Risk-adjusted management in catheterization procedures for non-ST-segment elevation myocardial infarction: A standard operating procedure pilot study

BACKGROUND

The effects of standardized risk-adjusted periprocedural management of cardiac catheterization procedures in Non-ST segment elevation myocardial infarction (NSTEMI) remain unknown. We implemented a standard operating procedure (SOP) specifying risk assessment (RA, using National Cardiovascular Data Registry (NCDR) risk models) and risk-adjusted management (RM, e.g. intensified monitoring) in 2018 and aimed to investigate staff SOP adherence and associations with patient outcomes.

METHODS AND RESULTS

All 430 invasively managed NSTEMI patients (mean age 72y; 70.9% male) in 2018 were analyzed for staff SOP adherence and in-hospital clinical outcomes. 207 patients (48.1%; RM+) received both RA and RM; 92 patients (21.4%; RM-) received RA but no RM; 131 patients (30.5%; RA-) received neither RA nor RM. Lower staff adherence to RA was associated with emergency settings (51.9% (RA-) vs. 22.1% (RA+); p<0.01), presentation in cardiogenic shock (17.6% (RA-) vs. 6.4% (RA+); p<0.01) and invasive mechanical ventilation (12.2% (RA-) vs. 3.3% (RA+); p<0.01). Early sheath removal (87.9% (RM+) vs. 56.5% (RM-); p<0.01) and intensified monitoring (p<0.01) were more frequent in the RM+ group. All-cause mortality was not different (1.4% (RM+) vs. 4.3% (RM-); p=0.13), but there were fewer major bleeding events with associated with RM (2.4% (RM+) vs. 12% (RM-); p<0.01), which remained independently associated with RM in a multivariate logistic regression model correcting for confounders (p<0.01).

CONCLUSION

In an all-comer patient cohort with NSTEMI, staff adherence to risk-adjusted periprocedural management was independently associated with fewer major bleeding events. Staff adherence to SOP-specified risk assessment was frequently neglected in more critical clinical situations.

National Cardiovascular Data Registry-Acute Kidney Injury (NCDR) vs. Mehran risk models for prediction of contrast-induced nephropathy and need for dialysis after coronary angiography in a German patient cohort

BACKGROUND

Contrast-induced nephropathy (CIN) is a major adverse event in patients undergoing coronary angiography. The Mehran risk model is the gold-standard for CIN risk prediction. However, its performance in comparison to more contemporary National Cardiovascular Data Registry-Acute Kidney Injury (NCDR-AKI) risk models remains unknown. We aimed to compare both in this study.

METHODS AND RESULTS

Predictions of Mehran and NCDR-AKI risk models and clinical events of CIN and need for dialysis were assessed in a total of 2067 patients undergoing coronary angiography with or without percutaneous coronary intervention. Risk models were compared regarding discrimination (receiver operating characteristic analysis), net reclassification improvement (NRI) and calibration (graphical and statistical analysis). The NCDR risk model showed superior risk discrimination for predicting CIN (NCDR c-index 0.75, 95% CI 0.72-0.78; vs. Mehran c-index 0.69, 95% CI 0.66-0.72, p < 0.01), and continuous NRI (0.22; 95% CI 0.12-0.32; p < 0.01) compared to the Mehran model. The NCDR risk model tended to underestimate the risk of CIN, while the Mehran model was more evenly calibrated. For the prediction of need for dialysis, NCDR-AKI-D also discriminated risk better (c-index 0.85, 95% CI 0.79-0.91; vs. Mehran c-index 0.75, 95% CI 0.66-0.84; p_NCDRvsMehran < 0.01), but continuous NRI showed no benefit and calibration analysis revealed an underestimation of dialysis risk.

CONCLUSION

In German patients undergoing coronary angiography, the modern NCDR risk model for predicting contrast-induced nephropathy showed superior discrimination compared to the GRACE model while showing less accurate calibration. Results for the outcome 'need for dialysis' were equivocal.

Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort

BACKGROUND AND PURPOSE

Risk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients.

METHODS AND RESULTS

A total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, p_{GRACE1.0vsGRACE2.0} = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; p_ACTIONvsNCDR < 0.0001; p_GRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (p_GRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, p_{GRACEvsACTION} = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); p_{GRACEvsACTION} = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models.

CONCLUSIONS

In a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.

Standardized risk management in catheterization procedures for non-ST-segment elevation myocardial infarction: associations with in-hospital clinical outcomes

Introduction and purpose

Patient risk in non-ST-segment elevation myocardial infarction (NSTEMI) depends on clinical setting, individual patient variables and procedural characteristics. Standardized risk-adjusted periprocedural management for catheterization procedures using a Standard Operating Procedure (SOP) was investigated to evaluate associations with in-hospital clinical outcomes.

Methods

In 01/2018, our heart center established an SOP for coronary catheterization procedures in NSTEMI, targeting 1) standardized pre-procedural risk assessment using National Cardiovascular Data Registry (NCDR) risk models, and 2) standardized post-procedural risk-adjusted safety measures, including advanced patient monitoring (intermediate/intensive care) and use of vascular closure devices. All patients presenting with invasively-managed NSTEMI in 2018 were retrospectively evaluated for SOP-based pre-procedural risk scoring, SOP-based post-procedural management and in-hospital clinical outcomes of mortality, major bleeding (MB, according to BARC ≥3) and acute kidney injury (AKI, according to KDIGO).

Results

A total of 430 patients (age 72±12 years, 71% male, BMI 27±5) presenting with NSTEMI from 01 to 12/2018 were included, 9.8% presented in cardiogenic shock and 4.7% had suffered a preclinical cardiac arrest. Overall in-hospital mortality was 3.7%, MB occurred in 6.5%. 207 patients (48.1%, SOP+ group) had received both 1) pre-procedural risk assessment and 2) post-procedural risk-adjusted safety measures; the other 223 patients (51.9%, SOP- group) had not received either 1) or 2). There were no significant differences in baseline characteristics and prior-existing medical conditions between groups, however, significantly more patients in SOP- group were treated in emergency settings (39.9% vs. 21.7%, p=0.004). However, significantly more patients in SOP- were treated in emergency settings at higher risk (39.9% (SOP-) vs. 21.7% (SOP+); p&lt;0.001). In univariate analysis, all in-hospital clinical outcomes of mortality (1.4% (SOP+) vs. 5.8% (SOP-); p=0.016), MB (2.9% (SOP+) vs. 9.9% (SOP-); p=0.003) and AKI were significantly lower in the SOP+ group (15.9% (SOP+) vs. 24.2% (SOP-); p=0.033). After correction for the difference in risk between groups due to emergency settings by multivariate logistic regression analysis, MB remained significantly lower in SOP+ (p=0.02), while mortality (p=0.14) and AKI (p=0.19) were not significantly associated with SOP-status anymore.

Conclusion

Standardized risk management in invasively managed NSTEMI was associated with significantly lower rates of in-hospital major bleedings.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Junior Clinician Scientist Track, Medical faculty, Heinrich-Heine-University Düsseldorf, Germany

Urine salts elucidate Early Neolithic animal management at Aşıklı Höyük, Turkey

The process of sheep and goat (caprine) domestication began by 9000 to 8000 BCE in Southwest Asia. The early Neolithic site at Aşıklı Höyük in central Turkey preserves early archaeological evidence of this transformation, such as culling by age and sex and use of enclosures inside the settlement. People's strategies for managing caprines evolved at this site over a period of 1000 years, but changes in the scale of the practices are difficult to measure. Dung and midden layers at Aşıklı Höyük are highly enriched in soluble sodium, chlorine, nitrate, and nitrate-nitrogen isotope values, a pattern we attribute largely to urination by humans and animals onto the site. Here, we present an innovative mass balance approach to interpreting these unusual geochemical patterns that allows us to quantify the increase in caprine management over a ~1000-year period, an approach that should be applicable to other arid land tells.

Strontium isotopes reveal distant sources of architectural timber in Chaco Canyon, New Mexico

Between A.D. 900 and 1150, more than 200,000 conifer trees were used to build the prehistoric great houses of Chaco Canyon, New Mexico, in what is now a treeless landscape. More than one-fifth of these timbers were spruce (Picea) or fir (Abies) that were hand-carried from isolated mountaintops 75-100 km away. Because strontium from local dust, water, and underlying bedrock is incorporated by trees, specific logging sites can be identified by comparing (87)Sr/(86)Sr ratios in construction beams from different ruins and building periods to ratios in living trees from the surrounding mountains. (87)Sr/(86)Sr ratios show that the beams came from both the Chuska and San Mateo (Mount Taylor) mountains, but not from the San Pedro Mountains, which are equally close. Incorporation of logs from two sources in the same room, great house, and year suggest stockpiling and intercommunity collaboration at Chaco Canyon. The use of trees from both the Chuska and San Mateo mountains, but not from the San Pedro Mountains, as early as A.D. 974 suggests that selection of timber sources was driven more by regional socioeconomic ties than by a simple model of resource depletion with distance and time.

A 22,000-Year Record of Monsoonal Precipitation from Northern Chile's Atacama Desert

Fossil rodent middens and wetland deposits from the central Atacama Desert (22 degrees to 24 degrees S) indicate increasing summer precipitation, grass cover, and groundwater levels from 16.2 to 10.5 calendar kiloyears before present (ky B.P.). Higher elevation shrubs and summer-flowering grasses expanded downslope across what is now the edge of Absolute Desert, a broad expanse now largely devoid of rainfall and vegetation. Paradoxically, this pluvial period coincided with the summer insolation minimum and reduced adiabatic heating over the central Andes. Summer precipitation over the central Andes and central Atacama may depend on remote teleconnections between seasonal insolation forcing in both hemispheres, the Asian monsoon, and Pacific sea surface temperature gradients. A less pronounced episode of higher groundwater levels in the central Atacama from 8 to 3 ky B.P. conflicts with an extreme lowstand of Lake Titicaca, indicating either different climatic forcing or different response times and sensitivities to climatic change.

Tectonic implications of U-Pb zircon ages of the himalayan orogenic belt in nepal

Metasedimentary rocks of the Greater Himalaya are traditionally viewed as Indian shield basement that has been thrust southward onto Lesser Himalayan sedimentary rocks during the Cenozoic collision of India and Eurasia. Ages determined from radioactive decay of uranium to lead in zircon grains from Nepal suggest that Greater Himalayan protoliths were shed from the northern end of the East African orogen during the late Proterozoic pan-African orogenic event. These rocks were accreted onto northern Gondwana and intruded by crustal melts during Cambrian-Ordovician time. Our data suggest that the Main Central thrust may have a large amount of pre-Tertiary displacement, that structural restorations placing Greater Himalayan rocks below Lesser Himalayan rocks at the onset of Cenozoic orogenesis are flawed, and that some metamorphism of Greater Himalayan rocks may have occurred during early Paleozoic time.

Unintended pregnancy and breast-feeding behavior

OBJECTIVES

This study assessed the effect of unintended pregnancy on breast-feeding behavior.

METHODS

All women delivering a live birth between January 1, 1995, and July 31, 1996 (n = 33,735), in the 15-county central New York region were asked whether they had intended to become pregnant and their breast-feeding plans.

RESULTS

Women with mistimed pregnancies, and pregnancies that were not wanted were significantly less likely to breast-feed than were women whose pregnancies were planned. After adjustment for confounding variables and contraindications for breast-feeding, the odds ratios of not breast-feeding remained significant.

CONCLUSIONS

Promoting breast-feeding among women with unintended pregnancies is important to improve health status.

Stable Isotopic Evidence for a Pedogenic Origin of Carbonates in Trench 14 near Yucca Mountain, Nevada

Layered carbonate and silica encrust fault fractures exposed in Trench 14 near Yucca Mountain, site of the proposed high-level nuclear waste repository in southern Nevada. Comparison of the stable carbon and oxygen isotopic compositions of the fracture carbonates with those of modern soil carbonates in the area shows that the fracture carbonates are pedogenic in origin and that they likely formed in the presence of vegetation and rainfall typical of a glacial climate. Their isotopic composition differs markedly from that of carbonate associated with nearby springs. The regional water table therefore remained below the level of Trench 14 during the time that the carbonates and silica precipitated, a period probably covering parts of at least the last 300,000 years.

Calcium-dependent protein phosphorylation in Babesia bovis and its role in growth regulation

Intracellular growth of protozoan parasite Babesia bovis has been followed to study the effect of some chemical agents on growth regulation. Using an in vitro parasite culture system we present evidence that the normal growth of the parasite is dependent upon available calcium and a Ca2(+)-binding protein, calmodulin, because sequestration of either of these 2 components from the culture medium causes inhibition of parasitic growth. Further studies demonstrate that the parasite contains a protein kinase that can phosphorylate a 40-kDa parasitic protein and its activity is regulated by calcium and calmodulin. Both the enzyme and its substrate are present in the membrane of the parasite. In addition, the parasite also contains a highly active protein kinase C activity that is documented by phosphorylating histone, a known substrate for protein kinase C. These findings suggest a possible correlation between the growth of parasite and calcium/calmodulin-dependent protein phosphorylation activity.