Search

Patients with submassive pulmonary embolism (PE) are vulnerable to sudden deterioration, recurrent PE, and progression to pulmonary hypertension and chronic right ventricular (RV) dysfunction. Previous studies have suggested a clinical benefit of using ultrasound-assisted catheter-directed thrombolysis (USCDT) to invasively manage patients with submassive PE. However, there is sparse data comparing the clinical outcomes of these patients when treated with USCDT versus anticoagulation (AC) alone. We sought to compare the outcomes of USCDT versus AC alone in the management of submassive PE.192 consecutive patients who underwent USCDT for submassive PE between January 2013 and February 2019 were identified. ICD9/ICD10 codes were used to detect 2554 patients diagnosed with PE who did not undergo thrombolysis. Propensity matching identified 192 patients with acute PE treated with AC alone. Clinical outcomes were compared between the two groups. Baseline demographics, laboratory values, and pulmonary embolism severity index scores were similar between the two cohorts.There was a significant reduction in mean systolic pulmonary artery pressure (sPAP) in the USCDT group compared to the AC group (∆11 vs ∆3.9 mmHg, p 0.001). There was significant improvement in proportion of RV dysfunction in all patients, but the difference was larger in the USCDT group (∆43.3% vs ∆17.3%, p 0.001). Patients who underwent USCDT had lower 30-day (4.3% vs 10.5%, p = 0.03), 90-day (5.5% vs 12.4%, p = 0.03), and 1-year mortality (6.2% vs 14.2%, p = 0.03).In patients with acute submassive PE, USCDT was associated with improved 30-day, 90-day, and 1 year mortality as compared to AC alone. USCDT also improved RV function and reduced sPAP to a greater degree than AC alone. Further studies are needed to verify these results in both short- and long-term outcomes.

Purpose The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. Summary Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. Conclusion Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Pulmonary arterial hypertension has evolved from a fatal disease with few treatment options to a chronic condition with improved survival. This improvement is possible through development of effective therapies as well as the expansion of risk stratification scores to assist clinical decision making. Despite improved disease control, quality of life, and overall prognosis, many challenges remain. The treatment itself is burdensome, with significant impact on quality of life. Many patients with pulmonary arterial hypertension still present with advanced, often end-stage disease. Increased use of mechanical circulatory support and catheter-based interventions have expanded use of extracorporeal life support and right ventricle assist devices. For these reasons as well as the long-term relationships pulmonary hypertension physicians have with patients and their families, navigating the course of the illness in a considered, proactive way is essential. Understanding individual goals and revisiting them as they change over time requires comfort with the conversation itself. There are many barriers and challenges to having effective, compassionate conversations in the clinical setting with time constraints being the most often cited. Compressed visits are necessarily focused on the clinical aspects, therapy and medication adherence and tolerance. Clinicians are sometimes wary of diminishing hope in the face of ongoing treatment. Having sufficient experience and comfort with these discussions can be empowering. In this paper, we discuss the challenges involved and propose a framework to assist in incorporating these discussions into clinical care.

Introduction Previous studies have shown that sleep disordered breathing (SDB) is common in patients with Interstitial Lung Disease (ILD), and oximetry is often used for screening prior to further diagnostic testing. Current guidelines recommend polysomnography (PSG) for diagnosis of SDB in patients with significant pulmonary disease, however, home sleep apnea tests (HSAT) are increasingly used in clinical practice for a variety of reasons despite lack of evidence regarding accuracy in this population. In this study, we evaluate the correlation between screening oximetry, a commercial brand HSAT (WatchPAT®) and PSG to examine the diagnostic accuracy of this HSAT technology in patients with ILD. Methods The institution electronic medical record was screened for patients with a diagnosis code for ILD who underwent screening oximetry followed by PSG or HSAT using peripheral arterial tonometry from July 1, 2012 to present. Clinical review confirmed presence of ILD according to American Thoracic Society guidelines. Among the respective cohorts, Paired Wilcoxon Test was used to compare the oximetry 4% oxygen desaturation index (ODI) to the HSAT ODI and PSG apnea-hypopnea index (AHI) as well as percent time spent below oxyhemoglobin saturation of 89%. Spearman correlation was used to correlate the oximetry ODI and parameters of SDB on HSAT and PSG. Results Data was analyzed for 25 patients who had undergone oximetry/HSAT and for 25 patients who had undergone oximetry/PSG. Oximetry ODI showed no significant difference from PSG AHI (p = 0.2635) or between HSAT ODI (p = 0.0755), and no difference was seen in hypoxic time between oximetry and PSG (p = 0.9789). Hypoxic time on HSAT was significantly longer than that on oximetry (p < 0.001). Using HSAT ODI as the standard, HSAT AHI and respiratory disturbance index (RDI) showed rs of 0.9638 and 0.8913 respectively, while oximetry ODI was 0.3893. Compared to PSG AHI, the PSG RDI and oximetry ODI rs were 0.9759 and 0.7407 respectively. Conclusion Among patients with ILD, screening oximetry appears to correlate more strongly with indices of SDB and hypoxic time on PSG rather than HSAT. Further studies are warranted to evaluate efficacy of additional HSAT testing modalities in this patient population. Support (If Any)

Objectives: Outcomes following isolated hip arthroscopy for patients with dysplasia have been unfavorable, results have included iatrogenic instability and conversion to total hip arthroplasty (THA) at a young age. However, patients with borderline dysplasia have portended more favorable results at short and medium term follow-up. The purpose of this study was to assess long term outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplasia (BD) patients (LCEA, 18°-25°) compared to a control cohort of nondysplastic patients (LCEA, 25°-40°). Methods: Between March 2009 and July 2012, a BD group of 33 patients (38 hips) was identified. An age- and sex-matched control group of 83 patients (96 hips) was also identified. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected preoperatively and subsequently at an average of 9.6 years post-operatively. Results: The mean LCEA and Tönnis angle was 22.4° ± 2.02° and 6.2° ± 3.23° in the BD group and 31.7° ± 3.52° and 2.42° ± 3.02° in the control group, respectively ( P Conclusions: Durable outcomes (>9 years) with low revision rates can be expected after isolated hip arthroscopy that includes cam resection, labral refixation and capsular closure in BD patients with equivalent outcomes to a nondysplastic cohort.

We propose and implement a procedure to dynamically hedge climate change risk. We extract innovations from climate news series that we construct through textual analysis of newspapers. We then use a mimicking portfolio approach to build climate change hedge portfolios. We discipline the exercise by using third-party ESG scores of firms to model their climate risk exposures. We show that this approach yields parsimonious and industry-balanced portfolios that perform well in hedging innovations in climate news both in sample and out of sample. We discuss multiple directions for future research on financial approaches to managing climate risk.

We perform a comparative analysis of machine learning methods for the canonical problem of empirical asset pricing: measuring asset risk premiums. We demonstrate large economic gains to investors using machine learning forecasts, in some cases doubling the performance of leading regression-based strategies from the literature. We identify the best-performing methods (trees and neural networks) and trace their predictive gains to allowing nonlinear predictor interactions missed by other methods. All methods agree on the same set of dominant predictive signals, a set that includes variations on momentum, liquidity, and volatility. Authors have furnished an Internet Appendix, which is available on the Oxford University Press Web site next to the link to the final published paper online.

We propose a new measure of time-varying tail risk that is directly estimable from the cross-section of returns. We exploit firm-level price crashes every month to identify common fluctuations in tail risk among individual stocks. Our tail measure is significantly correlated with tail risk measures extracted from S&P 500 index options and negatively predicts real economic activity. We show that tail risk has strong predictive power for aggregate market returns. Cross-sectionally, stocks with high loadings on past tail risk earn an annual three-factor alpha 5.4% higher than stocks with low tail risk loadings. We explore potential mechanisms giving rise to these asset pricing facts.

On July 20, 2004, the Securities and Exchange Commission (SEC) published for comment proposed rules under the Investment Advisers Act of 1940 (the Act), which would require many non‐U.S. hedge fund advisers to be registered with the SEC. The proposed rules would require non‐U.S. investment advisers to look through their hedge funds (U.S. and non‐U.S. funds) to count all U.S. investors therein as clients for purposes of the Section 203(b)(3) “private adviser” exemption. The SEC stated in the proposing release that it did not intend the proposed rules to change current policy of substantially limiting the extraterritorial application of the Act to dealings between a registered non‐U.S. investment adviser and its non‐U.S. clients. However, there remains some ambiguity as to the application of this policy, which has been developed over the past 12 years through a series of no‐action letters. In addition, notwithstanding the SEC’s statement in the proposing release, the proposed rules could be read as changing current SEC policy in a couple of respects. This article explains those issues.

We show that firms' idiosyncratic volatility in returns and cash flows obeys a strong factor structure. We find that the stocks of firms with large, negative common idiosyncratic volatility (CIV) factor betas earn high average returns. The CIV beta quintile spread is 6.4% per year. To explain this spread, we develop a heterogeneous investor model with incomplete markets in which the idiosyncratic volatility of investor consumption growth inherits the factor structure of firm cash flow growth. In our model, the CIV factor is a priced state variable, because an increase in volatility represents a worsening of the investment opportunity set for the average investor. The calibrated model is able to match the high degree of comovement in idiosyncratic volatilities, the CIV beta spread, along with a host of asset price moments.

We propose a network model of firm volatility in which the customers' growth rate shocks influence the growth rates of their suppliers, larger suppliers have more customers, and the strength of a customer-supplier link depends on the size of the customer firm. Even though all shocks are i.i.d., the network model produces firm-level volatility and size distribution dynamics that are consistent with the data. In the cross section, larger firms and firms with less concentrated customer networks display lower volatility. Over time, the volatilities of all firms co-move strongly, and their common factor is concentration of the economy-wide firm size distribution. Network effects are essential to explaining the joint evolution of the empirical firm size and firm volatility distributions.

We empirically analyze the pricing of political uncertainty, guided by a theo- retical model of government policy choice. After deriving the model’s predictions for option prices, we test those predictions in an international sample of national elections and global summits. We find that political uncertainty is priced in the option market in ways predicted by the theory. Options whose lives span political events tend to be more expensive. Such options provide valuable protection against the risk associated with political events, including not only price risk but also variance and tail risks. This protection is more valuable in a weaker economy as well as amid higher political uncertainty.Â

Firm volatilities comove strongly over time, and their common factor is the dispersion of the economy-wide firm size distribution. In the cross section, smaller firms and firms with a more concentr...

The research published in the Journal of Applied Behavior Analysis (1968 to 1975) was surveyed for three basic elements: data-collection methods, reliability procedures, and reliability scores. Three-quarters of the studies reported observational data. Most of these studies' observational methods were variations of event recording, trial scoring, interval recording, or time-sample recording. Almost all studies reported assessment of observer reliability, usually total or point-by-point percentage agreement scores. About half the agreement scores were consistently above 90%. Less than one-quarter of the studies reported that reliability was assessed at least once per condition.

Three publication sources were reviewed to determine the recent conventions for collecting, and assessing the reliability of, academic permanent-product data (handwriting, examination papers, etc in applied behavior analysis. The primary source was the Journal of Applied Behavior Analysis (1968–1974). Secondary sources included conference proceedings titled, A new direction in education: behavior analysis (E. Ramp and B. L. Hopkins, Eds., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1971), and Behavior Analysis and Education (G. Semb, Ed., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1972). Finally, as a test of the generality of the findings in the two applied behavior analysis sources, the current issue of each of 14 psychological and/or educational journals was reviewed. Thirty JABA studies reported academic permanent-product data, but only 14 reported reliability. Increasingly more product data through 1973 have been reported along with a greater proportion of authors reporting reliability. The review of the two conference proceeding publications revealed the same trend. In 1971, only three studies reported academic product data, none with reliability, while in 1972, 15 reported academic data, nine including reliability assessment. The review of 14 current education/psychology journal issues revealed four studies reporting academic data, none with reliability. Across all sources, about one-half of the studies reported reliability. Most of the studies reporting reliability described the frequency of reliability assessment, with approximately equal numbers of JABA studies reporting reliability for each paper or reliability for each session. The use of uninformed observers was reported in only three JABA studies and one conference study. Marks made on subjects' papers by either the teacher or the primary observer were reported masked for reliability purposes by only two JABA and two conference studies. Reliability was calculated on a session total basis in two JABA studies. Point-by-point agreement was given in nine JABA and three conference studies. Perfect reliability (mean agreement of 100%) was reported in only six JABA and three conference studies. Scores between 90 and 100% were reported in nine JABA and four conference studies. Scores below 80% were reported in three JABA studies. No other percentage agreement scores were reported, although one JABA study reported correlational reliability (Pearson r). In summary, recently more studies have dealt with academic data and, until 1974, a greater proportion of these studies reported reliability assessment, and relatively few studies reported either replicable methods, 100% agreement, or controls for maintaining rater independence.