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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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.

How sensory-motor systems impact the neural organization for language: direct contrasts between spoken and signed language.

To investigate the impact of sensory-motor systems on the neural organization for language, we conducted an H2 (15)O-PET study of sign and spoken word production (picture-naming) and an fMRI study of sign and audio-visual spoken language comprehension (detection of a semantically anomalous sentence) with hearing bilinguals who are native users of American Sign Language (ASL) and English. Directly contrasting speech and sign production revealed greater activation in bilateral parietal cortex for signing, while speaking resulted in greater activation in bilateral superior temporal cortex (STC) and right frontal cortex, likely reflecting auditory feedback control. Surprisingly, the language production contrast revealed a relative increase in activation in bilateral occipital cortex for speaking. We speculate that greater activation in visual cortex for speaking may actually reflect cortical attenuation when signing, which functions to distinguish self-produced from externally generated visual input. Directly contrasting speech and sign comprehension revealed greater activation in bilateral STC for speech and greater activation in bilateral occipital-temporal cortex for sign. Sign comprehension, like sign production, engaged bilateral parietal cortex to a greater extent than spoken language. We hypothesize that posterior parietal activation in part reflects processing related to spatial classifier constructions in ASL and that anterior parietal activation may reflect covert imitation that functions as a predictive model during sign comprehension. The conjunction analysis for comprehension revealed that both speech and sign bilaterally engaged the inferior frontal gyrus (with more extensive activation on the left) and the superior temporal sulcus, suggesting an invariant bilateral perisylvian language system. We conclude that surface level differences between sign and spoken languages should not be dismissed and are critical for understanding the neurobiology of language.

Safety and cost of stent-assisted coiling of unruptured intracranial aneurysms compared with coiling or clipping.

OBJECTIVE: Stent-assisted coiling (SAC) of unruptured intracranial aneurysms is a treatment alternative to clipping or coiling, although high complication and procedure-related mortality rates have been reported. METHODS: A retrospective study was conducted of patients undergoing SAC, coiling or clipping of unruptured intracranial aneurysms between 2003 and 2010. Rates of residual aneurysm, recanalization, complications, cost (adjusted to 2010), length of stay (LOS) and outcome were compared between groups. RESULTS: Of 116 subjects, 47 underwent SAC, 33 coiling and 36 clipping. The groups were similar in age, gender and aneurysm location, although the SAC group had significantly larger aneurysms with wider necks (p=0.001). Patients who underwent SAC had more residual aneurysm after initial treatment than those treated with coiling or clipping (75%, 52% and 19%, respectively, p<0.0001), but this difference was smaller at follow-up angiography (50%, 50% and 17% residual, respectively) and was not significant after adjusting for baseline aneurysm and neck size. SAC was not associated with increased recanalization, requirement for additional treatment, mortality or complications after adjusting for aneurysm and neck size. Patients who underwent SAC and those who underwent coiling were more likely to have a good discharge disposition than patients treated with clipping (100% vs 91%, p=0.042). LOS was significantly shorter for patients who underwent SAC or coiling compared with those treated with clipping (p<0.0001). The overall direct cost was higher for patients who underwent SAC than for those treated with coiling or clipping (median $22 544 vs $12 933 vs $14 656, p=0.001), even after adjusting for aneurysm and neck size, LOS and retreatment. CONCLUSIONS: SAC is a safe alternative to coiling or clipping of unruptured aneurysms but it is currently more expensive.

Mapping the reading circuitry for skilled deaf readers: an fMRI study of semantic and phonological processing.

We examined word-level reading circuits in skilled deaf readers whose primary language is American Sign Language, and hearing readers matched for reading ability (college level). During fMRI scanning, participants performed a semantic decision (concrete concept?), a phonological decision (two syllables?), and a false-font control task (string underlined?). The groups performed equally well on the semantic task, but hearing readers performed better on the phonological task. Semantic processing engaged similar left frontotemporal language circuits in deaf and hearing readers. However, phonological processing elicited increased neural activity in deaf, relative to hearing readers, in the left precentral gyrus, suggesting greater reliance on articulatory phonological codes, and in bilateral parietal cortex, suggesting increased phonological processing effort. Deaf readers also showed stronger anterior-posterior functional segregation between semantic and phonological processes in left inferior prefrontal cortex. Finally, weaker phonological decoding ability did not alter activation in the visual word form area for deaf readers.