Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study

ABSTRACT Objective: This study aimed to compare hemodynamic performances and clinical outcomes of patients with small aortic annulus (SAA) who underwent aortic valve replacement by means of sutureless aortic valve replacement (SUAVR) or transcatheter aortic valve implantation (TAVI). Methods: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) Results: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2 vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012). Conclusion: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.

A Retrospective Study of the Relationship Between Blood Transfusion and 30-Day Postoperative Outcomes in Patients Undergoing Isolated Off-Pump Coronary Artery Bypass Grafting

ABSTRACT Introduction: The objective of this single-center study it to retrospectively analyze the relationship between transfusion and 30-day postoperative outcomes in patients undergoing isolated off-pump coronary artery bypass grafting. Methods: Perioperative data of 2,178 patients who underwent isolated off-pump coronary artery bypass grafting from 2018 to 2019 were collected. A 1:1 propensity score matching was performed to control for potential biases between patients who received blood transfusion and those who did not. After propensity score matching, we analyzed the clinical outcomes of transfusion and non-transfusion patients. Postoperative complications and the survival of patients within 30 days after surgery in both groups were analyzed. Kaplan-Meier survival curve and log-rank test were used for survival analysis. Results: The total blood transfusion rate of all patients was 29%, including red blood cell (27.6%), plasma (7.3%), and platelet (1.9%). Four hundred and forty patients in each group were compared after propensity score matching. There were no significant differences in the incidence of stroke, myocardial infarction, atrial fibrillation, acute kidney function injury, and sternal wound infection of both groups (P>0.05). However, higher incidence of postoperative pulmonary infection and more mechanical ventilation time and days of stay in the intensive care unit and postoperative in-hospital stay were associated with blood transfusion (P<0.05). The 30-day cumulative survival rate of the transfusion group was lower than that of the control group (P<0.05). Conclusion: Perioperative blood transfusion increases the risks of postoperative pulmonary infection and short-term mortality in off-pump coronary artery bypass grafting patients.

The best partner. School effect assessment of different interorganizational collaboration using Propensity Matching Score / El mejor colaborador. Evaluación del efecto escolar de diferentes colaboraciones interorganizacionales utilizando Propensity Matching Score

Abstract The Chilean Skill for Life (CSFL) is a school mental health program implemented by local agencies from the Education, Health, and Social Services public sectors. It represents an excellent opportunity to study inter-organizational collaboration and its advantages to public and state-subsidized schools. The propensity score matching technique was used to compare school performance in second grade (the most intensive treatment level) between schools participating in the program and those not participating and between schools with different types of sectoral collaboration to identify the best partner for the school. To select all Chilean schools' participant in CSFL and the comparative group of schools' non-participant, a sequential sampling was applied. The measures were obtained from government public data, considering annual school performance and other educational indicators. It was found that public schools that implement the CSFL obtain better school performance than those that do not implement it (ATT = .042; p < .05), for state-subsidized schools, the same was not found. It was also observed that when educational agencies implement the program, the gain is more significant (ATT = .046; p < .05). The importance of aligning program values and goals with local agencies and schools is discussed, analyzing the possibilities for better collaboration in school mental health.

Resumen Habilidades para la Vida (HPV) es un programa chileno de salud mental escolar multinivel que llega a millones de estudiantes en miles de territorios del país, y es considerado uno de los programas de salud mental escolar más grandes del mundo. Es implementado en el país por agencias locales de los sectores públicos de educación, salud y servicios sociales, lo que representa una excelente oportunidad para estudiar la colaboración interorganizacional y sus ventajas para las escuelas públicas y subvencionadas por el Estado. Este constructo ha recibido gran atención en los últimos años en el campo de la salud mental escolar, dado que destaca la importancia de generar procesos que permitan compartir una identidad colectiva, una agenda coordinada, tener una comunicación efectiva y una colaboración mutua entre los diversos dispositivos que buscan contribuir al logro de las metas de salud mental y a los objetivos educativos de las escuelas. A pesar de los grandes beneficios que traería la colaboración interorganizacional en la ejecución de programas de salud mental escolar, los estudios al respecto son más bien escasos y centrados en intervenciones que vinculan tan solo un tipo de agencia ejecutora con las escuelas. Por este motivo, el presente estudio pretende analizar el impacto de la colaboración interorganizacional en el rendimiento académico de aquellos estudiantes que reciben el programa HPV, teniendo dos hipótesis a la base: (1) que aquellos estudiantes que forman parte de las escuelas en las que se entrega el programa tendrán un mejor rendimiento académico que aquellos que no reciben la intervención; y (2) que el sector educación será el mejor partner o colaborador, puesto que comparte las metas educativas con la escuela, lo que impactaría en el rendimiento académico de aquellos estudiantes que reciben el programa. Para medir esto, se utilizó la técnica Propensity Matching Score, la cual sirvió para comparar el rendimiento escolar de los estudiantes en segundo grado (el nivel de tratamiento más intensivo) entre las escuelas participantes y no participantes del programa, y entre las escuelas con diferentes tipos de colaboración sectorial. Para seleccionar a los participantes de las escuelas chilenas en HPV y del grupo comparativo se aplicó un muestreo secuencial. Las medidas se obtuvieron de datos públicos del gobierno de Chile, y se consideró el rendimiento escolar anual, la vulnerabilidad social de las escuelas y otros indicadores educativos. Se encontró que las escuelas públicas que implementan el HPV obtienen un mejor rendimiento escolar que las que no lo implementan (ATT = .042; p < .05), resultados que no se repitieron en aquellas escuelas subsidiadas por el Estado. También se observó que cuando las agencias educativas implementan el programa, el aumento del rendimiento académico es mayor (ATT = .046; p < .05) respecto que aquellas que lo implementan mediante agencias locales de salud o de servicios sociales. Se discute la importancia de alinear los valores y las metas del programa con las agencias locales y las escuelas, analizando las posibilidades de una mejor colaboración en la salud mental escolar. Esto implica también considerar las metas educativas de cada centro en el cual se implementan estas intervenciones, ya que es posible encontrarse en ocasiones con modelos educacionales restrictivos y tradicionales, centrados por sobre todo en lo cognitivo. Por este motivo, experimentan dificultades al alinearse con programas de habilidades socioemocionales, lo que termina obstaculizando las posibilidades de colaboración interorganizacional con agencias interventoras de dispositivos orientados a esto. En este marco, se exponen una serie de consideraciones clave vinculadas a la importancia de preparar las condiciones y los recursos para el trabajo interorganizacional entre escuelas y entidades ejecutoras de programas de salud mental escolar.

Does height catch-up in schoolchildren have an effect on bone mass in adolescents? Analysis in a Brazilian birth cohort / Catch-up de estatura em escolares tem efeito sobre massa óssea em adolescentes? Análise em uma coorte brasileira de nascimento

Abstract Objective: To analyze the effect of height catch-up at school age on the bone mass of adolescents of a Brazilian birth cohort. Methods: A cohort study using data obtained from the three moments (birth, 7/9 years and 18/19 years of age) of the Cohorts-RPS study. Height catch-up was defined based on the difference between the schoolchild's z-score and birth z-score. The adolescents' bone mineral mass was analyzed using the z-score index for the lumbar spine measured by dual emission X-ray absorptiometry. A theoretical model was developed for the proposed analysis using directed acyclic graphs paired through the nearest-neighbor matching propensity score using the STATA software, version 14.0. The level of significance was set at 5%. Results: Of the 297 studied children, 24.5% achieved height catch-up. The bone mass below the expected for age was observed in 5.39% of the subjects. The mean lumbar spine z-score was −0.34 (±1.01). After the adjustment, no effect was observed between height catch-up at school age and bone mass in adolescents (Coeff = 0.598; 95% CI −0.117 to 1.313; p = 0.101). Conclusion: Even using the directed acyclic graphs and the causal inference method by adjusting the propensity score, the height catch-up did not seem to affect bone mass in adolescents, a result perhaps related to the sample size.

Resumo: Objetivo: Analisar o efeito do catch-up de estatura na idade escolar na massa óssea em adolescentes em uma coorte brasileira de nascimento. Métodos: Estudo de coorte, utilizando dados dos três momentos (nascimento, aos 7/9 anos e 18/19 anos) da pesquisa Coortes-RPS. Catch-up de estatura foi definida a partir da diferença entre o Z-score do escolar e Z-score do nascimento. Para a análise da massa óssea em adolescentes foi utilizado o índice Z-score da coluna lombar medido pela densitometria por dupla emissão de raio X. Para análise proposta, foi construído modelo teórico usando os gráficos acíclicos direcionados e pareado por escore de propensão do tipo vizinho mais próximo utilizando o software STATA versão 14.0. O nível de significância adotado foi de 5%. Resultados: Das 297 crianças, 24,58% realizaram o catch-up estatural. Massa óssea abaixo do esperado para a idade foi de 5,39%. O Z-score médio da coluna lombar foi −0,34 (± 1,01). Após ajuste, não foi observado efeito entre catch-up de estatura na idade escolar e massa óssea no adolescente (Coef = 0,598; IC 95% −0,117-1,313; p = 0,101). Conclusão: Mesmo com os gráficos acíclicos direcionados e o método de inferência causal por ajuste do escore de propensão, o catch-up de estatura parece não afetar a massa óssea em adolescentes, resultado talvez relacionado ao tamanho da amostra.

The Effects of Visiting Nursing Services in Long-term Care Insurance: A Difference-in-Difference Analysis

PURPOSE: The purpose of this study was to demonstrate the effects of visiting nursing services in long-term care (LTC) insurance on changes in health status and physical functions among the elderly. METHODS: We analyzed survey data on the living status and welfare needs of the elderly from 2008 and 2011 using the difference-in-difference method with propensity score matching. RESULTS: The subjects were 76 elders including 38 visiting nursing service users(intervention group) and 38 home-based LTC service users (control group). Results from DID analysis confirmed that the subjective health status level of the intervention group was 2.2 points higher (p=.044) and the depression level was 0.3 point lower (p=.039) than the control group. In addition, the intervention group's ADL score was 1.9 (p=.027) and IADL 3.9 (p=.030), showing that their health was deteriorated less. CONCLUSION: Visiting nursing service in LTC insurance was associated with delayed deterioration of subjective health status, depression, ADL and IADL. These findings suggest the need of rebuilding visiting nursing service programs focusing on prevention services, which will be more contributive to elderly health care and the reduction of social costs.

Enfoques modernos del sesgo y la causalidad en la investigación epidemiológica / Modern approaches to bias and causation in epidemiological research

Los conceptos de causalidad y sesgo están en la base de la investigación biomédica moderna, desde el análisis de cientos de factores de exposición, hasta los megaestudios para evaluar intervenciones. Los consumidores de estos productos de la investigación, vemos con desconcierto, que una conclusión que se formula hoy, se pone en duda mañana, y se desecha poco tiempo después, para eventualmente ser retomada en el futuro bajo otras ópticas u otros presupuestos. Aunque no es el único responsable, el sesgo metodológico juega un papel importante como determinante de esta realidad. Este artículo tiene el propósito de destacar el concepto de sesgo, relevante, entre otras posibles acepciones, para la investigación biomédica contemporánea, y su asociación con la definición técnica de confusión, exponer la visión moderna sobre el significado práctico de una causa y examinar críticamente dos modernos recursos analíticos para afrontar el problema del sesgo y la causalidad: los puntajes de susceptibilidad y las variables instrumentales

The concepts of causation and bias are crucial to modern biomedical research, ranging from the analysis of hundreds of exposure factors to megatrials, in order to assess the impact of interventions. As consumers of these research products, we are amazed that a statement made today is put into question tomorrow, discarded afterwards, and eventually retaken in the future from different perspectives or under different assumptions. Although the methodological bias is not the only culprit, it plays an important role as determinant of this reality. This paper intended to clarify the concept of bias, which is relevant, among other possible meanings, to contemporary biomedical research, and its association with the technical meaning of confounding. Other objectives were to present the current vision on the practical meaning of cause in epidemiological causal inference, and to critically review two modern analytical tools to deal with bias and causation such as propensity scores and instrumental variables