Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication.
Objective
To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi.
Design, Setting, and Participants
A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period.
Exposures
Type and duration of anticoagulant use.
Main Outcomes and Measures
Clinically apparent SSE.
Results
A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57;P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72;P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43;P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66;P = .01) remained significantly associated with SSE.
Conclusions and Relevance
In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.
Despite known benefits, a significant proportion of patients with COPD do not complete pulmonary rehabilitation (PR). Little is known regarding which factors promote successful completion of PR.We analyzed data from a prospectively maintained database of subjects with COPD who attended a PR program at the University of Alabama at Birmingham, from 1996 to 2013. Subjects were categorized as either completers or non-completers, based on successful completion of at least 8 weeks of PR. Demographics and comorbidities were recorded. Short Form 36 Health Survey, Beck Depression Inventory-II, and San Diego Shortness of Breath Questionnaire were administered to all participants at baseline and on completion of PR to assess participants' perception of their health status, severity of depression, and dyspnea with performance of activities of daily living. Univariate and multivariable analyses were performed to identify predictors of successful completion of PR.Four hundred and forty subjects were included, of whom 229 completed PR. Forty-one percent were female, and 17% were African American. Compared with non-completers, completers had greater Short Form 36 Health Survey pain score, lower forced expiratory volume in the first second, and lower Beck Depression Inventory score, and included a lower percentage of current smokers. On multivariate analysis, cigarette smoking at enrollment was associated with lower likelihood of completion of PR (adjusted odds ratio 0.38, 95% confidence interval 0.16-0.90; P=0.02).Cigarette smoking was the sole independent predictor of PR dropout, and smoking cessation may warrant greater emphasis prior to enrollment.
Background: Peripheral artery disease (PAD) results in exercise-induced ischemia in leg muscles. 31 Phosphorus (P) magnetic resonance spectroscopy demonstrates prolonged phosphocreatine recovery time constant after exercise in PAD but has low signal to noise, low spatial resolution, and requires multinuclear hardware. Chemical exchange saturation transfer (CEST) is a quantitative magnetic resonance imaging method for imaging substrate (CEST asymmetry [CEST asym ]) concentration by muscle group. We hypothesized that kinetics measured by CEST could distinguish between patients with PAD and controls. Methods: Patients with PAD and age-matched normal subjects were imaged at 3T with a transmit-receive coil around the calf. Four CEST mages were acquired over 24-second intervals. The subjects then performed plantar flexion exercise on a magnetic resonance imaging-compatible ergometer until calf exhaustion. Twenty-five CEST images were obtained at end exercise. Regions of interest were drawn around individual muscle groups, and (CEST asym ) decay times were fitted by exponential curve to CEST values. In 10 patients and 11 controls, 31 P spectra were obtained 20 minutes later after repeat exercise. Five patients and 5 controls returned at a mean of 1±1 days later for repeat CEST studies. Results: Thirty-five patients with PAD (31 male, age 66±8 years) and 29 controls (11 male, age 63±8 years) were imaged with CEST. The CEST asym decay times for the whole calf (341±332 versus 153±72 seconds; P <0.03) as well as for the gastrocnemius and posterior tibialis were longer in patients with PAD. Agreement between CEST asym decay and phosphocreatine recovery time constant was good. Conclusions: CEST is a magnetic resonance imaging method that can distinguish energetics in patients with PAD from age-matched normal subjects on a per muscle group basis. CEST agrees reasonably well with the gold standard 31 P magnetic resonance spectroscopy. Moreover, CEST has higher spatial resolution, creates an image, and does not require multinuclear hardware and thus may be more suitable for clinical studies in PAD.
Asthma affects 30 million Americans and results in reduced productivity and quality of life. Pulmonary rehabilitation (PR) is known to improve physical conditioning and exercise performance in chronic lung diseases such as COPD, however, few studies have examined its benefits in patients with asthma. We aimed to determine the benefits of PR in this population as well as the predictors of completion of therapy.We performed a retrospective review of data from patients with a diagnosis of asthma who participated in PR at our institution from 1996 to 2013. Nine hundred and nineteen patients participated in the program of whom 75 were referred with a primary diagnosis of asthma. Patients underwent physiologic testing and their symptoms and quality of life were assessed using validated questionnaires. For patients who completed PR (n = 37), data obtained at the initial and exit visit was compared. Characteristics of completers were compared to non-completers to determine predictors of successful completion.Individuals with asthma completing PR had improvement from baseline to exit visit in Six Minute Walk Distance (326 vs. 390 feet; p < 0.0001), decreased body mass index (33 vs. 32 kg/m2; p < 0.046), decreased Beck Depression Inventory scores (15 vs. 9; p < 0.0009), and increased Short Form-36 scores (345 vs. 445; p = 0.0005). In a multivariate logistic regression analysis, lower depression scores predicted completion (OR 1.08, 95% CI 1.02-1.15, p = 0.02).Patients with asthma who completed PR had improvement in physical function and emotional well-being. Depression is a risk factor for non-completion of PR. Further research is needed to determine which patients will benefit most from therapy.
Most countries around the world offer financial support for students, in the sphere of higher education. The general goal is to give young people who have the abilities and the willingness to study access to higher education, despite a lack of their own financial means. But ensuring equality of access is not the only aim of financial support schemes. Promoting the most talented and encouraging effective study behaviour are other aims that can be sought. It is a question of priorities to what degree these aspects are emphasized in the design of the system. This paper compares the schemes in Germany, the Netherlands, Australia and Estonia. The financial support schemes of these countries differ substantially. The German system clearly emphasises a goal of equality in access, and a large degree of the legal and institutional framework created seeks to realise this goal. But the goal is reached at high costs, and the support is hardly performance-orientated. The case of the Netherlands offers an example of a country that reaches a good equality of access and at the same time gives incentives for efficient study behaviour. The systems in Australia and Estonia are again different from the German and Dutch cases. They do not put that much emphasis on equality but rather have the idea of supporting the most talented persons. Estonia is extremely orientated towards achievement. Both systems are also interesting because they rely on existing institutions (both tax offices and commercial banks) instead of creating new institutions (IB Group and BAfoG offices, respectively). In this manner, they reach high cost efficiency.
