Insights from Eye Blinks into the Cognitive Processes Involved in Visual Word Recognition.

Behavioral differences in speed and accuracy between reading familiar and unfamiliar words are well-established in the empirical literature. However, these standard measures of skill proficiency are limited in their ability to capture the moment-to-moment processing involved in visual word recognition. In the present study, the effect of word familiarity was initially investigated using an eye blink rate among adults and children. The probability of eye blinking was higher for familiar (real) words than for unfamiliar (pseudo)words. This counterintuitive pattern of results suggests that the processing of unfamiliar (pseudo)words is more demanding and perhaps less rewarding than the processing of familiar (real) words, as previously observed in both behavioral and pupillometry data. Our findings suggest that the measurement of eye blinks might shed new light on the cognitive processes involved in visual word recognition and other domains of human cognition.

Language-universal and script-specific factors in the recognition of letters in visual crowding: The effects of lexicality, hemifield, and transitional probabilities in a right-to-left script.

Peripheral letter recognition is fundamentally limited not by the visibility of letters but by the spacing between them, i.e., 'crowding'. Crowding imposes a significant constraint on reading, however, the interplay between crowding and reading is not fully understood. Using a letter recognition task in varying display conditions, we investigated the effects of lexicality (words versus pseudowords), visual hemifield, and transitional letter probability (bigram/trigram frequency) among skilled readers (N = 14. and N = 13) in Hebrew - a script read from right to left. We observed two language-universal effects: a lexicality effect and a right hemifield (left hemisphere) advantage, as well as a strong language-specific effect - a left bigram advantage stemming from the right-to-left reading direction of Hebrew. The latter finding suggests that transitional probabilities are essential for parafoveal letter recognition. The results reveal that script-specific contextual information such as letter combination probabilities is used to accurately identify crowded letters.

A developmental study of eye movements in Hebrew word reading: the effects of word familiarity, word length, and reading proficiency.

Previous studies examining the link between visual word recognition and eye movements have shown that eye movements reflect the time-course of cognitive processes involved in reading. Whereas most studies have been undertaken in Western European languages written in the Roman alphabet, the present developmental study investigates a non-European language-Hebrew, which is written in a non-alphabetic (abjadic) script. We compared the eye-movements of children in Grades 4 to 6 (N = 30) and university students (N = 30) reading familiar real words and unfamiliar (pseudo)words of 3 letters and 5 letters in length. Using linear mixed models, we focused on the effects of word familiarity, word length, and age group. Our results highlight both universal aspects of word reading (developmental and familiarity (lexicality) effects) as well as language-specific word length effect which appears to be related to the unique morphological and orthographic features of the Semitic abjad.

Preschool morphological awareness contributes to word reading at the very earliest stages of learning to read in a transparent orthography.

The purpose of the current study was to examine whether morphological awareness measured before children are taught to read (Kindergarten in Israel) predicts reading accuracy and fluency in the middle of first grade, at the very beginning of the process of learning to read pointed Hebrew - a highly transparent orthography, and whether this contribution remains after controlling for phonemic awareness. In a longitudinal design, 680 Hebrew-speaking children were administered morphological and phonemic awareness measures at the end of the preschool year (before they were taught to read) then followed up into first grade when reading was tested in mid-year. The results indicated that even at this early point in learning to read a transparent orthography, preschool morphological awareness contributes significantly to both reading accuracy and reading fluency, even after partialling out age, non-verbal general ability, and phonemic awareness. The current results extend the Functional Opacity argument (Share, 2008) which proposes that at the initial stages of reading acquisition, when children still have incomplete mastery of some aspects of the spelling-sound system, non-phonological sources of information about word identity such as morphology can assist in the decoding process. The practical implications of these results with regard to early reading instruction are discussed.

A pupillometric study of developmental and individual differences in cognitive effort in visual word recognition.

Throughout the history of modern psychology, the neural basis of cognitive performance, and particularly its efficiency, has been assumed to be an essential determinant of developmental and individual differences in a wide range of human behaviors. Here, we examine one aspect of cognitive efficiency-cognitive effort, using pupillometry to examine differences in word reading among adults (N = 34) and children (N = 34). The developmental analyses confirmed that children invested more effort in reading than adults, as indicated by larger and sustained pupillary responses. The within-age (individual difference) analyses comparing faster (N = 10) and slower (N = 10) performers revealed that in both age groups, the faster readers demonstrated accelerated pupillary responses compared to slower readers, although both groups invested a similar overall degree of cognitive effort. These findings have the potential to open up new avenues of research in the study of skill growth in word recognition and many other domains of skill learning.

Common Misconceptions about the Phonological Deficit Theory of Dyslexia.

In this discussion paper, I review a number of common misconceptions about the phonological deficit theory (PDH) of dyslexia. These include the common but mistaken idea that the PDH is simply about phonemic awareness (PA), and, consequently, is a circular "pseudo"-explanation or epiphenomenon of reading difficulties. I argue that PA is only the "tip of the phonological iceberg" and that "deeper" spoken-language phonological impairments among dyslexics appear well before the onset of reading and even at birth. Furthermore, not even reading-specific expressions of phonological deficits-PA or pseudoword naming, can be considered circular if we clearly distinguish between reading proper-real meaning-bearing words, or real text, and the mechanisms (subskills) of reading development (such as phonological recoding). I also explain why an understanding of what constitutes an efficient writing system explains why phonology is necessarily a major source of variability in reading ability and hence a core deficit (or at least one core deficit) among struggling readers whether dyslexic or non-dyslexic. I also address the misguided notion that the PDH has now fallen out of favor because most dyslexia researchers have (largely) ceased studying phonological processing. I emphasize that acceptance of the PDH does not imply repudiation of other non-phonological hypotheses because the PDH does not claim to account for all the variance in reading ability/disability. Finally, I ask where neurobiology enters the picture and suggest that researchers need to exercise more caution in drawing their conclusions.

Keeping an Eye on Effort: A Pupillometric Investigation of Effort and Effortlessness in Visual Word Recognition.

Rapid and seemingly effortless word recognition is a virtually unquestioned characteristic of skilled reading, yet the definition and operationalization of the concept of cognitive effort have proven elusive. We investigated the cognitive effort involved in oral and silent word reading using pupillometry among adults (Experiment 1, N = 30; Experiment 2, N = 20) and fourth through sixth graders (Experiment 3, N = 30; Experiment 4, N = 18). We compared multiple pupillary measures (mean, peak, and peak latency) for reading familiar words (real words) and unfamiliar letter strings (pseudowords) varying in length. Converging with the behavioral data for accuracy and response times, pupillary responses demonstrated a greater degree of cognitive effort for pseudowords compared with real words and stronger length effects for pseudowords than for real words. These findings open up new possibilities for studying the issue of effort and effortlessness in the field of word recognition and other fields of skill learning.

Learning to Spell in Arabic: The Impact of Script-Specific Visual-Orthographic Features.

Learning to spell is a challenging process, especially for young learners, in part because it relies on multiple aspects of linguistic knowledge, primarily phonological and morphological. However, alongside these universals, there are significant writing system specifics, namely, language-specific and script-specific factors that may also challenge young readers and writers (Daniels and Share, 2018). The current study focuses on the impact of four distinctive visual-orthographic features of the Arabic abjad on spelling, namely, (i) the similarity of many basic letter-forms, (ii) allography (the positional variants of the letter forms), (iii) ligaturing (the joining of letters), and (iv) non-linearity (extra-linear diacritic-like signs used to mark consonantal, short vowel and morpho-syntactic distinctions). We examined the distribution of visual-orthographic spelling errors across three grade levels as well as the developmental changes in these errors. We predicted that these errors would account for a significant proportion of children's spelling errors. Ninety-six Arabic-speaking pupils from three elementary grades (1st, 2nd, 4th grades) were presented with a sequence of six pictures and asked to write a story or several sentences about the events depicted. All spelling errors were analyzed and categorized according to two types of categories: six visual-orthographic categories and six additional categories that relate to the more traditional error types (e.g., phonological). The results showed that the visual-orthographic category was the second most common error category across the three grade levels, accounting for over one quarter of all spelling errors. Ligaturing and letter shape formation errors emerged as the two most prevalent types of errors in this category. These findings clearly demonstrate that visual-orthographic features of the Arabic abjad pose significant challenges in learning to spell.

Michigan Pharmacists Transforming Care and Quality: Developing a Statewide Collaborative of Physician Organizations and Pharmacists to Improve Quality of Care and Reduce Costs.

BACKGROUND: Inappropriate drug use, increasing complexity of drug regimens, continued pressure to control costs, and focus on shared accountability for clinical measures drive the need to leverage the medication expertise of pharmacists in direct patient care. A statewide strategy based on the collaboration of pharmacists and physicians regarding patient care was developed to improve disease state management and medication-related outcomes. PROGRAM DESCRIPTION: Blue Cross Blue Shield of Michigan (BCBSM) partnered with Michigan Medicine to develop and implement a statewide provider-payer program called Michigan Pharmacists Transforming Care and Quality (MPTCQ), which integrates pharmacists within physician practices throughout the state of Michigan. As the MPTCQ Coordinating Center, Michigan Medicine established an infrastructure integrating clinical pharmacists into direct patient care within patient-centered medical home (PCMH) practices and provides direction and guidance for quality and process improvement across physician organizations (POs) and their affiliated physician practices. The primary goal of MPTCQ is to improve patient care and outcomes related to Medicare star ratings and HEDIS measures through integration of clinical pharmacists into direct patient care. The short-term goal is to adopt and modify Michigan Medicine's integrated pharmacist practice model at participating POs, with the long-term goal of developing a sustainable model of pharmacist integration at each PO to improve patient care and outcomes. Initially, pharmacists are delivering disease management (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services with future plans to expand clinical services. OBSERVATIONS: In 2015, 10 POs participated in year 1 of the program. In collaboration with the MPTCQ Coordinating Center, each PO identified 1 "pharmacist transformation champion" (PTC). The PTC implemented the integrated pharmacist model at 2 or 3 practice sites with at least 2 practicing physicians per site. IMPLICATIONS: MPTCQ is a unique collaboration between a large academic institution, physician organizations, a payer, and a statewide coordinating center to improve patient care and address medication-related challenges by integrating pharmacists into a PCMH network. Pharmacists can actively provide their medication expertise to physicians and patients and optimize quality measure performance. DISCLOSURES: This project was funded by Blue Cross Blue Shield of Michigan. Choe and Spahlinger are employees of Michigan Medicine. Tungol Lin, Kobernik, Cohen, Qureshi, Leyden, and Darland are employees of Blue Cross Blue Shield of Michigan. At the time of manuscript preparation, Share and Wesolowicz were employees of Blue Cross Blue Shield of Michigan. Study concept and design were primarily contributed by Choe, along with the other authors. Choe, Tungol Lin, and Kobernik collected data, and data interpretation was performed by Choe, Tungol Lin, Cohen, and Wesolowicz. The manuscript was written primarily by Choe, along with Tungol Lin and assisted by Kobernik, Cohen, Leyden, and Qureshi. The manuscript was revised by Leyden, Spahlinger, Share, and Darland. Material from this manuscript was previously presented as an education session at the 2016 AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 19-22, 2016; San Francisco, California.

Clinical predictors of the medical interventions provided to patients with low back pain in the emergency department.

BACKGROUND: Low back pain is a common complaint in emergency departments (ED), where deviations from standard of care have been noted. OBJECTIVE: To relate the ordering of advanced imaging and opioid prescriptions with the presentation of low back pain in ED. METHODS: Six hundred adults with low back pain from three centers were prospectively analyzed for history, examination, diagnosis, and the ordering of tests and treatments. RESULTS: Of 559 cases the onset of pain was less than one week in 79.2%; however, most had prior low back pain, 63.5% having warning signs of a potential serious condition, and 83.9% had psychosocial risk factors. Computer tomography (CT) or magnetic resonance imaging (MRI) were ordered in 16.6%, opioids were prescribed in 52.6%, and hospital admission in 4.5%. A one-year follow-up of 158 patients found 40.8% received subsequent spine care and 5.1% had a medically serious condition. Caucasian race, age 50 years or older, warning signs, and radicular findings were associated with advanced imaging. Severe pain and psychosocial factors were associated with opioid prescribing. CONCLUSIONS: Most patients present to the ED with acute exacerbations of chronic low back pain. Risk factors for a serious condition are common, but rarely do they develop. Racial disparities and psychosocial factors had concerning relationships with clinical decision-making.

Learning to Read a Semitic Abjad: The Triplex Model of Hebrew Reading Development.

We introduce a model of Hebrew reading development that emphasizes both the universal and script-specific aspects of learning to read a Semitic abjad. At the universal level, the study of Hebrew reading acquisition offers valuable insights into the fundamental dilemmas of all writing systems-balancing the competing needs of the novice versus the expert reader (Share, 2008). At the script-specific level, pointed Hebrew initially employs supplementary vowel signs, providing the beginning reader a consistent, phonologically well-specified script while helping the expert-to-be unitize words and morphemes via (consonantal) spelling constancy. A major challenge for the developing Hebrew reader is negotiating the transition from pointed to unpointed Hebrew, with its abundance of homographs. Our triplex model emphasizes three phases of early Hebrew reading development: a progression from lower-order, phonological (sublexical) sequential spelling-to-sound translation (Phase 1, Grade 1) to higher-order, string-level (lexical) lexico-morpho-orthographic processing (Phase 2, Grade 2) followed, in the upper elementary grades, by a supralexical contextual level (Phase 3) essential for dealing with the pervasive homography of unpointed Hebrew.

Predicting emergency coronary artery bypass graft following PCI: application of a computational model to refer patients to hospitals with and without onsite surgical backup.

BACKGROUND: Clinical tools to stratify patients for emergency coronary artery bypass graft (ECABG) after percutaneous coronary intervention (PCI) create the opportunity to selectively assign patients undergoing procedures to hospitals with and without onsite surgical facilities for dealing with potential complications while balancing load across providers. The goal of our study was to investigate the feasibility of a computational model directly optimised for cohort-level performance to predict ECABG in PCI patients for this application. METHODS: Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry data with 69 pre-procedural and angiographic risk variables from 68 022 PCI procedures in 2004-2007 were used to develop a support vector machine (SVM) model for ECABG. The SVM model was optimised for the area under the receiver operating characteristic curve (AUROC) at the level of the training cohort and validated on 42 310 PCI procedures performed in 2008-2009. RESULTS: There were 87 cases of ECABG (0.21%) in the validation cohort. The SVM model achieved an AUROC of 0.81 (95% CI 0.76 to 0.86). Patients in the predicted top decile were at a significantly increased risk relative to the remaining patients (OR 9.74, 95% CI 6.39 to 14.85, p<0.001) for ECABG. The SVM model optimised for the AUROC on the training cohort significantly improved discrimination, net reclassification and calibration over logistic regression and traditional SVM classification optimised for univariate performance. CONCLUSIONS: Computational risk stratification directly optimising cohort-level performance holds the potential of high levels of discrimination for ECABG following PCI. This approach has value in selectively referring PCI patients to hospitals with and without onsite surgery.

If not now, when? Prescription of evidence-based medical therapy prior to hospital discharge increases utilization at 6 months in patients with symptomatic peripheral artery disease.

We evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p<0.001) with reported 6-month use: ASA (84.5% vs 39.2%), BB (82.5% vs 11.1%), ACE/ARB (78.2% vs 11.8%), statins (84.6% vs 21.8%). Multivariable analysis revealed that prescription of EBMT at the time of discharge remained strongly associated with use at 6 months for each of the individual component drugs as well as for the combination of all four EBMT medications. In conclusion, prescription of the component medications of EBMT at the time of PVI is associated with excellent utilization at 6 months, while failure to prescribe EBMT at discharge is associated with low use of these medications 6 months later. These data suggest that the time of a PVI is a therapeutic window in which to prescribe EBMT in this high-risk cohort and represents an opportunity for quality improvement.

Michigan's fee-for-value physician incentive program reduces spending and improves quality in primary care.

As policy makers and others seek to reduce health care cost growth while improving health care quality, one approach gaining momentum is fee-for-value reimbursement. This payment strategy maintains the traditional fee-for-service arrangement but includes quality and spending incentives. We examined Blue Cross Blue Shield of Michigan's Physician Group Incentive Program, which uses a fee-for-value approach focused on primary care physicians. We analyzed the program's impact on quality and spending from 2008 to 2011 for over three million beneficiaries in over 11,000 physician practices. Participation in the incentive program was associated with approximately 1.1 percent lower total spending for adults (5.1 percent lower for children) and the same or improved performance on eleven of fourteen quality measures over time. Our findings contribute to the growing body of evidence about the potential effectiveness of models that align payment with cost and quality performance, and they demonstrate that it is possible to transform reimbursement within a fee-for-service framework to encourage and incentivize physicians to provide high-quality care, while also reducing costs.

Comparative effectiveness and safety of a catheterization laboratory-only eptifibatide dosing strategy in patients undergoing percutaneous coronary intervention.

BACKGROUND: Eptifibatide, a small-molecule glycoprotein IIb/IIIa inhibitor, is conventionally administered as a bolus plus infusion. A growing number of clinicians are using a strategy of catheterization laboratory-only eptifibatide (an off-label use) as procedural pharmacotherapy for patients undergoing percutaneous coronary intervention although the comparative effectiveness of this approach is unknown. METHODS AND RESULTS: We compared the in-hospital outcome of patients undergoing percutaneous coronary intervention across 47 hospitals and treated with eptifibatide bolus plus infusion with those treated with a catheterization laboratory-only regimen. We used optimal matching to link the use of catheterization laboratory-only eptifibatide with clinical outcomes, including mortality, myocardial infarction, bleeding, and need for transfusion. Of the 84 678 percutaneous coronary interventions performed during 2010 to 2011, and meeting our inclusion criteria, eptifibatide was administered to 21 296 patients. Of these, a catheterization laboratory-only regimen was used in 4511 patients, whereas 16 785 patients were treated with bolus plus infusion. In the optimally matched analysis, compared with bolus plus infusion, a catheterization laboratory-only regimen was associated with a reduction in bleeding (optimally matched adjusted odds ratio, 0.74; 95% confidence interval, 0.58-0.93; P=0.014) and need for transfusion (optimally matched adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.92; P=0.012), with no difference in mortality or myocardial infarction. CONCLUSIONS: A catheterization laboratory-only eptifibatide regimen is commonly used in clinical practice and is associated with a significant reduction in bleeding complications in patients undergoing contemporary percutaneous coronary intervention.

Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism : a cohort study.

IMPORTANCE: Hospitalization for acute medical illness is associated with increased risk of venous thromboembolism (VTE). Although efforts designed to increase use of pharmacologic VTE prophylaxis are intended to reduce hospital-associated VTE, whether higher rates of prophylaxis reduce VTE in medical patients is unknown. OBJECTIVE: To examine the association between pharmacologic VTE prophylaxis rates and hospital-associated VTE. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, multicenter cohort study conducted at 35 Michigan hospitals participating in a statewide quality collaborative from January 1, 2011, through September 13, 2012. Trained medical record abstractors at each hospital collected data from 31 260 general medical patients. Use of VTE prophylaxis on admission, VTE risk factors, and VTE events 90 days after hospital admission were recorded using a combination of medical record review and telephone follow-up. Hospitals were grouped into tertiles of performance based on rate of pharmacologic prophylaxis use on admission for at-risk patients. MAIN OUTCOMES AND MEASURES: Association between hospital performance and time to development of VTE within 90 days of hospital admission. RESULTS: A total of 14 563 of 20 794 patients (70.0%) eligible for pharmacologic prophylaxis received prophylaxis on admission. The rates of pharmacologic prophylaxis use at hospitals in the high-, moderate-, and low-performance tertiles were 85.8%, 72.6%, and 55.5%, respectively. A total of 226 VTE events occurred during 1 765 449 days of patient follow-up. Compared with patients at hospitals in the highest-performance tertile, the hazard of VTE in patients at hospitals in moderate-performance (hazard ratio, 1.10; 95% CI, 0.74-1.62) and low-performance (hazard ratio, 0.96, 95% CI, 0.63-1.45) tertiles did not differ after adjusting for potential confounders. Results remained robust when examining mechanical prophylaxis, prophylaxis use throughout the hospitalization, and subsequent inpatient stays after discharge from the index hospitalization. CONCLUSIONS AND RELEVANCE: The occurrence of 90-day VTE in medical patients after hospitalization is low. Patients who receive care at hospitals that have lower rates of pharmacologic prophylaxis do not have higher adjusted hazards of VTE, even after accounting for individual receipt of pharmacologic prophylaxis. Efforts to increase rates of pharmacologic VTE prophylaxis in hospitalized medical patients may not substantively reduce this adverse outcome.

A random forest based risk model for reliable and accurate prediction of receipt of transfusion in patients undergoing percutaneous coronary intervention.

BACKGROUND: Transfusion is a common complication of Percutaneous Coronary Intervention (PCI) and is associated with adverse short and long term outcomes. There is no risk model for identifying patients most likely to receive transfusion after PCI. The objective of our study was to develop and validate a tool for predicting receipt of blood transfusion in patients undergoing contemporary PCI. METHODS: Random forest models were developed utilizing 45 pre-procedural clinical and laboratory variables to estimate the receipt of transfusion in patients undergoing PCI. The most influential variables were selected for inclusion in an abbreviated model. Model performance estimating transfusion was evaluated in an independent validation dataset using area under the ROC curve (AUC), with net reclassification improvement (NRI) used to compare full and reduced model prediction after grouping in low, intermediate, and high risk categories. The impact of procedural anticoagulation on observed versus predicted transfusion rates were assessed for the different risk categories. RESULTS: Our study cohort was comprised of 103,294 PCI procedures performed at 46 hospitals between July 2009 through December 2012 in Michigan of which 72,328 (70%) were randomly selected for training the models, and 30,966 (30%) for validation. The models demonstrated excellent calibration and discrimination (AUC: full model  = 0.888 (95% CI 0.877-0.899), reduced model AUC = 0.880 (95% CI, 0.868-0.892), p for difference 0.003, NRI = 2.77%, p = 0.007). Procedural anticoagulation and radial access significantly influenced transfusion rates in the intermediate and high risk patients but no clinically relevant impact was noted in low risk patients, who made up 70% of the total cohort. CONCLUSIONS: The risk of transfusion among patients undergoing PCI can be reliably calculated using a novel easy to use computational tool (https://bmc2.org/calculators/transfusion). This risk prediction algorithm may prove useful for both bed side clinical decision making and risk adjustment for assessment of quality.

The epidemiology and outcomes of percutaneous coronary intervention before high-risk noncardiac surgery in contemporary practice: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry.

BACKGROUND: Percutaneous coronary intervention (PCI) is sometimes performed with the intent to lower cardiovascular risk before high-risk noncardiac surgery (HRNCS). There are limited data on the frequency and outcome of PCIs performed in this setting. METHODS AND RESULTS: We assessed the frequency, characteristics, and in-hospital outcomes of patients undergoing PCI as part of the preoperative workup for HRNCS among all 61 145 elective PCIs performed between 2002 and 2009 at 14 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Propensity matching was performed to compare outcomes of patients undergoing PCI before HRNCS with all other elective PCI patients. The frequency of PCI before HRNCS was low (4.2%). Patients undergoing PCI before HRNCS were older (67.3 versus 64.9 years, P<0.0001) and had a greater burden of comorbidity. Patients undergoing PCI before HRNCS had an increase in unadjusted major adverse cardiovascular events, postprocedure transfusion, contrast-induced nephropathy, nephropathy requiring dialysis, and same-admission coronary artery bypass graft surgery, but there was no difference in mortality (0.27% versus 0.14%, P=0.11). However, in propensity score-matched samples, there was a significant difference only in nephropathy requiring dialysis. CONCLUSIONS: The incidence of PCI performed in preparation for high-risk noncardiac surgery is low, and these procedures are currently being performed on a highly selected high-risk patient population.

The association between contrast dose and renal complications post PCI across the continuum of procedural estimated risk.

BACKGROUND: Prior studies have proposed to restrict the contrast volume (CV) to <3x calculated creatinine clearance (CCC), to prevent contrast induced nephropathy (CIN) post percutaneous coronary interventions (PCI). The predictive value of this algorithm for CIN and therefore the benefit of this approach in high risk patients has been questioned. The aim of our study was to assess the association between contrast dose and the occurrence of CIN in patients at varying predicted risks of CIN and baseline CCC following contemporary PCI. METHODS: Consecutive patients undergoing PCI between 2010-2012 were included. Baseline risk of CIN was calculated using a previously validated risk tool. High contrast dose was defined as CV/CCC >3. Likelihood ratio tests were used to evaluate whether the effect of a high contrast dose on the risk of CIN and nephropathy requiring dialysis (NRD) varied across the spectrum of baseline predicted risk. RESULTS: Of the 82,120 PCI included in our analysis, 25% were performed using a high contrast dose. Patients treated with a high compared with a low contrast dose were at increased risks of CIN and NRD, throughout the entire range of baseline predicted risk and CCC in our population. The effect size of a high contrast dose on risks of both outcomes varied significantly with baseline predicted CIN risk and CCC (CIN p = 0.004, NRD p<0.001 for adding interactions), and was largest for patients with predicted CIN risk <10% and pre-existing chronic kidney disease. CONCLUSIONS: The use of a high contrast dose is associated with increased risks of CIN and NRD across the continuum of baseline predicted risk and CCC. Efforts to reduce contrast dose may therefore be effective in preventing renal complications in all patients undergoing PCI.