Implementing a comprehensive STEMI protocol to improve care metrics and outcomes in patients with in-hospital STEMI: an observational cohort study.

BACKGROUND: Patients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at improving the care of this vulnerable, yet understudied population are needed. METHODS: This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 1 January 2011 and 15 July 2019 at a single, tertiary referral centre. A comprehensive iSTEMI protocol (CSP) was implemented on 15 July 2014, incorporating: (1) cardiology fellow activation of the catheterisation lab using standardised criteria, (2) nursing chest pain protocol, (3) improved electronic access to electrocardiographic studies, (4) checklist for initial triage and management, (5) 24/7/365 catheterisation lab readiness and (6) radial-first PCI approach. Key metrics and clinical outcomes were compared before and after CSP implementation. RESULTS: Among 125 total subjects, the post-CSP cohort (n=81) was younger, had more males and were more likely to be hospitalised for cardiac-related reasons relative to the pre-CSP cohort (n=44) who were more likely hospitalised for operative-related aetiologies. After CSP adoption, median ECG-to-first-device-activation time decreased from 113 min to 64 min (p<0.001), goal ECG-to-first-device-activation time increased from 36% to 76% of patients (p<0.001), administration of guideline-directed medical therapy prior to PCI increased from 27.3% to 65.4% (p<0.001), trans-radial access increased from 16% to 70% (p<0.001) and rates of discharge home increased from 56.8% to 76.5% (p=0.04). Statistically insignificant numerical reductions were observed post-CSP in in-hospital mortality (18.2% vs 9.9%, p=0.30), 30-day mortality (15.9% vs 12.3%, p=0.78) and 1-year mortality (27.3% vs 21.0%, p=0.57). CONCLUSIONS: The implementation of a CSP was associated with marked enhancements in key care metrics among patients with iSTEMI. Among a larger cohort, the use of a CSP yielded a significant reduction in ECG-to-first-device-activation time in a particularly vulnerable population at high risk of death.

Intravascular Lithotripsy for Severe RVOT Calcification to Optimize Transcatheter Pulmonary Valve Replacement.

The presence of severe right ventricular outflow tract calcification may preclude safe and effective transcatheter pulmonary valve replacement in patients with pulmonary allograft stenosis owing to the risk of conduit tear and suboptimal annular expansion. Debulking calcium using intravascular lithotripsy within the right ventricular outflow tract may mitigate this risk and improve valve hemodynamics. (Level of Difficulty: Advanced.).

Prospects for developing allergen-depleted food crops.

In addition to the challenge of meeting global demand for food production, there are increasing concerns about food safety and the need to protect consumer health from the negative effects of foodborne allergies. Certain bio-molecules (usually proteins) present in food can act as allergens that trigger unusual immunological reactions, with potentially life-threatening consequences. The relentless working lifestyles of the modern era often incorporate poor eating habits that include readymade prepackaged and processed foods, which contain additives such as peanuts, tree nuts, wheat, and soy-based products, rather than traditional home cooking. Of the predominant allergenic foods (soybean, wheat, fish, peanut, shellfish, tree nuts, eggs, and milk), peanuts (Arachis hypogaea) are the best characterized source of allergens, followed by tree nuts (Juglans regia, Prunus amygdalus, Corylus avellana, Carya illinoinensis, Anacardium occidentale, Pistacia vera, Bertholletia excels), wheat (Triticum aestivum), soybeans (Glycine max), and kidney beans (Phaseolus vulgaris). The prevalence of food allergies has risen significantly in recent years including chance of accidental exposure to such foods. In contrast, the standards of detection, diagnosis, and cure have not kept pace and unfortunately are often suboptimal. In this review, we mainly focus on the prevalence of allergies associated with peanut, tree nuts, wheat, soybean, and kidney bean, highlighting their physiological properties and functions as well as considering research directions for tailoring allergen gene expression. In particular, we discuss how recent advances in molecular breeding, genetic engineering, and genome editing can be used to develop potential low allergen food crops that protect consumer health.

Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States.

Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.

Interaction Between Race and Income on Cardiac Outcomes After Percutaneous Coronary Intervention.

Background Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post-percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship. Methods and Results Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All-cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10-year follow-up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self-identified as Black Americans, and 20 649 (86.7%) self-identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long-term outpatient cardiology follow-up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all-cause mortality (18.0% versus 15.2%; P<0.001) and major adverse cardiac event (37.3% versus 34.6%; P<0.001) were greater among Black Americans and with lower income (both P<0.001); race, income, and their interaction were not significant predictors in multivariable models. At 10-year follow-up, increasing income was associated with improved outcomes only in White Americans but not Black Americans. In multivariable models for major adverse cardiac event, income (hazard ratio [HR], 0.97 [95% CI, 0.96-0.98]; P=0.005), Black race (HR, 1.77 [95% CI, 1.58-1.96]; P=0.006), and their interaction (HR, 0.98 [95% CI, 0.97-0.99]; P=0.003) were significant predictors. Similar findings were observed for cardiac death. Conclusions Early 3-year post-percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10-year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.

Radiation reduction in a modern catheterization laboratory: A single-center experience.

BACKGROUND: Measures were undertaken at the Cleveland Clinic to reduce radiation exposure to patients and personnel working in the catheterization laboratories. We report our experience with these improved systems over a 7-year period in patients undergoing diagnostic catheterization (DC) and percutaneous coronary interventions (PCIs). METHODS: Patients were categorized into preinitiative (2009-2012) and postinitiative (2013-2019) groups in the DC and PCI cohorts. Propensity score matching was done between the pre- and postinitiative groups for both cohorts based on age, sex, body surface area, total fluoroscopy time, and total acquisition time. The effectiveness of radiation reduction measures was assessed by comparing the total air kerma (Ka,r ), and fluoroscopy- and acquisition-mode air kerma in patients in the two groups. RESULTS: In the DC cohort, there was a significant reduction in Ka,r in the postinitiative group in comparison to the preinitiative group (median, 396 vs. 857 mGy; p < 0.001). In the PCI cohort, Ka,r in the postinitiative group was 1265 mGy, which was significantly lower than the corresponding values in the preinitiative group (1994 mGy; p < 0.001). We also observed a significant reduction in fluoroscopy- and acquisition-based air kerma rates, and air kerma area product in the postinitiative group in comparison to the preinitiative group in both matched and unmatched DC and PCI cohorts after the institution of radiation reduction measures. CONCLUSION: There was a significant and sustained reduction in radiation exposure to patients in the catheterization laboratory with the implementation of advanced protocols. Similar algorithms can be applied in other laboratories to achieve a similar reduction in radiation exposure.

COVID-19 and preventive strategy.

In December 2019, an unprecedented outbreak of the novel coronavirus disease 2019 (COVID-19), an infectious disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) began to spread internationally, now impacting more than 293,750,692 patients with 5,454,131 deaths globally as of January 5, 2022. COVID-19 is highly pathogenic and contagious which has caused a large-scale epidemic impacting more deaths than the severe acute respiratory syndrome (SARS) epidemic in 2002-2003 or the Middle East respiratory syndrome (MERS) epidemic in 2012-2013. Although COVID-19 symptoms are mild in most people, in those with pre-existing comorbidities there is an increased risk of progression to severe disease and death. In an attempt to mitigate this pandemic, urgent public health measures including quarantining exposed individuals and social distancing have been implemented in most states, while some states have even started the process of re-opening after considering both the economic and public health consequences of social distancing measures. While prevention is crucial, both novel agents and medications already in use with other indications are being investigated in clinical trials for patients with COVID-19. The collaboration between healthcare providers, health systems, patients, private sectors, and local and national governments is needed to protect both healthcare providers and patients to ultimately overcome this pandemic. The purpose of this review is to summarize the peer-reviewed and preprint literature on the epidemiology, transmission, clinical presentation, and available therapies as well as to propose a preventive strategy to overcome the present global pandemic.

Use of Machine Learning to Develop Prediction Models for Mortality and Stroke in Patients Undergoing Balloon Aortic Valvuloplasty.

OBJECTIVE: To develop an artificial intelligence, machine learning prediction model for estimating in-hospital mortality and stroke in patients undergoing balloon aortic valvuloplasty (BAV). METHODS: The National Inpatient Sample (NIS) database was used to identify patients who underwent BAV from 2005 to 2017. Outcomes analyzed were in-hospital all-cause mortality and stroke after BAV. Predictors of mortality and stroke were selected using LASSO regularization. A conventional logistic regression and a random forest machine learning algorithm were used to train the models for predicting outcomes. The performance of all the modeling algorithms for predicting in-hospital mortality and stroke was compared between models using c-statistic, F1 score, brier score loss, diagnostic accuracy, and Kolmogorov-Smirnov plots. RESULTS: A total of 6962 patients with severe aortic stenosis who underwent BAV were identified. The performance of random forest classifier was comparable with logistic regression for predicting in-hospital mortality for all measures of performance (F1 score 0.422 vs 0.409, ROC-AUC 0.822 [95 % CI 0.787-0.855] vs 0.815 [95 % CI 0.779-0.849], diagnostic accuracy 70.42 % vs 70.93 %, KS-statistic 0.513 vs 0.494 and brier score loss 0.295 vs 0.291). The random forest algorithm significantly outperformed logistic regression in predicting in-hospital stroke with respect to all performance metrics: F1 score 0.225 vs 0.095, AUC 0.767 [0.662-0.858] vs 0.637 [0.499-0.754], brier score loss [0.399 vs 0.407], and KS-statistic [0.465 vs 0.254]. CONCLUSIONS: The good discrimination of machine learning models reveal the potential of artificial intelligence to improve patient risk stratification for BAV.

Key Concepts Surrounding Cardiogenic Shock.

Cardiogenic shock (CS) is the final common pathway of impaired cardiovascular performance that results in ineffective forward cardiac output producing clinical and biochemical signs of organ hypoperfusion. CS represents the most common cause of shock in the cardiac intensive care unit (CICU) and accounts for a substantial proportion of CICU patient deaths. Despite significant advances in revascularization techniques, pharmacologic therapeutics and mechanical support devices, CS remains associated with a high mortality rate. Indeed, the prevalence of CS within the CICU appears to be increasing. CS can be differentiated as phenotypes reflecting different metabolic, inflammatory, and hemodynamic profiles, depending also on anatomic substrate and congestion profile. Future prospective studies and clinical trials may further characterize these phenotypes and apply targeted intervention for each phenotype and SCAI SHOCK stage rather than a one-size-fits-all approach. Overall, there are 8 key concepts of CS; 1) the mortality associated with CS; 2) Shock attributed to AMI may be declining in both incidence and associated mortality; 3) providers should think about hemodynamic, metabolic, inflammation and cardiac function in totality to assess CS; 4) CS is a dynamic process; 5) no randomized trials evaluating use of the PAC in patients with CS; 6) most data supporting neosynephrine as first line agent in CS; 7) most registries suggest that almost half of CS patients do not have any mechanical support, and the vast majority of the remainder utilize the IABP; and 8) patients with AMI CS should receive emergent PCI of the culprit vessel.

Temporal Trends in the Utilization and Outcomes of Balloon Aortic Valvuloplasty in the Pre-Transcatheter Aortic Valve Implantation (TAVI) and TAVI Eras.

We used a nationwide cohort to (1) compare characteristics and outcomes of patients who underwent balloon aortic valvuloplasty (BAV) in pre-transcatheter aortic valve transplantation (TAVI) and TAVI eras, (2) examine trends in utilization and outcomes of BAV from 2005 to 2017, (3) assess the association of BAV procedural volume with hospital-based TAVI volume, and (4) understand trends and outcomes of BAV in TAVI and non-TAVI centers in the TAVI era. Pre-TAVI era included hospitalizations from 2005 to 2011, and TAVI era included hospitalizations from 2012 to 2017. In the TAVI era, hospitals were classified into quartiles based on the number of TAVI procedures performed. Trends in volume of BAV procedures from 2012 to 2017 were assessed in non-TAVI and TAVI centers (based on TAVI volume). Between 2005 and 2017, a total of 6,962 hospitalizations for BAV were identified. There were no significant differences in in-hospital mortality or stroke between pre-TAVI and TAVI eras (mortality: pre-TAVI, 8.5% vs TAVI era, 9.3%, p = 0.354; stroke: pre-TAVI, 1.9% vs TAVI era, 1.3%, p = 0.083). However, acute kidney injury was more prevalent in the TAVI era and blood transfusion in the pre-TAVI era. Importantly, patients who underwent BAV in the TAVI era were more likely to have a greater number of co-morbidities and to undergo nonelective procedures. From 2005 to 2017, there was 10-fold increase in utilization of BAV. In the TAVI era, the maximum increase in number of BAV procedures was seen in hospitals with highest TAVI volume. In conclusion, although BAV procedural volume increased approximately 10-fold between 2005 and 2017, with concomitant expansion of TAVI, rates of mortality and stroke have remained stable. Despite this, the rate of BAV utilization continues to increase, thereby indicating a significant opportunity to improve outcomes in this patient population.

Plant-soil-microbes: A tripartite interaction for nutrient acquisition and better plant growth for sustainable agricultural practices.

Plants can achieve their proper growth and development with the help of microorganisms associated with them. Plant-associated microbes convert the unavailable nutrients to available form and make them useful for plants. Besides nutrient acquisition, soil microbes also inhibit the pathogens that cause harm to plant growth and induces defense response. Due to the beneficial activities of soil nutrient-microbe-plant interactions, it is necessary to study more on this topic and develop microbial inoculant technology in the agricultural field for better crop improvement. The soil microbes can be engineered, and plant growth-promoting rhizobacteria (PGPR) and plant growth-promoting bacteria (PGPB) technology can be developed as well, as its application can be improved for utilization as biofertilizer, biopesticides, etc., instead of using harmful chemical biofertilizers. Moreover, plant growth-promoting microbe inoculants can enhance crop productivity. Although, scientists have discussed several tools and techniques by omics and gene editing approaches for crop improvement to avoid biotic and abiotic stress and make the plant healthier and more nutritive. However, beneficial soil microbes that help plants with the nutrient acquisition, development, and stress resistance were ignored, and farmers started utilizing chemical fertilizers. Thus, this review attempts to summarize the interaction system of plant microbes, the role of beneficiary soil microbes in the rhizosphere zone, and their role in plant health promotion, particularly in the nutrition acquisition of the plant. The review will also provide a better understanding of soil microbes that can be exploited as biofertilizers and plant growth promoters in the field to create environmentally friendly, sustainable agriculture systems.

Readmission in Patients With ST-Elevation Myocardial Infarction in 4 Age Groups (<45, >45 to <60, 60 to <75, and >75).

The incidence of ST-elevation myocardial infarction (STEMI) among younger adults is increasing due to an increased prevalence of cardiometabolic risk factors. Readmissions after STEMI in young patients could lead to substantial health care costs and a significant burden on health care resources. Although STEMI readmissions are well studied in elderly patients, limited data are available regarding readmissions after STEMI in young patients and the etiologies remain poorly understood. Because younger patients with STEMI have different sociodemographic profiles th;an older patients with STEMI, one would postulate that the risk factors for readmissions in young patients would differ from that reported in the older patients with STEMI. We performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database to identify patterns of readmissions after STEMI in the young adult population. Our analysis of the Nationwide Readmissions Database revealed a total of 243,747 hospitalizations for STEMI between 2016 and 2017. Readmission rates demonstrated a steady increase from discharge, increasing to 7.8% at 30 days and 10.3% at 60 days before relatively plateauing at 12.1% at 90 days. Cardiovascular etiologies were the most common cause of readmission (53.6%). After multivariable analysis, development of cardiogenic shock (adjusted odds ratio 1.48, 95% confidence interval 1.11 to 1.97; p = 0.008) and acute renal failure (adjusted odds ratio 1.46, 95% confidence interval 1.14 to 1.87; p = 0.003) during the index admission were associated with significantly higher rates of readmission. In conclusion, close monitoring in young patients who presented with STEMI and concomitant with cardiogenic shock or acute renal failure, and possibly, aggressive therapy during index admission may be needed. However, this population may be heterogeneous and further research is needed.

Rare case of Histoplasma capsulatum endocarditis in a patient with a prosthetic valve.

Background: Diagnosis of fungal endocarditis can be challenging, especially among cases with negative blood culture results. Of fungal endocarditis cases, Histoplasma capsulatum constitutes an even smaller proportion with ∼58 prior cases reported. Due to the rarity of histoplasmosis endocarditis and thus limited data, there is no current diagnostic guideline for testing within culture negative infective endocarditis. Case summary: Our patient was a 58-year-old female presenting with worsening dyspnoea, hypotension, and near-syncope. In this case report, we depict the clinical presentation and diagnosis of H. capsulatum endocarditis in a female patient with a prosthetic aortic valve and negative blood cultures. We further demonstrate the rising risk of fungal endocarditis with use of external devices. Discussion: Despite the rarity of fungal endocarditis, there has been a recent upward trend in infections given the rising use of external devices, greater number of immunocompromised patients, and rising rates of intravenous drug use. Recently, more cases of fungal endocarditis have been occurring in patients with prosthetic valves compared to native. Although H. capsulatum constitutes a smaller proportion of fungal endocarditis cases, patients with appropriate risk factors and those who have been exposed to at-risk areas such as the Ohio and Mississippi River valleys, may benefit from further evaluation.