Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association

[Changes in the intestinal microbiota as a risk factor for dyslipidemia, atherosclerosis and the role of probiotics in their prevention]

The review presents an analysis of studies on the role of the intestinal microbiota and microbiome in lipid metabolism and the development of dyslipidemia, atherosclerosis and cardiovascular diseases. The role of the intestine as a metabolic organ with a multifactorial strain evolution, involved in lipid metabolism, cholesterol homeostasis and enterohepatic circulation is shown. The influence of microbial imbalance on the development of dyslipidemia and atherosclerosis is considered. Special attention is paid to preventive therapy with hypolipidemic probiotics. It is shown that the use of probiotics with hypolipidemic properties and consisting of a mixture of such strains asLactobacillus plantarumCECT7527, CET7528 and CECT7529, mixtures ofLactobacillus acidophilusLa-5,Bifidobacterium lactisBB-12,Bifidobacterium animalis lactisBB-12 contribute to reducing the level of LDL-C, CCS, TG, are safe and well tolerated, can be used as an adjuvant non-drug therapy in combination with hypolipidemic drugs for dyslipidemia, multifocal atherosclerosis.

[Atrial Fibrillation After Coronary Artery Bypass Surgery: Risk Factors, Prevention and Treatment]

This review focuses on the issue of atrial fibrillation (AF) following coronary bypass surgery in patients with ischemic heart disease. Risk factors of this complication are discussed in detail. The authors addressed the effect of diabetes mellitus on development of postoperative AF. Data on current methods for prevention and treatment of AF are provided.

Prostaglandin E receptors as targets for ischemic stroke: Novel evidence and molecular mechanisms of efficacy

Over the past two decades the interest has waned in therapeutically targeting cyclooxygenase-2 (COX-2) due to growing concerns over the potential cardiovascular and cerebrovascular toxicities of the long-term use of COX-2 inhibitors. Attention thus has recently been shifted downstream to the prostaglandin signaling pathways for new druggable anti-inflammatory targets aiming for higher therapeutic specificity. Prostaglandin E2 (PGE₂) is robustly synthesized in the ischemic cortex by quickly induced COX-2 and microsomal prostaglandin E synthase-1 (mPGES-1) following cerebral ischemia. The elevated PGE₂, in turn, divergently regulates the excitotoxic injury and neuroinflammation by acting on four membrane-bound G protein-coupled receptors (GPCRs), namely, EP1-EP4. Markedly, all four EP receptors have been implicated in the excitotoxicity-associated brain inflammation and injury in animal models of cerebral ischemia. However promising, these preclinical studies have not yet led to a clinical trial targeting any PGE₂ receptor for ischemic stroke. The goal of this article is to review the recent progress in understanding the pathogenic roles of PGE₂ in cerebral ischemia as well as to provide new mechanistic insights into the PGE₂ signaling via these four GPCRs in neuronal excitotoxicity and inflammation. We also discuss the feasibility of targeting EP1-EP4 receptors as an emerging delayed treatment, together with the first-line reperfusion strategy, to manage acute ischemic stroke with potentially extended window as well as improved specificity.

A Music-Based Digital Therapeutic: Proof-of-Concept Automation of a Progressive and Individualized Rhythm-Based Walking Training Program After Stroke

BACKGROUND

The rhythm of music can entrain neurons in motor cortex by way of direct connections between auditory and motor brain regions.

OBJECTIVE

We sought to automate an individualized and progressive music-based, walking rehabilitation program using real-time sensor data in combination with decision algorithms.

METHODS

A music-based digital therapeutic was developed to maintain high sound quality while modulating, in real-time, the tempo (ie, beats per minute, or bpm) of music based on a user's ability to entrain to the tempo and progress to faster walking cadences in-sync with the progression of the tempo. Eleven individuals with chronic hemiparesis completed one automated 30-minute training visit. Seven returned for 2 additional visits. Safety, feasibility, and rehabilitative potential (ie, changes in walking speed relative to clinically meaningful change scores) were evaluated.

RESULTS

A single, fully automated training visit resulted in increased usual (∆ 0.085 ± 0.027 m/s, P = .011) and fast (∆ 0.093 ± 0.032 m/s, P = .016) walking speeds. The 7 participants who completed additional training visits increased their usual walking speed by 0.12 ± 0.03 m/s after only 3 days of training. Changes in walking speed were highly related to changes in walking cadence (R² > 0.70). No trips or falls were noted during training, all users reported that the device helped them walk faster, and 70% indicated that they would use it most or all of the time at home.

CONCLUSIONS

In this proof-of-concept study, we show that a sensor-automated, progressive, and individualized rhythmic locomotor training program can be implemented safely and effectively to train walking speed after stroke. Music-based digital therapeutics have the potential to facilitate salient, community-based rehabilitation.

Temporal trends in prevalence of cardiovascular disease (CVD) and CVD risk factors among U.S. older workers: NHIS 2004-2018

PURPOSE

This study examined trends in the prevalence of cardiovascular disease (CVD) and CVD risk factors among U.S. older adults and workers. We also investigated correlations between the temporal prevalence of CVD and selected risk factors (hypertension, obesity, physical inactivity, smoking, and treated diabetes) among participants.

METHODS

Data were obtained from the National Health Interview Survey (2004-2018) for U.S. adults aged greater than or equal to 50 years (n = 207,539), of which 84,180 were employed. Temporal trends in prevalence were assessed by fitting weighted regression models to the age-standardized prevalence to the 2010 U.S.

POPULATION

The relationship between temporal prevalence of CVD with each risk factor was assessed using Spearman's correlation coefficient.

RESULTS

Among all older adults, the prevalence of CVD significantly declined (β = -0.16, P < .001) during 2004-2018; similar decline was observed among employed adults (β = -0.16, P = .001). Temporal prevalence in CVD was positively correlated to physical inactivity (r = 0.73, P = .002) and smoking (r = 0.81, P < .001), but not to any of the other risk factors.

CONCLUSIONS

Among employed adults aged greater than or equal to 50 years, the prevalence of CVD, physical inactivity, and smoking dramatically declined over the past 15 years. The temporal decline in prevalence of CVD was significantly associated with decline prevalence of physical inactivity and smoking.

Secondary prevention among uninsured stroke patients: A free clinic study

Objectives:

Free clinics manage a diversity of diseases among the uninsured. We sought to assess the medical management of stroke in a population of uninsured patients.

Methods:

A retrospective chart review was conducted to collect chronic disease statistics from 6558 electronic medical records and paper charts at nine free clinics in Tampa, Florida, from January 2016 to December 2017. Demographics and risk factors were compared between stroke patients and non-stroke patients. Medication rates for several comorbidities were also assessed.

Results:

Two percent (107) of patients had been diagnosed with a stroke. Stroke patients were older (mean (M) = 56.0, standard deviation (SD) = 11.2) than the rest of the sample (M = 43.3, SD = 15.4), p < 0.001 and a majority were men (n = 62, 58%). Of the stroke patients with hypertension (n = 79), 81% (n = 64) were receiving anti-hypertensive medications. Of the stroke patients with diabetes (n = 43), 72% (n = 31) were receiving diabetes medications. Among all stroke patients, 44% were receiving aspirin therapy (n = 47). Similarly, 39% of all stroke patients (n = 42) were taking statins.

Conclusions:

Uninsured patients with a history of stroke may not be receiving adequate secondary prevention highlighting the risk and vulnerability of uninsured patients. This finding identifies an area for improvement in secondary stroke prevention in free clinics.

Validation of radiofrequency determined lung fluid using thoracic CT: Findings in acute decompensated heart failure patients

Background

Noninvasive outpatient monitoring for heart failure (HF) has significant opportunity to reduce patient morbidity and the costs associated with recurrent hospitalization. The purpose of this study was to validate the ability of radiofrequency (RF) to assess lung fluid via a wearable patch device compared to thoracic CT in order to characterize volume overload.

Methods

120 subjects were studied: 66 acute heart failure (AHF) inpatients and 54 subjects without AHF (Control – 44 healthy and 10 stable HF). All underwent supine thoracic CT scans and supine RF readings from the wearable patch device placed on the left mid-axillary line (age = 74 ± 16 vs. 57 ± 15 yrs.; female = 38 vs. 44%; BMI = 33.2 ± 9.0 vs. 27.3 ± 5.1, AHF vs. Control respectively). Reflected RF signals and subject-specific anthropometric data were used to calculate the RF-determined lung fluid content. CT Lung fluid was reported as percentage of lung volume. Classification analyses were used to compare RF and CT performance.

Results

AHF presented with higher lung fluid than controls by both CT and RF (CT: 20.1 ± 4.2% vs. 15.4 ± 2.4%; RF: 20.7 ± 5.6% vs. 15.6 ± 3.3%; p < 0.05 for all). The correlation between lung fluid measured by CT vs. RF was r = 0.7 (p < 0.001). RF determined lung fluid performed as well as CT in distinguishing AHF from control subjects: Sensitivity: 70% vs. 86%; Specificity: 82% vs. 83%; Positive Predictive Value: 82% vs. 86%; Negative Predictive Value: 69% vs. 83%, CT vs. RF respectively.

Conclusions

Noninvasive nonionizing RF determined lung fluid provides a potential alternative to other measures for diagnosing and monitoring pulmonary fluid overload.

Clinical significance of Platelet-to-White Blood Cell Ratio (PWR) and National Institute of Health Stroke Scale (NIHSS) in acute ischemic stroke

Introduction

Ischemic stroke can occur due to disruption of blood and oxygen supply to brain tissue. White blood cells and platelets play an important role in the pathogenesis of ischemic stroke. Several studies have concluded that the lower the platelet count and the higher the number of white blood cells in ischemic stroke patients will result in a more severe stroke and had worsen prognosis. Platelet and white blood cells counts can be converted into Platelet-to-White Blood Cell Ratio (PWR) which is a comparison between the number of platelets and white blood cells, so the higher PWR will provide better clinical outcomes. Here, we examined correlation between PWR and clinical outcome in acute ischemic stroke using NIHSS tools.

Method

This research method was a retrospective analytic from 503 medical records of ischemic stroke patients from January 2015 to December 2017. Ischemic stroke divided into 2 groups: cardioembolic stroke and atherothrombotic stroke based on medical records. We calculated PWR and National Institute of Health Stroke Scale (NIHSS) for assessing clinical outcome. Statistical significance calculated with Spearman rank test, ANOVA, and multiple logistic regression.

Results

A total of 391 research subjects consisting of 213 females (54.5%) and 178 males (45.5%). The mean age of 57.14 years, and 82% subjects had hypertension as risk factor. Mean PWR of atherothrombotic stroke subjects were higher than cardioembolic stroke (33.02 vs 26.73) but had lower mean of NIHSS (5.81 vs 10.31) and had strong negative significant correlation between PWR and NIHSS (r = -0.9603; p < 0.001). From logistic regression, we found that PWR and platelet was statistically significance correlate with NIHSS (p < 0.05). The coefficient if PWR is the highest (absolute value) among other independent variables.It shows that PWR has positive effect on clinical outcome using NIHSS tools in acute ischemic stroke patients.

Conclusion

Cardioembolic stroke had higher PWR compared with atherothrombotic stroke. PWR had a strong correlation with NIHSS. The higher PWR will provide higher NIHSS and PWR has positive effect on clinical outcome using NIHSS tools in acute ischemic stroke patients.

Machine learning versus traditional risk stratification methods in acute coronary syndrome: a pooled randomized clinical trial analysis

Traditional statistical models allow population based inferences and comparisons. Machine learning (ML) explores datasets to develop algorithms that do not assume linear relationships between variables and outcomes and that may account for higher order interactions to make individualized outcome predictions. To evaluate the performance of machine learning models compared to traditional risk stratification methods for the prediction of major adverse cardiovascular events (MACE) and bleeding in patients with acute coronary syndrome (ACS) that are treated with antithrombotic therapy. Data on 24,178 ACS patients were pooled from four randomized controlled trials. The super learner ensemble algorithm selected weights for 23 machine learning models and was compared to traditional models. The efficacy endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. The safety endpoint was a composite of TIMI major and minor bleeding or bleeding requiring medical attention. For the MACE outcome, the super learner model produced a higher c-statistic (0.734) than logistic regression (0.714), the TIMI risk score (0.489), and a new cardiovascular risk score developed in the dataset (0.644). For the bleeding outcome, the super learner demonstrated a similar c-statistic as the logistic regression model (0.670 vs. 0.671). The machine learning risk estimates were highly calibrated with observed efficacy and bleeding outcomes (Hosmer-Lemeshow p value = 0.692 and 0.970, respectively). The super learner algorithm was highly calibrated on both efficacy and safety outcomes and produced the highest c-statistic for prediction of MACE compared to traditional risk stratification methods. This analysis demonstrates a contemporary application of machine learning to guide patient-level antithrombotic therapy treatment decisions.Clinical Trial Registration ATLAS ACS-2 TIMI 46: https://clinicaltrials.gov/ct2/show/NCT00402597. Unique Identifier: NCT00402597. ATLAS ACS-2 TIMI 51: https://clinicaltrials.gov/ct2/show/NCT00809965. Unique Identifier: NCT00809965. GEMINI ACS-1: https://clinicaltrials.gov/ct2/show/NCT02293395. Unique Identifier: NCT02293395. PIONEER-AF PCI: https://clinicaltrials.gov/ct2/show/NCT01830543. Unique Identifier: NCT01830543.

Ambra1 Alleviates Hypoxia/Reoxygenation Injury in H9C2 Cells by Regulating Autophagy and Reactive Oxygen Species

Reperfusion therapy is the most important method for treating acute myocardial infarction. However, myocardial ischemia reperfusion injury (MIRI) can offset the benefit of reperfusion therapy and worsen the outcome. In both ischemia and reperfusion, autophagy remains problematic. Activating molecule in Beclin1-regulated autophagy (Ambra1) is an important protein in autophagy regulation, and its function in MIRI remains unclear. Thus, we used H9C2 cells to investigate the function of Ambra1 in MIRI and the underlying mechanisms involved. Hypoxia and reoxygenation of H9C2 cells were used to mimic MIRI in vitro. During hypoxia, autophagy flux was blocked, then recovered in reoxygenation. Ambra1 overexpression increased autophagy in the H9C2 cells, as the LC3B II/I ratio increased, and alleviated cellular necrosis and apoptosis during hypoxia and reoxygenation. This effect was counteracted by an autophagy inhibitor. Knocking down Ambra1 can block autophagy which P62 sediment/supernatant ratio increased while the ratio of LC3B II/I decreased, and worsen outcomes. Ambra1 enhances autophagy in H9C2 cells by improving the stability and activity of the ULK1 complex. Reactive oxygen species (ROS) are an important cause of MIRI. ROS were reduced when Ambra1 was overexpressed and increased when Ambra1 was knocked down, indicating that Ambra1 can protect against hypoxia and reoxygenation injury in H9C2 cells by promoting autophagy and reducing ROS.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study

AIMS

Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival.

METHODS AND RESULTS

OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33).

CONCLUSIONS

This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

Examining Mother-Reported Poor Sleep and Blood Pressure in Black/African American Mother-Child Dyads

BACKGROUND

Poor sleep is a confirmed risk factor for hypertension (HTN), and Black/African American (AA) women have among the highest rates of HTN in the United States.

OBJECTIVE

We examined the relationship between sleep and blood pressure (BP) among Black/AA mother-child dyads using data from the Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure study.

METHODS

Data for this study were derived from 250 Black/AA mother-child dyads from low-income neighborhoods, collected via 4 home visits over 2 years. Mothers reported poor sleep, including reports of sleeping worse than usual and nighttime awakenings. Recordings of BP were obtained for mother and child. Mother BP was scored as normal (<120/<80 mm Hg), elevated (120-129/<80 mm Hg), stage 1 HTN (130-139/80-89 mm Hg), or stage 2 HTN (systolic ≥140 or diastolic ≥90 mm Hg). Generalized linear models examined the relationships between mother-reported poor sleep variables and both mother and child BP. Adjusted models examining mother BP controlled for the mother's age, education, marital status, smoking, body mass index, and depression symptoms.

RESULTS

In adjusted models, nighttime awakenings were associated with stage 2 HTN (b = 2.70, 95% confidence interval [CI], 0.54-4.86, P < .05). Compared with children whose mother who had normal BP, children whose mother had elevated BP had higher diastolic BP (b = 0.37; 95% CI, 0.19-0.54; P < .001). Mother elevated BP was associated with both child systolic BP (b = 2.49; 95% CI, 0.44-4.53; P < .05) and diastolic BP (b = 2.07; 95% CI, 0.39-3.76; P < .05). Mother stage 1 HTN was associated with both child systolic BP (b = 2.16; 95% CI, 0.29-4.03; P < .05) and diastolic BP (b = 3.91; 95% CI, 2.40-5.42; P < .001). We detected a significant interaction between mother stage 2 HTN and mother nighttime awakenings in predicting higher child diastolic BP (b = 8.16; 95% CI, 0.65-15.68; P < .05).

CONCLUSIONS

We found evidence for an association between mothers' nighttime awakenings and very high BP. Our study also illuminated a strong relationship between high mother BP and high child BP. Finally, our study found preliminary support for the potentially mediating role of mothers' nighttime awakenings in predicting the relationship between mother stage 2 HTN and child BP.

Time course of tolerance to adverse effects associated with the ingestion of a moderate dose of caffeine

PURPOSE

This study aimed to identify and describe the time course of tolerance to the most common caffeine-induced side effects.

METHODS

Eleven participants took part in a crossover, double-blind placebo-controlled experimental design. In one phase, participants ingested 3 mg/kg/day of caffeine for 20 days, while in another phase, they ingested a placebo. Resting heart rate and blood pressure were measured three times per week during each 20-day phase and a quantitative survey was used to categorise the magnitude of side effects.

RESULTS

In the pairwise comparison with the placebo, the ingestion of caffeine increased systolic (+ 7.8 ± 10.1%, P < 0.05) and diastolic blood pressure (+ 6.4 ± 12.9% P < 0.05) for the first 8 days of ingestion, but then this effect became attenuated for both outcomes (on day 20, - 1.1 ± 4.3% and + 0.9 ± 9.6%, respectively). The ingestion of caffeine did not affect heart rate at any time point. Caffeine increased the feelings of nervousness and vigour and the rating of gastrointestinal complaints, insomnia and diuresis at several time points in the treatment (P < 0.05) and they did not disappear after 20 days of ingestion.

CONCLUSIONS

The daily intake of 3 mg/kg of caffeine induced a meaningful elevation in arterial blood pressure that disappeared after 8 days. However, other caffeine-induced effects such as increased nervousness and vigour, irritability, insomnia and diuresis remained after 20 days of consecutive caffeine ingestion. Although there was clear tolerance to the effect of caffeine on blood pressure, the persistence of other side effects suggests the inconvenience of maintaining a chronic caffeine intake, at least at the dose of 3 mg/kg/day.

The Heart Failure Readmission Intervention by Variable Early Follow-up (THRIVE) Study

Background:

In-person clinic follow-up within 7 days after discharge from a heart failure hospitalization is associated with lower 30-day readmission. However, health systems and patients may find it difficult to complete an early postdischarge clinic visit, especially during the current pandemic. We evaluated the effect on 30-day readmission and death of follow-up within 7 days postdischarge guided by an initial structured nonphysician telephone visit compared with follow-up guided by an initial clinic visit with a physician.

Methods and Results:

We conducted a pragmatic randomized trial in a large integrated healthcare delivery system. Adults being discharged home after hospitalization for heart failure were randomly assigned to either an initial telephone visit with a nurse or pharmacist to guide follow-up or an initial in-person clinic appointment with primary care physicians providing usual care within the first 7 days postdischarge. Telephone appointments included a structured protocol enabling medication titration, laboratory ordering, and booking urgent clinic visits as needed under physician supervision. Outcomes included 30-day readmissions and death and frequency and type of completed follow-up within 7 days of discharge. Among 2091 participants (mean age 78 years, 44% women), there were no significant differences in 30-day heart failure readmission (8.6% telephone, 10.6% clinic, P =0.11), all-cause readmission (18.8% telephone, 20.6% clinic, P =0.30), and all-cause death (4.0% telephone, 4.6% clinic, P =0.49). Completed 7-day follow-up was higher in 1027 patients randomized to telephone follow-up (92%) compared with 1064 patients assigned to physician clinic follow-up (79%, P <0.001). Overall frequency of clinic visits during the first 7 days postdischarge was lower in participants assigned to nonphysician telephone guided follow-up (48%) compared with physician clinic-guided follow-up (77%, P <0.001).

Conclusions:

Early, structured telephone follow-up after hospitalization for heart failure can increase 7-day follow-up and reduce in-person visits with comparable 30-day clinical outcomes within an integrated care delivery framework.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03524534.

Performance of the Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Body Mass Index

IMPORTANCE

Obesity is a global health challenge and a risk factor for atherosclerotic cardiovascular disease (ASVCD). Performance of the pooled cohort equations (PCE) for ASCVD risk by body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) is unknown.

OBJECTIVE

To assess performance of the PCE across clinical BMI categories.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used pooled individual-level data from 8 community-based, prospective, longitudinal cohort studies with 10-year ASCVD event follow-up from 1996 to 2016. We included all adults ages 40 to 79 years without baseline ASCVD or statin use, resulting in a sample size of 37 311 participants. Data were analyzed from August 2017 to July 2020.

EXPOSURES

Participant BMI category: underweight (<18.5), normal weight (18.5 to <25), overweight (25 to <30), mild obesity (30 to <35), and moderate to severe obesity (≥35).

MAIN OUTCOMES AND MEASURES

Discrimination (Harrell C statistic) and calibration (Nam-D'Agostino χ2 goodness-of-fit test) of the PCE across BMI categories. Improvement in discrimination and net reclassification with addition of BMI, waist circumference, and high-sensitivity C-reactive protein (hsCRP) to the PCE.

RESULTS

Among 37 311 participants (mean [SD] age, 58.6 [11.8] years; 21 897 [58.7%] women), 380 604 person-years of follow-up were conducted. Mean (SD) baseline BMI was 29.0 (6.2), and 360 individuals (1.0%) were in the underweight category, 9937 individuals (26.6%) were in the normal weight category, 13 601 individuals (36.4%) were in the overweight category, 7783 individuals (20.9%) were in the mild obesity category, and 5630 individuals (15.1%) were in the moderate to severe obesity category. Median (interquartile range [IQR]) 10-year estimated ASCVD risk was 7.1% (2.5%-15.4%), and 3709 individuals (9.9%) developed ASCVD over a median (IQR) 10.8 [8.5-12.6] years. The PCE overestimated ASCVD risk in the overall cohort (estimated/observed [E/O] risk ratio, 1.22; 95% CI, 1.18-1.26) and across all BMI categories except the underweight category. Calibration was better near the clinical decision threshold in all BMI groups but worse among individuals with moderate or severe obesity (E/O risk ratio, 1.36; 95% CI, 1.25-1.47) and among those with the highest estimated ASCVD risk ≥20%. The PCE C statistic overall was 0.760 (95% CI, 0.753-0.767), with lower discrimination in the moderate or severe obesity group (C statistic, 0.742; 95% CI, 0.721-0.763) compared with the normal-range BMI group (C statistic, 0.785; 95% CI, 0.772-0.798). Waist circumference (hazard ratio, 1.07 per 1-SD increase; 95% CI, 1.03-1.11) and hsCRP (hazard ratio, 1.07 per 1-SD increase; 95% CI, 1.05-1.09), but not BMI, were associated with increased ASCVD risk when added to the PCE. However, these factors did not improve model performance (C statistic, 0.760; 95% CI, 0.753-0.767) with or without added metrics.

CONCLUSIONS AND RELEVANCE

These findings suggest that the PCE had acceptable model discrimination and were well calibrated at clinical decision thresholds but overestimated risk of ASCVD for individuals in overweight and obese categories, particularly individuals with high estimated risk. Incorporation of the usual clinical measures of obesity did not improve risk estimation of the PCE. Future research is needed to determine whether incorporation of alternative high-risk obesity markers (eg, weight trajectory or measures of visceral or ectopic fat) into the PCE may improve risk prediction.

Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

Accuracy of Doppler blood pressure measurement in HeartMate 3 ventricular assist device patients

Aims

Optimal blood pressure (BP) control is imperative to reduce complications, especially strokes, in continuous flow ventricular assist device (VAD) patients. Doppler BP has been shown to be an accurate and reliable non‐invasive BP measurement method in HeartMate II and HVAD patients. We examined whether Doppler BP is also accurate in patients with the HeartMate 3 VAD.

Methods and results

In a prospective, longitudinal cohort of HeartMate 3 patients, arterial line BP and simultaneously measured Doppler opening pressure were obtained. Correlation and agreement between Doppler opening pressure and arterial line mean arterial pressure (MAP) versus systolic blood pressure (SBP) were analysed, as well as the effect of pulse pressure on the accuracy of Doppler opening pressure.

A total of 589 pairs of simultaneous Doppler opening pressure and arterial line pressure readings were obtained in 43 patients. Doppler opening pressure had good correlation with intra‐arterial MAP (r = 0.754) and more closely approximated MAP than SBP (mean error 2.0 vs. −8.6 mmHg). Pulse pressure did not have a clinically significant impact on the accuracy of the Doppler BP method. These results in HeartMate 3 patients are very similar to previous results in HeartMate II and HVAD patients.

Conclusions

Doppler BP method should be the default non‐invasive BP measurement method in continuous flow VAD patients including patients implanted with the HeartMate 3.

Role of B cells and the aging brain in stroke recovery and treatment

As mitigation of brain aging continues to be a key public health priority, a wholistic and comprehensive consideration of the aging body has identified immunosenescence as a potential contributor to age-related brain injury and disease. Importantly, the nervous and immune systems engage in bidirectional communication and can exert profound influence on each other. Emerging evidence supports numerous impacts of innate, inflammatory immune responses and adaptive T cell-mediated immunity in neurological function and diseased or injured brain states, such as stroke. Indeed, a growing body of evidence supports key impacts of brain-resident immune cell activation and peripheral immune infiltration in both the post-stroke acute injury phase and the long-term recovery period. As such, modulation of the immune system is an attractive strategy for novel therapeutic interventions for a devastating age-related brain injury for which there are few readily available neuroprotective treatments or neurorestorative approaches. However, the role of B cells in the context of brain function, and specifically in response to stroke, has not been thoroughly elucidated and remains controversial, leaving our understanding of neuroimmune interactions incomplete. Importantly, emerging evidence suggests that B cells are not pathogenic contributors to stroke injury, and in fact may facilitate functional recovery, supporting their potential value as novel therapeutic targets. By summarizing the current knowledge of the role of B cells in stroke pathology and recovery and interpreting their role in the context of their interactions with other immune cells as well as the immunosenescence cascades that alter their function in aged populations, this review supports an increased understanding of the complex interplay between the nervous and immune systems in the context of brain aging, injury, and disease.

Management of internal carotid artery near-occlusion: the need for updated evidence

Near occlusion of internal carotid artery (ICA) is a rare and easily misdiagnosed condition and the decision for revascularisation still remains controversial. We conducted an updated meta-analysis in order to investigate outcomes after carotid endarterectomy (CEA), carotid artery stenting (CAS) or best medical treatment (BMT) in patients with near-occlusion of the ICA. We also aimed to investigate the role of time as a potential moderator of the near-ICA occlusion-stroke rate association. A multiple electronic health database search on articles published up to November 2019 was performed. The pooled stroke rate after CEA, CAS and BMT were calculated. We also investigated transient ischemic attack (TIA), stroke-related death, myocardial infarction (MI), any cause of death and ICA restenosis crude rates (%). A total of 33 articles were finally deemed eligible. The pooled stroke rate was 1.52% [95% confidence interval (CI): 0.09-4.02%] after CEA, 1.80% (95% CI: 0.61-3.40%) after CAS and 8.39% (95% CI: 3.39-14.80%) after BMT. Out of 896 CEA patients, we recorded 22 TIAs (2.5%), 33 all-cause deaths (3.7%), 5 stroke-related deaths (0.6%) and 6 MIs (0.7%). Concerning outcomes after 603 CAS patients, we recorded 7 TIAs (1.2%), 56 all-cause deaths (9.3%), 4 stroke-related deaths (0.7%) and 22 MIs (3.6%). Among 263 patients who were treated with BMT, we found 16 TIAs (6.1%), 10 all-cause deaths (3.8%), no stroke-related death, and no MI. Crude restenosis rate during follow-up was 9.0% (54/601) for CEA and 4.1% (24/592) for CAS patients. No significant effect of publication year upon stroke rate after CEA was recorded. However, there was a significant reversed association between pooled stroke rate after CAS and publication year (P=0.05). A statistically significant reversed association between pooled stroke rate after BMT and publication year was also recorded (P<0.01). The results of this updated meta-analysis revealed high stroke rate for patients with near-occlusion of ICA who treated only with BMT, while intervention seemed to be safe and effective. A downward trend in the stroke rates over time after CAS and BMT was also discovered. These highlight that patients with near-occlusion of ICA should be included and investigated in future studies.

Intermuscular coherence between homologous muscles during dynamic and static movement periods of bipedal squatting

Coordination of functionally coupled muscles is a key aspect of movement execution. Demands on coordinative control increase with the number of involved muscles and joints, as well as with differing movement periods within a given motor sequence. While previous research has provided evidence concerning inter- and intramuscular synchrony in isolated movements, compound movements remain largely unexplored. With this study, we aimed to uncover neural mechanisms of bilateral coordination through intermuscular coherence (IMC) analyses between principal homologous muscles during bipedal squatting (BpS) at multiple frequency bands (alpha, beta, and gamma). For this purpose, participants performed bipedal squats without additional load, which were divided into three distinct movement periods (eccentric, isometric, and concentric). Surface electromyography (EMG) was recorded from four homologous muscle pairs representing prime movers during bipedal squatting. We provide novel evidence that IMC magnitudes differ between movement periods in beta and gamma bands, as well as between homologous muscle pairs across all frequency bands. IMC was greater in the muscle pairs involved in postural and bipedal stability compared with those involved in muscular force during BpS. Furthermore, beta and gamma IMC magnitudes were highest during eccentric movement periods, whereas we did not find movement-related modulations for alpha IMC magnitudes. This finding thus indicates increased integration of afferent information during eccentric movement periods. Collectively, our results shed light on intermuscular synchronization during bipedal squatting, as we provide evidence that central nervous processing of bilateral intermuscular functioning is achieved through task-dependent modulations of common neural input to homologous muscles.

NEW & NOTEWORTHY It is largely unexplored how the central nervous system achieves coordination of homologous muscles of the upper and lower body within a compound whole body movement, and to what extent this neural drive is modulated between different movement periods and muscles. Using intermuscular coherence analysis, we show that homologous muscle functions are mediated through common oscillatory input that extends over alpha, beta, and gamma frequencies with different synchronization patterns at different movement periods.

Sudden cardiac arrest with shockable rhythm in patients with heart failure

BACKGROUND

Patients with shockable sudden cardiac arrest (SCA; ventricular fibrillation/tachycardia) have significantly better resuscitation outcomes than do those with nonshockable rhythm (pulseless electrical activity/asystole). Heart failure (HF) increases the risk of SCA, but presenting rhythms have not been previously evaluated.

OBJECTIVE

We hypothesized that based on unique characteristics, HFpEF (HF with preserved ejection fraction; left ventricular ejection fraction [LVEF] ≥50%), bHFpEF (HF with borderline preserved ejection fraction; LVEF >40% and <50%), and HFrEF (HF with reduced ejection fraction; LVEF ≤40%) manifest differences in presenting rhythm during SCA.

METHODS

Consecutive cases of SCA with HF (age ≥18 years) were ascertained in the Oregon Sudden Unexpected Death Study (2002-2019). LVEF was obtained from echocardiograms performed before and unrelated to the SCA event. Presenting rhythms were identified from first responder reports. Logistic regression was used to evaluate the independent association of presenting rhythm with HF subtype.

RESULTS

Of 648 subjects with HF and SCA (median age 72 years; interquartile range 62-81 years), 274 had HFrEF (23.4% female), 92 had bHFpEF (35.9% female), and 282 had HFpEF (42.5% female). The rates of shockable rhythms were 44.5% (n = 122), 48.9% (n = 45), and 27.0% (n = 76) for HFrEF, bHFpEF, and HFpEF, respectively (P < .001). Compared with HFpEF, the adjusted odds ratios for shockable rhythm were 1.86 (95% confidence interval 1.27-2.74; P = .002) in HFrEF and 2.26 (95% CI 1.35-3.77; P = .002) in bHFpEF. The rates of survival to hospital discharge were 10.6% (n = 29) in HFrEF, 22.8% (n = 21) in bHFpEF, and 9.9% (n = 28) in HFpEF (P = .003).

CONCLUSION

The rates of shockable rhythm during SCA depend on the HF clinical subtype. Patients with bHFpEF had the highest likelihood of shockable rhythm, correlating with the highest rates of survival.

FABP4 inhibitor BMS309403 protects against hypoxia-induced H9c2 cardiomyocyte apoptosis through attenuating endoplasmic reticulum stress

Acute myocardial infarction is characterized by ischaemia-induced cardiomyocyte apoptosis, in which the endoplasmic reticulum (ER) stress plays an important role. The fatty acid-binding protein-4 (FABP4) has been implicated in regulating ER stress and apoptosis. Yet, whether FABP4 is involved in modulating cardiomyocyte apoptosis remains unclarified. By applying an in vitro model of hypoxia-induced apoptosis of H9c2 cardiomyocytes, we found that FABP4 expression was elevated upon hypoxia stimulation, which was further demonstrated to be transcriptionally activated by the hypoxia-inducible factor 1a (HIF-1α). In addition, the pharmacological inhibition of FABP4 with BMS309403 protected against hypoxia-induced apoptosis in cardiomyocytes, indicating that FABP4 induction is detrimental for cardiomyocyte survival under hypoxic condition. Moreover, BMS309403 attenuated ER stress in cardiomyocytes exposed to hypoxia, which, however, was reversed by tunicamycin, an ER stress activator. More importantly, the protective effect of BMS309403 on cardiomyocytes vanished in the presence of tunicamycin. Thus, these observations establish that FABP4 inhibitor BMS309403 reduces hypoxia-induced cardiomyocyte apoptosis through attenuating excessive ER stress, implying that FABP4 inhibition may be of clinical benefit for MI treatment.

MiR-489 aggravates H2O2-induced apoptosis of cardiomyocytes via inhibiting IGF1

Myocardial infarction (MI) is a major type of cardiovascular disorder worldwide. In the present study, we established a new microRNA (miRNA)-mRNA cross-talk network by integrating data obtained from The National Center for Biotechnology Information Gene Expression Omnibus (NCBI GEO). In addition, functional assays, including Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway and Gene Ontology (GO) analyses, were conducted using the Database for Annotation, Visualization, and Integration Discovery (DAVID). In our study, we generated a new differentially expressed miRNA (DEmiRNA)-differentially expressed gene (DEG) cross-talk network of MI composed of three miRNA (miR-489, miR-375, and miR-142-3p) nodes and 163 mRNA nodes. In vitro experiments demonstrated that miR-489 expression was increased in H2O2-treated H9c2 cardiomyocytes in vitro, mimicking myocardial injury. We observed that down-regulation of miR-489 reduced H2O2-induced apoptosis, while overexpression of miR-489 had the opposite effects, as revealed by flow cytometry and Western blot analyses. Furthermore, we confirmed the relationship between miR-489 and IGF1 through double luciferase reporter gene assays, which partly explains the antiapoptotic mechanism of miR-489. In conclusion, the experimental results of the present study could provide important clues for investigating the mechanism of MI.

Occludin regulation of blood-brain barrier and potential therapeutic target in ischemic stroke

Occludin is a key structural component of the blood–brain barrier (BBB) that has recently become an important focus of research in BBB damages. Many studies have demonstrated that occludin could regulate the integrity and permeability of the BBB. The function of BBB depends on the level of occludin protein expression in brain endothelial cells. Moreover, occludin may serve as a potential biomarker for hemorrhage transformation after acute ischemic stroke. In this review, we summarize the role of occludin in BBB integrity and the regulatory mechanisms of occludin in the permeability of BBB after ischemic stroke. Multiple factors have been found to regulate occludin protein functions in maintaining BBB permeability, such as Matrix metalloproteinas-mediated cleavage, phosphorylation, ubiquitination, and related inflammatory factors. In addition, various signaling pathways participate in regulating the occludin expression, including nuclear factor-kappa B, mitogen-activated protein kinase, protein kinase c, RhoK, and ERK1/2. Emerging therapeutic interventions for ischemic stroke targeting occludin are described, including normobaric hyperoxia, Chinese medicine, chemical drugs, genes, steroid hormones, small molecular peptides, and other therapies. Since occludin has been shown to play a critical role in regulating BBB integrity, further preclinical studies will help evaluate and validate occludin as a viable therapeutic target for ischemic stroke.

Histological assessment of the human heart valves and its relationship with age

The human heart valves are complex anatomical structures consisting of leaflets with many supporting structures. With advancing age, the microstructure of the components of the valves can change. Knowledge and understanding of the anatomical relationships between the different components of the heart valve structures and their relationship with age is crucial for the development and progression of treatment of valvular disease. The purpose of this study was to determine histological changes of the components of the heart valves and their relationship with age. Fifty hearts taken from cadavers were included to examine the histology of the tricuspid, mitral, pulmonary, and aortic valves. All specimens were stained with Elastic Van Gieson, and picrosirius red to enable the evaluation of elastic and collagen fibers, respectively. There was a gradual increase in elastic and collagen fibers with advancing age, particularly over 40 years, in all valve types. In the case of tricuspid and mitral valves increases in collagen and elastic fibers were observed starting in the fifth decade. Elastic fiber fragmentation was observed in specimens over 50 years. In the case of the pulmonary and the aortic valves, collagen fibers were denser and more irregular in the sixth to seventh decades when compared to younger ages while elastic fibers were significantly increased in the sixth decade. In addition, an increase in fat deposition had an association with aging. These findings provide additional basic knowledge in age-related morphological changes of the heart valves and will increase understanding concerning valvular heart diseases and treatment options.

Atherosclerosis Linked to Aberrant Amino Acid Metabolism and Immunosuppressive Amino Acid Catabolizing Enzymes

Cardiovascular disease is the leading global health concern and responsible for more deaths worldwide than any other type of disorder. Atherosclerosis is a chronic inflammatory disease in the arterial wall, which underpins several types of cardiovascular disease. It has emerged that a strong relationship exists between alterations in amino acid (AA) metabolism and the development of atherosclerosis. Recent studies have reported positive correlations between levels of branched-chain amino acids (BCAAs) such as leucine, valine, and isoleucine in plasma and the occurrence of metabolic disturbances. Elevated serum levels of BCAAs indicate a high cardiometabolic risk. Thus, BCAAs may also impact atherosclerosis prevention and offer a novel therapeutic strategy for specific individuals at risk of coronary events. The metabolism of AAs, such as L-arginine, homoarginine, and L-tryptophan, is recognized as a critical regulator of vascular homeostasis. Dietary intake of homoarginine, taurine, and glycine can improve atherosclerosis by endothelium remodeling. Available data also suggest that the regulation of AA metabolism by indoleamine 2,3-dioxygenase (IDO) and arginases 1 and 2 are mediated through various immunological signals and that immunosuppressive AA metabolizing enzymes are promising therapeutic targets against atherosclerosis. Further clinical studies and basic studies that make use of animal models are required. Here we review recent data examining links between AA metabolism and the development of atherosclerosis.

Association between polymorphisms in interleukin-18 promoter and risk of coronary artery disease: a meta-analysis

Background: Previous studies have explored associations between interleukin-18 (IL-18) promoter polymorphisms and coronary artery disease (CAD). However, the results were controversial. We conducted a meta-analysis to clarify the association between the two polymorphisms and CAD risk. Methods: We searched English and Chinese databases and calculated the odds ratio (OR) and 95% confidence interval (CI) to estimate whether there are genetic associations between IL-18 promoter polymorphisms and the risk of CAD. All relevant studies were screened and meta-analyzed using STATA 15.0. Results: A total of 15 studies, including 12 studies for -137 G/C and 9 studies for -607 C/A, were identified for the meta-analysis. For -137 G/C, the results showed a significantly reduced risk of CAD in the dominant model (OR = 0.85) and heterozygous model (OR = 0.88) in the overall analysis. However, in subgroup analysis, decreased CAD risks were only observed in Asian populations for heterozygous genetic models. For -607 C/A, the overall OR revealed a reduced risk of CAD in all five genetic models (allelic, OR = 0.78; recessive, OR = 0.75; dominant, OR = 0.68; homozygous, OR = 0.61; heterozygous, OR = 0.72). In subgroup analysis, reduced CAD risk was also found in five genetic models of the Asian population. We also found that the IL-18 polymorphisms were correlated with myocardial infarction (MI) and multivessel (MV) disease. Conclusion: Our results suggested that the -137 polymorphism and -607 polymorphism in the IL-18 promoter were negatively associated with CAD, especially in the Asian population. In addition, some genetic models were correlated with the severity of CAD.

Heart Failure Training and Job Satisfaction: A Survey of Home Care Workers Caring for Adults with Heart Failure in New York City

Background

Home care workers (HCWs), who include home health aides and personal care attendants, frequently care for adults with heart failure (HF). Despite substantial involvement in HF care, prior qualitative studies have found that HCWs lack training and confidence, which creates challenges for this workforce and potentially for patient care. Herein, we quantified the prevalence of HF training among HCWs and determined its association with job satisfaction.

Methods

We conducted a cross-sectional survey of agency-employed HCWs caring for HF patients across New York, NY from 2018-2019. HF training was assessed with, "Have you received prior HF training?" Job satisfaction was assessed with, "How satisfied are you with your job?" The association between HF training and job satisfaction was determined with robust poisson regression.

Results

323 HCWs from 23 agencies participated; their median age was 50 years (IQR: 37,58), 94% were women, 44% were non-Hispanic Black, 23% were Hispanic, 78% completed ≥ high school education, and 72% were foreign-born. They had been caregiving for a median of 8.5 years (IQR: 4,15) and 73% had cared for 1-5 HF patients. Two-thirds received none/a little HF training and 82% felt satisfied with their job. In a fully adjusted model, HCWs with some/a lot of HF training had 14% higher job satisfaction than those with none/a little HF training (aPR 1.14; 95% CI 1.03-1.27).

Conclusions

The majority of HCWs have not received HF training. HF training was associated with higher job satisfaction, suggesting that HF training programs may improve HCWs' experience caring for this patient population.

Predicted quality benefits of achievable performance benchmarks of chronic heart failure care in China: results from a nationwide observational study

OBJECTIVES

This study aimed to set a data-driven achievable performance benchmark, explore the process-outcome association and speculate about the net gain in quality improvement with benchmarking.

DESIGN

Observational study.

SETTING

Patient survey conducted at 466 secondary and tertiary hospitals across 31 provinces, autonomous regions and municipalities in China.

PARTICIPANTS

183 334 patients diagnosed with chronic heart failure (CHF) who were treated at 466 Chinese hospitals from January 2011 through May 2017.

PRIMARY INDEPENDENT VARIABLES

Hospital process composite performance (HPCP).

SECONDARY INDEPENDENT VARIABLES

Patient-level and hospital-level characteristics.

PRIMARY OUTCOME MEASURE

Patients getting better or recovered after treatment, in-hospital mortality, length of hospital stay (LOS) and medical cost.

METHODS

HPCP was calculated using denominator-based weights. Mixed random-intercept models were used to evaluate the contributions of HPCP on patient outcomes and to speculate quality improvement after adjusting HPCP to benchmark level.

RESULTS

When all hospitals were to operate at the benchmark level, the proportion of patients getting better or recovered after treatment would increase in most hospitals, particularly those with low baseline rates. However, there was no evidence for lowering in-hospital mortality, significant savings in cost or shortening LOS.

CONCLUSIONS

Increasing the adherence rate of CHF care and closing the gap in HPCP between hospitals have important implications for improving patient condition.

Development and Evaluation of a Tailored Mobile Health Intervention to Improve Medication Adherence in Black Patients With Uncontrolled Hypertension and Type 2 Diabetes: Pilot Randomized Feasibility Trial

BACKGROUND

Research has underscored the need to develop socioculturally tailored interventions to improve adherence behaviors in minority patients with hypertension (HTN) and type 2 diabetes (T2D). Novel mobile health (mHealth) approaches are potential methods for delivering tailored interventions to minority patients with increased cardiovascular risk.

OBJECTIVE

This study aims to develop and evaluate the acceptability and preliminary efficacy of a tailored mHealth adherence intervention versus attention control (AC) on medication adherence, systolic blood pressure (SBP), diastolic blood pressure (DBP), and hemoglobin A1c (HbA1c) at 3 months in 42 Black patients with uncontrolled HTN and/or T2D who were initially nonadherent to their medications.

METHODS

This was a two-phase pilot study consisting of a formative phase and a clinical efficacy phase. The formative phase consisted of qualitative interviews with 10 members of the target patient population (7/10, 70% female; mean age 65.8 years, SD 5.6) to tailor the intervention based on the Information-Motivation-Behavioral skills model of adherence. The clinical efficacy phase consisted of a 3-month pilot randomized controlled trial to evaluate the tailored mHealth intervention versus an AC. The tablet-delivered intervention included a tailoring survey, an individualized adherence profile, and a personalized list of interactive adherence-promoting modules, whereas AC included the tailoring survey and health education videos delivered on the tablet. Acceptability was assessed through semistructured exit interviews. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale, whereas blood pressure and HbA1c were assessed using automated devices.

RESULTS

In phase 1, thematic analysis of the semistructured interviews revealed the following 5 major barriers to adherence: disruptions in daily routine, forgetfulness, concerns about adverse effects, preference for natural remedies, and burdens of medication taking. Patients recommended the inclusion of modules that address improving patient-provider communication, peer vignettes, and stress reduction strategies to facilitate adherence. A total of 42 Black patients (23/42, 55% male; mean age 57.6 years, SD 11.1) participated in the clinical efficacy pilot trial. At 3 months, both groups showed significant improvements in adherence (mean 1.35, SD 1.60; P<.001) and SBP (-4.76 mm Hg; P=.04) with no between-group differences (P=.50 and P=.10). The decreases in DBP and HbA1c over time were nonsignificant (-1.97 mm Hg; P=.20; and -0.2%; P=.45, respectively). Patients reported high acceptability of the intervention for improving their adherence.

CONCLUSIONS

This pilot study demonstrated preliminary evidence on the acceptability of a tailored mHealth adherence intervention among a sample of Black patients with uncontrolled HTN and T2D who were initially nonadherent to their medications. Future research should explore whether repeated opportunities to use the mHealth intervention would result in improvements in behavioral and clinical outcomes over time. Modifications to the intervention as a result of the pilot study should guide future efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01643473; http://clinicaltrials.gov/ct2/show/ NCT01643473.

A new analytical framework for missing data imputation and classification with uncertainty: Missing data imputation and heart failure readmission prediction

Background

The wide adoption of electronic health records (EHR) system has provided vast opportunities to advance health care services. However, the prevalence of missing values in EHR system poses a great challenge on data analysis to support clinical decision-making. The objective of this study is to develop a new methodological framework that can address the missing data challenge and provide a reliable tool to predict the hospital readmission among Heart Failure patients.

Methods

We used Gaussian Process Latent Variable Model (GPLVM) to impute the missing values. Specifically, a lower dimensional embedding was learned from a small complete dataset and then used to impute the missing values in the incomplete dataset. The GPLVM-based missing data imputation can provide both the mean estimate and the uncertainty associated with the mean estimate. To incorporate the uncertainty in prediction, a constrained support vector machine (cSVM) was developed to obtain robust predictions. We first sampled multiple datasets from the distributions of input uncertainty and trained a support vector machine for each dataset. Then an optimal classifier was identified by selecting the support vectors that maximize the separation margin of a newly sampled dataset and minimize the similarity with the pre-trained support vectors.

Results

The proposed model was derived and validated using Physionet MIMIC-III clinical database. The GPLVM imputation provided normalized mean absolute errors of 0.11 and 0.12 respectively when 20% and 30% of instances contained missing values, and the confidence bounds of the estimations captures 97% of the true values. The cSVM model provided an average Area Under Curve of 0.68, which improves the prediction accuracy by 7% as compared to some existing classifiers.

Conclusions

The proposed method provides accurate imputation of missing values and has a better prediction performance as compared to existing models that can only deal with deterministic inputs.

The Evolving Applications of Creatine Supplementation: Could Creatine Improve Vascular Health?

Creatine is a naturally occurring compound, functioning in conjunction with creatine kinase to play a quintessential role in both cellular energy provision and intracellular energy shuttling. An extensive body of literature solidifies the plethora of ergogenic benefits gained following dietary creatine supplementation; however, recent findings have further indicated a potential therapeutic role for creatine in several pathologies such as myopathies, neurodegenerative disorders, metabolic disturbances, chronic kidney disease and inflammatory diseases. Furthermore, creatine has been found to exhibit non-energy-related properties, such as serving as a potential antioxidant and anti-inflammatory. Despite the therapeutic success of creatine supplementation in varying clinical populations, there is scarce information regarding the potential application of creatine for combatting the current leading cause of mortality, cardiovascular disease (CVD). Taking into consideration the broad ergogenic and non-energy-related actions of creatine, we hypothesize that creatine supplementation may be a potential therapeutic strategy for improving vascular health in at-risk populations such as older adults or those with CVD. With an extensive literature search, we have found only four clinical studies that have investigated the direct effect of creatine on vascular health and function. In this review, we aim to give a short background on the pleiotropic applications of creatine, and to then summarize the current literature surrounding creatine and vascular health. Furthermore, we discuss the varying mechanisms by which creatine could benefit vascular health and function, such as the impact of creatine supplementation upon inflammation and oxidative stress.

Clinical Associations of Vascular Stiffness, Microvascular Dysfunction, and Prevalent Cardiovascular Disease in a Black Cohort: The Jackson Heart Study

Background

Measures of vascular dysfunction are related to adverse cardiovascular disease (CVD) outcomes in non‐Hispanic, White populations; however, data from Black individuals are limited. We aimed to investigate the associations between novel hemodynamic measures and prevalent CVD in a sample of Black individuals.

Methods and Results

Among older Black participants of the Jackson Heart Study, we assessed noninvasive vascular hemodynamic measures using arterial tonometry and Doppler ultrasound. We assessed 5 measures of aortic stiffness and wave reflection (carotid‐femoral pulse wave velocity, pulse wave velocity ratio, forward pressure wave amplitude, central pulse pressure, and augmentation index), and 2 measures of microvascular function (baseline and hyperemic brachial flow velocity). Using multivariable logistic regression models, we examined the relations between vascular hemodynamic measures and prevalent CVD. In models adjusted for traditional CVD risk factors, higher carotid‐femoral pulse wave velocity (odds ratio [OR],1.25; 95% CI, 1.01–1.55; P=0.04), lower augmentation index (OR, 0.84; 95% CI, 0.70–0.99; P=0.05), and lower hyperemic brachial flow velocity (OR, 0.77; 95% CI, 0.65–0.90; P=0.001) were associated with higher odds of CVD. After further adjustment for hypertension treatment, lower augmentation index (OR, 0.84; 95% CI, 0.70–0.99; P=0.04) and hyperemic brachial flow velocity (OR, 0.79; 95% CI, 0.67–0.94; P=0.006), but not carotid‐femoral pulse wave velocity (OR, 1.23; 95% CI, 0.99–1.051; P=0.06), were associated with higher odds of CVD.

Conclusions

In a sample of older Black individuals, more severe microvascular damage and aortic stiffness were associated with prevalent CVD. Further research on hemodynamic mechanisms that contribute to cardiovascular risk among older Black individuals is merited.

Behavioral tests in rodent models of stroke

Rodents are the most widely used experimental animals in stroke research due to their similar vascular anatomy, high reproductive rates, and availability of transgenic models. However, the difficulties in assessing higher brain functions, such as cognition and memory, in rodents decrease the translational potential of these studies. In this review, we summarize commonly used motor/sensorimotor and cognition tests in rodent models of stroke. Specifically, we first briefly introduce the objective and procedure of each behavioral test. Next, we summarize the application of each test in both ischemic stroke and hemorrhagic stroke. Last, the advantages and disadvantages of these tests in assessing stroke outcome are discussed. This review summarizes commonly used behavioral tests in stroke studies and compares their applications in different stroke types.

Adiponectin in heart failure

The adipose tissue, apart from storing energy, plays a role of an endocrine organ. One of the most important adipokines secreted by adipose tissue is adiponectin, which is also produced by cardiomyocytes and connective tissue cells within the heart. Adiponectin is known for its beneficial effect on the metabolism and cardiovascular system and its low level is a factor of development of many cardiovascular diseases. Paradoxically, in the course of heart failure, adiponectin level gradually increases with the severity of the disease and higher adiponectin level is a factor of poor prognosis. As a result, there is a growing interest in adiponectin as a marker of heart failure progression and a predictor of prognosis in the course of this disease.

The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.

Rural-Urban Residence and Stroke Risk and Severity in Postmenopausal Women: The Women's Health Initiative

Background: The impact of rural–urban residence on stroke risk and poor stroke outcomes among postmenopausal women is unknown.

Methods: We used data from the Women's Health Initiative (WHI) (1993–2014; n = 155,186) to test the hypothesis that women who live in rural compared with urban areas have higher stroke risk and worse stroke outcomes than urban women. We used rural–urban commuting area codes to categorize geocoded participant addresses into urban, large rural, or small rural areas. Incident strokes during follow-up were adjudicated by neurologists who used standardized criteria for reviewing brain imaging reports and other medical records and determining stroke subtype. Stroke functional recovery was measured with the Glasgow Stroke Outcomes Scale ascertained from the hospital record. We used univariable and multivariable-adjusted Cox proportional hazards models as well as logistic regression models to test whether rural–urban residence predicted stroke risk and odds of poor stroke outcome.

Results: Among the 155,186 women in our cohort, 2.3% (n = 3514) had an incident stroke. We observed a modest reduction in risk of incident stroke among women who lived in urban (adjusted hazard ratio [aHR]: 0.86, confidence interval [95% CI]: 0.71–1.05) and large rural areas (aHR: 0.79, 95% CI: 0.60–1.04) compared with women who lived in small rural areas. In contrast, women who lived in urban compared with large rural areas had a similarly modest increased risk of stroke (aHR: 1.09, 95% CI: 0.89–1.32). Women who lived in urban compared with large rural areas were more likely to have poor stroke outcome (odds ratio [OR]: 1.41, 95% CI: 1.06–1.88), but the association was attenuated after adjustment for covariates (adjusted OR [aOR]: 1.27, 0.93–1.74).

Conclusions: Future studies should confirm and examine the potential pathways of the reported associations among postmenopausal women.

Urban vs Suburban: Is the Door-to-Balloon Time Affected by Geographic, Socioeconomic, or Racial Differences? A Tale of Two Campuses

BACKGROUND

In 2004, the ACC/AHA released guidelines in the treatment of ST-segment elevation myocardial infarction (STEMI) within a time window from the time a patient physically enters the hospital to the time of percutaneous coronary intervention (PCI). This time window is defined as the door-to-balloon time (DTB) and is recommended to be under 90 minutes to improve patient mortality. To add another layer of complexity, patients with varying socioeconomic status and racial differences experience large disparities in health. Our institution provides care for patients in two locations separated by approximately 30 miles within the Detroit metropolitan area. We aimed this study to investigate any differences between DTB times of our two campuses (urban versus suburban population) as well as any differences in the components that comprise DTB times.

METHODS

We retrospectively collected data on all patients who presented to either Campus 1 or Campus 2 with a STEMI from 2016 to 17. DTB times, demographical, temporal, and anatomical data were collected and analyzed. Our search included 169 patients who met the full inclusion criteria.

RESULTS

The combined average of the overall DTB time for both campuses was 81 minutes, 15 seconds (95% CI: 78:05, 84:25). The average DTB time in Campus 1 was 78 minutes and 41 seconds (95% CI: 73:05, 84:18) versus 82 minutes and 46 seconds (95% CI: 78:55, 86:38) for Campus 2 (p=0.24). There were no statistically significant differences between either campuses within the separate metrics that comprise DTB times.

CONCLUSIONS

Our study demonstrated that we have been able to provide high-quality care to all of our patients presenting with STEMI at either campus, regardless of socioeconomic differences in the populations they serve. Additionally, each campus has demonstrated DTB well below the nationally recommended guidelines.

G protein-coupled estrogen receptor 1 as a novel regulator of blood pressure

The mechanisms underlying hypertension are multifaceted and incompletely understood. New evidence suggests that G protein-coupled estrogen receptor 1 (GPER1) mediates protective actions within the cardiovascular and renal systems. This mini-review focuses on recent advancements in our understanding of the vascular, renal, and cardiac GPER1-mediated mechanisms that influence blood pressure regulation. We emphasize clinical and basic evidence that suggests GPER1 as a novel target to aid therapeutic strategies for hypertension. Furthermore, we discuss current controversies and challenges facing GPER1-related research.

Revisiting the internal mammaries as recipient vessels in breast reconstruction: considerations in current practice

BACKGROUND

The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future.

METHODS

The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology's atheroscletoric and cardiovascular disease (ASCVD) risk calculator.

RESULTS

There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups.

CONCLUSION

Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.

IMAGINE study protocol of a clinical trial: a multi-center, investigator-blinded, randomized, 36-month, parallel-group to compare the effectiveness of motivational interview in rehabilitation of older stroke survivors

BACKGROUND

Rehabilitation pathways are crucial to reduce stroke-related disability. Motivational Interviewing (MI), as a person-centered complex intervention, aimed to empower and motivate, and could be a resource to improve rehabilitation outcomes for older stroke survivors. The IMAGINE project aims to assess the impact of MI, as a complement to standard geriatric rehabilitation, on functional improvement at 30 days after admission, compared to standard geriatric rehabilitation alone, in persons admitted to geriatric rehabilitation after a stroke. Secondary objectives include assessing the impact of MI on physical activity and performance, self-efficacy, safety, cost-utility, participants' experiences and functional status at 3 months.

METHODS

We will conduct a multicenter randomized clinical trial in three geriatric rehabilitation hospitals in Spain. Older adults after mild-moderate stroke without previous severe cognitive impairment or disability will be randomized into the control or intervention group (136 per group, total N = 272). The intervention group will receive 4 sessions of MI by trained nurses, including the design of a personalized rehabilitation plan agreed between stroke survivors and nurses based on stroke survivors´ goals, needs, preferences and capabilities. Main outcome will be the Functional Independence Measure (FIM). In-hospital physical activity will be measured through accelerometers and secondary outcomes using validated scales. The study includes a process evaluation and cost-utility analysis.

DISCUSSION

Final results are expected by end of 2020. This study will provide relevant information on the implementation of MI as a rehabilitation reinforcement tool in older stroke survivors. A potential reduction in post-stroke disability and dependence would increase person's health-related quality of life and well-being and reduce health and social care costs. IMAGINE has the potential to inform practice and policymakers on how to move forward towards shared decision-making and shared responsibilities in the vulnerable population of older stroke survivors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03434938 , registered on January 2018.

Neuroinflammatory Mechanisms in Ischemic Stroke: Focus on Cardioembolic Stroke, Background, and Therapeutic Approaches

One of the most important causes of neurological morbidity and mortality in the world is ischemic stroke. It can be a result of multiple events such as embolism with a cardiac origin, occlusion of small vessels in the brain, and atherosclerosis affecting the cerebral circulation. Increasing evidence shows the intricate function played by the immune system in the pathophysiological variations that take place after cerebral ischemic injury. Following the ischemic cerebral harm, we can observe consequent neuroinflammation that causes additional damage provoking the death of the cells; on the other hand, it also plays a beneficial role in stimulating remedial action. Immune mediators are the origin of signals with a proinflammatory position that can boost the cells in the brain and promote the penetration of numerous inflammatory cytotypes (various subtypes of T cells, monocytes/macrophages, neutrophils, and different inflammatory cells) within the area affected by ischemia; this process is responsible for further ischemic damage of the brain. This inflammatory process seems to involve both the cerebral tissue and the whole organism in cardioembolic stroke, the stroke subtype that is associated with more severe brain damage and a consequent worse outcome (more disability, higher mortality). In this review, the authors want to present an overview of the present learning of the mechanisms of inflammation that takes place in the cerebral tissue and the role of the immune system involved in ischemic stroke, focusing on cardioembolic stroke and its potential treatment strategies.

Trends in Left Ventricular Ejection Fraction for Patients With a New Diagnosis of Heart Failure

BACKGROUND

The left ventricular ejection fraction (LVEF) guides treatment of heart failure, yet this data has not been systematically collected in large data sets. We sought to characterize the epidemiology of incident heart failure using the initial LVEF.

METHODS

We identified 219 537 patients in the Veterans Affairs system between 2011 and 2017 who had an LVEF documented within 365 days before and 30 days after the heart failure diagnosis date. LVEF was obtained from natural language processing from imaging and provider notes. In multivariate analysis, we assessed characteristics associated with having an initial LVEF <40%.

RESULTS

Most patients were male and White; a plurality were within the 60 to 69 year age decile. A majority of patients had ischemic heart disease and a high burden of co-morbidities. Over time, presentation with an LVEF <40% became slightly less common, with a nadir in 2015. Presentation with an initial LVEF <40% was more common in younger patients, men, Black and Hispanic patients, an inpatient presentation, lower systolic blood pressure, lower pulse pressure, and higher heart rate. Ischemic heart disease, alcohol use disorder, peripheral arterial disease, and ventricular arrhythmias were associated with an initial LVEF <40%, while most other comorbid conditions (eg, atrial fibrillation, chronic obstructive pulmonary disease, malignancy) were more strongly associated with an initial LVEF >50%.

CONCLUSIONS

For patients with heart failure, particularly at the extremes of age, an initial preserved LVEF is common. In addition to clinical characteristics, certain races (Black and Hispanic) were more likely to present with a reduced LVEF. Further studies are needed to determine if racial differences are due to patient or health systems issues such as access to care.

Efficacy and safety of vascular intervention combined with intravenous thrombolysis in treatment of acute intracranial arterial occlusion

Efficacy and safety of vascular intervention combined with intravenous thrombolysis (IVT) was investigated in the treatment of acute intracranial arterial occlusion (AIAO). Ninety-two patients with AIAO treated in People's Hospital of Tongchuan from January 2014 to February 2016 were enrolled in this retrospective study. Forty-two patients were treated with vascular intervention (control group), while another 50 patients were treated with vascular intervention combined with IVT (study group). They were observed in terms of the improvement of clinical efficacy after treatment, the comparison of complications after treatment, the National Institute of Health Stroke Scale (NIHSS) score after treatment, the modified Rankin Scale (mRS) score at 3 months after treatment, and the Mini-Mental State Examination (MMSE) score at 3 months after treatment. Compared with those in the control group, patients in the study group had statistically significantly higher marked effectiveness and statistically significantly lower ineffectiveness (P=0.018), and a statistically significantly higher overall effective rate (P=0.042). The NIHSS score in the study group was statistically significantly lower than that in the control group after treatment (P=0.001). There was a statistically significant difference between the two groups in the mRS score at 3 months after treatment (Z=8.764, P>0.05). Compared with those in the control group, patients in the study group had a statistically significantly higher MMSE score after treatment, and a statistically significantly lower total incidence of postoperative complications (P=0.001). Vascular intervention combined with IVT has good efficacy and high safety in the treatment of AIAO, and the combination can statistically significantly improve patients' quality of life, so it has a good clinical application value.

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: From EvidenceNOW Southwest (ENSW)

PURPOSE

To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines.

STUDY DESIGN

A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support.

METHODS

Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison.

RESULTS

A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05).

CONCLUSIONS

Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.

Association Between Copper, Zinc, Iron, and Selenium Intakes and TC/HDL-C Ratio in US Adults

The trace minerals zinc, copper, iron, and selenium are essential micronutrients, and because of their antioxidant activity, they are hypothesized to improve cardiovascular health. However, their associations with different risk levels for cardiovascular diseases are less clear. Data from the National Health and Nutrition Examination Survey 2007-2014 were used. In this study, the ratio of total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) was used as a risk marker for cardiovascular disease, and a ratio ≥ 5 was considered to indicate high risk. A total of 7597 adults (3673 men and 3924 women) were included, and 15.9% of the participants had a high risk of cardiovascular disease. Using quantile regression analysis, we found the negative correlation between zinc, copper, iron, and selenium intakes and TC/HDL-C. The effects of copper and zinc were enhanced with increasing quantiles of risk levels. In addition, the difference in the associations of the trace minerals was sex-dependent. The correlation between iron and cardiovascular risk in males was stronger than those in females, while that of copper was weaker than that in females. Moreover, a significant nonlinear relationship between selenium and the TC/HDL-C ratio was only found in females, and this relationship was U-shaped. Our findings suggest that among healthy adults in the US, zinc, copper, iron, and selenium intakes are inversely associated with cardiovascular disease risk, and the effect is enhanced with increasing quantiles of risk levels, with magnitudes differing by sex. Therefore, trace minerals may have the ability to prevent cardiovascular disease.

Strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority

BACKGROUND

The US faces remarkable food and nutrition challenges. A new federal effort to strengthen and coordinate nutrition research could rapidly generate the evidence base needed to address these multiple national challenges. However, the relevant characteristics of such an effort have been uncertain.

OBJECTIVES

Our aim was to provide an objective, informative summary of 1) the mounting diet-related health burdens facing our nation and corresponding economic, health equity, national security, and sustainability implications; 2) the current federal nutrition research landscape and existing mechanisms for its coordination; 3) the opportunities for and potential impact of new fundamental, clinical, public health, food and agricultural, and translational scientific discoveries; and 4) the various options for further strengthening and coordinating federal nutrition research, including corresponding advantages, disadvantages, and potential executive and legislative considerations.

METHODS

We reviewed government and other published documents on federal nutrition research; held various discussions with expert groups, advocacy organizations, and scientific societies; and held in-person or phone meetings with >50 federal staff in executive and legislative roles, as well as with a variety of other stakeholders in academic, industry, and nongovernment organizations.

RESULTS

Stark national nutrition challenges were identified. More Americans are sick than are healthy, largely from rising diet-related illnesses. These conditions create tremendous strains on productivity, health care costs, health disparities, government budgets, US economic competitiveness, and military readiness. The coronavirus disease 2019 (COVID-19) outbreak has further laid bare these strains, including food insecurity, major diet-related comorbidities for poor outcomes from COVID-19 such as diabetes, hypertension, and obesity, and insufficient surveillance on and coordination of our food system. More than 10 federal departments and agencies currently invest in critical nutrition research, yet with relatively flat investments over several decades. Coordination also remains suboptimal, documented by multiple governmental reports over 50 years. Greater harmonization and expansion of federal investment in nutrition science, not a silo-ing or rearrangement of existing investments, has tremendous potential to generate new discoveries to improve and sustain the health of all Americans. Two identified key strategies to achieve this were as follows: 1) a new authority for robust cross-governmental coordination of nutrition research and other nutrition-related policy and 2) strengthened authority, investment, and coordination for nutrition research within the NIH. These strategies were found to be complementary, together catalyzing important new science, partnerships, coordination, and returns on investment. Additional complementary actions to accelerate federal nutrition research were identified at the USDA.

CONCLUSIONS

The need and opportunities for strengthened federal nutrition research are clear, with specific identified options to help create the new leadership, strategic planning, coordination, and investment the nation requires to address the multiple nutrition-related challenges and grasp the opportunities before us.

FGF21 alleviates neuroinflammation following ischemic stroke by modulating the temporal and spatial dynamics of microglia/macrophages

Background

Resident microglia and macrophages are the predominant contributors to neuroinflammation and immune reactions, which play a critical role in the pathogenesis of ischemic brain injury. Controlling inflammatory responses is considered a promising therapeutic approach for stroke. Recombinant human fibroblast growth factor 21 (rhFGF21) presents anti-inflammatory properties by modulating microglia and macrophages; however, our knowledge of the inflammatory modulation of rhFGF21 in focal cerebral ischemia is lacking. Therefore, we investigated whether rhFGF21 improves ischemic outcomes in experimental stroke by targeting microglia and macrophages.

Methods

C57BL/6 mice were subjected to middle cerebral artery occlusion (MCAO) and randomly divided into groups that received intraperitoneal rhFGF21 or vehicle daily starting at 6 h after reperfusion. Behavior assessments were monitored for 14 days after MCAO, and the gene expression levels of inflammatory cytokines were analyzed via qRT-PCR. The phenotypic variation of microglia/macrophages and the presence of infiltrated immune cells were examined by flow cytometry and immunostaining. Additionally, magnetic cell sorting (MACS) in combination with fluorescence-activated cell sorting (FACS) was used to purify microglia and macrophages.

Results

rhFGF21 administration ameliorated neurological deficits in behavioral tests by regulating the secretion of pro-inflammatory and anti-inflammatory cytokines. rhFGF21 also attenuated the polarization of microglia/macrophages toward the M1 phenotype and the accumulation of peripheral immune cells after stroke, accompanied by a temporal evolution of the phenotype of microglia/macrophages and infiltration of peripheral immune cells. Furthermore, rhFGF21 treatment inhibited M1 polarization of microglia and pro-inflammatory cytokine expression through its actions on FGF receptor 1 (FGFR1) by suppressing nuclear factor-kappa B (NF-κB) and upregulating peroxisome proliferator-activated receptor-γ (PPAR-γ).

Conclusions

rhFGF21 treatment promoted functional recovery in experimental stroke by modulating microglia/macrophage-mediated neuroinflammation via the NF-κB and PPAR-γ signaling pathways, making it a potential anti-inflammatory agent for stroke treatment.

Association between Neutrophil Percentage-to-Albumin Ratio and All-Cause Mortality in Critically Ill Patients with Coronary Artery Disease

Background

Neutrophil percentage-to-albumin ratio (NPAR) has been proved to be associated with clinical outcome of many diseases. This study was aimed at exploring the independent effect of NPAR on all-cause mortality of critically ill patients with coronary artery disease (CAD).

Method

NPAR was calculated as neutrophil percentage numerator divided by serum albumin concentration. Clinical endpoints were 30-day, 90-day, and 365-day all-cause mortality. Multivariable Cox proportional hazard models were performed to confirm the association between NPAR and all-cause mortality.

Result

3106 patients with CAD were enrolled. All-cause mortality rates of 30 days (P < 0.001), 90 days (P < 0.001), and 365 days (P < 0.001) increased as NPAR tertiles increased. And after adjusting for possible confounding variables, NPAR was still independently associated with 30-day (third tertile group versus first tertile group: HR, 95% CI: 1.924, 1.471-2.516; P for trend < 0.001), 90-day (third tertile group versus first tertile group: HR, 95% CI: 2.053, 1.646-2.560; P for trend < 0.001), and 365-day (third tertile group versus first tertile group: HR, 95% CI: 2.063, 1.717-2.480; P for trend < 0.001) all-cause mortality in patients with CAD. Subgroup analysis did not find obvious interaction in most subgroups.

Conclusion

NPAR was independently correlated with 30-day, 60-day, and 365-day all-cause mortality in critically ill patients with CAD.