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IMPORTANCE: Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear. OBJECTIVE: To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain–MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis. MAIN OUTCOMES AND MEASURES: In-hospital mortality and time-to-reperfusion metrics. RESULTS: This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06). CONCLUSIONS AND RELEVANCE: In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain–MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

Introduction: There is paucity of data on the outcomes of hospitalization for bicuspid aortic valve (BAV)-related aortopathies. Methods: We queried the NIS database (2012–2016) for hospitalizations for elective thoracic aortic repair or acute aortic syndrome (AAS) among those with BAV versus trileaflet aortic valve (TAV). Results: Our analysis yielded 38,010 hospitalizations for elective aortic repair, of whom 34.4% had BAV, as well as 81,875 hospitalizations for thoracic AAS, of whom 1.1% had BAV. Hospitalizations for BAV were younger and had fewer comorbidities compared with their TAV counterparts. The number of hospitalizations for BAV during the observational period was unchanged. After propensity matching, elective aortic repair for BAV was associated with lower mortality (0.5% versus 1.7%, odds ratio = 0.28; 95% CI 1.5–0.50, p< 0.001), use of mechanical circulatory support, acute stroke, and shorter length of hospital stay compared with TAV. After propensity matching, AAS among those with BAV had a greater incidence of bleeding events, blood transfusion, cardiac tamponade, ventricular arrhythmias, and a longer length of hospital stay compared with TAV. Among those with BAV, predictors of lower mortality if undergoing elective aortic repair included larger hospitals and teaching hospitals. Predictors of higher mortality in patients with AAS included heart failure, chronic kidney disease, and coronary artery disease. Conclusion: Data from a national database showed no change in the number of hospitalizations for BAV-related aortopathy, with relatively lower incidence of AAS. Compared with TAV, elective aortic repair for BAV is associated with lower mortality, while BAV-related AAS is associated with higher in-hospital complications.

Introduction: The outcomes of transfemoral (TF) compared with transapical (TA) access for transcatheter aortic valve replacement (TAVR) in diabetics are unknown. Methods: We queried the NIS database (2011–2014) to identify diabetics who underwent TAVR. We performed a propensity matching analysis comparing TF-TAVR versus TA-TAVR. Results: The analysis included 14.555 diabetics who underwent TAVR. After matching, in-hospital mortality was not different between TF-TAVR and TA-TAVR. (3.5 vs. 4.4%, p= 0.11). TF-TAVR was associated with lower rates of cardiogenic shock (2.7 vs. 4.7%, p= 0.02), use of mechanical circulatory support (2.0 vs. 2.9%, p= 0.03), acute renal failure (17.8 vs. 26.5%, p< 0.001), major bleeding (35.8 vs. 40.7%, p< 0.001) and respiratory complications (1.1 vs. 4.4%, p< 0.001) compared with TA-TAVR. However, TF-TAVR was associated with a higher rate of vascular complications (2.9 vs. 0.9%, p< 0.001), cardiac tamponade (0.5 vs. 0.0%, p< 0.001), complete heart block (10.8 vs. 7.7%, p< 0.001) and pacemaker insertion (11.8 vs. 8.3%, p< 0.001). There was no difference between both groups in acute stroke (1.8 vs. 2.2%, p= 0.39), hemodialysis (2.0 vs. 2.2%, p= 0.71), and ventricular arrhythmias (4.9 vs. 4.2%, p= 0.19). Notably, TF-TAVR was associated with higher mortality, acute stroke, AKI, hemodialysis, PCI, and respiratory complications in complicated diabetics compared with non-complicated diabetics. Conclusions: This observational analysis showed no difference in-hospital mortality between TF-TAVR and TA-TAVR among diabetic patients. Studies exploring the optimal access for TAVR among diabetics are recommended.

ABSTRACTBackground:There is a paucity of data regarding the comparative safety and effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with prior myocardial infarction (MI).Methods:We queried the NIS database (2012–2016) to identify patients with a prior history of MI who underwent isolated AVR. We conducted a propensity matching analysis comparing patients with TAVR versus SAVR based on patient demographics, comorbidities and hospital characteristics. The primary outcome was in-hospital mortality.Results:Among 24,090 hospitalizations with prior MI undergoing isolated AVR, 58.5% underwent TAVR. Over the study period, there was an increase in the proportion of patients undergoing TAVR and a decrease in patients undergoing SAVR (Ptrend<0.001). After propensity matching, in-hospital mortality was not different between TAVR and SAVR (odds ratio 1.07; 95% confidence interval 0.85–1.33). Compared with SAVR, TAVR was associated with lower rates of cardiac arrest, cardiogenic shock, acute kidney injury, respiratory complications, postoperative bleeding, blood transfusion, acute stroke, vascular complications and shorter length of stay. TAVR was associated with a higher incidence of complete heart block and pacemaker implantation.Conclusion:In this nationwide observational study, there has been a steady increase in the number of TAVRs performed in patients with prior MI. Compared with SAVR, TAVR was associated with similar in-hospital mortality and a lower rate of complications and length of stay.

Introduction: Little is known about ethnic and gender disparities for transcatheter aortic valve replacement (TAVR) procedures in the United States. Methods: We queried the Nationwide Inpatient Sample (NIS) database (2011–2014) to identify patients who underwent TAVR. We described the temporal trends in the uptake of TAVR procedures among various ethnicities and genders. Results: Our analysis identified 39,253 records; 20,497 (52.2%) were men and 18,756 (47.8%) were women. Among all TAVRs, 87.2% were Caucasians, 3.9% were African Americans (AA), 3.7% were Hispanics, and 5.2% were of other ethnicities. We found a significant rise in the trend of TAVRs in all groups: in Caucasian men (coefficient?=?0.946, p?&lt;?0.001), Caucasian women (coefficient?=?0.985, p?&lt;?0.001), AA men (coefficient?=?0.940, p?&lt;?0.001), AA women (coefficient?=?0.864, p?&lt;?0.001), Hispanic men (coefficient?=?0.812, p?=?0.001), Hispanic women (coefficient?=?0.845, p?&lt;?0.001). Hence, the uptrend was most significant among Caucasian women, and relatively least significant among Hispanic men. Multivariate regression analysis was conducted to evaluate in-hospital mortality among different groups after adjusting for demographics and baseline characteristics. After multivariable regression for baseline characteristics overall, the in-hospital mortality per 100 TAVRs was highest among Hispanic men 5.5%, followed by Caucasian women 5.0%, Hispanic women 4.6%, AA women 3.7%, AA men 3.4%, and Caucasian men 3.38% (adjusted pvalue?=?0.004). Conclusions: In this observational study, we demonstrated that there is evidence of ethnic and gender differences in the overall uptake and adjusted mortality of TAVRs in the United States.

AbstractBackground:The role of percutaneous patent foramen ovale (PFO) closure for prevention of migraine is controversial.Methods:We performed a computerised search of MEDLINE, EMBASE and COCHRANE databases through December 2017 for randomised trials evaluating PFO closure versus control in patients with migraine headaches (with or without aura). The main study outcome was the reduction in monthly migraine attacks after PFO closure compared with the control group.Results:The final analysis included three randomised trials with a total of 484 patients. Reduction in monthly migraine attacks was higher in PFO closure compared with the control group (standardised mean difference-SMD = 0.25; 95% CI: 0.06–0.43; p = .01). There was higher reduction of monthly migraine days in PFO closure group compared with control group (SMD = 0.30; 95% CI: 0.08–0.53; p = .01). There was no statistically significant difference in complete resolution of migraine attacks (OR: 3.67; 95% CI: 0.66–20.41; p = .14) and in responders’ rate (OR: 1.92; 95% CI: 0.76–4.85; p = .17) between PFO closure and control groups. In patients whose majority of migraine attacks are with aura, there was an observed reduction in migraine attacks in PFO closure compared with control groups (SMD = 0.86; 95% CI: 0.07–1.65; p = .03).Conclusion:PFO closure might be beneficial in migraine patients by reducing migraine attacks and migraine days, especially in patients whose majority of migraine attacks are with aura. However, those benefits were not associated with an improvement in responders’ rate or complete resolution of migraine; raising concerns on the magnitude of clinical benefit of PFO closure in migraine prevention.

Introduction: The impact of therapeutic hypothermia (TH) on outcomes of percutaneous coronary intervention (PCI) and the optimal antiplatelet treatment remains debatable. Methods: Electronic databases were searched for randomized trials and observational studies to evaluate the available clinical evidence comparing the use of clopidogrel versus newer P2Y12 antagonists in cases of TH after PCI. The primary outcome was in-hospital definite stent thrombosis while the secondary outcomes were in-hospital mortality and major bleeding. Fixed-effects risk ratios (RRs) were estimated using Mantel–Haenszel method. Results: The final analysis included five studies with a total of 290 patients. There was no difference in the incidence of stent thrombosis (RR 0.92; 95% CI 0.35–2.38), in-hospital mortality (RR 1.38; 95% CI 0.72–2.65), and major bleeding (RR 0.89; 95% CI 0.33–2.40) between patients receiving clopidogrel versus those receiving newer agents. Conclusions: This meta-analysis showed no difference between clopidogrel and newer antiplatelet agents in the incidence of stent thrombosis or in-hospital mortality for PCI in cases of TH. Further randomized studies are needed to explore the optimal dual antiplatelet treatment in TH.

Background: The effect of Tridax procumbensaqueous ethanolic extract on the rat corpus cavernosum smooth muscles was evaluated in the present study.

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The electrochemical performance of the Li/O2 battery under different operation conditions was studied to elucidate the effects of discharge rate, discharge depth and charge taper voltage on the performance and state of charge of the battery. Galvanostatic discharge profiles at various discharge rates showed that the effective capacity of the cell drops with increase in the discharge rate. However the cell's cycleability improved with increase in the discharge rate probably due to the ease of stripping the Li2O2 film formed on the electrode surface reversibly at higher rates, compared with the incomplete removal of discharge products formed within the pores at low discharge rates. The performance of the cell discharged at different cut off voltages showed that decreasing the depth of discharge decreases the rate of capacity fade and improves the cell cycleability. Study of the cell performance at different charge taper voltages showed that the cell capacity increases with charge taper voltage for charge potentials up to 4.45 V. For charge potentials above 4.45 V, the cell performance deteriorates with increasing charge taper voltage significantly, probably due to the decomposition of the electrolyte at higher charge potentials. It is believed that a potential of 4.45 V is the edge of breakdown potential of propylene carbonate based electrolytes.

Here we demonstrate the use of polymer derived activated carbons as the potential electrode material for Li/O2 batteries. The activated carbons were synthesized by sol-gel polycondensation of low cost phenol and formaldehyde followed by carbonization at 1050degC in an inert atmosphere and activation under CO2 to different degrees of burn off. Galvanostatic charge/discharge measurements performed on the activated carbon based electrodes show that discharge capacity increases with mesopore volume, with the highest discharge capacity of 1852 mAh/g obtained for the carbon having the highest mesopore volume of 1.8717 cm3/g. Galvanostatic rate capability tests show that discharge capacity of the cell decreases with increasing discharge rates significantly.

This cross-sectional, community-based study was carried out among commercial motorcyclists in Igboora. All the commercial motor parks in Igboora were visited and all the commercial motorcyclists who consented to participate in the study were interviewed. Information on the respondents' socio-demographic characteristics, and the practice of road safety measures was collected using an interviewer administered questionnaire. A total of 299 motorcyclists were interviewed. All (100%) of them were males. The mean age of the respondents was 27.4 ± 7.4 years. One hundred eighty-two (60.7%) of the motorcyclists had the correct knowledge of the purpose of Highway Code. Only 70 (23.3%) could recognize more than half of the currently used road safety codes and 47 (15.7%) obey these road safety codes more than half of the time they see it. Only 183 (61.2%) of them had a driving license and 72 (24.1%) were able to produce these licenses on demand. All (100%) of the respondents did not use any protective helmet. Those who have longer years of working experience, higher level of education and higher knowledge of the safety codes practice it more regularly (r= 0.198, p= 0.001, χ2= 9.31, p= 0.025, and r= 0.28, p= 0.001 respectively). One hundred thirty-six (45.5%) have been involved in at least one accident in the preceding year. The overall incidence of road traffic accident was 2.16 per 1,000. There was however on statistically significant association between the practice of road safety codes and the occurrence of road traffic accidents (χ2= 0.176, p= 0.916). The study shows that the practice of road safety measures was low in this rural Nigerian community and was not associated with the incidence of road traffic accidents. Introducing road safety education particularly targeted at educating the motorcyclists on the importance and practice of road safety measures would lead to an increase in the practice of the safety measures and hopefully a reduction in the incidence of road traffic accidents.

The objective of this study was to examine the complications associated with the orthopedic management of bladder exstrophy. The records of all patients seen for bladder exstrophy repair at the authors' institution between 1988 and 2002 were examined. Orthopedic complications were found to have occurred in 26 of 624 patients, yielding a complication rate of 4. The observed complications were divided into five categories bony complications at the osteotomy site, neurologic complications at the osteotomy site, complications of traction, deep infection, and late infections of the plate. Five of the 26 (19.2) complications were bony and involved non-union, delayed union, joint pain, or leg length inequality stemming from the osteotomy. Thirteen of the 26 (50) were neurologic complications. Four of the 26 (15.4) resulted from traction. All were due to tight dressing around the legs following surgery. Two of the 26 (7.7) were early deep infection and of the 26 (7.7) were late infections. This study highlights many of the complications associated with the management of exstrophy and provides suggestions on how to minimize them.

P-glycoprotein (PGP), the product of the multidrug resistance gene (MDR1), acts as an energy-dependent efflux pump that exports its substrates out of the cell. PGP expression is an important factor regulating absorption of a wide variety of medications. It has also been associated with intrinsic and acquired cross resistance to a number of structurally unrelated anticancer drugs. A single nucleotide polymorphism (SNP) in exon 26 of the MDR1gene, C3435T, was recently correlated with PGP protein levels and substrate uptake. Individuals homozygous for the T allele have more than four-fold lower PGP expression compared with CC individuals. As overexpression of PGP has been associated with altered drug absorption, therapy-resistant malignancies, and lower concentrations of HIV-1 protease inhibitors, this SNP may provide a useful approach to individualize therapy. To facilitate clinical application throughout the world, 1280 subjects from 10 different ethnic groups were evaluated for this SNP using the polymerase chain reaction-restriction fragment length polymorphism assay and the genotype and allele frequency for each group were ascertained. Marked differences in genotype and allele frequency were apparent between the African populations and the Caucasian/Asian populations (P< 0.0001). The Ghanaian, Kenyan, African American and Sudanese populations studied had frequencies of 83, 83, 84 and 73, respectively, for the C allele. The British Caucasian, Portuguese, South-west Asian, Chinese, Filipino and Saudi populations had lower frequencies of the C allele compared to the African group (48, 43, 34, 53, 59, and 55, respectively). The high frequency of the C allele in the African group implies overexpression of PGP and may have important therapeutic and prognostic implications for use of PGP dependent drugs in individuals of African origin.

Esophageal perforation complicating anterior cervical spine surgery is a potentially fatal complication. Early identification and immediate treatment may lower adverse effects for the patient. The purpose of this study is to assess the efficacy of intraesophageal dye injection to detect an esophageal injury and to test two novel techniques.

Introduction:There is paucity of data on the role of platelets in the pathophysiology of abdominal aortic aneurysm (AAA), yet most AAA are coincident with luminal thrombus.Hypothesis:Platelets and thrombus in aortic aneurysmal segments may have a role in AAA.Methods:We examined the association between platelet activation and the pathophysiology of AAA. We isolated protein from the aortic wall and platelets from patients with infrarenal AAA which were separated by SDS-PAGE and quantified by immunoblotting. We assessed matrix metalloproteinase (MMP) activity by in-gel zymography. Protein extracts from fresh cadaveric aorta served as a control. Platelet activation from patients with AAA taking aspirin (n=16) was compared to control subjects (not on any medications) (n=11) by flow cytometry (surface p-selectin). Platelet activation was assessed before and after stimulation with a thromboxane receptor agonist, a protease activated receptor-1 (PAR1) agonist , or a P2Y12agonist. We queried the National Inpatient Sample (NIS) database (2009-2016) for hospitalizations with AAA. Multivariable regression analysis was conducted to evaluate the association of chronic anti-platelets use with AAA prevalence, AAA dissection, and AAA rupture, after adjusting for 27 clinical and hospital variables.Results:MMP9 content and MMP9 activity are significantly increased in aorta and platelets from patients with AAA compared with controls. Tissue Inhibitor of MMP9 content was markedly decreased in platelets with high MMP activity. Platelet reactivity is paradoxically enhanced in patients with AAA taking aspirin compared with controls. Our analysis of the NIS demonstrated that the use of antiplatelet drugs was associated with lower rates of AAA (OR= 0.70; 95%CI:0.68-0.72, p<0.001), AAA dissection (OR= 0.53; 95%CI:0.50-0.57, p<0.001) and AAA rupture (OR= 0.67; 95%CI:0.54-0.82, p<0.001).Conclusions:AAA appears to promote platelet activation and enhanced platelet activation might play a role in pathophysiology of AAA in a feed-forward loop. Further studies are warranted to explore the nature of bidirectional communication between the aorta and platelet function in the etiology of AAA.

No relevant conflicts of interest to declare.

Introduction: In the general population, von Willebrand factor (VWF) and factor VIII (FVIII) levels are known to increase with age. However, in patients with bleeding disorders such as von Willebrand's disease (VWD), the effect of ageing is unclear. With a growing population of elderly patients with bleeding disorders, it is important to understand these changes and their effects on hemostasis, which may preclude the need for hemostatic therapy. The results of two prior studies conducted in the Netherlandsand Canada suggest that VWF levels increase with age in patients with VWD. Our study looks at the trends of VWF with age and the extent of normalization of levels in patients with Type 1VWD. It is the first to be conducted in a United States (U.S.) population, and the largest of its kind to date.

The electrochemical performance of the Li/O2battery under different operation conditions was studied to elucidate the effects of discharge rate, discharge depth and charge taper voltage on the performance and state of charge of the battery. Galvanostatic discharge profiles at various discharge rates showed that the effective capacity of the cell drops with increase in the discharge rate. However the cell's cycleability improved with increase in the discharge rate probably due to the ease of stripping the Li2O2film formed on the electrode surface reversibly at higher rates, compared with the incomplete removal of discharge products formed within the pores at low discharge rates. The performance of the cell discharged at different cut off voltages showed that decreasing the depth of discharge decreases the rate of capacity fade and improves the cell cycleability. Study of the cell performance at different charge taper voltages showed that the cell capacity increases with charge taper voltage for charge potentials up to 4.45 V. For charge potentials above 4.45 V, the cell performance deteriorates with increasing charge taper voltage significantly, probably due to the decomposition of the electrolyte at higher charge potentials. It is believed that a potential of 4.45 V is the edge of breakdown potential of propylene carbonate based electrolytes.

Here we demonstrate the use of polymer derived activated carbons as the potential electrode material for Li/O2batteries. The activated carbons were synthesized by sol-gel polycondensation of low cost phenol and formaldehyde followed by carbonization at 1050°C in an inert atmosphere and activation under CO2to different degrees of burn off. Galvanostatic charge/discharge measurements performed on the activated carbon based electrodes show that discharge capacity increases with mesopore volume, with the highest discharge capacity of 1852 mAh/g obtained for the carbon having the highest mesopore volume of 1.8717 cm3/g. Galvanostatic rate capability tests show that discharge capacity of the cell decreases with increasing discharge rates significantly.