Effects of acute hyperoxia on autonomic function and coronary tone in patients with peripheral artery disease.

Numerous studies have shown that oxidative stress plays an important role in peripheral artery disease (PAD). Prior reports suggested autonomic dysfunction in PAD. We hypothesized that responses of the autonomic nervous system and coronary tone would be impaired in patients with PAD during exposure to acute hyperoxia, an oxidative stressor. In 20 patients with PAD and 16 healthy, sex- and age-matched controls, beat-by-beat heart rate (HR, from ECG) and blood pressure (BP, with Finometer) were recorded for 10 min during room air breathing and 5 min of hyperoxia. Cardiovagal baroreflex sensitivity and HR variability (HRV) were evaluated as measures of autonomic function. Transthoracic coronary echocardiography was used to assess peak coronary blood flow velocity (CBV) in the left anterior descending coronary artery. Cardiovagal baroreflex sensitivity at rest was lower in PAD than in healthy controls. Hyperoxia raised BP solely in the patients with PAD, with no change observed in healthy controls. Hyperoxia induced an increase in cardiac parasympathetic activity assessed by the high-frequency component of HRV in healthy controls but not in PAD. Indices of parasympathetic activity were lower in PAD than in healthy controls throughout the trial as well as during hyperoxia. Hyperoxia induced coronary vasoconstriction in both groups, while the coronary perfusion time fraction was lower in PAD than in healthy controls. These results suggest that the response in parasympathetic activity to hyperoxia (i.e., oxidative stress) is blunted and the coronary perfusion time is shorter in patients with PAD.NEW & NOTEWORTHY Patients with peripheral artery disease (PAD) showed consistently lower parasympathetic activity and blunted cardiovagal baroreflex sensitivity compared with healthy individuals. Notably, hyperoxia, which normally boosts parasympathetic activity in healthy individuals, failed to induce this response in patients with PAD. These data suggest altered autonomic responses during hyperoxia in PAD.

Ketone body levels and its associations with cardiac markers following an acute myocardial infarction: a post hoc analysis of the EMMY trial.

BACKGROUND: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been suggested to exert cardioprotective effects in patients with heart failure, possibly by improving the metabolism of ketone bodies in the myocardium. METHODS: This post hoc analysis of the EMMY trial investigated the changes in serum ß-hydroxybutyrate (3-ßOHB) levels after acute myocardial infarction (AMI) in response to 26-week of Empagliflozin therapy compared to the usual post-MI treatment. In addition, the association of baseline and repeated measurements of 3-ßOHB with cardiac parameters and the interaction effects of Empagliflozin were investigated. Cardiac parameters included N-terminal pro-B-type natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), left ventricle end-systolic volume (LVESV), left ventricle end-diastolic volume (LVEDV), and left ventricular filling pressure (E/é ratio). RESULTS: The mean 3-ßOHB levels increased from baseline (46.2 ± 3.0 vs. 51.7 ± 2.7) to 6 weeks (48.8 ± 2.2 vs. 42.0 ± 2.3) and 26 weeks (49.3 ± 2.2 vs. 35.8 ± 1.9) in the Empagliflozin group compared to a consistent decline in placebo over 26 weeks (pinteraction < 0.001). Baseline and longitudinal measurements of 3-ßOHB were not significantly associated with NT-proBNP and E/é ratio. Baseline 3-ßOHB value was negatively associated with LVEF (coefficient: - 0.464, 95%CI - 0.863;- 0.065, p = 0.023), while an increase in its levels over time was positively associated with LVEF (0.595, 0.156;1.035, 0.008). The baseline 3-ßOHB was positively associated with LVESV (1.409, 0.186;2.632, 0.024) and LVEDV (0.640, - 1.170;- 2.449, 0.488), while an increase in its levels over time was negatively associated with these cardiac parameters (LVESV: - 2.099, - 3.443;- 0.755, 0.002; LVEDV: - 2.406, - 4.341;- 0.472, 0.015). Empagliflozin therapy appears to modify the association between 3-ßOHB, LVEF (pinteraction = 0.090), LVESV (pinteraction = 0.134), and LVEDV (pinteraction = 0.168), particularly at 26 weeks; however, the results were not statistically significant. CONCLUSION: This post hoc analysis showed that SGLT2i increased 3-ßOHB levels after AMI compared to placebo. Higher baseline 3-ßOHB levels were inversely associated with cardiac function at follow-up, whereas a sustained increase in 3-ßOHB levels over time improved these markers. This highlights the importance of investigating ketone body metabolism in different post-MI phases. Although more pronounced effect of 3-ßOHB on cardiac markers was observed in the SGLT2i group, further research is required to explore this interaction effect.

Systematic review and meta-analysis to assess the racial disparities in the outcomes of carotid endarterectomy in the United States.

OBJECTIVE: Race-based disparities in health care have been related to a myriad of prevailing factors among minorities in the United States. This study aims to study the race-based differences in the outcomes of carotid endarterectomy (CEA). METHODS: The PROSPERO database registered the review protocol (CRD42023428253). A systematic English literature review was performed using literature databases PubMed and Scopus from inception till June 2023. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included studies reporting mortality, stroke, or composite outcome of mortality and stroke after CEA for carotid artery disease, regardless of any degree of stenosis including both symptomatic and asymptomatic patients. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a P value of < .05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS: Twelve studies were identified which included a total of 574,055 patients who underwent CEA from 1998 to 2022. Eleven of 12 studies reported 30-day mortality as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,797 (7.5%) were non-White. The overall pooled OR indicated a statistical significance in 30-day mortality between White and non-White patients undergoing CEA (OR, 1.73; 95% confidence interval [CI], 1.37-2.18; P = .011) with substantial heterogeneity (I2 = 56.3%). Eleven of 12 studies reported stroke as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,801 (7.5%) were non-White. The overall pooled OR indicated no statistical significance in stroke between White and non-White patients undergoing CEA (OR, 1.46; 95% CI, 1.28-1.65; P = .111) with moderate heterogeneity (I2 = 35.9%). Five of 12 studies reported composite mortality or stroke as an outcome for patients undergoing CEA. The overall pooled OR indicated no statistical significance in composite mortality or stroke between White and non-White patients undergoing CEA (OR, 1.40; 95% CI, 1.24-1.59; P = .467) with no heterogeneity (I2 = 0.0%). CONCLUSIONS: Non-White patients have a relatively higher risk of mortality; however, no significant difference was observed between the racial groups in terms of stroke or a composite outcome of mortality or stroke. The odds of mortality in non-White patients have been persistent throughout recent studies.

Patients living farther from a tertiary care center are more likely to undergo peripheral arterial bypass for acute and chronic limb-threatening ischemia.

OBJECTIVE: The aim of this study was to assess the association between the proximity to the tertiary care hospital and the severity of peripheral arterial disease (PAD) at the time of lower extremity bypass (LEB) in a rural-urban mix region. METHODS: Patients undergoing LEB from 2010 to 2020 at Penn State Milton S. Hershey Medical Center were reviewed and stratified into two study groups based on a median distance from hospital (ie, Group I: ≥34 miles and Group II: <34 miles). Patients' demographic features, preoperative data including comorbidities, and medications were analyzed. A univariate analysis for the patient characteristics between the two study groups, along with evaluation of postoperative outcomes, and a multivariate predictive modeling to study the PAD stage as the indication of LEB was performed. A P-value of < .05 was set as a significant difference between the groups for all the analyses. RESULTS: There were 175 patients (49.9%) in Group I and 176 patients (50.1%) in Group II with a mean age of 65 ± 11.92 years (median, 64.61 years). No significant difference was observed in gender (P = .530), age (P = .906), and functional status (P = .830) between study groups. It was observed that patients in Group I were more likely to be overweight or obese (71.3% vs 57%; P = .007) and had a prior history of myocardial infarction (24.3% vs 15.3%; P = .036) in comparison to Group II. No postoperative outcomes were found to be statistically different between the study groups. The multivariate analyses based on various confounders displayed that patients in Group I had 56% higher likelihood of LEB for chronic limb-threatening ischemia (adjusted odds ratio, 1.56; 95% confidence interval, 0.92-2.62; P = .042). Group I patients also had five times higher odds of LEB for acute limb ischemia (adjusted odds ratio, 5.07; 95% confidence interval, 1.42-18.13; P = .012) as compared with those in the Group II. CONCLUSIONS: Patients' proximity to a major tertiary hospital may have implications on the disease progression for patients with PAD and could also be related to inadequate vascular services in primary and secondary hospitals. Lack of preventive care and disease management in regions afar from a tertiary hospital could be other implicating factors and highlights the need for outreach programs, along with distribution of vascular specialists, to reduce geographical disparities and ensure equity in access to care.

Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair.

OBJECTIVE: With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. METHODS: The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. RESULTS: Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. CONCLUSIONS: The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.

Cancer Health Literacy and Its Correlated Factors in the United Arab Emirates-A Cross Sectional Study.

INTRODUCTION: Cancer Health literacy (CHL) is the health literacy related to cancer knowledge, prevention, treatment, screening, and access to services. It is an important indicator of people's adherence to screening and preventive measures, which helps to reduce the incidence and prevalence of cancer. The study assessed the CHL level and its association with relevant socio-demographic characteristics and sources of information among primary health care patients and visitors in the United Arab Emirates (UAE). METHODS: A cross-sectional study recruited survey participants who consented to respond to an interviewer-administered questionnaire. The assessment of CHL was done by using 15 questions. CHL level was measured as a median score and also categorized as poor/inadequate, moderate, good/excellent. Nominal logistic regression was used to analyze the relationship between CHL categories and participants' sociodemographic characteristics and CHL sources of information. RESULTS: Of the total 492 participants, 45.5% were young adults (30-39 years old), 32.9% were males, and 70.8% were UAE nationals. The overall median CHL score was 8.0 (IQR = 5.0-10). 33.7% of the participants had a poor/inadequate level of CHL, 49.6% had a moderate level and 16.7% had a good to excellent level of CHL. 76.9% of the participants knew the importance of early cancer screening tests, 72.7% acknowledged the metastatic capacity of cancer, and the protective factors of cancer, especially, in colon cancer (71.7%). A high proportion of participants received health information about cancer via the internet (50.7%), television (45.3%), social media (40.2%), and doctors (43.6%). Nationality other than UAE (aOR = 1.62, 95% CI = 1.03-2.56, P = .038), having university education (aOR = 2.20, 95% CI = 1.21-3.99, P = .010) compared to those with lower than high school, and having a family history of cancer (aOR = 2.42, 95% CI = 1.33-4.41, P = .004) were positively associated with CHL. Older age (aOR = .36, 95% CI = .17-.75, P = .007 for 50-59 years, and aOR = .29, 95% CI = .11-.82, P = .019) for 60-69 years, higher-income (aOR = .57, 95% CI = .33-.99, P = .047 for 10,000-19,999 AED; aOR = .53, 95% CI = .33-.88, P = .013 for ≥20,000) compared with those earning <10,000 AED were negatively associated with CHL. CONCLUSIONS: CHL among the resident UAE population was moderately adequate, therefore implementation of awareness campaigns seems to be warranted. Moreover, evaluation research targeting the CHL impact on cancer prevention practices and screening is also advocated.

Glycated haemoglobin, HOMA2-B, C-peptide to glucose ratio and type 2 diabetes clusters as predictors for therapy failure in individuals with type 2 diabetes without insulin therapy: A registry analysis.

AIM: Some people with type 2 diabetes mellitus (T2D) and declining ß-cell function do require insulin over time. Various laboratory parameters, indices of glucose metabolism or phenotypes of T2D (clusters) have been suggested, which might predict future therapy failure (TF), indicating the need for insulin therapy initiation. This analysis evaluated glycated haemoglobin (HbA1c), homeostatic model assessment (HOMA)2-B, C-peptide to glucose ratio (CGR) and diabetes clusters as predictive parameters for the occurrence of glycaemic TF in individuals diagnosed with T2D without previous insulin therapy. MATERIALS AND METHODS: In total, 159 individuals with T2D [41% female, median age 50 (IQR: 53-69) years, diabetes duration 9 (5-15) years], without insulin therapy were prospectively evaluated for the occurrence of a composite primary endpoint, including HbA1c increasing or remaining >8.0% (64 mmol/mol) 3 months after baseline on non-insulin glucose-lowering agents, insulin initiation or hospital admissions because of acute hyperglycaemic events. Diabetes clusters were formed according to previously described characteristics. Only severe autoimmune diabetes clusters were excluded because of a small amount of glutamate decarboxylase antibody-positive participants. The other clusters were distributed as mild age-related diabetes 33%; severe insulin-deficient diabetes 31%; mild obesity-related diabetes 20%; and severe insulin-resistant diabetes 15%. RESULTS: During a median observation of 57 months, higher tertiles of HbA1c at baseline, HOMA2-B, as well as a lower CGR were significantly predictive for the occurrence of the primary endpoint. The probability of meeting the primary endpoint was the highest for mild obesity-related diabetes [hazard ratio 3.28 (95% confidence interval 1.75-6.2)], followed by severe insulin-deficient diabetes [hazard ratio 2.03 (95% confidence interval 1.1-3.7)], mild age-related diabetes and the lowest for severe insulin-resistant diabetes. The best performance to predict TF with an area under the curve (AUC) of 0.77 was HbA1c at baseline, followed by HOMA2-B (AUC 0.69) and CGR (AUC 0.64). CONCLUSION: HbA1c, indices of insulin secretion capacity (HOMA2-B and CGR) and T2D clusters might be applicable tools to guide practitioners in the decision of whether insulin is required in people already diagnosed with T2D. These findings need to be validated in prospective studies.

Longer Operative Time for Lower Extremity Bypass Surgery is Associated With Inferior Outcomes.

INTRODUCTION: This study aims to assess the association of operative time with the postoperative length of stay and unplanned return to the operating room in patients undergoing femoral to below knee popliteal bypasses, stratified by autologous vein graft or polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: A retrospective analysis of vascular quality initiative database (2003-2021). The selected patients were grouped into the following: vein bypass (group I) and PTFE (group II) patients. Each group was further stratified by a median split of operative time (i.e., 210 min for autologous vein and 155 min for PTFE) to study the outcomes. The outcomes were assessed by univariate and multivariate approach. RESULTS: Of the 10,902 patients studied, 3570 (32.7%) were in the autologous vein group, while 7332 (67.3%) were in the PTFE group. Univariate analysis revealed autologous vein and PTFE graft recipients that had increased operative times were associated with a longer mean postoperative length of stay and a higher incidence of all-cause return to the operating room. In PTFE group, patients with prolonged operative times were also found to be associated with higher incidence of major amputation, surgical site infection, and cardiovascular events, along with loss of primary patency within a year. CONCLUSIONS: For patients undergoing femoral to below knee popliteal bypasses using an autologous vein or PTFE, longer operative times were associated with inferior outcomes. Mortality was not found to be associated with prolonged operative time.

Impulse control disorders in patients with dopamine agonist-treated pituitary adenomas: a cross-sectional multicenter study.

BACKGROUND: Impulse control disorders (ICDs) have been described as underrecognized side effects of dopamine agonists (DAs) in neurological disorders but are not sufficiently understood in endocrine conditions. OBJECTIVE: To identify the prevalence of DAs induced ICDs and determine potential risk factors related to these disorders in patients with prolactinoma and non-function pituitary adenomas (NFPAs). METHODS: This is a cross-sectional multicenter study involving 200 patients with prolactinoma and NFPAs, who received follow-ups in tertiary referral centers. DA-induced ICDs were assessed using ICD questionnaires modified from prior studies. RESULT: At least one ICD was reported by 52% of participants, among whom 28.5% mentioned compulsive shopping, 24.5% punding, and 24.5% hypersexuality. Furthermore, 33% of the patients reported the presence of one type of ICD behavior, while 12% specified two and 7% had three types of such behavior. The multivariable logistic regression showed that the significant risk factors of ICD were younger age (adjusted odds ratio [AOR]: 0.92, 95% confidence interval [CI]: 0.88-0.97, p 0.001), being single (AOR: 0.15, 95%CI: 0.03-0.84, p 0.03), and a positive history of psychiatric illness (AOR: 7.67, 95% CI: 1.37-42.97, p 0.021). CONCLUSION: ICDs with a broad range of psychiatric symptoms are common in individuals with DA-treated prolactinoma and NFPAs. Endocrinologists should be aware of this potential side effect, particularly in patients with a personal history of psychiatric disorder.

Preoperative Chronic Steroid Use is Associated with Increased Incidence of Postoperative Mortality and Limb Loss following Peripheral Arterial Bypass Surgery for Chronic Limb Threatening Ischemia.

BACKGROUND: Steroids are a commonly prescribed medication in the United States and have been associated with poor surgical and treatment outcomes. The objective of this study is to assess the relationship between chronic steroid use and surgical outcomes of femoropopliteal and femoral-distal bypasses in patients suffering from chronic limb threatening ischemia (CLTI). METHODS: All adult patients undergoing femoropopliteal and femoral-distal bypasses with single segment autologous vein with an indication of CLTI in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2012 and 2021 were stratified between chronic preoperative steroid use (Group I) and no preoperative use (Group II). Primary outcomes of the study included 30-day mortality, amputation, and combined outcome of mortality and/or limb loss. Secondary outcomes included specific bypass related, cardiovascular, respiratory and renal outcomes. RESULTS: A total of 8,324 patients (66.8% Male, 33.2% Females) underwent peripheral arterial bypass operations for the indication of chronic limb threatening ischemia. The median age was 68 years. Group I included 408 patients (4.9%) and Group II included 7,916 patients (95.1%). As compared to patients in Group II, those in Group I were more likely to be females (Group I: 42.2% vs. Group II: 32.8%), more likely to have co-existing chronic obstructive pulmonary disease (Group I: 20.6% vs. Group II: 11.8%), less likely to be diabetic (Group I: 45.9% vs. Group II: 48%), less likely to be smokers (Group I: 30.6% vs. Group II: 45.4%) and more likely to be in American Society of Anesthesiologists III or IV Classes (Group I: 98% vs. Group II: 96.5%) (all P < 0.05). Primary outcomes were as follows: 30-day mortality (Group I: 3.3% vs. Group II: 1.7%), amputation (Group I: 5.9% vs. Group II: 2.8%), 30-day mortality and/or amputation (Group I: 9.1% vs. Group II: 4.5%) (all P < 0.05). Among secondary outcomes, the following were found to be statistically significant: untreated loss of patency (Group I: 4.2% vs. Group II: 1.7%), significant bleeding (Group I: 26.2% vs. Group II: 16.5%), wound infection/complication (Group I: 18.6% vs. Group II: 15%), and return to operating room (Group I: 21.8% vs. Group II: 16.7%) (all P < 0.05). As compared to patients with an indication of tissue loss (Rutherford's class V and VI), patients in Group I with an indication of rest pain (Rutherford's class IV) were more likely to experience 30-day mortality, major amputation and a composite of mortality and amputation. Risk adjusted analysis showed that chronic steroid use has a statistically significant effect on 30-day mortality (adjusted odds ratio [AOR] 1.7, P = 0.05), amputation (AOR 2.05, P < 0.001), composite outcomes of mortality and amputation (AOR 1.959, P < 0.001), untreated loss of patency (AOR 2.31, P = 0.002), bleeding (AOR 1.33, P < 0.011) and unplanned return to the operating room (AOR 1.36, P = 0.014). CONCLUSIONS: Chronic steroid use in patients undergoing femoropopliteal or femoral-distal bypass is associated with a higher risk of 30-day mortality, major amputation, readmission, bleeding, return to operating room, and untreated loss of patency. No significant difference in outcomes were appreciated in patients with chronic steroid use and with Rutherford class V or VI disease (tissue loss), suggesting that the effects of steroids may be less prominent in those with the most advanced peripheral arterial disease. These findings may aid physicians with risk stratification and preoperative discussions regarding open revascularization in patients receiving chronic steroid therapy. More studies including randomized trials are needed to guide perioperative management of steroids in this cohort.

Race-Based Variation in the Utilization of Epidural Analgesia in Addition to General Anesthesia for Open Abdominal Aortic Aneurysm Repair in the United States.

BACKGROUND: Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS: A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS: A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS: Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.

Coping among South Asian individuals living with chronic illnesses: A latent profile analysis.

Individuals' coping differs based on sociocultural determinants and the nature of illness. This study developed a coping typology for South Asians with chronic illnesses and differentiated the coping profiles based on sociocultural determinants. Individuals (n = 384) with chronic illness were recruited. The Brief COPE scale was used for data collection and latent profile analysis for typology development. The class differences were examined in terms of age, gender, socioeconomic status, education, type of family, smoking, primary decision maker in the family, type of community, number of years living with chronic illness and type of health care services used. Latent profile analysis supported four class model: Avoider-Emotion (n = 34, 9%), Problem-Emotion (n = 128, 33.9%), Problem-Avoider (n = 55, 14.6%) and Emotion-Avoider (n = 161, 42.6%) copers. Comparison of classes across chronic illness showed that individuals with chronic respiratory disorders were Emotion-Avoider and Avoider-Emotion copers, those with cardiac problems were Problem-Emotional and Problem-Avoiders copers, those with renal problems were Emotional-Avoiders and Problem-Emotions copers, and individuals with mental health issues were mainly Problem-Emotional and Emotion-Avoider copers. These class differences were statistically different (χ2 = 134, df = 18, p < .001). The findings can be useful for developing coping programmes for South Asian populations in low- and middle-income countries and South Asian immigrants.

Aortic blood pressure and pulse wave indices responses to exercise in peripheral artery disease.

Peripheral artery disease (PAD) refers to obstructed blood flow in peripheral arteries typically due to atherosclerotic plaques. How PAD alters aortic blood pressure and pressure wave propagation during exercise is unclear. Thus, this study examined central blood pressure responses to plantar flexion exercise by investigating aortic pulse wave properties in PAD. Thirteen subjects with PAD and 13 healthy [age-, sex-, body mass index (BMI) matched] subjects performed rhythmic plantar flexion for 14 min or until fatigue (20 contractions/min; started at 2 kg with 1 kg/min increment up to 12 kg). Brachial (oscillometric cuff) and radial (SphygmoCor) blood pressure and derived-aortic waveforms were analyzed during supine rest and plantar flexion exercise. At rest, baseline augmentation index (P = 0.0263) and cardiac wasted energy (P = 0.0321) were greater in PAD due to earlier arrival of the reflected wave (P = 0.0289). During exercise, aortic blood pressure (aMAP) and aortic pulse pressure showed significant interaction effects (P = 0.0041 and P = 0.0109, respectively). In particular, PAD had a greater aMAP increase at peak exercise (P = 0.0147). Moreover, the tension time index was greater during exercise in PAD (P = 0.0173), especially at peak exercise (P = 0.0173), whereas the diastolic time index (P = 0.0685) was not different between the two groups. Hence, during exercise, the subendocardial viability ratio was lower in PAD (P = 0.0164), especially at peak exercise (P = 0.0164). The results suggest that in PAD, the aortic blood pressure responses and myocardial oxygen demand during exercise are increased compared with healthy controls.

Alterations in trimethylamine-N-oxide in response to Empagliflozin therapy: a secondary analysis of the EMMY trial.

INTRODUCTION: The relationship between sodium glucose co-transporter 2 inhibitors (SGLT2i) and trimethylamine N-oxide (TMAO) following acute myocardial infarction (AMI) is not yet explored. METHODS: In this secondary analysis of the EMMY trial (ClinicalTrials.gov registration: NCT03087773), changes in serum TMAO levels were investigated in response to 26-week Empagliflozin treatment following an AMI compared to the standard post-MI treatment. Additionally, the association of TMAO changes with clinical risk factors and cardiorenal biomarkers was assessed. RESULTS: The mean age of patients (N = 367) was 57 ± 9 years, 82% were males, and 14% had type 2 diabetes. In the Empagliflozin group, the median TMAO value was 2.62 µmol/L (IQR: 1.81) at baseline, 3.74 µmol/L (2.81) at 6 weeks, and 4.20 µmol/L (3.14) at 26 weeks. In the placebo group, the median TMAO value was 2.90 µmol/L (2.17) at baseline, 3.23 µmol/L (1.90) at 6 weeks, and 3.35 µmol/L (2.50) at 26 weeks. The serum TMAO levels increased significantly from baseline to week 6 (coefficient: 0.233; 95% confidence interval 0.149-0.317, p < 0.001) and week 26 (0.320, 0.236-0.405, p < 0.001). The average increase in TMAO levels over time (pinteraction = 0.007) was significantly higher in the Empagliflozin compared to the Placebo group. Age was positively associated with TMAO, whereas eGFR and LVEF were negatively associated with TMAO. CONCLUSIONS: Our results are contrary to existing experimental studies that showed the positive impact of SGLT2i on TMAO precursors and cardiovascular events. Therefore, we recommend further research investigating the impact of SGLT2i therapy on acute and long-term changes in TMAO in cardiovascular cohorts.

Impact of the SGLT2-inhibitor empagliflozin on inflammatory biomarkers after acute myocardial infarction - a post-hoc analysis of the EMMY trial.

BACKGROUND: SGTL2-inhibitors are a cornerstone in the treatment of heart failure, but data on patients with acute myocardial infarction (AMI) is limited. The EMMY trial was the first to show a significant reduction in NTproBNP levels as well as improved cardiac structure and function in post-AMI patients treated with Empagliflozin compared to placebo. However, data on the potential impact of SGLT2-inhibitors on inflammatory biomarkers after AMI are scarce. MATERIALS AND METHODS: The EMMY trial is an investigator-initiated, multicentre, double-blind, placebo-controlled trial, which enrolled patients after AMI, receiving either 10 mg Empagliflozin once daily or placebo over a period of 26 weeks on top of standard guideline-recommended therapy starting within 72 h after percutaneous coronary intervention. In this post-hoc subgroup analysis of the EMMY trial, we investigated inflammatory biomarkers of 374 patients. The endpoints investigated were the mean change in inflammatory biomarkers such as high-sensitive c-reactive protein (hsCRP), interleukin-6 (IL-6), neutrophils, leukocytes, neutrophile/lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) from baseline to 26 weeks. RESULTS: Baseline median (interquartile ranges) IL-6 was 17.9 pg/mL (9.0-38.7), hsCRP 18.9 mg/L (11.2-37.1), neutrophil count 7.9 x G/L (6.2-10.1), leukocyte count 10.8 x G/L (9.1-12.8) and neutrophile/lymphocyte ratio (NLR) of 0.74 (0.67-0.80). At week 26, a significant mean reduction in inflammatory biomarkers was observed, being 35.1 ± 3.2% (p < 0.001) for IL-6, 57.4 ± 0.7% (p < 0.001) for hsCRP, 26.1 ± 0.7% (p < 0.001) for neutrophils, 20.5 ± 0.6% (p < 0.001) for leukocytes, 10.22 ± 0.50% (p < 0.001) for NLR, and - 2.53 ± 0.92% for PLR (p = 0.006) with no significant difference between Empagliflozin and placebo treatment. CONCLUSION: Trajectories of inflammatory biomarkers showed a pronounced decline after AMI, but Empagliflozin treatment did not impact this decline indicating no central role in blunted systemic inflammation mediating beneficial effects.

Timing of SGLT2i initiation after acute myocardial infarction.

BACKGROUND: Pharmacological post-MI treatment is routinely initiated at intensive/cardiac care units. However, solid evidence for an early start of these therapies is only available for dual platelet therapy and statins, whereas data on beta blockers and RAAS inhibitors are heterogenous and mainly limited to STEMI and heart failure patients. Recently, the EMMY trial provided the first evidence on the beneficial effects of SGLT2 inhibitors (SGLT2i) when initiated early after PCI. In patients with type 2 diabetes mellitus, SGLT2i are considered "sick days drugs" and it, therefore, remains unclear if very early SGLT2i initiation following MI is as safe and effective as delayed initiation. METHODS AND RESULTS: The EMMY trial evaluated the effect of empagliflozin on NT-proBNP and functional and structural measurements. Within the Empagliflozin group, 22 (9.5%) received early treatment (< 24 h after PCI), 98 (42.2%) within a 24 to < 48 h window (intermediate), and 111 (48.1%) between 48 and 72 h (late). NT-proBNP levels declined by 63.5% (95%CI: - 69.1; - 48.1) in the early group compared to 61.0% (- 76.0; - 41.4) in the intermediate and 61.9% (- 70.8; - 45.7) in the late group (n.s.) within the Empagliflozin group with no significant treatment groups-initiation time interaction (pint = 0.96). Secondary endpoints of left ventricular function (LV-EF, e/e`) as well as structure (LVESD and LVEDD) were also comparable between the groups. No significant difference in severe adverse event rate between the initiation time groups was detected. CONCLUSION: Very early administration of SGLT2i after acute myocardial infarction does not show disadvantageous signals with respect to safety and appears to be as effective in reducing NT-proBNP as well as improving structural and functional LV markers as initiation after 2-3 days.

Patients from distressed communities are more likely to be symptomatic at endovascular aneurysm repair and have an increased risk of being lost to long-term follow-up.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the preferred modality to repair abdominal aortic aneurysms (AAAs). However, the effect of the distressed communities index (DCI) on the outcomes of EVAR is still unknown. In the present study, we investigated the effect of DCI on the postoperative outcomes after EVAR. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was used for the present study. Patients who had undergone EVAR from 2003 to 2021 were selected for analysis. The study cohort was divided into two groups according to their DCI score. Patients with DCI scores ranging from 61 to 100 were assigned to group I (DCI >60), and those with DCI scores ranging from 0 to 60 were assigned to group II (DCI ≤60). The primary outcomes included the 30-day and 1-year mortality and major adverse cardiovascular events at 30 days. Regression analyses were performed to study the postoperative outcomes. P values ≤ .05 were deemed statistically significant for all analyses in the present study. RESULTS: A total of 60,972 patients (19.5% female; 80.5% male) had undergone EVAR from 2003 to 2021. Of these patients, 18,549 were in group I (30.4%) and 42,423 in group II (69.6%). The mean age of the study cohort was 73 ± 8.9 years. Group I tended to be younger (mean age, 72.6 vs 73.7 years), underweight (3.5% vs 2.5%), and African American (10.8% vs 3.5%) and were more likely to have Medicaid insurance (3.6% vs 1.9%; P < .05 for all). Group I had had more smokers (87.3% vs 85.3%), a higher rate of comorbidities, including hypertension (84.5% vs 82.9%), diabetes (21.7% vs 19.7%), coronary artery disease (30.3% vs 28.6%), chronic obstructive pulmonary disease (36.9% vs 31.8%), and moderate to severe congestive heart failure (2.6% vs 2%; P < .05 for all). The group I patients were more likely to undergo EVAR for symptomatic AAAs (11.1% vs 7.9%; P < .001; adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.15-1.37; P < .001) with a higher risk of mortality at 30 days (aOR, 3.98; 95% CI, 2.23-5.44; P < .001) and 1 year (aOR, 1.74; 95% CI, 1.43-2.13; P < .001). A higher risk of being lost to follow-up (28.9% vs 26.3%; P < .001) was also observed in group I. CONCLUSIONS: Patients from distressed communities who require EVAR tended to have multiple comorbidities. These patients were also more likely to be treated for symptomatic AAAs, with a higher risk of mortality. An increased incidence of lost to long-term follow-up was also observed for this population. Surgeons and healthcare systems should consider these outcomes and institute patient-centered approaches to ensure equitable healthcare.

The implications of surgeon case volume and hospital volume on outcomes of aortobifemoral bypasses in obese patients.

BACKGROUND: Aortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels. METHODS: This study used the Society of Vascular Surgery Vascular Quality Initiative suprainguinal bypass database from 2003 to 2021. The selected study cohort was divided into obese patients (body mass index ≥30) (group I) and nonobese patients (body mass index <30) (group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in group I. Operative time and postoperative LOS were transformed into binary values by median split for regression analysis. A P value of .05 or less was deemed statistically significant in all the analyses of this study. RESULTS: The study cohort consisted of 5392 patients. In this population, 1093 were obese (group I) and 4299 were nonobese (group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in group I had increased odds of prolonged operative time (≥250 minutes) and an increased LOS (≥6 days). Patients in this group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of coronary artery disease, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for a LOS of more than 6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of an operative time of 250 minutes or more; however, no significant impact was found on postoperative LOS. Hospitals where 25% or more of ABF bypasses were performed on obese patients were also more likely to have LOS of less than 6 days after ABF operations, compared with hospitals where less than 25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for chronic limb-threatening ischemia or acute limb ischemia had a longer LOS and increased operative times. CONCLUSIONS: ABF bypass in obese patients is associated with prolonged operative times and a longer LOS than in nonobese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. A hospital's increasing proportion of obese patients was related to a decreased LOS. These findings support the known volume-outcome relationship that, with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.

Blood glucose response to running or cycling in individuals with type 1 diabetes: A systematic review and meta-analysis.

AIMS: The aim of this systematic review and meta-analysis was to assess how running and cycling influence the magnitude of blood glucose (BG) excursions in individuals with type 1 diabetes. METHODS: A systematic literature search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Knowledge for publications from January 1950 until February 2021. Parameters included for analysis were population (adults and adolescents), exercise type, intensity, duration and insulin preparation. The meta-analysis was performed to estimate the pooled mean with a 95% confidence interval (CI) of delta BG levels. In addition, sub-group and meta-regression analyses were performed to assess the influence of these parameters on delta BG. RESULTS: The database search identified 3192 articles of which 69 articles were included in the meta-analysis. Due to crossover designs within articles, 151 different results were included for analysis. Data from 1901 exercise tests of individuals with type 1 diabetes with a mean age of 29 ± 4 years were included. Overall, exercise tests BG decreased by -3.1 mmol/L [-3.4; -2.8] within a mean duration of 46 ± 21 min. The pooled mean decrease in BG for running was -4.1 mmol/L [-4.7; -2.4], whilst the pooled mean decrease in BG for cycling was -2.7 mmol/L [-3.0; -2.4] (p < 0.0001). Overall results can be found in Table S2. CONCLUSIONS: Running led to a larger decrease in BG in comparison to cycling. Active individuals with type 1 diabetes should be aware that current recommendations for glycaemic management need to be more specific to the mode of exercise.

Joint longitudinal and time-to-event modelling compared with standard Cox modelling in patients with type 2 diabetes with and without established cardiovascular disease: An analysis of the EXSCEL trial.

AIM: To demonstrate the gain in predictive performance when cardiovascular disease (CVD) risk prediction tools (RPTs) incorporate repeated rather than only single measurements of risk factors. MATERIALS AND METHODS: We used data from the Exenatide Study of Cardiovascular Event Lowering (EXSCEL) trial to compare the quality of predictions of future major adverse cardiovascular events (MACE) with the Cox proportional hazards model (using single values of risk factors) compared to the Bayesian joint model (using repeated measures of risk factors). The risk of MACE was calculated in patients with type 2 diabetes with and without established CVD. We assessed the predictive ability of the following cardiovascular risk factors: glycated haemoglobin, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, triglycerides, estimated glomerular filtration rate, low-density lipoprotein cholesterol (LDL-C), total cholesterol, and systolic blood pressure (SBP) using the time-dependent area under the receiver-operating characteristic curve (aROC) for discrimination and the time-dependent Brier score for calibration. RESULTS: In participants without history of CVD, the aROC of SBP increased from 0.62 to 0.69 when repeated rather than only single measurements of SBP were incorporated into the predictive model. Similarly, the aROC increased from 0.67 to 0.80 when repeated rather than only single measurements of both SBP and LDL-C were incorporated into the predictive model. For all other investigated cardiovascular risk factors, the measures of discrimination and calibration both improved when using the joint model as compared to the Cox proportional hazards model. The improvement was evident in participants with and without history of CVD but was more pronounced in the latter group. CONCLUSIONS: The analysis demonstrates that the joint modelling approach, considering trajectories of cardiovascular risk factors, provides superior predictive performance compared to standard RPTs that use only a single timepoint.