Citations

This study examines the importance of four psychosocial factors—personality, cognitive appraisal of quality of life, social support, and current reserve-building—in predicting treatment burden in chronically ill patients. Chronically ill patients ( n = 446) completed web-based measures. Structural equation modeling was used to investigate psychosocial factors predicting treatment burden. Reserve-building activities indirectly reduced treatment burden by: (1) reducing health worries appraisals, (2) reducing financial difficulties, (3) increasing calm and peaceful appraisals, and (4) increasing perceived social support. These findings point to key behaviors that chronically ill people can use to attenuate their treatment burden.

Left ventricular assist devices (LVADs) have become an important advancement for patients with end-stage heart failure. Left ventricular assist devices come with the risk of stroke and pump thrombosis, and to mitigate these risks, anticoagulation is given to these patients. With anticoagulation comes increased bleeding risk, and urgent reversal may be necessary. Reports have shown that the risk of thrombosis with prothrombin complex concentrate (PCC) does exist, especially in patients with baseline risk factors for thrombosis. We describe two cases of warfarin reversal with low-dose 4-factor PCC (4F-PCC) in two different LVAD patient scenarios. Low-dose 4F-PCC was administered to one patient with a Heart Mate II (HM II) LVAD, international normalized ratio (INR) of 4.7 on admission and in need of an urgent procedure. He received approximately 16 units/kg of 4F-PCC with reversal of his INR to 2.3 within 45 minutes. The second patient also had a HM II LVAD and presented with a right occipital intraparenchymal hemorrhage and subdural hematoma with an INR of 3.7. He received approximately 11 units/kg of 4F-PCC with INR reversal to 1.6 within 1 hour. Both of these patients had no thrombotic complications and successful reversal of their INR with low-dose 4F-PCC. Further investigation into low-dose 4F-PCC dosing strategies is warranted.

Background Differences in anticoagulation rates and direct oral anticoagulant use by provider specialty may identify an area of practice improvement to reduce future stroke events in patients with atrial fibrillation ( AF ). Methods and Results We examined anticoagulant prescription fills in 388 045 (mean age, 68±15 years; 59% male) patients with incident AF from the MarketScan databases between 2009 and 2014. Provider specialty and filled anticoagulant prescriptions around the time of AF diagnosis (3 months before through 6 months after) were obtained from outpatient services and pharmacy claims. We estimated the association of provider specialty (cardiology versus primary care) with filling oral anticoagulant prescriptions, adjusting for patient characteristics. The risk of stroke and bleeding events also was explored. A total of 235 739 patients (61%) had a cardiology provider claim, whereas 152 306 (39%) were exclusively managed by primary care. Patients seen by cardiology providers were more likely to fill anticoagulant prescriptions than those seen by primary care (39% versus 27%; relative risk, 1.39; 95% confidence interval [ CI ], 1.37–1.40). Differences were observed for direct oral anticoagulants (relative risk, 1.74; 95% CI , 1.71–1.78) and warfarin (relative risk, 1.24; 95% CI , 1.22–1.26). A reduced risk of stroke events was observed among those seen by cardiology providers (hazard ratio, 0.90; 95% CI , 0.86–0.94) compared with primary care, without an increased bleeding risk (hazard ratio, 1.03; 95% CI , 0.98–1.07). Conclusions Patients seen by an outpatient cardiology provider shortly after AF diagnosis were more likely to initiate oral anticoagulation and were at lower risk of future stroke events without a higher rate of bleeding. Early referral to cardiology specialists may increase initiation of anticoagulant therapies and improve outcomes in AF .

Background Atrial fibrillation ( AF ) has been associated with faster cognitive decline and increased dementia risk. Factors associated with dementia in patients with AF have been seldom studied. Methods and Results We studied 6432 individuals from the ARIC ‐NCS (Atherosclerosis Risk in Communities Neurocognitive Study). In 2011 to 2013, participants underwent a physical exam, echocardiography, detailed cognitive assessments, and a subset, brain magnetic resonance imaging. Dementia and mild cognitive impairment ( MCI ), as well as etiology of MCI /dementia, Alzheimer's disease–related or vascular, were adjudicated by an expert panel. AF was defined by study ECGs and past hospitalizations. We used logistic regression to estimate odds ratios and 95% CI of MCI /dementia by AF status and to assess cross‐sectional correlates of MCI /dementia in patients with AF . Among 6432 participants, 611 (9.5%) had prevalent AF . AF was associated with increased odds of dementia and MCI (odds ratio, 95% CI , 2.25, 1.64–3.10, and 1.28, 1.04–1.56, respectively). Prevalence of Alzheimer's disease–related MCI /dementia and vascular MCI /dementia were higher in participants with AF than without AF (odds ratio, 95% CI , 1.29, 1.04–1.61, and 1.50, 0.99–2.25, respectively). In multivariable analyses, older age, lower body mass index, diabetes mellitus, stroke, and APOE genotype were associated with dementia prevalence in participants with AF . In models evaluating MCI /dementia subtypes, diabetes mellitus was associated with Alzheimer's disease–related MCI /dementia, whereas male sex and stroke were risk factors for vascular MCI /dementia. Conclusions In a large, community‐based study, AF was associated with higher prevalence of MCI and dementia. Controlling cardiometabolic risk factors is a potential target for prevention of adverse cognitive outcomes in AF patients.

Abstract The Arc CHECK ‐ MR diode array utilizes a correction system with a virtual inclinometer to correct the angular response dependencies of the diodes. However, this correction system cannot be applied to measurements on the ViewRay MR ‐ IGRT system due to the virtual inclinometer's incompatibility with the ViewRay's multiple simultaneous beams. Additionally, the Arc CHECK 's current correction factors were determined without magnetic field effects taken into account. In the course of performing ViewRay IMRT quality assurance with the Arc CHECK , measurements were observed to be consistently higher than the ViewRay TPS predictions. The goals of this study were to quantify the observed discrepancies and test whether applying the current factors improves the Arc CHECK 's accuracy for measurements on the ViewRay. Gamma and frequency analysis were performed on 19 ViewRay patient plans. Ion chamber measurements were performed at a subset of diode locations using a PMMA phantom with the same dimensions as the Arc CHECK . A new method for applying directionally dependent factors utilizing beam information from the ViewRay TPS was developed in order to analyze the current Arc CHECK correction factors. To test the current factors, nine ViewRay plans were altered to be delivered with only a single simultaneous beam and were measured with the Arc CHECK . The current correction factors were applied using both the new and current methods. The new method was also used to apply corrections to the original 19 ViewRay plans. It was found the Arc CHECK systematically reports doses higher than those actually delivered by the ViewRay. Application of the current correction factors by either method did not consistently improve measurement accuracy. As dose deposition and diode response have both been shown to change under the influence of a magnetic field, it can be concluded the current Arc CHECK correction factors are invalid and/or inadequate to correct measurements on the ViewRay system.

Objectives Explore the potential of dual-source dual-energy (DSDE) computed tomography (CT) to retrospectively analyze the uniformity of iron distribution and establish iron concentration ranges and distribution patterns found in healthy livers. Materials and Methods Ten mixtures consisting of an iron nitrate solution and deionized water were prepared in test tubes and scanned using a DSDE 128-slice CT system. Iron images were derived from a 3-material decomposition algorithm (optimized for the quantification of iron). A conversion factor (mg Fe/mL per Hounsfield unit) was calculated from this phantom study as the quotient of known tube concentrations and their corresponding CT values. Retrospective analysis was performed of patients who had undergone DSDE imaging for renal stones. Thirty-seven patients with normal liver function were randomly selected (mean age, 52.5 years). The examinations were processed for iron concentration. Multiple regions of interest were analyzed, and iron concentration (mg Fe/mL) and distribution was reported. Results The mean conversion factor obtained from the phantom study was 0.15 mg Fe/mL per Hounsfield unit. Whole-liver mean iron concentrations yielded a range of 0.0 to 2.91 mg Fe/mL, with 94.6% (35/37) of the patients exhibiting mean concentrations below 1.0 mg Fe/mL. The most important finding was that iron concentration was not uniform and patients exhibited regionally high concentrations (36/37). These regions of higher concentration were observed to be dominant in the middle-to-upper part of the liver (75%), medially (72.2%), and anteriorly (83.3%). Conclusions Dual-source dual-energy CT can be used to assess the uniformity of iron distribution in healthy subjects. Applying similar techniques to unhealthy livers, future research may focus on the impact of hepatic iron content and distribution for noninvasive assessment in diseased subjects.

Rationale Trials conducted decades ago demonstrated that carotid endarterectomy by skilled surgeons reduced stroke risk in asymptomatic patients. Developments in carotid stenting and improvements in medical prevention of stroke caused by atherothrombotic disease challenge understanding of the benefits of revascularization. Aim Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) will test whether carotid endarterectomy or carotid stenting plus contemporary intensive medical therapy is superior to intensive medical therapy alone in the primary prevention of stroke in patients with high-grade asymptomatic carotid stenosis. Methods and design CREST-2 is two multicenter randomized trials of revascularization plus intensive medical therapy versus intensive medical therapy alone. One trial randomizes patients to carotid endarterectomy plus intensive medical therapy versus intensive medical therapy alone; the other, to carotid stenting plus intensive medical therapy versus intensive medical therapy alone. The risk factor targets of centrally directed intensive medical therapy are LDL cholesterol <70 mg/dl and systolic blood pressure <140 mmHg. Study outcomes The primary outcome is the composite of stroke and death within 44 days following randomization and stroke ipsilateral to the target vessel thereafter, up to four years. Change in cognition and differences in major and minor stroke are secondary outcomes. Sample size Enrollment of 1240 patients in each trial provides 85% power to detect a treatment difference if the event rate in the intensive medical therapy alone arm is 4.8% higher or 2.8% lower than an anticipated 3.6% rate in the revascularization arm. Discussion Management of asymptomatic carotid stenosis requires contemporary randomized trials to address whether carotid endarterectomy or carotid stenting plus intensive medical therapy is superior in preventing stroke beyond intensive medical therapy alone. Whether carotid endarterectomy or carotid stenting has favorable effects on cognition will also be tested. Trial registration United States National Institutes of Health Clinicaltrials.gov NCT02089217

Abstract Purpose: To identify within demographic features and theoretical models of health behavior, the variables demonstrating differences in the behaviors, beliefs, attitudes, associations, and capacities of sporadic (non-adherent) and persistent (adherent) mammographic screeners for the purpose of guiding future interventions to improve mammographic screening adherence. Procedures: A survey was designed and mailed to all screening-age women of one Bemidji Area tribe. The survey incorporated demographic questions, and questions designed to inform about salient features of respondents' health literacy, social networks, social support, social norms, planned behavior, and health beliefs. Prior to mailing, each survey was assigned a unique identifier and sealed in an envelope. Surveys were mailed to 1,554 women in manner that ensured anonymity of the women's responses and no potential for investigators to discern women's identity via their mailing addresses or other information. Self-report data from returned surveys was used to determine women's mammographic screening status as adherent with local screening guidelines (annual mammogram beginning at age 40 for women at average risk) or non-adherent. Responses for all demographic and theoretical models of health behavior were appropriately categorized and analyzed utilizing global tests of hypotheses. Inherent multicollinearity issues required a two-step process of factor analysis followed by a multivariate analysis of variance. Where themes (e.g., demographics, health literacy, etc.) and factors within themes were significant, a univariate analysis was conducted to ascertain specific questions and responses that significantly differentiated the non-adherent from adherent screeners. Summary of data: We found no significant differences in non-adherent and adherent screeners' responses to questions related to social networks or social norms. We did find that responses from these two groups did differ on demographic features as well as on aspects of health literacy, social support, planned behavior and health beliefs. o Demographic differences involved biopsy histories and employment status. o Differentiating health literacy variables involved recognition of certain terms (e.g., annual) and understanding concepts such as ultrasound and biopsy. o Social support variables that distinguished non-adherent from adherent screeners involved sources of information support, characteristics of providers of emotional support, and sources of emotional support (e.g., solitary or communal). o Planned behavior variables illuminating differences between the screening groups involved (in additions to self-reported screening behaviors): attitudes toward the behavior of obtaining mammograms, intentions to engage in screening, and control beliefs. o Health Beliefs variables distinguishing the two sets of screeners comprised responses to questions about perceived barriers, self-efficacy, and cues to action. Conclusions: Study findings point to opportunities for tribal health and Indian Health Service (IHS) providers and staff to intervene in two broad areas. 1. Some findings associated with social support, planned behavior, and health beliefs can be used to design patient intake forms to alert tribal health and IHS providers to current and potentially non-adherent. 2. Using this information, providers can design interventions to move non-adherent and potentially non-adherent women toward persistent mammographic screening participation. An intervention study will be funded by the Minnesota Department of Health through its Eliminating Health Disparities Initiative. Citation Format: Wesley O. Petersen, Ann M. Nicometo, Robert A. Vierkant, Corinna Sabaque. Elements of theoretical models of health behavior: Planning for breast cancer screening interventions in an American Indian tribe. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B83.

Objective: Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate. Synthesis: We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences. Conclusions: We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.