Post-operative atrial fibrillation and risk of heart failure hospitalization.

AIMS: Post-operative atrial fibrillation (POAF) is associated with stroke and mortality. It is unknown if POAF is associated with subsequent heart failure (HF) hospitalization. This study aims to examine the association between POAF and incident HF hospitalization among patients undergoing cardiac and non-cardiac surgeries. METHODS AND RESULTS: A retrospective cohort study was conducted using all-payer administrative claims data that included all non-federal emergency department visits and acute care hospitalizations across 11 states in the USA. The study population included adults aged at least 18 years hospitalized for surgery without a prior diagnosis of HF. Cox proportional hazards regression models were used to examine the association between POAF and incident HF hospitalization after making adjustment for socio-demographics and comorbid conditions. Among 76 536 patients who underwent cardiac surgery, 14 365 (18.8%) developed incident POAF. In an adjusted Cox model, POAF was associated with incident HF hospitalization [hazard ratio (HR) 1.33; 95% confidence interval (CI) 1.25-1.41]. In a sensitivity analysis excluding HF within 1 year of surgery, POAF remained associated with incident HF hospitalization (HR 1.15; 95% CI 1.01-1.31). Among 2 929 854 patients who underwent non-cardiac surgery, 23 763 (0.8%) developed incident POAF. In an adjusted Cox model, POAF was again associated with incident HF hospitalization (HR 2.02; 95% CI 1.94-2.10), including in a sensitivity analysis excluding HF within 1 year of surgery (HR 1.49; 95% CI 1.38-1.61). CONCLUSIONS: Post-operative atrial fibrillation is associated with incident HF hospitalization among patients without prior history of HF undergoing both cardiac and non-cardiac surgeries. These findings reinforce the adverse prognostic impact of POAF and suggest that POAF may be a marker for identifying patients with subclinical HF and those at elevated risk for HF.

American Board of Orthodontics: Progress of the scenario-based clinical examination.

In 2017, the directors of the American Board of Orthodontics (ABO) decided to move forward with a new clinical examination format-a scenario-based examination. The first examination of this type was administered in February 2019, and 2 more exams have been given since then. Each examination consisted of at least 6 scenarios with 4-7 questions for each scenario. Questions came from 4 domains or categories-data gathering and diagnosis, treatment objectives and planning, treatment implementation and management, and critical analysis and outcomes assessment. As of today, 49% of members of the American Association of Orthodontists are ABO certified. For more information about the scenario-based examination and ABO certification or certification renewal processes, go to AmericanBoardOrtho.com.

Clinical Correlates and Prognostic Value of Elevated Right Atrial Pressure in Patients With Hypertrophic Cardiomyopathy.

BACKGROUND: The clinical characteristics associated with elevated right atrial pressure (RAP) in hypertrophic cardiomyopathy (HCM) are unknown. Few data exist as to whether elevated RAP has prognostic implications in patients with HCM. This study investigated the clinical correlates and prognostic value of elevated RAP in HCM.Methods and Results:This retrospective cohort study was performed on 180 patients with HCM who underwent right heart catheterization between 1997 and 2014. Elevated RAP was defined as >8 mmHg. Baseline characteristics, mean pulmonary artery pressure, and mean pulmonary capillary wedge pressure (PCWP) were assessed for association with elevated RAP. The predictive value of elevated RAP for all-cause mortality and the development of atrial fibrillation (AF), ventricular tachycardia/fibrillation (VT/VF), and stroke was evaluated. Elevated RAP was associated with higher New York Heart Association class, dyspnea on exertion, orthopnea, edema, jugular venous distention, larger left atrial size, right ventricular hypertrophy, higher pulmonary artery pressure, and higher PCWP. RAP independently predicted all-cause mortality (adjusted hazard ratio [aHR] 2.18 per 5-mmHg increase, 95% confidence interval [CI] 1.05-4.50, P=0.04) and incident AF (aHR 1.85 per 5-mmHg increase, 95% CI 1.20-2.85, P=0.005). Elevated RAP did not predict VT/VF (P=0.36) or stroke (P=0.28). CONCLUSIONS: Elevated RAP in patients with HCM is associated with left-sided heart failure and is an independent predictor of all-cause mortality and new-onset AF.

The biology of linguistic expression impacts neural correlates for spatial language.

Biological differences between signed and spoken languages may be most evident in the expression of spatial information. PET was used to investigate the neural substrates supporting the production of spatial language in American Sign Language as expressed by classifier constructions, in which handshape indicates object type and the location/motion of the hand iconically depicts the location/motion of a referent object. Deaf native signers performed a picture description task in which they overtly named objects or produced classifier constructions that varied in location, motion, or object type. In contrast to the expression of location and motion, the production of both lexical signs and object type classifier morphemes engaged left inferior frontal cortex and left inferior temporal cortex, supporting the hypothesis that unlike the location and motion components of a classifier construction, classifier handshapes are categorical morphemes that are retrieved via left hemisphere language regions. In addition, lexical signs engaged the anterior temporal lobes to a greater extent than classifier constructions, which we suggest reflects increased semantic processing required to name individual objects compared with simply indicating the type of object. Both location and motion classifier constructions engaged bilateral superior parietal cortex, with some evidence that the expression of static locations differentially engaged the left intraparietal sulcus. We argue that bilateral parietal activation reflects the biological underpinnings of sign language. To express spatial information, signers must transform visual-spatial representations into a body-centered reference frame and reach toward target locations within signing space.

Duration of Heightened Risk of Acute Ischemic Stroke After Hospitalization for Acute Systolic Heart Failure.

Background The duration and magnitude of increased stroke risk after a hospitalization for acute systolic heart failure (HF) remains uncertain. Methods and Results The authors performed a retrospective cohort study using claims (2008-2018) from a nationally representative 5% sample of Medicare beneficiaries aged ≥66 years. Cox regression models were fitted separately for the groups with and without acute systolic HF to examine its association with the incidence of ischemic stroke after adjustment for demographics, stroke risk factors, and Charlson comorbidities. Corresponding survival probabilities were used to compute the hazard ratio (HR) in each 30-day interval after discharge. The authors stratified patients by the presence of atrial fibrillation (AF) before or during the hospitalization for acute systolic HF. Among 2 077 501 eligible beneficiaries, 94 641 were hospitalized with acute systolic HF. After adjusting for demographics, stroke risk factors, and Charlson comorbidities, the risk of ischemic stroke was highest in the first 30 days after discharge from an acute systolic HF hospitalization for patients with AF (HR, 2.4 [95% CI, 2.1-2.7]) and without AF (HR, 4.6 [95% CI, 4.0-5.3]). The risk of stroke remained elevated for 60 days in patients with AF (HR, 1.4 [95% CI, 1.2-1.6]) and was not significantly elevated afterward. The risk of stroke remained significantly elevated through 330 days in patients without AF (HR, 2.1 [95% CI, 1.7-2.7]) and was no longer significantly elevated afterward. Conclusions A hospitalization for acute systolic HF is associated with an increased risk of ischemic stroke up to 330 days in patients without concomitant AF.

Motion-sensitive cortex and motion semantics in American Sign Language.

Previous research indicates that motion-sensitive brain regions are engaged when comprehending motion semantics expressed by words or sentences. Using fMRI, we investigated whether such neural modulation can occur when the linguistic signal itself is visually dynamic and motion semantics is expressed by movements of the hands. Deaf and hearing users of American Sign Language (ASL) were presented with signed sentences that conveyed motion semantics ("The deer walked along the hillside.") or were static, conveying little or no motion ("The deer slept along the hillside."); sentences were matched for the amount of visual motion. Motion-sensitive visual areas (MT+) were localized individually in each participant. As a control, the Fusiform Face Area (FFA) was also localized for the deaf participants. The whole-brain analysis revealed static (locative) sentences engaged regions in left parietal cortex more than motion sentences, replicating previous results implicating these regions in comprehending spatial language for sign languages. Greater activation was observed in the functionally defined MT+ ROI for motion than static sentences for both deaf and hearing signers. No modulation of neural activity by sentence type was observed in the FFA. Deafness did not affect modulation of MT+ by motion semantics, but hearing signers exhibited stronger neural activity in MT+ for both sentence types, perhaps due to differences in exposure and/or use of ASL. We conclude that top down modulation of motion-sensitive cortex by linguistic semantics is not disrupted by the visual motion that is present in sign language sentences.

Effects of deafness and sign language experience on the human brain: voxel-based and surface-based morphometry.

We investigated how deafness and sign language experience affect the human brain by comparing neuroanatomical structures across congenitally deaf signers (n = 30), hearing native signers (n = 30), and hearing sign-naïve controls (n = 30). Both voxel-based and surface-based morphometry results revealed deafness-related structural changes in visual cortices (grey matter), right frontal lobe (gyrification), and left Heschl's gyrus (white matter). The comparisons also revealed changes associated with lifelong signing experience: expansions in the surface area within left anterior temporal and left occipital lobes, and a reduction in cortical thickness in the right occipital lobe for deaf and hearing signers. Structural changes within these brain regions may be related to adaptations in the neural networks involved in processing signed language (e.g. visual perception of face and body movements). Hearing native signers also had unique neuroanatomical changes (e.g. reduced gyrification in premotor areas), perhaps due to lifelong experience with both a spoken and a signed language.

The neural correlates for spatial language: Perspective-dependent and -independent relationships in American Sign Language and spoken English.

In American Sign Language (ASL) spatial relationships are conveyed by the location of the hands in space, whereas English employs prepositional phrases. Using event-related fMRI, we examined comprehension of perspective-dependent (PD) (left, right) and perspective-independent (PI) (in, on) sentences in ASL and audiovisual English (sentence-picture matching task). In contrast to non-spatial control sentences, PD sentences engaged the superior parietal lobule (SPL) bilaterally for ASL and English, consistent with a previous study with written English. The ASL-English conjunction analysis revealed bilateral SPL activation for PD sentences, but left-lateralized activation for PI sentences. The direct contrast between PD and PI expressions revealed greater SPL activation for PD expressions only for ASL. Increased SPL activation for ASL PD expressions may reflect the mental transformation required to interpret locations in signing space from the signer's viewpoint. Overall, the results suggest both overlapping and distinct neural regions support spatial language comprehension in ASL and English.

Modulation of BOLD response in motion-sensitive lateral temporal cortex by real and fictive motion sentences.

Can linguistic semantics affect neural processing in feature-specific visual regions? Specifically, when we hear a sentence describing a situation that includes motion, do we engage neural processes that are part of the visual perception of motion? How about if a motion verb was used figuratively, not literally? We used fMRI to investigate whether semantic content can "penetrate" and modulate neural populations that are selective to specific visual properties during natural language comprehension. Participants were presented audiovisually with three kinds of sentences: motion sentences ("The wild horse crossed the barren field."), static sentences, ("The black horse stood in the barren field."), and fictive motion sentences ("The hiking trail crossed the barren field."). Motion-sensitive visual areas (MT+) were localized individually in each participant as well as face-selective visual regions (fusiform face area; FFA). MT+ was activated significantly more for motion sentences than the other sentence types. Fictive motion sentences also activated MT+ more than the static sentences. Importantly, no modulation of neural responses was found in FFA. Our findings suggest that the neural substrates of linguistic semantics include early visual areas specifically related to the represented semantics and that figurative uses of motion verbs also engage these neural systems, but to a lesser extent. These data are consistent with a view of language comprehension as an embodied process, with neural substrates as far reaching as early sensory brain areas that are specifically related to the represented semantics.

Outcomes of Hospitalizations for Cardiogenic Shock at Left Ventricular Assist Device Versus Non-Left Ventricular Assist Device Centers.

Background Cardiogenic shock (CS) is a complex syndrome associated with high morbidity and mortality. In recent years, many US hospitals have formed multidisciplinary shock teams capable of rapid diagnosis and triage. Because of preexisting collaborative systems of care, hospitals with left ventricular assist device (LVAD) programs may also represent "centers of excellence" for CS care. However, the outcomes of patients with CS at LVAD centers have not been previously evaluated. Methods and Results Patients with CS were identified in the 2012 to 2014 National Inpatient Sample. Clinical characteristics, revascularization rates, and use of mechanical circulatory support were analyzed in LVAD versus non-LVAD centers. The association between hospital type and in-hospital mortality was examined using multivariable logistic regression models. Of 272 075 hospitalizations, 26.0% were in LVAD centers. CS attributable to causes other than acute myocardial infarction represented most cases. In-hospital mortality was lower in LVAD centers (38.9% versus 43.3%; P<0.001). In multivariable analysis, the odds of mortality remained significantly lower for hospitalizations in LVAD centers (odds ratio, 0.89; P<0.001). In patients with CS secondary to acute myocardial infarction, revascularization rates were similar between LVAD and non-LVAD centers. The use of intra-aortic balloon pump (18.7% versus 18.8%) and Impella/TandemHeart (2.6% versus 1.9%) was similar between hospital types, whereas extracorporeal membrane oxygenation was used more frequently in LVAD centers (4.3% versus 0.2%; P<0.001). Conclusions Risk-adjusted mortality was lower in patients with CS who were hospitalized at LVAD centers. These centers likely represent specialized, shock team capable institutions across the country that may be best suited to manage patients with CS.

Orthographic and phonological selectivity across the reading system in deaf skilled readers.

People who are born deaf often have difficulty learning to read. Recently, several studies have examined the neural substrates involved in reading in deaf people and found a left lateralized reading system similar to hearing people involving temporo-parietal, inferior frontal, and ventral occipito-temporal cortices. Previous studies in typical hearing readers show that within this reading network there are separate regions that specialize in processing orthography and phonology. We used fMRI rapid adaptation in deaf adults who were skilled readers to examine neural selectivity in three functional ROIs in the left hemisphere: temporoparietal cortex (TPC), inferior frontal gyrus (IFG), and the visual word form area (VWFA). Results show that in deaf skilled readers, the left VWFA showed selectivity for orthography similar to what has been reported for hearing readers, the TPC showed less sensitivity to phonology than previously reported for hearing readers using the same paradigm, and the IFG showed selectivity to orthography, but not phonology (similar to what has been reported previously for hearing readers). These results provide evidence that while skilled deaf readers demonstrate coarsely tuned phonological representations in the TPC, they develop finely tuned representations for the orthography of written words in the VWFA and IFG. This result suggests that phonological tuning in the TPC may have little impact on the neural network associated with skilled reading for deaf adults.

The neural underpinnings of reading skill in deaf adults.

We investigated word-level reading circuits in skilled deaf readers (N=14; mean reading age=19.5years) and less skilled deaf readers (N=14; mean reading age=12years) who were all highly proficient users of American Sign Language. During fMRI scanning, participants performed a semantic decision (concrete concept?), a phonological decision (two syllables?), and a false-font control task (string underlined?). No significant group differences were observed with the full participant set. However, an analysis with the 10 most and 10 least skilled readers revealed that for the semantic task (vs. control task), proficient deaf readers exhibited greater activation in left inferior frontal and middle temporal gyri than less proficient readers. No group differences were observed for the phonological task. Whole-brain correlation analyses (all participants) revealed that for the semantic task, reading ability correlated positively with neural activity in the right inferior frontal gyrus and in a region associated with the orthography-semantics interface, located anterior to the visual word form area. Reading ability did not correlate with neural activity during the phonological task. Accuracy on the semantic task correlated positively with neural activity in left anterior temporal lobe (a region linked to conceptual processing), while accuracy on the phonological task correlated positively with neural activity in left posterior inferior frontal gyrus (a region linked to syllabification processes during speech production). Finally, reading comprehension scores correlated positively with vocabulary and print exposure measures, but not with phonological awareness scores.

The neural circuits recruited for the production of signs and fingerspelled words.

Signing differs from typical non-linguistic hand actions because movements are not visually guided, finger movements are complex (particularly for fingerspelling), and signs are not produced as holistic gestures. We used positron emission tomography to investigate the neural circuits involved in the production of American Sign Language (ASL). Different types of signs (one-handed (articulated in neutral space), two-handed (neutral space), and one-handed body-anchored signs) were elicited by asking deaf native signers to produce sign translations of English words. Participants also fingerspelled (one-handed) printed English words. For the baseline task, participants indicated whether a word contained a descending letter. Fingerspelling engaged ipsilateral motor cortex and cerebellar cortex in contrast to both one-handed signs and the descender baseline task, which may reflect greater timing demands and complexity of handshape sequences required for fingerspelling. Greater activation in the visual word form area was also observed for fingerspelled words compared to one-handed signs. Body-anchored signs engaged bilateral superior parietal cortex to a greater extent than the descender baseline task and neutral space signs, reflecting the motor control and proprioceptive monitoring required to direct the hand toward a specific location on the body. Less activation in parts of the motor circuit was observed for two-handed signs compared to one-handed signs, possibly because, for half of the signs, handshape and movement goals were spread across the two limbs. Finally, the conjunction analysis comparing each sign type with the descender baseline task revealed common activation in the supramarginal gyrus bilaterally, which we interpret as reflecting phonological retrieval and encoding processes.

Neural organization for recognition of grammatical and emotional facial expressions in deaf ASL signers and hearing nonsigners.

Recognition of emotional facial expressions is universal for all humans, but signed language users must also recognize certain non-affective facial expressions as linguistic markers. fMRI was used to investigate the neural systems underlying recognition of these functionally distinct expressions, comparing deaf ASL signers and hearing nonsigners. Within the superior temporal sulcus (STS), activation for emotional expressions was right lateralized for the hearing group and bilateral for the deaf group. In contrast, activation within STS for linguistic facial expressions was left lateralized only for signers and only when linguistic facial expressions co-occurred with verbs. Within the fusiform gyrus (FG), activation was left lateralized for ASL signers for both expression types, whereas activation was bilateral for both expression types for nonsigners. We propose that left lateralization in FG may be due to continuous analysis of local facial features during on-line sign language processing. The results indicate that function in part drives the lateralization of neural systems that process human facial expressions.

Simultaneous perception of a spoken and a signed language: The brain basis of ASL-English code-blends.

Code-blends (simultaneous words and signs) are a unique characteristic of bimodal bilingual communication. Using fMRI, we investigated code-blend comprehension in hearing native ASL-English bilinguals who made a semantic decision (edible?) about signs, audiovisual words, and semantically equivalent code-blends. English and ASL recruited a similar fronto-temporal network with expected modality differences: stronger activation for English in auditory regions of bilateral superior temporal cortex, and stronger activation for ASL in bilateral occipitotemporal visual regions and left parietal cortex. Code-blend comprehension elicited activity in a combination of these regions, and no cognitive control regions were additionally recruited. Furthermore, code-blends elicited reduced activation relative to ASL presented alone in bilateral prefrontal and visual extrastriate cortices, and relative to English alone in auditory association cortex. Consistent with behavioral facilitation observed during semantic decisions, the findings suggest that redundant semantic content induces more efficient neural processing in language and sensory regions during bimodal language integration.

Clinical Features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is an increasingly used supportive measure for patients with refractory cardiogenic shock (CS). Despite its increasing use, there remain minimal data regarding which patients with refractory CS are most likely to benefit from ECMO. We retrospectively studied all patients (n = 123) who underwent initiation of ECMO for CS from February 2009 to September 2014 at a single center. Baseline patient characteristics, including demographics, co-morbid illness, cause of CS, available laboratory values, and patient outcomes were analyzed. Overall, 69 patients (56%) were weaned from ECMO, with 48 patients (39%) surviving to discharge. Survivors were younger (50 vs 60 years; p ≤0.0001), had a lower rate of previous smoking (27 vs 56%; p = 0.01) and chronic kidney disease (2% vs 13%; p = 0.03), and had lower lactate measured soon after ECMO initiation (3.1 vs 10.2 mmol/l; p = 0.01). Patients with pulmonary embolism (odds ratio 8.0, 95% confidence interval 2.00 to 31.99; p = 0.01) and acute cardiomyopathy (odds ratio 7.5, 95% confidence interval 1.69 to 33.27; p = 0.01) had a higher rate of survival than acute myocardial infarction, chronic cardiomyopathy, and miscellaneous etiologies compared to postcardiotomy CS as a referent. In conclusion, survival after ECMO initiation differs based on underlying cause of CS. Survival may be lower in older patients and those with early evidence of persistent hypoperfusion after initiation of ECMO for CS.

Neural systems underlying lexical retrieval for sign language.

Positron emission tomography was used to investigate whether signed languages exhibit the same neural organization for lexical retrieval within classical and non-classical language areas as has been described for spoken English. Ten deaf native American sign language (ASL) signers were shown pictures of unique entities (famous persons) and non-unique entities (animals) and were asked to name each stimulus with an overt signed response. Proper name signed responses to famous people were fingerspelled, and common noun responses to animals were both fingerspelled and signed with native ASL signs. In general, retrieving ASL signs activated neural sites similar to those activated by hearing subjects retrieving English words. Naming famous persons activated the left temporal pole (TP), whereas naming animals (whether fingerspelled or signed) activated left inferotemporal (IT) cortex. The retrieval of fingerspelled and native signs generally engaged the same cortical regions, but fingerspelled signs in addition activated a premotor region, perhaps due to the increased motor planning and sequencing demanded by fingerspelling. Native signs activated portions of the left supramarginal gyrus (SMG), an area previously implicated in the retrieval of phonological features of ASL signs. Overall, the findings indicate that similar neuroanatomical areas are involved in lexical retrieval for both signs and words.

Motor-iconicity of sign language does not alter the neural systems underlying tool and action naming.

Positron emission tomography was used to investigate whether the motor-iconic basis of certain forms in American Sign Language (ASL) partially alters the neural systems engaged during lexical retrieval. Most ASL nouns denoting tools and ASL verbs referring to tool-based actions are produced with a handshape representing the human hand holding a tool and with an iconic movement depicting canonical tool use, whereas the visual iconicity of animal signs is more idiosyncratic and inconsistent across signs. We investigated whether the motor-iconic relation between a sign and its referent alters the neural substrate for lexical retrieval in ASL. Ten deaf native ASL signers viewed photographs of tools/utensils or of actions performed with or without an implement and were asked to overtly produce the ASL sign for each object or action. The control task required subjects to judge the orientation of unknown faces. Compared to the control task, naming tools engaged left inferior and middle frontal gyri, bilateral parietal lobe, and posterior inferotemporal cortex. Naming actions performed with or without a tool engaged left inferior frontal gyrus, bilateral parietal lobe, and posterior middle temporal gyrus at the temporo-occipital junction (area MT). When motor-iconic verbs were compared with non-iconic verbs, no differences in neural activation were found. Overall, the results indicate that even when the form of a sign is indistinguishable from a pantomimic gesture, the neural systems underlying its production mirror those engaged when hearing speakers name tools or tool-based actions with speech.