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Current guidelines recommend targeting an international normalized ratio (INR) of 2.5 to 3.5 for patients with mechanical aortic valve replacement (AVR) and additional risk factors for thromboembolic events. Available literature supporting the higher intensity (INR) goal is lacking. We aimed to evaluate the association of standard and higher intensity anticoagulation on outcomes in this patient population. The Michigan Anticoagulation Quality Improvement Initiative database was used to identify patients with mechanical AVR and at least one additional risk factor. Patients were classified into 2 groups based on INR goal: standard-intensity (INR goal 2.5) or higher-intensity (INR goal 3.0). Cox-proportional hazard model was used to calculate adjusted hazard ratios. One hundred and forty-six patients were identified of whom 110 (75.3%) received standard-intensity anticoagulation and 36 (24.7%) received higher intensity anticoagulation. Standard-intensity patients were older and more likely to be on aspirin. Atrial fibrillation was the most common additional risk factor for inclusion. The primary outcome of thromboembolic events, bleeding, or all-cause death was 13.9 and 19.5/100-person-years in the standard-intensity and higher intensity groups, respectively (adjusted HR 2.58, 95% confidence interval 1.28 to 5.18). Higher-intensity anticoagulation was significantly associated with any bleeding (adjusted HR 2.52, 95% confidence interval 1.27 to 5.00) and there were few thromboembolic events across both groups (5 events total). These results challenge current guideline recommendations for anticoagulation management of mechanical AVR in patients with additional risk factors.

Introduction The direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are increasingly utilized for the management of venous thromboembolic disease (VTE) and/or non-valvular atrial fibrillation (NVAF). Adding aspirin (ASA) to warfarin or DOAC therapy increases bleeding risk. Patients on combination therapy with ASA and an anticoagulant were not well represented in clinical trials comparing DOACs to warfarin. We sought to compare bleeding and thrombotic outcomes with DOACs and ASA compared to warfarin and ASA in a non-trial setting. Methods We conducted a retrospective registry-based cohort study of adults on DOAC or warfarin therapy for VTE and/or NVAF. Warfarin treated patients were followed by six anticoagulation clinics. Four out of the six clinics contributed data on their patients that were on DOACs in the Michigan Anticoagulation Quality Improvement Initiative (MAQI 2) from January 2009 to June 2021. Patients were excluded if they had a history of heart valve replacement, recent myocardial infarction, or less than 3 months of follow-up. Two propensity matched cohorts (warfarin+ASA vs DOAC+ASA) of patients were analyzed based on ASA use at the time of study enrollment. The primary outcome was any new bleeding event. Secondary outcomes included new episodes of arterial or venous thrombosis, bleeding event type (major, fatal, life threatening, central nervous system, and non-major bleeding), emergency room visits, hospitalizations, transfusions, and death. Random chart audits were done to confirm the accuracy of the abstracted data. Event rates were compared using Poisson regression. Results We identified a total of 1,139 patients on DOACs plus ASA and 4,422 patients on warfarin plus ASA. After propensity matching, we compared two groups of 1,114 matched patients. DOAC treated patients were predominately on apixaban (62.3%) and rivaroxaban (30.4%), most often at therapeutic doses (Table 1). Patients were largely (90.5%) on low dose ASA (≤ 100 mg). Patient demographics, co-morbidities, indication for anticoagulation, history of bleeding or clotting, medications, and duration of follow-up were well-balanced after matching. Patients were followed for a median of 11.7 months (interquartile range 4.4 and 34 months). Patients treated with DOAC+ASA had 2.4 thrombotic events per 100 patient years compared to 2.2 thrombotic events per 100 patient years with warfarin+ASA (P=0.78). There were no significant differences observed between groups by thrombotic subtype (stroke, transient ischemic attack, pulmonary embolism, deep vein thrombosis, table 1). Bleeding was also similar with 30.1 bleeding events per 100 patient years with DOAC+ASA compared to 27.8 bleeds per 100 patient years with warfarin+ASA (P=0.24). There were no significant differences by bleeding subtype (table 1). Hospitalizations for clotting occurred less frequently with DOAC+ASA (0.9 hospitalizations per 100 patient years) compared to warfarin+ASA (1.7 hospitalizations per 100 patient years, P=0.03). Mortality, transfusions, and healthcare utilization were otherwise similar between the two groups. Conclusions For patients on a DOAC versus warfarin with ASA for atrial fibrillation and/or venous thromboembolic disease without a recent myocardial infarction or heart valve replacement, bleeding and thrombotic outcomes were similar. Figure 1 Figure 1. Disclosures Kaatz: Gilead: Consultancy; CSL Behring: Consultancy; Novartis: Consultancy; Bristol Myer Squibb: Consultancy, Research Funding; Pfizer: Consultancy; Alexion: Consultancy; Janssen: Consultancy, Research Funding; Osmosis Research: Research Funding. Kline-Rogers: Janssen: Consultancy; American College of Physicians: Consultancy. Sood: Bayer: Consultancy. Froehlich: Merck: Consultancy; Janssen: Consultancy; Novartis: Consultancy; Boehringer-Ingelheim: Consultancy; Pfizer: Consultancy; Blue Cross Blue Shield of Michigan: Research Funding; Fibromuscular Disease Society of America: Research Funding. Barnes: National Certification Board of Anticoagulation Providers: Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy; Acelis: Consultancy; AMAG Pharmaceuticals: Consultancy; Connected Health: Consultancy; Blue Cross Blue Shield of Michigan: Research Funding; AC Forum: Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy; Bristol-Myers Squibb: Consultancy.

The small punch test, also known as miniature disk bend test, is a relatively new method for the creep test of specimens of small dimensions. Experiments have shown that the small punch test can be used to describe the time to failure by means of an equation of the Dorn type, in which stress is replaced by load. The activation energies calculated using such a modified equation are somewhat smaller than the activation energies calculated from the results obtained using conventional creep testing methods. However, the constant value of the activation energy and the almost constant value of the load exponent in the modified Dorn equation confirm the hypothesis about the almost iso-stress nature of the small punch creep test. A finite element analysis of the small punch test has been carried out taking into account the constitutive theta -projection concept of the law of creep of the experimental steel 14 MoV 6 3, obtained from conventional, constant load creep test data. The viscosity parameters were evaluat...

s S307 (p= 6.22e-06 for interaction) and may play a role in disease progression and impaired myocardial energetics. Conclusion: A bioinformatic analysis may identify previously unreported miRs potentially involved in HF development. This is a novel approach using public access data for identify potential biomarkers of subjects with high risk for HF development or progression. FONDAP 15130011 ACCDIS.

We present and use a new rough-surface thermal model to aid in the analysis of new mid-infrared spectral measurements of Mercury from 5–12.5 μm. The model calculates spatially resolved thermal emission from slowly rotating, airless bodies. The Mercury data contain the first spectral measurements of Mercury between 5–7.5 μm, a region not accessible from ground-based telescopes, and are also the first observations of Mercury to be made while flying on the Kuiper Airborne Observatory (KAO). They were obtained with the High- efficiency Infrared Faint Object Grating Spectrometer (HIFOGS). Our rough surface thermal model which best fit the KAO data has a Hapke θ of 20°. A strong 5-μm emission feature was present during both observing periods. We suggest the 5-μm excess may be a result of near surface thermal gradients in regolith materials with a 30 to 100-μm grainsize, but cannot entirely rule out an observational artifact resulting from our instrumentation or the telescope on the KAO. Other features in the spectra are consistent with a feldspathic and feldspathoidal surface composition.

High-resolution spectroscopic measurements of Mercury were made at 4227 A to search for neutral calcium in the atmosphere An upper limit to the intensity is 9.0 kR; the corresponding Ca column abundance is 8 atoms cm -2 with a Ca/Na ratio of

The composition and chemistry of Mercury's regolith has beets calculated from MESSENGER MASCS 0 3-1 3 mu m spectra from the first flyby, using an implementation of Hapke's radiative transfer-based photometric model for light scattering in semi-transparent porous media, and a linear spectral mixing algorithm We combine this investigation with linear spectral fitting results from mid-infrared spectra and compare derived oxide abundances with mercurian formation models and lunar samples Hapke modeling results indicate a regolith that is optically dominated by finely comminuted particles with average area weighted grain size near 20 pin Mercury shows lunar-style space weathering, with maturation-produced microphase iron present at similar to 0 065 wt% abundance, with only small variations between mature and immature sites, the amount of which is unable to explain Mercury's low brightness relative to the Moon The average modal mineralogies for the flyby 1 spectra derived from Hapke modeling are 35-70% Na-rich plagioclase or orthoclase, up to 30% Mg-rich clinopyroxene

Groundbased observations of midinfrared (7.5- to 11.4-μm) spectral radiance from five locations on the Moon are reported. We have obtained medium resolution spectra from three locations in Copernicus crater and two locations in mare basalt. Two locations in the crater walls of Copernicus show similar spectra which in turn differ from spectra from the eastermost central peak. Mineralogic interpretation of the features in the central peak spectra is consistent with the composition of the locations as determined by near-infrared reflectance (0.67- to 2.5-μm) spectroscopy. In addition to emission minima, which we attribute to olivine, there are unidentified features in the spectra which may provide additional compositional information. An emissivity maximum at shorter wavelengths than the reststrahlen bands is identified as the Christiansen feature in the Copernicus spectra. The wavelength of maximum emission shifts to longer wavelengths with increasing mafic composition as predicted by laboratory spectroscopy. The mare locations observed are of different albedos and our spectra indicate that the locations are of slightly different composition. We see a broad emission minimum centered at 8.5 μm in the Kepler ejecta spectrum but not in that from the mare east of Euler. Spectra from both mare locations have a triplet of minima at 8.1, 8.4, and 8.75 μm which are not identified. Spectra from both mare locations exhibit local maxima just longward of 9 μm and a sharp drop in emissivity at wavelengths longer than 11 μm.

The development approach and design solutions employed for the 380 V AC direct-input 48 V 30 A switch-mode rectifier are described. The unit achieved all design goals set out prior to development. The net result is a unit which incorporates the following characteristics: direct 380 V AC three-phase input, compact size, high efficiency and power factor, front to back cooling, stackable without baffles, ease of installation and set-up, and IEC 380 safety requirements. >

Use of the ECG for diagnosis of ischemic heart disease is more difficult in the setting of ventricular paced rhythms (VPRs). ST-segment/T-wave configuration are changed by the altered intraventricular conduction associated with ventricular pacing. The anticipated, or expected, morphology in patients with VPRs is one of QRS-complex-ST-segment to T-wave discordance. Several strategies are available to the physician to assist in the correct interpretation of the 12-lead ECG in patients with permanent ventricular pacemakers, including: a knowledge of the anticipated ST-segment-T-wave changes of VPRs and consequently the ability to recognize acute, ischemic morphologies; the performance of serial ECGs or ST-segment trend monitoring demonstrating dynamic changes encountered in acutely ischemic patients; a comparison with previous ECGs; and, if appropriate, an analysis of the native, underlying rhythm. The first strategy, an awareness of the anticipated ST-segment morphologies of VPRs, is the most important and not dependent on additional diagnostic testing, past medical records, or additional expertise in pacemaker function. Two cases are reported in which an analysis of the ECG in the setting of VPR assisted the treating physicians in establishing the correct diagnosis of acute myocardial infarction.

Thrombolytic dissolution of coronary artery thrombus has added new dimensions to early myocardial infarction treatment. Reperfusion via streptokinase infusion has been shown to be beneficial; however, adverse effects are being noted. We present the case of a patient so treated who subsequently developed left ventricular free wall rupture.

The exercise stress test is one of the most useful procedures available in the management of ischemic heart disease. It can provide a good deal of information, in addition to ST segment changes, for the clinician to interpret. Analysis of test results allows more accurate diagnosis, estimation of the severity of disease, and establishment of prognosis.

Static scale model tests were conducted to evaluate exhaust system mixers for a high bypass ratio engine as part of the NASA sponsored Energy Efficient program. Gross thrust coefficients were measured for a series of mixer configurations which included variations in the number of mixer lobes, tailpipe length, mixer penetration, and length. All of these parameters have a significant impact on exhaust system performance. In addition, flow visualization pictures and pressure/temperature traverses were obtained for selected configurations. Parametric performance trends are discussed and the results considered relative to the Energy Efficient Engine program goals.

Environmental hazards for patients with pacemakers have long been recognized.1,2 Interference with pacemaker function by diagnostic and therapeutic modalities is of particular concern to physicians. Sources of disturbance include surgical diathermy, electrical defibrillation, radiation therapy, electrical muscle stimulation, low-frequency acupuncture and dental ultrasonic cleaning. Cardiokymography is being used clinically at some institutions to detect segmental wall motion abnormalities of the heart.3–5 Observation of a case of pacemaker interference by the cardiokymographic (CKG) transducer prompted us to examine other patients with pacemakers in a similar manner.

A recent experimental investigation has identified the aero/acoustic characteristics of exhaust nozzles for duct heating turbofan engines over a range of simulated flow conditions. Jet noise and performance levels are summarized for a series of coannular nozzles representing both acoustically suppressed and unsuppressed designs operating in a static environment. The basic coannular nozzles were found to provide inherent noise suppression. Multi-element suppressor nozzles provided additional noise suppression, but with appreciable thrust loss. The impact of these results on the advanced supersonic transport studies is also presented, indicating potentially large reductions in take-off gross weight or community noise footprints.