Acute freshwater CO2 exposure does not impair seawater transfer in three different sizes of Atlantic salmon (Salmo salar) subjected to different photoperiod manipulations.

There is a growing interest in Atlantic salmon (Salmo salar) aquaculture to extend the time fish are reared in freshwater (FW) recirculating aquaculture systems (RAS), producing larger FW salmon that can then be induced to undergo smoltification before transfer into marine net pens for grow-out and harvest. Smolts can be produced by photoperiod (PT) manipulation in RASs, but little is known about how delaying smoltification to larger body sizes affects susceptibility to elevated CO2 levels (hypercapnia), which can occur at high stocking densities in FW RAS or during transport from FW RAS rearing facilities to marine net pens. To address this, Atlantic salmon were reared from hatch to one of three different sizes (~230, ~580, or ~1300 g) in FW (3 ppt) under continuous light (24:0, light:dark). Once fish reached the desired sizes, a group of salmon were maintained on continuous light 24L:0D to serve as a control salmon. A second group of salmon were exposed to 8 weeks of 12L:12D and then to 4 weeks of 24L:0D to serve as PT treatment salmon, which is the PT manipulation commonly used in Atlantic salmon aquaculture to induce smoltification. At the end of PT manipulation, both control and PT treatment salmon were exposed to 0% or 1.5% CO2 (30 mg/L) for 96 h in FW and then transferred to air-equilibrated seawater (SW, 35 ppt, normocapnia). Salmon were sampled at the end of the 96-h FW CO2 exposure and at 24 h and 7 days in SW for measurements of blood ion/acid-base status, muscle water content (MWC), and gill and kidney Na+/K+ ATPase (NKA) activity. Exposure to 96 h of CO2 in FW resulted in acid-base disturbances in fish from all three size classes, with decreases in blood pH and increases in blood PCO2 and plasma [HCO3 -] but no mortality. Despite these large acid-base disturbances in FW, after transfer to normocapnic SW, there were no significant effects of CO2 exposure on extracellular blood pH, intracellular red blood cell pH, or plasma osmoregulatory status for all three sizes of post-smolt salmon. In general, SW transfer was associated with significant increases in plasma ions and osmolality, as well as gill and kidney NKA activity after 24 h and 1 week in SW with no significant impacts between different sizes of salmon. Thus, exposure to 30 mg CO2/L that mimics levels experienced during transport from FW RAS to an SW transfer site may have minimal effects on Atlantic salmon smolts up to 1300 g.

Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection.

OBJECTIVE: To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection. METHODS: From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests. RESULTS: Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006). CONCLUSION: Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.

Visual recognition is heralded by shifts in local field potential oscillations and inhibitory networks in primary visual cortex.

Learning to recognize and filter familiar, irrelevant sensory stimuli eases the computational burden on the cerebral cortex. Inhibition is a candidate mechanism in this filtration process, and oscillations in the cortical local field potential (LFP) serve as markers of the engagement of different inhibitory neurons. We show here that LFP oscillatory activity in visual cortex is profoundly altered as male and female mice learn to recognize an oriented grating stimulus-low frequency (∼15 Hz peak) power sharply increases while high frequency (∼65 Hz peak) power decreases. These changes report recognition of the familiar pattern, as they disappear when the stimulus is rotated to a novel orientation. Two-photon imaging of neuronal activity reveals that parvalbumin-expressing inhibitory neurons disengage with familiar stimuli and reactivate to novelty, whereas somatostatin-expressing inhibitory neurons show opposing activity patterns. We propose a model in which the balance of two interacting interneuron circuits shifts as novel stimuli become familiar.SIGNIFICANCE STATEMENT:Habituation, familiarity and novelty detection are fundamental cognitive processes that enable organisms to adaptively filter meaningless stimuli and focus attention on potentially important elements of their environment. We have shown that this process can be studied fruitfully in the mouse primary visual cortex by using simple grating stimuli for which novelty and familiarity are defined by orientation, and by measuring stimulus-evoked and continuous local field potentials. Altered event-related and spontaneous potentials, and deficient habituation, are well-documented features of several neurodevelopmental psychiatric disorders. The paradigm described here will be valuable to interrogate the origins of these signals and the meaning of their disruption more deeply.

Characterizing the hypoxic performance of a fish using a new metric: PAAS-50.

The hypoxic constraint on peak oxygen uptake (MO2,peak) was characterized in rainbow trout over a range of ambient oxygen tensions with different testing protocols and statistical models. The best-fit model was selected using both statistical criteria (R2 and AIC) and the model's prediction of three anchor points for hypoxic performance: critical PO2 (Pcrit), maximum MO2 and a new metric, the minimum PO2 that supports 50% of absolute aerobic scope (PAAS-50). The best-fitting model was curvilinear using five strategically selected PO2 values. This model predicted PAAS-50 as 70 mmHg (coefficient of variation, CV=9%) for rainbow trout. Thus, while a five-point hypoxic performance curve can characterize the limiting effects of hypoxia in fish, as envisaged by Fry over 75 years ago, PAAS-50 is a promising metric to compare hypoxic constraints on performance in a standardized manner both within and across fish species.

Rapid blood acid-base regulation by European sea bass (Dicentrarchus labrax) in response to sudden exposure to high environmental CO2.

Fish in coastal ecosystems can be exposed to acute variations in CO2 of between 0.2 and 1 kPa CO2 (2000-10,000 µatm). Coping with this environmental challenge will depend on the ability to rapidly compensate for the internal acid-base disturbance caused by sudden exposure to high environmental CO2 (blood and tissue acidosis); however, studies about the speed of acid-base regulatory responses in marine fish are scarce. We observed that upon sudden exposure to ∼1 kPa CO2, European sea bass (Dicentrarchus labrax) completely regulate erythrocyte intracellular pH within ∼40 min, thus restoring haemoglobin-O2 affinity to pre-exposure levels. Moreover, blood pH returned to normal levels within ∼2 h, which is one of the fastest acid-base recoveries documented in any fish. This was achieved via a large upregulation of net acid excretion and accumulation of HCO3- in blood, which increased from ∼4 to ∼22 mmol l-1. While the abundance and intracellular localisation of gill Na+/K+-ATPase (NKA) and Na+/H+ exchanger 3 (NHE3) remained unchanged, the apical surface area of acid-excreting gill ionocytes doubled. This constitutes a novel mechanism for rapidly increasing acid excretion during sudden blood acidosis. Rapid acid-base regulation was completely prevented when the same high CO2 exposure occurred in seawater with experimentally reduced HCO3- and pH, probably because reduced environmental pH inhibited gill H+ excretion via NHE3. The rapid and robust acid-base regulatory responses identified will enable European sea bass to maintain physiological performance during large and sudden CO2 fluctuations that naturally occur in coastal environments.

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD.

BACKGROUND: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. METHODS: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. RESULTS: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. CONCLUSIONS: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

Medication adherence patterns in aortic dissection survivors.

BACKGROUND & OBJECTIVES: Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD. METHODS: This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale. RESULTS: Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to 'forget to take medications' and eight reported yes to 'careless with medications.' Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this. INTERPRETATION & CONCLUSIONS: The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients' beliefs about drug therapy, all of which have been shown to increase medication adherence.

Recurrent Aortic Dissection: Observations From the International Registry of Aortic Dissection.

BACKGROUND: Improved medical care after initial aortic dissection (AD) has led to increased survivorship and a population of individuals at risk for further cardiovascular events, including recurrent AD. Reports describing recurrent ADs have been restricted to small numbers of patients from single institutions. We used the IRAD (International Registry of Acute Aortic Dissection) database to examine the clinical profiles and outcomes of patients with recurrent AD. METHODS: We identified 204 patients enrolled in IRAD with recurrent AD. For the primary analysis, patient characteristics, interventions, and outcomes were analyzed and compared with 3624 patients with initial AD. Iterative logistic modeling was performed to investigate variables associated with recurrent AD. Cox regression analyses were used to determine variables associated with 5-year survival. A subset of recurrent AD patients was analyzed for anatomic and demographic details of initial and recurrent ADs. RESULTS: Patients with recurrent AD were more likely to have Marfan syndrome (21.5% versus 3.1%; P<0.001) but not bicuspid aortic valve (3.6% versus 3.2%; P=0.77). Descending aortic dimensions were greater in patients with recurrent AD than in patients with initial AD independently of sentinel dissection type (type A: 4.3 cm [3.5-5.6 cm] versus 3.3 cm [2.9-3.7 cm], P<0.001; type B: 5.0 cm [3.9-6.0 cm] versus 4.0 cm [3.5-4.8 cm], P<0.001), and this observation was accentuated among patients with Marfan syndrome. In multivariate analysis, the diagnosis of Marfan syndrome independently predicted recurrent AD (hazard ratio, 8.6; 95% confidence interval, 5.8-12.8; P<0.001). Patients with recurrent AD who presented with proximal followed by distal AD were younger than patients who experienced distal followed by proximal dissection AD (42.1±16.1 versus 54.3±14.8 years; P=0.004). CONCLUSIONS: Among those suffering acute aortic dissection, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with Marfan syndrome.

Predictors of Stable Aortic Dimensions in Medically Managed Acute Aortic Syndromes.

BACKGROUND: We aimed to identify predictors of stable aortic dimensions in medically managed type B aortic dissections (TBAD). METHODS: Medically managed TBAD patients from the International Registry of Acute Aortic Dissection with available aortic measurements at up to 24 months were included. Growth rate was calculated by dividing the largest descending diameter at the latest end point not influenced by intervention minus initial descending diameter, by the recorded time interval. Patients were split into 2 groups: without aortic growth (<0.0 mm/year, group I) and with aortic growth (>0.0 mm/year, group II). RESULTS: 219 patients had available data for our inclusion criteria and comprised group I (n = 89, 40.6%) and group II (n = 130, 59.4%). Mean expansion rate of the total cohort was 0.19 ± 0.81 cm, mean expansion rate in group I was -0.47 ± 0.54 cm, and in group II, it was +0.63 ± 0.64 cm. Patients in group I were more frequently of Asian descent (15.9% vs. 3.1%, P = 0.001), showed more often intramural hematoma on imaging (57.3% vs. 30.0%, P < 0.001) and demonstrated complete false lumen thrombosis more frequently (25.0% vs. 9.9%, P = 0.009). Group II patients were more Caucasian (77.3% vs. 92.2%, P = 0.002), presented more with posterior chest pain (57.8% vs. 74.7%, P = 0.025), back pain (68.2% vs. 80.2%, P = 0.046), a visible double lumen (50.6% vs. 63.8%, P = 0.050), dissection originating from the left subclavian artery (51.2% vs. 68.5%, P = 0.011), and a completely patent false lumen (37.5% vs. 62.4%, P = 0.002). Mortality rates between groups were similar (2.2% vs. 1.5%, P = 0.708). Complete false lumen thrombosis was an independent predictor of no growth (hazard ratio [HR]: 3.640, P = 0.011), while a larger sinotubular junction (STJ) (HR: 0.304, P = 0.004) and female gender (HR: 0.325, P = 0.030) were negative predictors of no growth. CONCLUSIONS: Complete false lumen thrombosis was a predictor of no growth, while a large STJ and female gender were predictors of aortic growth. This study might help predict which medically treated TBAD patients might show a stable clinical course during follow-up.

Shock complicating type A acute aortic dissection: Clinical correlates, management, and outcomes.

AIMS: Shock is among the most dreaded and common complications of type A acute aortic dissection (TAAAD). However, clinical correlates, management, and short- and long-term outcomes of TAAAD patients presenting with shock in real-world clinical practice are not known. METHODS AND RESULTS: We evaluated 2,704 patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection between January 1, 1996, and August 18, 2012. On admission, 407 (15.1%) TAAAD patients presented with shock. Most in-hospital complications (coma, myocardial or mesenteric ischemia or infarction, and cardiac tamponade) were more frequent in shock patients. In-hospital mortality was significantly higher in TAAAD patients with than without shock (30.2% vs 23.9%, P=.007), regardless of surgical or medical treatment. Most shock patients underwent surgical repair, with medically managed patients demonstrating older age and more complications at presentation. Estimates using Kaplan-Meier survival analysis indicated that most (89%) TAAAD patients with shock discharged alive from the hospital survived 5years, a rate similar to that of TAAAD patients without shock (82%, P=.609). CONCLUSIONS: Shock occurred in 1 of 7 TAAAD patients and was associated with higher rates of in-hospital adverse events and mortality. However, TAAAD survivors with or without shock showed similar long-term mortality. Successful early and aggressive management of shock in TAAAD patients has the potential for improving long-term survival in this patient population.

Modifying memory for a museum tour in older adults: Reactivation-related updating that enhances and distorts memory is reduced in ageing.

Memory reactivation, the activation of a latent memory trace when we are reminded of a past experience, strengthens memory but can also contribute to distortions if new information present during reactivation is integrated with existing memory. In a previous study in young adults we found that the quality of memory reactivation, manipulated using the principle of encoding specificity and indexed by recollection ratings, modulated subsequent true and false memories for events experienced during a museum tour. Here in this study, we examined age-related changes in the quality of memory reactivation on subsequent memory. Memories of museum stops in young and older adults were reactivated and then immediately followed by the presentation of a novel lure photo from an alternate tour version (i.e., reactivation plus new information). There was an increase in subsequent true memories for reactivated targets and for subsequent false memories for lures that followed reactivated targets, when compared to baseline target and lure photos. However, the influence of reactivation on subsequent memories was reduced in older adults. These data reveal that ageing alters reactivation-related updating processes that allow memories to be strengthened and updated with new information, consequently reducing memory distortions in older adults compared to young adults.

Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting. OBJECTIVE OF REVIEW: This article describes the fundamentals of ECMO and familiarizes the emergency medicine physician with its use in critically ill pediatric patients. DISCUSSION: ECMO can be utilized as either venoarterial (VA) or venovenous (VV), to support oxygenation and perfusion in respiratory failure, sepsis, cardiac arrest, and environmental hypothermia.

Outcomes of patients presenting with acute type A aortic dissection in the setting of prior cardiac surgery: an analysis from the International Registry of Acute Aortic Dissection.

BACKGROUND: Prior cardiac surgery (PCS) can complicate the presentation and management of patients with type A acute aortic dissection (TAAAD). This report from the International Registry of Acute Aortic Dissection examines this hypothesis. METHODS AND RESULTS: A total of 352 of 2196 patients with TAAAD (16%) enrolled in the International Registry of Acute Aortic Dissection had cardiac surgery before dissection, including coronary artery bypass grafting (34%), aortic or mitral valve surgery (36%), aortic surgery (42%), and other cardiac surgery (16%). Those with PCS were older, had a higher frequency of diabetes mellitus, hypertension, and atherosclerosis, and presented later from symptom onset to hospital presentation and diagnosis (all P<0.05). In-hospital mortality was significantly higher for PCS patients (34% versus 23%; P<0.001). Five-year mortality was independently predicted by PCS (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.05-3.95), age >70 years (HR, 2.65; 95% CI, 1.40-5.05), medical management (HR, 5.10; 95% CI, 2.43-10.71), distal communication (HR, 2.64; 95% CI, 1.35-5.14), and coma (HR, 9.50; 95% CI, 2.05-44.05). Among patients with PCS, in-hospital (43% medical versus 30% surgical; P=0.033) and intermediate-term mortality was higher in patients with medical versus surgical management. Propensity-matched analysis revealed significant increase in mortality with medical management, but not with PCS. CONCLUSIONS: PCS delays presentation, diagnosis, and treatment of TAAAD and is an important adverse risk factor for early and intermediate-term mortality. This effect may be because of increased medical management in this patient population.

Stroke and outcomes in patients with acute type A aortic dissection.

BACKGROUND: Stroke is a highly dreaded complication of type A acute aortic dissection (TAAAD). However, little data exist on its incidence and association with prognosis. METHODS AND RESULTS: We evaluated 2202 patients with TAAAD (mean age 62 ± 14 years, 1487 [67.5%] men) from the International Registry of Acute Aortic Dissection to determine the incidence and prognostic impact of stroke in TAAAD. Stroke was present at arrival in 132 (6.0%) patients with TAAAD. These patients were older (65 ± 12 versus 62 ± 15 years; P=0.002) and more likely to have hypertension (86% versus 71%; P=0.001) or atherosclerosis (29% versus 22%; P=0.04) than patients without stroke. Chest pain at arrival was less common in patients with stroke (70% versus 82%; P<0.001), and patients with stroke presented more often with syncope (44% versus 15%; P<0.001), shock (14% versus 7%; P=0.005), or pulse deficit (51% versus 29%; P ≤ 0.001). Arch vessel involvement was more frequent among patients with stroke (68% versus 37%; P<0.001). They had less surgical management (74% versus 85%; P<0.001). Hospital stay was significantly longer in patients with stroke (median 17.9 versus 13.3 days; P<0.001). In-hospital complications, such as hypotension, coma, and malperfusion syndromes, and in-hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 0.99-2.65) were higher among patients with stroke. Among hospital survivors, follow-up mortality was similar between groups (adjusted hazard ratio, 1.15; 95% confidence interval, 0.46-2.89). CONCLUSIONS: Stroke occurred in >1 of 20 patients with TAAAD and was associated with increased in-hospital morbidity but not long-term mortality. Whether aggressive early invasive interventions will reduce negative outcomes remains to be evaluated in future studies.

Respiratory acidosis and O2 supply capacity do not affect the acute temperature tolerance of rainbow trout (Oncorhynchus mykiss).

The mechanisms that determine the temperature tolerances of fish are poorly understood, creating barriers to disentangle how additional environmental challenges-such as CO2-induced aquatic acidification and fluctuating oxygen availability-may exacerbate vulnerability to a warming climate and extreme heat events. Here, we explored whether two acute exposures (~0.5 hours or ~72 hours) to increased CO2 impact acute temperature tolerance limits in a freshwater fish, rainbow trout (Oncorhynchus mykiss). We separated the potential effects of acute high CO2 exposure on critical thermal maximum (CTmax), caused via either respiratory acidosis (reduced internal pH) or O2 supply capacity (aerobic scope), by exposing rainbow trout to ~1 kPa CO2 (~1% or 10 000 µatm) in combination with normoxia or hyperoxia (~21 or 42 kPa O2, respectively). In normoxia, acute exposure to high CO2 caused a large acidosis in trout (blood pH decreased by 0.43 units), while a combination of hyperoxia and ~1 kPa CO2 increased the aerobic scope of trout by 28%. Despite large changes in blood pH and aerobic scope between treatments, we observed no impacts on the CTmax of trout. Our results suggest that the mechanisms that determine the maximum temperature tolerance of trout are independent of blood acid-base balance or the capacity to deliver O2 to tissues.

Acute Aortic Dissection: Observational Lessons Learned From 11 000 Patients.

BACKGROUND: Over the past 25 years, diagnosis and therapy for acute aortic dissection (AAD) have evolved. We aimed to study the effects of these iterative changes in care. METHODS: Patients with nontraumatic AAD enrolled in the International Registry of Acute Aortic Dissection (61 centers; 15 countries) were divided into time-based tertiles (groups) from 1996 to 2022. The impact of changes in diagnostics, therapeutic care, and in-hospital and 3-year mortality was assessed. Cochran-Armitage trend and Jonckheere-Terpstra tests were conducted to test for any temporal trend. RESULTS: Each group consisted of 3785 patients (mean age, ≈62 years old; ≈65.5% males); nearly two-thirds had type A AAD. Over time, the rates of hypertension increased from 77.8% to 80.4% (P=0.002), while smoking (34.1% to 30.6%, P=0.033) and atherosclerosis decreased (25.6%-16.6%; P<0.001). Across groups, the percentage of surgical repair of type A AAD increased from 89.1% to 92.5% (P<0.001) and was associated with decreased hospital mortality (from 24.1% in group 1 to 16.7% in group 3; P<0.001). There was no difference in 3-year survival (P=0.296). For type B AAD, stent graft therapy (thoracic endovascular aortic repair) was used more frequently (22.3%-35.9%; P<0.001), with a corresponding decrease in open surgery. Endovascular in-hospital mortality decreased from 9.9% to 6.2% (P=0.003). As seen with the type A AAD cohort, overall 3-year mortality for patients with type B AAD was consistent over time (P=0.084). CONCLUSIONS: Over 25 years, substantial improvements in-hospital survival were associated with a more aggressive surgical approach for patients with type A AAD. Open surgery has been partially supplanted by thoracic endovascular aortic repair for complicated type B AAD, and in-hospital mortality has decreased over the time period studied. Postdischarge survival for up to 3 years was similar over time.

Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection.

BACKGROUND: Acute aortic intramural hematoma (IMH) is an important subgroup of aortic dissection, and controversy surrounds appropriate management. METHODS AND RESULTS: Patients with acute aortic syndromes in the International Registry of Acute Aortic Dissection (1996-2011) were evaluated to examine differences between patients (based on the initial imaging test) with IMH or classic dissection (AD). Of 2830 patients, 178 had IMH (64 type A [42%], 90 type B [58%], and 24 arch). Patients with IMH were older and presented with similar symptoms, such as severe pain. Patients with type A IMH were less likely to present with aortic regurgitation or pulse deficits and were more likely to have periaortic hematoma and pericardial effusion. Although type A IMH and AD were managed medically infrequently, type B IMH were more frequently treated medically. Overall in-hospital mortality was not statistically different for type A IMH compared to AD (26.6% versus 26.5%; P=0.998); type A IMH managed medically had significant mortality (40.0%), although less than classic AD (61.8%; P=0.195). Patients with type B IMH had a hospital mortality that was less but did not differ significantly (4.4% versus 11.1%; P=0.062) from classic AD. One-year mortality was not significantly different between AD and IMH. CONCLUSIONS: Acute IMH has similar presentation to classic AD but is more frequently complicated with pericardial effusions and periaortic hematoma. Patients with IMH have a mortality that does not differ statistically from those with classic AD. A small subgroup of type A IMH patients are managed medically and have a significant in-hospital mortality.

Impact of adding aspirin to beta-blocker and statin in high-risk patients undergoing major vascular surgery.

BACKGROUND: Beta-blockers (BB) and statins (S) independently have been shown to reduce perioperative mortality and myocardial infarction (MI) in patients undergoing vascular surgery. In this study we evaluated the benefits of adding aspirin (A) to BB and S (ABBS), with/without angiotensin-converting enzyme inhibitor (ACE-I) on postoperative outcome in high-risk patients undergoing major vascular surgery. METHODS: Analysis of consecutive patients undergoing elective vascular surgery at the University of Michigan Cardiovascular Center was performed. Univariate and multivariate analyses were done using cardiac risk index [Revised Cardiac Risk Index (RCRI), coronary artery disease (CAD), insulin-dependent diabetes mellitus (IDDM), cerebral vascular disease, renal dysfunction, congestive heart failure, and major surgery]; pulmonary disease; and A, BB, S (ABBS)±ACE-I use. Baseline clinical characteristics and medication were adjusted using propensity scores. Endpoints were bleeding, 30-day MI, stroke, and 12-month mortality. RESULTS: Between 2003 and 2010, 4,149 arterial procedures were performed, 819 of which were risk stratified as RCRI≥3. The incidence of MI was 3-fold lower (2.5% vs. 7.8%, OR 0.31, 95% CI 0.15-0.61, P=0.001) in ABBS±ACE-I (n=513) as compared with non-ABBS±ACE-I (n=306). The 12-month mortality was 8-fold lower in ABBS±ACE-I as compared non-ABBS±ACE-I (5.9% vs. 37.5%, HR 0.13, 95% CI 0.08-0.20, P<0.0001). After adjustment for the propensity to use various therapies, A (HR 0.35, 95% CI 0.24-0.53, P<0.0001), BB (HR 0.65, 95% CI 0.43-1.0, P=0.05), and S (HR 0.36, 95% CI 0.25-0.53, P<0.0001) remained associated with improved 12-month survival. ACE-I use (HR 0.80, 95% CI 0.54-1.19, P=0.27) was not predictive. Aspirin did not predict severe/moderate bleeding. CONCLUSIONS: In high-risk patients undergoing major vascular surgery, ABBS therapy has superior 30-day and 12-month risk reduction benefits for MI, stroke, and mortality as compared with A, BB, or S independently. ACE-I did not demonstrate additional risk-reduction benefits.

Cardiometabolic Risk and Dietary Behaviors in Middle-School Children Consuming School-Sourced Lunch.

OBJECTIVE: Childhood obesity remains a major public health issue. This study assessed the association between school-sourced lunches and cardiometabolic risk factors in middle-school students. METHODS: Data from health behavior surveys and physiologic screenings in a Michigan middle-school wellness program between 2005 and 2019 were used to analyze the association of school lunch consumption with cardiometabolic risk factors (overweight/obesity, non-fasting lipids/glucose, blood pressure) and dietary behaviors (fruit/vegetable consumption, intake of sugar-sweetened beverages/foods). Students were divided into three groups based on their responses to the survey item if they 1) always, 2) sometimes, or 3) never consumed school-sourced lunches. Groups were compared using descriptive statistics and chi-squared tests. RESULTS: Students consuming school-sourced lunches were more likely to have overweight or obesity, without significant differences in total, HDL, or LDL cholesterol. There was no difference in non-fasting glucose levels, blood pressure, or resting heart rate. Students consuming school sourced lunch were more likely to have increased sugary and fatty food or beverage consumption. Students consuming school sourced lunch were more likely to attend school in a low or middle socioeconomic status region. CONCLUSIONS: In this large cohort of middle-school children, consuming school-sourced lunches was associated with a greater prevalence of overweight and obesity and consumption of fatty foods and sugary beverages. School-based interventions should target methods to reduce consumption of sugary beverages and unhealthy snacks and promote consumption of fruits and vegetables, particularly among high-risk individuals.

Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community.

OBJECTIVE: The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS: IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS: Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS: IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.