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Objectives This study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days. Background Veterans with severe aortic stenosis frequently undergo TAVR at VA medical centers. Methods Consecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization. Results Nine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63). Conclusions Veterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.

Background Reproductive factors reflective of endogenous sex hormone exposure might have an effect on cardiac remodeling and the development of heart failure (HF). Objectives This study examined the association between key reproductive factors and the incidence of HF. Methods Women from a cohort of the Women's Health Initiative were systematically evaluated for the incidence of HF hospitalization from study enrollment through 2014. Reproductive factors (number of live births, age at first pregnancy, and total reproductive duration [time from menarche to menopause]) were self-reported at study baseline in 1993 to 1998. We employed Cox proportional hazards regression analysis in age- and multivariable-adjusted models. Results Among 28,516 women, with an average age of 62.7 ± 7.1 years at baseline, 1,494 (5.2%) had an adjudicated incident HF hospitalization during an average follow-up of 13.1 years. After adjusting for covariates, total reproductive duration in years was inversely associated with incident HF: hazard ratios (HRs) of 0.99 per year (95% confidence interval [CI]: 0.98 to 0.99 per year) and 0.95 per 5 years (95% CI: 0.91 to 0.99 per 5 years). Conversely, early age at first pregnancy and nulliparity were significantly associated with incident HF in age-adjusted models, but not after multivariable adjustment. Notably, nulliparity was associated with incident HF with preserved ejection fraction in the fully adjusted model (HR: 2.75; 95% CI: 1.16 to 6.52). Conclusions In post-menopausal women, shorter total reproductive duration was associated with higher risk of incident HF, and nulliparity was associated with higher risk for incident HF with preserved ejection fraction. Whether exposure to endogenous sex hormones underlies this relationship should be investigated in future studies.

Women with history of pregnancy loss (PL) have higher burden of cardiovascular disease (CVD) later in life, yet it is unclear whether this is attributable to an association with established CVD risk factors (RFs). We examined whether PL is associated with CVD RFs and biomarkers in parous postmenopausal women in the Women's Health Initiative, and whether the association between PL and CVD RFs accounted for the association between PL and incident CVD. Linear and logistic regressions were used to estimate associations between baseline history of PL and CVD RFs. Cox proportional hazards regression models were used to estimate the associations between baseline history of PL and incident CVD after adjustment for baseline RFs. Of 79,121 women, 27,272 (35%) had experienced PL. History of PL was associated with higher body mass index (p0.0001), hypertension (p0.0001), diabetes (p = 0.003), depression (p0.0001), and lower income (p0.0001), physical activity (p = 0.01), poorer diet (p0.0001), smoking (p0.0001), and alcohol use (p0.0001). After adjustment for CVD RFs, PL was significantly associated with incident CVD over mean follow up of 16 years (hazard ratio 1.11, 95% confidence interval 1.06 to 1.16). In conclusion, several CVD RFs are associated with PL, but they do not entirely account for the association between PL and incident CVD.

Objectives The purpose of this study was to document the incidence and extent of cardiovascular toxicity among advanced renal cell carcinoma patients treated with newer targeted cancer agents. Background The potential for targeted cancer agents to induce cardiovascular toxicity has been increasingly recognized, but the overall incidence and extent of toxicity have not been well characterized. Early detection of asymptomatic patients could preempt symptomatic toxicity and reduce treatment-related morbidity and mortality. Methods The incidence of hypertension, left ventricular dysfunction, and heart failure was assessed for all advanced renal cell carcinoma patients treated with targeted therapies at our institution between 2004 and 2011. Grading was performed according to the Common Terminology Criteria for Adverse Events version 4.0. Results Cardiovascular toxicity developed in 116 of 159 patients (73%), including 52 of 159 patients (33%) when hypertension was excluded. Toxicity varied from occurrences of asymptomatic drops in left ventricular ejection fraction to rises in N-terminal-pro-B-type natriuretic peptide to severe heart failure. The tyrosine kinase inhibitor sunitinib was the agent most frequently used, with 66 of 101 sunitinib-treated patients (65%) developing a form of cardiovascular toxicity, including 32 of 101 patients (32%), excluding hypertension. Other VEGF inhibitors such as bevacizumab, sorafenib, and pazopanib also elicited significant cardiovascular toxicity with incidences ranging from 51% to 68%. Conclusions The frequency and severity of cardiovascular toxicity in advanced renal cell carcinoma patients treated with targeted cancer therapies are high.

The medical student performance evaluation (MSPE), a letter summarizing academic performance, is included in each medical student's residency application. The extent to which medical schools follow Association of American Medical Colleges (AAMC) recommendations for comparative and transparent data is not known. This study's purpose was to describe the content, interpretability, and transparency of MSPEs.This cross-sectional study examined one randomly selected MSPE from every Liaison Committee on Medical Education-accredited U.S. medical school from which at least one student applied to the Stanford University internal medical residency program during the 2013-2014 application cycle. The authors described the number, distribution, and range of key words and clerkship grades used in the MSPEs and the proportions of schools with missing or incomplete data.The sample included MSPEs from 117 (89%) of 131 medical schools. Sixty schools (51%) provided complete information about clerkship grade and key word distributions. Ninety-six (82%) provided comparative data for clerkship grades, and 71 (61%) provided complete key word data. Key words describing overall performance were extremely heterogeneous, with a total of 72 used and great variation in the assignment of the top designation (median: 24% of students; range: 1%-60%). There was also great variation in the proportion of students awarded the top internal medicine clerkship grade (median: 29%; range: 2%-90%).The MSPE is a critical component of residency applications, yet data contained within MSPEs are incomplete and variable. Approximately half of U.S. medical schools do not follow AAMC guidelines for MSPEs.

For well over a century, there have been boarding schools for American Indian children. During the last decades, the long history of these boarding schools has increasingly come under the review of historians and social scientists. The reviews making the biggest splash focused on those boarding schools having misguided policies or run by incompetent administrators. But often overlooked in these post-hoc assessments of boarding schools is the complexity of the issues they have faced and continue to face. There are no perfect boarding schools that have gotten everything “right,” just as there are no other perfect social organizations. The situation each boarding school faces is complex; each has achieved some sort of functional equilibrium of key factors which form a unique constellation: staff, administration, resources, programs, current state and federal policy, community of location, communities of origin, families, and tribes. The unique configuration that makes up each boarding school’s environment attempts to meet the needs of as many students as possible, and tries to maximize positive outcomes. Recognizing that there is room for improvement, the Office of Indian Education Programs (OIEP) provided several years of funding to a group of schools in order to enhance their services to children. Respecting the diversity of the schools, the OIEP invited boarding schools to submit proposals that enhanced their extant strengths and linked “clinicians, counselors, and mental health professionals with academic program personnel in a culturally sensitive residential program tailored to the particular needs of Indian students” in order “to achieve positive changes in attitudes, behavior and academic performance of Indian youth attending boarding schools.” (Improving America’s Schools Act of 1994). The selected boarding schools were provided Therapeutic Residential Model (TRM) funding to carry out their proposals. To determine each site’s accomplishments as well as the efficacy of this approach, the OIEP concurrently implemented a cross-site evaluation. The evaluation was designed to (1) provide a record and evaluation of the characteristics of each site’s environment prior to funding, (2) document the course of planning and implementation of changes during TRM funding, (3) collect data on incoming students and outcome data agreed upon by all sites, (4) provide ongoing analyses of the data to the sites so that administrators could make program changes, and (5) use process and outcome data from these diverse sites to draw cross-site conclusions. Retention is the clearest and most basic indicator of success in a boarding school because it represents the convergence of a number of factors: the ability of the system to meet the particular needs of each child, the capacity of the system to stabilize children emotionally and to socialize them into acceptable behavior patterns, the comfort level of children with the environment provided, and parents’ perception that staying in the system is in the best interests of their children. Conversely, major reasons why children leave the system are homesickness, belief that they are needed at home, failure to adjust to the demands of the system, perturbation of the system to the extent that it rejects them, and removal by parents who need them at home or are either unhappy with or unimpressed by what the system has to offer. Simply put, high retention means that the system is working for the students entrusted to its care. Two of the 5 sites involved in the TRM program achieved high levels of retention; one did so in the years prior to TRM funding, and the other site made impressive gains during the study. Section 1 of this cross-site evaluation identifies the factors that were common to sites that achieved high retention, and it describes the prevailing situation at those sites that were not successful at retaining students.

Recruiting and retaining direct-care staff has long been a challenge for administrators of programs that serve persons with disabilities. A literature review revealed that beginning in 1950, researchers set out to develop a paper-and-pencil test that would identify good employees. Regardless of how they defined good, employers were unable to identify tests that selected promising job applicants. Efforts to develop research-based selection tools decreased in the early 1970s with the transition from state institutions to community programs. However, the growth of community programs did not mitigate the turnover problem, and the need remains for a reliable hiring tool. Whereas recent researchers have identified practices that can reduce turnover, these practices should be more widely implemented and their efficacy examined.

We thank Dr. El-Battrawy and colleagues for their interest in our work, as well as for proposing a potential mechanism that may underlie the association between a longer period of exposure to endogenous sex hormones and a lower risk of heart failure after menopause [(1)][1]. We had hypothesized that

The infrared spectra (4000-50 cm−1) of the complexes cis-[Rh(CO)2(NH3)(X)] (XCl, Br) and their 15NH3, ND3 and 13CO isotopomers have been determined. Empirical assignments of the infrared-active modes are based on the frequency shifts caused by selective isotopic substitution experiments. The empirical assignments have been verified by a normal coordinate analysis of the in-plane vibrational modes. The potential energy distribution reveals very little coupling between the normal vibrational modes. However, there exists some coupling between ν(RhX) and ν(RhC) in the choro complex.

A significant amount of research has examined supported employment but little has dealt with the delivery of supported employment services to persons with developmental disabilities who live in rural areas. This study investigated the relationship between demographic variables and job development of persons with developmental disabilities in South Dakota. A survey of job developers at eleven community-based adult service facilities and two major public school systems was conducted. Results are discussed pertaining to the effect of rate of unemployment, percentage of service jobs, and community size on the development of community-based jobs for persons with developmental disabilities.

13C nmr spectra of the complexes cis-[Rh(CO))2(pyO)(X)] (X = Cl, Br; pyO = pyridine N-oxide) are discussed. Variable temperature 13C nmr spectroscopy has been used to monitor the exchange process occurring in acetone-d 6 solution. Rate constants for the exchange reaction have been determined by complete band shape analysis. The enthalpy of activation for the chloro- and bromo-complexes was found to be 53.3 ± 1.0 kJ mol−1 and 48.3 ± 0.8 kJ mol−1 respectively. The entropy of activation was found to be 5.5 ± 0.6 J mol−1 K−1 and -11.0 ± 0.3 J mol−1 K−1, for the chloro- and bromo-complexes, respectively. It is suggested that the fluxionality of the molecules results from an intermolecular exchange of pyridine N-oxide rather than from loss of carbon monoxide. A mechanism for the exchange process is proposed.

The infrared spectra (4000 - 50 cm−1) of the square planar rhodium(I) complexes cis-[Rh(CO)2 (pyridine) (X)] (X = Cl, Br) and their isotopomers with pyridine-d 5 and 13CO have been determined. Assignments are based on earlier studies on pyridine and its complexes and on the shifts in infrared bands which are caused by the isotopic substitutions employed. Normal coordinate analysis following the procedure of Becher and Mattes has been used to confirm the empirical assignments. The two v(RhC) bands are observed near 490 and 450 cm−1. v(RhN) is found near 210 cm−1 and v(RhX) occurs at 310 (X = Cl) and 235 (X = Br) cm−1. At frequencies below 200 cm−1, the bands are assigned to bending modes in the following sequence: δ (RhN) > δ (CRhC) > δ (RhCl) > γ (RhCl) > γ (RhN).

The complexes cis-[Rh(CO)2(pyO)(X)] (X  Cl, Br; pyO, pyridine-N-oxide and their labelled analogues containing 13CO and pyO-d5 were synthesized. The isotopically labelled species were used to assign the internal ligand modes and the skeletal vibrations in the IR spectra over the range 4000-50 cm−1. The vRhC and vRhO bands occur within the range 400–500 cm−1, while vRhCl and vRhBr occur at 310 and 213 cm−1 respectively. The 1H and 13C nuclear magnetic resonance spectra are discussed. The electronic spectra reveal a strong, broad band at 271 nm which is assigned to the combined X − → Rh + , π → π∗ (CO) and π → π∗ (pyO) transitions, while the somewhat weaker band at 327 nm originates in the 4d(Rh) → π∗(CO) transition.

Forty-one π-acid complexes of the type cis-[Pt(bipyO2H)(A)X2]X and trans-[PtL(A)X2] (A = C2H4, CO; X = Cl, Br; L = pyridazine {pdz}, pyrazine N-oxide {pzO}, quinoline {quin}, quinoline N-oxide {quinO}, 2,2′-bipyridine {bipy}, 1,10-phenanthroline {phen}) and their deuterated L and C2D4 analogues have been characterised employing infrared and 1H nmr spectroscopy. The employment of v12 (CH2 scissors ∼1460 cm−1) of η2-ethene as a diagnostic probe in distinguishing between 4- and 5-coordination is proposed, while the summed percentage decrease of v2+v3 (vC=C/δCH2) may be used to distinguish between N- and O-coordination. The use of chemical shifts (1H nmr spectroscopy) is confirmed as a suitable means to distinguish between 4- and 5-coordination and is also shown to be suitable for distinction between N- and O-coordination in four coordinate Pt(II) η2-ethene complexes. In contradiction of previous reports, it is found that JPt-H cannot be employed to determine the coordination number.

This site is an intertribal residential grant school annually enrolling over 250 students in grades 1-8 from tribes located in three states on the Northern Great Plains. From its inception in 1890, the boarding school's mission has been to provide services for young children in need of a safe and supportive living and learning environment. For over a decade, this site has used strategies centered on respecting children, structuring students' time, and providing the therapeutic benefits of a well-maintained campus. This site also has a long history of believing in each child's inherent value and potential. When Therapeutic Residential Model funding commenced at the midpoint of the 2002-2003 school year, L1 focused these new resources on strengthening and refining its program. The number of personnel positions increased from 98 to 135, with new positions principally going to dormitory staff and four Masters-level counselor positions. This increase in staff allowed L1 to proactively address the children's developmental needs. The site also adopted and implemented the Applied Humanism caregiving model. In accordance with Applied Humanism, an interview was utilized that allowed the site to identify and hire applicants possessing the attitudes and skills necessary to be good caregivers, existing staff were trained so that they understood the kind of caregiving that would be expected of them, supervision procedures and practices were implemented that supported and encouraged good caregivers and provided time-limited assistance to those who were not, and relevant agency policies and procedures were revised as needed to align with the Applied Humanism philosophy. In addition, the Morningside program was brought in to systematically address the students' academic lags in reading. The results of implementing the Therapeutic Residential Model were a reduction in behavioral incidents, a decrease in the amount of money spent on external mental health services, an increase in the retention rate, an increase in academic skills in selected areas, and higher scores on pre-post measures of adjustment, interpersonal relationships, and adaptability. Language: en

4610 Background: Almost all patients with advanced RCC are treated with therapies targeting the hypoxia inducible factor axis. The potential for these agents to cause cardiovascular (CV) toxicity has been increasingly recognized but the overall incidence and extent have not been well described. We sought to identify and characterize the incidence and severity of CV toxicity among RCC patients treated with targeted therapies. Methods: Between 2004 and 2011, all RCC patients treated with targeted therapies directed against the VEGF or mTOR axes were identified at our institution. The incidence of hypertension, left ventricular (LV) dysfunction, changes in serum markers of CV toxicity (e.g., troponin I, NT-proBNP) and heart failure were assessed and graded according to the Common Terminology Criteria for Adverse Events (CTCAE v.4.0). Results: Cardiovascular toxicity developed in 116 of 159 patients (73%). Excluding hypertension, 52 of 159 (33%) developed cardiovascular toxicity. Cardiac toxicity ranged from asymptomatic drops in LV ejection fraction (LVEF) to rises in NT-proBNP to severe heart failure. Asymptomatic cardiotoxicity as defined by decrease in LVEF or increase in NT-proBNP occurred in 43 patients (27%). Symptomatic heart failure (grade 2-3) and grade 3-4 decrease in LVEF each occurred in 4%. Sunitinib was the most frequently used and most common offending agent, with 66 of 101 sunitinib-treated patients (65%) developing a form of CV toxicity, or 32 of 101 (32%) excluding hypertension. However, it was notable that CV toxicity was observed in 68%, 66%, and 51% of patients treated with bevacizumab, sorafenib, and pazopanib as well. The mTOR inhibitors elicited significantly less CV toxicity, but sample sizes were small. Conclusions: Cardiovascular toxicity is an important adverse event related to targeted therapy administration. Close monitoring for the development of CV toxicity with the use of these agents should become standard of care as early detection of asymptomatic patients could preempt symptomatic toxicity and reduce treatment-related morbidity and mortality.

The 1H-NMR spectra of the complexes trans-[PtX2(C2H4)(Him)] (X = Cl or Br, Him = imidazole) are discussed. Variable temperature spectra are used to monitor the exchange processes which occur in acetone-d6 solution. It is found, contrary to previous work, that intermolecular exchange occurs for both the chloro- and bromo- complexes. In addition, it is also found that changing the solvent has a marked effect on the rate of exchange. Using an iterative simulation program and assuming intermolecular exchange, the rate constants for the exchange process are determined by band shape analysis, and the enthalpy and entropy of activation are calculated.

The 1 H NMR, IR and electronic spectra are reported for the complexes trans -[PBr 2 (L)-(Ran)] where L = C 2 H 4 , CO; comprising sixteen variously substituted anilines Ran. In the ethylene complexes, the coupling constant J PtH , is approximately 65 Hz which is consistent with trans -configuration. The chemical shift of the olefinic protons is relatively unaffected by the nature of R but the shielding of the aromatic protons is slightly modified in these complexes and in the analogous complexes with CO replacing ethylene. Both of the infrared modes v PtC 2 (or v PtC) and v PtN are increased by electron releasing substituents showing that the electronic effects of R are transmitted to these bonds. Assignments are provided for the UV spectra which indicate that the π → π * transition within the aniline ring is the electronic transition of maximum sensitivity to R.

IR, 1 H NMR and electronic spectra are reported for the complexes trans -[PtX 2 (CO)(L)] (X = Cl or Br; L = NH 3 , pyridine, pyridine- N -oxide, aniline or imidazole) and trans -[Pt 2 X 4 (CO) 2 (pyrazine)] (X = Cl or Br). Assignments for the internal ligand modes and metal-ligand vibrations are deduced from the band shifts caused by deuteration of the ligands (L). The simplicity of the IR spectra, particularly in the v (CO) region, is consistent with a trans -configuration. The 1 H NMR data show 195 Pt-H coupling at ambient temperature, suggesting a slow exchange, unlike the corresponding ethylene complexes which are highly fluxional at ambient temperatures. Assignments are provided for the UV spectra and the previously reported red shift is observed in the 5 d (Pt) →π* transition which results from the replacement of Cl by Br in the complexes.

This study investigated the effect of cognition on the extinction of a conditioned GSR. The difference between extinction rates indicated that the Ss who could form the cognition that the UCS would no longer be presented extinguished more rapidly than Ss who could not. The data were interpreted as support for the role of awareness in the extinction of a classically conditioned response.