A Heart Team Approach to Assessing Frailty in the Cardiac Catheterization Laboratory.

INTRODUCTION: Frailty is a well-documented risk factor for increased morbidity and mortality among patients undergoing percutaneous coronary intervention (PCI). There remains a lack of knowledge regarding the impact of patient frailty in cardiac patient management and outcomes. Thus, this study examined whether the Heart Team, without using frailty assessments, made decisions regarding coronary interventions [medical management (MM) vs. PCI vs. coronary artery bypass grafting (CABG)] that aligned with formally quantified frailty status. MATERIAL AND METHODS: This cross-sectional quality-improvement (QI) study was performed at a single, large, urban Veterans Affairs Hospital. From September 2019 to November 2020, heart team nurses approached patients prior to coronary angiograms and assessed for frailty using the Risk Analysis Index Questionnaire (RAIC). Interventional cardiologists were blinded to the results. This study's independent variable was RAI-C score. The outcome variables were "intervention performed" (MM, PCI, or CABG) and presence of a "reduced invasiveness intervention" (RI). RESULTS: Ninety-five of the 182 participants had obstructive coronary artery disease. Among them, there were 69 PCIs, 10 CABGs, and 16 MMs. 26 received RIs. The primary outcomes demonstrated that frailty score was positively associated with receiving RI [adjusted OR = 1.13, 95% CI = 1.02-1.24, p = 0.02] and MM [adjusted OR = 1.13, CI = 1.02-1.25, p = 0.02], and negatively associated with receiving PCI [adjusted OR = 0.94, CI = 0.88-0.998, p = 0.04]. There was no significant association between frailty and the likelihood of undergoing CABG [AOR = 0.95, CI = 0.81-1.10, p = 0.47]. CONCLUSION: This study demonstrated that the Heart Team and patients at baseline reduced high-risk interventions in frailer patients. A Heart Team, shared-decision-making model utilizing the RAI-C was found to be efficient and effective at measuring frailty in coronary angiogram patients and should be considered for use in the clinical setting.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system.

ABSTRACT: Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Stress and neurodevelopmental processes in the emergence of psychosis.

The notion that stress plays a role in the etiology of psychotic disorders, especially schizophrenia, is longstanding. However, it is only in recent years that the potential neural mechanisms mediating this effect have come into sharper focus. The introduction of more sophisticated models of the interplay between psychosocial factors and brain function has expanded our opportunities for conceptualizing more detailed psychobiological models of stress in psychosis. Further, scientific advances in our understanding of adolescent brain development have shed light on a pivotal question that has challenged researchers; namely, why the first episode of psychosis typically occurs in late adolescence/young adulthood. In this paper, we begin by reviewing the evidence supporting associations between psychosocial stress and psychosis in diagnosed patients as well as individuals at clinical high risk for psychosis. We then discuss biological stress systems and examine changes that precede and follow psychosis onset. Next, research findings on structural and functional brain characteristics associated with psychosis are presented; these findings suggest that normal adolescent neuromaturational processes may go awry, thereby setting the stage for the emergence of psychotic syndromes. Finally, a model of neural mechanisms underlying the pathogenesis of psychosis is presented and directions for future research strategies are explored.

Spectroscopic detection of methane by use of guided-wave diode-pumped difference-frequency generation.

We report spectroscopic gas detection by the use of mid-infrared difference-frequency mixing of two diode lasers in a channel waveguide. The waveguide was fabricated by annealed proton exchange in periodically poled lithium niobate. We generated 3.43-3.73-microm tunable radiation in a single waveguide at room temperature by mixing diode lasers near 780 and 1010 nm. High-resolution spectra of methane were obtained in 2 s with electronically controlled frequency scans of 45 GHz. The use of highly efficient waveguide frequency converters pumped by fiber-coupled diode lasers will permit construction of compact, solid-state, room-temperature mid-infrared sources for use in trace-gas detection.

Pulse compression and spatial phase modulation in normally dispersive nonlinear Kerr media.

Numerical simulations show that, because of the spatiotemporal coupling implied by the multidimensional nonlinear Schrödinger equation, self-focusing of ultrashort optical pulses can lead to pulse compression even in the normal-dispersion regime of a nonlinear Kerr medium. We show how this coupling can be further exploited to control the compression by use of spatial phase modulation. Both the compression factor and the position at which the minimum pulse width is realized change with the amplitude of the phase modulation.

Steering of optical beams in nonlinear Kerr media by spatial phase modulation.

A simple scheme to steer optical beams is proposed. The basic idea is to impose a sinusoidal phase modulation on the optical beam and then propagate it in a nonlinear Kerr medium. Spatial phase modulation splits the input beam into multiple subbeams, while the nonlinear medium shapes a particular subbeam into a spatial soliton in such a way that most of the beam power appears in a narrow beam whose direction can be controlled by changing the modulation parameters. We present numerical results showing how spatial phase modulation can be used to alter the path of an optical beam propagating in a nonlinear Kerr medium.

An appraisal of some lesioning methods applied to the posterior hypothalamus in rats.

The behavioral changes and histological damage to the brain of rats were examined following lesions of the midlateral posterior hypothalamic area (MLPHA) made by passing electrical current through a metal electrode or through a glass pipette containing hydrogen ion (HCl) or kainic acid. Control experiments included placement of pipettes containing saline and imposing the same current as used in kainic-acid-containing electrodes (sham). Subcutaneous injections of kainic acid assessed damage that may be attributed to general neuronal cytotoxicity or limbic seizures. The effect of diazepam on alleviating behavioral changes and structural damage in kainic-acid-injected rats was examined. The current used to inject kainic acid produced significant damage to both neurons and axons of passage at the injection site. Degeneration of nerve terminals following kainic acid injections in the MLPHA was widespread, not predictably reduced by diazepam premedication and differed in only minor details from degeneration induced by subcutaneous injections.

Sleep-waking patterns of intact and carotid sinus nerve-transected rats during hypoxic-CO2 breathing.

Two groups, each consisting of six male rats, breathed 21% O2-4% CO2 or 10% O2-4% CO2, respectively, before and after carotid sinus nerve (CSN) transection. Polygraphic recording techniques served to monitor sleep and wakefulness. The effects of these gas mixtures on the sleep-waking pattern (SWP) were studied. The SWPs of the intact and CSN-transected rats breathing 21% O2-4% CO2 were no different from rats breathing air. While breathing 10% O2-4% CO2, the greatest alteration in the rat's SWP, compared with breathing 10% O2 devoid of CO2, was in the pattern of frequency of change of states, an effect unchanged by CSN transection. We conclude that CO2 added to air did not affect the rat's SWP. However, a hypoxic-CO2 gas mixture radically altered all parameters of the SWP, an effect which was centrally mediated.

The effects of hypoxia and CO2 on the sleep-waking pattern of the potoroo (Potorous tridactylus apicalis).

Four male potoroos (Potorous tridactylus apicalis) breathed 21% and 7% O2 with and without the addition of 5% CO2. The effects of these gas mixtures on the potoroo's sleeping-waking pattern (SWP) were studied. The SWP while breathing 21% O2/5% CO2 was unchanged when compared with that of breathing ambient air (21% O2). While breathing 7% O2, the SWP was severely disrupted: total sleep time (TST) and slow wave sleep (SWS) increased markedly. Brain temperature fell substantially. Paradoxical sleep (PS) was almost abolished and wakefulness (W) decreased. The addition of 5% CO2 to the O2 deficient gas mixture, i.e., 7% O2/5% CO2, restored the SWP to that obtained while breathing ambient air. It is concluded that CO2 neutralizes the disruptive effect which hypoxia has on the potoroo's SWP. It is hypothesized that this constitutes a homeostatic mechanism for stabilizing the SWP and is carried over from pouch life.

Constriction of ear arteries from normotensive and renal hypertensive rabbits against different transmural pressures.

Isolated segments of rabbit ear arteries were made to constrict against normotensive and hypertensive transmural pressures by perfusion with submaximal concentrations of norepinephrine (NE). Changes in load (force/unit length of artery) and stress (force/wall cross-sectional area) during constriction against a constant pressure have been evaluated. Weak concentrations of NE constricted the arteries equally well against transmural pressures of 80 and 120 mm Hg and, in doing so, utilized much of the contractile capacity of the muscle. A stretch-mediated, co-operative interaction between muscle cells has been put forward to explain these observations. Ear arteries from renal hypertensive rabbits differed from those of normotensive rabbits in having a higher NE threshold concentration and in constricting better against 140 mm Hg. They did so because of the mechanical advantage provided by a smaller internal radius and a thicker wall which reduced the load and stress placed on the muscle by the pressure. No muscle hyperplasia or hypertrophy was detected.

Sleep-wake patterns of intact and carotid sinus nerve sectioned rats during hypoxia.

Six male rats breathed 21 an 10% O2 before and after carotid sinus nerve (CSN) section. Polygraphic recording techniques were used to monitor sleep and wakefulness. The effects that these gas mixtures had on the rats' sleep-wake pattern (SWP) were studied. The SWP of CSN sectioned rats breathing 21% O2 was unchanged compared with that of intact rats. While breathing 10% O2, the intact rats' SWP was altered dramatically. Paradoxical sleep (PS) was absent on the first day's exposure to hypoxia. After CSN section, the SWP approximated that of rats in normoxic conditions. The amount of PS increased considerably. It is concluded that the peripheral chemoreceptor reflex pathway contributes, in part, to disruption of the SWP under hypoxic conditions, but not under normoxic conditions. Mechanisms underlying changes in states of consciousness due to hypoxia are discussed.

An electrophysiological analysis of sleep and respiration of rats breathing different gas mixtures: diaphragmatic muscle function.

The effects of breathing 21% O2, 21% O2 + 5% CO2, 10% O2 + 4% CO2 and 10% O2 on the sleep-waking rhythm, respiratory rate, diaphragmatic EMG, inspiratory (Ti) and expiratory (Te) times were studied in rats. They carried chronically implanted electrodes to permit polygraphic recordings of the ECoG, EOG and dorsal neck and integrated diaphragmatic EMG activity. Average respiratory rates, independent of state of consciousness varied depending on the gas mixture breathed. Sleep-waking times, expressed as percentages, were determined as a function of the gas mixture breathed. Oxygen deficiency caused PS deprivation which was partially alleviated by the addition of 4% CO2. Diaphragmatic EMG activity decreased during PS when rats breathed gas mixtures rich in CO2 but increased when they breathed 10% O2. In general, at a given frequency of breathing, Ti was shorter during PS than during SWS except when rats breathed 10% O2. It is concluded that: (1) regardless of the state of consciousness hypoxia is a more potent stimulus of respiratory rate than hypercapnia, (2) diaphragmatic effort is reduced when rats breathe CO2 enriched gas mixtures but is increased by hypoxia due to changes in upper airway resistance, and (3) low O2 content of an inspired gas disrupts the inspiratory and expiratory off-switch mechanisms, this disruption being prevented by the addition of CO2.