Temporal Pattern of CABG and PCI after Non-ST Elevation Myocardial Infarction Among Elderly Patients from NHDS.

Background Management of elderly patients with Non-ST Elevation Myocardial Infarction (NSTEMI) continues to be a source of controversy due to underrepresentation in large-scale clinical trials and the increased risk of adverse outcomes after both invasive (Percutaneous coronary intervention and Coronary artery bypass grafting) and non-invasive therapies. Recent randomized clinical trials have shown improved short term and intermediate term outcomes among high risk NSTEMI patients receiving early invasive management versus conservative medical management. However, how this is reflected in U.S. clinical practice for elderly patients has not been reported. Objective To identify the trend of invasive management in patients with NSTEMI, particularly among elderly population. Methods We used data from National Hospital Discharge Survey to identify all adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for NSTEMI from the years 2005 to 2009. The goal was to investigate the trends in time of invasive therapy for patients diagnosed with NSTEMI. We then stratified the patients according to age >65 and ≤65, and compared the temporal trends between two age groups. Results Among 21,306 patients diagnosed with NSTEMI between 2005 and 2009, the median age was 73 years (IQR: 61-82 years), 54% were males and 57% were White. The proportions of patients age>65 years receiving invasive management (21%, N=13978) was significantly lower than those age≤65 (41%, N=7328) (p<0.001). Moreover, in both age groups, the proportion of patients receiving early invasive management decreased substantially over time (p<0.001). Conclusion Despite numerous studies promoting the use of early invasive management for NSTEMI patients, the proportion of patients receiving invasive intervention gradually decreased from 2005-2009, more so in elderly population. The decrease seen in overall proportion of patients receiving invasive therapy could be associated with older median age of NSTEMI patients; 73 years (IQR: 61-82). Our future analyses will investigate if this trend maintains after adjusting for other factors (sex, co-morbid conditions, insurance status, year of procedure, hospital region, and hospital bed-size) thought to be associated with the management of NSTEMI in elderly patients.

Inclusion of Sex and Gender in Emergency Medicine Research-A 2018 Update.

OBJECTIVES: The objectives were to 1) evaluate the inclusion of sex and gender in publications by emergency medicine (EM) researchers following the 2014 federal mandate and an Academic Emergency Medicine consensus conference on sex- and gender-based research and 2) assess trends compared with 2011 status report that showed 29% studies used sex and gender in the study design and 2% reported it as a primary outcome. METHODS: Using MEDLINE, the term "emergency" was used to identify all English-language studies of adult humans published between 2014 and 2017 as EM affiliated (i.e., the first, second, or last author belonged to an EM section, division, center, or institution functioning as emergency department). Four trained abstractors reviewed the data using a standardized data abstraction form. RESULTS: The search revealed 6,442 articles using the selected "emergency" terms, and 2,628 original studies coded as EM-affiliated publications were reviewed, 2,340 met inclusion criteria, and 2,336 were analyzed. This compared to 750 articles reviewed in 2011 using similar search strategy. The adjusted inter-rater reliability for data abstraction was 97% (95% confidence interval [CI] = 95.4%-98.6%]. The leading study areas contributing the most articles were cardiovascular (17.5%), administration/crowding (15.8%), infectious diseases (9.2%), trauma/injury (9.2%), emergency medical services (6.1%), and pulmonary (6.1%). Eighty-six percent (n = 1,921) reported the sex/gender composition of the sample and 0.4% (n = 8) reported transgender identity. Thirty-four percent used sex/gender in the study design, with 27% (n = 609) reporting it as a control variable, 24% (n = 543) as an independent variable, and 2% using sex/gender as primary outcome. Studies funded by federal sources were significantly more likely to include sex/gender in the study design than other sources of funding (odds ratio = 1.77; 95% CI = 1.4-2.2). CONCLUSIONS: Compared to 2011, we noted an increase in the number of EM scholarship and use of sex and gender in study design, yet the proportion evaluating it as a primary outcome remained unchanged.

Cytotoxic effects of aflatoxin B1 on human brain microvascular endothelial cells of the blood-brain barrier.

Aflatoxins are mycotoxins produced by Aspergillus spp. Although AFB1 is implicated as a carcinogen in hepatocellular carcinoma, brain autopsies in affected areas have revealed its presence in 81% of cases. Given its haematogenous spread, here we determined the cytotoxic effects of AFB1 on primary human brain microvascular endothelial cells (HBMEC), which constitute the blood-brain barrier, human umbilical vein endothelial cells (HUVEC) as well as immortalized epithelial cells of human hepatocellular carcinoma (Huh7). The cell types were exposed to AFB1 (3-32 nM) for 24 h and release of lactate dehydrogenase was measured as cell cytotoxicity marker. Furthermore, DNA was collected from both cell types and DNA adduct formation was determined by immunoblot using anti-AFB1-DNA adduct antibody. At 32 nM, AFB1 killed >85% HBMEC, while controls showed minimal effects (P < .05). Similar concentrations of AFB1 showed 22% cell death of HUVEC, while the same concentration did not kill Huh7. At low concentrations, in other words, 3.2 nM, AFB1 produced DNA adduct formation in HBMEC, while high concentration (32 nM) did not form DNA adducts. For HUVEC, 16 nM and 32 nM exhibited DNA adduct formation. For Huh7, 3.2 nM did not form DNA adducts, while 32 nM exhibited DNA adduct formation. For the first time, we report that AFB1 affected the viability of primary endothelial cells but not immortalized Huh7 cells. Cytotoxicity of brain endothelial cells suggests extra-hepatic complications post-AFB1 exposure.

Risk assessment for obstructive sleep apnea and anxiety in a Pakistani population with coronary artery disease.

PURPOSE: Previous studies in the western world have reported the possible association of obstructive sleep apnea (OSA) with anxiety and cardiovascular diseases. However, the data from developing countries such as Pakistan remains scarce in this regard. The main aim of this study was to investigate the prevalence of coronary artery disease (CAD) patients who are at high risk of OSA and to determine the association between the risk of OSA and levels of anxiety. METHODS: The sample population consisted of 400 participants including 200 patients, who had been previously diagnosed with CAD, and 200 healthy controls. The 200 CAD patients were approached for inclusion in the study on their follow-ups after their acute symptoms had subsided. The patients were interviewed after a mean time period of 13 weeks post event. All patients with lung disease or respiratory infection were excluded from the study. The risk of OSA was determined using Berlin questionnaire, while the levels of anxiety were measured by Beck anxiety inventory scale (BAI). RESULTS: More than half (n = 104) of the CAD patients were at high risk of OSA while majority (n = 168) of the healthy controls were at low risk. The high risk of OSA was significantly (P < 0.0001) more prevalent in CAD patients compared with controls. It was also observed that the patients who were at high risk of OSA, among both cases and controls, had significantly (P values <0.001) higher levels of anxiety. CONCLUSION: A significant proportion of CAD patients are at high risk of OSA in our region. Moreover, OSA is also associated with greater levels of anxiety in both healthy people and CAD patients.