Search

Background Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs-ARBs) improve outcomes in heart failure (HF). Less is known about this association in nursing home (NH) residents. Methods Of the 8024 hospitalized HF patients, 542 were NH residents, of whom 250 received ACEIs-ARBs. We assembled a propensity score-matched cohort of 157 pairs of NH residents receiving and not receiving ACEIs-ARBs balanced on 29 baseline characteristics (mean age, 83 years, 74% women, 17% African American), in which we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with ACEI-ARB use. We then checked for interaction in a matched cohort of 5130 patients (378 were NH residents) assembled from the 8024 patients. Results Among 314 matched NH residents, HRs (95% CIs) for 30-day all-cause readmission, HF readmission, and all-cause mortality were 0.78 (0.47-1.28), 0.68 (0.29-1.60), and 1.26 (0.70-2.27), respectively. Respective HRs (95% CIs) at 1 year were 0.76 (0.56-1.02), 0.68 (0.42-1.09), and 1.04 (0.78-1.38). Among 5130 matched patients, ACEI-ARB use was associated with a significantly lower risk of all outcomes at both times, with no significant interactions, except for 1-year mortality, which was only significant in the non-NH subgroup (P for interaction, 0.026). Conclusions We found no evidence that the use of ACEIs or ARBs is associated with improved outcomes in patients with HF in the NH setting. However, we also found no evidence that this association is different in NH residents with HF versus non-NH patients with HF. Future larger studies are needed to demonstrate effectiveness of these drugs in the NH setting.

The mendicant friars, especially the Dominicans and the Franciscans, made an enormous impact in thirteenth-century Spain influencing almost every aspect of society. In a revolutionary break from the Church’s past, these religious orders were deeply involved in earthly matters while preaching the Gospel to the laity and producing many of the greatest scholars of the time. Furthermore, the friars reshaped the hierarchy of the Church, often taking up significant positions in the episcopate. They were prominent in the establishment of the Inquisition in Aragon and at the same time they played a major part in interfaith relations between Jews, Muslims and Christians. In addition, they were key contributors in the transformation of urban life, becoming an essential part of the fabric of late medieval cities, while influencing policies of monarchs such as James I of Aragon and Ferdinand III of Castile. Their missions in the towns and their educational role, as well as their robust associations with the papacy and the crown, often raised criticism and lead to internal tensions and conflict with other clergymen and secular society. They were to be both widely admired and the subjects of biting literary satire. As this collection demonstrates, the story of medieval Spain cannot possibly be fully told without mention of the critical role of the friars.

Tobacco smoking is a risk factor for atrial fibrillation (AF), but little is known about the impact of smoking in patients with AF. Of the 4060 patients with recurrent AF in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 496 (12%) reported having smoked during the past two years. Propensity scores for smoking were estimated for each of the 4060 patients using a multivariable logistic regression model and were used to assemble a matched cohort of 487 pairs of smokers and nonsmokers, who were balanced on 46 baseline characteristics. Cox and logistic regression models were used to estimate the associations of smoking with all-cause mortality and all-cause hospitalization, respectively, during over 5 years of follow-up. Matched participants had a mean age of 70 ± 9 years (± S.D.), 39% were women, and 11% were non-white. All-cause mortality occurred in 21% and 16% of matched smokers and nonsmokers, respectively (when smokers were compared with nonsmokers, hazard ratio = HR = 1.35; 95% confidence interval = 95% CI = 1.01–1.81; p = 0.046). Unadjusted, multivariable-adjusted and propensity-adjusted HR (95% CI) for all-cause mortality associated with smoking in the pre-match cohort were: 1.40 (1.13–1.72; p = 0.002), 1.45 (1.16–1.81; p = 0.001), and 1.39 (1.12–1.74; p = 0.003), respectively. Smoking had no association with all-cause hospitalization (when smokers were compared with nonsmokers, odds ratio = OR = 1.21; 95% CI = 0.94–1.57, p = 0.146). Among patients with AF, a recent history of smoking was associated with an increased risk of all-cause mortality, but had no association with all-cause hospitalization.

To determine the association between cardiology consultation and evidence-based care for nursing home (NH) residents with heart failure (HF).Hospitalized NH residents (n = 646) discharged from 106 Alabama hospitals with a primary discharge diagnosis of HF during 1998-2001.Observational. MEASUREMENTS OF EVIDENCE-BASED CARE: Preadmission estimation of left ventricular ejection fraction (LVEF) for patients with known HF (n = 494), in-hospital LVEF estimation for HF patients without known LVEF (n = 452), and discharge prescriptions of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs or ARBs) to systolic HF (LVEF45%) patients discharged alive who were eligible to receive those drugs (n = 83). Eligibility for ACEIs or ARBs was defined as lack of prior allergy or adverse effect, serum creatinine lower than 2.5 mg/dL, serum potassium lower than 5.5 mEq/L, and systolic blood pressure higher than 100 mm Hg.Preadmission LVEF was estimated in 38% and 12% of patients receiving and not receiving cardiology consultation, respectively (adjusted odds ratio [AOR], 3.49; 95% CI, 2.16-5.66; P.001). In-hospital LVEF was estimated in 71% and 28% of patients receiving and not receiving cardiology consultation, respectively (AOR, 6.01; 95% CI, 3.69-9.79; P.001). ACEIs or ARBs were prescribed to 62% and 82% of patients receiving and not receiving cardiology consultation, respectively (AOR, 0.24; 95% CI, 0.07-0.81; P = .022).In-hospital cardiology consultation was associated with significantly higher odds of LVEF estimation among NH residents with HF; however, it did not translate into higher odds of discharge prescriptions for ACEIs or ARBs to NH residents with systolic HF who were eligible for the receipt of these drugs.

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

OBJECTIVES: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare-eligible older African Americans. DESIGN: The Cardiovascular Health Study. SETTING: Four U.S. states. PARTICIPANTS: Seven hundred ninety-five pairs of community-dwelling Medicare-eligible African-American and white adults aged 65 and older, balanced according to age and sex. MEASUREMENTS: Data on self-reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline. RESULTS: Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60�0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56�0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59�1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00�8.28; P

En este ensayo se examinarán las representaciones de conflictos intramusulmanes entre los Almohades y los caudillos andalusíes reflejadas en la crónica almohade, al-Mann bi l-imama de Ibn Sahib al-Sala. Siguiendo la noción foucauldiana de la “violencia de la representación”, analizo las estrategias discursivas que emplea el autor para construir “oposiciones binarias”, contrastando la legitimidad del poder almohade a la ilegitimidad de sus enemigos, centrándome particularmente en los “compañeros cristianos” de los rebeldes andalusíes, y comparando las imágenes de la violencia almohade y rebelde. Concluyo que las representaciones de conflicto violento juegan un papel positivo, reafirmando la identidad almohade como defensora de la religión verdadera.

Heart failure (HF) in older adults presents challenges which are different in many ways than those for younger adults. Diagnosis of HF in older adults can be delayed due to attributing early symptoms to normal changes of aging, or in the setting of a normal ejection fraction, failing to appreciate diastolic heart failure. Moreover, treatment of HF in the elderly is often complicated by comorbidities and polypharmacy. The long-term care setting can present even more challenges, yet can be made easy by following a simple mnemonic DEFEAT-HF. After making a clinical Diagnosis and determining the Etiology, Fluid volume must be assessed to achieve euvolemia, and Ejection frAction must be determine to guide Therapy.

This article analyzes the rhetorical and ritual characteristics of pious exhortation ( wa ,z ) as practiced in al-Andalus and the Maghreb, based on specimens from two homiletic sources. The texts are considered in light of hagiographical and juridical data in order to assess the social role of exhortatory preachers and to explain the extraordinary impact of their sermons. The sermon's affective power derives from the preacher's personal charisma, rhetorical prowess, and his active engagement of his audience in the production of their own charismatic experience. The hagiographies considered depict the w a , i z as a witness to God's omnipotence, precipitating the religious conversion of even the socially marginalized.

Background— Characteristics and outcomes of patients with heart failure and reduced ejection fraction receiving care at Veterans Affairs (VA) versus non-VA hospitals have not been previously reported. Methods and Results— In the randomized controlled Beta-blocker Evaluation of Survival Trial (BEST; 1995-1999), of the 2707 (bucindolol=1353; placebo=1354) patients with heart failure and left ventricular ejection fraction ≤35%, 918 received care at VA hospitals, of which 98% (n=898) were male. Of the 1789 receiving care at non-VA hospitals, 68% (n=1216) were male. Our analyses were restricted to these 2114 male patients. VA patients were older with higher symptom and comorbidity burdens. There was no significant between-group difference in unadjusted primary end point of 2-year all-cause mortality (35% VA versus 32% non-VA; hazard ratio associated with VA hospitals, 1.09; 95% confidence interval, 0.94–1.26), which remained unchanged after adjustment for age and race (hazard ratio, 1.00; 95% confidence interval, 0.86–1.16) or multivariable adjustment, including cardiovascular morbidities (hazard ratio, 0.94; 95% confidence interval, 0.80–1.10). There was no between-group difference in cause-specific mortalities or hospitalizations. Chronic kidney disease, pulmonary edema, left ventricular ejection fraction Conclusions— Patients with heart failure and reduced ejection fraction receiving care at VA hospitals were older and sicker; yet their risk of mortality and hospitalization was similar to younger and healthier patients receiving care at non-VA hospitals. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00000560.

This article focuses on the sermons and preaching method of Ibn 'Abbad of Ronda (d. 1390), a Sufi mystic and chief liturgical preacher of Fez, in order to introduce the tradition of medieval Islamic preaching to specialists of its Christian counterpart. It begins with a brief description of the formal characteristics of Islamic homiletic genres and of the social milieu in which Ibn 'Abbad preached. Particular attention will be given to an eyewitness account of Ibn 'Abbad's preaching and his own writings on the subject, the latter of which must be understood less as a preaching manual than a manifesto of the preacher's social roles and responsibilities. Finally, a detailed analysis of his most famous sermon for the Prophet's birthday celebration (mawlid al-nabi) will be undertaken to highlight the key characteristics of the 'Abbadian homily. It is argued that the rhetorical devices that he employs, namely the citation of the canonical authorities of Sunni Islam, as well as Sufi mystics; the use of ...

Little is known about the molecular processes that govern female gametophyte (FG) development and function, and few FG-expressed genes have been identified. We report the identification and phenotypic analysis of 31 new FG mutants in Arabidopsis. These mutants have defects throughout development, indicating that FG-expressed genes govern essentially every step of FG development. To identify genes involved in cell death during FG development, we analyzed this mutant collection for lines with cell death defects. From this analysis, we identified one mutant, gfa2, with a defect in synergid cell death. Additionally, the gfa2 mutant has a defect in fusion of the polar nuclei. We isolated the GFA2 gene and show that it encodes a J-domain-containing protein. Of the J-domain-containing proteins in Saccharomyces cerevisiae (budding yeast), GFA2 is most similar to Mdj1p, which functions as a chaperone in the mitochondrial matrix. GFA2 is targeted to mitochondria in Arabidopsis and partially complements a yeast mdj1 mutant, suggesting that GFA2 is the Arabidopsis ortholog of yeast Mdj1p. These data suggest a role for mitochondria in cell death in plants.

High doses of propranolol inhibit phosphatidate phosphohydrolase (PAP) activity in intact cells, thus blocking metabolism of phosphatidic acid (PA), product of the phospholipase D (PLD) reaction. Vasopressin and phorbol ester activate PLD and ERK (extracellular signal-regulated protein kinase) mitogen-activated protein kinases in A7r5, a rat vascular smooth muscle cell line. Propranolol increased PA levels in intact A7r5 cells and inhibited cytosolic PAP and membrane calcium-independent phospholipase A2 but did not activate PLD or enhance agonist-induced PA accumulation. Incubation of cells with 200 microM propranolol for 10-45 min markedly elevated PA but caused only partial activation of ERKs. Propranolol and other lipophilic amines caused a time- and dose-dependent detachment of cells from their substrate. These results confirm that elevation of PA is not a strong signal for ERK activation and emphasize that caution should be exercised in using propranolol as a PAP inhibitor in intact cells.

Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.

One of the lacunas in Almohad scholarship is the role that preaching played in disseminating Almohad ideology throughout the empire and its contributions to fostering unity between Muslim Iberia and the Maghrib. This article analyzes the distinctive rhetorical, ritual, and juridical features of the Almohad sermon (khuṭba) and explores how the Almohads deployed religious preaching and ceremonial oratory to pursue their religio-political objectives of purifying Islamic institutions and practices. I argue that the ritual and juridical innovations Ibn Tūmart and the Mu’minids introduced into the khuṭba ceremony, such as the obligatory Berberization and the compulsory invocation of the Almohad creed, exemplified the revolutionary aspects of Almohad power. Accordingly, the Almohad khuṭba would come to simultaneously focalize allegiance and opposition to the regime on both sides of the Strait. I conclude that the institutionalization of the Almohad khuṭba as well as the resistance to it must be considered among the elements that fostered unity between Arabs and Berbers across the Strait of Gibraltar.

Objectives:To determine the effect of different methods of training on the ability of hospital workers to wear respirators and pass a qualitative fit test, and to compare the direct cost of the training.Design:179 hospital employees were recruited for study and were stratified into three groups based on the type of training they received in the use of respirators. Employees in Group A received one-on-one training by the hospital's industrial hygienist and were fit tested as part of this training. Employees in Group B received classroom instruction and demonstration by infection control nurses in the proper use of respirators, but were not fit tested as part of training. Employees in Group C received no formal training. Each participant in our study underwent a subsequent qualitative fit test using irritant smoke to check for the employee's ability to adjust correctly the fit and seal of the respirator. The direct cost of each method of training was determined by accounting for the cost of trainers and the cost of employee-hours lost during training.Setting:775-bed Veterans' Affairs hospital.Results:94% of Group A participants (49 of 52) passed the qualitative fit test, compared to 91% of Group B participants (58 of 64) and 79% of Group C participants (50 of 63; P=.036, 2 × 3 chi-square). Group A had a significantly higher pass rate than Group C (P=.043), but Group B did not differ significantly from Group A or Group C. Location or professional status did not affect pass rate, but prior experience wearing respirators did. When the study groups were compared after stratifying for prior experience, we found no difference in pass rates, except when Groups A and B (those with any training) were combined and compared with Group C (107 of 116 versus 50 of 63, P=.05, Mantel-Haenszel chi-square).We estimate that the method of training involving individual instruction followed by fit testing took 20 minutes per employee to complete, compared to 10 minutes per six employee class for the method of classroom demonstration. The difference in direct cost between the two methods, applied to the training of 1,200 employees at our hospital, would be approximately $19,000 per year.Conclusion:Our study indicates that training in the proper use of respirators is important, but the method of training may not be, as the two methods we evaluated were nearly equivalent in their pass rates on fit testing (94% versus 91%). Fit testing as part of training may have enhanced the performance of our participants marginally, but was more time consuming and accounted for most of the excess cost.

The aims of this study were to determine whether endothelin-1 (ET-1), a positive inotropic agent, altered the production of cyclic AMP (cAMP) in adult feline cardiac myocytes and to characterize the effect with respect to G-protein-coupling and calcium regulation of adenylyl cyclase. ET-1 inhibited basal and/or stimulated cAMP accumulation in the intact cardiac myocyte and in membrane preparations in a dose-dependent manner. In intact cells, maximal inhibition of forskolin-stimulated cAMP accumulation was 90-95% with an EC50 of 5 x 10(-10) M. Inhibition of isoproterenol-stimulated cAMP was biphasic with maximal inhibition of 70% observed by 10(-11)M; at higher doses inhibition was not consistently observed. The inhibitory response to ET-1 occurred in the absence or presence of isobutylmethylxanthine suggesting that activation of cAMP phosphodiesterases was not the means for reducing cAMP levels. Prior exposure of cardiac myocytes to 100ng/ml pertussis toxin blocked the inhibitory action of ET-1, indicating that this response is mediated through the involvement of a pertussis toxin-sensitive G-protein such as Gi. Studies carried out in the absence of extracellular calcium and under conditions of cell-loading with the intracellular calcium chelator, 1,2-bis-(2-aminophenoxy)-ethane-N,N,N'N'-tetraacetic acid-acetoxymethyl ester (BAPTA/AM), suggest that the mechanism by which ET-1 inhibits cAMP accumulation is not calcium-dependent. Thus, inhibition of cAMP accumulation by ET-1 appears to be mediated through a pertussis toxin sensitive protein rather than by activation of phosphodiesterases or calcium inhibition of cardiac forms of adenylyl cyclase. Though unlikely to play a role in the positive inotropic effect of ET-1, transduction of ET-1 responses through Gi suggests another means for regulation of growth in these adult cardiac myocytes.