Racial, ethnic, and socioeconomic disparities in trajectories of morbidity accumulation among older Americans.

Introduction: Multimorbidity, the presence of multiple chronic health conditions, generally starts in middle and older age but there is considerable heterogeneity in the trajectory of morbidity accumulation. This study aimed to clarify the number of distinct trajectories and the potential associations between race/ethnicity and socioeconomic status and these trajectories. Methods: Data from 13,699 respondents (age ≥51) in the Health and Retirement Study between 1998 and 2016 were analyzed with growth mixture models. Nine prevalent self-reported morbidities (arthritis, cancer, cognitive impairment, depressive symptoms, diabetes, heart disease, hypertension, lung disease, stroke) were summed for the morbidity count. Results: Three trajectories of morbidity accumulation were identified: low [starting with few morbidities and accumulating them slowly (i.e., low intercept and low slope); 80% of sample], increasing (i.e., low intercept and high slope; 9%), and high (i.e., high intercept and low slope; 11%). Compared to non-Hispanic (NH) White adults in covariate-adjusted models, NH Black adults had disadvantages while Hispanic adults had advantages. Our results suggest a protective effect of education for NH Black adults (i.e., racial health disparities observed at low education were ameliorated and then eliminated at increasing levels of education) and a reverse pattern for Hispanic adults (i.e., increasing levels of education was found to dampen the advantages Hispanic adults had at low education). Compared with NH White adults, higher levels of wealth were protective for both NH Black adults (i.e., reducing or reversing racial health disparities observed at low wealth) and Hispanic adults (i.e., increasing the initial health advantages observed at low wealth). Conclusion: These findings have implications for addressing health disparities through more precise targeting of public health interventions. This work highlights the imperative to address socioeconomic inequalities that interact with race/ethnicity in complex ways to erode health.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group.

OBJECTIVE: This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults. DESIGN: Prospective, observational, population-based 16-year follow-up study of nationally representative sample. SETTING AND PARTICIPANTS: Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age). METHODS: Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth. RESULTS: Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively]. CONCLUSIONS AND IMPLICATIONS: Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-R2): a multisite, randomised, 12-month trial to compare efficacy of standard versus peer-based approaches to retain rural people who use drugs in research.

INTRODUCTION: Rural communities bear a disproportionate share of the opioid and methamphetamine use disorder epidemics. Yet, rural people who use drugs (PWUD) are rarely included in trials testing new drug use prevention and treatment strategies. Numerous barriers impede rural PWUD trial engagement and advancing research methods to better retain rural PWUD in clinical trials is needed. This paper describes the Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-R2) study protocol to test the effectiveness of a peer-driven intervention to improve study retention among rural PWUD. METHODS AND ANALYSIS: The PROUD-R2 study is being implemented in 21 rural counties in three states (Kentucky, Ohio and Oregon). People who are 18 years or older, reside in the study area and either used opioids or injected any drug to get high in the past 30 days are eligible for study inclusion. Participants are allocated in a 1:1 ratio to two arms, stratified by site to assure balance at each geographical location. The trial compares the effectiveness of two retention strategies. Participants randomised to the control arm provide detailed contact information and receive standard retention outreach by study staff (ie, contacts for locator information updates, appointment reminders). Participants randomised to the intervention arm are asked to recruit a 'study buddy' in addition to receiving standard retention outreach. Study buddies are invited to participate in a video training and instructed to remind their intervention participant of follow-up appointments and encourage retention. Assessments are completed by intervention, control and study buddy participants at 6 and 12 months after enrolment. ETHICS AND DISSEMINATION: The protocol was approved by a central Institutional Review Board (University of Utah). Results of the study will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders. TRIAL REGISTRATION NUMBER: NCT03885024.

The importance of chronic conditions for potentially avoidable hospitalizations among non-Hispanic Black and non-Hispanic White older adults in the US: a cross-sectional observational study.

BACKGROUND: Non-Hispanic (NH) Black older adults experience substantially higher rates of potentially avoidable hospitalization compared to NH White older adults. This study explores the top three chronic conditions preceding hospitalization and potentially avoidable hospitalization among NH White and NH Black Medicare beneficiaries in the United States. METHODS: Data on 4993 individuals (4,420 NH White and 573 NH Black individuals) aged ≥ 65 years from 2014 Medicare claims were linked with sociodemographic data from previous rounds of the Health and Retirement Study. Conditional inference random forests were used to rank the importance of chronic conditions in predicting hospitalization and potentially avoidable hospitalization separately for NH White and NH Black beneficiaries. Multivariable logistic regression with the top three chronic diseases for each outcome adjusted for sociodemographic characteristics were conducted to quantify the associations. RESULTS: In total, 22.1% of NH White and 24.9% of NH Black beneficiaries had at least one hospitalization during 2014. Among those with hospitalization, 21.3% of NH White and 29.6% of NH Black beneficiaries experienced at least one potentially avoidable hospitalization. For hospitalizations, chronic kidney disease, heart failure, and atrial fibrillation were the top three contributors among NH White beneficiaries and acute myocardial infarction, chronic obstructive pulmonary disease (COPD), and chronic kidney disease were the top three contributors among NH Black beneficiaries. These chronic conditions were associated with increased odds of hospitalization for both groups. For potentially avoidable hospitalizations, asthma, COPD, and heart failure were the top three contributors among NH White beneficiaries and fibromyalgia/chronic pain/fatigue, COPD, and asthma were the top three contributors among NH Black beneficiaries. COPD and heart failure were associated with increased odds of potentially avoidable hospitalization among NH White beneficiaries, whereas only COPD was associated with increased odds of potentially avoidable hospitalizations among NH Black beneficiaries. CONCLUSION: Having at least one hospitalization and at least one potentially avoidable hospitalization was more prevalent among NH Black than NH White Medicare beneficiaries. This suggests greater opportunity for increasing prevention efforts among NH Black beneficiaries. The importance of COPD for potentially avoidable hospitalizations further highlights the need to focus on prevention of exacerbations for patients with COPD, possibly through greater access to primary care and continuity of care.

Physical Activity as a Mediator Between Race/Ethnicity and Changes in Multimorbidity.

OBJECTIVES: Studies report racial/ethnic disparities in multimorbidity (≥2 chronic conditions) and their rate of accumulation over time as well as differences in physical activity. Our study aimed to investigate whether racial/ethnic differences in the accumulation of multimorbidity were mediated by physical activity among middle-aged and older adults. METHOD: We assessed racial/ethnic differences in the accumulation of multimorbidity (of 9 conditions) over 12 years (2004-2016) in the Health and Retirement Study (N = 18,264, mean age = 64.4 years). Structural equation modeling was used to estimate latent growth curve models of changes in multimorbidity and investigate whether the relationship of race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White participants) to changes in the number of chronic conditions was mediated by physical activity after controlling for age, sex, education, marital status, household wealth, insurance coverage, smoking, alcohol, and body weight. RESULTS: There was a significant increase in multimorbidity over time. Initial levels and changes in multimorbidity over time varied significantly across individuals. Indirect effects of the relationship between race/ethnicity and changes in multimorbidity as mediated by physical activity were significant, consistent with the mediational hypothesis. Black respondents engaged in significantly lower levels of physical activity than White respondents after controlling for covariates, but there were no differences between Hispanic and White respondents once education was included. Discussion: These results provide important new information for understanding how modifiable lifestyle factors may help explain disparities in multimorbidity in mid-to-late life, suggesting greater need to intervene to reduce sedentary behavior and increase physical activity.

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA.

BACKGROUND: Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD. METHODS: We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models. RESULTS: Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99). CONCLUSIONS: Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Perioperative Amiodarone to Prevent Atrial fibrillation after Septal Myectomy in obstrUctive hypeRtroPHic cardiomyopathy.

AIMS: Amiodarone reduces the incidence of atrial fibrillation (AF) following coronary artery bypass surgery; however, the benefit of perioperative amiodarone in patients undergoing septal myectomy (SM) for obstructive hypertrophic cardiomyopathy (oHCM) has not been studied. We hypothesized that prophylactic amiodarone would reduce the incidence of postoperative AF (POAF) following SM for oHCM. METHODS AND RESULTS: A single-centre, pre-post intervention open-label study of oral amiodarone (200 mg twice daily starting 7 days preoperatively and 200 mg once daily continuing for 30 days postoperatively) in patients without prior AF undergoing SM for oHCM from 2014 to 2018. The primary outcome was incident AF within 30 days. Secondary outcomes were unplanned readmission, AF treatment, total and intensive care unit (ICU) length of stay (LOS), and pacemaker implantation for high-grade atrioventricular (AV) block. 61 patients met inclusion criteria with 34 (55.8%) in the pre-intervention (control) group and 27 (44.2%) in the post-intervention (amiodarone) group. The incidence of POAF was 11.0% in the amiodarone group compared with 38.2% in the control group (P = 0.017). After adjusting for age, amiodarone was associated with less POAF [adjusted odds ratio (aOR) 0.21; 95% confidence interval (CI) 0.05, 0.76; P = 0.016]. ICU (2 days [IQR 1, 4] vs. 3 days [IQR 2, 4]; P = 0.165) and total (6 days [IQR 5, 6] vs. 6 days [IQR 5, 7]; P = 0.165) LOS were similar, as was the rate of pacemaker implantation (7.4% vs. 8.3%, P > 0.999). There were no adverse events associated with amiodarone. CONCLUSIONS: Perioperative oral amiodarone is safe and was associated with lower incidence of POAF following SM for oHCM.

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study.

BACKGROUND: Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH. OBJECTIVES: To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors. SETTING: Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers. METHODS: A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors. RESULTS: In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting. CONCLUSION: Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.

Racial and Ethnic Differences in Multimorbidity Changes Over Time.

BACKGROUND: Our understanding of how multimorbidity progresses and changes is nascent. OBJECTIVES: Assess multimorbidity changes among racially/ethnically diverse middle-aged and older adults. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study using latent class analysis to identify multimorbidity combinations over 16 years, and multinomial logistic models to assess change relative to baseline class membership. Health and Retirement Study respondents (age 51 y and above) in 1998 and followed through 2014 (N=17,297). MEASURES: Multimorbidity latent classes of: hypertension, heart disease, lung disease, diabetes, cancer, arthritis, stroke, high depressive symptoms. RESULTS: Three latent classes were identified in 1998: minimal disease (45.8% of participants), cardiovascular-musculoskeletal (34.6%), cardiovascular-musculoskeletal-mental (19.6%); and 3 in 2014: cardiovascular-musculoskeletal (13%), cardiovascular-musculoskeletal-metabolic (12%), multisystem multimorbidity (15%). Remaining participants were deceased (48%) or lost to follow-up (12%) by 2014. Compared with minimal disease, individuals in cardiovascular-musculoskeletal in 1998 were more likely to be in multisystem multimorbidity in 2014 [odds ratio (OR)=1.78, P<0.001], and individuals in cardiovascular-musculoskeletal-mental in 1998 were more likely to be deceased (OR=2.45, P<0.001) or lost to follow-up (OR=3.08, P<0.001). Hispanic and Black Americans were more likely than White Americans to be in multisystem multimorbidity in 2014 (OR=1.67, P=0.042; OR=2.60, P<0.001, respectively). Black compared with White Americans were more likely to be deceased (OR=1.62, P=0.01) or lost to follow-up (OR=2.11, P<0.001) by 2014. CONCLUSIONS AND RELEVANCE: Racial/ethnic older adults are more likely to accumulate morbidity and die compared with White peers, and should be the focus of targeted and enhanced efforts to prevent and/or delay progression to more complex multimorbidity patterns.

High-intensity ultrasound catheter ablation achieves deep mid-myocardial lesions in vivo.

BACKGROUND: Radiofrequency ablation of epicardial and mid-myocardial ventricular arrhythmias is limited by lesion depth. OBJECTIVE: The purpose of this study was to generate deep mid-interventricular septal (IVS) lesions using high-intensity ultrasound (US) from an endocardial catheter-based approach. METHODS: Irrigated US catheters (12 F) were fabricated with 3 × 5 mm transducers of 5.0, 6.5, and 8.0 MHz frequencies and compared in an ex vivo perfused myocardial ablation model. In vivo septal ablation in swine (n = 12) was performed via femoral venous access to the right ventricle. Lesions were characterized by echocardiography, cardiac magnetic resonance imaging, and electroanatomic voltage mapping pre- and post-ablation, and at 30 days. Four animals were euthanized immediately post-ablation to compare acute and chronic lesion histology and gross pathology. RESULTS: In ex vivo models, maximal lesion depth and volume was achieved by 6.5 MHz catheters, which were used in vivo. Lesion depth by gross pathology was similar post-ablation (10.8 mm; 95% confidence interval [CI] 9.9-12.4 mm) and at 30 days (11.2 mm; 95% CI 10.6-12.4 mm) (P = .56). Lesion volume decreased post-ablation to 30 days (from 255 [95% CI 198-440] to 162 [95% CI 133-234] mm3; P = .05), yet transmurality increased from 58% (95% CI 50%-76%) to 81% (95% CI 74%-93%), attributable to a reduction in IVS thickness (from 16.0 ± 1.7 to 10.6 ± 2.4 mm; P = .007). Magnetic resonance imaging confirmed dense septal ablation by delayed enhancement, with increased T1 time post-ablation and at 30 days and increased T2 time only post-ablation. Voltage mapping of both sides of IVS demonstrated reduced unipolar (but not bipolar) voltage along the IVS. CONCLUSION: High-intensity US catheter ablation may be an effective treatment of mid-myocardial or epicardial ventricular arrhythmias from an endocardial approach.

Stellate Ganglion Blockade With Continuous Infusion Versus Single Injection for Treatment of Ventricular Arrhythmia Storm.

OBJECTIVES: This study sought to compare the efficacy and safety of single-injection stellate ganglion block (SGB) with a novel continuous-infusion SGB procedure. BACKGROUND: SGB for ventricular arrhythmia (VA) storm is typically performed with a single injection of local anesthetic agents. METHODS: Eighteen patients underwent left-sided SGB (9 single injection and 9 continuous infusion). The number of implantable cardioverter-defibrillator therapies and sustained VAs/24 h were compared between the pre-SGB and post-SGB periods. Adverse effects of SGB and in-hospital outcomes were also compared. RESULTS: The mean age was 61.1 ± 13.7 years. The presenting arrhythmia was ventricular tachycardia in 13 (72%) patients, ventricular fibrillation in 4 (22%), and both in 1 (6%). Single-injection SGB reduced VA/24 h by a median of 0.3 (interquartile range: 0.2 to 0.9), which was a 45% reduction (p = 0.008), resulting in 5 of 9 patients with no recurrent VA. Continuous-infusion SGB reduced VA/24 h by a median of 2.0 (interquartile range: 1.3 to 3.0), which was a 94% reduction (p = 0.004), resulting in 7 of 9 patients with no recurrent VA (p = 0.006 for comparison with single injection). Transient left arm weakness and voice hoarseness were each noted in 1 patient in both groups. Repeat SGB was required in 4 (44%) patients in the single-injection group. In-hospital outcomes were similar between the groups. CONCLUSIONS: In patients with VA storm, SGB performed via both continuous-infusion and single-injection approaches provided significant reductions in VA burden. Compared to single-injection SGB, continuous-infusion was associated with a greater reduction in VA burden and similar adverse events, without the need for repeat procedures.

Annual Wellness Visits and Influenza Vaccinations among Older Adults in the US.

OBJECTIVES: Investigate whether combinations of sociodemographic factors, chronic conditions, and other health indicators pose barriers for older adults to access Annual Wellness Visits (AWVs) and influenza vaccinations. METHODS: Data on 4999 individuals aged ≥65 years from the 2012 wave of the Health and Retirement Study linked with Medicare claims were analyzed. Conditional Inference Tree (CIT) and Random Forest (CIRF) analyses identified the most important predictors of AWVs and influenza vaccinations. Multivariable logistic regression (MLR) was used to quantify the associations. RESULTS: Two-year uptake was 22.8% for AWVs and 65.9% for influenza vaccinations. For AWVs, geographical region and wealth emerged as the most important predictors. For influenza vaccinations, number of somatic conditions, race/ethnicity, education, and wealth were the most important predictors. CONCLUSIONS: The importance of geographic region for AWV utilization suggests that this service was unequally adopted. Non-Hispanic black participants and/or those with functional limitations were less likely to receive influenza vaccination.

Associations of Pregnancy After Bariatric Surgery with Long-Term Weight Trajectories and Birth Weight: LABS-2 Study.

OBJECTIVE: This study aimed to examine whether pregnancy following bariatric surgery affects long-term maternal weight change and offspring birth weight. METHODS: Using data from the Longitudinal Assessment of Bariatric Surgery (LABS)-2 study, linear regression was used to evaluate percent change in total body weight over a 5-year follow-up period among reproductive-aged women who underwent Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding as well as evaluate the association of bariatric procedure type and offspring birth weight. RESULTS: Of 727 women with preoperative age of 36.1 (6.3) years (mean [SD]) and BMI of 46.9 (7.0) kg/m2 , 80 (11%) reported at least one pregnancy. After adjusting for covariates, percent change in total body weight was not significantly different between women who became pregnant and those who did not during a 5-year follow-up period (ß = 2.02; 95% CI: -1.03 to 5.07; P = 0.19). Additionally, mean birth weight was not significantly different between mothers who underwent Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding (P = 0.99). CONCLUSIONS: Postoperative pregnancy did not diminish long-term weight loss in women in the LABS-2 study. The finding of comparable weight loss is relevant for providers counseling women of reproductive age on weight-loss expectations and family planning following bariatric surgery.

Unintended consequences of a reflex urine culture order set on appropriate antibiotic use.

We evaluated the impact of reflex urine culture screen results on antibiotic initiation. More patients with positive urine screen but negative culture received antibiotics than those with a negative screen (30.5 vs 7.1%). Urine screen results may inappropriately influence antibiotic initiation in patients with a low likelihood of infection.

Coronary vascular growth matches IGF-1-stimulated cardiac growth in fetal sheep.

As loss of contractile function in heart disease could often be mitigated by increased cardiomyocyte number, expansion of cardiomyocyte endowment paired with increased vascular supply is a desirable therapeutic goal. Insulin-like growth factor 1 (IGF-1) administration increases fetal cardiomyocyte proliferation and heart mass, but how fetal IGF-1 treatment affects coronary growth and function is unknown. Near-term fetal sheep underwent surgical instrumentation and were studied from 127 to 134 d gestation (term = 147 d), receiving either IGF-1 LR3 or vehicle. Coronary growth and function were interrogated using pressure-flow relationships, an episode of acute hypoxia with progressive blockade of adenosine receptors and nitric oxide synthase, and by modeling the determinants of coronary flow. The main findings were that coronary conductance was preserved on a per-gram basis following IGF-1 treatment, adenosine and nitric oxide contributed to hypoxia-mediated coronary vasodilation similarly in IGF-1-treated and Control fetuses, and the relationships between coronary flow and blood oxygen contents were similar between groups. We conclude that IGF-1-stimulated fetal myocardial growth is accompanied by appropriate expansion and function of the coronary vasculature. These findings support IGF-1 as a potential strategy to increase cardiac myocyte and coronary vascular endowment at birth.

Appropriate and inappropriate shocks in hypertrophic cardiomyopathy patients with subcutaneous implantable cardioverter-defibrillators: An international multicenter study.

BACKGROUND: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) are attractive for preventing sudden cardiac death in hypertrophic cardiomyopathy (HCM) as they mitigate risks of transvenous leads in young patients. However, S-ICDs may be associated with increased inappropriate shock (IAS) in HCM patients. OBJECTIVE: The purpose of this study was to assess the incidence and predictors of appropriate shock and IAS in a contemporary HCM S-ICD cohort. METHODS: We collected electrocardiographic and clinical data from HCM patients who underwent S-ICD implantation at 4 centers. Etiologies of all S-ICD shocks were adjudicated. We used Firth penalized logistic regression to derive adjusted odds ratios (aORs) for predictors of IAS. RESULTS: Eighty-eight HCM patients received S-ICDs (81 for primary and 7 for secondary prevention) with a mean follow-up of 2.7 years. Five patients (5.7%) had 9 IAS episodes (3.8 IAS per 100 patient-years) most often because of sinus tachycardia and/or T-wave oversensing. Independent predictors of IAS were higher 12-lead electrocardiographic R-wave amplitude (aOR 2.55 per 1 mV; 95% confidence interval 1.15-6.38) and abnormal T-wave inversions (aOR 0.16; 95% confidence interval 0.02-0.97). There were 2 appropriate shocks in 7 secondary prevention patients and none in 81 primary prevention patients, despite 96% meeting Enhanced American College of Cardiology/American Heart Association criteria and the mean European HCM Risk-SCD score predicting 5.7% 5-year risk. No patients had sudden death or untreated sustained ventricular arrhythmias. CONCLUSION: In this multicenter HCM S-ICD study, IAS were rare and appropriate shocks confined to secondary prevention patients. The R-wave amplitude increased IAS risk, whereas T-wave inversions were protective. HCM primary prevention implantable cardioverter-defibrillator guidelines overestimated the risk of appropriate shocks in our cohort.

Antibiotic prescribing without documented indication in ambulatory care clinics: national cross sectional study.

OBJECTIVES: To identify the frequency with which antibiotics are prescribed in the absence of a documented indication in the ambulatory care setting, to quantify the potential effect on assessments of appropriateness of antibiotics, and to understand patient, provider, and visit level characteristics associated with antibiotic prescribing without a documented indication. DESIGN: Cross sectional study. SETTING: 2015 National Ambulatory Medical Care Survey. PARTICIPANTS: 28 332 sample visits representing 990.9 million ambulatory care visits nationwide. MAIN OUTCOME MEASURES: Overall antibiotic prescribing and whether each antibiotic prescription was accompanied by appropriate, inappropriate, or no documented indication as identified through ICD-9-CM (international classification of diseases, 9th revision, clinical modification) codes. Survey weighted multivariable logistic regression was used to evaluate potential risk factors for receipt of an antibiotic prescription without a documented indication. RESULTS: Antibiotics were prescribed during 13.2% (95% confidence interval 11.6% to 13.7%) of the estimated 990.8 million ambulatory care visits in 2015. According to the criteria, 57% (52% to 62%) of the 130.5 million prescriptions were for appropriate indications, 25% (21% to 29%) were inappropriate, and 18% (15% to 22%) had no documented indication. This corresponds to an estimated 24 million prescriptions without a documented indication. Being an adult male, spending more time with the provider, and seeing a non-primary care specialist were significantly positively associated with antibiotic prescribing without an indication. Sulfonamides and urinary anti-infective agents were the antibiotic classes most likely to be prescribed without documentation. CONCLUSIONS: This nationally representative study of ambulatory visits identified a large number of prescriptions for antibiotics without a documented indication. Antibiotic prescribing in the absence of a documented indication may severely bias national estimates of appropriate antibiotic use in this setting. This study identified a wide range of factors associated with antibiotic prescribing without a documented indication, which may be useful in directing initiatives aimed at supporting better documentation.

Clinical and Echocardiographic Predictors of Outcomes in Patients With Moderate (Mean Transvalvular Gradient 20 to 40 mm Hg) Aortic Stenosis.

Risk factors for adverse clinical outcomes in patients with moderate aortic stenosis are not well defined. Previous studies have suggested that certain patients with moderate AS may be at an increased risk of heart failure (HF) or death. All patients with moderate AS seen in our institution during the study period (6/1/2014 to 6/30/2017) with a minimum 1-year follow-up were included. Clinical and echocardiographic data were collected retrospectively. End points were defined as HF hospitalization, aortic valve replacement (AVR), or death. Kaplan-Meier and multivariable Cox proportional hazard models analyses were conducted using composite outcomes of (1) HF hospitalization or AVR and (2) HF hospitalization, AVR, or all-cause death. A total of 151 subjects met the inclusion criteria. The most significant risk factors associated with the composite outcomes were an ejection fraction (EF) <50% ((1) hazard ratio [HR]: 4.1; 95% confidence interval [CI]: 2.34, 7.12; (2) HR: 3.8; 95% CI: 2.2, 6.6), atrial fibrillation ((1) HR: 2.0; 95% CI: 1.2, 3.2; (2) HR: 2.1; 95% CI: 1.43, 3.2), left ventricular hypertrophy ((1) HR: 5.85; 95% CI: 2.0, 15.8; (2) HR: 3.2; 95% CI: 1.4, 7.4), aortic valve area ((1) HR: 0.3; 95% CI: 0.1, 0.6; (2) HR: 0.32; 95% CI: 0.1, 0.65), and abnormal right ventricular function ((1) HR: 4.3; 95% CI: 2.5, 7.5; (2) HR: 5.5; 95% CI: 3.0, 9.8). In conclusion, presence of reduced ejection fraction, atrial fibrillation, left ventricular hypertrophy, and abnormal right ventricular function are associated with an increased risk of HF hospitalization, AVR, and death in patients with moderate aortic stenosis.

Healthcare-associated urinary tract infections with onset post hospital discharge.

OBJECTIVE: Current surveillance for healthcare-associated (HA) urinary tract infection (UTI) is focused on catheter-associated infection with hospital onset (HO-CAUTI), yet this surveillance does not represent the full burden of HA-UTI to patients. Our objective was to measure the incidence of potentially HA, community-onset (CO) UTI in a retrospective cohort of hospitalized patients. DESIGN: Retrospective cohort study. SETTING: Academic, quaternary care, referral center. PATIENTS: Hospitalized adults at risk for HA-UTI from May 2009 to December 2011 were included. METHODS: Patients who did not experience a UTI during the index hospitalization were followed for 30 days post discharge to identify cases of potentially HA-CO UTI. RESULTS: We identified 3,273 patients at risk for potentially HA-CO UTI. The incidence of HA-CO UTI in the 30 days post discharge was 29.8 per 1,000 patients. Independent risk factors of HA-CO UTI included paraplegia or quadriplegia (adjusted odds ratio [aOR], 4.6; 95% confidence interval [CI], 1.2-18.0), indwelling catheter during index hospitalization (aOR, 1.5; 95% CI, 1.0-2.3), prior piperacillin-tazobactam prescription (aOR, 2.3; 95% CI, 1.1-4.5), prior penicillin class prescription (aOR, 1.7; 95% CI, 1.0-2.8), and private insurance (aOR, 0.6; 95% CI, 0.4-0.9). CONCLUSIONS: HA-CO UTI may be common within 30 days following hospital discharge. These data suggest that surveillance efforts may need to be expanded to capture the full burden to patients and better inform antibiotic prescribing decisions for patients with a history of hospitalization.