Factors Impacting Physician Prognostic Accuracy in Heart Failure Patients With Reduced Left Ventricular Ejection Fraction.

BACKGROUND: A recent study showed that the accuracy of heart failure (HF) cardiologists and family doctors to predict mortality in outpatients with HF proved suboptimal, performing less well than models. OBJECTIVES: The authors sought to evaluate patient and physician factors associated with physician accuracy. METHODS: The authors included outpatients with HF from 11 HF clinics. Family doctors and HF cardiologists estimated patient 1-year mortality. They calculated predicted mortality using the Seattle HF Model and followed patients for 1 year to record mortality (or urgent heart transplant or ventricular assist device implant as mortality-equivalent events). Using multivariable logistic regression, the authors evaluated associations among physician experience and confidence in estimates, duration of patient-physician relationship, patient-physician sex concordance, patient race, and predicted risk, with concordant results between physician and model predictions. RESULTS: Among 1,643 patients, 1-year event rate was 10% (95% CI: 8%-12%). One-half of the estimates showed discrepant results between model and physician predictions, mainly owing to physician risk overestimation. Discrepancies were more frequent with increasing patient risk from 38% in low-risk to ∼75% in high-risk patients. When making predictions on male patients, female HF cardiologists were 26% more likely to have discrepant predictions (OR: 0.74; 95% CI: 0.58-0.94). HF cardiologist estimates in Black patients were 33% more likely to be discrepant (OR: 0.67; 95% CI: 0.45-0.99). Low confidence in predictions was associated with discrepancy. Analyses restricted to high-confidence estimates showed inferior calibration to the model, with risk overestimation across risk groups. CONCLUSIONS: Discrepant physician and model predictions were more frequent in cases with perceived increased risk. Model predictions outperform physicians even when they are confident in their predictions. (Predicted Prognosis in Heart Failure [INTUITION]; NCT04009798).

Adherence to clinical practice guidelines for pulmonary valve intervention after tetralogy of Fallot repair: A nationwide cohort study.

Objectives: To determine guideline adherence pertaining to pulmonary valve replacement (PVR) referral after tetralogy of Fallot (TOF) repair. Methods: Children and adults with cardiovascular magnetic resonance imaging scans and at least moderate pulmonary regurgitation were prospectively enrolled in the Comprehensive Outcomes Registry Late After TOF Repair (CORRELATE). Individuals with previous PVR were excluded. Patients were classified according to presence (+) versus absence (-) of PVR and presence (+) versus absence (-) of contemporaneous guideline satisfaction. A validated score (specific activity scale [SAS]) classified adult symptom status. Results: In total, 498 participants (57% male, mean age 32 ± 14 years) were enrolled from 14 Canadian centers (2013-2020). Mean follow-up was 3.8 ± 1.8 years. Guideline criteria for PVR were satisfied for the majority (n = 422/498, 85%), although referral for PVR occurred only in a minority (n = 167/498, 34%). At PVR referral, most were asymptomatic (75% in SAS class 1). One participant (0.6%) received PVR without meeting criteria (PVR+/indication-). The remainder (n = 75/498, 15%) did not meet criteria for and did not receive PVR (PVR-/indication-). Abnormal cardiovascular imaging was the most commonly cited indication for PVR (n = 61/123, 50%). The SAS class and ratio of right to left end-diastolic volumes were independent predictors of PVR in a multivariable analysis (hazard ratio, 3.33; 95% confidence interval, 1.92-5.8, P < .0001; hazard ratio, 2.78; 95% confidence interval, 2.18-3.55, P < .0001). Conclusions: Although a majority of patients met guideline criteria for PVR, only a minority were referred for intervention. Abnormal cardiovascular imaging was the most common indication for referral. Further research will be necessary to establish the longer-term clinical impact of varying PVR referral strategies.

Predicting 1-Year Mortality in Outpatients With Heart Failure With Reduced Left Ventricular Ejection Fraction: Do Empiric Models Outperform Physician Intuitive Estimates? A Multicenter Cohort Study.

BACKGROUND: Many studies have demonstrated that physicians often err in estimating patient prognosis. No studies have directly compared physician to model predictive performance in heart failure (HF). We aimed to compare the accuracy of physician versus model predictions of 1-year mortality. METHODS: This multicenter prospective cohort study on 11 HF clinics in 5 provinces in Canada included consecutive consented outpatients with HF with reduced left ventricular ejection fraction (<40%). By collecting clinical data, we calculated predicted 1-year mortality using the Seattle HF Model (SHFM), the Meta-Analysis Global Group in Chronic HF score, and the HF Meta-Score. HF cardiologists and family doctors, blinded to model predictions, estimated patient 1-year mortality. During 1-year follow-up, we recorded the composite end point of mortality, urgent ventricular assist device implant, or heart transplant. We compared physicians and model discrimination (C statistic), calibration (observed versus predicted event rate), and risk reclassification. RESULTS: The study included 1643 patients with ambulatory HF with a mean age of 65 years, 24% female, and mean left ventricular ejection fraction of 28%. Over 1-year follow-up, 9% had an event. The SHFM had the best discrimination (SHFM C statistic 0.76; HF Meta-Score 0.73; Meta-Analysis Global Group in Chronic Heart Failure 0.70) and calibration. Physicians' discrimination differed little (0.75 for HF cardiologists and 0.73 for family doctors) but both physician groups substantially overestimated risk by >10% in both low- and high-risk patients (poor calibration). In risk reclassification analysis, among patients without events, the SHFM better classified 51% in comparison to HF cardiologists and 43% in comparison to family doctors. In patients with events, the SHFM erroneously assigned lower risk to 44% in comparison to HF cardiologists and 34% in comparison to family doctors. CONCLUSIONS: Family doctors and HF cardiologists showed adequate risk discrimination, with however substantial overestimation of absolute risk. Predictive models showed higher accuracy. Incorporating models in family and HF cardiology practices may improve patient care and resource use in HF with reduced left ventricular ejection fraction. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04009798.

Increased Mortality in Patients With Acutely Decompensated Heart Failure During the COVID-19 Pandemic in Toronto, Canada.

Background: Coronavirus disease 2019 (COVID-19) has resulted in a reduction in patients seeking timely consultation for illnesses that are not related to COVID-19. Previously, we reported a decline in the number of emergency department (ED) visits and hospitalizations for acute decompensated heart failure (ADHF) during the 2020 COVID-19 pandemic vs that in 2019. We aimed to determine the consequences of these early trends on ADHF-patient morbidity and mortality. Methods: We compared consecutive patients presenting with ADHF to 3 academic medical centres in Toronto, Canada from March 1-September 28, 2020, vs those from the same time period in 2019. We used multivariate logistic regression models to evaluate whether the odds of hospitalization after presenting to the ED, recurrent ED visits or readmission within 30 days, and in-hospital all-cause mortality differed by timeframe. Results: We observed that, during the COVID-19 pandemic, a lower total number of patients presented to the hospital with ADHF, vs that in 2019. Despite this difference, the probability of being admitted to the hospital did not differ for patients seen in 2020 vs 2019. Among ADHF patients admitted to the hospital, however, we observed a significantly higher proportion being admitted to the intensive care unit, and a relative 66% increase in in-hospital mortality during the 2020 COVID-19 era, compared to that in 2019. Conclusions: Our findings suggest that improved messaging may be needed for patients living with chronic health conditions, including HF, during the pandemic, to educate and encourage them to present to hospital services when in need.

Contexte: La maladie à coronavirus 2019 (COVID-19) s'est traduite par une diminution du nombre de patients demandant des consultations médicales pour des états de santé sans lien avec la COVID-19. Nous avons précédemment décrit une diminution du nombre de consultations aux urgences et d'hospitalisations en raison d'une insuffisance cardiaque aiguë décompensée (ICAD) au cours de la pandémie de COVID-19 en 2020, par rapport à 2019. Nous avons voulu déterminer les conséquences de ces tendances précoces sur la morbidité et la mortalité chez les patients atteints d'ICAD. Méthodologie: Nous avons comparé les données pour les patients consécutifs atteints d'ICAD de trois centres médicaux hospitaliers de Toronto (Canada) traités entre le 1er mars et le 28 septembre 2020 et durant la même période en 2019. À l'aide de modèles de régression logistique multivariée, nous avons évalué les différences entre les probabilités d'hospitalisation après une consultation aux urgences, de consultations récurrentes aux urgences ou de réadmission dans les 30 jours suivant la visite initiale, ainsi que de mortalité hospitalière toutes causes confondues pour les patients vus durant ces deux périodes. Résultats: Durant la pandémie de COVID-19, le nombre total de patients atteints d'ICAD s'étant présentés à l'hôpital a été plus faible que celui relevé pour l'année 2019. Malgré cet écart, la probabilité d'admission à l'hôpital ne différait pas pour les patients vus en 2020 et en 2019. Parmi les patients atteints d'ICAD admis à l'hôpital, nous avons toutefois observé une proportion significativement plus élevée de séjours aux soins intensifs et une hausse relative de 66 % du taux de mortalité hospitalière, en comparant les données de 2020 (pandémie de COVID-19) et celles de 2019. Conclusions: Nos observations indiquent qu'il pourrait être nécessaire d'améliorer la communication avec les patients atteints de problèmes de santé chroniques (y compris l'IC) en situation de pandémie de façon à mieux les informer et à les encourager à consulter les services hospitaliers lorsque nécessaire.

Regional Vascular Changes and Aortic Dilatation in Pediatric Patients With Bicuspid Aortic Valve.

BACKGROUND: Bicuspid aortic valve (BAV) is the most common congenital heart disease, often associated with valve dysfunction, coarctation of the aorta, and ascending aorta dilatation. Aortic dilatation might result from abnormal regional hemodynamics or inherent vascular disease. Vascular function in pediatric BAV remains poorly characterized. METHODS: A cross-sectional study was performed to evaluate vascular function in 142 children with BAV aged 7-18 years compared with healthy control children. Echocardiography was performed to assess aortic dimensions, BAV function, and vascular function (aortic arch pulse wave velocity [PWV]), carotid intima media thickness, and aortic stiffness and distensibility). Carotid-femoral and carotid-radial PWV were assessed using tonometry. Vascular function was compared for 4 patient groups stratified according to aortic dilatation and a history of coarctation of the aorta. Multivariate regression analysis was performed to determine predictors of aortic dilatation. RESULTS: Children with BAV had stiffer and less distensible ascending aortas with higher aortic arch PWV compared with control children. Carotid-femoral and carotid-radial PWV were not increased in patients with BAV, and the vascular assessment of the abdominal aorta was unremarkable. Multivariate regression revealed that aortic arch PWV was the only vascular function parameter that was associated with aortic dilatation. CONCLUSIONS: Children with BAV have differences in vascular function that are confined to their proximal aorta, even in normal functioning BAV. The observed differences in vascular function are likely multifactorial, with contributions from abnormal regional flow and a potential localized primary aortopathy.

Is there a role for endovascular stent implantation in the management of postoperative right ventricular outflow tract obstruction in the era of transcatheter valve implantation?

BACKGROUND: The optimal management pathway for the dysfunctional right ventricular outflow tract (RVOT) is uncertain. We evaluated the long-term outcomes and clinical impact of stent implantation for obstructed RVOTs in an era of rapidly progressing transcatheter pulmonary valve technology. METHODS: Retrospective review of 151 children with a biventricular repair who underwent stenting of obstructed RVOT between 1991 and 2017. RESULTS: RVOT stenting resulted in significant changes in peak right ventricle (RV)-to-pulmonary artery (PA) gradient (39.4 ± 17.1-14.9 ± 8.3; p < 0.001) and RV-to-aortic pressure ratio (0.78 ± 0.22-0.49 ± 0.13; p < 0.001). Subsequent percutaneous reinterventions in 51 children to palliate recurrent stenosis were similarly effective. Ninety-nine (66%) children reached the primary outcome of subsequent pulmonary valve replacement (PVR). Freedom from PVR from the time of stent implantation was 91%, 51%, and 23% at 1, 5, and 10 years, respectively. Small balloon diameters for stent deployment were associated with shorter freedom from PVR. When additional children without stent palliation (with RV-to-PA conduits) were added to the stent cohort (total 506 children), the multistate analysis showed the longest freedom from PVR in those with stent palliation and subsequent catheter reintervention. Pulmonary regurgitation was well-tolerated clinically. Indexed RV dimensions and function estimated by echocardiography remained stable at last follow up or before primary outcome. CONCLUSION: Prolongation of conduit longevity with stent implant remains an important strategy to allow for somatic growth to optimize the risk-benefit profile for subsequent surgical or transcatheter pulmonary valve replacement performed at an older age.

Female media use behavior and agreement with publicly promoted agenda-specific health messages.

This study set out to explore the relationship between female media use behavior and agreement with agenda-specific publicly promoted health messages. A random digit dial telephone cross-sectional survey was conducted using a nationally representative sample of female residents aged 25 and over. Respondents' agreement with health messages was measured by a six-item Health Information Scale (HIS). Data were analyzed using chi-square tests and multiple logistic regression. This survey achieved a response rate of 86% (n = 1074). In this study the longest duration of daily television news watching (OR = 2.32), high self-efficacy (OR = 1.56), and greater attention to medical and health news (OR = 5.41) were all correlates of greater agreement with the selected health messages. Surprisingly, Internet use was not significant in the final model. Many women that public health interventions need to be targeting are not receptive to health information that can be accessed through Internet searches. However, they may be more readily targeted by television campaigns. Agenda-specific public health campaigns aiming to empower women to serve as nodes of information transmission and achieve efficient trickle down through the family unit might do better to invest more heavily in television promotion.

Perception of spokespersons' performance and characteristics in crisis communication: experience of the 2003 severe acute respiratory syndrome outbreak in Taiwan.

BACKGROUND/PURPOSE: To explore perception of spokespersons' performance and characteristics in response to the 2003 severe acute respiratory syndrome (SARS) outbreak. METHODS: This study was conducted from March to July, 2005, using semi-structured in-depth interviews to collect data. All interviews were audio-recorded and transcribed verbatim. A qualitative content analysis was employed to analyze the transcribed data. Interviewees included media reporters, media supervisors, health and medical institution executives or spokespersons, and social observers. RESULTS: Altogether, 35 interviewees were recruited for in-depth interviews, and the duration of the interview ranged from 1 hour to 2 hours. Results revealed that the most important characteristics of health/medical institutions spokespersons are professional competence and good interaction with the media. In contrast, the most important behaviors they should avoid are concealing the truth and misreporting the truth. Three major flaws of spokespersons' performance were identified: they included poor understanding of media needs and landscape; blaming the media to cover up a mistake they made in an announcement; and lack of sufficient participation in decision-making or of authorization from the head of organization. CONCLUSION: Spokespersons of health and medical institutions play an important role in media relations during the crisis of a newly emerging infectious disease.

Persistent proteinuria and dyslipidemia increase the risk of progressive chronic kidney disease in lupus erythematosus.

Advances in immunotherapy have improved survival of patients with systemic lupus erythematosus who now face an increasing burden of chronic diseases including that of the kidney. As systemic inflammation is also thought to contribute directly to the progression of chronic kidney disease (CKD), we assessed this risk in patients with lupus, with and without a diagnosis of nephritis, and also identified modifiable risk factors. Accordingly, we enrolled 631 patients (predominantly Caucasian), of whom 504 were diagnosed with lupus within the first year and followed them an average of 11 years. Despite the presence of a chronic inflammatory disease, the rate of decline in renal function of 238 patients without nephritis was similar to that described for non-lupus patient cohorts. Progressive loss of kidney function developed exclusively in patients with lupus nephritis who had persistent proteinuria and dyslipidemia, although only six required dialysis or transplantation. The mortality rate was 16% with half of the deaths attributable to sepsis or cancer. Thus, despite the presence of a systemic inflammatory disease, the risk of progressive CKD in this lupus cohort was relatively low in the absence of nephritis. Hence, as in idiopathic glomerular disease, persistent proteinuria and dyslipidemia (modifiable risks) are the major factors for CKD progression in lupus patients with renal involvement.

Full-scale class A biosolids production by two-stage continuous-batch thermophilic anaerobic digestion at the hyperion treatment plant, Los Angeles, California.

The City of Los Angeles Hyperion Treatment Plant (HTP) (California) converted its anaerobic digesters to thermophilic operation to produce Class A biosolids. Phase IV tests demonstrated compliance of a two-stage, continuous-batch process with Alternative 1 of U.S. Environmental Protection Agency 40 CFR Part 503 (U.S. EPA, 1993), which defines the time-temperature requirement for batch treatment (T > or = 56.3 degrees C at 16-h holding). Fecal coliforms, Salmonella sp., viable helminth ova, and enteric viruses were not detected in biosolids in the postdigestion train, including the truck-loading facility and the farm for land application as the last points of plant control where compliance is to be demonstrated. The same results were achieved during Phase V tests, after lowering the second-stage holding temperature to 52.6 degrees C to reduce the elevated methyl mercaptan production that was observed during Phase IV. Hence, the Phase V process complied with Alternative 3 of 40 CFR Part 503. Currently, HTP operates its digesters under the same conditions as tested in Phase V. In 2003, monthly monitoring of the biosolids at the truck-loading facility and the farm for land application demonstrated consistent compliance with Alternative 3.

Short-term and long-term effects of increasing temperatures on the stability and the production of volatile sulfur compounds in full-scale thermophilic anaerobic digesters.

This study compares the effect of a rapid increase of the digester temperature (from 54 degrees C to 58 degrees C in 2 weeks) with a slow increase (from 53.9 degrees C to 57.2 degrees C at a rate of 0.55 degrees C per month) on full-scale thermophilic anaerobic digestion at Hyperion Treatment Plant. The short-term test demonstrated that rapidly increasing the digester temperature caused elevated production of volatile sulfur compounds, most notably methyl mercaptan, but volatile solids destruction and methane production were not significantly affected. The increase of the volatile fatty acid to alkalinity ratio from 0.1 to over 0.3 indicated a transient change in digester biochemistry, which was reversed by lowering the temperature. In the long term-test, a slow increase of digester temperature, the production of hydrogen sulfide increased above temperatures of 56.1 degrees C, but was controlled by increased injection of ferrous chloride. Methyl mercaptan was detected in trace amounts at the highest temperature tested (57.2 degrees C). This test showed insignificant effects on other digestion parameters, although some temperature-independent changes were observed that could have been seasonal effects over the year that the long-term test lasted. Thus a slow temperature increase was preferable. This observation contrasts with previous results showing the desirability of a rapid temperature rise to first establish a thermophilic culture when converting from mesophilic operation. Further research is warranted on temperature limits and process changes to optimize thermophilic anaerobic digestion.