ABSTRACT
Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.
Subject(s)
Atrial Appendage , Atrial Fibrillation , Heart Failure , Stroke , Humans , Infant , Child, Preschool , Atrial Fibrillation/complications , Atrial Fibrillation/surgery , Atrial Appendage/surgery , Risk Factors , Risk Assessment , Stroke/epidemiology , Stroke/etiology , Stroke/prevention & control , Treatment OutcomeABSTRACT
BACKGROUND: Nutritional and sports supplements are commonly used by soldiers, with uncertain implications for health and mission readiness. METHODS: An anonymous survey was conducted of a company of U.S. Army paratroopers deployed to eastern Afghanistan between December 2011 and October 2012. Survey questions covered supplements used, duration of use, adverse effects, and medication interactions. Exercise habits, goals for exercise and supplement use, and information and acquisition sources were also queried. RESULTS: Out of 112 surveys distributed, 100 completed surveys were returned. 77 respondents reported using at least one supplement during deployment. On average, 2.5 supplements were used per individual surveyed. Nine respondents reported adverse effects of supplement use. No respondents reported serious complications of supplement use, drug interactions, or seeking medical care for supplement adverse effects. The Internet was the most frequently reported source of information on supplement use. Most frequently, supplements were acquired by Internet mail order. CONCLUSIONS AND RELEVANCE: Supplement use occurs during deployment among paratroopers at a higher rate than reported in garrison, despite their remote and austere deployed location. These findings have profound implications for military health care providers and policy makers considering the health of deployed combat soldiers.
Subject(s)
Dietary Supplements/statistics & numerical data , Military Personnel/statistics & numerical data , Adolescent , Adult , Afghan Campaign 2001- , Afghanistan , Exercise , Female , Humans , Male , Middle Aged , Sports , Surveys and Questionnaires , United States , Young AdultABSTRACT
OBJECTIVES: The aim of this study was to characterize levels of serum biomarkers in patients with severe refractory cardiogenic shock (SRCS) and to document temporal changes in these levels during restoration of circulation. BACKGROUND: Patients with SRCS have been challenging to study because of their rapidly changing clinical condition while undergoing multiple simultaneous interventions. METHODS: Twenty-one patients with SRCS received circulatory support via a percutaneously implanted ventricular assist device (PVAD). Serum samples obtained prior to PVAD support initiation, at 24 h of PVAD support, and at 7 days of PVAD support were assayed for B-type natriuretic peptide (BNP), high-sensitivity C-reactive protein (hsCRP), soluble tumor necrosis factor receptor-1 (sTNFR1), soluble Fas (sFas), soluble Fas ligand (sFasL), endothelin-1, and procollagen III N-terminal peptide (PIIINP). Baseline biomarker levels were qualitatively compared to reference values; levels at 24 h of PVAD support and at 7 days of PVAD support were compared to baseline using 2-tailed Wilcoxon matched pair signed rank tests with Bonferroni correction for multiple comparisons. RESULTS: These patients with SRCS had elevated serum levels of BNP, hsCRP, sTNFR1, endothelin-1, and PIIINP. Ventricular unloading and restoration of circulation via PVAD support in patients with SRCS were associated with reductions in serum BNP, sFas, and endothelin-1 levels and increases in serum sFasL and PIIINP levels. CONCLUSIONS: This study characterizes several important baseline serum biomarker levels in patients with SRCS and introduces a novel PVAD-based protocol with the potential to "reverse"-model the pathophysiology of cardiogenic shock.
Subject(s)
Biomarkers/blood , Shock, Cardiogenic/blood , Female , Humans , Male , Middle Aged , Prospective Studies , Severity of Illness IndexABSTRACT
Pertussis, or whooping cough, which is commonly thought of as a pediatric illness, is an underappreciated adult pathogen. Recent outbreaks highlight the significance of pertussis in adults and the risk of transmission to at-risk infants who are most susceptible to complications, including death. This article describes the recent epidemiologic shifts and reviews the clinical presentation, diagnosis, and treatment of pertussis. New vaccination recommendations by the Advisory Committee on Immunization Practices in response to recent outbreaks and infant deaths are highlighted.
Subject(s)
Communicable Diseases, Emerging/epidemiology , Diphtheria-Tetanus-acellular Pertussis Vaccines/administration & dosage , Whooping Cough/epidemiology , Adolescent , Adult , Aged , Anti-Bacterial Agents/therapeutic use , Communicable Diseases, Emerging/diagnosis , Communicable Diseases, Emerging/drug therapy , Communicable Diseases, Emerging/prevention & control , Disease Outbreaks , Humans , Incidence , Infant , Infant Mortality/trends , Middle Aged , Practice Guidelines as Topic , United States/epidemiology , Whooping Cough/diagnosis , Whooping Cough/drug therapy , Whooping Cough/prevention & control , Young AdultABSTRACT
We evaluated a 47-year-old woman for recurrent migraine and syncope. The patient had 7 children (not examined by the authors), all of whom also experienced migraine and syncope. The patient's father, now deceased, had reportedly experienced migraine and episodes of feeling faint. All 5 of the patient's siblings reported migraine, and 4 of the 5 reported syncope. The case of our patient, which we discuss herein, suggests a genetic link between these 2 conditions, both of which include vascular dysregulation in their pathogenesis. To our knowledge, the medical literature contains no previous description of familial associations of combined migraine and syncope.