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We document that global board reforms are associated with a significant reduction in IPO underpricing. The effect is amplified for IPOs with greater agency problems and mitigated for IPOs certified by reputable intermediaries, IPOs with greater disclosure specificity, and IPOs in countries with better shareholder protection and stringent financial reporting regulations. Furthermore, global board reforms have led to an improvement in the long-term market performance, proceeds, and subscription level of IPOs, and have enhanced board independence in the issuing firms. Our findings suggest that global board reforms have strengthened board oversight in the issuing firms, leading to less underpriced IPOs.

Additional file 1: Table S1. Patient characteristics according to documentation of heart failure, stratified by physician specialty.

This paper examines the impact of cross-country variation in shareholders' and debt holders' rights on post-IPO performance and survival of newly listed stocks across the globe. Using a sample of 10,490 initial public offerings (IPOs) in 40 countries between 2000 and 2013, we find that post-IPO performance and survival is better in countries with stronger shareholder protection, but the impact of creditor protection is negative i.e. stronger creditor protection leads to poor post-IPO performance and survival. This effect is driven by rules requiring creditors’ consent for company reorganization and the mandatory replacement of incumbent managers. Reputable IPO advisors exacerbate the positive impact of shareholder rights and the negative impact of creditor rights.

We analyze the role of firm-level corporate governance in determining the precommitment payout policy of emerging market firms and investigate if there is a precommitment lifecycle effect. Unlike previous studies for the U.S. firms, we only find evidence of precommitment among relatively well-governed firms, who combine good governance with large dividend payouts to shareholders and large debt-related repayments to creditors. We also document a strong precommitment lifecycle effect. Firms in the growth and mature stages of their lifecycle tend to use both debt and dividends to precommit to investors, with an increasing proportion of dividends in total payout measures. Our results are robust to an array of control variables, alternate payout proxies and market setting, firm-level corporate governance and addresses any potential endogeneity concerns in the sample.

Background: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. Cardiovascular disease is a major determinant of morbidity and mortality in patients with KT. Temporal trends in perioperative cardiovascular outcomes after KT are understudied, especially in light of an aging KT waitlist population. Methods: We performed a retrospective observational cohort study using the National Inpatient Sample for the years 2004–2013. All adult patients undergoing KT were identified using the appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. Demographic and hospital characteristics, discharge disposition, payer status, and major adverse cardiovascular events (MACEs) were summarized using summary statistics. Multivariate logistic regression was used to identify predictors of MACEs in the perioperative period of KT. Results: A total of 147,431 KTs were performed between 2004 and 2013. The mean age at KT went up from 48.1 to 51.8 years from 2004 to 2013. Medicare was the primary payer for 59.6% of the KTs. Overall average perioperative mortality was 0.5%, median length of stay was 5 days, and 6.5% of patients experienced an MACE, 78% of which were heart failures (HFs). Important predictors of perioperative MACEs were age ≥65 years (OR = 2.14), Medicare as primary payer (OR = 1.51), diabetes (OR = 1.46), recreational drug use (OR = 1.72), pulmonary circulation disorders (OR = 3.28), and malnutrition (OR = 1.91). Conclusion: Despite increases in age at the time of KT, the absolute risk of perioperative MACEs has remained stable from 2004 to 2013. HF is a major component of postoperative MACEs in KT. Malnutrition and pulmonary hypertension are major nontraditional predictors of perioperative MACE outcomes.

The 1245.29 Trial recently showed that empaglifozin improved both blood pressure and glucose control in African American (AA) patients with type 2 diabetes (T2D) and hypertension. Using the Diabetes Collaborative Registry, a large-scale US registry of outpatients with diabetes recruited from primary care, cardiology and endocrinology practices, we sought to understand the potential impact of these observations in routine clinical practice. Among 74 290 AA patients with T2D from 368 US clinics, 60.4% had hypertension, of whom 34.5% had systolic blood pressure ≥ 140 mm Hg (20.8% of the total AA T2D population). Only 1.7% of this eligible population had been prescribed a sodium-glucose co-transporter two inhibitor. The mean estimated 5-year risk of cardiovascular death was 7.7%, which could be reduced to 6.2% when modelling the antihypertensive effect of empagliflozin across the eligible population (based on an 8-mm Hg blood pressure reduction). These findings may represent a potential opportunity for better management of cardiovascular risk factors and improved outcomes in this vulnerable cohort.

Guidelines suggest that patients who receive implantable cardioverter-defibrillators (ICDs) for primary prevention should be expected to live more than one year after placement. However, tools for validating this prognosis are not sufficiently predictive. We sought to identify definitive predictors of one-year survival after ICD placement. By reviewing medical records and the Social Security Death Index, we analyzed baseline characteristics and survival outcomes of 3,164 patients who underwent ICD placement at our institution from January 2006 through March 2014. Survival outcome could be confirmed for 2,346 patients (74%). Of these, 184 (7.8%) died within one year of ICD placement. We noted significant differences in numerous variables between those who lived and died. However, multivariable analysis revealed only 5 independent predictors of earlier death: worse New York Heart Association functional class (hazard ratio [HR]=1.87 per class [95% CI, 1.22–2.87]; P Despite significant univariate differences between the ICD recipients who did and did not live beyond one year, we found only moderate predictors of survival. Better tools are needed to predict outcomes when considering ICD placement for primary prevention.

BACKGROUND:Cardiovascular disease (CVD) imparts a heavy economic burden on the U.S. health care system. Evidence regarding the long-term costs after comprehensive CVD screening is limited. OBJECTIVES:This study calculated 10-year health care costs for 6,814 asymptomatic participants enrolled in MESA (Multi-Ethnic Study of Atherosclerosis), a registry sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health. METHODS:Cumulative 10-year costs for CVD medications, office visits, diagnostic procedures, coronary revascularization, and hospitalizations were calculated from detailed follow-up data. Costs were derived by using Medicare nationwide and zip code-specific costs, inflation corrected, discounted at 3% per year, and presented in 2014 U.S. dollars. RESULTS:Risk factor prevalence increased dramatically and, by 10 years, diabetes, hypertension, and dyslipidemia was reported in 19%, 57%, and 53%, respectively. Self-reported symptoms (i.e., chest pain or shortness of breath) were common (approximately 40% of enrollees). At 10 years, approximately one-third of enrollees reported having an echocardiogram or exercise test, whereas 7% underwent invasive coronary angiography. These utilization patterns resulted in 10-year health care costs of $23,142. The largest proportion of costs was associated with CVD medication use (78%). Approximately $2 of every $10 were spent for outpatient visits and diagnostic testing among the elderly, obese, those with a high-sensitivity C-reactive protein level >3 mg/l, or coronary artery calcium score (CACS) ≥400. Costs varied widely from $35,800 for high-risk (persons with diabetes, Framingham risk score ≥20%, or CACS ≥400) subgroups. Among high-risk enrollees, CVD costs accounted for $74 million of the $155 million consumed by MESA participants. CONCLUSIONS:Longitudinal patterns of health care resource use after screening revealed new evidence on the economic burden of treatment and testing patterns not previously reported. Maintenance of a healthy population has the potential to markedly reduce the economic burden of CVD among asymptomatic individuals.

We examine the predilection for private bonds over bank financing (debt structure) for emerging markets within the frameworks of both transaction cost economics and a transparency explanation, emphasizing the distinction between public monitoring (bonds) and private monitoring (banks), as well as considering the influence of national culture on institutions. Employing several tests, including structural equation modeling, we find, among many results that in emerging markets bonds are preferred over bank loans when there is less corporate opacity and fewer foreign access restrictions, as well as in environment of greater political instability, transaction cost, and limits to legal protection. Bonds are also favored over banks in cultural environments of greater uncertainty avoidance, masculinity, long-term orientation, and indulgence and less individualism. Overall, we attribute our results to culture and institutional quality together influencing debt structure, particularly by impacting attitudes toward public monitoring. Our results will be of great interest to researchers interested in the legal, social, and cultural environments of emerging markets.

Colonic ischemia most often presents with abdominal pain and rectal bleeding. Presentation of colonic ischemia as a prominent mass is exceptionally unique and is not often reported. Concern for neoplasm prompted a repeat scope, which revealed the mass had vanished. We present a case of colonic ischemia, which produced a transient colonic mass formed by inflammatory tissue and clots.

We examine the impact on firm cash holdings of uncertainty of uncertainty, measured as the ex post volatility of economic policy uncertainty. Using the news-based index developed by Baker, Bloom, and Davis (2016) for twenty-two countries, we find that, when there is greater volatility of economic uncertainty, firms hold more cash. Our results are robust to controlling for a host of firm-level and country-level factors. Consistent with Baker, Bloom, and Davis (2016), we consider that less economic policy uncertainty is associated with more investment; and so the real-option value of cash is sensitive to the possibility of a future desirability of investment. Therefore, when there is greater expected volatility of uncertainty, measured under rational expectations as the recent ex post volatility of uncertainty, firms will hold more cash. We also find that the volatility of economic policy uncertainty is much more economically significant in determining firm cash holdings than economic policy uncertainty itself. Therefore, our paper not only adds to the literature on uncertainty and cash holdings, but also, importantly, to the limited literature in finance on the impact of uncertainty of uncertainty.

BackgroundThe COVID-19 pandemic adversely affected the socially vulnerable and minority communities in the USA initially, but the temporal trends during the year-long pandemic remain unknown.ObjectiveWe examined the temporal association of county-level Social Vulnerability Index (SVI), a percentile-based measure of social vulnerability to disasters, its subcomponents and race/ethnic composition with COVID-19 incidence and mortality in the USA in the year starting in March 2020.MethodsCounties (n=3091) with ≥50 COVID-19 cases by 6 March 2021 were included in the study. Associations between SVI (and its subcomponents) and county-level racial composition with incidence and death per capita were assessed by fitting a negative-binomial mixed-effects model. This model was also used to examine potential time-varying associations between weekly number of cases/deaths and SVI or racial composition. Data were adjusted for percentage of population aged ≥65 years, state-level testing rate, comorbidities using the average Hierarchical Condition Category score, and environmental factors including average fine particulate matter of diameter ≥2.5 μm, temperature and precipitation.ResultsHigher SVI, indicative of greater social vulnerability, was independently associated with higher COVID-19 incidence (adjusted incidence rate ratio per 10 percentile increase: 1.02, 95% CI 1.02 to 1.03, pConclusionExcept for the winter ‘third wave’, when majority of the white communities had the highest incidence of cases, counties with greater social vulnerability and proportionately higher minority populations experienced worse COVID-19 outcomes.

Using an extensive, time-series, cross-sectional data-set of actively traded Indian stocks with up to 1.75 million firm-day observations, we discern the key determinants of commonality in liquidity among emerging markets. The paper shows evidence for both supply-side and demand-side factors contributing to liquidity commonality. However, the results are more supportive towards supply-side rationale for liquidity commonality among the firms where regulators and banks play an important source of commonality in liquidity, especially during market turmoil. Results are partially driven by the fact that the Indian stick exchange is an order-driven market. Economic activities like cheap exports and undervalued currency, rather than correlated trading by the institutional investors determine the demand for liquidity. These findings endorse the effect of high firm value, market return, liquidity, volatility, turnover, and alternate proxies of commonality in liquidity estimation.

We show, for a sample of up to 757 industrial firms, in seven Latin American countries from 1994-2014, that these firms exhibit comparatively flexible payout behavior. Flexibility is defined in respect to (i) variability in firm payout status and amounts and (ii) parameters of the Lambrecht-Myers (2012) theory on the Lintner (1956) dividend equation. The results indicate that Latin American firms have higher speeds of adjustment and target payout ratios as well as lower rates of habit formation than found in the payout policies of United States firms. This note, thus, highlights an open question regarding conspicuously flexible payout policies in Latin American firms. (c) 2017 Elsevier Inc. All rights reserved.

Background: The efficacy of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death (SCD) has not been studied in patients with end-stage renal disease (ESRD) and left ventricular dysfunction. We sought to identify predictors of long-term survival among ICD recipients with and without ESRD. Methods: Patients implanted with an ICD at our institution from January 2006 to March 2014 were retrospectively identified. Clinical and demographic characteristics were collected. Patients were stratified by the presence of ESRD at the time of ICD implant. Mortality data were collected from the Social Security Death Index (SSDI). Results: A total of 3453 patients received an ICD at our institution in the pre-specified time period, 184 (5.3%) of whom had ESRD. In general, ESRD patients were sicker and had more comorbidities. Kaplan Meier survival curve showed that ESRD patients had worse survival as compared with non-dialysis patients (p

Aims Recent trials (EMPA-REG OUTCOME and Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results [LEADER]) have shown improved cardiovascular (CV) mortality with specific currently available glucose-lowering medications (empagliflozin and liraglutide, respectively), but were limited to selected patient populations. We sought to evaluate the current use and potential real-world impact of empagliflozin (and other sodium-glucose co-transporter 2 inhibitors [SGLT2is]) and liraglutide (and other glucagonlike peptide-1 receptor agonist [GLP-1 RAs]) among patients in the Diabetes Collaborative Registry (DCR). Methods and results We evaluated 182,525 patients from the DCR - a large, US-based outpatient registry of individuals with type 2 diabetes from 313 sites that included cardiology, endocrinology and primary care practices. Among these patients, 26.2% met major eligibility criteria for EMPA-REG OUTCOME and 48.0% met major eligibility criteria for LEADER. Of these potentially eligible patients, only a small minority were actually prescribed these agents: 5.2% on an SGLT2i and 6.0% on a GLP-1 RA, respectively. Patients receiving these studied medications or medication classes, in general, had lower CV disease burden compared with those not on these agents. Assuming similar risk reductions as in the clinical trials, if all potentially trial-eligible patients in the DCR were treated for 1 year with empagliflozin (or other SGLT2is, assuming a class effect) or liraglutide (or other GLP-1 RAs, assuming a class effect), this may have prevented 354 CV deaths, 231 heart failure hospitalizations, 329 CV deaths and 247 myocardial infarctions, respectively. Conclusion In a large, US-based outpatient registry, we found a significant number of patients would have been potentially eligible for glucose-lowering agents that demonstrated CV benefit in recent clinical trials. In view of these findings, a broader and better-targeted use of these medications in evidence-based patient populations should be considered.

Background/Aims Esophageal stricture is usually managed with outpatient endoscopic dilation. However, patients with food impaction or failure to thrive undergo inpatient dilation. Esophageal perforation is the most feared complication, and its risk in inpatient setting is unknown. Methods We used National Inpatient Sample (NIS) database for 2007–2013. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes were used to identify patients with esophageal strictures. Logistic regression was used to assess association between hospital/patient characteristics and utilization of esophageal dilation. Results There were 591,187 hospitalizations involving esophageal stricture; 4.2% were malignant. Endoscopic dilation was performed in 28.7% cases. Dilation was more frequently utilized (odds ratio [OR], 1.36; p

INTRODUCTION: African Americans (AAs) have the highest risk of developing heart failure (HF) among all ethnicities in the United States and are associated with higher rates of readmissions and mortality. This study aims to determine the prevalence and relationship of common psychiatric conditions to outcomes of patients hospitalized with HF. HYPOTHESIS: Psychiatric conditions lead to worse outcomes in HF patients. METHODS: This single‐center retrospective study enrolled 611 AA patients admitted to an urban teaching community hospital for HF from 2010 to 2013. Patient demographics, clinical variables, and history of psychiatric disorders were obtained. Cox proportional hazards regression was used to assess impact of psychiatric disorders on readmission rates and mortality. RESULTS: The mean age was 66 ± 15 years; 53% were men. Median follow‐up time from index admission for HF was 3.2 years. Ninety‐seven patients had a psychiatric condition: 46 had depression, 11 had bipolar mood disorder (BMD), and 40 had schizophrenia. After adjustment of known risk factors and clinical metrics, our study showed that AA HF patients with a psychiatric illness were 3.84× more likely to be admitted within 30 days for HF, compared with those without (P

Several previous studies have shown obesity to be counterintuitively associated with more favorable mortality in patients with acute myocardial infarction (AMI); however, the association of obesity with in-hospital mortality of cardiogenic shock complicating AMI has not been previously examined. We queried the 2004 to 2013 National Inpatient Sample databases to identify all patients ≥18 years hospitalized with the principal diagnosis of AMI. Multivariable regression models adjusting for demographics, hospital characteristics, and co-morbidities were used to examine differences in incidence and in-hospital mortality of cardiogenic shock complicating AMI between obese and nonobese patients. Of 6,097,817 patients with AMI, 290,894 (4.8%) had cardiogenic shock. There was no difference in risk-adjusted incidence of cardiogenic shock between obese and nonobese patients (adjusted odds ratio 1.00, 95% CI 0.98 to 1.01; p = 0.46). Of the patients with cardiogenic shock complicating AMI, 8.9% had a documented diagnosis of obesity. Obese patients were on average 6 years younger and had higher prevalence of most cardiovascular co-morbidities. Obese patients were more likely to receive revascularization (73.0% vs 63.4%, p

Background Intracardiac thrombosis (ICT) is a complication of Acute myocardial infarction (AMI). Hypothesis Our aim was to evaluate the impact of ICT on mortality, thromboembolism, length of stay in patients with AMI. Methods Data was collected from the Nationwide Inpatient Sample (NIS) for the year 2016, where patients with a primary diagnosis of ICT as a complication of AMI (ICD10-CM code I23.6) were included. Comparisons were made between patients with ICT post-AMI (ICD10-CM code I23.6) vs those with AMI (ICD10-CM I21.0). Results Of a total of 200930 cases of AMI, 488 (0.5%) had ICT. The patients with ICT had an increased length of stay (LOS) (8.5±9.8 vs 5.7±7.4 days; p Table 1. Patient characteristics AMI% (n=200,930) ICT post AMI% (n=488) p-values Demographic variables a. Males 59 73 b. Females 41 27 Conclusion ICT as a complication of AMI is associated with increased hospital LOS and adverse events.

Background Little is known regarding use of cardiac therapies and clinical outcomes among older myocardial infarction ( MI ) patients with cognitive impairment. Methods and Results Patients ≥65 years old with MI in the NCDR (National Cardiovascular Data Registry) Chest Pain– MI Registry between January 2015 and December 2016 were categorized by presence and degree of chart‐documented cognitive impairment. We evaluated whether cognitive impairment was associated with all‐cause in‐hospital mortality after adjusting for known prognosticators. Among 43 812 ST‐segment–elevation myocardial infarction (STEMI) patients, 3.9% had mild and 2.0% had moderate/severe cognitive impairment; among 90 904 non–ST‐segment–elevation myocardial infarction (NSTEMI patients, 5.7% had mild and 2.6% had moderate/severe cognitive impairment. A statistically significant but numerically small difference in the use of primary percutaneous coronary intervention was observed between patients with STEMI with and without cognitive impairment (none, 92.1% versus mild, 92.8% versus moderate/severe, 90.4%; P =0.03); use of fibrinolysis was lower among patients with cognitive impairment (none, 40.9% versus mild, 27.4% versus moderate/severe, 24.2%; P NSTEMI patients without cognitive impairment, rates of angiography, percutaneous coronary intervention, and coronary artery bypass grafting were significantly lower among patients with NSTEMI with mild (41%, 45%, and 70% lower, respectively) and moderate/severe cognitive impairment (71%, 74%, and 93% lower, respectively). After adjustment, compared with no cognitive impairment, presence of moderate/severe ( STEMI : odds ratio, 2.2, 95% CI , 1.8–2.7; NSTEMI : odds ratio, 1.7, 95% CI , 1.4–2.0) and mild cognitive impairment ( STEMI : OR , 1.3, 95% CI , 1.1–1.5; NSTEMI : odds ratio, 1.3, 95% CI , 1.2–1.5) was associated with higher in‐hospital mortality. Conclusions Patients with NSTEMI with cognitive impairment are substantially less likely to receive invasive cardiac care, while patients with STEMI with cognitive impairment receive similar primary percutaneous coronary intervention but less fibrinolysis. Presence and degree of cognitive impairment was independently associated with increased in‐hospital mortality. Approaching clinical decision making for older patients with MI with cognitive impairment requires further study.

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS3 days and TFI with LOS3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that$300 million could be saved if prevalence of the TRI with LOS3 days and TFI with LOS3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.

Contrast-induced acute kidney injury (AKI) is a common and severe complication of percutaneous coronary intervention (PCI). Despite its substantial burden, contemporary data on the incremental costs of AKI are lacking. We designed this large, nationally representative study to examine: (1) the independent, incremental costs associated with AKI after PCI and (2) to identify the departmental components of cost contributing to the incremental costs associated with AKI. In this observational cross-sectional study from the Premier database, we analyzed 1,443,297 PCI patients at 518 US hospitals from 1/2006 to 12/2015. Incremental cost of AKI from a hospital perspective obtained by a microcosting approach, was estimated using mixed-effects, multivariable linear regression with hospitals as random effects. Costs were inflation-corrected to 2016 US$. AKI occurred in 82,683 (5.73%) of the PCI patients. Those with AKI had higher hospitalization cost than those without ($38,869, SD 42,583 vs $17,167 SD 13,994, p

Background: Heart failure (HF) is one of the most common and morbid complications of T2D. Prompt recognition of early signs of HF may avert HF hospitalization and may also impact T2D meds (e.g., TZDs or possibly SGLT2i). We determined the rate and factors associated with HF diagnosis in T2D patients with evidence of volume overload requiring loop diuretics. Methods: DCR is a U.S. registry of outpatient T2D patients from 3074 cardiology, endocrinology, and primary care providers. Among T2D patients receiving loop diuretics, we examined the rate of documentation of HF. We excluded patients with chronic liver disease, as they may have a non-HF indication for loop diuretics. Results: Among 931,361 adults with T2D, 215,957 (23%) were on a loop diuretic of whom 110,809 (51%) had documentation of HF. Patients seen by cardiologists and PCPs were more likely have HF documented vs. endocrinologists (52% and 50% vs. 22%; p Conclusions: Among U.S. outpatients with T2D, 23% had evidence of volume overload of whom half had a diagnosis of HF. While there may be non-HF indications for loop diuretics, our data suggest that a substantial proportion of T2D patients may have unrecognized HF and therefore could be missing therapies that could alter the clinical course of HF. Disclosure S.V. Arnold: None. M.N. Kosiborod: Consultant; Self; Amgen Inc., AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Eisai Co., Ltd., GlaxoSmithKline plc., Glytec, LLC, Intarcia Therapeutics, Inc., Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novartis AG, Novo Nordisk A/S, Sanofi. Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. P. Jones: None. M.H. Beasley: None. A. Goyal: None. J.M. Cordova: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. G.C. Fonarow: Consultant; Self; Abbott, Amgen Inc., Bayer US, Janssen Pharmaceuticals, Inc., Medtronic, Novartis Pharmaceuticals Corporation. L.J. Seman: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc.

Background: For heart transplant recipients, guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy (CAV). However, current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize CAV as a unique PCI indication, and thus PCI for CAV is often labeled “rarely appropriate (RA).” The AUC-R’s omission of CAV patients, and its impact on RA PCI rates and hospital pay-for-performance reimbursement have never been described. Methods: Using NCDR CathPCI Registry data, we identified all elective PCIs from 96 Medicare-approved heart transplant centers between 2009Q3 and 2017Q2. NCDR-reported rates of RA elective PCI were compared before and after exclusion of CAV patients using paired t-tests. The annual pay-for-performance financial incentives potentially lost by heart transplant centers were estimated based on AUC-R performance thresholds published by Anthem Blue Cross and Blue Shield’s Quality-In-Sights®: Hospital Incentive Program (Q-HIP®). Results: Of 168,802 elective PCIs performed in heart transplant centers, 1,854 (1.1%) were for CAV. CAV patients, compared with non-heart transplant recipients, were more frequently asymptomatic (81.9% vs. 33.4%, pFigure ). In a sample of 16 heart transplant centers participating in Q-HIP® during the 2017 calendar year measurement period, 2 (13%) centers could have each observed reimbursement increases estimated at ~$90,000 dollars if their Q-HIP® scorecards were re-scored after excluding CAV patients. Conclusion: Two-thirds of PCI cases in CAV patients are deemed RA by the AUC-R. The failure of the AUC-R to recognize CAV as a unique PCI indication may lead to inflated RA PCI rates and has the potential for substantial negative pay-for-performance implications in heart transplant centers. The AUC-R should recognize CAV as a unique PCI indication so that heart transplant centers are not penalized for performing PCI for CAV.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

SYNOPSIS We study the impact of corporate secretary tenure on the governance quality of Chinese A-share listed firms. Results show that corporate secretary tenure is negatively associated with board meeting frequency, outside director in-meeting dissent, and incidence of fraud and lawsuit. Key findings are robust to an array of additional tests including propensity score matching, instrument variable analysis, as well as alternate governance measures such as analyst coverage, modified auditor opinion, number of institutional shareholders, and outside director board meeting absence. Overall, our study confirms the importance of corporate secretary in favor of modern corporate governance outcomes and board processes. JEL Classifications: G15; G30; K22; M41.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry–Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P P P P P Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

Gitelman syndrome is an inherited renal disorder characterized by hypomagnesemia, hypokalemia, hypocalciuria and metabolic alkalosis linked to the genes encoding the thiazide sensitive NaCl cotransporter (NCCT) located on the distal convoluted tubule of the kidney. It usually presents in late childhood or early adulthood with electrolyte abnormalities resembling chronic thiazide diuretic use. Acquired Gitelman syndrome is a very rare disorder mostly associated with Sjogren’s syndrome.

Based on rodent models, researchers have theorized that the hippocampus supports episodic memory and navigation via the theta oscillation, a ~4–10-Hz rhythm that coordinates brain-wide neural activity. However, recordings from humans have indicated that hippocampal theta oscillations are lower in frequency and less prevalent than in rodents, suggesting interspecies differences in theta’s function. To characterize human hippocampal theta, we examined the properties of theta oscillations throughout the anterior–posterior length of the hippocampus as neurosurgical subjects performed a virtual spatial navigation task. During virtual movement, we observed hippocampal oscillations at multiple frequencies from 2 to 14 Hz. The posterior hippocampus prominently displayed oscillations at ~8-Hz and the precise frequency of these oscillations correlated with the speed of movement, implicating these signals in spatial navigation. We also observed slower ~3-Hz oscillations, but these signals were more prevalent in the anterior hippocampus and their frequency did not vary with movement speed. Our results converge with recent findings to suggest an updated view of human hippocampal electrophysiology. Rather than one hippocampal theta oscillation with a single general role, high-and low-theta oscillations, respectively, may reflect spatial and non-spatial cognitive processes.

Background We sought to determine temporal trends in use of evidence‐based therapies and clinical outcomes among myocardial infarction ( MI) patients with chronic kidney disease ( CKD ). Methods and Results MI patients from the NCDR (National Cardiovascular Data Registry) Chest Pain– MI Registry between January 2007 and December 2015 were categorized into 3 groups by degree of CKD (end‐stage renal disease on dialysis, CKD [glomerular filtration rate 2 ] not requiring dialysis, and no CKD [glomerular filtration rate ≥60 mL/min per 1.73 m 2 ]). Logistic regression modeling was used to determine the association between calendar years (2014–2015 versus 2007–2008) and each outcome by degree of CKD . Among 325 396 patients with ST‐segment–elevation MI, 1.0% had end‐stage renal disease requiring dialysis, and 26.1% had CKD not requiring dialysis. Use of primary percutaneous coronary intervention increased over time regardless of the presence or degree of CKD ( P= 0.40 for interaction). In‐hospital mortality was temporally higher among patients with preserved renal function (odds ratio: 1.25; 95% confidence interval, 1.13–1.39; P CKD ( P =0.035 for interaction). Among 506 876 non–ST‐segment–elevation MI patients, 3.4% had end‐stage renal disease requiring dialysis, and 34.4% had CKD not requiring dialysis. P2Y 12 inhibitor use within 24 hours increased over time only among dialysis patients ( P for interaction P for interaction CKD ( P =0.64 for interaction). Conclusions Uptake of evidence‐based medical and invasive therapies has increased over the past decade among MI patients with CKD , particularly dialysis patients, with improvement of in‐hospital mortality observed among patients with non–ST‐segment–elevation MI, but not ST‐segment–elevation MI, and CKD .

Deep brain stimulation (DBS) is used to treat a wide array of neurologic conditions. However, traditional programming of stimulation parameters relies upon short term subjective observation of patient symptoms and undesired stimulation effects while in the clinic. To gain a more objective measure of the neuronal activity that contributes to patient symptoms and response to treatment, there is a clear need for a fully-implantable DBS system capable of chronically recording patient-specific electrophysiological biomarker signals over time. By providing an objective correlate of a patient’s disease and response to treatment, this capability has the potential to improve therapeutic benefit while preventing undesirable side effects. Herein, the engineering and capabilities of the Percept PC, the first FDA-approved, fully-implantable DBS device capable of nearly-simultaneous electrophysiological recordings and stimulation, are discussed. The device’s ability to chronically record local field potentials (LFPs) at implanted DBS leads was validated in patients with neurological disorders. Lastly, the electrophysiological activity correlates of clinically relevant patient-reported events are presented. While FDA approved for conditions such as Parkinson’s disease, essential tremor, dystonia, obsessive-compulsive disorder, and epilepsy, chronic electrophysiological recordings in humans has broad applications within basic science and clinical practice beyond DBS, offering a wealth of information related to normal and abnormal neurophysiology within distinct brain areas.

Background/Aims There is lack of consensus on the optimal time allotted for colonoscopy, which increases patient wait times. Our aim was to identify and quantify the individual pre-procedural factors that determine the total procedure time (TPT) of colonoscopy. Methods This retrospective study involved 4,494 subjects, undergoing outpatient colonoscopy. Effects of age, sex, body mass index, abdominal surgery history, procedure indication (screening, surveillance, or diagnostic), procedure session (morning or afternoon), and endoscopist’s experience (fellow or attending) on TPT were evaluated using multiple regression analysis. A p0.05) as did afternoon session colonoscopies (p=0.004). Less experienced endoscopists had longer TPTs (p>0.05). Screening (p=0.01) and surveillance (p=0.008) colonoscopies had a longer TPT than diagnostic procedures. Overall, the F-value of the regression model was 0.0009. Conclusions The indication for colonoscopy and the time of day have statistically significant associations with TPT. These results will help in streamlining workflow, reduce wait time, and improve patient satisfaction.

A drop in blood pressure (BP) or blunted BP response is an established high-risk marker during exercise myocardial perfusion imaging (MPI); however, data are sparse regarding the prognostic value of BP response in patients undergoing vasodilator stress rubidium-82 (Rb-82) Positron Emission Tomography (PET) MPI. From the PET Prognosis Multicenter Registry, a cohort of 3413 patients underwent vasodilator stress Rb-82 PET MPI with dipyridamole or adenosine. We used multivariable Cox proportional hazard regression to analyze the association with mortality of four BP variables: stress minus rest systolic BP (∆SBP), stress minus rest diastolic BP (∆DBP), resting systolic BP (rSBP), and resting diastolic BP (rDBP). Covariates that had univariate P values

Background— Among older patients with acute myocardial infarction (MI), it remains uncertain whether there is a time-dependent difference in the risk of recurrent mortality and nonfatal cardiovascular and cerebrovascular events for those with ST-segment–elevation MI (STEMI) compared with those with non–ST-segment–elevation MI. Methods and Results— Older patients ≥65 years with acute MI and significant coronary artery disease identified with coronary angiography from the ACTION Registry-GWTG (Get With the Guidelines) were linked to Medicare claims data from 2007 to 2010. We examined the unadjusted cumulative incidence of each outcome studied from hospital discharge through 2 years with log-rank tests and then performed a piece-wise proportional hazards modeling with 2 time periods: discharge to 90 days and 90 days to 2 years. Among the 46 199 patients linked with Medicare data, 17 287 (37.4%) presented with STEMI. Through 2 years, the unadjusted cumulative incidence of all-cause mortality (16.0% versus 19.8%; P P P P Conclusions— Among older acute MI patients with angiographically confirmed coronary artery disease discharged alive, STEMI patients (compared with non–ST-segment–elevation MI patients) were found to have a lower frequency of unadjusted postdischarge mortality and composite cardiovascular and cerebrovascular outcomes through 2 years after hospital discharge. This analysis provides unique insight into differential short- and long-term risks of ischemic cardiovascular and cerebrovascular outcomes by MI classification among older MI patients with confirmed coronary artery disease surviving to hospital discharge.

Background— Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non–ST-segment–elevation myocardial infarction. Methods and Results— Using Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines (ACTION Registry–GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non–ST-segment–elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; P trend =0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; p trend =0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%–100%; 0%–78%, respectively; P value Conclusions— Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non–ST-segment–elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years.

Background/Aims: Obesity is a much-debated factor with conflicting evidence regarding its association with cecum intubation rates during colonoscopy. We aimed to identify the association between cecal intubation (CI) time and obesity by eliminating confounding factors. Methods: A retrospective chart review of subjects undergoing outpatient colonoscopy was conducted. The population was categorized by sex and obesity (body mass index [BMI, kg/m2]: I

A generation of experimental and clinical research provides the pathophysiological construct for the classification of myocardial infarction (MI) described in the 2012 European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation Expert Consensus Document on the Third Universal Definition of Myocardial Infarction.1 Notably, subtypes of Type 1 MI (ie, ST elevation MI [STEMI] and non-ST elevation MI [NSTEMI]) share common pathophysiological mechanisms (typically spontaneous plaque rupture, ulceration, erosion, or dissection with thrombus formation resulting in myocyte necrosis), with extensive guidelines defining best clinical practice. By contrast, Type 2 MI, defined as myocardial injury with myocyte necrosis due to an acute ischemic imbalance between myocardial oxygen supply and/or demand without plaque disruption, has heterogeneous underlying causes (eg, coronary spasm, coronary endothelial dysfunction, arrhythmias, anemia, respiratory failure, shock, severe hypertension, or hypotension). Despite distinct causes, Type 1 NSTEMI and Type 2 MI can be particularly difficult to distinguish at presentation, with the diagnosis becoming clear only after further testing.2,3 The difficulty in distinguishing between these diagnoses complicates both initial patient management and systematic research about Type 2 MI, and no set of guidelines is currently appropriate for Type 2 MI patient management. Through the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) Coordination and Maintenance Committee of the Centers for Medicare and Medicaid Services (CMS), representatives of the American Heart Association …

IMPORTANCE: Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown. OBJECTIVE: To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards. DESIGN, SETTING, AND PARTICIPANTS: This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018. EXPOSURES: Prior heart transplant. MAIN OUTCOMES AND MEASURES: Rates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield’s Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients. RESULTS: Of 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P

The optimal antiplatelet duration after percutaneous coronary intervention (PCI) with stenting is not completely understood. PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials (RCTs) comparing antiplatelet duration strategies after PCI. The outcomes of interest were

The association of the Hospital Readmission Reduction Program (HRRP) with reductions in racial disparities in 30-day outcomes for myocardial infarction (MI), is unknown, including whether this varies by HRRP hospital penalty status.To assess temporal trends in 30-day readmission and mortality rates among black and nonblack patients discharged after hospitalization for acute MI at low-performing and high-performing hospitals, as defined by readmission penalty status after HRRP implementation.This observational cohort analysis used data from the multicenter National Cardiovascular Data Registry Chest Pain-MI Registry centers that were subject to the first cycle of HRRP, between January 1, 2008, and November 30, 2016. All patients hospitalized with MI who were included in National Cardiovascular Data Registry Chest Pain-MI Registry were included in the analysis. Data were analyzed from April 2018 to September 2019.Hospital performance category and race (black compared with nonblack patients). Centers were classified as high performing or low performing based on the excess readmission ratio (predicted to expected 30-day risk adjusted readmission rate) for MI during the first HRRP cycle (in October 2012).Thirty-day all-cause readmission and mortality rates.Among 753 hospitals that treated 155 397 patients with acute MI (of whom 11 280 [7.3%] were black), 399 hospitals (53.0%) were high performing. Thirty-day readmission rates declined over time in both black and nonblack patients (annualized 30-day readmission rate: 17.9% vs 20.8%). Black (compared with nonblack) race was associated with higher unadjusted odds of 30-day readmission in both low-performing and high-performing centers (odds ratios: before HRRP: low-performing hospitals, 1.14 [95% CI, 1.03-1.26]; P = .01; high-performing hospitals, 1.17 [95% CI, 1.04-1.32]; P = .01; after HRRP: low-performing hospitals, 1.23 [95% CI, 1.13-1.34]; P .001; high-performing hospitals, 1.25 [95% CI, 1.12-1.39]; P .001). However, these racial differences were not significant after adjustment for patient characteristics. The 30-day mortality rates declined significantly over time in nonblack patients, with stable (nonsignificant) temporal trends among black patients. Adjusted associations between race and 30-day mortality showed that 30-day mortality rates were significantly lower among black (compared with nonblack) patients in the low-performing hospitals (odds ratios: pre-HRRP, 0.79 [95% CI, 0.63-0.97]; P = .03; post-HRRP, 0.80 [95% CI, 0.68-0.95]; P = .01) but not in high-performing hospitals. Finally, the association between race and 30-day outcomes did not vary after the HRRP period began in either high-performing or low-performing hospitals.In this analysis, 30-day readmission rates among patients with MI declined over time for both black and nonblack patients. Differences in race-specific 30-day readmission rates persisted but appeared to be attributable to patient-level factors. The 30-day mortality rates have declined for nonblack patients and remained stable among black patients. Implementation of the HRRP was not associated with improvement or worsening of racial disparities in readmission and mortality rates.

Previous research finds market financing is favored over relationship financing in environments of better governance, since the transaction costs to investors of vetting asymmetric information are thereby reduced. For industries supplying public goods, for-profits rely on market financing, while nonprofits rely on relationships with donors. This suggests that for-profits will be more inclined than nonprofits to improve financial transparency. We examine the impact of for-profit versus nonprofit status on the financial transparency of firms engaged with supplying public goods. There are relatively few industries that have large number of both for-profit and nonprofit firms across countries. However, the microfinance industry provides the opportunity of a large number of both for-profit and nonprofit firms in relatively equal numbers, across a wide array of countries. Consistent with our prediction, we find that financial transparency is positively associated with a for-profit status. Results will be of broad interest both to scholars interested in the roles of transparency and transaction costs on market versus relational financing; as well as to policy makers interested in the impact of for-profit on the supply of public goods, and on the microfinance industry in particular.