Quality of Life After Transcatheter Aortic Valve Replacement in Normal-Flow, Low-Gradient Aortic Stenosis.

Background: Prior studies of aortic valve replacement (AVR) in patients with normal-flow, low-gradient aortic stenosis (NF-LG AS) have demonstrated conflicting results regarding the survival benefit of AVR. Changes in quality of life (QoL) after transcatheter AVR (TAVR) have not been reported in this population. Objectives: The purpose of this study was to compare changes in QoL after TAVR for patients with NF-LG AS to patients with high-gradient aortic stenosis (HG-AS). Methods: Patients who underwent TAVR for severe aortic stenosis (AS) were divided into 4 hemodynamic profiles of AS, including NF-LG AS. Changes in Kansas City Cardiomyopathy Questionnaire-12 score from baseline to 1 year were compared between AS groups. The primary composite outcome indicating clinical improvement consisted of survival to 1 year and improved Kansas City Cardiomyopathy Questionnaire overall summary score of ≥5 points while adjusting for relevant baseline factors. Results: Out of 860 patients who underwent TAVR, high gradient AS was present in 368 (42.8%) patients and NF-LG AS in 245 (28.5%). HG-AS and NF-LG AS groups had a similar proportion of patients who met the primary unadjusted outcome of clinical improvement (70.4% vs 63.9%, respectively; P = 0.189). One-year Kaplan-Meier mortality estimates were higher for NF-LG AS patients than HG-AS patients (12.9% vs 5.8%, P < 0.001). In the primary adjusted analysis, there was no significant difference in the composite outcome between HG and NF-LG AS groups (adjusted OR: 0.72, 95% CI: 0.47-1.11). Conclusions: Selected patients with NF-LG AS experienced similar improvement in QoL after TAVR compared with HG-AS. Further investigation of patients with NF-LG AS will help to inform optimal selection for treatment with TAVR.

Admission respiratory status predicts mortality in COVID-19.

COVID-19 has significant case fatality. Glucocorticoids are the only treatment shown to improve survival, but only among patients requiring supplemental oxygen. WHO advises patients to seek medical care for "trouble breathing," but hypoxemic patients frequently have no respiratory symptoms. Our cohort study of hospitalized COVID-19 patients shows that respiratory symptoms are uncommon and not associated with mortality. By contrast, objective signs of respiratory compromise-oxygen saturation and respiratory rate-are associated with markedly elevated mortality. Our findings support expanding guidelines to include at-home assessment of oxygen saturation and respiratory rate in order to expedite life-saving treatments patients to high-risk COVID-19 patients.

Aortic Stenosis: Guidelines and Evidence Gaps.

Current guidelines for management of adults with aortic stenosis recommend aortic valve replacement for patients with clinical consequences due to hemodynamically severe valve obstruction. However, advances in surgical and transcatheter techniques, and improved valve design have led to decreased procedural risk and improved long-term outcomes. Transcatheter aortic valve replacement (TAVR) is recommended for patients with prohibitive surgical risk and is reasonable in intermediate and high-risk patients. Recent trials demonstrated favorable short-term outcomes in patients with low surgical risk undergoing TAVR compared with surgical AVR. We review the current Guidelines recommendations and highlight key controversies in management due to evidence gaps.

Investigation of a community cluster of cutaneous Mycobacterium marinum infection, an emerging zoonotic pathogen in aquaculture industry, Haliburton, Kawartha, Pine Ridge District Health Unit, Ontario, Canada, July-August 2015.

In July 2015, a cluster of five suspect cases of clinically diagnosed Mycobacterium marinum (M. marinum) skin infections were reported to the Haliburton, Kawartha, Pine Ridge District Health Unit (HKPRDHU), Ontario, Canada, with two additional cases subsequently identified through case finding. All seven cases presented with cutaneous lesions located on the finger, hand and/or elbow regions typical of M. marinum infection. Specimens were collected by skin biopsy for two of the seven cases; both cases tested positive for M. marinum by molecular detection (hsp65 gene amplification and sequencing), and one was confirmed positive for M. marinum by culture. All seven cases reported handling raw shrimp from an aquaculture facility in the Health Unit's jurisdiction. M. marinum is not a reportable disease in Ontario, and there are no known previous reports of a cluster of M. marinum reported in Ontario, Canada. A cluster investigation working group was struck that included representation from various agencies including Public Health Ontario (PHO), Public Health Ontario Laboratories (PHOL), Ontario Ministry of Agriculture and Rural Affairs (OMAFRA) and the two health units involved in case investigations. Several public health and aquaculture farming recommendations were made to mitigate further risks associated with handling of raw shrimp from the facility. Several challenges were faced during the investigation process. The paper discusses these challenges and public health recommendations made in order to mitigate occupational and public health risks related to the hazard identified.

Cardiopulmonary resuscitation: the science behind the hands.

Sudden cardiac arrest is a leading cause of death worldwide. Despite significant advances in resuscitation science since the initial use of external chest compressions in humans nearly 60 years ago, there continues to be wide variability in rates of successful resuscitation across communities. The American Heart Association (AHA) and European Resuscitation Council emphasise the importance of high-quality chest compressions as the foundation of resuscitation care. We review the physiological basis for the association between chest compression quality and clinical outcomes and the scientific basis for the AHA's key metrics for high-quality cardiopulmonary resuscitation. Finally, we highlight that implementation of strategies that promote effective chest compressions can improve outcomes in all patients with cardiac arrest.

Cardiac Magnetic Resonance Imaging Versus Transthoracic Echocardiography for Prediction of Outcomes in Chronic Aortic or Mitral Regurgitation.

In subjects with aortic regurgitation (AR) or mitral regurgitation (MR), transthoracic echocardiography (TTE) is recommended for surveillance. Few prospective studies have directly compared the ability of TTE and cardiac magnetic resonance (CMR) to predict clinical outcomes in AR and MR. We hypothesized that, given its higher reproducibility, CMR would predict the need for valve surgery or heart failure (HF) hospitalization better than TTE. Quantitative TTE and CMR were performed on the same day for 51 subjects: 29 with chronic AR and 22 with chronic, primary MR for quantification of valve regurgitation. Baseline measurements of valve regurgitation were compared to the combined primary end point of new HF and valve surgery using receiver operating characteristics, simple logistic regression, and Kaplan-Meier survival analyses. The primary end point occurred in 5 AR subjects (all surgery) and 8 MR subjects (7 surgery, 1 HF) after a mean follow-up of 4.4 ± 1.5 years. For AR, CMR-derived regurgitant volume >50 ml identified those at high risk with 50% undergoing valve surgery versus 0% for those with regurgitant volume ≤50 ml and was more strongly associated with outcomes than regurgitant volume by TTE (p <0.05). For MR, 6.8% of those with regurgitant volume by TTE ≤30 ml developed the primary end point versus 70% in those with regurgitant volume >30 ml. Regurgitant volume by CMR showed no significant separation of survival curves for MR. In conclusion, regurgitant volume by CMR was more predictive of outcomes than by TTE in subjects with AR. In MR, the 2 methods performed similarly.

Incidence and prevalence of chronic obstructive pulmonary disease among aboriginal peoples in Alberta, Canada.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major respiratory disorder, largely caused by smoking that has been linked with large health inequalities worldwide. There are important gaps in our knowledge about how COPD affects Aboriginal peoples. This retrospective cohort study assessed the epidemiology of COPD in a cohort of Aboriginal peoples relative to a non-Aboriginal cohort. METHODS: We used linkage of administrative health databases in Alberta (Canada) from April 1, 2002 to March 31, 2010 to compare the annual prevalence, and the incidence rates of COPD between Aboriginal and non-Aboriginal cohorts aged 35 years and older. Poisson regression models adjusted the analysis for important sociodemographic factors. RESULTS: Compared to a non-Aboriginal cohort, prevalence estimates of COPD from 2002 to 2010 were 2.3 to 2.4 times greater among Registered First Nations peoples, followed by the Inuit (1.86 to 2.10 times higher) and the Métis (1.59 to 1.67 times higher). All Aboriginal peoples had significantly higher COPD incidence rates than the non-Aboriginal group (incidence rate ratio [IRR]: 2.1; 95% confidence interval [CI]: 1.97, 2.27). COPD incidence rates were higher in First Nation peoples (IRR: 2.37; 95% CI: 2.19, 2.56) followed by Inuit (IRR: 1.92; 95% CI: 1.64, 2.25) and Métis (IRR: 1.49; 95% CI: 1.32, 1.69) groups. CONCLUSIONS: We found a high burden of COPD among Aboriginal peoples living in Alberta; a province with the third largest Aboriginal population in Canada. Altogether, the three Aboriginal peoples groups have higher prevalence and incidence of COPD compared to a non-Aboriginal cohort. The condition affects the three Aboriginal groups differently; Registered First Nations and Inuit have the highest burden of COPD. Reasons for these differences should be further explored within a framework of social determinants of health to help designing interventions that effectively influence modifiable COPD risk factors in each of the Aboriginal groups.

Hockey-related emergency department visits after a change in minor hockey age groups.

OBJECTIVE: To examine ice hockey injury rates presenting to emergency departments (EDs) in 2 separate cohorts of players before and after a policy change for age groups in minor hockey. DESIGN: : Retrospective cross-sectional study. SETTING: Retrospective review of ice hockey injuries presenting to 2 tertiary care and 5 community care EDs in Edmonton, Alberta. PATIENTS: Two cohorts of minor ice hockey players were constructed. The pre-age change cohort consisted of 4215 registered male hockey players. The post-age change cohort consisted of 3811 registered male hockey players. ASSESSMENT OF RISK FACTORS: The risk of fracture, head and neck injury (intracranial and nonintracranial), and all other injuries presenting to EDs were compared between the pre-age change and post-age change cohorts. MAIN OUTCOME MEASURES: Presentation to an ED with an injury occurring in ice hockey between September 1 and April 31 for the years 1997 through 2010. RESULTS: Overall, significantly lower injury rates were observed in the post-age change cohort for players in the Peewee division; however, no significant differences were observed for the rate of fractures, and intracranial or nonintracranial head and neck injuries. There were no statistically significant differences observed between the pre-age change and post-age change cohorts in the Atom or Bantam divisions. CONCLUSIONS: Introducing body checking 1 year earlier than in a previous cohort (11 vs 12 years of age) neither significantly decreased nor increased the rate of serious ice hockey injuries occurring 2 years after the introduction of body checking. Further research is recommended to evaluate the claim that introducing body checking lowers injury rates in older divisions of hockey.

A population-based study of sport and recreation-related head injuries treated in a Canadian health region.

OBJECTIVES: To report the rates of SR-related HIs presenting to EDs in a Canadian population-based sample. DESIGN: Descriptive epidemiology study. METHODS: Using administrative data, sport and recreation-related emergency department presentations for persons 0-35 years of age, from April 1997 through March 2008, were obtained from the Edmonton Zone (formerly the Capital Health Region), Alberta Health Services through the Ambulatory Care Classification System. RESULTS: Of the 3,230,890 visits to the emergency departments of the five hospitals in Edmonton, 63,219 sport and recreation-related injury records and 4935 sport and recreation-head injury records were identified. Head injuries were most frequently treated for the activities of hockey (20.7%), cycling (12.0%), and skiing/snowboarding/sledding. Males accounted for 71.9% (n=3546) and patients less than 18 years of age sustained 3446 (69.8%) sport and recreation-head injuries. CONCLUSIONS: Sport and recreation-related head injuries most frequently treated in emergency departments involve common activities such as hockey, cycling, skiing/snowboarding/sledding, and soccer. Males and those less than 18 years of age sustain the majority of sport and recreation-related head injuries treated in emergency departments. These findings underscore the importance of sport-specific policies and safety promotion for the prevention of head injuries, in sports and recreational activities.

Time-to-subsequent head injury from sports and recreation activities.

OBJECTIVE: To provide population-based risk estimates for sustaining subsequent head injuries (HIs), which occur in sports and recreation (SR). DESIGN: Population-based, retrospective, cross-sectional study. SETTING: Retrospective review of data from 2 tertiary care and 3 community care emergency departments (EDs) in Edmonton, Alberta, Canada. PATIENTS: Individuals younger than 36 years presenting to an ED with an SR-related injury between April 1, 1997, and March 31, 2008. There were 9246 subsequent ED records identified for 8958 patients in the main analysis. MAIN OUTCOME MEASURES: Clinically diagnosed HI occurring in SR activities after an index presentation, and the number of days between ED presentations for diagnosed SR-HIs. RESULTS: Individuals with 1 and 2 previous SR-related HIs were 2.62 [95% confidence interval (CI), 2.23-3.07] and 5.94 times, respectively, more likely (95% CI, 3.43-10.29) to sustain a subsequent HI than those without a previous HI. The median time-to first HI was 758 days from an initial injury and decreased to 613 days and 303 days for those at risk of second and third SR-related HIs (P < 0.0001). Individuals aged 7 to 13 years were 4.29 times more likely (95% CI, 2.65-6.92) to sustain an HI when presenting with a subsequent SR injury, compared with those aged 30 to 35 years. CONCLUSIONS: The odds of sustaining a subsequent HI substantially increase with each successive HI. Time between SR-related HIs shortens as the number of HIs increases. Initial HI may be a key marker to institute high-risk injury prevention measures directed at young persons who present to EDs.

Ribose sugars generate internal glycation cross-links in horse heart myoglobin.

Glycation of horse heart metmyoglobin with d-ribose 5-phosphate (R5P), d-2-deoxyribose 5-phosphate (dR5P), and d-ribose with inorganic phosphate at 37°C generates an altered protein (Myo-X) with increased SDS-PAGE mobility. The novel protein product has been observed only for reactions with the protein myoglobin and it is not evident with other common sugars reacted over a 1 week period. Myo-X is first observed at 1-2 days at 37°C along with a second form that is consistent in mass with that of myoglobin attached to several sugars. MALDI mass spectrometry and other techniques show no evidence of the cleavage of a peptide from the myoglobin chain. Apomyoglobin in reaction with R5P also exhibited this protein form suggesting its occurrence was not heme-related. While significant amounts of O(2)(-) and H(2)O(2) are generated during the R5P glycation reaction, they do not appear to play roles in the formation of the new form. The modification is likely due to an internal cross-link formed during a glycation reaction involving the N-terminus and an internal amine group; most likely the neighboring Lys133. The study shows the unique nature of these common pentose sugars in spontaneous glycation reactions with proteins.

The multiple Maillard reactions of ribose and deoxyribose sugars and sugar phosphates.

Ribose 5-phosphate (R5P) undergoes the Maillard reaction with amines at significantly higher rates than most other sugars and sugar phosphates. The presence of an intramolecular phosphate group, which catalyzes the early stages of the Maillard reaction, provides the opportunity for the R5P molecule to undergo novel reaction paths creating unique Maillard products. The initial set of reactions leading to an Amadori product (phosphorylated) and to an alpha-dicarbonyl phosphate compound follows a typical Maillard reaction sequence, but an observed phosphate hydrolysis accompanying the reaction adds to the complexity of the products formed. The reaction rate for the loss of R5P is partially dependent on the pK(a) of the amine but also is correlated to the protonation of an early intermediate of the reaction sequence. In the presence of oxygen, a carboxymethyl group conjugated to the amine is a major product of the reaction of R5P with N-acetyllysine while little of this product is generated in the absence of oxygen. Despite lacking a critical hydroxyl group necessary for the Maillard reaction, 2-deoxyribose 5-phosphate (dR5P) still generates an Amadori-like product (with a carbonyl on the C-3 carbon) and undergoes phosphate cleavage. Two highly UV-absorbing products of dR5P were amine derivatives of 5-methylene-2-pyrrolone and 2-formylpyrrole. The reaction of dR5P with certain amines generates a set of products that exhibit an interesting absorbance at 340nm and a high fluorescence.