Lower Risk of Death and Kidney Failure Associated with Higher Target (vs. Below-Target) Doses of RAS Inhibitors in Octogenarians with HFrEF.

Background: Renin-angiotensin system inhibitors (RASIs) at higher target doses reduce the risk of death in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their effectiveness in octogenarians, the examination of which was the objective of this study.

Methods: Of 32,964 Veterans ≥80 years with HFrEF (ejection fraction ≤40%) receiving RASIs, 6655 received target-dose.

Digoxin Discontinuation in Patients With HFrEF on Beta-Blockers: Implication for Future 'Knock-Out Trials' in Heart Failure.

Background: National heart failure guidelines recommend quadruple therapy with renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors for patients with heart failure with reduced ejection fraction (HFrEF), most of whom also receive loop diuretics. However, the guidelines are less clear about the safe approaches to discontinuing older drugs whose decreasing or residual benefit is less well understood. The objective of this study was to examine whether digoxin can be safely discontinued in patients with HFrEF receiving beta-blockers.

Identification and outcomes of KDIGO-defined chronic kidney disease in 1.4 million U.S. Veterans with heart failure.

Aims: According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes.

A multicenter prospective study to define the natural history of BK viral infections in kidney transplantation.

Background: BK polyomavirus (BKV) can cause permanent loss of allograft function due to BKV-associated nephropathy (BKVN) in kidney transplant recipients. Besides immunosuppression reduction, there are no consistently effective interventions for BKV infection. Study purpose was to define natural history of BKV infection, identify risk factors for BKV reactivation and BKVN in kidney transplant recipients, and inform the design/conduct of future clinical trials of BKV-targeted therapeutics.

Do people with epilepsy want to participate in an exercise intervention randomized controlled trial? - Results of a brief survey and its preliminary application.

Our goal was to survey people with epilepsy (PWE) about their interest in and factors that may influence willingness and ability to participate in an exercise randomized controlled trial (RCT). A brief survey was administered to 100 PWE asking if they would take part in a hypothetical 6-week exercise intervention RCT. Follow-up questions queried reasons for and against participation and why participation would be difficult.

Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis.

Introduction: According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA.

Risk of new disease activity in patients with multiple sclerosis who continue or discontinue disease-modifying therapies (DISCOMS): a multicentre, randomised, single-blind, phase 4, non-inferiority trial.

Background: Multiple sclerosis typically has onset in young adults and new disease activity diminishes with age. Most clinical trials of disease-modifying therapies for multiple sclerosis have not enrolled individuals older than 55 years. Observational studies suggest that risk of return of disease activity after discontinuation of a disease-modifying therapies is greatest in younger patients with recent relapses or MRI activity.

Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial.

Background: The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that has been proposed as an effective motor-sparing block for total hip arthroplasty. Recent randomised studies show conflicting results regarding the analgesic efficacy of the PENG block for total hip arthroplasty.

Methods: We conducted a randomised controlled observer-blinded single-centre superiority trial comparing the efficacy of the PENG block with no block for patients undergoing primary total hip arthroplasty under spinal anaesthesia.

Sugammadex versus neostigmine for routine reversal of neuromuscular blockade and the effect on perioperative efficiency.

Sugammadex produces recovery from neuromuscular blockade more rapidly and reliably than neostigmine. We sought to determine if sugammadex is associated with improved perioperative efficiency when compared to traditional neuromuscular blockade reversal with neostigmine, potentially offsetting the higher medication cost. This retrospective analysis involved patients receiving either neostigmine or sugammadex for reversal of neuromuscular blockade at a single academic tertiary care hospital.

Assessment of Lung Cancer Risk Among Smokers for Whom Annual Screening Is Not Recommended.

Importance: The US Preventive Services Task Force does not recommend annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who are former smokers with 20 or more pack-years of smoking who quit 15 or more years ago or current smokers with less than 20 pack-years of smoking.

Objective: To determine the risk of lung cancer in older smokers for whom LDCT screening is not recommended.

Design, Settings, And Participants: This cohort study used the Cardiovascular Health Study (CHS) data sets obtained from the National Heart, Lung and Blood Institute, which also sponsored the study.

In-Hospital Weight Loss and Outcomes in Patients With Heart Failure.

Background: Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF.

Methods: We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics.

Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH. A SU5416-hypoxia rat model was used for inducing PAH.

Income disparity and incident cardiovascular disease in older Americans.

Objective: To examine the association between income and cardiovascular disease (CVD) in community-dwelling older adults.

Methods: Of the 5795 Medicare-eligible community-dwelling older Americans aged 65-100 years in the Cardiovascular Health Study (CHS), 4518 (78%) were free of baseline CVD, defined as heart failure, acute myocardial infarction, stroke, or peripheral arterial disease. Of them, 1846 (41%) had lower income, defined as a total annual household income <$16,000.

Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting.

Background: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies.

Abnormalities in the copper transporter CTR1 in postmortem hippocampus in schizophrenia: A subregion and laminar analysis.

Dysbindin-1 modulates copper transport, which is crucial for cellular homeostasis. Several brain regions implicated in schizophrenia exhibit decreased levels of dysbindin-1, which may affect copper homeostasis therein. Our recent study showed decreased levels of dysbindin-1, the copper transporter-1 (CTR1) and copper in the substantia nigra in schizophrenia, providing the first evidence of disrupted copper transport in schizophrenia.

End-of-Procedure Volume Responsiveness Defined by the Passive Leg Raise Test Is Not Associated With Acute Kidney Injury After Cardiopulmonary Bypass.

Objectives: Renal hypoperfusion is a common mechanism of cardiac surgery-related acute kidney injury (CS-AKI). However, the optimal amount of volume resuscitation to correct systemic hypoperfusion and prevent the postoperative development of CS-AKI has been a subject of debate. The goal of this study was to assess the association of volume responsiveness determined by stroke volume variation using the passive leg raise test (PLRT) at chest closure, with the development of CS-AKI according to the Kidney Disease Improving Global Outcomes criteria.

Systolic Blood Pressure and Outcomes in Older Patients with HFpEF and Hypertension.

Background: New hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to <130 mm Hg.

Methods: Of the 6778 hospitalized patients with HFpEF and a history of hypertension in the Medicare-linked OPTIMIZE-HF registry, 3111 had a discharge SBP <130 mm Hg. Using propensity scores for SBP <130 mm Hg, we assembled a matched cohort of 1979 pairs with SBP <130 versus ≥130 mm Hg, balanced on 66 baseline characteristics (mean age, 79 years; 69% women; 12% African American).

Effects of Intraoperative Ketamine on Post-Operative Recovery in Obstructive Sleep Apnea Patients: A Case-Control Study.

Objective To evaluate the post-operative outcomes of patients with obstructive sleep apnea (OSA) given intraoperative ketamine. Design: case-control study A total of 574 patients (287 received ketamine and 287 were matched controls) diagnosed with OSA and body mass index (BMI) > 30 who received general anesthesia were included in this study. Patients given intraoperative ketamine were matched (1:1) with those who did not receive ketamine for age, gender, BMI, ethnicity, anesthesia time, intraoperative fentanyl dose, ketamine dose, and surgery type.

Circulating and tissue biomarkers as predictors of bromine gas inhalation.

The threat from deliberate or accidental exposure to halogen gases is increasing, as is their industrial applications and use as chemical warfare agents. Biomarkers that can identify halogen exposure, diagnose victims of exposure or predict injury severity, and enable appropriate treatment are lacking. We conducted these studies to determine and validate biomarkers of bromine (Br ) toxicity and correlate the symptoms and the extent of cardiopulmonary injuries.

Digoxin Initiation and Outcomes in Patients with Heart Failure (HFrEF and HFpEF) and Atrial Fibrillation.

Background: Digoxin reduces the risk of heart failure hospitalization but has no effect on mortality in patients with heart failure without atrial fibrillation in the randomized controlled trial setting. Observational studies of digoxin use in patients with atrial fibrillation have suggested a higher risk for poor outcomes. Less is known about this association in patients with heart failure and atrial fibrillation, the examination of which was the objective of the current study.

Incoming Interns Recognize Inadequate Physical Examination as a Cause of Patient Harm.

Introduction: As providers of a large portion of the care delivered at academic health centers, medical trainees have a unique perspective on medical error. Despite data suggesting that errors in physical examination (PE) can lead to adverse patient events, we are not aware of previous studies exploring medical trainee perceptions of the relationship between patient harm and inadequate PE. We investigated whether first-year residents at a large tertiary care academic medical center perceive inadequate PE as a cause of adverse patient events.