Search

We study the broadband emission of Mrk 501 using multiwavelength observations from 2017 to 2020 performed with a multitude of instruments, involving, among others, MAGIC, Fermi's Large Area Telescope (LAT), NuSTAR, Swift, GASP-WEBT, and the Owens Valley Radio Observatory. Mrk 501 showed an extremely low broadband activity, which may help to unravel its baseline emission. Nonetheless, significant flux variations are detected at all wave bands, with the highest occurring at X-rays and very-high-energy (VHE) γ -rays. A significant correlation (>3 σ ) between X-rays and VHE γ -rays is measured, supporting leptonic scenarios to explain the variable parts of the emission, also during low activity. This is further supported when we extend our data from 2008 to 2020, and identify, for the first time, significant correlations between the Swift X-Ray Telescope and Fermi-LAT. We additionally find correlations between high-energy γ -rays and radio, with the radio lagging by more than 100 days, placing the γ -ray emission zone upstream of the radio-bright regions in the jet. Furthermore, Mrk 501 showed a historically low activity in X-rays and VHE γ -rays from mid-2017 to mid-2019 with a stable VHE flux (>0.2 TeV) of 5% the emission of the Crab Nebula. The broadband spectral energy distribution (SED) of this 2 yr long low state, the potential baseline emission of Mrk 501, can be characterized with one-zone leptonic models, and with (lepto)-hadronic models fulfilling neutrino flux constraints from IceCube. We explore the time evolution of the SED toward the low state, revealing that the stable baseline emission may be ascribed to a standing shock, and the variable emission to an additional expanding or traveling shock.

Objectives: To evaluate the efficacy of multi-functional root canal irrigating solutions in the removal of canal wall smear layers, antibacterial activity, cytotoxicity, and tissue dissolution efficacy., Methods: Forty single-rooted teeth were mechanically instrumented and irrigated with Triton, EndoJuice™, EDTA, and 0.9 % saline. Each tooth was evaluated for smear layer removal using scanning electron microscopy. Antibacterial activity of the irrigants was assessed against Enterococcus faecalis biofilms using colony-forming unit analysis. Neutral red, clonogenic, and cytokinesis-block micronucleus assays were performed on Chinese hamster V79 cells to evaluate the short-term and long-term cytotoxicity and genotoxicity of the irrigants. Tissue dissolution efficacy was tested on shrimp meat placed in resorptive cavities prepared in root canals., Results: EndoJuice™ and EDTA showed better smear layer removal than Triton in the coronal-third and middle-third of the canal walls. There was no significant difference between EndoJuice™ and EDTA. In the apical-third, EndoJuice™ removed the smear layer more effectively than EDTA and Triton. Specimens treated with saline were heavily smeared. Triton and sodium hypochlorite were similar in reducing intracanal E. faecalis counts, while specimens treated with EndoJuice™ had higher colony-forming units compared to Triton or sodium hypochlorite. EndoJuice™ was less cytotoxic and genotoxic compared to Triton. Sodium hypochlorite dissolved the most soft tissue, followed by Triton and EndoJuice™., Conclusion: EndoJuice™ was less toxic and more effective in smear layer removal. Triton demonstrated better antimicrobial activity and tissue dissolution efficacy., Clinical Significance: Evaluating the smear layer removal, antibacterial activity, toxicity, and tissue dissolution abilities of multi-functional root canal irrigants is essential to ensure their effectiveness and safety for clinical use in root canal treatment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

More than 1 million transcatheter-based cardiovascular procedures across the spectrum of interventional cardiology are performed annually in the United States. With the expanded indications for and increased complexities associated with these procedures, interventional cardiologists are expected to possess the requisite expertise to complete these interventions safely and effectively. While the art of vascular access and closure remains a prerequisite and critical skillset in contemporary practice, there remain significant variations in the techniques employed, resulting in the bleeding and vascular complications encountered in clinical practice. With an increasing recognition of the potential merits to standardized approaches to vascular access and closure, cardiovascular societies have put forth recommendations around best practices for performing these procedures in the cardiac catheterization laboratories. In this review, we aim to: (1) Examine the evolving definitions of bleeding and vascular complications; (2) Review best practices for transradial and transfemoral access and closure, including for large bore procedures; and (3) Highlight knowledge gaps and proposed areas of clinical research pertaining to vascular access which may inform clinical practice and potentially optimize the outcomes of patients undergoing transcatheter-based cardiac and vascular interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Eltelbany, Fabbri, Batchelor, Cilia, Ducoffe, Endicott, Epps, McBurnie, Neville, Rosner, Sherwood, Spinosa, Truesdell, Vorgang, Damluji and Tehrani.)

Background: How diabetes mellitus (DM), race/ethnicity, and sex impact ischemic events following coronary artery stent procedures is unknown., Methods: Using the PLATINUM Diversity and PROMUS Element Plus Post-Approval Pooled Study (N = 4184), we examined the impact of race/ethnicity, sex, and DM on coronary stent outcomes. Primary outcome was 1-year major adverse cardiac events (MACE) (MACE composite: death, myocardial infarction [MI], and target vessel revascularization)., Results: The study sample included 1437 diabetic patients (501 White men, 470 White women, 246 minority men, 220 minority women) and 2641 patients without medically treated DM (561 minority, 1090 women). Mean age (years) ranged from 61 in minority men to 65 in White women. Diabetic patients had a higher prevalence of atherosclerotic risk factors and comorbidities. Diabetic minority women (DMW; 70% Black, 27% Hispanic) had similar atherosclerotic risk factors to other diabetics, but experienced higher 1-year MACE (14.4% vs 7.5%, P <.01) and MI (4.3% vs 1.6%, P <.01) rates compared with patients without medically treated DM. No other diabetic cohort (White men, White women, minority men) showed an increased risk of MACE vs patients without medically treated DM. The incremental risk of MACE in DMW was associated with insulin use and persisted after risk adjustment (adjusted odds ratio 1.6 vs patients without medically treated DM; 95% CI, 1.0-2.5). Independent predictors of 1-year MACE included insulin use, hyperlipidemia, renal disease, and prior MI., Conclusions: DMW face the highest risk of ischemic events following coronary stenting, driven, in part, by insulin use. Aggressive secondary prevention and strict glycemic control are imperative in this cohort, and further research is warranted to elucidate the biologic mechanisms underpinning these observations., Clinical Trial Registration: NCT02240810 (http://clinicaltrials.gov/).

Beta-hemolytic streptococci are common causes of bloodstream infection (BSI). There is emerging data regarding oral antibiotics for BSI but limited for beta-hemolytic streptococcal BSI. We conducted a retrospective study of adults with beta-hemolytic streptococcal BSI from a primary skin/soft tissue source from 2015 to 2020. Patients transitioned to oral antibiotics within 7 days of treatment initiation were compared to those who continued intravenous therapy, after propensity score matching. The primary outcome was 30-day treatment failure (composite of mortality, infection relapse, and hospital readmission). A prespecified 10% noninferiority margin was used for the primary outcome. We identified 66 matched pairs of patients treated with oral and intravenous antibiotics as definitive therapy. Based on an absolute difference in 30-day treatment failure of 13.6% (95% confidence interval 2.4 to 24.8%), the noninferiority of oral therapy was not confirmed ( P  = 0.741); on the contrary, the superiority of intravenous antibiotics is suggested by this difference. Acute kidney injury occurred in two patients who received intravenous treatment and zero who received oral therapy. No patients experienced deep vein thrombosis or other vascular complications related to treatment. In patients treated for beta-hemolytic streptococcal BSI, those who transitioned to oral antibiotics by day 7 showed higher rates of 30-day treatment failure than propensity-matched patients. This difference may have been driven by underdosing of oral therapy. Further investigation into optimal antibiotic choice, route, and dosing for definitive therapy of BSI is needed., Competing Interests: The authors declare a conflict of interest. A.V. reports being an inventor for Mayo Clinic Travel App interaction with Smart Medical Kit and Medical Kit for Pilgrims and receiving funding from Moderna Inc for Advisory Board participation. All other authors have no potential conflicts of interest to report.

The Cardiovascular Disease in Women Committee of the American College of Cardiology convened a working group to develop a consensus regarding the continuing rise of mortality rates in young women aged 35 to 54 years. Heart disease mortality rates in young women continue to increase. Young women have increased mortality secondary to ischemic heart disease (IHD) compared with comparably aged men and similar mortality to that observed among older women. The authors reviewed the published evidence, including observational and mechanistic/translational data, and identified knowledge gaps pertaining to young women. This paper provides clinicians with pragmatic, evidence-based management strategies for young women at risk for IHD. Next-step research opportunities are outlined. This report presents highlights of the working group review and a summary of suggested research directions to advance the IHD field in the next decade., Competing Interests: Funding Support and Author Disclosures This study was funded by National Institute for Nursing Research grants 1K99NR018679-01 and F31NR015725, UCLA Clinical and Translational Science Institutes grants UL1TR000124 and UL1TR001881-01, and the Preventive Cardiovascular Nurses Association grant #5362 through the American Nurses Foundation (Dr Minissian). Additional support was provided by the Cedars-Sinai Department of Obstetrics and Gynecology, the Cedars-Sinai Brawerman Nursing Institute, Department of Nursing Research, and the Cedars-Sinai Barbra Streisand Women’s Heart Center, Beta Chi Chapter, and Cedars-Sinai Precision Health Institute grant #42254 (Dr Minissian). Dr Wei is supported by National Institutes of Health (NIH) grants K23HL125941 and R01HL146158. Dr Bairey Merz is supported by NIH grants R01HL124649 and U54 AG065141, the Barbra Streisand Women’s Cardiovascular Research and Education Program, Cedars-Sinai Medical Center Los Angeles, the Linda Joy Pollin Women’s Heart Health Program, the Erika Glazer Women’s Heart Health Project, and the Adelson Family Foundation, Cedars-Sinai Medical Center, Los Angeles, California. Dr Reynolds is supported by American Heart Association grant SFRN 20-A0-00-1005066. Dr Quesada is supported by NIH grants T32HL116273 and K23HL151867. Dr Minissian has received honoraria from the National Lipid Association, North American Menopause Society, MJH Life Sciences, Vox Media, Medtelligence, Minneapolis Heart Institute, Primed, Good Samaritan Hospital Los Angeles, California, Cardiometabolic Health Congress, American Heart Association, Preventive Cardiovascular Nurses Association, and the American College of Cardiology; has been a consultant for and served on a medical advisory board for Amgen; and has served as a co-chair for CME for the North American Center for Continuing Medical Education honorarium. Dr Wei has received institutional fees for serving on an advisory board for Abbott Vascular. Dr Bairey Merz has received consulting fees from Abbott Diagnostics, Caladrius, and Sanofi Vascular; and receives consulting fees, is on the board of directors and owns stock in iRhythm. Dr Volgman has served as a consultant and on advisory boards for Merck, Bristol Myers Squibb Foundation, Novo Nordisk, and Janssen; has received research funding from Novartis; and hold stocks in Apple, Inc. Dr Elgendy has received research grants from Caladrius Biosciences, Inc, unrelated to this paper. Dr Mamas has been a speaker for Daiichi-Sankyo. Dr Reynolds has received in-kind donations for research from Abbott Vascular, Siemens, and BioTelemetry, Inc. Dr Piazza has received research grants from BMS/Pfizer, Janssen, Alexion, Bayer, Amgen, and BSC; and has an advisory role in BSC, Amgen, BCRI, PERC, Syntactx, BMS, and Janssen. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Objective: Women who experience adverse pregnancy outcomes (APO) are at increased risk for cardiovascular disease (CVD); however, their knowledge of CVD risk is not well characterized. We aimed to evaluate knowledge and perception of CVD risk in young women and to determine whether these factors differ based on experience of an APO., Methods: We conducted a cross-sectional study among women with a recent live birth at an urban medical center. Knowledge and perception of CVD risk were assessed through a self-administered online survey adapted from the American Heart Association Survey of Women's CVD Awareness., Results: Of 5612 individuals contacted between 3/1/21 and 4/18/21, 714 completed the survey; the mean (SD) age was 34 (4) years and 25% reported an APO. While 62% of respondents identified CVD as the leading cause of death in women, there was no significant difference in CVD knowledge scores between participants who reported experiencing an APO and those who did not (6.9 vs 6.8 out of 10; p = 0.51). Participants who reported experiencing an APO had higher perception of personal risk for CVD (adjusted odds ratio, 2.64 [95% CI 1.83-3.80]) compared with participants who did not. Half of participants who experienced an APO reported perceiving average, or below average, risk for CVD and only 41 (22.5%) reported speaking with a healthcare professional about CVD within the past year., Conclusions: Gaps remain in knowledge of CVD risk among young women, particularly after an APO. The peripartum period may represent a unique opportunity for targeted education when healthcare engagement is high., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier B.V.)

Sudden cardiac death is hypothesized to be one of the leading causes of mortality in peripartum cardiomyopathy. This case illustrates a patient who presented with cardiac arrest, and it discusses the importance of considering multiple causes of fulminant ventricular arrhythmias in the setting of decreased left ventricular function during the peripartum period. ( Level of Difficulty: Advanced. )., Competing Interests: Dr Shah has received grant support from the National Institutes of Health (1K23HL143179). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2022 The Authors.)

Background: We aimed to evaluate the influence of heart failure (HF) on clinical and economic outcomes among older adults ≥75 years of age during their acute myocardial infarction (AMI) admission in large population-based study from the United States. We also evaluated the clinical characteristics associated with the presence of HF and the predictors of mortality, healthcare utilization, and cost among older adults with AMI., Methods: From January 1, 2000, to December 31, 2016, AMI admission was identified using the primary diagnosis and concomitant HF was identified using any non-primary diagnoses in the Premier Healthcare Database., Results: Of the 468,654 patients examined, 42,946 (9%) had concomitant HF during their AMI admission. These patients were older, more often female, and were more likely to be White. Patients with concomitant HF were more likely to be frail than non-HF patients (59% vs 15%, P < .001). The mean (SD) Elixhauser comorbidity index was 2.6 (2.5) vs 0.4 (1.1), P < .001 in the AMI with HF vs AMI only group. The use of percutaneous coronary intervention in those with AMI and HF was lower than those with AMI only (15% vs 31%, P < .001). The overall mortality rate for those with HF was 12%, the median [IQR] hospital length of stay was 5 [3,9] days, and only 25% of patients were discharged home. A higher proportion of patients were discharged to rehabilitation or hospice if they had AMI and HF (Rehabilitation: 33% vs 20%, P < .001; Hospice: 5% vs 3%, P < .001). The mean unadjusted cost of an AMI hospitalization in patients with concomitant HF was lower ($12,411 ± $14,860) than in those without HF ($15,828 ± $19,330). After adjusting for age, gender, race, hypertension, frailty, revascularization strategy, and death, the average cost of hospitalization attributed to concomitant HF was +$1,075 (95% CI +876 to $1,274) when compared to AMI patients without HF., Conclusion: In patients ≥75 years of age, AMI with concomitant HF carries higher risk of death, but at ages ≥85 years, the risk difference diminishes due to other competing risks. HF was also associated with longer hospital length of stay and higher likelihood of referral to hospice and rehabilitation facilities when compared to older patients without HF. Care for these older adults is associated with increased hospitalization costs. Measures to identify HF in older adults during their AMI admission are necessary to optimize health outcomes, care delivery, and costs., Competing Interests: Conflict of interest The authors declare that they have no relevant interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, electronic health record (EHR) informatics, compliance, legal, medical ethics, engineering, administration, and other critical areas. Clear communication and a culture in which all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our patients with COVID-19 in the outpatient setting are met., (Copyright © 2021. Published by Elsevier Inc.)

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up., Competing Interests: Funding Support and Author Disclosures Supported by National Institutes of Health/National Heart, Lung, and Blood Institute grants K23 HL136853-03 and R01 HL153382-01 (Dr. Bello). Dr. Brown is a coauthor of UpToDate. Dr. Park has served as a consultant for Abbott Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the incidence, prognosis, and predictors of major Valve Academic Research Consortium (VARC-2) vascular complications (VCs) and percutaneous vascular closure device failure (PCDF) following contemporary percutaneous transfemoral transcatheter aortic valve replacement (TF-TAVR)., Background: Limited data exists on the incidence and predictors of VCs and PCDFs following percutaneous TF-TAVR using contemporary 14-16 French (F) sheaths., Methods: We recorded clinical and procedural characteristics, computer tomography (CT) angiographic data, 30-day VCs, mortality, and length of stay (LOS) in all consecutive percutaneous TF-TAVRs at a single center from June 2016 to October 2018. CT measures included common femoral artery (CFA) and external iliac artery (EIA) diameters, sheath to CFA and EIA ratios (SFAR and SEIAR), depth of CFA, extent and location of CFA calcification and pelvic vessel tortuosity (2 bends ≥90°). Multivariable regression was used to predict major VCs and percutaneous closure device failure (PCDF), respectively., Results: The final sample consisted of 303 percutaneous TF-TAVRs. Median age was 80 years, 51% were male, 86% Caucasian, 33% had diabetes mellitus (DM) and mean STS score was 5.8 ± 3.8%. Baseline characteristics were similar in patients with vs. without VCs, other than coronary artery disease (CAD) (69% vs. 54%, respectively; p = 0.029) and DM (21% vs. 36%, respectively; p = 0.02). There were 65 (21%) vascular complications: 19 major VCs [6.3%], 29 minor [VCs 9.6%] and 17 PCDFs [5.6%]. Overall, 30-day mortality was low (2.6%). Major VCs were associated with higher mortality (42% vs. 0%, p < 0.0001) while minor VCs (3% vs. 0%, mortality p = 0.99) and PCDFs (3% vs. 0% mortality, p = 0.99) were not. PCDFs were associated with a longer median LOS (4 vs. 3 days, p = 0.02). The independent predictors of major VCs were pelvic vessel tortuosity (OR 3.1; 95% CI 1.1-9.2) and presence of CAD (OR 8.2; 95% CI 1.8-37). Female gender showed a strong trend toward increased risk (OR 3.4; CI 0.84-14; p = 0.086). There were no independent predictors of PCDF., Conclusion: Contemporary percutaneous TF-TAVR is associated with a low risk of mortality, major VCs and PCDFs. Major VCs confer increased mortality and PCDFs prolong LOS. Pelvic vessel tortuosity and a history of CAD predict major VCs; there were no predictors of PCDFs. These results provide a contemporary update on the incidence and implications of these important vascular complications in the current era of percutaneous TF-TAVR using 14-16F vascular sheaths., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Skeletal muscle wasting, or sarcopenia, affects a significant proportion of patients undergoing transcatheter aortic valve replacement (TAVR). However, its influence on post-TAVR recovery and 1-year health-related quality of life (HR-QOL) remains unknown. We examined the relationship between skeletal muscle index (SMI), post-TAVR length of hospital stay (LOS), and 1-year QOL., Methods: The study sample consisted of 300 consecutive patients undergoing TAVR from 2012 to 2018 who had pre-TAVR computed tomographic scans suitable for analysis of body composition. Skeletal muscle mass was quantified as cm 2 of skeletal mass per m 2 of body surface area from the cross-sectional computed tomographic image at the third lumbar vertebra. Sarcopenia was defined using established sex-specific cutoffs (women: SMI < 39 cm 2 /m 2 ; men: < 55 cm 2 /m 2 ). Multivariable linear regression analysis was used to determine the relationship between SMI, LOS, and HR-QOL using the Kansas City Cardiomyopathy Questionnaire., Results: Sarcopenia was present in most (59%) patients and associated with older age (82 vs 76 years; P < .001) and lower body mass index (27 vs 33 kg/m 2 ; P < .001). There were no other differences in baseline clinical or echocardiographic characteristics among the 4 quartiles of SMI. SMI was positively correlated with LOS and 1-year QOL. After adjusting for age, gender, race, and body mass index, SMI remained a significant predictor of both LOS (P = .01) and 1-year QOL (P = .012). For every 10 cm 2 /m 2 higher SMI, there was an 8-point increase in Kansas City Cardiomyopathy Questionnaire score, a difference that is clinically meaningful., Conclusions: Sarcopenia is prevalent in TAVR patients. Higher SMI is associated with shorter LOS and better 1-year HR-QOL. To achieve optimal TAVR benefits, further study into how body composition influences post-TAVR recovery and durable improvement in QOL is warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Remodeling of the radial artery (RA) after transradial percutaneous coronary intervention (TRI) is under studied., Objectives: To examine the impact of TRI on RA diameter and intimal-medial thickness (IMT) in men and women using 55 Mhz ultrahigh frequency duplex ultrasound (UHFDU)., Methods: We performed UHFDU at 24 h and 90 days after non-emergent TRI in 41 patients (25 men, 16 women). Changes in RA diameter, IMT and RA injury were compared by patient gender. Multivariate linear regression was used to determine the predictors of RA diameter and IMT., Results: Of the 41 patients, mean age was 66 ± 9.8. Baseline RA diameter was larger in men vs. women (3.1 ± 0.40 mm vs. 2.8 mm ± 0.36, p = 0.02), however there were similar reductions in 90-day diameter (-0.57 ± 0.32 mm vs. -0.64 ± 0.40 mm, respectively; p = 0.48). Baseline IMT was also similar in men and women (0.28 ± 0.04 vs. 0.27 ± 0.06 mm; p = 0.37) and there were 0.073 ± 0.11 mm (26%) and 0.05 ± 0.080 mm (19%) increases in IMT noted, respectively (p < 0.0001 vs. baseline, p = 0.48 for men vs. women). Although UHFDU occasionally detected limited access site intimal tears (12%) at 90 days, frank dissections (2.4%), pseudoaneurysms (2.4%) and total occlusions (4.9%) were infrequent. Female gender correlated with smaller RA diameter at follow-up and there were no predictors of IMT., Conclusions: Following TRI, there is a 20% reduction in RA diameter and a 20-25% increase in IMT. Only gender predicted RA diameter. As a simple, noninvasive method to accurately depict the RA healing response following TRI, UHFDU may inform future clinical investigation in this area., Competing Interests: Declaration of Competing Interest The authors report the following conflicts of interest: WB - Institutional grant/research support: Boston Scientific, Speakers bureau and Consultant: Abbott Medical, Medtronic, Boston Scientific, Education grant: Medtronic; MS- Speakers bureau: Medtronic; AT - Consultant and Speakers bureau: Abiomed, Inc.; TN – Speaker's bureau: Abbott, Medtronic, Education grant: Medtronic. SY:Consultant: Boston Scientific; Proctor: Edwards; Proctor: CSI , Proctor: Boston Scientific. All other authors have no conflicts., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Penicillin allergy is the most commonly reported drug allergy in hospitalized patients, resulting in increased second-line antibiotic use, nosocomial infections, and health care use. Given that most patients are not truly allergic, a safe strategy that empowers the admitting physician is needed., Objective: To assess the effect on antibiotic prescribing practices for hospitalized patients with penicillin allergy using a validated intervention., Methods: An intervention was implemented to educate health care professionals on management of patients with penicillin allergy using a validated risk stratification algorithm to guide testing and antibiotic use. Thirty days of control data using current standard of care was compared with 60 days of postintervention data measuring documentation of penicillin allergy history and antibiotic selection., Results: The relative use of cephalosporin and penicillin antibiotics increased by 121.2% (P = .03) and 256% (P = .04), respectively, without an increase in adverse drug reactions. There was a decrease in the use of broad-spectrum antibiotics: vancomycin, 67.2% (P = .04); quinolones, 33.3% (P = .31); carbapenems, 81.9% (P = .08); and aztreonam, 73.8% (P = .18)., Conclusion: The antibiotic choice in patients admitted to the hospital with a reported penicillin allergy can be improved by better evaluation of the allergy history and the use of a risk stratification guideline., (Copyright © 2018 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: Evaluation of the clinical impact of a pharmacist led-penicillin allergy assessment initiative to enhance antibiotic selection is reported., Methods: A retrospective analysis was conducted on patients with a self-reported penicillin allergy (SRPA) at a 529-bed community teaching hospital and compared clinical response rate before and after implementation of a penicillin allergy assessment initiative, consisting of pharmacy staff education and pocket card development. Patients admitted with SRPA who received antibiotics with gram-negative coverage for at least 48 hours were included. The primary outcome was the clinical response rate of penicillin-allergic patients determined preimplementation and postimplementation of the initiative and was based upon improvement in signs and symptoms of infection. Secondary outcomes included antibiotics used, antibiotic durations, length of stay, survival rate, antibiotic discontinuation rate, and Clostridium difficile infection rate., Results: A total of 280 patients were reviewed. Clinical response rate improved after implementation of the initiative ( p = 0.047). There were significant differences in the type of antibiotics prescribed between the preimplementation group and the postimplementation group: increased cephalosporin use ( p < 0.001), decreased aztreonam use ( p = 0.017), and lower fluoroquinolone use ( p = 0.008). Median length of stay ( p = 0.943), in-hospital mortality rate ( p = 0.173), and C. difficile infection rate ( p = 0.426) were similar before and after implementation of the initiative., Conclusion: After implementation of an initiative to encourage the use of cephalosporins rather than aztreonam in patients with SRPA, the rate of clinical response and cephalosporin use increased and rates of exposure to aztreonam and fluoroquinolones decreased., Competing Interests: DisclosuresThe authors have declared no potential conflicts of interest., (Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Objectives: Vancomycin is commonly used in patients with cystic fibrosis (CF) to treat acute pulmonary exacerbations, but few guidelines exist to help dose and monitor patients. The objective of this study was to assess vancomycin use and monitoring strategies at Cystic Fibrosis Foundation (CFF)-accredited centers in hopes of developing and implementing vancomycin dosing and monitoring standards., Methods: An anonymous national cross-sectional survey of pharmacists affiliated with CFF-accredited pediatric and/or adult centers was performed by using Surveymonkey.com. The survey consisted of 3 sections: (1) CF Center Demographic Information (10 questions); 2) vancomycin use in pediatric CF patients (31 questions); and 3) vancomycin use in adult CF patients (29 questions); it was administered from March 9, 2015, to April 13, 2015., Results: The survey was completed by 31/69 (45%) pharmacists and 28 (90.3%) reported using vancomycin in the pediatric population. The most common initial starting dose for pediatric patients was 15 mg/kg/dose (57.1%) and every 6 hours was the most common dosing frequency (67.9%). The most common monitoring strategy was collection of a trough concentration (92.9%) with 57.7% of pharmacist targeting a range of 15 to 20 mg/L. The most common initial starting vancomycin dose in adults with CF was 15 mg/kg/dose (61.5%), and initial frequency of every 8 hours (73.1%). The most common monitoring strategy was a trough concentration (96.2%) with 83.3% of pharmacists reporting a goal trough range of 15 to 20 mg/L., Conclusions: The most common vancomycin dosing reported was 15 to 20 mg/kg/dose every 6 hours (pediatric) and 15 to 20 mg/kg/dose every 8 to 12 hours (adults). Serum concentrations measured to meet monitoring parameters of trough concentrations of 15 to 20 mg/L, or area under the curve to minimum inhibitory concentration ratio > 400, were the same in both pediatric and adult patients., Competing Interests: Disclosure The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Purpose: Results of a study to evaluate the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) surveillance screening protocol are reported., Methods: A retrospective single-center, quasi-experimental, pre-post cohort study was conducted to assess medication-use and clinical outcomes before and after implementation of a protocol allowing pharmacists to order nasal swabs and polymerase chain reaction (PCR) testing for MRSA in selected patients receiving vancomycin for pneumonia or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Negative assay results were used to guide de-escalation of vancomycin therapy. The primary outcome was vancomycin days of therapy (DOT). Secondary outcomes included hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality., Results: A total of 300 patients were identified for inclusion in the preprotocol group ( n = 150) or postprotocol group ( n = 150) through medical records review. Compared with patients in the preprotocol group, those in the postprotocol group had a median 2.1-day reduction in vancomycin DOT (2.1 days versus 4.2 days, p < 0.0001). Protocol implementation was also associated with a decrease in the median number of vancomycin serum levels obtained per patient but did not have a significant impact on other secondary outcomes., Conclusion: Among patients with suspected or confirmed pneumonia or an AECOPD, the expansion of pharmacists' traditional scope of practice to include a surveillance protocol using a MRSA PCR nares assay to guide vancomycin de-escalation resulted in a reduction in vancomycin utilization without compromising clinical outcomes., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Objectives: Survey suggests that recommended doses and dosage regimens for antipseudomonal antibiotics for the treatment of acute pulmonary exacerbations in cystic fibrosis (CF) patients are not used, and one way to address these disparities is the involvement of pharmacists who are dedicated to CF. This is the first survey specifically designed for pharmacists at Cystic Fibrosis Foundation (CFF)-accredited centers to identify how tobramycin and antipseudomonal beta-lactams are being used. The purpose of this survey is to quantify this information and to promote future study to allow for implementation of tobramycin and beta-lactam dosage and monitoring standardization., Methods: An anonymous national cross-sectional survey of pharmacists that are affliated with CFF-accredited programs was performed using Qualtrics.com., Results: The survey had a 48.5% response rate. Most pediatric pharmacists (78.6%) report using extended-interval tobramycin dosage. The most common reported starting dosage was 10 mg/kg every 24 hours; most centers aim for a maximum serum concentration (Cmax) between 20 and 40 mg/L (78.6%). A total of 26 adult pharmacists reported using extended-interval dosage (96%), using an initial dosage of 10 mg/kg/day. The most common parameters used to adjust dosage were Cmax and area under the curve (AUC; 31%); the Cmax goal was 20 to 40 mg/L (84.2%). Most respondents (79%) report using beta-lactams in combination with tobramycin. Extended-infusion and continuous-infusion beta-lactams were used more in adults than pediatric patients., Conclusions: Most CF pharmacists report using extended-interval tobramycin. With the information from this survey, the establishment of future consensus recommendations by pharmacists for optimal and consistent tobramycin and antipseudomonal beta-lactam dosage and monitoring strategies needs to be considered.

Factor X is a blood clotting protein that associates at membrane surfaces to become activated during the coagulation cascade. A molecular level understanding of the protein-membrane phospholipid interactions has not been reached, although it is thought that the protein binds to phospholipids in the presence of calcium through a bridge with the Gla (gamma-carboxyglutamic acid) domain on the protein. In this work, phospholipid Langmuir monolayers have been utilized as model membranes to study factor X association with phospholipid membrane components. Surface pressure measurements indicate that subphase addition of sodium, magnesium, and calcium ions enhances protein penetration of the lipid monolayer, with the largest association found with calcium ions in the subphase. Fluorescence microscopy images collected after protein penetration of lipid monolayers indicate monolayer condensation in the presence of sodium and magnesium ions. Aggregation of lipid domains is induced when calcium is in the subphase, indicating binding-induced flocculation of surface lipid aggregates. Calcium binding to factor X likely causes a conformational change which allows protein-membrane interaction via hydrophobic association with lipid molecules.

Seventeen of 59 patients admitted to hospital for treatment of Obsessive-Compulsive Disorder (OCD) were found to have significant slowness, mainly due to difficulty in initiating goal-directed action and suppressing intrusive and perseverative behaviour. In this subgroup subtle neurological abnormalities were found more frequently than in healthy controls and included loss of motor fluency, hesitancy of initiation of limb movements, speech and gait abnormalities, cogwheel rigidity, complex repetitive movements and tics. Difficulties in cognitive set-shifting and complex spatial-and-shifting abilities were found on neuropsychological testing, but no correlation was found between these disturbances and either the degree of obsessionality or the severity of motor dysfunction. These results suggest that patients with obsessional slowness may have a dysfunction in the frontal-basal-ganglia loop system.