Impact of Early Coronary Revascularization on Long-Term Outcomes in Patients With Myocardial Ischemia on Dobutamine Stress Echocardiography

The role of early coronary revascularization in the management of stable coronary artery disease remains controversial. The aim of this study was to evaluate the impact of early coronary revascularization on long-term outcomes (>10 years) after an ischemic dobutamine stress echocardiography (DSE) in patients with known or suspected coronary artery disease. Patients without stress-induced ischemia on DSE and those who underwent late coronary revascularization (>90 days after DSE) were excluded. The final study cohort consisted of 905 patients. A DSE with a peak wall motion score index of 1.1 to 1.7 was considered mild

Ischemia burden on stress SPECT MPI predicts long-term outcomes after revascularization in stable coronary artery disease

Background: It is not entirely clear whether ischemia burden on stress single-photon emission computed tomography (SPECT) effectively identifies patients who have a long-term benefit from coronary revascularization. Methods: The study population consisted of 719 patients with ischemia on stress SPECT. Early coronary revascularization was defined as percutaneous coronary intervention or coronary artery bypass grafting ≤90 days after SPECT. Patients who underwent late revascularization (>90 days after SPECT) were excluded (n = 164). Results: Of the 538 patients (73% men, mean age 59.8 ± 11 years), 348 patients had low ischemia burden (<3 ischemic segments) and 190 patients had moderate to high ischemia burden (≥3 ischemic segments). A total of 76 patients underwent early revascularization. During a median follow-up of 12 years (range 4-17), 283 patients died of whom 125 due to cardiac causes. Early revascularization was beneficial on all-cause mortality (HR 0.46, 95% CI 0.30-0.46) and cardiac mortality (HR 0.54, 95% CI 0.29-0.99). Conclusions: Patients with myocardial ischemia on stress SPECT who underwent early revascularization had a lower all-cause mortality and cardiac mortality during long-term follow-up as compared to patients who received pharmacological therapy alone. This difference in long-term outcomes was mainly influenced by the survival benefit of early revascularization in the patients with moderate to high ischemia burden

Cardiac stress imaging for the prediction of very long-term outcomes: Dobutamine stress echocardiography or dobutamine 99mTc-sestamibi SPECT?

Background: Both dobutamine stress echocardiography (DSE) and myocardial perfusion imaging (MPI) using single-photon emission computed tomography (SPECT) are frequently used for cardiac risk stratification. The long-term relative prognostic

The impact of gender on long-term mortality in patients with multivessel disease after primary percutaneous coronary intervention

Background Gender and complete revascularisation are known to affect mortality. The objective of this study was to analyse a gender difference in mortality with respect to complete revascularisation for multivessel disease after primary percutaneous coronary intervention (PPCI) in STelevation myocardial infarction (STEMI) patients. Method In a prospective consecutive cohort of 1472 patients presenting with STEMI for PPCI, between January 2006 and January 2010, 832 patients with multivessel disease were analysed. The primary outcome was long-term mortality. Results Median follow-up was 3.3 ± 1.2 years. Complete revascularisation was performed less in females than in males (30 vs. 38%; p = 0.04). At PPCI, women (27%, n = 221) were ± 10 years older (p = 0.001), had more hypertension, renal failure and symptoms of heart failure (all p < 0.01). Cumulative long-term mortality with incomplete revasculari-sation was higher in females (F: 30 vs. M: 15%, p = 0.01). After adjustment for baseline characteristics, complete revascularisation (0.84; 95% CI 0.54–1.32) and gender (1.11; 95% CI 0.73–1.69) lost significance. Also the gender-bycomplete revascularisation interaction was not significant at long term. In women, age under 60 years independently predicted higher mortality (HR 10.09; 95% CI 3.08–33.08; p < 0.001). Conclusion In STEMI patients with multivessel disease at PPCI, women under the age of 60 years had higher mortality, but in women olde

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Digestibility and intestinal fermentability of canola meal from Brassica juncea and Brassica napus fed to ileal-cannulated grower pigs

Yellow-seeded Brassica (B.) juncea is a novel canola species. Therefore, its meal co-product requires feed quality evaluation and comparison to conventional, dark-seeded B. napus canola meal for pigs. The B. juncea canola meal contains less fibre than B. napus canola meal (190 vs. 260 g NDF/kg, as is), but also less lysine (20.3 vs. 22.1 g/kg). Nutrient digestibility and fermentibility of B. juncea and B. napus canola meal were assessed in a 2 × 2factorial arrangement. Six ileal-cannulated pigs (47 kg BW) were fed six diets in a 6 × 6 Latin square: basal diet (460 g wheat/kg and corn starch), 4 diets with 460 g wheat/kg and either B. juncea or B. napus canola meal at 250 or 500 g/kg replacing corn starch, sugar and canola oil, and an N-free diet based on corn starch. The B. juncea canola meal had greater (P < 0.05) CATTD of gross energy than B. napus canola meal (0.70 vs. 0.63) most likely due to its lower fibre content. Ileal total VFA concentration was lower (P < 0.001) in pigs fed B. juncea than B. napus canola meal diets (15.2 vs. 20.8 μmol/g of wet digesta). In pigs fed B. juncea canola meal instead of B. napus canola meal diets, the molar ratio was greater (P < 0.01) for digesta propionate and faecal acetate, but lower (P < 0.05) for digesta and faecal butyrate. Canola meal species did not affect the CAID of gross energy, CSID of amino acid and faecal VFA content. The digestible energy (DE) value was greater (P < 0.01; 12.1 vs. 10.9 MJ/kg, standardised to 100 g/kg moisture) for B. juncea than B. napus canola meal. Increasing dietary inclusion of canola meal up to 500 g/kg reduced (P < 0.01) diet digestibility of gross energy but not amino acids and decreased (P < 0.05) intestinal fermentability of B. napus but not B. juncea. In conclusion, B. juncea canola meal had greater fermentability and ATTD of gross energy than B. napus canola meal, but digestibility of amino acids did not differ. Increasing dietary inclusion of canola meal up to 500 g/kg reduced digestibility of gross energy but not digestibility of AA. Fermentability of B. napus canola meal but not B. juncea canola meal decreased in the pig intestine with increased dietary inclusion. Hence, yellow-seeded B. juncea canola meal had a greater DE value, similar amino acid digestibility as conventional dark-seed B. napus canola meal and may limit protein fermentation in the pig intestine

Digestibility energy and amino acids of canola meal from two species (Brassica juncea and Brassica napus) fed to distal ileum cannulated grower pigs

Yellow-seeded Brassica juncea is a novel canola species targeted to grow in the southern Canadian prairies where thermotolerance, disease resistance, and adaptation to dry agronomic conditions are required. The support of its cultivation needs nutritional evaluation of its coproduct. The B. juncea canola meal (CM) contains less fiber than conventional, dark-seeded Brassica napus CM but also slightly less Lys. In a 6 × 6 Latin square, 6 distal ileum cannulated pigs (47 kg BW) were fed 6 diets to determine the apparent ileal digestibility (AID) and standardized ileal digestibility (SID) of CP and AA, AID and apparent total tract digestibility (ATTD) of energy, and VFA content in digesta and feces. Pigs were fed 6 diets: basal [46% wheat (Triticum aestivum) and corn (Zea mays) starch], 4 diets with 46% wheat and either B. juncea or B. napus CM at 25 or 50%, and a N-free diet based on corn starch. The B. juncea CM had higher (P <0.05) ATTD of energy than B. napus CM (68.6 vs. 60.3%) likely due to its lower fiber content. Ileal total VFA was lower (P <0.001) in pigs fed B. juncea than B. napus CM diets. In pigs fed B. juncea CM, the molar ratio in digesta was lower (P <0.001) for acetate and butyrate whereas the propionate ratio was lower (P <0.001) in feces than in pigs fed B. napus CM diets. The CM species did not affect the AID of energy, SID of AA, and feces VFA content. The DE value was higher (P <0.05) and content of SID Lys was lower (P <0.05) for B. juncea than B. napus CM. In conclusion, availability of B. juncea CM, a coproduct of a canola species grown in Canadian prairie land, will increase flexibility in swine feed formulation

The Unilever Study: Positive effects on stress and risk for dropout from work after the Finding Peace in a Frantic World Training

Organizations are confronted with a constant need for efficiency, which affects the working atmosphere, often typified by velocity, time pressure, competition, job insecurity, and information overload, which may lead to stress, burnout, work-life disbalance, and lowered work functioning. This study evaluated an 8-week, 1.5 h-per-week group-based standardized mindfulness program (“Finding peace in a frantic world”), applied on-site in a large multinational company. In a naturalistic longitudinal design self-selected employees (n = 150) completed measurements at wait-list, pre-test, post-test, and 2 and 6 months follow-up. Nearly all participants followed at least five out of eight sessions, were highly satisfied with the training (8.3 out 10), and almost 90% intended to continue with mindfulness practices. Primary outcomes were stress and risk for dropout from work. Using multilevel analyses, mean pre-test scores were compared to the other measurement occasions, and the rate of change in the training period (M = 67 days; SD = 12) was compared to the rate of change in the wait-list period (M = 29 days; SD = 8). Direct and long-term positive effects on risk for dropout from work (p < .001; effect size (ES) = 0.67, 0.73, and 0.88, respectively) and stress (p < .001; ES = 0.72, 0.86, and 1.02, respectively) were found. The risk for dropout from work declined from 54.4% at wait-list (45.8% at pre-test) to 16.4% at 6 months follow-up, and declined significantly faster (p < .001) during the training than during the wait-list period, but stress did not. In addition, positive effects on secondary measures of psychological well-being and functioning at work were found. In conclusion, a standardized mindfulness training in a multinational company reduces stress and risk for dropout and improves well-being and functioning at work, also in the long term, but a comparison of the training against alternative stress-reducing interventions is needed