Association of Changes in A1C Following Continuous Glucose Monitoring Acquisition in People with Sub-Optimally Treated Type 2 Diabetes Taking GLP-1 RA Therapy.

INTRODUCTION: Both glucagon-like peptide-1 receptor agonists (GLP-1 RA) and continuous glucose monitoring (CGM) improve glycemia in patients with type 2 diabetes (T2D). However, it is unknown whether adding CGM to GLP-1 RA therapy further improves A1c. We evaluated changes in A1c levels 6 months after initiation of FreeStyle Libre (FSL) in adults with sub-optimally controlled T2D already on GLP-1 RA therapy. METHODS: This retrospective, observational study used Optum's de-identified Market Clarity Data, a linked electronic health record-claims database to assess changes in A1c after FSL acquisition. Inclusion criteria were T2D diagnosis, ≥ 18 years, baseline A1c ≥ 8%, with the first FSL acquisition between 2018 and 2022. Patients were required to be on GLP-1 RA prior to FSL with at least one GLP-1 RA prescription within 90 days of FSL acquisition. GLP-1 RA initiation was defined as the earliest GLP-1 RA prescription from 2017 onwards. Paired changes in A1c were assessed at 6 months after initial FSL acquisition. RESULTS: The study cohort included 1454 adults with T2D (age 55 ± 10 years, 52% male, 38% with intensive insulin therapy, median 471 days from GLP-1 RA initiation to FSL, and baseline A1c 9.8 ± 1.5%). After FSL acquisition, patients experienced an A1c decrease of 1.5 ± 1.9% (p < 0.001). Patients with a baseline A1c > 10% had the largest reduction (n = 497, - 2.7 ± 2.2%, p < 0.001). Significant improvements were observed in subgroups based on insulin therapy and GLP-1 RA formulation. Those initiating GLP-1 RA therapy > 24 months before FSL acquisition also showed improvements in A1c (n = 478; - 1.3 ± 1.7%, p < 0.001). CONCLUSIONS: In a large, real-world study of adults with T2D, those on prior GLP-1 RA therapy experienced significant A1c improvements after acquiring FSL, irrespective of GLP-1 RA duration, GLP-1 RA formulation, or insulin therapy type. These findings support the use of FSL in adults with T2D treated with GLP-1 RA.

Initiating GLP-1 Therapy in Combination with FreeStyle Libre Provides Greater Benefit Compared with GLP-1 Therapy Alone.

Background and Aim: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) therapy provides glycemic benefits to individuals with type 2 diabetes (T2D). However, the effects of GLP-1 RA therapy in combination with FreeStyle Libre systems (FSL) are unknown. This study aimed to compare changes in hemoglobin A1c (HbA1c) between people acquiring GLP-1 with FSL (GLP-1+FSL) versus GLP-1 without FSL (GLP-1). Methods: This real-world study used Optum's de-identified Market Clarity Data, a linked electronic health records (EHR)-claims database, and included adults with T2D and HbA1c ≥8% who acquired their first GLP-1 RA medication between 2018 and 2022. GLP-1+FSL subjects acquired their first FSL within ±30 days of their first GLP-1 acquisition. Cohorts were matched 1:5 on baseline insulin therapy, age, sex, baseline HbA1c, and GLP-1 type. Paired changes in HbA1c were compared between unmatched and matched groups at 6 months. Results: The study included 24,724 adults in the unmatched cohort (GLP-1+FSL, n = 478; GLP-1, n = 24,246). The matched cohort included 478 GLP-1+FSL users and 2,390 GLP-1 users: mean age 53.5 ± 11.8 and 53.5 ± 11.3 years, HbA1c 10.25 ± 1.68% and 10.22 ± 1.69%, respectively. HbA1c reduction was greater in the GLP-1+FSL group compared with the GLP-1 group in the unmatched cohort (-2.43% vs. -1.73%, difference 0.70%, P < 0.001, respectively) and in the matched cohort (-2.43% vs. -2.06%, difference 0.37%, P < 0.001). GLP-1+FSL vs. GLP-1 treatment was associated with greater HbA1c reduction in the intensive insulin (-2.32% vs. -1.50%), nonintensive insulin (-2.50% vs. -1.74%), and noninsulin group (-2.46% vs. -1.78%), as well as in patients using semaglutide (-2.73% vs. -1.92%) and dulaglutide (-2.45% vs. -1.71%) GLP-1 RA, all P < 0.001. Conclusions: Adults with suboptimally controlled T2D, initiating GLP-1 RA with FreeStyle Libre, had greater improvement in HbA1c compared with those treated with GLP-1 RA only. These results suggest an additional glycemic benefit of FSL when used with a GLP-1 RA in T2D treatment.

Dynamic light manipulation via silicon-organic slot metasurfaces.

Active metasurfaces provide the opportunity for fast spatio-temporal control of light. Among various tuning methods, organic electro-optic materials provide some unique advantages due to their fast speed and large nonlinearity, along with the possibility of using fabrication techniques based on infiltration. In this letter, we report a silicon-organic platform where organic electro-optic material is infiltrated into the narrow gaps of slot-mode metasurfaces with high quality factors. The mode confinement into the slot enables the placement of metallic electrodes in close proximity, thus enabling tunability at lower voltages. We demonstrate the maximum tuning sensitivity of 0.16nm/V, the maximum extinction ratio of 38% within ± 17V voltage at telecommunication wavelength. The device has 3dB bandwidth of 3MHz. These results provide a path towards tunable silicon-organic hybrid metasurfaces at CMOS-level voltages.

Malglycemia in the critical care setting. Part III: Temporal patterns, relative potencies, and hospital mortality.

INTRODUCTION: The relationship between critical care mortality and combined impact of malglycemia remains undefined. METHODS: We assessed the risk-adjusted relationship (n = 4790) between hospital mortality with malglycemia, defined as hypergycemia (hours Glycemic Ratio ≥ 1.1, where GR is quotient of mean ICU blood glucose (BG) and estimated average BG), absolute hypoglycemia (hours BG < 70 mg/dL) and relative hypoglycemia (excursions GR < 0.7 in those with HbA1c ≥ 8%). RESULTS: Each malglycemia was independently associated with mortality - hyperglycemia (OR 1.0020/h, 95%CI 1.0009-1.0031, p = 0.0004), absolute hypoglycemia (OR 1.0616/h, 95%CI 1.0190-1.1061, p = 0.0043), and relative hypoglycemia (OR 1.2813/excursion, 95%CI 1.0704-1.5338, p = 0.0069). Absolute (7.4%) and relative hypoglycemia (6.7%) exposure dominated the first 24 h, decreasing thereafter. While hyperglycemia had lower risk association with mortality, it was persistently present across the length-of-stay (68-76% incidence daily), making it the dominant form of malglycemia. Relative contributions in the first five days from hyperglycemia, absolute hypoglycemia and relative hypoglycemia were 60%, 21% and 19% respectively. CONCLUSIONS: Absolute and relative hypoglycemia occurred largely in the first 24 h. Relative to all hypoglycemia, the associated mortality from the seemingly less potent but consistently more prevalent hyperglycemia steadily accumulated with increasing length-of-stay. This has important implications for interpretation of study results.

Receiver operating characteristics of computed tomography (CT) compared to cystoscopy in diagnosis of canine ectopic ureters: Thirty-five cases.

OBJECTIVE: The aim of the study was to determine receiver operating characteristics (ROC) of computed tomographic excretory urography (CTEU) in predicting cystoscopic findings of ureteral anatomy. STUDY DESIGN: Retrospective cohort study. ANIMALS: Thirty-five client-owned dogs. METHODS: The medical records of dogs referred for suspected ectopic ureters were reviewed. Inclusion criteria included CTEU findings reported by board-certified radiologists, followed by rigid cystoscopy with or without ureteral cystoscopic laser ablation (CLA). Data included signalment, urinary incontinence degree, body condition score, weight, degree of colon distension, CTEU and cystoscopy findings. ROC analysis was used to compare CT-predicted ureteral orthotopia/ectopia to cystoscopy findings. Additionally, ROC of CT predicted ureteral orifice locations was analyzed. Regression covariate analysis was performed to identify factors that may have influenced accuracy of diagnosis. RESULTS: The ability of CT to identify a normal and intra-or extramural ectopic ureters conclusively and correctly was 13/26 (50%) and 32/41(78%), respectively. Sensitivity and specificity of identifying extramural versus intramural ureters was 2/7 versus 30/46 (29 vs. 65%) and 61/63 versus 17/24 (97 vs. 71%), respectively. Ectopic orifice determination sensitivity and specificity varied widely depending on location from 0% to 76% and 67% to 97%, respectively. Covariate analysis failed to identify interfering factors. CONCLUSIONS: CT did not accurately predict anatomy of ureters; CT findings may need confirmation by cystoscopy and possibly intraoperative fluoroscopy prior to determining if CLA is indicated or not. CLINICAL SIGNIFICANCE: Our results may be of importance for surgeons interpreting the CTEU findings. CTEU prediction of the location of the ureteral orifice shows low sensitivity especially in or close to the urethral sphincter area.

Understanding the relation between reading and anxiety among upper elementary students with reading difficulties.

This study examined the relations between reading anxiety, general anxiety, and test anxiety in a sample of students with reading difficulties (n = 536). It also tested if dimensions of anxiety were differentially related to word reading accuracy and fluency, text reading fluency, or reading comprehension. The results indicated that the three anxiety measures were significantly related (r = 0.51 to 0.56, p < .001). Additionally, higher reading anxiety was related to poorer word reading fluency, text reading fluency, and comprehension outcomes. Further analyses indicated that these relations existed in students who fell in the middle and upper quantiles for reading, but not the lowest quantile. This pattern of findings suggests that the relation is complex and varies depending on severity of reading difficulty. Results may help to inform future efforts to support students with reading difficulties, including students with dyslexia.

Radiographic analysis of the dorsal hoof wall thickness in clinically normal draft horses.

OBJECTIVE: To evaluate the radiographic thickness of the dorsal hoof wall in normal draft horse feet. ANIMALS: 33 adult draft horses with no history of laminitis, no clinically obvious lameness, and visibly unremarkable front feet were included. METHODS: This was a prospective, descriptive study of clinically normal draft horses' front feet. Lateromedial radiographs were acquired of the front feet. A ratio of the dorsal hoof wall thickness to the length of the distal phalanx (DHWP3 ratio) was calculated. RESULTS: The dorsal hoof wall thickness to length of the distal phalanx was calculated as 0.33 ± 0.03 (range of 0.28 to 0.39) in this population of draft horses. CLINICAL RELEVANCE: With very few exceptions, the heterogeneous population of draft horses evaluated in this study had a DHWP3 ratio greater than previously published values in lighter breeds (< 0.30).

Evaluating the Efficacy of a Narrative Language Intervention for Bilingual Students.

PURPOSE: This study examines the narrative language and reading outcomes of monolingual and bilingual students who received instruction with the Supporting Knowledge in Language and Literacy (SKILL) program, a narrative language intervention. METHOD: The main effects of the SKILL program were evaluated in a randomized controlled trial in which students (N = 355) who were at risk for English language and literacy difficulties were randomized to the SKILL intervention or a business-as-usual instruction. This article reports secondary analyses examining the efficacy of SKILL for bilingual (n = 148) and monolingual (n = 207) students who completed measures of oral and written narrative language and reading comprehension in English. RESULTS: Moderation results showed that the effects of SKILL did not differ for monolinguals and bilinguals across most narrative language measures and did not vary for monolinguals or bilinguals based on their pre-intervention language performance. CONCLUSION: These findings that suggest a language-based approach to improving narrative production and comprehension yielded similar results for monolinguals and bilinguals and that neither monolinguals nor bilinguals in this study needed to meet a certain threshold of English language proficiency to benefit from the intervention.

The occurrence of Hospital-Acquired Pneumonia is independently associated with elevated Stress Hyperglycaemia Ratio at admission but not elevated blood glucose.

BACKGROUND: The association between stress-induced hyperglycaemia (SIH) and increased infection rates in hospitalised subjects is well-known. It is less clear if SIH at admission independently drives new-onset infections. We assessed the relationship between early exposure at admission to both the Stress Hyperglycaemia Ratio (SHR) and Blood Glucose (BG) with Hospital-Acquired Pneumonia (HAP). METHODS: This observational retrospective study included those with length-of-stay > 1 day, BG within 24 h of admission and recent haemoglobin A1c. SIH was defined as BG ≥ 10 mmol/L, or SHR ≥ 1.1, measured at both admission and as a 24-hour maximum. Multivariable analyses were adjusted for length-of-stay, age, mechanical ventilation, and chronic respiratory disease. RESULTS: Of 5,339 eligible subjects, 110 (2.1%) experienced HAP. Admission SHR ≥ 1.1 was independently associated with HAP (OR 3.04, 95% CI 1.98-4.68, p < 0.0001) but not BG ≥ 10 mmol/L (OR 0.65, 95% CI 0.41-1.03, p = 0.0675). The association with SHR strengthened using maximum 24-hour values (OR 3.37, 95% CI 2.05-5.52, p < 0.0001) while BG ≥ 10 mmol/L remained insignificant (OR 0.96, 95% CI 0.63-1.46, p = 0.86). Of those experiencing HAP 40 (36.4%) occurred in subjects with no recorded BG ≥ 10 mmol/L but SHR ≥ 1.1. CONCLUSION: SIH at admission defined as SHR ≥ 1.1, but not the conventional marker of BG ≥ 10 mmol/L, was independently associated with the subsequent onset of HAP, commonly at BG < 10 mmol/L.

Opportunities for clinical decision support targeting medication safety in remote primary care management of chronic kidney disease: A qualitative study in Northern Australia.

INTRODUCTION: This study aimed to identify opportunities for clinical decision support targeting medication safety in remote primary care, by investigating the relationship between clinical workflows, health system priorities, cognitive tasks, and reasoning processes in the context of medicines used in people with chronic kidney disease (CKD). METHODS: This qualitative study involved one-on-one, semistructured interviews. The participants were healthcare professionals employed in a clinical or managerial capacity with clinical work experience in a remote health setting for at least 1 year. RESULTS: Twenty-five clinicians were interviewed. Of these, four were rural medical practitioners, nine were remote area nurses, eight were Aboriginal health practitioners, and four were pharmacists. Four major themes were identified from the interviews: (1) the need for a clinical decision support system to support a sustainable remote health workforce, as clinicians were "constantly stretched" and problems may "fall through the cracks"; (2) reliance on digital health technologies, as medical staff are often not physically available and clinicians-on-duty usually "flick an email and give a call so that I can actually talk it through to our GP"; (3) knowledge gaps, as "it takes a lot of mental space" to know each patient's renal function and their medication history, and clinicians believe "mistakes can be made"; and (4) multiple risk factors impacting CKD management, including clinical, social and behavioural determinants. CONCLUSIONS: The high prevalence of CKD and reliance on digital health systems in remote primary health settings can make a clinical decision support system valuable for supporting clinicians who may not have extensive experience in managing medicines for people with CKD.

Multi-dimensional wavefront sensing using volumetric meta-optics.

The ideal imaging system would efficiently capture information about the fundamental properties of light: propagation direction, wavelength, and polarization. Most common imaging systems only map the spatial degrees of freedom of light onto a two-dimensional image sensor, with some wavelength and/or polarization discrimination added at the expense of efficiency. Thus, one of the most intriguing problems in optics is how to group and classify multiple degrees of freedom and map them on a two-dimensional sensor space. Here we demonstrate through simulation that volumetric meta-optics consisting of a highly scattering, inverse-designed medium structured with subwavelength resolution can sort light simultaneously based on direction, wavelength, and polarization. This is done by mapping these properties to a distinct combination of pixels on the image sensor for compressed sensing applications, including wavefront sensing, beam profiling, and next-generation plenoptic sensors.

Cloud condensation nuclei activity of internally mixed particle populations at a remote marine free troposphere site in the North Atlantic Ocean.

This study reports results from research conducted at the Observatory of Mount Pico (OMP), 2225 m above mean sea level on Pico Island in the Azores archipelago in June and July 2017. We investigated the chemical composition, mixing state, and cloud condensation nuclei (CCN) activities of long-range transported free tropospheric (FT) particles. FLEXible PARTicle Lagrangian particle dispersion model (FLEXPART) simulations reveal that most air masses that arrived at the OMP during the sampling period originated in North America and were highly aged (average plume age > 10 days). We probed size-resolved chemical composition, mixing state, and hygroscopicity parameter (κ) of individual particles using computer-controlled scanning electron microscopy with an energy-dispersive X-ray spectrometer (CCSEM-EDX). Based on the estimated individual particle mass from elemental composition, we calculated the mixing state index, χ. During our study, FT particle populations were internally mixed (χ of samples are between 53 % and 87 %), owing to the long atmospheric aging time. We used data from a miniature Cloud Condensation Nucleus Counter (miniCCNC) to derive the hygroscopicity parameter, κCCNC. Combining κCCNC and FLEXPART, we found that air masses recirculated above the North Atlantic Ocean with lower mean altitude had higher κCCNC due to the higher contribution of sea salt particles. We used CCSEM-EDX and phase state measurements to predict single-particle κ (κCCSEM-EDX) values, which overlap with the lower range of κCCNC measured below 0.15 % SS. Therefore, CCSEM-EDX measurements can be useful in predicting the lower bound of κ, which can be used in climate models to predict CCN activities, especially in remote locations where online CCN measurements are unavailable.

Multi-campaign ship and aircraft observations of marine cloud condensation nuclei and droplet concentrations.

In-situ marine cloud droplet number concentrations (CDNCs), cloud condensation nuclei (CCN), and CCN proxies, based on particle sizes and optical properties, are accumulated from seven field campaigns: ACTIVATE; NAAMES; CAMP2EX; ORACLES; SOCRATES; MARCUS; and CAPRICORN2. Each campaign involves aircraft measurements, ship-based measurements, or both. Measurements collected over the North and Central Atlantic, Indo-Pacific, and Southern Oceans, represent a range of clean to polluted conditions in various climate regimes. With the extensive range of environmental conditions sampled, this data collection is ideal for testing satellite remote detection methods of CDNC and CCN in marine environments. Remote measurement methods are vital to expanding the available data in these difficult-to-reach regions of the Earth and improving our understanding of aerosol-cloud interactions. The data collection includes particle composition and continental tracers to identify potential contributing CCN sources. Several of these campaigns include High Spectral Resolution Lidar (HSRL) and polarimetric imaging measurements and retrievals that will be the basis for the next generation of space-based remote sensors and, thus, can be utilized as satellite surrogates.

Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke.

AIMS: After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke. METHODS AND RESULTS: Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA2DS2-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM. CONCLUSION: Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.

3D-patterned inverse-designed mid-infrared metaoptics.

Modern imaging systems can be enhanced in efficiency, compactness, and application through the introduction of multilayer nanopatterned structures for manipulation of light based on its fundamental properties. High transmission multispectral imaging is elusive due to the commonplace use of filter arrays which discard most of the incident light. Further, given the challenges of miniaturizing optical systems, most cameras do not leverage the wealth of information in polarization and spatial degrees of freedom. Optical metamaterials can respond to these electromagnetic properties but have been explored primarily in single-layer geometries, limiting their performance and multifunctional capacity. Here we use advanced two-photon lithography to realize multilayer scattering structures that achieve highly nontrivial optical transformations intended to process light just before it reaches a focal plane array. Computationally optimized multispectral and polarimetric sorting devices are fabricated with submicron feature sizes and experimentally validated in the mid-infrared. A final structure shown in simulation redirects light based on its angular momentum. These devices demonstrate that with precise 3-dimensional nanopatterning, one can directly modify the scattering properties of a sensor array to create advanced imaging systems.

Constraining Continuous Topology Optimizations to Discrete Solutions for Photonic Applications.

Photonic topology optimization is a technique used to find the permittivity distribution of a device that optimizes an electromagnetic figure-of-merit. Two common versions are used: continuous density-based optimizations that optimize a gray scale permittivity defined over a grid, and discrete level-set optimizations that optimize the shape of the material boundary of a device. In this work we present a method for constraining a continuous optimization such that it is guaranteed to converge to a discrete solution. This is done by inserting a constrained suboptimization with low computational overhead cost at each iteration of an overall gradient-based optimization. The technique adds only one hyperparameter with straightforward behavior to control the aggressiveness of binarization. Computational examples are provided to analyze the hyperparameter behavior, show this technique can be used in conjunction with projection filters, show the benefits of using this technique to provide a nearly discrete starting point for subsequent level-set optimization, and show that an additional hyperparameter can be introduced to control the overall material/void fraction. This method excels for problems where the electromagnetic figure-of-merit is majorly affected by the binarization requirement and situations where identifying suitable hyperparameter values becomes challenging with existing methods.

MRI and CT characteristics of a grade I meningioma with concurrent cribriform plate lysis in a dog.

A 6-year-old female spayed German Shepherd mixed-breed dog was presented for treatment of a frontal lobe mass diagnosed on MRI, after an acute onset of generalized seizures and behavior changes. Computed tomography of the head was performed for radiation therapy planning and revealed concurrent cribriform plate lysis without nasal sinus invasion, and focal lysis of the left ventrolateral cranial fossa. Histopathology of the mass obtained via surgical excision was consistent with a grade I fibrous meningioma. The dog had a good outcome following surgery and radiation therapy.

Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill.

Context: The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective: This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods: This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results: Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM. Conclusion: These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.

Ambulatory Pulmonary Artery Pressures After Transcatheter Edge-to-Edge Repair of the Mitral Valve in Patients With Heart Failure and Mitral Regurgitation.

The objective of this study was to assess ambulatory hemodynamics after transcatheter edge-to-edge repair (TEER) of the mitral valve. Pulmonary artery pressure (PAP) measurements from implanted sensors were collected through a remote monitoring database and linked to Medicare fee-for-service claims data. Among patients with linked data, those undergoing TEER were included if the ambulatory PAP monitor was implanted ≥3 months before TEER and ≥3 months of PAP data after TEER were available. The primary end point was diastolic PAP (dPAP) at 3 months after TEER compared with baseline. A total of 50 patients undergoing TEER between July 2014 and March 2020 were included, with an average age of 75 ± 8 years and 70% were men. dPAP was significantly lower at 3 months after TEER than baseline, -1.8 ± 4.8 mm Hg, p = 0.010. The cumulative reduction in dPAP (area under the curve) was significantly lower at 3 months after TEER, 113 ± 267 mm Hg-days, p = 0.004. A reduction in dPAP at 3 months after TEER was independently associated with a significantly lower risk of heart failure hospitalization (p = 0.023). TEER of the mitral valve is associated with a clinically relevant and sustained reduction in dPAP.

Quantification of stress-induced hyperglycaemia associated with key diagnostic categories using the stress hyperglycaemia ratio.

AIM: Stress-induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A1c (HbA1c ). METHODS: We identified eligible patients for eight medical (n = 892) and eight surgical (n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR. RESULTS: Analysis of variance indicated differing SHR and BG within both the medical (p < 0.0001 for both) and surgical cohort (p < 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST-elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34). SHR values remained independent of HbA1c , with no difference for those with HbA1c above or below 6.5% (p > 0.11 for each). BG however was highly dependent on HbA1c , invariably elevated in those with HbA1c  ≥ 6.5% (p < 0.001 for each), and unreliably reflected SIH. CONCLUSION: The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA1c spectrum while BG did not and poorly reflected SIH.