Association of Patient Reported Outcomes With Caregiver Burden in Older Patients With Advanced Heart Failure: Insights From the SUSTAIN-IT Study.

BACKGROUND: Caregivers of patients with advanced heart failure may experience burden in providing care, but whether changes in patient health status are associated with caregiver burden is unknown. METHODS: This observational study included older patients (60-80 years old) receiving advanced surgical heart failure therapies and their caregivers at 13 US sites. Patient health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores are better). Caregiver burden was assessed using the Oberst Caregiving Burden Scale, which measures time on task (OCBS-time) and task difficulty (OCBS-difficulty; range, 1-5; lower scores are better). Measurements occurred before surgery and 12 months after in 3 advanced heart failure cohorts: patients receiving long-term left ventricular assist device support; heart transplantation with pretransplant left ventricular assist device support; and heart transplantation without pretransplant left ventricular assist device support. Multivariable linear regression was used to identify predictors of change in OCBS-time and OCBS-difficulty at 12 months. RESULTS: Of 162 caregivers, the mean age was 61.0±9.4 years, 139 (86%) were female, and 140 (86%) were the patient's spouse. At 12 months, 99 (61.1%) caregivers experienced improved OCBS-time, and 61 (37.7%) experienced improved OCBS-difficulty (versus no change or worse OCBS). A 10-point higher baseline 12-item Kansas City Cardiomyopathy Questionnaire predicted lower 12-month OCBS-time (ß=-0.09 [95% CI, -0.14 to -0.03]; P<0.001) and OCBS-difficulty (ß=-0.08 [95% CI, -0.12 to -0.05]; P<0.001). Each 10-point improvement in the 12-item Kansas City Cardiomyopathy Questionnaire predicted lower 12-month OCBS-time (ß=-0.07 [95% CI, -0.12 to -0.03]; P=0.002) and OCBS-difficulty (ß=-0.09 [95% CI, -0.12 to -0.06]; P<0.001). CONCLUSIONS: Among survivors at 12 months, baseline and change in patient health status were associated with subsequent caregiver time on task and task difficulty in dyads receiving advanced heart failure surgical therapies, highlighting the potential for serial 12-item Kansas City Cardiomyopathy Questionnaire assessments to identify caregivers at risk of increased burden. REGISTRATION: URL: https://www.clinicaltrials.gov; unique identifier: NCT02568930.

Breast Cancer Surgery: A Qualitative Exploration of Concerns Over Time.

INTRODUCTION: As outcomes for breast cancer patients improve, addressing the side effects and distress of treatment can optimize survivorship. Although distress in breast cancer is well known in literature, there is a lack of information on how these concerns change through the phases of the cancer care continuum. Therefore, this study investigates the longitudinal trajectory of worry in patients with nonmetastatic breast cancer. METHODS: Female patients with newly diagnosed stage I-III breast cancer comprised a mixed-methods, longitudinal study at a cancer center from June 2019 to June 2023. Patients completed an open-ended survey regarding their top three concerns. Responses were obtained before surgery and two weeks, three, six, nine months, and one year postoperatively. Responses were qualitatively coded and analyzed to determine themes of cancer-related distress. RESULTS: Participants (n = 262) were aged an average 57.53 y (±12.54), 65.8% had stage I disease at diagnosis, and 91.1% were White. Responses revealed that patients' top three sources of concerns varied by treatment phase. Overall, patients were worried about their cancer diagnosis and the risk of recurrence. Preoperatively, patients were worried about treatment timeline, while postoperative concerns transitioned to physical appearance and surgical side effects. CONCLUSIONS: Breast cancer patients consistently reported worries about cancer diagnosis, recurrence, and metastasis as well as the side effects and fear of treatments. However, patient worry appeared to be intrinsically linked with their treatment phase. Therefore, support and interventions should be catered to reflect the changing patterns of patients' sources of distress to optimize breast cancer patients' quality of life.

Use of Deep Learning to Evaluate Tumor Microenvironmental Features for Prediction of Colon Cancer Recurrence.

Deep learning may detect biologically important signals embedded in tumor morphologic features that confer distinct prognoses. Tumor morphologic features were quantified to enhance patient risk stratification within DNA mismatch repair (MMR) groups using deep learning. Using a quantitative segmentation algorithm (QuantCRC) that identifies 15 distinct morphologic features, we analyzed 402 resected stage III colon carcinomas [191 deficient (d)-MMR; 189 proficient (p)-MMR] from participants in a phase III trial of FOLFOX-based adjuvant chemotherapy. Results were validated in an independent cohort (176 d-MMR; 1,094 p-MMR). Association of morphologic features with clinicopathologic variables, MMR, KRAS, BRAFV600E, and time-to-recurrence (TTR) was determined. Multivariable Cox proportional hazards models were developed to predict TTR. Tumor morphologic features differed significantly by MMR status. Cancers with p-MMR had more immature desmoplastic stroma. Tumors with d-MMR had increased inflammatory stroma, epithelial tumor-infiltrating lymphocytes (TIL), high-grade histology, mucin, and signet ring cells. Stromal subtype did not differ by BRAFV600E or KRAS status. In p-MMR tumors, multivariable analysis identified tumor-stroma ratio (TSR) as the strongest feature associated with TTR [HRadj 2.02; 95% confidence interval (CI), 1.14-3.57; P = 0.018; 3-year recurrence: 40.2% vs. 20.4%; Q1 vs. Q2-4]. Among d-MMR tumors, extent of inflammatory stroma (continuous HRadj 0.98; 95% CI, 0.96-0.99; P = 0.028; 3-year recurrence: 13.3% vs. 33.4%, Q4 vs. Q1) and N stage were the most robust prognostically. Association of TSR with TTR was independently validated. In conclusion, QuantCRC can quantify morphologic differences within MMR groups in routine tumor sections to determine their relative contributions to patient prognosis, and may elucidate relevant pathophysiologic mechanisms driving prognosis. SIGNIFICANCE: A deep learning algorithm can quantify tumor morphologic features that may reflect underlying mechanisms driving prognosis within MMR groups. TSR was the most robust morphologic feature associated with TTR in p-MMR colon cancers. Extent of inflammatory stroma and N stage were the strongest prognostic features in d-MMR tumors. TIL density was not independently prognostic in either MMR group.

Ocular injuries associated with motor vehicle accidents: long term effects on quality of life.

PURPOSE: To describe the prevalence and outcome of motor vehicle accidents-associated ocular injuries. METHODS: A survey of patients who presented to the emergency room at a level 1 trauma center with motor vehicle accidents-associated ocular injuries. A patient questionnaire and review of clinical notes were conducted for all patients. RESULTS: Of 274 motor vehicle accident victims with ocular injuries who presented to the emergency room, 40 (15%) responded to the survey. Over half of them were driving a vehicle, and most reported wearing a seat belt or a helmet. Most ocular injuries were mild. The most common injuries were bone fractures, subconjunctival hemorrhage, eyelid involvement and corneal injury. Most respondents had no change in vision and perceived their ocular involvement as a minor part of their injury. Most respondents returned to work and to driving within a year. CONCLUSION: Our study sheds light on the details and extent of ocular involvement and the visual ability to perform daily activities following motor vehicle accidents.

Perioperative immunotherapy for esophageal squamous cell carcinoma.

Esophageal squamous cell carcinoma (ESCC) is the main prevalent histological subtype and accounts for 85% of esophageal cancer cases worldwide. Traditional treatment for ESCC involves chemotherapy, radiotherapy, and surgery. However, the overall prognosis remains unfavorable. Recently, immune checkpoint blockade (ICB) therapy using anti-programmed cell death-1 (PD-1)/PD-1 ligand (PD-L1) antibodies have not only achieved remarkable benefits in the clinical management of ESCC but have also completely changed the treatment approach for this cancer. In just a few years, ICB therapy has rapidly advanced and been added to standard first-line treatment regimen in patients with ESCC. However, preoperative immunotherapy is yet to be approved. In this review, we summarize the ICB antibodies commonly used in clinical immunotherapy of ESCC, and discuss the advances of immunotherapy combined with chemotherapy and radiotherapy in the perioperative treatment of ESCC, aiming to provide reference for clinical management of ESCC patients across the whole course of treatment.

Time to bystander cardiopulmonary resuscitation by patient sex for out-of-hospital cardiac arrest.

BACKGROUND: Delays in bystander cardiopulmonary resuscitation (CPR) are associated with worse out-of-hospital cardiac arrest (OHCA) outcomes. Whether disparities exist in time to CPR between women and men is unknown. METHODS: We included witnessed OHCAs treated with bystander CPR from the Cardiac Arrest Registry Enhancing Survival between 2013-2021. The primary outcome was time to first bystander CPR, and secondary outcomes were survival to hospital discharge and favorable neurological survival. Hierarchical ordinal regression was used to model time to first CPR, which estimates the odds of having a 2-minute longer delay (from 0 to ≥10 minutes) in receiving bystander CPR. The model included sex, age, race, location of arrest, cardiac arrest etiology, day of week, and season as fixed effects and EMS agency as a random effect to account for clustering of patients within an agency. RESULTS: Of 78,043 patients with a witnessed OHCA that received bystander CPR, 25,197 (32.3%) were women. The median [IQR] time to first bystander CPR was 2 [1,5] minutes for both women and men. In adjusted analysis, time to bystander CPR was similar in men and women (p = 0.26). Moreover, there was a statistically significantly graded inverse association between time to bystander CPR and survival. CONCLUSION: For patients with witnessed OHCA that received bystander CPR, women and men had similar times to CPR, although 5-minute or greater delays in initiating CPR was not uncommon. Delays in bystander CPR in OHCA were associated with worse survival outcomes.

Association Between Delays in Time to Bystander CPR and Survival for Witnessed Cardiac Arrest in the United States.

BACKGROUND: Prompt initiation of bystander cardiopulmonary resuscitation (CPR) is critical to survival for out-of-hospital cardiac arrest (OHCA). However, the association between delays in bystander CPR and OHCA survival is poorly understood. METHODS: In this observational study using a nationally representative US registry, we identified patients who received bystander CPR from a layperson for a witnessed OHCA from 2013 to 2021. Hierarchical logistic regression was used to estimate the association between time to CPR (<1 minute versus 2-3, 4-5, 6-7, 8-9, and ≥10-minute intervals) and survival to hospital discharge and favorable neurological survival (survival to discharge with cerebral performance category of 1 or 2 [ie, without severe neurological disability]). RESULTS: Of 78 048 patients with a witnessed OHCA treated with bystander CPR, the mean age was 63.5±15.7 years and 25, 197 (32.3%) were women. The median time to bystander CPR was 2 (1-5) minutes, with 10% of patients having a≥10-minute delay before initiation of CPR. Overall, 15 000 (19.2%) patients survived to hospital discharge and 13 159 (16.9%) had favorable neurological survival. There was a graded inverse relationship between time to bystander CPR and survival to hospital discharge (P for trend <0.001). Compared with patients who received CPR within 1 minute, those with a time to CPR of 2 to 3 minutes were 9% less likely to survive to discharge (adjusted odds ratio, 0.91 [95% CI, 0.87-0.95]) and those with a time to CPR 4 to 5 minutes were 27% less likely to survive (adjusted odds ratio, 0.73 [95% CI, 0.68-0.77]). A similar graded inverse relationship was found between time to bystander CPR and favorable neurological survival (P for trend <0.001). CONCLUSIONS: Among patients with witnessed OHCA, there was a dose-response relationship between delays in bystander initiation of CPR and lower survival rates.

The Natural History of Disability and Caregiving Before and After Long-Term Care Entry.

Importance: Many older persons move into long-term care facilities (LTCFs) due to disability and insufficient home caregiving options. However, the extent of disability and caregiving provided around the time of entry is unknown. Objective: To quantitatively describe disability and caregiving before and after LTCF entry, comparing nursing home (NH), assisted living (AL), and independent living (IL) entrants. Design, Setting, and Participants: A longitudinal cohort study using prospectively collected annual data from the National Health and Aging Trends Study from 2011 to 2020 including participants in the continental US. Overall, 932 community-dwelling Medicare beneficiaries entering LTCF from 2011 to 2019 were included. Entry into LTCF was set as t = 0, and participant interviews from 4 years before and 2 years after were used. Main Outcomes and Measures: Prevalence of severe disability (severe difficulty or dependence in ≥3 activities of daily living), prevalence of caregivers, and median weekly caregiving hours per entrant, using weighted mixed-effects regression against time as linear spline. Results: At entry, mean (SD) age was 84 (8.4) years, 609 (64%, all percentages survey weighted) were women, 143 (6%) were Black, 29 (3%) were Hispanic, 30 (4%) were other (other race and ethnicity included American Indian, Asian, Native Hawaiian, and other), and 497 (49%) had dementia. 349 (34%) entered NH, 426 (45%) entered AL, and 157 (21%) entered IL. Overall, NH and AL entry were preceded by months of severe disability and escalating caregiving. Before entry, 49% (95% CI, 29%-68%) of NH entrants and 10% (95% CI, 3%-24%) of AL entrants had severe disability. Most (>97%) had at least a caregiver, but only one-third (NH, 33%; 95% CI, 20%-50%; AL, 33%; 95% CI, 24%-44%) had a paid caregiver. Median care was 27 hours weekly (95% CI, 18-40) in NH entrants and 18 (95% CI, 14-24) in AL entrants. On NH and AL entry, severe disability rose to 89% (95% CI, 82%-94%) and 28% (95% CI, 16%-44%) on NH and AL entry and was 66% (95% CI, 55%-75%) 2 years after entry in AL residents. Few IL entrants (<2%) had severe disability and their median care remained less than 7 hours weekly before and after entry. Conclusions: This study found that persons often enter NHs and ALs after months of severe disability and substantial help at home, usually from unpaid caregivers. Assisted living residents move when less disabled, but approach levels of disability similar to NH entrants within 2 years. Data may help clinicians understand when home supports approach a breaking point.

The Economic Burden of Heart Failure with Reduced Ejection Fraction: Living Longer but Poorer?

Treatment of heart failure with reduced ejection fraction (HFrEF) has benefitted from a proliferation of new medications and devices. These treatments carry important clinical benefits, but also come with costs relevant to payers, providers, and patients. Patient out-of-pocket costs have been implicated in the avoidance of medical care, nonadherence to medications, and the exacerbation of health care disparities. In the absence of major health care policy and payment redesign, high-quality HFrEF care delivery requires transparent integration of cost considerations into system design, patient-clinician interactions, and medical decision making.

Adapting to New Hearing Aids and Hearing Aid Adjustments in Adult Danish Users.

PURPOSE: This study was aimed at understanding the effect of time taken to adapt to the new hearing aids (HAs) and the timeline of HA adjustments performed over more than a year of rehabilitation on self-reported HA outcomes. METHOD: A self-report of the time it took to get accustomed to the new HAs and adjustment of the HAs during a year of rehabilitation collected from 690 HA users using a nonstandardized questionnaire were analyzed. The abbreviated version of the Speech, Spatial, and Quality of Hearing questionnaire and the International Outcome Inventory for Hearing Aids were used as the self-reported HA outcome. RESULT: Out of 690 participants, 442 (64%) got accustomed to HAs within 2 months. Ninety-one participants (13%) did not get accustomed to the HAs at all, out of which 74 (81%) were first-time HA users. Eighty-four participants (12%) did not receive any HA adjustments after their initial fitting, and 49 (7%) had their HAs adjusted four or more times during the 1 year of rehabilitation. Three hundred ninety (57%) participants got their HA adjusted only at the 2-month follow-up visit, showing the intent to adjust given an opportunity. The stepwise multiple linear regression results showed the significant impact of getting accustomed to the HA and having HA adjusted at multiple instances on the self-reported HA outcomes. CONCLUSION: This study showed the importance of getting accustomed to the HA and having a minimal number of adjustments to have a better long-term self-reported HA outcome.

Baseline Health Status and its Association With Subsequent Cardiovascular Events in Patients With Atrial Fibrillation.

BACKGROUND: Clinical practice guidelines recommend optimizing the health status of patients with atrial fibrillation (AF) as a primary treatment goal. Whether disease-specific health status is associated with subsequent clinical events is unknown. OBJECTIVES: The aim of this study was to investigate the association between health status and subsequent clinical events among patients with AF. METHODS: Using a prospective cohort study of patients with new-onset AF referred to 11 hospitals (n = 3,313, 68.4% men, mean age 67.8 ± 11.6 years), data were extracted from 3,296 patients (99.4%) who completed the disease-specific Atrial Fibrillation Effects on Quality-of-Life (AFEQT) questionnaire between 2012 and 2018. Factors associated with baseline AFEQT overall summary (OS) score and associations between major adverse cardiovascular or neurologic events (MACNE; a composite of all-cause death, stroke, or new-onset heart failure hospitalization) over 2 years were investigated. RESULTS: Overall, 517 participants (15.6%) had poor to fair health status (AFEQT OS <60), and 1,035 (31.2%) had fair to good health status (AFEQT OS 60 to <80) at baseline. Female sex, younger age, family history of AF, higher baseline heart rate, paroxysmal AF, initial visit to the emergency department, and history of heart failure were associated with lower AFEQT OS scores. Of those, 226 participants (6.8%) experienced MACNE; restricted cubic spline analysis with adjustment for factors associated with baseline AFEQT score showed a nonlinear increase in the risk for MACNE with AFEQT OS score <80. The strongest associations were observed for baseline AFEQT daily activity scores (for AFEQT daily activity score of <80 vs ≥80, HR: 1.65; 95% CI: 1.21-2.25). CONCLUSIONS: Diminished health status in patients with AF is common and is independently associated with subsequent adverse cardiovascular events.

Health status and clinical outcomes in older adults with chronic coronary disease: the ISCHEMIA trial

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Clinical features and management of keratoconjunctivitis associated with inadequate tear drainage.

OBJECTIVE: To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome). DESIGN: Retrospective observational case series. METHODS: Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions. RESULTS: Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids. CONCLUSIONS: Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients.

Time for More Support? Stakeholder Engagement for a Long-Term Care Planning Dementia Decision Aid Prototype.

Clinical decision aids around long-term care can help support persons living with dementia (PLWD), family care partners, and healthcare providers navigate current and future care decisions. This study describes the iterative development of a long-term care planning dementia decision aid and explores care partner and geriatric providers' insights regarding its acceptability and usability. Using a convergent parallel mixed methods design, we gathered surveys and completed interviews with 11 care partners and 11 providers. The quantitative and qualitative data were then converged, resulting in four findings: (1) helpfulness of the decision aid in supporting future care planning; (2) versatility of the decision aid in practice; (3) preferences for structure and content of the decision aid; and (4) perceived shortcomings of the decision aid in decision making. Future work should continue to refine the decision aid, pilot implementation, and evaluate potential effects on decision making as part of dementia care.

Self-Reported Hearing-Aid Use Patterns in an Adult Danish Population.

The retrospective reporting of users' hearing aid (HA) usage can provide insight into individualized HA usage patterns. Understanding these HA usage patterns can help to provide a tailored solution to meet the usage needs of HA users. This study aims to understand the HA usage pattern in daily-life situations from self-reported data and to examine its relationship to self-reported outcomes. A total of 1537 participants who responded to questions related to situations where they always took off or put on the HAs were included in the study. A latent class analysis was performed to stratify the HA users according to their HA usage pattern. The results showed distinct usage patterns in the latent classes derived for both scenarios. The demographics, socio-economic indicators, hearing loss, and user-related factors were found to impact HA usage. The results showed that the HA users who reported using the HAs all the time (regular users) had better self-reported HA outcomes than situational users, situational non-users, and non-users. The study explained the underlying distinct HA usage pattern from self-reported questionnaires using latent class analysis. The results emphasized the importance of regular use of HAs for a better self-reported HA outcome.

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial.

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Artificial intelligence-enabled mobile electrocardiograms for event prediction in paroxysmal atrial fibrillation.

Background: Paroxysmal atrial fibrillation (AF) often eludes early diagnosis, resulting in significant morbidity and mortality. Artificial intelligence (AI) has been used to predict AF from sinus rhythm electrocardiograms (ECGs), but AF prediction using sinus rhythm mobile electrocardiograms (mECG) remains unexplored. Objective: The purpose of this study was to investigate the utility of AI to predict AF events prospectively and retrospectively using sinus rhythm mECG data. Methods: We trained a neural network to predict AF events from sinus rhythm mECGs obtained from users of the Alivecor KardiaMobile 6L device. We tested our model on sinus rhythm mECGs within ±0-2 days, ±3-7 days, and ±8-30 days from AF events to determine the optimal screening window. Finally, we tested our model on mECGs from before an AF event to determine whether AF can be predicted prospectively. Results: We included 73,861 users with 267,614 mECGs (mean age 58.14 years; 35% women). Users with paroxysmal AF contributed 60.15% of mECGs. Model performance on the test set comprising control and study samples across all windows of interest showed an area under the curve (AUC) score of 0.760 (95% confidence interval [CI] 0.759-0.760), sensitivity of 0.703 (95% CI 0.700-0.705), specificity of 0.684 (95% CI 0.678-0.685), and accuracy of 69.4% (95% CI 0.692-0.700). Model performance was better on ±0-2 day samples (sensitivity 0.711; 95% CI 0.709-0.713) and worse on the ±8-30 day window (sensitivity 0.688; 95% CI 0.685-0.690), with performance on the ±3-7 day window falling in between (sensitivity 0.708; 95% CI 0.704-0.710). Conclusion: Neural networks can predict AF using a widely scalable and cost-effective mobile technology prospectively and retrospectively.

Optical Coherence Tomography Angiography for the Differentiation of Glaucoma from Pituitary Macroadenoma Related Optic Disc Measurements.

OBJECTIVE: To determine the potential of optical coherence tomography (OCT) and OCT angiography (OCTA) to distinguish between glaucoma and pituitary macroadenoma by optic disc appearance. METHODS: This prospective case-control study comprised 31 patients: 23 with glaucoma (18 male, 5 female) and 8 with pituitary macroadenoma and chiasmatic compression (3 male, 5 female). The corresponding mean ages were 72.8 years (range 58-90) and 60.7 years (range 43-73). All participants underwent complete ophthalmological examination, spectral domain OCT and OCTA, and visual field testing. Clinical, imaging, and visual field results were compared between the groups. RESULTS: On OCT analysis, the glaucoma group had relatively lower peripapillary retinal nerve fiber layer (RNFL) thickness (65.79 ± 15.46, 86.0 ± 11.37, respectively, P = .002) and lower rim area (1.00 ± 0.22 mm2 and 1.2 ± 0.15 mm2, respectively, P = .005). On OCTA, peripapillary vessel density was significantly lower in all quadrants in the glaucoma group. The significance of these between-group differences was maintained when patients were stratified by visual field mean deviation. CONCLUSIONS: This is the first comparative analysis of optic disc morphology between glaucoma and pituitary macroadenoma using combined OCT and OCTA. The results yielded lower peripapillary RNFL thickness, lower rim area, and lower peripapillary vessel density in the glaucoma group. These parameters may aid in the initial differentiation between these two optic neuropathies.