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BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) is an important pretreatment marker of systemic inflammation and tumor aggressiveness. Increased levels of this ratio have been associated with reduced survival in several observational studies of lung cancer. However, supporting analyses from large clinical trial data are lacking. METHODS: To validate the prognostic role of NLR, the current study evaluated data from a randomized phase III study (PROCLAIM; clinicaltrial.gov ID: NCT00686959) of patients with stage IIIA/B, unresectable, non-squamous, non-small cell lung cancer (NSCLC), originally comparing combination pemetrexed-cisplatin chemoradiotherapy with etoposide-cisplatin chemoradiotherapy. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for survival were estimated using a Cox proportional hazards model. Models were adjusted for age, race, sex, stage, treatment, and body mass index (BMI). Patients were followed for a median of 24 months. RESULTS: Increased NLR levels at baseline were associated with reduced overall (P(Trend)

The role of prophylactic cranial irradiation (PCI) and thoracic radiation therapy (TRT) in extensive-stage small cell lung cancer remains controversial. The authors examined the National Cancer Database and identified patients with extensive-stage small cell lung cancer with no brain metastasis. Patients were excluded if they died 30 days from diagnosis, did not receive polychemotherapy, had other palliative radiation or had missing information. A propensity score-matched analysis was also performed. A total of 21,019 patients were identified. The majority of patients did not receive radiation (69%), whereas 10% received PCI and 21% received TRT. The addition of PCI and TRT improved median survival and survival at 1 and 2 years (p ≤ 0.05). The propensity score-matched analysis confirmed the same overall survival benefit with both PCI and TRT. This registry-based analysis of1500 accredited cancer programs shows that PCI and TRT are not commonly utilized for extensive-stage small cell lung cancer patients who are treated with multiagent chemotherapy. The addition of PCI and TRT significantly improves overall survival in this otherwise poor prognostic group. Further research is needed to confirm the role of PCI and TRT, especially in the era of improved systemic therapy.Lay abstract The role of radiation therapy in patients with metastatic small cell lung cancer remains controversial. The authors examined the National Cancer Database and identified patients with metastatic small cell lung cancer without brain metastasis. Patients were excluded if they died 30 days from diagnosis, did not receive multiagent chemotherapy, had other palliative radiation or had missing information regarding treatment. A total of 21,019 patients were identified. The majority of patients did not receive radiation (69%), whereas 10% received radiation to the brain and 21% received radiation to their lungs. The addition of brain and lung radiation therapy improved median survival and survival at 1 and 2 years. The addition of prophylactic cranial irradiation and thoracic radiation therapy improves survival in extensive-stage small cell lung cancer. Future research is needed to evaluate the role of radiation in the era of chemoimmunotherapy.

About 25–35% of United States veterans who fought in the 1990–1991 Gulf War report several moderate or severe chronic systemic symptoms, defined as Gulf War illness (GWI). Thirty years later, there is little consensus on the causes or biological underpinnings of GWI. The Gulf War Era Cohort and Biorepository (GWECB) was designed to investigate genetic and environmental associations with GWI and consists of 1343 veterans. We investigate candidate gene–toxicant interactions that may be associated with GWI based on prior associations found in human and animal model studies, focusing on SNPs in or near ACHE, BCHE, and PON1 genes to replicate results from prior studies. SOD1 was also considered as a candidate gene. CDC Severe GWI, the primary outcome, was observed in 26% of the 810 deployed veterans included in this study. The interaction between the candidate SNP rs662 and pyridostigmine bromide (PB) pills was found to be associated with CDC Severe GWI. Interactions between PB pill exposure and rs3917545, rs3917550, and rs2299255, all in high linkage disequilibrium in PON1, were also associated with respiratory symptoms. These SNPs could point toward biological pathways through which GWI may develop, which could lead to biomarkers to detect GWI or to better treatment options for veterans with GWI.

The study aims to determine the shared genetic architecture between COVID-19 severity with existing medical conditions using electronic health record (EHR) data. We conducted a Phenome-Wide Association Study (PheWAS) of genetic variants associated with critical illness (n=35) or hospitalization (n=42) due to severe COVID-19 using genome-wide association summary from the Host Genetics Initiative. PheWAS analysis was performed using genotype-phenotype data from the Veterans Affairs Million Veteran Program (MVP). Phenotypes were defined by International Classification of Diseases (ICD) codes mapped to clinically relevant groups using published PheWAS methods. Among 658,582 Veterans, variants associated with severe COVID-19 were tested for association across 1,559 phenotypes. Variants at the ABO locus (rs495828, rs505922) associated with the largest number of phenotypes (nrs495828= 53 and nrs505922=59); strongest association with venous embolism, odds ratio (ORrs495828 1.33 (p=1.32 × 10−199), and thrombosis ORrs505922 1.33, p=2.2 ×10−265. Among 67 respiratory conditions tested, 11 had significant associations including MUC5B locus (rs35705950) with increased risk of idiopathic fibrosing alveolitis OR 2.83, p=4.12 × 10−191; CRHR1 (rs61667602) associated with reduced risk of pulmonary fibrosis, OR 0.84, p=2.26× 10−12. The TYK2 locus (rs11085727) associated with reduced risk for autoimmune conditions, e.g., psoriasis OR 0.88, p=6.48 ×10−23, lupus OR 0.84, p=3.97 × 10−06. PheWAS stratified by genetic ancestry demonstrated differences in genotype-phenotype associations across ancestry. LMNA (rs581342) associated with neutropenia OR 1.29 p=4.1 × 10−13 among Veterans of African ancestry but not European. Overall, we observed a shared genetic architecture between COVID-19 severity and conditions related to underlying risk factors for severe and poor COVID-19 outcomes. Differing associations between genotype-phenotype across ancestries may inform heterogenous outcomes observed with COVID-19. Divergent associations between risk for severe COVID-19 with autoimmune inflammatory conditions both respiratory and non-respiratory highlights the shared pathways and fine balance of immune host response and autoimmunity and caution required when considering treatment targets.

Background Over two-thirds of older Australians use different types/levels of aged care at some point in later life. Our aims were to estimate transitional probabilities and to identify risk factors influencing the movement between different levels of long-term care. Methods The sample consisted of 9007 women from the 1921-26 birth cohort of the Australian Longitudinal Study on Women’s Health. Transitional probabilities between different levels of long-term care were estimated using a continuous-time Markov model. Results An 11-fold transition rates ratio was observed for the movement from non-user to home and community care (HACC) versus non-user to residential aged care (RAC). The predicted probabilities of remaining in the non-user state, HACC, and RAC after 10 years from the baseline were .28, .24, and .11, respectively. While the corresponding probabilities of dying from these states were .36, .65, and .90. The risk of transitioning from the non-user state to either HACC or RAC was greater for participants who were older at baseline, widowed, living outside of major cities, having difficulties in managing income, or having chronic condition, poor/fair self-rated health, or lower SF-36 scores (p < .05). Conclusion Women spend a substantial period of their later life using long-term care. Typically, this will be in the community setting with a low level of care. The transition to either HACC or RAC was associated with several demographic and health-related factors. Our findings are important for the planning and improvement of long-term care among future generations of older people. Trial registration Not applicable.

OBJECTIVE To test the hypothesis that blood donor demographics are associated with transfused polytrauma patients' post-injury multiple organ failure (MOF) status. SUMMARY BACKGROUND DATA Traumatic shock and MOF are preventable causes of death and post-traumatic haemorrhage is a frequent indication for transfusion. The role of blood donor demographics on transfusion recipients is not well known. METHODS A log-linear analysis accounting for the correlated structure of the data based on our prospective MOF database was utilised. Tests for trend and interaction were computed using a likelihood ratio procedure. RESULTS A total of 229 critically injured transfused trauma patients were included, with 68% of them being males and a mean age of 45 years. On average 10 units of blood components were transfused per patient. A total of 4379 units of blood components were donated by donors aged 46 years on average, 74% of whom were males. Blood components used were red blood cells (47%), cryoprecipitate (29%), fresh frozen plasma (24%), and platelets (less than 1%). Donor-recipient sex mismatched red blood cells transfusions were more likely to be associated with MOF (p = ·0012); fresh frozen plasma and cryoprecipitate recipients were more likely to experience MOF when transfused with a male (versus female) component (p = ·0014 and

After Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the third coronavirus posing serious threats to human society in this century and is the causative agent of COVID-19 disease. With 67,367,046 confirmed cases and 1,545,331 deaths worldwide, this disease has become a global emergency. Mortality rates are higher among the elderly population with comorbidities such as cancer, diabetes, cardiovascular problems, and hypertension obesity. Increased oxidative stress/cytokine storm also is one of the main causes of COVID-19 associated complications. Carnosine is a well-established anti-inflammatory, anti-aging, antihypertensive, antineoplastic, antichelating, and neuroprotective agent which is helpful in maintaining the body’s pH balance. It is a naturally occurring dipeptide and is present in human skeletal muscles, cardiac muscles and brain. The compound reduces the concentration of oxygen-free-radicals, chelates heavy metals such as iron, zinc and copper, as well as inhibiting protein glycation and the generation of protein carbonyls. The Carnosine/non-hydrolysed isopeptide of Carnosine/N-acetylcarnosine, which is available without prescription, merits further consideration as a low-cost prophylaxis approach to COVID-19 and the associated complication of this disease. This is especially relevant to low-resource regions of the world which may be the last to achieve population-based herd immunity through vaccination.

The Systemic Immune-Inflammation Index (SII) is an important marker of immune function, defined as the product of neutrophil-to-lymphocyte ratio (NLR) and platelet count (P). Higher baseline SII levels have been associated with improved survival in various types of cancers, including lung cancer. Data were obtained from PROCLAIM, a randomized phase III trial comparing two different chemotherapy regimens pemetrexed + cisplatin (PEM) vs. etoposide + cisplatin (ETO), in combination with radiotherapy (RT) for the treatment of stage III non-squamous non-small cell lung cancer (NSCLC). We aimed to determine if SII measured at the mid-treatment window for RT (weeks 3&ndash, 4) is a significant predictor of survival, and if the effect of PEM vs. ETO differs by quartile (Q) level of SII. Hazard-ratios (HR) for survival were estimated using a proportional hazards model, accounting for the underlying correlated structure of the data. A total of 548 patients were included in our analysis. The median age at baseline was 59 years. Patients were followed for a median of 24 months. Adjusting for age, body mass index, sex, race, and chemotherapy regimen, SII was a significant mid-treatment predictor of both overall (adjusted HR (aHR) = 1.6, p &lt, 0.0001, OS) and progression-free (aHR = 1.3, p = 0.0072, PFS) survival. Among patients with mid-RT SII values above the median (6.8), those receiving PEM (vs. ETO) had superior OS (p = 0.0002) and PFS (p = 0.0002). Our secondary analysis suggests that SII is an informative mid-treatment marker of OS and PFS in locally advanced non-squamous NSCLC.

We read with interest several manuscripts recently published in the International Journal of Environmental Research and Public Health (IJERPH) on the ongoing coronavirus pandemic. While these articles provide a well-rounded overview on the risk and current status of this virus, we herein add some relevant information on its etiology, prevention and management, especially for resource-limited healthcare systems. The use of protective actions is both complex and expensive. Affordable options are essential to respond to this and future viral outbreaks.

The aims of this study were to investigate patterns of home and community care (HACC) use and to identify factors influencing first HACC use among older Australian women. Our analysis included 11,133 participants from the Australian Longitudinal Study of Women's Health (1921-1926 birth cohort) linked with HACC use and mortality data from 2001 to 2011. Patterns of HACC use were analysed using a k-median cluster approach. A multivariable competing risk analysis was used to estimate the risk of first HACC use. Approximately 54% of clients used a minimum volume and number of HACC services; 25% belonged to three complex care use clusters (referring to higher volume and number of services), while the remainder were intermediate users. The initiation of HACC use was significantly associated with (1) living in remote/inner/regional areas, (2) being widowed or divorced, (3) having difficulty in managing income, (4) not receiving Veterans' Affairs benefits, (5) having chronic conditions, (6) reporting lower scores on the SF-36 health-related quality of life, and (7) poor/fair self-rated health. Our findings highlight the importance of providing a range of services to meet the diverse care needs of older women, especially in the community setting.

Background Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass graft (CABG) surgery. This arrhythmia occurs more frequently among patients who receive perioperative inotropic therapy (PINOT). Administration of nitrates with antiplatelet agents reduces the conversion rate of cyclic guanosine monophosphate to guanosine monophosphate. This process is associated with increased concentrations of free radicals, catecholamines, and blood plasma volume. We hypothesized that patients undergoing CABG surgery who receive PINOT may be more susceptible to POAF when nitrates are administered with antiplatelet agents. Methods Clinical records were examined from a prospectively maintained cohort of 4,124 patients undergoing primary isolated CABG surgery to identify POAF-associated factors. Results POAF risk was increased among patients receiving PINOT, and the greatest effect was observed when nitrates were administered with antiplatelet therapy. Adjustment for comorbidities did not substantively change the study results. Conclusions Administration of nitrates with certain antiplatelet agents was associated with an increased POAF risk among patients undergoing CABG surgery. Additional studies are needed to determine whether preventive strategies such as administration of antioxidants will reduce this risk.

Triple negative breast cancer (TNBC) is an aggressive subtype that accounts for 15-20% of cases, with a higher incidence of relapse/death. Even with adjuvant chemotherapy, the 5 year distant metastasis-free survival rate remains low. A total of 452 tumor registry patients with TNBC and no evidence of metastatic disease were identified over the period of 1996-2011. The median age and follow-up time were 51 (range=21-88) and 3.9 (range=0.14-14) years. Approximately 75% of patients with stage III disease received neoadjuvant chemotherapy (NACT) compared with 47% for stage II. Patients with stage I disease predominantly received adjuvant chemotherapy (ACT). Among those who underwent NACT (n=202), 33% had a pathological complete response (pCR). Overall (OS) and disease-free (DFS) survival were significantly longer among patients achieving pCR (versus residual disease) following NACT (OS: all patients P

Owing to its aggressive course, triple-negative breast cancer remains an important clinical issue of current interest compared with hormone-receptor positive subtypes. Recent research has focused on determining the optimal local therapy (breast conversation therapy vs mastectomy) for this cancer subtype. In this overview, we examine outcomes based on immunohistochemistry, gene expression profiles, type of local therapy and in the era of neoadjuvant chemotherapy. Based on multiple observational reports risk for locoregional recurrence appears to be similar to reported outcomes in other subtypes. However, distant recurrence continues to be a significant concern for triple-negative breast cancer, indicating the need for better systemic therapies. To date, insufficient evidence exists to determine whether breast conserving therapy or mastectomy results in superior outcomes.

Compared with HIV-negative individuals, HIV-positive individuals have a higher prevalence of anogenital human papillomavirus (HPV) infection, the causative agent of anogenital cancer. TNF-alpha is a major proinflammatory cytokine. sTNFR2 is the soluble form of one of its receptors and is strongly expressed on stimulated lymphocytes. To further understand the role of TNF-alpha, sTNFR2 and other cytokines in the pathogenesis in HPV-related neoplasia, the profiles of serum cytokines in high-risk patients were analyzed for association with anal lesion status. Patients were categorized into 4 groups based on HIV status (HIV-negative vs. HIV-positive with a CD4+ level

BACKGROUND Both perioperative chemotherapy (PECT) and postoperative chemoradiotherapy (POCRT) have a significant survival advantage over surgery alone for the treatment of patients with gastric cancer. However, to the best of our knowledge, these regimens have not been compared in a randomized clinical trial. The purpose of the current observational study was to compare overall survival among patients receiving PECT versus POCRT for the treatment of gastric/gastroesophageal junction (GEJ) adenocarcinomas. METHODS Patients with resected clinical American Joint Committee on Cancer TNM stage II or III adenocarcinomas of the stomach or GEJ from 2004 through 2013 were identified utilizing the National Cancer Data Base. Hazard ratios (HRs), 95% confidence intervals, and P values were computed using a Cox proportional hazards procedure. Multivariable models were adjusted for treatment regimen, age, race, ethnicity, tumor size, TNM stage, Charlson comorbidity index, and tumor grade. RESULTS Patients receiving PECT had a 72% survival advantage compared with those treated with POCRT (5058 patients; HR, 0.58 [adjusted P 1500 American College of Surgeons Commission on Cancer-accredited facilities, patients receiving PECT were shown to survive longer than those receiving POCRT. Cancer 2017;123:2909-17. © 2017 American Cancer Society.

Background It is unknown if higher levels of ambient particulate matter (PM) exposure increase the risk for premature ventricular contractions (PVC) in a population-based study of men and women, and if this relationship varies by race or sex. Methods We examined the association of PM Results PVCs were detected in 1719 (6.6%) study participants. Short- (OR=1.08, 95%CI=1.03, 1.14) and long- (OR=1.06, 95%CI=1.01, 1.12) term PM2.5 exposures were associated with PVCs. Interactions were not detected by race or sex. An interaction between short-term PM2.5 exposure and PVCs was detected for those with cardiovascular disease (OR=1.16, 95%CI=1.06, 1.27) compared with those without cardiovascular disease (OR=1.05, 95%CI=0.99, 1.12; p-interaction=0.027). Conclusion Our findings suggest that PM2.5 exposure is associated with an increased risk for PVCs in a biracial population-based study of men and women. We also have identified persons with cardiovascular disease as an at-risk population for PVCs when increases in short-term PM2.5 concentration occur.

IntroductionAnterior cruciate ligament reconstruction (ACLR) is associated with poor return to sport and high graft re-rupture rates. This study explored the use of a wearable inertial sensor (ViMove) that incorporates an accelerometer and gyroscope, and MatScan pressure sensing mat (TekScan, South Boston, Massachusetts, USA) to provide objective return-to-sport measures.MethodsThree cohorts’ ACLR patients, non-athletic controls and elite athletes (Australian seven’s rugby Olympic Gold medallist). Patients performed biometric and functional tests (thigh circumference and triple hop) and the ViMove knee module (consisting of single and double leg squats, hops and box drops) for lower limb alignment assessment, concurrently with force plate.ResultsElite athletes had less varus/valgus (VV) movement during ViMove exercises compared with the ACLR cohort, who in turn had less VV malalignment than controls. When analysing side-to-side differences, single leg squats and box drop were asymmetrical in the ACL group, with greater malalignment in the reconstructed leg (pConclusionThe inertial sensor detected differences in motion for patients following ACLR, which are known to be associated with graft rupture and were not detected with functional return to sport testing. Coupling the device with data from a pressure plate provides a powerful assessment tool detecting alignment differences known to be associate with graft failure only previously detected in formal gait analysis.

Background: We performed an observational Veterans Health Administration cohort analysis to assess how risk factors affect 30-day mortality in SARS-CoV-2-infected subjects relative to those uninfected. While the risk factors for coronavirus disease 2019 (COVID-19) have been extensively studied, these have been seldom compared with uninfected referents. Methods: We analyzed 341,166 White/Black male veterans tested for SARS-CoV-2 from March 1 to September 10, 2020. The relative risk of 30-day mortality was computed for age, race, ethnicity, BMI, smoking status, and alcohol use disorder in infected and uninfected subjects separately. The difference in relative risk was then evaluated between infected and uninfected subjects. All the analyses were performed considering clinical confounders. Results: In this cohort, 7% were SARS-CoV-2-positive. Age &gt, 60 and overweight/obesity were associated with a dose-related increased mortality risk among infected patients relative to those uninfected. In contrast, relative to never smoking, current smoking was associated with a decreased mortality among infected and an increased mortality in uninfected, yielding a reduced mortality risk among infected relative to uninfected. Alcohol use disorder was also associated with decreased mortality risk in infected relative to the uninfected. Conclusions: Age, BMI, smoking, and alcohol use disorder affect 30-day mortality in SARS-CoV-2-infected subjects differently from uninfected referents. Advanced age and overweight/obesity were associated with increased mortality risk among infected men, while current smoking and alcohol use disorder were associated with lower mortality risk among infected men, when compared with those uninfected.

Aims This study characterizes Gulf War Illness (GWI) among U.S. veterans who participated in the Gulf War Era Cohort and Biorepository (GWECB). Main methods Mailed questionnaires were collected between 2014 and 2016. Self-reported GWI symptoms, symptom domain criteria, exclusionary diagnoses, and case status were examined based on the originally published Kansas and Centers for Disease Control (CDC) definitions in the GWECB cohort (n = 849 deployed to Gulf and n = 267 non-deployed). Associations among GWI and deployment status, demographic, and military service characteristics were examined using logistic regression. Key findings Among deployed veterans in our sample, 39.9% met the Kansas criteria and 84.2% met the CDC criteria for GWI. Relative to non-deployed veterans, deployed veterans had a higher odds of meeting four GWI case status-related measures including the Kansas symptom criteria (aOR = 2.05, 95% CI = 1.50, 2.80), Kansas GWI case status (aOR = 1.42, 95% CI = 1.05, 1.93), the CDC GWI case status (aOR = 1.57, 95% CI = 1.07, 2.29) and the CDC severe criteria (aOR = 2.67, 95% CI = 1.79, 3.99). Forty percent met the Kansas exclusionary criteria, with no difference by deployment status. Some symptoms were nearly universally endorsed. Significance This analysis provides evidence of a sustained, multisymptom illness in veterans who deployed to the Persian Gulf War compared to non-deployed Gulf War era veterans nearly 25 years later. Differences in symptoms attributed to GWI by deployment status have diminished since initial reports, suggesting the need to update GWI definitions to account for aging-related conditions and symptoms. This study provides a foundation for future efforts to establish a single GWI case definition and analyses that employ the biorepository.

There has been growing interest in utilizing information from cone-beam computed tomography (CBCT) to help guide both treatment delivery and prognosis. In this assessment of locally advanced unresectable stage III non-small cell lung cancer (NSCLC) treated with definitive chemoradiation, we aimed to determine the survival advantage associated with using CBCT to measure tumor regression. Patient, tumor, and treatment characteristics were collected. The serial tumor shrinkage for each patient was determined from tumor volume contours on weekly CBCTs. Survival analysis was performed using the Kaplan–Meier technique and a Cox proportional hazards model. At least two-thirds of patients had a tumor volume reduction of at least 5% after each week of chemoradiation. A weekly reduction in tumor volume of 5% or greater seen on the CBCT images during radiation therapy was significantly associated with improved overall survival, which remained significant when adjusted for age, histology, grade, and T- and N-stages (p = 0.0036). Additionally, the presence of N3 disease was associated with a five-fold increased risk of recurrence (p = 0.0006) and a nearly three-fold increased risk of death (p = 0.053) compared with N0–N2 disease. Tumor volume shrinkage observed in the CBCT images during definitive chemoradiation holds promise as a prognostic indicator of stage III NSCLC, especially given its affordability, availability, and applicability. Further evaluation in a prospective fashion is warranted to validate the tumor volume shrinkage and its clinical utility.

African-Americans sometimes rate their health as Poor/Fair in the absence of chronic diseases. Theoretically, this lack of correspondence between self-rated health and objective health is due to racial discrimination that results in rating one’s health negatively and in terms of social rather than health variables. We tested this Health Pessimism model with 2118 African-Americans. Results revealed that Poor/Fair self-rated health was predicted mostly by objective health for the Low Discrimination group but mostly by demographic variables for the High Discrimination group, in a manner consistent with Health Pessimism. Inconsistencies among prior studies might reflect differences in the prevalence of high discrimination among their samples.

Absract Introduction Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer with poor 5-year survival. Knowledge and information about IBC with the triple negative (TNBC) phenotype are limited. Here, we report the characteristics and outcome of inflammatory TNBC (I-TNBC) cancer cohorts from a large TNBC dataset. Patients and Methods After obtaining institutional review board approval, we collected information on 476 women with a diagnosis of TNBC from 1996 to 2011. Data on patient characteristics, tumor, and treatment were collected. Overall survival (OS) was computed from the date of diagnosis to the date of death or last follow-up. For disease-free survival (DFS), patients were scored if they failed. Statistical analysis was performed using SAS v9.3. Results A total of 34 (7%) patients were diagnosed with inflammatory TNBC. The median age was 52 years, and 56% were white. The median follow-up was 13 months (interquartile range, 2-126 months). Twenty-one percent (n = 7) presented with stage IV disease, while 91% had axillary nodal involvement. All but 2 (94%; n = 32) patients had neoadjuvant chemotherapy, with 6% (n = 2) achieving complete response. Twenty-one (62%) patients underwent mastectomy; 71% (n = 24) received radiation. The 2- and 5-year OS and DFS were 34%, 26% (vs. 65%, 46%) and 27%, 23% (vs. 53%, 40%), respectively, for I-TNBC and non-inflammatory stage III-IV TNBC. Compared with the non-inflammatory group, the 2- and 5-year OS (P Conclusion IBC with the triple negative phenotype is an aggressive disease with a significantly inferior outcome compared with non-inflammatory locally advanced TNBC. Newer strategies are required to improve survival outcome.

Background Although many patients with chronic obstructive pulmonary disease (COPD) require a prolonged length of stay (PLOS) following coronary artery bypass grafting (CABG), the impact of PLOS on long-term survival has not been examined in this population. Objectives To determine the association between PLOS and long-term survival among COPD and non-COPD patients after CABG and to examine consequent policy and practice-based implications. Methods A retrospective cohort study of CABG patients was conducted between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by PLOS. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. Results A total of 203 patients (4.2%) had PLOS after nonemergent CABG (N = 4801). PLOS was an important independent predictor of decreased long-term survival (no COPD, no PLOS: HR = 1.0; COPD, no PLOS: adjusted HR [95% CI], 1.8 [1.5-2.1]; no COPD, PLOS: 3.3 [2.5-4.4]; COPD, PLOS: 6.0 [4.4-8.2]; PTrend Conclusions COPD and PLOS are 2 of many factors that affect long-term mortality in postoperative CABG patients. Aggressive treatment strategies aimed at early weaning off of mechanical ventilation and prevention of reintubation among COPD patients must be considered carefully as a means to reduce length of stay after CABG. Our results also have important implications for the long-term management of these patients and strategies for containing costs over the life course of the patient.

Obesity has been identified as a risk factor for postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG). However, no studies have addressed the influence of race on this association. A total of 13,594 patients undergoing first-time, isolated CABG without preoperative atrial fibrillation between 1992 and 2011 were included in our study. The association between body mass index (BMI) and POAF was compared by race. Relative risk and 95% confidence intervals were computed using maximum likelihood log-binomial regression. Increasing levels of BMI were associated with higher POAF risk following CABG among black but not white patients (Pinteraction=0.0009).

Objectives In this study, the effects of sociodemographic and clinical factors on heart failure (HF) readmission risk were examined. Background Hospitals now incur financial penalties for excessive HF readmission rates; therefore, identifying factors associated with risk is essential for designing risk-reduction strategies. Methods A retrospective cohort study using chart reviews compared HF inpatients (N = 245) who were readmitted with those who were not readmitted. Results The sample included mostly white (64%) elderly (mean [SD] age, 69.8 [15.1] years) men (49%) and women (51%). Using Cox regression, the number of comorbidities (3-4 or 5-8) and type of comorbidities, specifically renal insufficiency (readmission ratio [RR], 1.7; P = .003), atrial fibrillation (RR, 1.7; P = .005), cardiomyopathy (RR, 1.5; P = .020), followed by a history of myocardial infarction/coronary artery disease (RR, 1.4; P = .055), were the predictors of HF readmission. Conclusions Targeting those with high-risk comorbidities is important in designing measures to prevent or delay readmission of HF patients.

In this US-based study of the National Cancer Database (NCDB), we examined 8550 patients diagnosed with non-metastatic, invasive inflammatory breast cancer (IBC) who received surgery from 2004–2013. Patients were grouped into four biologic subtypes (HR+/HER2−, HR+/HER2+, HR−/HER2+, HR−/HER2−). On average, women were 56 years of age at diagnosis and were followed for a median of 3.7 years. The majority were white (80%), had private health insurance (50%), and presented with poorly differentiated tumors (57%). Approximately 46% of the cancers were &gt, 5 cm. Most patients underwent mastectomy (94%) and received radiotherapy (71%). Differences by biologic subtypes were observed for grade, lymph node invasion, race, and tumor size (p &lt, 0.0001). Patients experiencing pathologic complete response (pCR, 12%) vs. non-pCR had superior 5-year overall survival (OS) (77% vs. 54%) (p &lt, 0.0001). Survival was poor for triple-negative (TN) tumors (37%) vs. other biologic subtypes (60%) (p &lt, 0.0001). On multivariable analysis, TN-IBC, positive margins, and not receiving either chemotherapy, hormonal therapy or radiotherapy were independently associated with poor 5-year survival (p &lt, 0.0001). In this analysis of IBC, categorized by biologic subtypes, we observed significant differential tumor, patient and treatment characteristics, and OS.

Purpose: While the intellectual and scientific rationale for research collaboration has been articulated, a paucity of information is available on a strategic approach to facilitate the collaboration within a research network designed to reduce health disparities. This study aimed to (1) develop a conceptual model to facilitate collaboration among biostatisticians in a research network, (2) describe collaborative engagement performed by the Network&rsquo, s Data Coordinating Center (DCC), and (3) discuss potential challenges and opportunities in engaging the collaboration. Methods: Key components of the strategic approach will be developed through a systematic literature review. The Network&rsquo, s initiatives for the biostatistical collaboration will be described in the areas of infrastructure, expertise and knowledge management and experiential lessons will be discussed. Results: Components of the strategic approach model included three Ps (people, processes and programs) which were integrated into expert management, infrastructure management and knowledge management, respectively. Ongoing initiatives for collaboration with non-DCC biostatisticians included both web-based and face-to-face interaction approaches: Network&rsquo, s biostatistical capacities and needs assessment, webinar statistical seminars, mobile statistical workshop and clinics, adjunct appointment program, one-on-one consulting, and on-site workshop. The outreach program, as a face-to-face interaction approach, especially resulted in a useful tool for expertise management and needs assessment as well as knowledge exchange. Conclusions: Although fostering a partnered research culture, sustaining senior management commitment and ongoing monitoring are a challenge for this collaborative engagement, the proposed strategies centrally performed by the DCC may be useful in accelerating the pace and enhancing the quality of the scientific outcomes within a multidisciplinary clinical and translational research network.

Background: Radiotherapy (RT) plays an important role in the management and survival of patients with breast cancer. The aim of this study was to examine the association between age, comorbidities and use of RT in this population. Methods: Patients diagnosed with breast cancer from 2004&ndash, 2013 were identified from the American College of Surgeons National Cancer Database (NCDB). Follow-up time was measured from the date of diagnosis (baseline) to the date of death or censoring. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were used as the measure of association. Results: Independently of comorbidities and other important outcome-related factors, patients &gt, 65 years of age who received RT survived significantly longer than those who did not receive RT (aHR = 0.53, 95% CI = 0.52&ndash, 0.54). However, as women aged, those with comorbidities were less likely to receive RT (adjusted p-trend by age &lt, 0.0001). Conclusions: The development of decision-making tools to assist clinicians, and older women with breast cancer and comorbidities, are needed to facilitate personalized treatment plans regarding RT. This is particularly relevant as the population ages and the number of women with breast cancer is expected to increase in the near future.

BACKGROUND Although mortality associated with atrial fibrillation (AF) has been reported to decrease over prior decades, the mortality risk of asymptomatic, nonhospitalized AF has not been examined. HYPOTHESIS Asymptomatic, nonhospitalized AF is associated with an increased risk of death. METHODS This analysis included 25,976 participants (mean age, 65 ± 9.4 years; 55% female; 38% black) from the Reasons for Geographic And Racial Differences (REGARDS) study. Atrial fibrillation was detected on the baseline electrocardiogram (ECG AF) or by self-reported history. Atrial fibrillation unawareness was defined as present if ECG evidence of the arrhythmia was detected but no self-reported history was reported. All-cause mortality was confirmed during follow-up through March 31, 2014. RESULTS A total of 2208 (8.5%) participants had AF at baseline (ECG: n = 371/17%; self-reported: n = 1837/83%). Over a median follow-up of 7.6 years, 3481 deaths occurred. In a multivariable Cox regression model, AF was associated with a 32% increased risk of mortality (95% confidence interval [CI]: 1.19-1.46). Risk of death was higher among those with ECG AF (hazard ratio: 1.71, 95% CI: 1.42-2.07) compared with self-reported cases (hazard ratio: 1.15, 95% CI: 1.03-1.29). Those who were unaware of their AF diagnosis had a 94% increased risk of death (95% CI: 1.50-2.52) compared with AF participants who were aware of their diagnosis. CONCLUSIONS Asymptomatic, nonhospitalized AF is associated with an increased risk of mortality in the general population. Mortality is higher in those with ECG-confirmed cases and among those who are unaware of their diagnosis.

Objectives The purpose of this study was to evaluate the plethysmographic signal-derived oxygen desaturation index (ODI) as an inpatient screening strategy to identify sleep-disordered breathing (SDB) in patients with congestive heart failure (CHF). Background SDB is highly prevalent among patients hospitalized with CHF but is widely underdiagnosed. We evaluated overnight photoplethysmography as a possible screening strategy for hospitalized patients with CHF. Methods Consecutively admitted heart failure patients with high clinical suspicion of SDB and ODI ≥5 were offered outpatient polysomnography (PSG), which was completed within 4 weeks of discharge. PSG was considered positive if the apnea hypoxia index (AHI) was ≥5. A Bland-Altman plot was used to assess agreement between ODI and AHI. Receiver-operator characteristics were determined for ODI ≥5 and AHI ≥5. Results A screening questionnaire identified 246 of 282 consecutive patients with positive symptoms for SDB. Of these patients, 105 patients were offered further evaluation and 86 had ODI ≥5 (mean ODI 17 ± 17). Among these 86 patients, 68 underwent outpatient PSG within 4 weeks of discharge. PSG showed that 64 (94%) had SDB, with a mean AHI of 28. Inpatient ODI correlated well with PSG-derived AHI. The area under the curve was 0.82 for AHI ≥5. The Bland-Altman plot revealed no major bias. Matthew’s correlation coefficient revealed that the optimal cut-off for ODI is 5. Conclusions Screening hospitalized patients with heart failure using targeted inpatient ODI identifies a cohort of patients with a high prevalence of SDB. Our screening strategy provides a potentially cost-effective method for early detection and treatment of SDB.

Prolongation of the QT interval is associated with an increased risk of atrial fibri llation (AF) and stroke. The purpose of this analysis was to determine if AF explains the association between prolonged QT and stroke. A total of 6305 participants (mean age 62 ± 10 years; 54 % women; 38 % whites; 27 % blacks; 23 % Hispanics; 12 % Chinese–Americans) from the Multi-Ethnic Study of Atherosclerosis (MESA) were included in this analysis. A linear scale was used to compute heart rate-adjusted QT (QTa). Prolonged QTa was defined as ≥460 ms in women and ≥450 ms in men. Incident AF cases were identified using hospital discharge records and Medicare claims data. Vascular neurologists adjudicated stroke events by medical record review. Cox regression was used to examine the association between prolonged QTa and stroke with and without AF. A total of 216 (3.4 %) of study participants had prolonged QTa. Over a median follow-up of 8.5 years, 280 (4.4 %) participants developed AF and 128 (2.0 %) participants developed stroke. In a multivariable Cox regression analysis adjusted for socio-demographics, cardiovascular risk factors, and potential confounders, prolonged QTa was associated with an increased risk of AF (HR = 1.7, 95 % CI 1.1, 2.6) and stroke (HR = 2.3, 95 % CI 1.3, 4.1). When AF was included as a time-dependent covariate, the association between prolonged QTa and stroke was not substantively altered (HR = 2.4, 95 % CI 1.3, 4.3). The increased risk of stroke in those with prolonged QT potentially is not explained by documented AF. Further research is needed to determine if subclinical AF explains the association between the QT interval and stroke.

Objectives This study sought to determine whether plasma catecholamines and monoamine oxidase-B (MOA-B) are associated with post-operative atrial fibrillation (POAF) in patients undergoing elective cardiac surgery. Background Although intra- and post-operative adrenergic tone has been demonstrated to be an causative factor for POAF, the role and association of pre-operative plasma catecholamines remains unclear. Methods Prior to administration of anesthesia on the morning of surgery, blood samples were obtained from 324 patients undergoing nonemergent coronary artery bypass graft and/or aortic valve surgery with cardiopulmonary bypass at East Carolina Heart Institute. The concentrations of norepinephrine (NE), dopamine (DA), epinephrine (EPI), and enzyme MAO-B were assessed in platelet-rich plasma. A log-binomial regression model was used to determine the association between quartiles of these variables and POAF. Results Levels of NE (p = 0.0006) and EPI (p = 0.047) in the 4th quartile ( Q 4 NE + ) were positively associated with POAF, whereas DA (p = 0.0034) levels in the 4th quartile ( Q 4 DA + ) were inversely associated with POAF. Adjusting for age, heart failure (HF), and history of atrial fibrillation, the composite pre-operative (adrenergic) plasma marker ( Q 4 NE + V Q 4 DA − ) was associated with a 4-fold increased occurrence of POAF (adjusted p = 0.0001). No association between plasma MAO-B and POAF was observed. Conclusions Our results suggest that pre-operative adrenergic tone is an important factor underlying POAF. This information provides evidence that assessment of plasma catecholamines may be a low-cost method that is easy to implement for predicting which patients are likely to develop POAF. More investigation in a multicentric setting is needed to validate our results.

Refugees represent a diverse group of displaced individuals with unique health issues and disease risks. The obstacles facing this population have their origins in war, violence, oppression, exploitation, and fear of persecution. Regardless of country of origin, a common bond exists, with refugees often confronting inadequate healthcare resources, xenophobia, discrimination, and a complex web of legal barriers in their new homelands. In many cases, the plight of refugees is multigenerational, manifesting as mental health issues, abuse, poverty, and family disruption. The health trajectory of refugees remains an ongoing commitment and challenge.

Concomitant lung/brain traumatic injury results in significant morbidity and mortality. Lung protective ventilation (Acute Respiratory Distress Syndrome Network [ARDSNet]) has become the standard for managing adult respiratory distress syndrome; however, the resulting permissive hypercapnea may compound traumatic brain injury. Airway pressure release ventilation (APRV) offers an alternative strategy for the management of this patient population. APRV was hypothesized to retard the progression of acute lung/brain injury to a degree greater than ARDSNet in a swine model.Yorkshire swine were randomized to ARDSNet, APRV, or sham. Ventilatory settings and pulmonary parameters, vitals, blood gases, quantitative histopathology, and cerebral microdialysis were compared between groups using χ2, Fisher's exact, Student's t test, Wilcoxon rank-sum, and mixed-effects repeated-measures modeling.Twenty-two swine (17 male, 5 female), weighing a mean (SD) of 25 (6.0) kg, were randomized to APRV (n = 9), ARDSNet (n = 12), or sham (n = 1). PaO2/FIO2 ratio dropped significantly, while intracranial pressure increased significantly for all three groups immediately following lung and brain injury. Over time, peak inspiratory pressure, mean airway pressure, and PaO2/FIO2 ratio significantly increased, while total respiratory rate significantly decreased within the APRV group compared with the ARDSNet group. Histopathology did not show significant differences between groups in overall brain or lung tissue injury; however, cerebral microdialysis trends suggested increased ischemia within the APRV group compared with ARDSNet over time.Previous studies have not evaluated the effects of APRV in this population. While our macroscopic parameters and histopathology did not observe a significant difference between groups, microdialysis data suggest a trend toward increased cerebral ischemia associated with APRV over time. Additional and future studies should focus on extending the time interval for observation to further delineate differences between groups.

Navigational bronchoscopy is utilized to guide biopsies of peripheral lung nodules and place fiducial markers for treatment of limited stage lung cancer with stereotactic body radiotherapy. The type of sedation used for this procedure remains controversial. We performed a retrospective chart review to evaluate the differences of diagnostic yield and overall success of the procedure based on anesthesia type.Electromagnetic navigational bronchoscopy was performed using the superDimension software system. Once the targeted lesion was within reach, multiple tissue samples were obtained. Statistical analysis was used to correlate the yield with the type of sedation among other factors. A successful procedure was defined if a diagnosis was made or a fiducial marker was adequately placed.Navigational bronchoscopy was performed on a total of 120 targeted lesions. The overall complication rate of the procedure was 4.1%. The diagnostic yield and success of the procedure was 74% and 87%, respectively. Duration of the procedure was the only significant difference between the general anesthesia and IV sedation groups (mean, 58 vs. 43 min, P=0.0005). A larger tumor size was associated with a higher diagnostic yield (P=0.032). All other variables in terms of effect on diagnostic yield and an unsuccessful procedure did not meet statistical significance.Navigational bronchoscopy is a safe and effective pulmonary diagnostic tool with relatively low complication rate. The diagnostic yield and overall success of the procedure does not seem to be affected by the type of sedation used.

Background A more accurate measure of long-term survival among patients who have undergone a successful resection for pancreatic adenocarcinoma may be computed by accounting for time already survived during the initial treatment window. Methods Patients diagnosed with pancreatic adenocarcinoma, from 2004 through 2013, were identified from the American College of Surgeons National Cancer Database (NCDB). A risk-stratification matrix was constructed including age, histopathologic factors and the use of adjuvant therapy, given successful treatment and survival at 3-month following diagnosis. Results A total of 25,897 patients (50% male, 53% >65 years of age) presented with stage I–III pancreatic cancer. The majority of patients had tumors >2 cm size (82%), grade I/II (65%), lymphatic invasion (LI) (66%), and negative margins (76%). A survival advantage for adjuvant therapy was observed among all patients, independent of their risk-profile. For example, a patient ≤65 years of age, with early stage cancer (size ≤2 cm, grade I/II, −ve LI, −ve margins) who received adjuvant therapy had a 62% probability of being alive beyond three years (95%CI = 59%–66%). In contrast, the survival probability decreased to 53% (95%CI = 59%–66%) without adjuvant therapy. Conclusions These results provide surgeons and patients with more accurate information regarding long-term survival, as well as the benefit of opting for adjuvant therapy after successful pancreatic surgery.

Trauma is a transgenerational process that overwhelms the community and the ability of family members to cope with life stressors. An anthropologist trained in ethnographic methods observed three focus groups from a non-profit agency providing trauma and mental health services to Asian Americans living in the San Francisco Bay Area of United States. Supplemental information also was collected from staff interviews and notes. Many of the clients were immigrants, refugees, or adult children of these groups. This report consisted of authentic observations and rich qualitative information to characterize the impact of trauma on refugees and immigrants. Observations suggest that collective trauma, direct or indirect, can impede the success and survivability of a population, even after many generations.

The Rohingya people are one of the most ill-treated and persecuted refugee groups in the world, having lived in a realm of statelessness for over six generations, and who are still doing so. In recent years, more than 500,000 Rohingyas fled from Myanmar (Burma) to neighboring countries. This article addresses the Rohingya refugee crisis in Bangladesh, with special emphasis on the living conditions of this vulnerable population. We reviewed several documents on Rohingya refugees, visited a registered refugee camp (Teknaf), collected case reports, and conducted a series of meetings with stakeholders in the Cox's Bazar district of Bangladesh. A total of 33,131 registered Rohingya refugees are living in two registered camps in Cox's Bazar, and up to 80,000 additional refugees are housed in nearby makeshift camps. Overall, the living conditions of Rohingya refugees inside the overcrowded camps remain dismal. Mental health is poor, proper hygiene conditions are lacking, malnutrition is endemic, and physical/sexual abuse is high. A concerted diplomatic effort involving Bangladesh and Myanmar, and international mediators such as the Organization of Islamic Countries and the United Nations, is urgently required to effectively address this complex situation.

Aim: Studies have shown increased pretreatment neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios to be predictive of survival in various cancers. Our aim was to evaluate the prognostic role of such inflammatory markers in non-small-cell lung cancer (NSCLC). Methods: One hundred and sixty-three patients with stage III NSCLC who received definitive treatment were included. Survival analysis was performed using Kaplan–Meier method. Hazard ratios for overall and recurrence-free survival were estimated using Cox proportional hazards model. Results: Both neutrophil-to-lymphocyte >Q75 (4.5) and lymphocyte nadir values

Objective— It is unknown whether endothelial dysfunction precedes atrial fibrillation (AF) development. The objective of this study was to examine the association of brachial flow-mediated dilation (FMD) with incident AF. Approach and Results— A total of 2936 participants (mean age, 61±9.9 years; 50% women; 66% nonwhites) from the Multi-Ethnic Study of Atherosclerosis with available ultrasound brachial FMD measurements who were free of baseline AF were included in this analysis. Baseline (2000–2002) FMD was computed from the percentage difference (%FMD) in brachial artery diameter and maximum diameter during measured vasodilator response. AF was ascertained from hospitalization data including Medicare claims during a median follow-up of 8.5 years. Probability-weighted Cox proportional-hazards regression was used to compute hazard ratios and 95% confidence intervals for the association between FMD as a continuous variable (%FMD values per 1-SD increase) and incident AF. Incident AF was detected in 137 (4.7%) participants. Those with %FMD values below the sex-specific median value (median %FMD; men, 3.6%; women, 4.2%; incidence rate per 1000 person-years, 7.3; 95% confidence interval, 5.9–9.0) were more likely to develop AF than people whose %FMD values were above the median value (incidence rate per 1000 person-years, 4.5; 95% confidence interval, 3.4–5.8; log-rank P =0.0043). In a multivariable Cox regression analysis, each 1-SD increase in %FMD values (SD, 2.8%) was associated with less incident AF (hazard ratio, 0.84; 95% confidence interval, 0.70–0.99). These results were consistent across subgroups stratified by age, sex, and race/ethnicity. Conclusions— Smaller brachial FMD values are associated with higher rates of AF, suggesting a role for endothelial dysfunction in AF pathogenesis.

Calcified coronary arteries are associated with the development of cardiovascular disease and stroke. It is currently unknown whether coronary artery calcium (CAC) is associated with an increased risk for atrial fibrillation (AF). The aim of this study was to address this question in 6,641 participants (mean age 62 ± 10 years, 53% women, 62% nonwhites) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of baseline clinical cardiovascular disease and AF. CAC measurements were assessed by cardiac computed tomography at study baseline. AF was ascertained by review of hospital discharge records and from Medicare claims data until December 31, 2010. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between CAC and AF. During a median follow-up period of 8.5 years, 308 participants (4.6%) developed AF. In a model adjusted for sociodemographics, cardiovascular risk factors, and potential confounders, higher CAC scores were associated with increased risk for AF (CAC = 0: HR 1.0, referent; CAC = 1 to 100: HR 1.4, 95% CI 1.01 to 2.0; CAC = 101 to 300: HR 1.6, 95% CI 1.1 to 2.4; CAC >300: HR 2.1, 95% CI 1.4 to 2.9). The addition of CAC to the Framingham Heart Study and Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) AF risk scores yielded integrated discrimination improvement of 0.0033 (95% CI 0.0015 to 0.0066) and 0.0028 (95% CI 0.0012 to 0.0057), with relative integrated discrimination improvement of 0.10 (95% CI 0.061 to 0.15) and 0.077 (95% CI 0.040 to 0.11), respectively. In conclusion, CAC is independently associated with increased risk for AF.

Aims The associations of mitral annular calcification (MAC) with atrial fibrillation (AF) risk factors and related outcomes suggest a possible association between MAC and AF. The aim of this study was to examine the association between MAC and AF in a racially and ethnically diverse population. Methods and results This analysis included 6641 participants (mean age 62 ± 10 years; 53% women; 27% Blacks; 22% Hispanics; 12% Chinese-Americans) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease and AF at baseline. The presence of MAC was defined by cardiac computed tomography (CT) as an Agatston score >0. Atrial fibrillation was ascertained by hospital discharge records and from Medicare claims data until 31 December 2010. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between MAC and AF. At baseline, 619 (9.3%) participants had MAC. Over a median follow-up of 8.5 years, 308 (4.6%) participants developed AF. In a multivariable adjusted model, MAC was associated with an increased risk of AF (HR = 1.9, 95% CI = 1.5, 2.5). This association was consistent across subgroups of age, sex, race/ethnicity (Whites vs. non-Whites), hypertension, diabetes, and left atrial enlargement. The addition of MAC to the Framingham Heart Study and CHARGE AF risk scores for AF improved the C-statistics from 0.769 to 0.776 ( P = 0.038) and 0.788 to 0.792 ( P = 0.089), respectively. Conclusion The presence of MAC was predictive of incident AF in MESA. Potentially, these findings suggest a usefulness of cardiac CT to identify individuals at risk for AF.

Previous studies have explored the ability of the Cardiac Infarction/Injury Score (CIIS) to identify individuals who are high-risk for cardiovascular disease (CVD) mortality. However, its prognostic significance among those without CVD in the United States general population has not been established. This analysis included 6,298 participants (mean age: 59 ± 13 years; 53% female; 51% non-whites) from the Third National Health and Nutrition Examination Survey (NHANES III), excluding participants with a history of CVD or electrocardiographic evidence of old myocardial infarction or ischemic ST depression at baseline. Subclinical myocardial injury was defined as CIIS ≥10. Mortality data were ascertained using the National Death Index. Cox proportional-hazards regression was used to compute hazard ratios (HR) and 95% confidence intervals (CI) for association between subclinical myocardial injury with CVD and all-cause mortalities. Subclinical myocardial injury was detected in 1,376 (22%) participants. A total of 1,928 deaths occurred during a median of 14 years follow-up, of which 765 (40%) were due to CVD. In a multivariable model adjusted for demographics, traditional CVD risk factors, and other medical comorbidities, subclinical myocardial injury was associated with an increased risk of CVD (HR=1.26, 95%CI=1.02, 1.56) and all-cause (HR=1.42, 95%CI=1.23, 1.63) mortalities. In conclusion, subclinical myocardial injury in persons without manifestations of CVD is associated with an increased risk of CVD and all-cause mortalities. These findings highlight the important role of CIIS to identify subclinical myocardial injury and its association with mortality among men and women in the United States.

Previous studies have shown conflicting evidence regarding the impact of inappropriate, initial antibiotic therapy. The purpose of this study was to evaluate the impact of inappropriate empiric antimicrobial therapy for the treatment of infection among surgical patients. We hypothesized that inappropriate empiric antimicrobial therapy would predict increased mortality risk compared with appropriate therapy. This was a retrospective analysis of a prospectively maintained database of all surgical patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes were compared between inappropriately and appropriately treated groups. Multivariable log-binomial regression was performed. There were 2,855 patients (7,158 infectious episodes) identified by culture analysis as either appropriately or inappropriately treated. Three hundred seventeen (15%) inappropriately treated infectious episodes resulted in death compared with 718 (14%) of the appropriately treated infectious episodes. After adjusting for statistically significant variables, inappropriately treated episodes of infection were not found to be associated with an increased risk for mortality compared with appropriately treated episodes of infection (relative risk, 1.0; 95% confidence interval, 0.99 - 1.02; P = 0.36). Our study observed no difference in mortality between appropriately and inappropriately treated infections within a surgical population.

As obesity and type II diabetes continue to rise, bariatric surgery offers a solution, but few long-term studies are available. The purpose of this study was to evaluate the long-term outcomes of diabetic patients after gastric bypass.This was a retrospective cohort study of all diabetic patients undergoing gastric bypass at our institution, from 1998 to 2012. Patients were compared by postoperative diabetic response to treatment (i.e., response = off oral medication/insulin versus refractory = on oral medication/insulin) and followed at 1-, 3-, 5-, and 10-y intervals. Continuous data were analyzed using Student t-test or Wilcoxon rank-sum test. Multivariable, Cox proportional hazard regression model was performed to compute diabetic cure ratios and 95% confidence intervals.A total of 2454 bariatric surgeries were performed at our institution during the time period. A total of 707 diabetic patients were selected by Current Procedural Terminology codes for gastric bypass. Mean follow-up was 2.1 y. Incidence of diabetic response was 56% (1 y), 58% (3 y), 60% (5 y), and 44% (10 y). Postoperatively, responsive patients experienced greater percentage of total body weight loss (1 y [P 0.0001], 3 y [P = 0.0087], and 5 y [P = 0.013]), and less hemoglobin A1c levels (1 y [P = 0.035] and 3 y [P = 0.040]) at follow-up than refractory patients. Multivariable analysis revealed a significant, independent inverse trend in incidence of diabetic cure as both age and body mass index decreased (Ptrend = 0.0019 and0.0001, respectively). In addition, degenerative joint disease was independently associated with responsive diabetes (cure ratio = 1.6 [95% confidence interval = 1.1-2.2]).At follow-up, both groups in our study experienced substantial weight loss; however, a greater loss was observed among the response group. Further research is needed to evaluate methods for optimizing patient care preoperatively and improving patient follow-up.

The objective of this study was to test the hypothesis that there is seasonal variation in the incidence of Stanford type A aortic dissection (SA-AoD) among patients admitted to our cardiovascular surgical service. A sinusoidal logistic regression model was used to analyze event data for 6081 calendar days. A cyclic peak risk for SA-AoD was observed for calendar day 304 (p=0.019). The odds ratios for the 3- and 6-month window surrounding this peak were 1.6 (p=0.054) and 1.7 (p=0.0040), respectively. Our results suggest than a seasonal variation exists in the incidence of SA-AoD.