Incidence, characteristics, and risk factors of new liver disorders 3.5 years post COVID-19 pandemic in the Montefiore Health System in Bronx.

PURPOSE: To determine the incidence of newly diagnosed liver disorders (LD) up to 3.5-year post-acute COVID-19, and risk factors associated with new LD. METHODS: We analyzed 54,699 COVID-19 patients and 1,409,547 non-COVID-19 controls from March-11-2020 to Jan-03-2023. New liver disorders included abnormal liver function tests, advanced liver failure, alcohol and non-alcohol related liver disorders, and cirrhosis. Comparisons were made with ambulatory non-COVID-19 patients and patients hospitalized for other lower respiratory tract infections (LRTI). Demographics, comorbidities, laboratory data, incomes, insurance status, and unmet social needs were tabulated. The primary outcome was new LD at least two weeks following COVID-19 positive test. RESULTS: Incidence of new LD was not significantly different between COVID-19 and non-COVID-19 cohorts (incidence:1.99% vs 1.90% p>0.05, OR = 1.04[95%CI: 0.92,1.17], p = 0.53). COVID-19 patients with new LD were older, more likely to be Hispanic and had higher prevalence of diabetes, hypertension, chronic kidney disease, and obesity compared to patients without new LD. Hospitalized COVID-19 patients had no elevated risk of LD compared to hospitalized LRTI patients (2.90% vs 2.07%, p>0.05, OR = 1.29[0.98,1.69], p = 0.06). Among COVID-19 patients, those who developed LD had fewer patients with higher incomes (14.18% vs 18.35%, p<0.05) and more with lower incomes (21.72% vs 17.23%, p<0.01), more Medicare and less Medicaid insurance, and more patients with >3 unmet social needs (6.49% vs 2.98%, p<0.001) and fewer with no unmet social needs (76.19% vs 80.42%, p<0.001). CONCLUSIONS: Older age, Hispanic ethnicity, and obesity, but not COVID-19 status, posed increased risk for developing new LD. Lower socioeconomic status was associated with higher incidence of new LD.

Digital Behavior Change Intervention Designs for Habit Formation: Systematic Review.

BACKGROUND: With the development of emerging technologies, digital behavior change interventions (DBCIs) help to maintain regular physical activity in daily life. OBJECTIVE: To comprehensively understand the design implementations of habit formation techniques in current DBCIs, a systematic review was conducted to investigate the implementations of behavior change techniques, types of habit formation techniques, and design strategies in current DBCIs. METHODS: The process of this review followed the PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. A total of 4 databases were systematically searched from 2012 to 2022, which included Web of Science, Scopus, ACM Digital Library, and PubMed. The inclusion criteria encompassed studies that used digital tools for physical activity, examined behavior change intervention techniques, and were written in English. RESULTS: A total of 41 identified research articles were included in this review. The results show that the most applied behavior change techniques were the self-monitoring of behavior, goal setting, and prompts and cues. Moreover, habit formation techniques were identified and developed based on intentions, cues, and positive reinforcement. Commonly used methods included automatic monitoring, descriptive feedback, general guidelines, self-set goals, time-based cues, and virtual rewards. CONCLUSIONS: A total of 32 commonly design strategies of habit formation techniques were summarized and mapped to the proposed conceptual framework, which was categorized into target-mediated (generalization and personalization) and technology-mediated interactions (explicitness and implicitness). Most of the existing studies use the explicit interaction, aligning with the personalized habit formation techniques in the design strategies of DBCIs. However, implicit interaction design strategies are lacking in the reviewed studies. The proposed conceptual framework and potential solutions can serve as guidelines for designing strategies aimed at habit formation within DBCIs.

Motion Tracking of Daily Living and Physical Activities in Health Care: Systematic Review From Designers' Perspective.

BACKGROUND: Motion tracking technologies serve as crucial links between physical activities and health care insights, facilitating data acquisition essential for analyzing and intervening in physical activity. Yet, systematic methodologies for evaluating motion tracking data, especially concerning user activity recognition in health care applications, remain underreported. OBJECTIVE: This study aims to systematically review motion tracking in daily living and physical activities, emphasizing the critical interaction among devices, users, and environments from a design perspective, and to analyze the process involved in health care application research. It intends to delineate the design and application intricacies in health care contexts, focusing on enhancing motion tracking data's accuracy and applicability for health monitoring and intervention strategies. METHODS: Using a systematic review, this research scrutinized motion tracking data and their application in health care and wellness, examining studies from Scopus, Web of Science, EBSCO, and PubMed databases. The review used actor network theory and data-enabled design to understand the complex interplay between humans, devices, and environments within these applications. RESULTS: Out of 1501 initially identified studies, 54 (3.66%) were included for in-depth analysis. These articles predominantly used accelerometer and gyroscope sensors (n=43, 80%) to monitor and analyze motion, demonstrating a strong preference for these technologies in capturing both dynamic and static activities. While incorporating portable devices (n=11, 20%) and multisensor configurations (n=16, 30%), the application of sensors across the body (n=15, 28%) and within physical spaces (n=17, 31%) highlights the diverse applications of motion tracking technologies in health care research. This diversity reflects the application's alignment with activity types ranging from daily movements to specialized scenarios. The results also reveal a diverse participant pool, including the general public, athletes, and specialized groups, with a focus on healthy individuals (n=31, 57%) and athletes (n=14, 26%). Despite this extensive application range, the focus primarily on laboratory-based studies (n=39, 72%) aimed at professional uses, such as precise activity identification and joint functionality assessment, emphasizes a significant challenge in translating findings from controlled environments to the dynamic conditions of everyday physical activities. CONCLUSIONS: This study's comprehensive investigation of motion tracking technology in health care research reveals a significant gap between the methods used for data collection and their practical application in real-world scenarios. It proposes an innovative approach that includes designers in the research process, emphasizing the importance of incorporating data-enabled design framework. This ensures that motion data collection is aligned with the dynamic and varied nature of daily living and physical activities. Such integration is crucial for developing health applications that are accessible, intuitive, and tailored to meet diverse user needs. By leveraging a multidisciplinary approach that combines design, engineering, and health sciences, the research opens new pathways for enhancing the usability and effectiveness of health technologies.

SARS-CoV-2 infection increases long-term multiple sclerosis disease activity and all-cause mortality in an underserved inner-city population.

BACKGROUND: Although certain subsets patients with multiple sclerosis (MS), an immune-mediated disorder, are at higher risk of worse acute COVID-19 outcomes compared to the general population, it is not clear whether SARS-CoV-2 infection impacts long-term outcomes compared with MS patients without COVID-19 infection. OBJECTIVES: This study investigated MS disease activity and mortality 3.5 years post SARS-CoV-2 infection and compared with MS patients without COVID-19. METHODS: This retrospective study evaluated 1,633 patients with MS in the Montefiore Health System in the Bronx from January 2016 to July 2023. This health system serves a large minority population and was an epicenter for the early pandemic and subsequent surges of infection. Positive SARS-CoV-2 infection was determined by a positive polymerase-chain-reaction test. Primary outcomes were all-cause mortality, and optic neuritis post SARS-CoV-2 infection. Secondary outcomes included change in disease-modifying therapy (DMT), treatment with high-dose methylprednisolone, cerebellar deficits, relapse, and all-cause hospitalization post-infection. RESULTS: MS patients with COVID-19 had similar demographics but higher prevalence of pre-existing major comorbidities (hypertension, type-2 diabetes, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, and coronary artery disease), optic neuritis, and history of high dose steroid treatment for relapses compared to MS patients without COVID-19. MS patients with COVID-19 had greater risk of mortality (adjusted HR=4.34[1.67, 11.30], p < 0.005), greater risk of post infection optic neuritis (adjusted HR=2.97[1.58, 5.58], p < 0.005), higher incidence of methylprednisolone treatment for post infection acute relapse (12.65% vs. 2.54 %, p < 0.001), and more hospitalization (78.92% vs. 66.81 %, p < 0.01), compared to MS patients without COVID-19. CONCLUSIONS: MS patients who survived COVID-19 infection experienced worse long-term outcomes, as measured by treatment for relapse, hospitalization and mortality. Identifying risk factors for worse long-term outcomes may draw clinical attention to the need for careful follow-up of at-risk individuals post-SARS-CoV-2 infection.

A protein kinase C α and ß inhibitor blunts hyperphagia to halt renal function decline and reduces adiposity in a rat model of obesity-driven type 2 diabetes.

Type 2 diabetes (T2D) and its complications can have debilitating, sometimes fatal consequences for afflicted individuals. The disease can be difficult to control, and therapeutic strategies to prevent T2D-induced tissue and organ damage are needed. Here we describe the results of administering a potent and selective inhibitor of Protein Kinase C (PKC) family members PKCα and PKCß, Cmpd 1, in the ZSF1 obese rat model of hyperphagia-induced, obesity-driven T2D. Although our initial intent was to evaluate the effect of PKCα/ß inhibition on renal damage in this model setting, Cmpd 1 unexpectedly caused a marked reduction in the hyperphagic response of ZSF1 obese animals. This halted renal function decline but did so indirectly and indistinguishably from a pair feeding comparator group. However, above and beyond this food intake effect, Cmpd 1 lowered overall animal body weights, reduced liver vacuolation, and reduced inguinal adipose tissue (iWAT) mass, inflammation, and adipocyte size. Taken together, Cmpd 1 had strong effects on multiple disease parameters in this obesity-driven rodent model of T2D. Further evaluation for potential translation of PKCα/ß inhibition to T2D and obesity in humans is warranted.

Complex Percutaneous Coronary Intervention Outcomes in Older Adults.

Background Complex percutaneous coronary intervention (PCI) is increasingly performed in older adults (age ≥75 years) with stable ischemic heart disease. However, little is known about clinical outcomes. Methods and Results We derived a cohort of older adults undergoing elective PCI for stable ischemic heart disease across a large health system. We compared 12-month event-free survival (freedom from all-cause death, nonfatal myocardial infarction, stroke, and major bleeding), all-cause death, target lesion revascularization, and bleeding events for patients receiving complex versus noncomplex PCI and derived risk estimates with Cox regression models. We included 513 patients (mean age, 81±5 years). Patients receiving complex PCI versus noncomplex PCI did not significantly differ across a host of clinical characteristics including cardiovascular disease features, noncardiac comorbidities, guideline-directed medical therapy use, and frailty. Patients receiving complex PCI versus noncomplex PCI experienced worse event-free survival (80.4% versus 86.8%), which was not significant in adjusted analyses (hazard ratio [HR], 1.38 [95% CI, 0.88-2.16]). All-cause death at 1 year for patients undergoing complex PCI was nearly double that seen for patients receiving noncomplex PCI (10.2% versus 5.9%), and the risk was significant in models adjusted for clinical characteristics (HR, 1.97 [95% CI, 1.02-3.79]). Target lesion revascularization risk was lower for patients receiving complex PCI (2.2% versus 3.5%, adjusted HR), but bleeding events were not statistically different between groups (25.3% versus 20.5%; P=0.19). Conclusions Complex PCI in older adults with stable ischemic heart disease was associated with lower risk of target lesion revascularization but higher all-cause death compared with noncomplex PCI.

The SUPER reporting guideline suggested for reporting of surgical technique.

Background: Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation. Methods: Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants. Results: The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22). Conclusions: The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique. Trial Registration: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

The SUPER reporting guideline suggested for reporting of surgical technique: explanation and elaboration.

Background: Surgical technique plays an essential role in achieving good health outcomes. However, the quality of surgical technique reporting remains heterogeneous. Reporting checklists could help authors to describe the surgical technique more transparently and effectively, as well as to assist reviewers and editors evaluate it more informatively, and promote readers to better understand the technique. We previously developed SUPER (surgical technique reporting checklist and standards) to assist authors in reporting their research that contains surgical technique more transparently. However, further explanation and elaboration of each item are needed for better understanding and reporting practice. Methods: We searched surgical literature in PubMed, Google Scholar and journal websites published up to January 2023 to find multidiscipline examples in various article types for each SUPER item. Results: We explain the 22 items of the SUPER and provide rationales item by item alongside. We provide 69 examples from 53 literature that present optimal reporting of the 22 items. Article types of examples include pure surgical technique, and case reports, observational studies and clinical trials that contain surgical technique. Examples are multidisciplinary, including general surgery, orthopaedical surgery, cardiac surgery, thoracic surgery, gastrointestinal surgery, neurological surgery, oncogenic surgery, and emergency surgery etc. Conclusions: Along with SUPER article, this explanation and elaboration file can promote deeper understanding on the SUPER items. We hope that the article could further guide surgeons and researchers in reporting, and assist editors and peer reviewers in reviewing manuscripts related to surgical technique.

Exogenous DNA enhances DUOX2 expression and function in human pancreatic cancer cells by activating the cGAS-STING signaling pathway.

Pro-inflammatory cytokines upregulate the expression of the H2O2-producing NADPH oxidase dual oxidase 2 (DUOX2)2 which, when elevated, adversely affects survival from pancreatic ductal adenocarcinoma (PDAC). Because the cGAS-STING pathway is known to initiate pro-inflammatory cytokine expression following uptake of exogenous DNA, we examined whether activation of cGAS-STING could play a role in the generation of reactive oxygen species by PDAC cells. Here, we found that a variety of exogenous DNA species markedly increased the production of cGAMP, the phosphorylation of TBK1 and IRF3, and the translocation of phosphorylated IRF3 into the nucleus, leading to a significant, IRF3-dependent enhancement of DUOX2 expression, and a significant flux of H2O2 in PDAC cells. However, unlike the canonical cGAS-STING pathway, DNA-related DUOX2 upregulation was not mediated by NF-κB. Although exogenous IFN-ß significantly increased Stat1/2-associated DUOX2 expression, intracellular IFN-ß signaling that followed cGAMP or DNA exposure did not itself increase DUOX2 levels. Finally, DUOX2 upregulation subsequent to cGAS-STING activation was accompanied by the enhanced, normoxic expression of HIF-1α and VEGF-A as well as DNA double strand cleavage, suggesting that cGAS-STING signaling may support the development of an oxidative, pro-angiogenic microenvironment that could contribute to the inflammation-related genetic instability of pancreatic cancer.

Patients with prediabetes are at greater risk of developing diabetes 5 months postacute SARS-CoV-2 infection: a retrospective cohort study.

INTRODUCTION: Patients with prediabetes who contract SARS-CoV-2 infection (COVID-19) could be at higher risk of developing frank diabetes compared those who do not. This study aims to investigate the incidence of new-onset diabetes in patients with prediabetes after COVID-19 and if it differs from those not infected. RESEARCH DESIGN AND METHODS: Using electronic medical record data, 42 877 patients with COVID-19, 3102 were identified as having a history of prediabetes in the Montefiore Health System, Bronx, New York. During the same time period, 34 786 individuals without COVID-19 with history of prediabetes were identified and 9306 were propensity matched as controls. SARS-CoV-2 infection status was determined by a real-time PCR test between March 11, 2020 and August 17, 2022. The primary outcomes were new-onset in-hospital diabetes mellitus (I-DM) and new-onset persistent diabetes mellitus (P-DM) at 5 months after SARS-CoV-2 infection. RESULTS: Compared with hospitalized patients without COVID-19 with history of prediabetes, hospitalized patients with COVID-19 with history of prediabetes had a higher incidence of I-DM (21.9% vs 6.02%, p<0.001) and of P-DM 5 months postinfection (14.75% vs 7.51%, p<0.001). Non-hospitalized patients with and without COVID-19 with history of prediabetes had similar incidence of P-DM (4.15% and 4.1%, p>0.05). Critical illness (HR 4.6 (95% CI 3.5 to 6.1), p<0.005), in-hospital steroid treatment (HR 2.88 (95% CI 2.2 to 3.8), p<0.005), SARS-CoV-2 infection status (HR 1.8 (95% CI 1.4 to 2.3), p<0.005), and hemoglobin A1c (HbA1c) (HR 1.7 (95% CI 1.6 to 1.8), p<0.005) were significant predictors of I-DM. I-DM (HR 23.2 (95% CI 16.1 to 33.4), p<0.005), critical illness (HR 2.4 (95% CI 1.6 to 3.8), p<0.005), and HbA1c (HR 1.3 (95% CI 1.1 to 1.4), p<0.005) were significant predictors of P-DM at follow-up. CONCLUSIONS: SARS-CoV-2 infection confers a higher risk for developing persistent diabetes 5 months post-COVID-19 in patients with prediabetes who were hospitalized for COVID-19 compared with COVID-19-negative counterparts with prediabetes. In-hospital diabetes, critical illness, and elevated HbA1c are risk factors for developing persistent diabetes. Patients with prediabetes with severe COVID-19 disease may need more diligent monitoring for developing P-DM postacute SARS-CoV-2 infection.

Incidence, characteristics, risk factors and outcomes of diabetic ketoacidosis in COVID-19 patients: Comparison with influenza and pre-pandemic data.

AIMS: This study characterized incidence, patient profiles, risk factors and outcomes of in-hospital diabetic ketoacidosis (DKA) in patients with COVID-19 compared with influenza and pre-pandemic data. METHODS: This study consisted of 13 383 hospitalized patients with COVID-19 (March 2020-July 2022), 19 165 hospitalized patients with influenza (January 2018-July 2022) and 35 000 randomly sampled hospitalized pre-pandemic patients (January 2017-December 2019) in Montefiore Health System, Bronx, NY, USA. Primary outcomes were incidence of in-hospital DKA, in-hospital mortality, and insulin use at 3 and 6 months post-infection. Risk factors for developing DKA were identified. RESULTS: The overall incidence of DKA in patients with COVID-19 and influenza, and pre-pandemic were 2.1%, 1.4% and 0.5%, respectively (p < .05 pairwise). Patients with COVID-19 with DKA had worse acute outcomes (p < .05) and higher incidence of new insulin treatment 3 and 6 months post-infection compared with patients with influenza with DKA (p < .05). The incidence of DKA in patients with COVID-19 was highest among patients with type 1 diabetes (12.8%), followed by patients with insulin-dependent type 2 diabetes (T2D; 5.2%), non-insulin dependent T2D (2.3%) and, lastly, patients without T2D (1.3%). Patients with COVID-19 with DKA had worse disease severity and higher mortality [odds ratio = 6.178 (4.428-8.590), p < .0001] compared with those without DKA. Type 1 diabetes, steroid therapy for COVID-19, COVID-19 status, black race and male gender were associated with increased risk of DKA. CONCLUSIONS: The incidence of DKA was higher in COVID-19 cohort compared to the influenza and pre-pandemic cohort. Patients with COVID-19 with DKA had worse outcomes compared with those without. Many COVID-19 survivors who developed DKA during hospitalization became insulin dependent. Identification of risk factors for DKA and new insulin-dependency could enable careful monitoring and timely intervention.

Management of Stable Angina in the Older Adult Population.

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Complex Inferior Vena Cava Filter Retrievals: Success Rate and Predictors of Adverse Events at a Large Specialized Referral Center.

BACKGROUND. Specialized inferior vena cava (IVC) filter referral centers can achieve improved retrieval outcomes, potentially facilitating complex retrievals after long filter dwell times. OBJECTIVE. The purpose of this study was to determine the success rate of complex IVC filter retrievals at a large specialized IVC filter referral center and to identify predictors of adverse events during complex retrievals. METHODS. This retrospective study included patients who underwent complex IVC filter retrieval from March 2014 to June 2018 at a large regional health system with specialized complex retrieval referral centers and interventional radiologists with expertise in such procedures. Complex retrievals methods included a range of loop snare, coaxial sheath, forceps, and snare techniques. Data were collected from the electronic medical record. The success rate of complex retrieval was determined. Factors associated with adverse events during retrieval procedures were explored. RESULTS. The study included 125 patients (51 women, 74 men; mean age, 60 years). The mean filter dwell time at retrieval was 47.5 months (median, 21.8 months). The complex retrieval success rate was 99.2% on the first attempt and 100.0% overall. A total of 11.2% (14/125) of patients experienced an adverse event during retrieval, including 10.4% (13/125) with minor and 0.8% (1/125) with major events. Prolonged dwell time was the only indication for complex retrieval that was significantly associated with adverse events (adverse event rate, 16.7% for patients with this indication vs 5.1% for patients without this indication; p = .04). In multiple regression analysis, the only significant independent predictor of adverse events was a filter dwell time of 5 years or longer (odds ratio, 6.98 [95% CI, 1.64-29.81]; p = .009). CONCLUSION. In a specialized referral system with expertise in complex retrieval methods, high retrieval success rates can be achieved in patients who have filters with long dwell times. Nonetheless, longer dwell times are associated with adverse events during retrieval procedures. CLINICAL IMPACT. The observations support performing early filter retrieval and referring patients who have filters with prolonged dwell times to specialized centers.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action.

OBJECTIVES: To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement. STUDY DESIGN AND SETTING: A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021. RESULTS: We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description. CONCLUSION: Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Readmission rates and risk factors for readmission after transcatheter aortic valve replacement in patients with end-stage renal disease.

OBJECTIVES: We sought to examine readmission rates and predictors of hospital readmission following TAVR in patients with ESRD. BACKGROUND: End-stage renal disease (ESRD) is associated with poor outcomes following transcatheter aortic valve replacement (TAVR). METHODS: We assessed index hospitalizations for TAVR from the National Readmissions Database from 2017 to 2018 and used propensity scores to match those with and without ESRD. We compared 90-day readmission for any cause or cardiovascular cause. Length of stay (LOS), mortality, and cost were assessed for index hospitalizations and 90-day readmissions. Multivariable logistic regression was performed to identify predictors of 90-day readmission. RESULTS: We identified 49,172 index hospitalizations for TAVR, including 1,219 patients with ESRD (2.5%). Patient with ESRD had higher rates of all-cause readmission (34.4% vs. 19.2%, HR 1.96, 95% CI 1.68-2.30, p<0.001) and cardiovascular readmission (13.2% vs. 7.7%, HR 1.85, 95% CI 1.44-2.38, p<0.001) at 90 days. During index hospitalization, patients with ESRD had longer length of stay (mean difference 1.9 days), increased hospital cost (mean difference $42,915), and increased in-hospital mortality (2.6% vs. 0.9%). Among those readmitted within 90 days, patients with ESRD had longer LOS and increased hospital charge, but similar in-hospital mortality. Diabetes (OR 1.86, 95% CI 1.31-2.64) and chronic pulmonary disease (OR 1.51, 95% CI 1.04-2.18) were independently associated with higher odds of 90-day readmission in patients with ESRD. CONCLUSION: Patients with ESRD undergoing TAVR have higher mortality and increased cost associated with their index hospitalization and are at increased risk of readmission within 90 days following TAVR.

Measures of Financial Hardship From Health Care Expenses Among Families With a Member With Atherosclerotic Cardiovascular Disease in the US.

Importance: Patients with atherosclerotic cardiovascular disease (ASCVD) face substantial financial burden from health care costs as assessed by many disparate measures. However, evaluation of the concordance of existing measures and the prevalence of financial burden based on these measures is lacking. Objective: To compare subjectively reported and objectively measured financial burden from health care in families of patients with ASCVD. Design Setting and Participants: This cross-sectional study used data from the Medical Expenditure Panel Survey, a nationally representative survey of individuals and families in the US, and included all families with 1 or more members with ASCVD from 2014 to 2018. Analyses were conducted from October 2021 to April 2022. Main Outcomes and Measures: Using accepted definitions, objective financial hardship represented annual out-of-pocket medical expenses exceeding 20% of annual postsubsistence income, and subjective financial hardship represented self-reported problems paying medical bills or paying them over time. Prevalence of financial hardship was identified based on individual definitions and their concordance was assessed. Factors associated with each type of financial hardship were examined using risk-adjusted survey logistic regression. Multivariable logistic regression was used to model the odds of subjective financial hardship vs objective financial hardship across subgroups. The association between measures of financial hardship and self-reported deferral of care was also assessed. Results: Among 10 975 families of patients with ASCVD, representing 22.5 million families nationally (mean [SD] age of index individual, 66 [24] years; estimated 54% men]), 37% experienced either objective or subjective financial hardship. This group included 11% (95% CI, 10%-11%) with objective financial hardship, 21% (95% CI, 20%-22%) with subjective financial hardship, and 5% (95% CI, 5%-6%) with both objective and subjective financial hardship. Mean age was 70 (95% CI, 68-71) years vs 61 (95% CI, 60-62) years for index patients in families reporting objective financial hardship only vs subjective financial hardship only, with no difference in sex (50% [95% CI, 46%-54%] of men vs 49% [95% CI, 47%-52%] of women). In risk-adjusted analyses, among families of patients with ASCVD, patient age of 65 years or older was associated with lower odds of subjective financial hardship than objective financial hardship (odds ratio [OR], 0.39; 95% CI, 0.20-0.76), whereas higher income (OR, 6.08; 95% CI, 3.93-9.42 for an income of >100%-200% of the federal poverty level [FPL] vs ≤100% of the FPL and OR, 20.46; 95% CI, 11.45-36.56 for >200% of FPL vs ≤100% of FPL), public insurance (OR, 6.60; 95% CI, 4.20-10.37), and being uninsured (OR, 5.36; 95% CI, 2.61-10.98) were associated with higher odds of subjective financial hardship than objective financial hardship. Subjective financial hardship alone was associated with significantly higher adjusted odds of self-reporting deferred or forgone care compared with objective financial hardship alone (OR, 2.69; 95% CI, 1.79-4.06). Conclusions and Relevance: In this cross-sectional study of US adults, 2 in 5 families of patients with ASCVD experienced health care-related financial hardship, but a focus on objective or subjective measures alone would have captured only half the burden and not identified those deferring health care. The findings suggest that a comprehensive framework that evaluates both objective and subjective measures is essential to monitor financial consequences of health care.

Choice of antihypertensive agent in isolated systolic hypertension and isolated diastolic hypertension: A secondary analysis of the ALLHAT trial.

Despite broad treatment recommendations, there are limited published reports comparing the efficacy of different antihypertensive agents in patients with isolated systolic hypertension or isolated diastolic hypertension. This study was a secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. We compared the use of chlorthalidone, amlodipine, or lisinopril on the primary outcome of combined coronary heart disease, stroke, or all-cause mortality in patients with isolated systolic hypertension or isolated diastolic hypertension.

Characteristics of patients referred to a cardiovascular disease clinic for post-acute sequelae of SARS-CoV-2 infection.

Introduction: There is limited literature on cardiovascular manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC). Methods: This observational study aimed to describe the characteristics, diagnostic evaluations, and new cardiac diagnoses in patients referred to a cardiovascular disease clinic designed for patients with PASC, and to identify factors associated with cardiovascular symptoms with no identifiable cardiac pathology. Results: Of 126 patients, average age was 46 years, and 34 % were male. Patients presented on average five months after COVID-19 diagnosis. The most common symptoms were dyspnea (52 %), chest pain/pressure (48 %), palpitations (44 %), and fatigue (42 %), commonly associated with exertion or exercise intolerance. New cardiovascular diseases were present in 23 % of cases. The remainder exhibited common symptoms which we termed "cardiovascular PASC syndrome." Discussion: We found that only one in four patients had a new cardiovascular diagnosis, but most displayed a pattern of symptoms associated with exercise intolerance.

Subjective Financial Hardship due to Medical Bills Among Patients With Heart Failure in the United States: The 2014-2018 Medical Expenditure Panel Survey.

BACKGROUND: Heart failure (HF) poses a substantial economic burden on the United States (US) health care system. In contrast, little is known about the financial challenges faced by patients with HF. In this study, we examined the scope and sociodemographic predictors of subjective financial hardship due to medical bills incurred by patients with HF. METHODS: In the Medical Expenditure Panel Survey (MEPS; years 2014--2018), a US nationally representative database, we identified all patients who reported having HF. Any subjective financial hardship due to medical bills was assessed based on patients' reporting either themselves or their families (1) having difficulties paying medical bills in the past 12 months, (2) paying bills late or (3) being unable to pay bills at all. Logistic regression was used to evaluate independent predictors of financial hardship among patients with HF. All analyses took into consideration the survey's complex design. RESULTS: A total of 116,563 MEPS participants were included in the analysis, of whom 858 (0.7%) had diagnoses of HF, representing 1.8 million (95% CI 1.6-2.0) patients annually. Overall, 33% (95% CI 29%-38%) reported any financial hardship due to medical bills, and 13.2% were not able to pay bills at all. Age ≤ 65 years and lower educational attainment were independently associated with higher odds of subjective financial hardship due to medical bills. CONCLUSION: Subjective financial hardship is a prevalent issue for patients with HF in the US, particularly those who are younger and have lower educational attainment. There is a need for policies that reduce out-of-pocket costs for the care of HF, an enhanced identification of this phenomenon in the clinical setting, and approaches to help minimize financial toxicity in patients with HF while ensuring optimal quality of care.

Functional landscapes of POLE and POLD1 mutations in checkpoint blockade-dependent antitumor immunity.

Defects in pathways governing genomic fidelity have been linked to improved response to immune checkpoint blockade therapy (ICB). Pathogenic POLE/POLD1 mutations can cause hypermutation, yet how diverse mutations in POLE/POLD1 influence antitumor immunity following ICB is unclear. Here, we comprehensively determined the effect of POLE/POLD1 mutations in ICB and elucidated the mechanistic impact of these mutations on tumor immunity. Murine syngeneic tumors harboring Pole/Pold1 functional mutations displayed enhanced antitumor immunity and were sensitive to ICB. Patients with POLE/POLD1 mutated tumors harboring telltale mutational signatures respond better to ICB than patients harboring wild-type or signature-negative tumors. A mutant POLE/D1 function-associated signature-based model outperformed several traditional approaches for identifying POLE/POLD1 mutated patients that benefit from ICB. Strikingly, the spectrum of mutational signatures correlates with the biochemical features of neoantigens. Alterations that cause POLE/POLD1 function-associated signatures generate T cell receptor (TCR)-contact residues with increased hydrophobicity, potentially facilitating T cell recognition. Altogether, the functional landscapes of POLE/POLD1 mutations shape immunotherapy efficacy.