Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study.

OBJECTIVE: Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function. METHODS: In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models. RESULTS: We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group. CONCLUSIONS: In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling.

Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis.

BACKGROUND: There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS). OBJECTIVES: The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS. METHODS: This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex. RESULTS: The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men. CONCLUSIONS: Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.

An Overview of Missed Nursing Care and Its Predictors in Saudi Arabia: A Cross-Sectional Study.

Background: Nursing care is holistic, and missing any aspect of care can be critical to patients' health. However, due to the complex and intense nature of the nursing practice, nurses have to unintentionally prioritize some activities, forcing them to omit some aspects of nursing care. Aim: To explore the dimensions of missed nursing care and its predictors within the Saudi Arabian healthcare system. Methods: Quantitative, cross-sectional study used the MISSCARE survey by utilizing nonprobability convenience sampling to collect the data of 604 staff nurses working in inpatient wards in Jazan, Saudi Arabia. Results: The overall mean of missed nursing care is (m = 1.37, SD = 0.45). Missed nursing care activities were mostly failure to attend interdisciplinary care conferences (m = 1.66, SD = 0.96) and patient ambulation thrice a day (m = 1.63, SD = 0.97). Missed nursing care was mainly caused by human resource shortage (m = 3.53, SD = 0.88). Missed nursing care is predicted by the turnover intention (B = 2.380, t = 3.829, p < 001) and job satisfaction (B = -0.864, t = -4.788, p < 001). Conclusion: Although missed nursing care is evident in Saudi Arabia, it is significantly lower than the international rates, and it is mainly caused by labor resource shortage which directly influences nurses' job satisfaction and intention to leave. Optimizing the recruitment process, resource allocation and effective nurses' retention programs are proposed solutions that may be beneficial to mitigate missed nursing care.

Supplemental calcium and vitamin D and long-term mortality in aortic stenosis.

OBJECTIVE: Calcium metabolism has long been implicated in aortic stenosis (AS). Studies assessing the long-term safety of oral calcium and/or vitamin D in AS are scarce yet imperative given the rising use among an elderly population prone to deficiency. We sought to identify the associations between supplemental calcium and vitamin D with mortality and progression of AS. METHODS: In this retrospective longitudinal study, patients aged ≥60 years with mild-moderate native AS were selected from the Cleveland Clinic Echocardiography Database from 2008 to 2016 and followed until 2018. Groups were stratified into no supplementation, supplementation with vitamin D alone and supplementation with calcium±vitamin D. The primary outcomes were mortality (all-cause, cardiovascular (CV) and non-CV) and aortic valve replacement (AVR), and the secondary outcome was AS progression by aortic valve area and peak/mean gradients. RESULTS: Of 2657 patients (mean age 74 years, 42% women) followed over a median duration of 69 months, 1292 (49%) did not supplement, 332 (12%) took vitamin D alone and 1033 (39%) supplemented with calcium±vitamin D. Calcium±vitamin D supplementation was associated with a significantly higher risk of all-cause mortality (absolute rate (AR)=43.0/1000 person-years; HR=1.31, 95% CI (1.07 to 1.62); p=0.009), CV mortality (AR=13.7/1000 person-years; HR=2.0, 95% CI (1.31 to 3.07); p=0.001) and AVR (AR=88.2/1000 person-years; HR=1.48, 95% CI (1.24 to 1.78); p<0.001). Any supplementation was not associated with longitudinal change in AS parameters in a linear mixed-effects model. CONCLUSIONS: Supplemental calcium with or without vitamin D is associated with lower survival and greater AVR in elderly patients with mild-moderate AS.

The Prevalence and The Relationship of Workplace Bullying and Nurses Turnover Intentions: A Cross Sectional Study.

Introduction: Sustaining a healthy work environment is a major challenge for health care organizations worldwide. Nursing professionals are often exposed to workplace bullying, which imposes serious challenges to nursing retention. Objectives: To determine the prevalence of workplace bullying and turnover intention among nurses, and to investigate the relationship between workplace bullying and nurse turnover. Methods: A cross-sectional correlational design. Convenience sampling was applied, whereby 347 nurses working in a tertiary medical city in Riyadh, Saudi Arabia, were recruited. Data were collected using the Negative Acts Questionnaire and the Anticipated Turnover Scale. Results: The rate of workplace bullying was high, bullying occurred at a cumulative rate of 33.4% (n = 116). Work related bullying behaviors formed the most common bullying acts with (34.5%) followed by personal bullying with (31.1%) meanwhile physical intimidating accounted by (25.6%). Among the participants, 31.7% exhibited a high turnover intention. The demographic variable age was revealing an inverse correlation with workplace bullying. There was a positive significant correlation between workplace bullying and turnover intentions (r = .24, p < 0.01). Conclusion: The alarming prevalence of both bullying and turnover intention among participants confirms that when nurses are exposed to workplace bullying, they are more likely to demonstrate an increased intention for turnover. Managers are urged to use proper enforcement of anti-bullying policies along with education and training to create a healthy environment and mitigate workplace bullying.

Primary and secondary prevention of atherosclerotic cardiovascular disease: A case-based approach.

Estimating the risk of atherosclerotic cardiovascular disease (ASCVD) is a daily challenge for clinicians and is crucial to tailoring preventive medical care and guiding shared decision-making. New imaging modalities and novel biomarkers allow for more accurate assessment of patient risk and minimize the risk of over- or undertreating patients. Major cardiovascular medicine societies have incorporated new diagnostic modalities in their guidelines to aid clinical decision-making for primary and secondary prevention of ASCVD. This review presents commonly encountered cases relevant to estimating and reducing ASCVD risk based on available guidelines and expert opinion.

Cardiac arrhythmias associated with COVID-19 infection: state of the art review.

INTRODUCTION: COVID-19 infection is associated with many different systemic complications. Among these, cardiovascular system complications are particularly important as these are associated with significant mortality. There are many different subgroups of cardiovascular complications, with Arrhythmias being one of them. Arrhythmias are especially important as there are a substantial percentage of patients who have arrhythmia after a COVID-19 infection, and these patients are seen with an increased mortality rate. The main interest of this review is understanding some of the specific post-COVID-19 arrhythmic complications and their predisposing factors. AREAS COVERED: This paper will highlight the findings of studies on cardiovascular system disease after COVID-19 infection, different specific arrhythmic complications of COVID-19, and changes in electrophysiologic interventions post-COVID-19 outbreak in different centers around the world. An extensive literature search was made to find pertinent articles. EXPERT OPINION: Studies show us that a significant percentage of COVID-19 patients have arrhythmia. Many distinct types of arrhythmias are associated with COVID-19 infection, and specific risk factors of these arrhythmias are important as this information can be used to detect and prioritize certain at-risk patients for early treatment, which can mean life or death in some cases.

Simultaneous Pulmonary Artery Pressure and Left Ventricle Stroke Volume Assessment Predicts Adverse Events in Patients With Pulmonary Embolism.

Background Certain echocardiographic parameters may serve as early predictors of adverse events in patients with hemodynamically compromising pulmonary embolism (PE). Methods and Results An observational analysis was conducted for patients with acute pulmonary embolism evaluated by a Pulmonary Embolism Response Team (PERT) between 2014 and 2020. The performance of clinical prediction algorithms including the Pulmonary Embolism Severity Index and Carl Bova score were compared using a ratio of right ventricle and left ventricle hemodynamics by dividing the pulmonary artery systolic pressure by the left ventricle stroke volume. The primary outcome of in-hospital mortality, cardiac arrest, and the need for advanced therapies was evaluated by univariate and multivariable analyses. Of the 343 patients meeting the inclusion criteria, 215 had complete data. Pulmonary artery systolic pressure/left ventricle stroke volume was a clear predictor of the primary end point (odds ratio [OR], 2.31; P=0.005), performing as well or better than the Pulmonary Embolism Severity Index (OR, 1.43; P=0.06) or the Bova score (OR, 1.28; P=0.01). Conclusions This study is the first study to demonstrate the utility of early pulmonary artery systolic pressure/left ventricle stroke volume in predicting adverse clinical events in patients with acute pulmonary embolism. Pulmonary artery systolic pressure/left ventricle stroke volume may be a surrogate marker of ventricular asynchrony in high-risk pulmonary embolism and should be prognostically evaluated.

The Psychological Impact of Coronavirus Disease 2019 on Nurses in Saudi Arabia and Their Coping Strategies.

AIMS AND OBJECTIVES: To explore the psychological impact of coronavirus disease 2019 on frontline nurses working in Jazan, Saudi Arabia, and their coping strategies. BACKGROUND: As the coronavirus disease 2019 pandemic continues to expand globally, healthcare systems have become more overwhelmed than ever before, placing a great psychological strain on frontline nurses. DESIGN: A cross-sectional, observational, quantitative study. METHODS: In total, 215 frontline nurses working at 12 hospitals across Jazan, Saudi Arabia, were recruited. Data were collected during August 2020 using a modified version of the severe acute respiratory syndrome team questionnaire. RESULTS: Roughly two-thirds (62.3%) of the participants reported moderate to high levels of nervousness and fear at work. Ethical and moral responsibility has been determined as the main motivator for frontline nurses to practice their profession, with 88% of them expressing a willingness to work even if the situation deteriorated further. However, 87% of the participants were extremely concerned about transmitting the disease to their family members. The most common coping strategy adopted by the nurses appeared to be adherence to strict protective measures (93.5%), followed by the acquisition of more knowledge about the disease (82.3%). CONCLUSION: Frontline nurses experience severe psychological stress, which is mainly caused by their fear of contracting the infection or passing it on to their family members. Thus, proper education, adherence to infection control protocols, effective social support system, and access to sufficient personal protective equipment will help nurses enhance their coping abilities.

The BDNF polymorphism Val66Met may be predictive of swallowing improvement post pharyngeal electrical stimulation in dysphagic stroke patients.

BACKGROUND: The aim of this study was to explore the effect of brain-derived neurotrophic factor (BDNF) polymorphism rs6265 (Val66Met) in both "natural" and treatment induced recovery of swallowing after dysphagic stroke. METHODS: Sixteen dysphagic stroke patients that completed a single-blind randomized sham controlled trial of pharyngeal electrical stimulation (PES) within 6 weeks of their stroke (N=38), were genotyped for the BDNF SNP Val66Met (rs6265) from saliva samples. These patients received active or sham PES according to randomized allocation. PES was delivered at a set frequency (5 Hz), intensity (75% of maximal tolerated), and duration (10 minutes) once a day for three consecutive days. Clinical measurements were taken from patients at baseline, 2 weeks and 3 months post entering the study. Changes in swallowing ability based on the dysphagia severity rating scale (DSRS) were compared between active and sham groups and associated with BDNF SNP status. KEY RESULTS: In the active stimulation group, patients with the Met BDNF allele demonstrated significantly greater improvements in DSRS at 3 months compared to patients homozygous for the Val allele (P=.009). By comparison, there were no significant associations at the 2 week stage in either the active or sham group, or at 3 month in the sham group. Functional scores including the Barthel Index and modified Rankin scale were also unaffected by BDNF status. CONCLUSIONS & INFERENCES: Our findings suggest an association between BDNF and stimulation induced swallowing recovery. Further work will be required to validate these observations and demonstrate clinical utility in patients.

Residues of tetracycline compounds in poultry products in the eastern province of Saudi Arabia.

Chicken muscle, liver and egg samples were collected from 33 broiler and 5 layer farms in the eastern province of Saudi Arabia over a period of two years starting from January 1996. Antibiotic-residue positive samples were identified in the products of 23 (69.7%) broiler and 3 (60%) layer poultry farms. 87% and 100.0% of the antibiotic-residue positive broiler farms were positive for at least one tetracycline compound in raw muscle and liver respectively, while 73.9% and 95.5% were positive for 2 or more tetracyclines in these two tissues, respectively. Furthermore, 82.6% and 95.5% of the antibiotic-residue-positive farms had mean concentrations of at least one tetracycline compound in excess of the permissible maximum residue limit (MRL) in raw muscle and liver, respectively. These compounds also remained chemically detectable after cooking. Tetracycline levels exceeded MRL in 14.4% of antibiotic-positive raw eggs but the overall mean tetracycline concentration in each farm was below MRL. This study confirmed widespread misuse of tetracycline agents including multiple use of drugs belonging to the same pharmacological group and lack of implementation of recommended withdrawal times. This may be contributing to the high resistance rates to tetracyclines in both chicken and human microbial isolates observed in the region. This study, therefore, stresses the need for stricter regulations for the use of antimicrobial drugs in the poultry industry as well as the inspection of chicken for drug residues prior to marketing.

Value of intraprostatic injection of zinc and vitamin C and of ultrasound application in infertile men with chronic prostatitis.

Seventy infertile men with chronic prostatitis were treated by prostatic massage and wide-spectrum chemotherapy as basic treatment to which intraprostatic injection of zinc or vitamin C with or without ultrasound application was added as a new line of treatment. Comparison showed no significant improvement of the additive treatment over the conventional treatment used alone. Pus cells in the expressed prostatic smear diminished significantly after treatment, which was associated with significant increase of percentage of motile spermatozoa and significant decrease of abnormal forms. Bacterial flora was studied in comparison with findings in 20 cases of infertile males without prostatitis; staphylococci predominated in both patient and control groups.