Trends and Disparities in Firearm Deaths Among Children.

BACKGROUND AND OBJECTIVES: In 2020, firearm injuries became the leading cause of death among US children and adolescents. This study aimed to evaluate new 2021 data on US pediatric firearm deaths and disparities to understand trends compared with previous years. METHODS: Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research was queried for firearm mortalities in children/adolescents from 2018 to 2021. Absolute mortality, death rates, and characteristics were reported. Death rates were defined per 100 000 persons in that population per year. Death rates across states were illustrated via geographic heat maps, and correlations with state poverty levels were calculated. RESULTS: In 2021, firearms continued to be the leading cause of death among US children. From 2018 to 2021, there was a 41.6% increase in the firearm death rate. In 2021, among children who died by firearms, 84.8% were male, 49.9% were Black, 82.6% were aged 15 to 19 years, and 64.3% died by homicide. Black children accounted for 67.3% of firearm homicides, with a death rate increase of 1.8 from 2020 to 2021. White children accounted for 78.4% of firearm suicides. From 2020 to 2021, the suicide rate increased among Black and white children, yet decreased among American Indian or Alaskan Native children. Geographically, there were worsening clusters of firearm death rates in Southern states and increasing rates in Midwestern states from 2018 to 2021. Across the United States, higher poverty levels correlated with higher firearm death rates (R = 0.76, P < .001). CONCLUSIONS: US pediatric firearm deaths increased in 2021, above the spike in 2020, with worsening disparities. Implementation of prevention strategies and policies among communities at highest risk is critical.

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions.

BACKGROUND: Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients. OBJECTIVES: To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions. METHODS: We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions. RESULTS: ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001). CONCLUSIONS: Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.

#BodyPositive? A critical exploration of the body positive movement within physical cultures taking an intersectionality approach.

Feminist activists and critical sport scholars in the global north have advocated for more inclusive representation of bodies and more accessible physical cultures. Body positivity, a contentious movement and concept, has been taken up in various ways by different groups. Some scholars believe it holds power to liberate individuals from patriarchal, neoliberal, capitalist, and colonial ideologies of what constitutes a "good" body. On the contrary, critics assert this movement has been gentrified by white-centered politics. Intersectionality has a similar genealogy as body positivity, with a rich history in Black feminist thought but now considered by many as coopted and whitened. In this article, we trace the rich and divergent legacies of both movements and explore at the structural level how body positivity is represented within physical cultures on Instagram. We use a social-justice oriented intersectionality framework exploring #BodyPositivity and #BodyPositive across a total of 141 posts using reflexive thematic analysis. We organize our findings into four themes: 1) Disclosure-Privilege of Body-Related Journeys; 2) The Absent-Present; 3) Consuming Positivity; and 4) Disrupting Normative Body Positivity Posts. Overall, we found that only certain bodies (and transformations) were visible within the data: those of (now) lean, white, cis-gendered individuals, many of whom were engaged in bodybuilding, and who were sharing their bodily transformation. We observe a remarkable absence of BIPOC, 2S LGBTQAI+, fat/thick/thicc/curvy, older, gender-nonconforming, and/or disabled representations. We also note the myriad ways that body positivity has been commodified and packaged into a product or service for consumption. Lastly, we outline and celebrate the exceptions to this norm where a minority of posts align more closely with the original intentions of the body positivity movement. We conclude with our position on how to do intersectionality research, and call on researchers to honor Black feminist origins and rich social justice history in these movements.

ALSN 2021 Conference: Nursing Science for Leadership in the New Decade.

The Association for Leadership Science in Nursing's 2021 conference provided an opportunity to further enhance professional understanding of the difficulties facing nurse leaders as the COVID-19 pandemic continues to create unimaginable challenges. Presentations provided evidence in support of courageous caring leadership interventions.

A Targeted Needs Assessment for the Development of a Surgical Sub-internship Curriculum.

OBJECTIVE: Medical students often feel inadequately prepared for the responsibilities of surgical internship because of insufficient exposure to resident responsibilities prior to starting residency. This lack of preparation may contribute to burnout and attrition early in residency. Sub-internships should provide these experiences. Significant variation, however, exists in the structure of these rotations. We conducted a targeted needs assessment to inform the development of a didactic curriculum to address gaps in the surgical sub-internship experience and better prepare students for general surgery residency. DESIGN: A 25-item needs assessment survey was developed and distributed to senior medical students in their surgical sub-internship, current junior residents, and prior students (alumni) from the past 4 years who matched into general surgery residencies at other institutions. SETTING: Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, a tertiary-care academic medical center. PARTICIPANTS: Nine senior medical students; 12 current residents and 14 alumni, including 9 PGY-1, 13 PGY-2, and 4 PGY-3 residents. RESULTS: The topics rated most important by medical students were floor management topics, specifically lines, tubes, and drains, hypotension, post-operative fever, chest pain, oliguria, and post-operative pain. In contrast, there was a wider variety of topics rated highly by residents. Residents emphasized non-technical communication and documentation skills. Residents at every training level rated presenting patients on rounds as the most important skill for incoming interns to acquire, whereas only one-third of medical students considered this to be an essential topic. CONCLUSIONS: Medical students rank management of common clinical problems as the most critical aspect in their preparation for residency. Residents recognized these topics as important, but also placed high emphasis on non-technical communication and documentation skills. The findings from this need's assessment can be used to guide content structure for a sub-intern curriculum.

Disparities in SARS-CoV-2 seroprevalence among individuals presenting for care in central North Carolina over a six-month period.

Background: Robust community-level SARS-CoV-2 prevalence estimates have been difficult to obtain in the American South and outside of major metropolitan areas. Furthermore, though some previous studies have investigated the association of demographic factors such as race with SARS-CoV-2 exposure risk, fewer have correlated exposure risk to surrogates for socioeconomic status such as health insurance coverage. Methods: We used a highly specific serological assay utilizing the receptor binding domain of the SARS-CoV-2 spike-protein to identify SARS-CoV-2 antibodies in remnant blood samples collected by the University of North Carolina Health system. We estimated the prevalence of SARS-CoV-2 in this cohort with Bayesian regression, as well as the association of critical demographic factors with higher prevalence odds. Findings: Between April 21st and October 3rd of 2020, a total of 9,624 unique samples were collected from clinical sites in central NC and we observed a seroprevalence increase from 2·9 (1·7, 4·3) to 9·1 (7·2, 11·1) over the study period. Individuals who identified as Latinx were associated with the highest odds ratio of SARS-CoV-2 exposure at 7·77 overall (5·20, 12·10). Increased odds were also observed among Black individuals and individuals without public or private health insurance. Interpretation: Our data suggests that for this care-accessing cohort, SARS-CoV-2 seroprevalence was significantly higher than cumulative total cases reported for the study geographical area six months into the COVID-19 pandemic in North Carolina. The increased odds of seropositivity by ethnoracial grouping as well as health insurance highlights the urgent and ongoing need to address underlying health and social disparities in these populations.

Patient Satisfaction with Telephone Neuropsychological Assessment.

OBJECTIVE: Telephone-based neuropsychological assessment (TeleNP) has been shown to be a valid alternative to in-person or video-based assessment. However, there is limited information regarding patients' satisfaction with TeleNP. This report presents satisfaction survey data from a diverse, clinical sample who received TeleNP during the coronavirus disease pandemic. METHOD: A total of 43 adult patients (30.2% Hispanic/Latinx, 32.6% Black), aged 24-75, who received TeleNP as part of routine clinical care participated in a postassessment satisfaction survey. Responses were analyzed qualitatively and via nonparametric comparisons based on demographic factors. RESULTS: Given options of "Not Satisfied," "Somewhat Satisfied," "Satisfied," or "Very Satisfied," 97.7% of patients reported satisfaction with their visit as well as the visit length, and 80% felt the visit met their needs ("Good" + "Very Good"). There were no significant differences in responses based on age, race/ethnicity, sex, or education. Endorsed advantages of TeleNP included "Avoid potential exposure to illness" and "Flexibility/Convenience," and 20% reported difficulty communicating, concentrating, and/or connecting with their provider as potential disadvantages. Although 67.7% reported a preference for in-person visits, 83.7% expressed interest in another "virtual visit" (telephone or video conference) with their provider. CONCLUSIONS: TeleNP was well received by the sample and demonstrated good patient satisfaction. These results in conjunction with other research supporting the validity of TeleNP support consideration of this assessment modality for patients who might not otherwise have access to in-person or video conference-based neuropsychological services. Based on these findings, a greater focus on rapport building may be warranted when utilizing TeleNP to enhance patients' sense of connection to their provider.

Disruptive Innovation: Impact for Practice, Policy, and Academia.

The 2019 Association for Leadership Science in Nursing International Conference, Disruptive Innovation, was held in Los Angeles, California, with attendees from 30 US states, Canada, Brazil, and China. Presenters discussed the need for nurse leaders to advocate for health equity, lead evidence-based innovation, how robots and other technology are generating disruptive innovations in healthcare, and building strong academic-practice partnerships to address nursing workforce challenges. This article will report on these important insights.

Latent influence networks in global environmental politics.

International environmental treaties are the key means by which states overcome collective action problems and make specific commitments to address environmental issues. However, systematically assessing states' influence in promoting global environmental protection has proven difficult. Analyzing newly compiled data with a purpose-built statistical model, we provide a novel measurement of state influence within the scope of environmental politics and find strong influences among states and treaties. Specifically, we report evidence that states are less likely to ratify when states within their region ratify, and results suggesting that countries positively influence other countries at similar levels of economic development. By examining several prominent treaties, we illustrate the complex nature of influence: a single act of ratification can dramatically reshape global environmental politics. More generally, our findings and approach provide an innovative means to understand the evolution and complexity of international environmental protection.

Association of Medication Nonadherence Among Adult Survivors of Stroke After Implementation of the US Affordable Care Act.

Importance: Among adults with chronic disease, survivors of stroke have high out-of-pocket financial burdens. The US government enacted the Affordable Care Act (ACA) in 2010 and implemented the law in 2014 to provide more low-income adults with health insurance coverage. Objective: To assess whether ACA implementation is associated with cost-related nonadherence (CRN) to medication among adult survivors of stroke. Design, Setting, and Participants: This study analyzed data from the 2000 to 2016 National Health Interview Survey, an in-person household survey of the noninstitutionalized US population conducted annually by the National Center for Health Statistics. Conducted at the University of Michigan Medical School, Ann Arbor, from July 24, 2017, to February 28, 2018, the study had a sample of 13 930 survivors of stroke. Analyses were stratified by age (45-64 years vs ≥65 years). Time was treated as a continuous variable and as a categorical variable across 4 periods (2000-2005, historical control; 2006-2010, economic recession and peak unemployment; 2011-2013, before ACA implementation; and 2014-2016, after ACA implementation). Percentages are weighted to reflect US population estimates. Main Outcomes and Measures: The primary outcome was the self-report of CRN, defined as the inability to afford prescribed medications within the past 12 months. Results: Among the 13 930 total survivors of stroke, 38.1% were aged 45 to 64 years (50.5% were female and 49.5% were male, with a mean [SE] age of 56.0 [0.10] years), and 61.9% were aged 65 years or older (54.9% were female and 45.1% were male, with a mean [SE] age of 76.2 [0.09] years). From 2011 to 2013 through 2014 to 2016, Medicaid increased (from 24.0% [95% CI, 21.0%-27.2%] in 2011-2013 to 30.8% [95% CI, 27.3%-34.6%] in 2014-2016; P < .001) and uninsurance decreased (from 13.7% [95% CI, 11.3%-16.4%] to 6.8% [95% CI, 5.3%-8.8%]; P < .001) among survivors of stroke aged 45 to 64 years. Among survivors aged 45 to 64 years, CRN increased over time before ACA implementation (from 18.6% [95% CI, 16.5%-20.9%] in 2000-2005, to 22.6% [95% CI, 19.7%-25.9%] in 2006-2010, to 23.8% [95% CI, 20.7%-27.3%] in 2011-2013) and decreased after ACA implementation to 18.1% (95% CI, 15.4%-21.3%; P = .01) in 2014 to 2016. The period after ACA implementation was associated with lower odds of CRN after adjustment for sociodemographics, year, and clinical factors (odds ratio [OR], 0.63; 95% CI, 0.47-0.85). The difference was attenuated after further adjustment for health insurance coverage (OR, 0.76; 95% CI, 0.56-1.03). Conclusions and Relevance: After the ACA implementation, health insurance coverage increased and CRN decreased among adult survivors of stroke, suggesting that further expansion of Medicaid coverage is likely to be advantageous for survivors.

An evaluation of the burden placed on the General Internal Medicine team at the Role 3 Hospital in Camp Bastion by UK Armed Forces personnel presenting with symptoms resulting from previously identified disease.

INTRODUCTION: During previous deployments of the British Armed Forces, a significant proportion of aeromedical evacuations were accounted for with recurrent symptoms from a known disease that had often triggered occupational medical downgrading. Many servicemen and women had deployed inappropriately, and by doing so became a burden on the deployed medical facilities. Commanders performing systematic medical risk assessments prior to departure might have prevented these individuals from deploying. This study was designed to assess the avoidable burden from recurrent disease during the current Afghanistan operation. METHODS: A cross-sectional study reviewing the hospital and computerised primary care medical records of consecutive patients admitted under the General Physicians to the Role 3 Hospital in Camp Bastion over 9 months from April 2011. The occupational medical grading, diagnosis, disposal and whether the disease was recurrent were recorded. RESULTS: Of 270 patients admitted, 14 (5.2%) were medically downgraded. The computerised records were unavailable for 31 (11.5%) patients. All those patients who were medically downgraded were graded 'Medically Limited Deployable'. In the downgraded group, only one patient presented with recurrent symptoms from their pre-existing condition (Crohn's disease). In the non-downgraded group, two patients presented with symptoms relating to their previous diagnoses. One presented with a second heat illness and should have been medically downgraded and not have been deployed, while the other patient had previously been investigated for recurrent syncope and was upgraded 6 months prior to deploying. All three patients underwent aeromedical evacuation but only two of these were considered to have been avoidable. DISCUSSION: The number of general medical admissions to the Role 3 Hospital due to a pre-existing disease is very low.

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial.

BACKGROUND: Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS. DESIGN: A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome. DISCUSSION: The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction. TRIAL REGISTRATION: Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Asthma clinic attendance improves quality of life of Jamaican asthmatic children and their parents.

BACKGROUND: With the increasing incidence of paediatric asthma, there has been a corresponding increase in the physical, emotional and financial burden. This has led to a greater interest in determining the impact of asthma and its treatment on many aspects of patient functioning and wellbeing. AIM: To assess the usefulness of the Asthma Clinic established in Jamaica in 1997 by ascertaining whether there has been improvement in quality of life of children and care-givers who attend the clinic. METHODS: The quality of life of patients and their parents/care-givers before attending the Asthma Clinic of Bustamante Hospital for Children in Kingston, Jamaica was compared with that of 1 year afterwards. Parents or guardians were interviewed using the Pediatric Asthma Quality of Life Questionnaire which consists of three domains [symptoms (ten questions), emotional (eight questions) and activity (five questions)] and the Pediatric Asthma Caregiver's Quality of life Questionnaire which consist of two domains [emotional (nine questions) and activity (four questions)]. RESULTS: Quality of life improved in patients and their parents/care-givers in all domains. CONCLUSION: Attendance at an asthma clinic in Jamaica improved the quality of life of asthmatic children and their parents/care-givers.

Economic returns to Holstein and Jersey herds under multiple component pricing.

This study analyzed component data from herds participating in the Mideast Federal Milk Marketing Order from 2000 through 2002, and its implications for herd profitability. A monthly simulation model was developed to evaluate the economic returns for a representative Holstein and Jersey herd in Pennsylvania under multiple component pricing. Component levels were highly seasonal and variable from farm to farm. A third of the herds during the course of a year realized a 1- to 3-mo temporary reduction in milk fat or protein greater than one standard deviation. Consistently producing milk fat and protein one standard deviation below the mean reduced the Class III value by $0.82/cwt (100 pounds), or 7.09%. The simulation model indicated that a herd of 100 Holstein cows generated $31,221 more income over feed costs (IOFC) a year than a herd of 100 Jersey cows. Although Jersey milk had greater gross value than Holstein milk due to higher component levels, total volume of milk and components produced by Holsteins offset this difference. Simulation results confirm that increasing milk fat and protein percentages by one standard deviation increased IOFC 7.7% for Holsteins and 9.2% for Jerseys relative to the baseline IOFC, with similar losses for component reductions. Increasing milk yield by one standard deviation increased IOFC by 19.6% for Holsteins and 23.9% for Jerseys relative to the baseline IOFC, again with similar losses for reductions in milk production. In all of the scenarios analyzed, the most important factor affecting IOFC was total amount of milk fat and protein produced, not the component percentage levels.

Use of surgery to aid weight reduction-experience of two regions of Northern England: a database study.

OBJECTIVE: To determine the usage of surgery in the management of obesity. DESIGN: Analysis of routine statistics. DATA SOURCES: Hospital Episode Statistics extract held by Public Health Observatories. GEOGRAPHICAL AREAS: Two Government Office Regions in England with a population of 7.6 million. TIME PERIOD: Data analysed in the study covered the 6 y 1996/1997-2001/2002. RESULTS: The availability and uptake of surgery for obesity in the two regions was hugely variable. The overall utilisation of the procedures examined (OPCS operation codes: G30.1, G30.2, G32.10, G61.00) was 5.6 per million per annum, but ranged by Primary Care Trust from zero (the case in eight of the 50 PCTs in the two regions) to 24.0 operations per million per year. The rates of access to this surgery differed over six-fold between the two regions (1.4 operations per year per million population to 7.9 operations per year per million population). The PCTs with the highest rates of surgery, were those closest to the large providers of service. CONCLUSIONS: Access to this intervention is highly variable. Primary Care Trusts in England and service providers need to ensure that there is appropriate access to this effective procedure in carefully selected cases. The surgical expertise required for these operations could be concentrated in fewer centres.

A multiple-component analysis of US dairy trade.

This paper develops a multiple component-based methodology to account for imports and exports of dairy products and products with a significant dairy content. More specifically, it accounts for imports, exports, and net trade for all dairy products on the basis of milk fat, protein, other solids, and moisture. This approach provides a less biased method of assessing the amount of dairy imports entering the US than the USDA's milk equivalent conversions.

Estimation of the protein content of US imports of milk protein concentrates.

Recent declines in milk prices in the United States have sparked renewed concern that imports of milk protein concentrates (MPC) are increasingly entering the United States with very low tariff rates and is having an adverse impact on the US dairy industry. Milk protein concentrates are used in the United States in many different products, including the starter culture of cheese, or in nonstandard cheeses such as baker's cheese, ricotta, Feta and Hispanic cheese, processed cheese foods, and nutritional products. One of the difficult aspects of trying to assess the impact of MPC imports on the US dairy industry is to quantify the protein content of these imports. The protein content of MPC imports typically ranges from 40 to 88%. The purpose of this study is to develop a methodology that can be used to estimate the protein content of MPC on a country by country basis. Such an estimate would not only provide information regarding the quantity of protein entering the United States, but would also provide a profile of low- and high-value MPC importers. This is critical for market analysis, since it is the lower valued MPC imports that more directly displaces US-produced skim milk powder.

An evaluation of federal order reform.

The Federal Agricultural Improvement and Reform Act of 1996 required the Secretary of Agriculture to reform federal milk marketing orders. The Secretary carried out this task and issued a final rule on March 31, 1999, that was eventually approved by dairy farmers in a national referendum. However, a temporary restraining order (TRO) was issued on September 28, 1999, that halted the reform process. The TRO was effectively overturned and the reform process restarted when President Bill Clinton signed the Consolidated Appropriations Act of 2000 on November 29, 1999. The final rule as amended consolidates the number of orders, develops a multiple component pricing system that determines new formulas for class prices, and provides a new system for pricing fluid milk based on county-level price differentials. The impact of these changes is to provide more transparency in pricing and improved market signals to farmers. But the new system is also much more vulnerable to changes in dairy commodity prices. The objective of this report is to provide a comprehensive overview of federal order reform and to analyze the impact of recent changes in class price formulas.

Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment.

BACKGROUND: Myocardial infarction (MI) can directly cause ischemic mitral regurgitation (IMR), which has been touted as an indicator of poor prognosis in acute and early phases after MI. However, in the chronic post-MI phase, prognostic implications of IMR presence and degree are poorly defined. METHODS AND RESULTS: We analyzed 303 patients with previous (>16 days) Q-wave MI by ECG who underwent transthoracic echocardiography: 194 with IMR quantitatively assessed in routine practice and 109 without IMR matched for baseline age (71+/-11 versus 70+/-9 years, P=0.20), sex, and ejection fraction (EF, 33+/-14% versus 34+/-11%, P=0.14). In IMR patients, regurgitant volume (RVol) and effective regurgitant orifice (ERO) area were 36+/-24 mL/beat and 21+/-12 mm(2), respectively. After 5 years, total mortality and cardiac mortality for patients with IMR (62+/-5% and 50+/-6%, respectively) were higher than for those without IMR (39+/-6% and 30+/-5%, respectively) (both P<0.001). In multivariate analysis, independently of all baseline characteristics, particularly age and EF, the adjusted relative risks of total and cardiac mortality associated with the presence of IMR (1.88, P=0.003 and 1.83, P=0.014, respectively) and quantified degree of IMR defined by RVol >/=30 mL (2.05, P=0.002 and 2.01, P=0.009) and by ERO >/=20 mm(2) (2.23, P=0.003 and 2.38, P=0.004) were high. CONCLUSIONS: In the chronic phase after MI, IMR presence is associated with excess mortality independently of baseline characteristics and degree of ventricular dysfunction. The mortality risk is related directly to the degree of IMR as defined by ERO and RVol. Therefore, IMR detection and quantification provide major information for risk stratification and clinical decision making in the chronic post-MI phase.

Intermittent claudication: an objective office-based assessment.

OBJECTIVES: We sought to compare standard lower extremity vascular laboratory treadmill exercise with the office-based active pedal plantarflexion technique. BACKGROUND: Intermittent claudication is relatively common in elderly patients and is an important predictor of cardiovascular morbidity and mortality. Noninvasive testing using resting and posttreadmill exercise ankle:brachial systolic blood pressure indices is often required to confirm the diagnosis and objectively assess the severity of lower extremity arterial occlusive disease. This is traditionally performed in a formal vascular laboratory setting. METHODS: Fifty consecutive patients (100 lower extremities) with known or suspected intermittent claudication referred for lower extremity treadmill exercise testing were also tested with active pedal plantarflexion using a prospective, randomized crossover design. Supine ankle:brachial systolic blood pressure indices were measured immediately before and after each form of exercise. RESULTS: There was an excellent correlation (r = 0.95, 95% confidence interval 0.93 to 0.97) between mean postexercise ankle:brachial systolic blood pressure indices for treadmill exercise and active pedal plantarflexion. There was no significant difference in outcome based on the order of testing or the severity of arterial occlusive disease. Symptoms of angina or dyspnea occurred in 11 patients (22%) with treadmill exercise versus zero patients with active pedal plantarflexion. CONCLUSIONS: Active pedal plantarflexion is an office-based test that compares favorably with treadmill exercise for the noninvasive, safe, objective and economical assessment of lower extremity arterial occlusive disease.