Does pulmonary artery pulsatility index predict mortality in pulmonary arterial hypertension?

AIMS: Pulmonary artery pulsatility index (PAPi), defined as [(pulmonary artery systolic pressure - diastolic pulmonary artery pressure)/mean right atrial pressure], is a novel haemodynamic index that predicts right ventricular failure after myocardial infarction and left ventricular assist device implantation. We analysed if a low PAPi is associated with death in our 14 - â€‹year pulmonary arterial hypertension (PAH) registry. METHODS: Consecutive patients with newly diagnosed PAH and complete haemodynamic data were prospectively enrolled into our standing registry between January 2003 and December 2016. PAPi was calculated from baseline invasive right heart catheterization data. A prognostic cut-off value was determined with a decision tree. Baseline characteristics of 'high' and 'low' PAPi groups based on this cut-off were compared, as well as odds of death and time-to-death. RESULTS: One hundred and two patients were included. Mean age was 53 years, and 77% were women. Our multi-ethnic cohort was 64% Chinese, 23% Malay, and 10% Indian. The aetiologies were idiopathic (33%), connective tissue disease (31%), congenital heart disease (24%), and others (12%). The low PAPi group (<5.3) had a greater age (56 years vs. 49 years), lower pulmonary artery systolic pressure (71 mmHg vs. 85 mmHg), and higher mean right atrial pressure (14 mmHg vs. 6 mmHg). Mortality risk was higher in the low PAPi group (adjusted odds ratio: 2.98 and adjusted hazard ratio: 2.23). Mean right atrial pressure was the strongest predictor (hazard ratio 1.114, P = 0.009) when components of PAPi were analysed. CONCLUSIONS: Pulmonary artery pulsatility index was found to be predictive of mortality in PAH and may be a valuable marker for risk stratification. Its prognostic strength may be driven by mean right atrial pressure.

Pulmonary arterial hypertension in a multi-ethnic Asian population: Characteristics, survival and mortality predictors from a 14-year follow-up study.

BACKGROUND AND OBJECTIVE: Pulmonary arterial hypertension (PAH) is a rare and fatal disease. Data from Asia are lacking compared with the West. We aim to describe disease characteristics in an ethnically diverse South-East Asian population and assess predictors for survival. METHODS: We consecutively enrolled patients with PAH referred to our pulmonary hypertension specialty centre from January 2003 to December 2016. Baseline characteristics and survival were analysed. Based on a forward predictor selection procedure, a multi-level structural equation model was applied to identify predictors associated with mortality. RESULTS: Out of 148 patients enrolled, 77% were females and mean age was 50.8 ± 15.9 years. Racial distribution was consistent with our population census. The most common aetiologies were congenital heart disease-associated PAH (35.8%), idiopathic PAH (29.7%) and then connective tissue disease-associated PAH (24.3%). Most patients presented in World Health Organization (WHO) Functional Class (FC) II (48.6%), followed by FC III (28.8%). Majority of patients (54.1%) were on phosphodiesterase type 5 (PDE5) inhibitor monotherapy. Survival rates were 85.8% at the end of the first year, 70.9% at 3 years, 66.9% at 5 years, 61.5% at 7 years and 55.4% at 10 years. The Registry to Evaluate Early And Long-term PAH Disease Management (REVEAL) score (RS) was found to be the best predictor of mortality. A score > 6 was identified as a cut-off. Other predictors include mean right atrial pressure, heart rate, aetiology, age and N-terminal pro-brain natriuretic peptide. CONCLUSION: In this first registry study from a South-East Asian population, our survival rates are comparable with other national registries. The RS is validated in our population to be a good predictor of mortality.

Impact of financial background and student debt on postgraduate residency choices of medical students in Singapore.

INTRODUCTION: Medical school fees are rising globally. Student debt and financial background may affect residency choices, but few studies have been conducted in Asia. This study aimed to explore the relationship between financial background, student debt and postgraduate residency choices among medical students in Singapore. METHODS: An anonymised survey of all medical students in Singapore was conducted and had a response rate of 67.9%. RESULTS: 40.5% of our study population would graduate with debt. Medical students with monthly per capita household income < SGD 1,000 were more likely to graduate with debt (unadjusted odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.7; p < 0.001) and feel burdened by the cost of medical education (unadjusted OR 2.8, 95% CI 2.0-3.9; p < 0.001). Students with monthly per capita household income < SGD 1,000 (unadjusted OR 1.818, 95% CI 1.338-2.470, p < 0.001; adjusted OR 1.692, 95% CI 1.202-2.381, p = 0.003) and those with debt (unadjusted OR 1.623, 95% CI 1.261-2.090, p < 0.001; adjusted OR 1.393, 95% CI 1.048-1.851, p = 0.022) were more likely to rank at least one economic factor as 'very significant' in influencing their postgraduate training choices. CONCLUSION: It is concerning that despite financial aid schemes, the cost of medical education remains a burden to students from lower-income households in Singapore. Student debt and financial background may distort postgraduate career choices, creating an undue push towards high-paying specialties.

An update on finances and financial support for medical students in Yong Loo Lin School of Medicine.

INTRODUCTION: Increasing financial challenges have resulted in great debt among medical graduates worldwide. In Singapore, more scholarships and bursaries have been disbursed in recent years to support students who are financially challenged. We aimed to study the financial status of medical students in National University of Singapore (NUS) Yong Loo Lin School of Medicine (i.e. NUS Medicine), Singapore, and the financial support available to them. METHODS: A cross-sectional quantitative study was performed. Surveys were distributed and completed by medical students of NUS Medicine. Information regarding household income, financial assistance, monthly allowance and expense, and concurrent occupations was collected. We compared our findings with the results of a similar study performed in 2007 and national income data. RESULTS: A total of 956 (66.2%) out of 1,445 medical students completed the survey. 19.5% and 58.5% of respondents came from households with monthly incomes < SGD 3,000 and > SGD 7,000, respectively. 20.6% of students had loans, 18.9% had scholarships and bursaries, and 14.4% worked to support themselves. CONCLUSION: Medical school fees have risen by more than 50% over the past ten years. Our study found that there were increases in the proportion of students from both the lower- and higher-income segments, with proportionally fewer students from the middle-income segment. A large number of students were working and/or had some form of financial support. More should be done to meet the needs of financially challenged medical students to ensure equal access to quality medical education.