Training in statistical analysis reduces the framing effect among medical students and residents in Argentina

Purpose The framing effect refers to a phenomenon wherein, when the same problem is presented using different representations of information, people make significant changes in their decisions. This study aimed to explore whether the framing effect could be reduced in medical students and residents by teaching them the statistical concepts of effect size, probability, and sampling for use in the medical decision-making process. Methods Ninety-five second-year medical students and 100 second-year medical residents of Austral University and Buenos Aires University, Argentina were invited to participate in the study between March and June 2017. A questionnaire was developed to assess the different types of framing effects in medical situations. After an initial administration of the survey, students and residents were taught statistical concepts including effect size, probability, and sampling during 2 individual independent official biostatistics courses. After these interventions, the same questionnaire was randomly administered again, and pre- and post-intervention outcomes were compared among students and residents. Results Almost every type of framing effect was reproduced either in the students or in the residents. After teaching medical students and residents the analytical process behind statistical concepts, a significant reduction in sample-size, risky-choice, pseudo-certainty, number-size, attribute, goal, and probabilistic formulation framing effects was observed. Conclusion The decision-making of medical students and residents in simulated medical situations may be affected by different frame descriptions, and these framing effects can be partially reduced by training individuals in probability analysis and statistical sampling methods

Impact of preoperative clopidogrel in off pump coronary artery bypass surgery: A propensity score analysis

ObjectiveThe aim of our study was to evaluate the impact of recent clopidrogel use before off-pump coronary artery bypass grafting on the postoperative risk of bleeding.MethodsDuring the period January 2003 to December 2006, 1104 consecutive patients underwent off-pump coronary artery bypass grafting. Patients were divided into two groups according to the recent use of clopidrogel (within 7 days). We performed a propensity score to further adjust for differences between the patients with and without recent use of clopidrogel.ResultsMean age was 64 ± 14 years and 87% were male. The clopidrogel group had a greater incidence of patients in unstable condition, requiring emergency coronary bypass grafting, and with a high EuroSCORE. Propensity score analysis selected 88 patients with and 176 without recent use of clopidrogel. By propensity score, the clopidrogel group had higher requirements for fresh frozen plasma units (18.1% vs 8.5%; P = .02), reoperation owing to bleeding (5.6% vs 0.5%; P = .009), and higher need for postoperative mechanical ventilation (4% vs 10%; P = .04), whereas mortality and length of stay were similar between groups.ConclusionRecent use of clopidogrel before off-pump coronary artery bypass grafting is associated with greater risk for bleeding with similar mortality rate

Low plasma triiodothyronine levels in heart failure are associated with a reduced anabolic state and membrane damage

BACKGROUND: Low plasma triiodothyronine (T(3)) levels are considered a prognostic predictor of death in heart failure (HF) patients. AIM: To study an association between plasma T(3) levels and several cardiac, neurohormonal, and metabolic markers of HF. METHODS: A total of 133 ambulatory HF patients (114 males; mean age 63.2 years) with left ventricular ejection fraction <40% were enrolled. TSH, total tetraiodothyronine (T(4)) and T(3), N-terminal pro-brain natriuretic peptide (NT-proBNP), and other cardiac and metabolic parameters were measured. The lowest tertile of T(3) (group 1) was compared against the two upper ones (group 2). RESULTS: In simple logistic regression, the lowest T(3) tertile was associated with more advanced HF disease status: older (age: odds ratio (OR)=1.05; confidence interval (CI) 95% 1.01-1.09, P=0.004), lower functional capacity (walking test: OR=0.996; CI 95% 0.993-0.999, P=0.008), higher NT-proBNP (OR=1.64; CI 95% 1.19-2.27, P=0.003) and adiponectin levels (OR=1.07; CI 95% 1.02-1.11, P=0.004), lower DHEAS log-transformed (OR=0.50; CI 95% 0.31-0.80, P=0.004), and the presence of lower phase angle values as measured by body bioelectrical impedance analysis (OR=3.18; CI 95% 1.50-6.71, P=0.04) and worse renal function (OR=0.96; CI 95% 0.94-0.98, P=0.003). T(3) levels in the lowest tertile were independently associated with low phase angle values (OR=2.95, CI 95% 1.16-7.50, P=0.02) and the log transformation of DHEAS (OR=0.56; CI 95% 0.32-0.97, P=0.04). CONCLUSION: We have demonstrated an association between plasma T(3) levels in the lower range and other deranged hormonal and metabolic parameters in HF patients.Fil: Brenta, Gabriela. Gobierno de la Ciudad de Buenos Aires. Hospital César Milstein; ArgentinaFil: Thierer, Jorge. Instituto Cardiovascular de Buenos Aires; ArgentinaFil: Sutton, Marcela. Instituto Cardiovascular de Buenos Aires; ArgentinaFil: Acosta, Adriana. Instituto Cardiovascular de Buenos Aires; ArgentinaFil: Vainstein, Nora. Instituto Cardiovascular de Buenos Aires; ArgentinaFil: Brites, Fernando Daniel. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Boero, Laura. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica; ArgentinaFil: Gomez Rosso, Leonardo Adrián. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Anker, Stefan. Istituto di Ricovero e Cura a Carattere Scientifico; Italia. Charité Universitätsmedizin Berlin; Alemani

Cardio-Renal-Metabolic Overlap, Outcomes, and Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction

Background: Cardio-renal-metabolic (CRM) conditions are individually common among patients with heart failure (HF), but the prevalence and influence of overlapping CRM conditions in this population have not been well-studied. Objectives: This study aims to evaluate the impact of overlapping CRM conditions on clinical outcomes and treatment effects of dapagliflozin in HF. Methods: In this post hoc analysis of DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure), we evaluated the prevalence of comorbid CRM conditions (atherosclerotic cardiovascular disease, chronic kidney disease, and type 2 diabetes), their impact on the primary outcome (cardiovascular death or worsening HF), and treatment effects of dapagliflozin by CRM status. Results: Among 6,263 participants, 1,952 (31%), 2,245 (36%), and 1,236 (20%) had 1, 2, and 3 additional CRM conditions, respectively. HF alone was uncommon (13%). Greater CRM multimorbidity was associated with older age, higher body mass index, longer-duration HF, worse health status, and lower left ventricular ejection fraction. Risk of the primary outcome increased with higher CRM overlap, with 3 CRM conditions independently associated with highest risk of primary events (adjusted HR: 2.16 [95% CI: 1.72-2.72]; P &lt; 0.001) compared with HF alone. Relative benefits of dapagliflozin on the primary outcome were consistent irrespective of the type of CRM overlap (Pinteraction = 0.773) and by the number of CRM conditions (Pinteraction = 0.734), with greatest absolute benefits among those with highest CRM multimorbidity. Estimated 2-year numbers needed to treat with dapagliflozin to prevent 1 primary event were approximately 52, 39, 33, and 24 for participants with 0, 1, 2, and 3 additional CRM conditions at baseline, respectively. Adverse events between treatment arms were similar across the CRM spectrum. Conclusions: CRM multimorbidity was common and associated with adverse outcomes among patients with HF and left ventricular ejection fraction &gt;40% in DELIVER. Dapagliflozin was safe and effective across the CRM spectrum, with greater absolute benefits among those with highest CRM overlap (Dapagliflozin Evaluation to Improve the LIVEs of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).</p

Geographical variation in patient characteristics and outcomes in heart failure with mildly reduced and preserved ejection fraction

Aims: Compared to heart failure (HF) with reduced ejection fraction, HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction (HFmrEF) are increasing in prevalence, yet little is known about the geographic variation in patient characteristics, treatments and outcomes among these two HF phenotypes. The aim of this study was to investigate geographic differences in HFpEF and HFmrEF. Methods and results: We conducted an individual patient analysis of five clinical trials enrolling patients with HFpEF or HFmrEF from North America (NA), Latin America (LA), Western Europe (WE), Central/Eastern Europe and Russia (CEER), and Asia‐Pacific (AP). We compared regions using descriptive statistics and multivariable regression models. Among the 19 959 patients included, 4066 (23.1%) had HFmrEF and 15 353 (76.9%) HFpEF. Regardless of HF phenotype, patients from WE were oldest, and those in CEER youngest. LA had the largest portion of females and NA most black patients. Obesity and diabetes were most prevalent in NA and hypertension and coronary heart disease most common in CEER. Self‐reported health status varied strikingly and was the worst in NA and best in AP. Among patients with HFmrEF, rates of the primary composite endpoint (cardiovascular death or HF hospitalization) were: NA 12.56 per 100 patient‐years (/100py), AP 11.67/100py, CEER 10.12/100py, LA 8.90/100py, and WE 8.43/100py, driven by differences in the rate of HF hospitalization. The corresponding values in HFpEF were 11.47/100py, 7.80/100py, 5.47/100py, 5.92/100py, and 7.80/100py, respectively. Conclusions: There is substantial geographic variation in patient characteristics, treatment and outcomes among patients with HFpEF and HFmrEF. These findings have implications for interpretation and generalizability of trial results, design and conduct of future trials, and optimization of care for these patients