The Addition of a Defibrillator to Resynchronization Therapy Decreases Mortality in Patients With Nonischemic Cardiomyopathy.

OBJECTIVES: The aim of this study was to determine whether patients with heart failure with reduced ejection fraction (HFrEF) due to nonischemic etiology eligible for cardiac resynchronization therapy (CRT) benefit from an implantable cardioverter-defibrillator (ICD). BACKGROUND: It is uncertain whether CRT with an ICD (CRT-D) compared to without an ICD (CRT-P) is associated with a survival benefit in patients with nonischemic etiologies of HFrEF. METHODS: Analyses of the COMPANION (Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure) trial were performed, using Cox proportional hazards modeling stratified by HFrEF etiology of nonischemic cardiomyopathy (NICM) or ischemic cardiomyopathy (ICM). The primary outcome was all-cause mortality (ACM), and secondary outcomes were the combination of cardiovascular mortality or heart failure hospitalization and sudden cardiac death. RESULTS: Among patients randomized to CRT (n = 1,212), 236 (19.5%) died, 131 and 105 in the CRT-P and CRT-D arms, respectively. The unadjusted and adjusted hazard ratios (HRs) for CRT-D versus CRT-P were both 0.84 (95% confidence interval [CI]: 0.65 to 1.09) for ACM, with a significant device-etiology interaction (pinteraction = 0.015 adjusted; pinteraction = 0.040 unadjusted). In patients with NICM (n = 555), CRT-D versus CRT-P was associated with reduced ACM (adjusted HR: 0.54; 95% CI: 0.34 to 0.86), while patients with ICM (n = 657) did not exhibit a between-device reduction in ACM (adjusted HR: 1.05; 95% CI: 0.77 to 1.44). The effects of CRT-D versus CRT-P on sudden cardiac death (advantage CRT-D) and cardiovascular mortality or heart failure hospitalization (no difference between CRT-P and CRT-D) were similar between the 2 HFrEF etiologies. CONCLUSIONS: COMPANION patients with NICM exhibited a decrease in ACM associated with CRT-D but not CRT-P treatment, whereas patients with ICM did not.

Prognostic value of fasting versus nonfasting low-density lipoprotein cholesterol levels on long-term mortality: insight from the National Health and Nutrition Examination Survey III (NHANES-III).

BACKGROUND: National and international guidelines recommend fasting lipid panel measurement for risk stratification of patients for prevention of cardiovascular events. However, the prognostic value of fasting versus nonfasting low-density lipoprotein cholesterol (LDL-C) is uncertain. METHODS AND RESULTS: Patients enrolled in the National Health and Nutrition Examination Survey III (NHANES-III), a nationally representative cross-sectional survey performed from 1988 to 1994, were stratified on the basis of fasting status (≥8 or <8 hours) and followed for a mean of 14.0 (±0.22) years. Propensity score matching was used to assemble fasting and nonfasting cohorts with similar baseline characteristics. The risk of outcomes as a function of LDL-C and fasting status was assessed with the use of receiver operating characteristic curves and bootstrapping methods. The interaction between fasting status and LDL-C was assessed with Cox proportional hazards modeling. Primary outcome was all-cause mortality. Secondary outcome was cardiovascular mortality. One-to-one matching based on propensity score yielded 4299 pairs of fasting and nonfasting individuals. For the primary outcome, fasting LDL-C yielded prognostic value similar to that for nonfasting LDL-C (C statistic=0.59 [95% confidence interval, 0.57-0.61] versus 0.58 [95% confidence interval, 0.56-0.60]; P=0.73), and LDL-C by fasting status interaction term in the Cox proportional hazards model was not significant (Pinteraction=0.11). Similar results were seen for the secondary outcome (fasting versus nonfasting C statistic=0.62 [95% confidence interval, 0.60-0.66] versus 0.62 [95% confidence interval, 0.60-0.66]; P=0.96; Pinteraction=0.34). CONCLUSIONS: Nonfasting LDL-C has prognostic value similar to that of fasting LDL-C. National and international agencies should consider reevaluating the recommendation that patients fast before obtaining a lipid panel.

Gender differences in cardiovascular mortality by C-reactive protein level in the United States: evidence from the National Health and Nutrition Examination Survey III.

BACKGROUND: The association between C-reactive protein (CRP) and cardiovascular (CV) mortality by gender has not been previously described using a data set that is representative of the US population. METHODS: We used Cox proportional hazards models to explore gender differences in CRP-associated mortality via the National Health and Nutrition Examination Survey III 1988-1994 linked to the National Death Index with mortality follow-up through 2006. We examined CV mortality as well as all-cause mortality hazards. RESULTS: The final sample size included a total of 13,878 individuals (7,364 women and 6,514 men) with a median follow up of 18.2 years. All models controlled for race, age, smoking, high-density lipoprotein, hypertension, diabetes mellitus, waist circumference, and total cholesterol. Men with a CRP >3.0 mg/L relative to those with a CRP ≤3.0 mg/L had elevated CV mortality hazards (hazard ratio [HR] 1.79, 95% CI 1.23-2.60) and all-cause mortality hazards (HR 1.57, 95% CI 1.29-1.90). In women, elevated CRP was not significantly associated with either increased CV (HR 1.20, 95% CI 0.90-1.59) or all-cause mortality hazards (HR 1.09, CI 0.93-1.29). CONCLUSION: National guidelines from various agencies that make recommendations on the diagnostic and prognostic use of CRP have treated men and women equally. We find that there may be reason to tailor recommendations based upon one's gender.

The experience of burnout across different surgical specialties in the United Kingdom: a cross-sectional survey.

BACKGROUND: We used a cross-sectional e-mail survey to assess the prevalence of psychological morbidity across different surgical specialties and identify predictor variables of burnout in surgeons. METHOD: The survey was sent to 1971 surgeons from 127 National Health Service (NHS) hospital trusts across the United Kingdom. Burnout prevalence and mood were assessed using the Maslach Burnout Inventory-General Survey and Profile of Mood States (POMS), respectively. Demographic and POMS factors were investigated as predictors of burnout using linear and stepwise regression analyses. RESULTS: Responses to the survey were received from 342 surgeons (17% response rate). One-third of 313 respondents showed high mean levels of burnout on exhaustion (2.32; standard deviation [SD], 1.62) and cynicism (2.34; SD, 1.44) subscales. Some specialties worked significantly more hours per week (F[8, 252] = 2.89; P = .004), but burnout prevalence did not differ significantly between specialty, grade, age, gender, hours worked per week, or years spent in post. The number of years in specialty (ß = -0.17; P = .003) independently predicted surgeons' scores on exhaustion. POMS factors significantly predicted burnout, where fatigue (ß = 0.58; P < .001) was the best predictor of exhaustion scores, depression (ß = 0.28; P < .001) the best predictor of cynicism, and vigor (ß = 0.29; P < .001) the best predictor of professional efficacy. Management issues were cited as contributing to psychological morbidity. CONCLUSION: UK surgeons show high levels of cynicism and exhaustion burnout irrespective of their specialty, grade, or hours worked per week. Surgeons' mood profiles significantly predicted burnout, indicating the POMS could be used as part of an assessment for preventive interventions. NHS management and infrastructure are highlighted as influences on surgeons' psychological health.

Routine opt-out HIV testing in an urban community health center.

Undiagnosed HIV infection remains a significant public health problem. To address this, the Centers for Disease Control and Prevention revised testing recommendations, calling for routine opt-out HIV screening among adults in health care settings. However, these recommendations have not been widely implemented in primary care settings. We examined acceptability of opt-out HIV testing in an urban community health center and factors associated with accepting testing. From July 2007 to March 2008, physicians or a designated HIV tester approached patients presenting for primary care visits during 52 clinical sessions at an urban community health center. Patients were told they "would be tested for HIV unless they declined testing." Enzyme-linked immunosorbent assays, which required venipuncture, were used to test for HIV infection. We extracted demographic, clinical, and visit characteristics from medical records and examined associations between these characteristics and accepting HIV testing using logistic regression. Of 300 patients, 35% agreed to HIV testing, with no new HIV infections detected. Common reasons for declining testing were perceived low risk (54.4%) and self-reported HIV testing previously (45.1%). Younger age (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.96-0.99), Hispanic ethnicity (AOR = 1.78, 95% CI = 1.01-3.14), and having another blood test during the visit (AOR = 6.36, 95% CI = 3.58-11.28) were independently associated with accepting HIV testing. This study questions whether expanding HIV testing by conducting routine opt-out HIV testing in primary care settings is an acceptable strategy. It is important to understand how various testing strategies may affect HIV testing rates. In addition, further exploration of patients' reasons for declining HIV testing in these settings is warranted.