Physicians and Machine-Learning Algorithm Performance in Predicting Left-Ventricular Systolic Dysfunction from a Standard 12-Lead-Electrocardiogram.

Early detection of left ventricular systolic dysfunction (LVSD) may prompt early care and improve outcomes for asymptomatic patients. Standard 12-lead ECG may be used to predict LVSD. We aimed to compare the performance of Machine Learning Algorithms (MLA) and physicians in predicting LVSD from a standard 12-lead ECG. By utilizing a dataset of 13,820 pairs of ECGs and echocardiography, a deep residual convolutional neural network was trained for predicting LVSD (ejection fraction (EF) < 50%) from ECG. The ECGs of the test set (n = 850) were assessed for LVSD by the MLA and six physicians. The performance was compared using sensitivity, specificity, and C-statistics. The interobserver agreement between the physicians for the prediction of LVSD was moderate (κ = 0.50), with average sensitivity and specificity of 70%. The C-statistic of the MLA was 0.85. Repeating this analysis with LVSD defined as EF < 35% resulted in an improvement in physicians' average sensitivity to 84% but their specificity decreased to 57%. The MLA C-statistic was 0.88 with this threshold. We conclude that although MLA outperformed physicians in predicting LVSD from standard ECG, prior to robust implementation of MLA in ECG machines, physicians should be encouraged to use this approach as a simple and readily available aid for LVSD screening.

Indwelling Urinary Catheter and Dementia Are Associated with Enterococcal Urinary Tract Infections in Hospitalized Patients.

BACKGROUND: The recent increase in enterococcal urinary tract infections (EUTI) and the potential morbidity and mortality associated with inappropriate antimicrobial treatment underscores the need for early risk assessment and institution of appropriate empirical antimicrobial therapy. OBJECTIVES: To identify high-risk features associated with hospitalized patients with EUTI. METHODS: Demographic, clinical, laboratory, and bacteriological data of 285 patients hospitalized with UTI during 2016 were retrieved from the computerized database of Shamir Medical Center. Patients were divided into two groups: EUTI and non-EUTI (NEUTI), according to the presence or absence of enterococcus in the urine culture. The features of the two groups were compared. RESULTS: We obtained 300 urine cultures from 285 patients. Of the total, 80 patients (26.6%) had EUTI and 220 patients (73.3%) had NEUTI. A higher prevalence of urinary multi-bacterial cultures was found in EUTI compared to NEUTI patients (P < 0.01). Higher prevalence of permanent indwelling urinary catheter and dementia were found in hospitalized patients with community-acquired EUTI and nosocomial EUTI respectively (P = 0.02, P = 0.016) compared to patients with NEUTI. CONCLUSIONS: Indwelling urinary catheter and dementia are risk factors for EUTI in patients with community and hospital acquired infection, respectively.

ECG changes after non-cardiac surgery: a prospective observational study in intermediate-high risk patients.

BACKGROUND: Efforts to mitigate the risk for perioperative cardiac events focus on both patient's and operation's risk and often include a preprocedural electrocardiogram (ECG). The merits of postprocedural ECG for detection of occult cardiac events occurring during surgery are unknown. We aim to explore the incidence of pre, and new postprocedural ECG pathologies in an intermediate-high risk population undergoing non-cardiac surgery. METHODS: This single-center, prospective, observational study, included patients older than 18 years with at least two cardiovascular risk factors who were scheduled for non-cardiac surgery. All patients had pre, and postprocedural ECG. The ECG was analyzed and coded according to the Minnesota criteria. A multivariable logistic regression analysis was performed for indices associated with new postoperative ECG pathologies. RESULTS: A total of 217 patients were enrolled. Preoperative pathologic ECG changes were recorded in 62.2% of the patients. Postoperatively, new ECG pathologies were documented in 49.8% of patients, most commonly T-wave changes (36.4% of changes). Pathologic ECG changes at baseline (OR 3.15, 95% CI [1.61-6.17]; P<0.01), diabetes (OR 1.93, 95% CI [1.02-3.64]; P=0.04), history of ischemic heart disease (OR 2.14, 95% CI [1.03-4.47]; P=0.04), higher volumes of fluid replacement (OR 1.70, 95% CI [1.10-2.61]; P=0.01) and higher levels of preoperative hemoglobin (OR 1.24, 95% CI [1.04-1.47]; P=0.01) were all independently associated with postoperative ECG changes. CONCLUSIONS: Pre-, but most importantly, postoperative ECG changes are common in intermediate-high risk surgical patients. Postoperative ECG may be valuable to disclose silent cardiovascular events that occurred during surgery.

Coronary atherosclerosis severity is closely associated with decreased GLP-1R positivity among CD16+ pro-inflammatory and patrolling monocyte subsets.

Background and aims: Glucagon Like Peptide-1 Receptor (GLP-1R) activation reduces pro-inflammatory responses of human monocytes, their accumulation in the vascular wall and foam cell formation inhibiting atherosclerogenesis. This suggests that reduction of circulating GLP-1-1R positive monocytes may have pro-atherogenic effects. It is unknown whether different CD14/CD16 monocytes subsets display GLP-1R and whether their relative proportions correlate with atherosclerosis severity. We evaluated the association between GLP-1R positivity in different CD14/CD16 monocyte subsets and coronary atherosclerosis severity. Methods: Relative amounts of classical (CD14+/CD16-), intermediate pro-inflammatory (CD14+/CD16+) and non-classical patrolling (CD14-/CD16+) subsets of total circulating monocytes and the proportions of GLP-1R positive monocytes in these subsets were determined in 13 control subjects and 10 dyslipidemic ischemic heart disease (IHD) patients with severe angiographic proven coronary atherosclerosis using flow cytometry analysis. Atherosclerosis severity was calculated by SYNTAX score. Results: In univariable analysis, severe atherosclerosis was associated with decreased proportion of classical monocytes and two fold increased CD16+ pro-inflammatory and patrolling subsets as compared with controls (p = 0.01, p = 0.02 and p = 0.01, respectively). Frequency of GLP-1R positive monocytes was decreased in both CD16+ subsets (p = 0.02 and p = 0.05, respectively) and negatively correlated with atherosclerosis severity (r = -0.65, p = 0.005 and r = -0.44, p = 0.05, respectively). Conclusions: Increased skewing of the classical monocyte population toward CD16+ pro-inflammatory and patrolling subsets accompanied by decreased in GLP-1R positivity are associated with coronary atherosclerosis severity in IHD patients with dyslipidemia. Although the effect of potential confounders cannot be ruled out, our data suggest that failure of GLP-1R-dependent anti-inflammatory/anti-atherogenic control results in innate immune system dysfunction and can promote atherosclerogenesis.

Hyper-Activation of Endogenous GLP-1 System to Gram-negative Sepsis Is Associated With Early Innate Immune Response and Modulated by Diabetes.

BACKGROUND: Culture-positive gram-negative sepsis induces greater magnitude of early innate immunity /inflammatory response compared with culture-negative sepsis. We previously demonstrated increased activation of anti-inflammatory Glucagon Like Peptide-1 (GLP-1) hormone in initial phase of sepsis more pronounced in diabetes patients. However, whether GLP-1 system is hyperactivated during the early innate immune response to gram-negative sepsis and modulated by diabetes remains unknown. OBJECTIVES: Total and active GLP-1, soluble Dipeptidyl peptidase 4 (sDPP-4) enzyme, and innate immunity markers presepsin (sCD14) and procalcitonin (PCT) in plasma were determined by ELISA on admission and after 2 to 4 days in 37 adult patients with and without type 2 diabetes and gram-negative or culture-negative sepsis of different severity. RESULTS: Severe but not non-severe sepsis was associated with markedly increased GLP-1 system response, which correlated with PCT and the organ dysfunction marker lactate. Culture-positive gram-negative bacteria but not culture-negative sepsis induced hyper-activation of GLP-1 system, which correlated with increased innate immune markers sCD14, PCT, and lactate. GLP-1 inhibitory enzyme sDPP-4 was down regulated by sepsis and correlated negatively with sCD14 in gram-negative sepsis. Diabetic patients demonstrated increased GLP-1 response but significantly weaker innate immune response to severe and gram-negative sepsis. CONCLUSIONS: Early stage of gram-negative sepsis is characterized by endogenous GLP-1 system hyperactivity associated with over activation of innate immune response and organ dysfunction, which are modulated by diabetes. Total GLP-1 may be novel marker for rapid diagnosis of gram-negative sepsis and its severity.

Sepsis-induced activation of endogenous GLP-1 system is enhanced in type 2 diabetes.

BACKGROUND: High levels of circulating GLP-1 are associated with severity of sepsis in critically ill nondiabetic patients. Whether patients with type 2 diabetes (T2D) display different activation of the endogenous GLP-1 system during sepsis and whether it is affected by diabetes-related metabolic parameters are not known. METHODS: Serum levels of GLP-1 (total and active forms) and its inhibitor enzyme sDPP-4 were determined by ELISA on admission and after 2 to 4 days in 37 sepsis patients with (n = 13) and without T2D (n = 24) and compared to normal healthy controls (n = 25). Correlations between GLP-1 system activation and clinical, inflammatory, and diabetes-related metabolic parameters were performed. RESULTS: A 5-fold (P < .001) and 2-fold (P < .05) increase in active and total GLP-1 levels, respectively, were found on admission as compared to controls. At 2 to 4 days from admission, the level of active GLP-1 forms in surviving patients were decreased significantly (P < .005), and positively correlated with inflammatory marker CRP (r = 0.33, P = .05). T2D survivors displayed a similar but more enhanced pattern of GLP-1 response than nondiabetic survivors. Nonsurvivors demonstrate an early extreme increase of both total and active GLP-1 forms, 9.5-fold and 5-fold, respectively (P < .05). The initial and late levels of circulating GLP-1 inhibitory enzyme sDPP-4 were twice lower in all studied groups (P < .001), compared with healthy controls. CONCLUSIONS: Taken together, these data indicate that endogenous GLP-1 system is activated during sepsis. Patients with T2D display an enhanced and prolonged activation as compared to nondiabetic patients. Extreme early increased GLP-1 levels during sepsis indicate poor prognosis.

Egocentric reference in bidirectional readers as measured by the straight-ahead pointing task.

The present study aimed to show that bidirectional reading and language exposure influence the position of egocentric reference (ER), the perceived direction of the body's sagittal axis proposed to act as an anchor for movements in extracorporeal space. Directional factors (e.g., visual scanning bias and reading habits) have been proposed to influence visuospatial performance, such as in line bisection and figure drawing. In past studies, bidirectional readers have been less consistent in demonstrating a bias compared to unidirectional readers. Using a straight-ahead pointing task to assess egocentric reference, we compared 14 unidirectional left-to-right readers (Uni-LR) to three bidirectional reading groups that differed in the reading direction of their native language and/or the level of their second language literacy: 16 low-English literate, native right-to-left, bidirectional readers (Lo-Bi-RL), 13 high-English literate, native right-to-left, bidirectional readers (Hi-Bi-RL), and 15 native left-to-right, bidirectional readers (Bi-LR). Participants were asked to point straight-ahead while blindfolded using either a left-to-right or a right-to-left scanning direction to approach the subjective sagittal midline. Uni-LRs showed left-side spatial bias when scanning left-to-right and right-side bias during right-to-left scanning, Bi-LRs and Lo-Bi-RLs (i.e., intermediate level or less in their second language) demonstrated the opposite pattern, and Hi-Bi-RLs showed left-side spatial bias regardless of scanning direction. Results are discussed in terms of accuracy and spatial bias regarding the interaction between reading direction and spatial cognition based on the level of bidirectional literacy and language exposure.