results from this research provide decision-relevant information to policy makers regarding the impact of land use changes and human driven deforestation on fire frequency and population exposure to degraded air quality.This research was supported in part by a L’Oréal-UNESCO UK and Ireland Fellowship For Women In Science (to PC), the Natural Environmental Research Council (NERC) through the LICS the SAMBBA project (ref. NE/J009822/1), the EPA STAR program (R835422), and the National Research Fellow Award (NRF2012NRFNRFF001-031). EB is partly supported by funding from UBoC. Further support was provided by the Lilly Endowment, Inc., through its support for the Indiana University Pervasive Technology Institute and the Indiana METACyt Initiative. This work makes use of the LandScan (2013)™ High Resolution global Population Data Set copyrighted by UT-Battelle, LLC, operator of Oak Ridge National Laboratory under Contract No. DE-AC05- 00OR22725 with the United States Department of Energy. Global Burden of Disease used in this study have been accessed from the Institute for Health Metric and Evaluation website: http://ghdx.healthdata.org/ihme_data. We gratefully acknowledge the National Environment Agency (NEA) of Singapore for collecting and providing PM2.5 and PSI data (available at http://www.nea.gov.sg/anti-pollution-radiation-protection/air-pollution-control/psi/historical-psi-readings). The National Center for Atmospheric Research is operated by the University Corporation for Atmospheric Research under the sponsorship of the National Science Foundation. We thank Louisa Emmons for providing the boundary conditions for dust from CAM-Chem. We also acknowledge the NASA scientists responsible for MODIS products, WRF-Chem developers and ACOM scientists at NCAR for useful discussion on model set-up

Diode area melting single-layer parametric analysis of 316L stainless steel powder

Diode area melting (DAM) is a novel additive manufacturing process that utilises customised architectural arrays of low power laser diode emitters for high speed parallel processing of metallic powdered feedstock. The laser diodes operate at shorter laser wavelengths (808 nm) than conventional SLM fibre lasers (1064 nm) theoretically enabling more efficient energy absorption for specific materials. This investigation presents a parametric analysis of the DAM process, identifying the effect of powder characteristics, laser beam profile, laser power and scan speed on the porosity of a single-layer sample. Also presented is the effect of process energy density on melt pool depth (irradiated thermal energy penetration capable of achieving melting) on 316L stainless steel powder. An analysis of the density and the melt depth fraction of single layers is presented in order to identify the conditions that lead to the fabrication of fully dense DAM parts. Energy densities in excess of 86 J/mm3 were theorised as sufficient to enable processing of fully dense layers

Assessment of left ventricular diastolic dysfunction following anthracyclinebased chemotherapy in breast cancer patients

Cardiotoxicity is a side effect of anthracycline-based chemotherapy. Clinical and prognostic significance of left ventricular diastolic dysfunction in heart failure patients is undeniable.The aim. To assess dynamic changes in the left ventricular diastolic function after anthracycline-based chemotherapy (ANT) in breast cancer patients.Material and methods. The study included 40 women aged 35 to 72 years with breast cancer (BC) undergoing ANT chemotherapy. The main group (n = 40) consisted of women with breast cancer examined at admission, after 6 months the same women (n = 37) were examined again. Women without breast cancer (n = 25) were used as the control group.Results. Dynamic changes in mitral annular velocities were revealed by Doppler tissue imaging. Lateral early diastolic mitral annular velocity (e’ lateral) was significantly lower in breast cancer patients as compared to the control group (p = 0.031). Six months after ANT chemotherapy, there was a definite increase in the lateral late diastolic mitral annular velocity (a’ lateral) (p = 0.033). Average early diastolic transmitral flow velocity to early diastolic velocity (E/e’ lateral) ratio was within the normative values in all groups, but E/e’ lateral in the main group was higher compared to the control group (p = 0.003). In the main group, septal early diastolic mitral annular velocity (e’ septal) was lower compared to the control group (p = 0.0005). Moreover, an increase in the septal mitral annular velocity (a’ septal) (p = 0.01) and higher E/e’ septal ratio (p = 0.011) were revealed during dynamic observation. Multiple logistic regression disclosed that E/A, e’ lateral, e’/a’ lateral, and E/e’ lateral were affected by heart rate, psychological status, age, hypertension, and body mass index, but not anthracycline chemotherapy. The total dose of anthracycline was independently associated with e’ septal and E/e’ septal: F(4.18) = 16.466 (p < 0.001; R2 = 0.775) and F(3.16) = 7.271 (p = 0.004; R2 = 0.627).Conclusion. Left ventricular diastolic function worsens in women undergoing anthracycline-based chemotherapy for breast cancer (lower e’, e’/a’ lateral, and e’ septal, higher E/e’ septal ratio). However, anthracycline does not significantly affect LVEF and LV deformation indicators. E/e’ septalande’ septal are independently associated with the total dose of anthracycline

Disse index and free fatty acids as markers of insulin resistance and their association with hospital outcomes of coronary bypass surgery in patients with different glycemic status

AIM: to analyze various indices of insulin resistance and plasma free fatty acid (FFA) levels, and their association with the preoperative status and in-hospital complications after coronary artery bypass grafting (CABG) in normoglycemic patients and patients with carbohydrate metabolism disorders (CMD).MATERIALS AND METHODS: The study included 708 patients who underwent CABG. The glycemic status, preoperative parameters, the specifics of surgical intervention, in-hospital complications were analyzed. The patients were divided into 2 groups: Group 1 (n=266) — patients with CMD (type 2 diabetes mellitus (T2DM) and prediabetes); Group 2 (n=442) — patients without CMD. Plasma FFA and fasting plasma insulin levels were determined, the Disse index, the quantitative insulin sensitivity check index (QUICKI), revised QUICKI were estimated in 383 patients.RESULTS: Screening prior to CABG increased the number of patients with T2DM from 15.2% to 24.1%, prediabetes – from 3.0% to 13.4%, with any CMD – from 18.2% to 37.5%.Patients with CMD showed a higher percentage of significant hospital complications (25.2% vs 17.0%, p=0.007), progression of renal failure (6.3% vs 2.9%, p=0.021), multiple organ failure (4.5% vs 1.7%, p=0.039), sternal wound complications (6.3% vs 2.9%, p=0.018), renal replacement therapy (3.7% vs 1.1%, p=0.020), surgery on peripheral arteries (1.5% vs 0%, p=0.039).According to the results of multivariate analysis, the Disse index turned out to be a significant predictor of the end point (hospital stay >10 days or any significant complication CABG) in several regression models (OR 1.060 in one of the models; 95% CI 1.016–1.105; p=0.006). Independent predictors of the end point were: female gender, age, body mass index, cardiopulmonary bypass duration, left atrium size, left ventricular end diastolic dimension, T2DM, FFA levels (OR 3.335; 95% CI 1.076–10.327; p=0.036), average postoperative glycemia on the 1st day after CABG, failure to achieve the target range of perioperative glycemia.CONCLUSION: Screening for CMD prior to CABG can significantly increase the number of patients with diagnosed CMD. Significant in-hospital complications after CABG tend to be more prevalent in patients with CMD compared with normoglycemic patients. Insulin resistance index Disse, FFA, postoperative glycemia are independent predictors of prolonged hospital stay or postoperative complications of CABG

Проверка сообщения о ненадлежащем оказании медицинской помощи (доследственная проверка) – что следует знать анестезиологу-реаниматологу

The objective: to raise the awareness of medical professionals about one of the stages of investigation – pre-investigation check.Results: the article presents the information on the legal aspects of the review of a report on medical crime (pre-investigation check). It outlines potential legal consequences for a physician at this stage of the legal proceedings. Lawyers' advice on the principles of conduct for a medical professional during pre-investigation checks is discussed. Physicians, who are the subject for the review of a report on medical crime are advised to take active participation in the proceedings, to clarify the circumstances of the case and potential legal consequences. At the same time, they are recommended to use affirmative defense based on existing regulations and get experienced lawyers involved.Цель: ознакомить врачей с особенностями одного из этапов расследования преступлений, связанных с медицинской деятельностью, ‒ доследственной проверки.Результаты: приведены сведения о юридических аспектах проверки сообщения о преступлении, связанном с оказанием медицинской помощи (доследственной проверке). Обозначаются возможные правовые последствия для врача на данном этапе юридического разбирательства. Обсуждаются советы юристов в отношении правил поведения медработника при доследственной проверке. Врачам, в отношении которых проводится проверка сообщения о ненадлежащем оказании медицинской помощи, рекомендуется активно участвовать в процессуальных действиях, выяснять обстоятельства дела, возможные юридические последствия. При этом следует использовать аргументы в свою защиту на основе имеющейся нормативной базы, привлекать опытных юристов

ВЫЖИВАЕМОСТЬ ПОСЛЕ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ БОЛЬНЫХ С МУЛЬТИФОКАЛЬНЫМ АТЕРОСКЛЕРОЗОМ В РАЗЛИЧНЫХ ВОЗРАСТНЫХ ГРУППАХ

The purpose: Conducting the analysis of survival after surgery and the study of factors associated with mortality in patients with multifocal atherosclerosis (MFA) in diferent age groups.Material and methods. It were included 764 consecutive patients aged 39 to 84 years with the MFA, who underwent isolated coronary artery bypass grafting (CABG) or CABG in combination with simultaneous or staged surgical interventions in the non-coronary vascular beds. The treatment procedure was determined by the heart team. Depending on the age of patients formed 4 groups: Group 1 - patients up to 60 years (n = 338), 2 group - 60-64 years (n = 185), 3 group - 65-69 years (n = 137) and group 4 - patients 70 years and older (n = 104).Results. Analysis of hospital mortality after CABG surgery showed no signifcant diference between the groups, despite its increase among patients older than 65 years (p = 0.373). A similar trend was observed for remote mortality rates without statistical signifcance between the groups. Survival analysis showed no diference between groups in the time to onset of death (p = 0.205), the proportion of survivors over the period of observation in all groups was more than 75%. The regression survival Cox model showed that, in time before the fatal outcome after revascularization surgery were signifcantly associated female gender (p = 0.009), presence of diabetes mellitus (p = 0.003), stroke history (p = 0.002), the risk of surgical intervention on a scale EuroSCORE (p = 0.011) and left ventricular ejection fraction (p = 0.008).Conclusion. Advanced age in combination with the MFA is a marker of increased mortality after revascularization surgery; however, these patients have favorable results on the long-term survival after staged surgeryЦель. Проведение анализа выживаемости после хирургических вмешательств и изучение факторов, ассоциированных со временем наступления летального исхода у больных с мультифокальным атеросклерозом (МФА) в различных возрастных группах.Материал и методы. Включено 764 последовательных больных в возрасте от 39 до 84 лет с МФА, которым выполнялось изолированное коронарное шунтирование (КШ), либо КШ в сочетании с одномоментными или этапными хирургическими вмешательствами на некоронарных сосудистых бассейнах. Выбор тактики лечения определялся мультидисциплинарным консилиумом. В зависимости от возраста пациентов сформировано 4 группы: 1-я группа – больные до 60 лет (n=338), 2-я группа – 60-64 года (n=185), 3-я группа − 65-69 лет (n=137) и 4-я группа – больные 70 лет и старше (n=104).Результаты. Анализ госпитальной летальности после проведенной операции КШ не выявил значимой разницы между группами, несмотря на ее увеличение среди больных старше 65 лет (р=0,373). Подобная тенденция наблюдалась и по отдаленным показателям смертности без статистической достоверности между группами. Анализ выживаемости выявил отсутствие различий между группами по времени до наступления летального исхода (р=0,205), доля выживших за указанный период наблюдения во всех группах составила более 75%. Регрессионная модель выживаемости Кокса показала, что со временем наступления летального исхода после реваскуляризирующих вмешательств были достоверно связаны женский пол (р=0,009), наличие сахарного диабета (р=0,003), перенесенное ОНМК (р=0,002), риск оперативного вмешательства по шкале EuroScore (р=0,011) и ФВЛЖ (р=0,008).Заключение. Пожилой возраст в сочетании с МФА является маркером повышенной смертности после реваскуляризирующих операций, тем не менее, у данной категории больных могут быть получены благоприятные показатели по отдаленной выживаемости после хирургических операций

Properties and Evolution of the Redback Millisecond Pulsar Binary PSR J2129-0429

PSR J2129−0429 is a "redback" eclipsing millisecond pulsar binary with an unusually long 15.2 hr orbit. It was discovered by the Green Bank Telescope in a targeted search of unidentified Fermi gamma-ray sources. The pulsar companion is optically bright (mean m_R = 16.6 mag), allowing us to construct the longest baseline photometric data set available for such a system. We present 10 years of archival and new photometry of the companion from the Lincoln Near-Earth Asteroid Research Survey, the Catalina Real-time Transient Survey, the Palomar Transient Factory, the Palomar 60 inch, and the Las Cumbres Observatory Global Telescope. Radial velocity spectroscopy using the Double-Beam Spectrograph on the Palomar 200 inch indicates that the pulsar is massive: 1.74 ± 0.18 M_☉. The G-type pulsar companion has mass 0.44 ± 0.04 M_☉, one of the heaviest known redback companions. It is currently 95 ± 1% Roche-lobe filling and only mildly irradiated by the pulsar. We identify a clear 13.1 mmag yr^(−1) secular decline in the mean magnitude of the companion as well as smaller-scale variations in the optical light curve shape. This behavior may indicate that the companion is cooling. Binary evolution calculations indicate that PSR J2129−0429 has an orbital period almost exactly at the bifurcation period between systems that converge into tighter orbits as black widows and redbacks and those that diverge into wider pulsar–white dwarf binaries. Its eventual fate may depend on whether it undergoes future episodes of mass transfer and increased irradiation

An Accreting White Dwarf near the Chandrasekhar Limit in the Andromeda Galaxy

The iPTF (Intermediate Palomar Transient Factory) detection of the most recent outburst of the recurrent nova system RX J0045.4+4154 in the Andromeda Galaxy has enabled the unprecedented study of a massive (mass is greater than 1.3 solar masses) accreting white dwarf (WD). We detected this nova as part of the near daily iPTF monitoring of M31 to a depth of R (red band-pass filter) approximately equal to magnitude 21 and triggered optical photometry, spectroscopy and soft X-ray monitoring of the outburst. Peaking at an absolute magnitude of MR (red, mid-infrared band-pass filter) equals magnitude 6.6, and with a decay time of 1 magnitude per day, it is a faint and very fast nova. It shows optical emission lines of He/N and expansion velocities of 1900 to 2600 kilometers per second 1-4 days after the optical peak. The Swift monitoring of the X-ray evolution revealed a supersoft source (SSS) with kT (energy: Boltzmann constant times temperature) (sub eff (effective)) approximately equal to 90-110 electronvolts that appeared within 5 days after the optical peak, and lasted only 12 days. Most remarkably, this is not the first event from this system, rather it is a recurrent nova with a time between outbursts of approximately 1 year, the shortest known. Recurrent X-ray emission from this binary was detected by ROSAT in 1992 and 1993, and the source was well characterized as a mass greater than 1.3 solar masses WD SSS. Based on the observed recurrence time between different outbursts, the duration and effective temperature of the SS phase, MESA models of accreting WDs allow us to constrain the accretion rate to mass greater than 1.7x10 (sup 7) solar masses per year and WD mass greater than 1.30 solar masses. If the WD keeps 30 percent of the accreted material, it will take less than a million years to reach core densities high enough for carbon ignition (if made of C/O) or electron capture (if made of O/Ne) to end the binary evolution