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BACKGROUND: In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment--elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes. METHODS: The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction P values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes. RESULTS: Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59--1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55--0.90]), with no evidence of a differential treatment effect (interaction P=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction P=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43--0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39--0.60]). CONCLUSIONS: Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes. GRAPHIC ABSTRACT: A graphic abstract is available for this article. [ABSTRACT FROM AUTHOR]

BACKGROUND: The COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI) demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular events in patients with ST-segment-elevation myocardial infarction and multivessel coronary artery disease. It is unclear whether consistent benefit is observed in patients undergoing a pharmacoinvasive strategy compared with primary PCI. METHODS: Following culprit lesion PCI, 4041 patients with ST-segment-elevation myocardial infarction and multivessel coronary artery disease were randomized to either routine nonculprit lesion PCI or culprit lesion only PCI. In a prespecified analysis, we determined the treatment effect in 303 patients undergoing a pharmacoinvasive strategy versus 3738 patients undergoing primary PCI on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. RESULTS: The first coprimary was reduced with complete revascularization both in the patients undergoing a pharmacoinvasive strategy (2.1%/y versus 4.7%/y, hazard ratio, 0.45 [95% CI, 0.21-0.97]) and in patients undergoing primary PCI (2.7%/y versus 3.6%/y, hazard ratio, 0.77 [95% CI, 0.62-0.95]; interaction P=0.18). The second coprimary outcome was reduced with complete revascularization in patients undergoing a pharmacoinvasive strategy (2.3%/y versus 8.5%/y, hazard ratio, 0.28 [95% CI, 0.14-0.56]), and in patients undergoing primary PCI (3.2%/y versus 6.0%/y, hazard ratio, 0.53 [95% CI, 0.44-0.64], interaction P=0.07). CONCLUSIONS: Among patients with ST-segment-elevation myocardial infarction and multivessel disease, complete revascularization with multivessel PCI consistently reduces major cardiovascular events in patients undergoing an initial pharmacoinvasive strategy as well as in those undergoing primary PCI. [ABSTRACT FROM AUTHOR]

Background—The objective of this study was to assess the efficacy of sealing intermediate nonobstructive coronary saphenous vein graft (SVG) lesions with drug-eluting stents (DES; paclitaxel- or everolimus-eluting stents) for reducing major adverse cardiac events (MACE). Methods and Results—This was a randomized controlled multicenter clinical trial that enrolled patients with a previous coronary artery bypass graft who had developed at least 1 intermediate nonobstructive SVG lesion (30%–60% diameter stenosis by visual estimation). Patients were randomized (1:1) to DES implantation (SVG-DES) or medical treatment (SVG-MT) of the target SVG lesion. The primary efficacy outcome was the first occurrence of MACE defined as the composite of cardiac death, myocardial infarction, or coronary revascularization related to the target SVG during the duration of follow-up (minimum of 2 years). Secondary efficacy outcomes included MACE related to the target SVG lesion and overall MACE. A total of 125 patients (mean age 70±9 years, 87% men) were included, with a mean time from coronary artery bypass graft of 12±5 years. Sixty and 65 patients were allocated to the SVG-DES and SVG-MT groups, respectively. There were no events related to the target SVG at 30 days. After a median follow-up of 3.4 (interquartile range: 2.8–3.9) years, the MACE rate related to the target SVG was not significantly different in the 2 groups (SVG-DES: 15.0%, SVG-MT: 20.0%; hazard ratio, 0.65; 95% confidence interval, 0.23–1.53; P=0.33). There were no significant differences between groups in MACE related to the target SVG lesion (SVG-DES: 10.0%, SVG-MT: 16.9%; hazard ratio, 0.53; 95% confidence interval, 0.20–1.43; P=0.21) or global MACE (SVG-DES: 36.7%, SVG-MT: 44.6%; hazard ratio, 0.73; 95% confidence interval, 0.42–1.27; P=0.26). Conclusions—Sealing intermediate nonobstructive SVG lesions with DES was safe but was not associated with a significant reduction of cardiac events at 3-year follow-up. [ABSTRACT FROM AUTHOR]

We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility. [ABSTRACT FROM AUTHOR]

Purpose of review Transcatheter aortic valve implantation (TAVI) is the recommended treatment for most patients with symptomatic aortic stenosis at high surgical risk. However, TAVI may be clinically futile for patients who have multiple comorbidities and excessive frailty. This group benefits from transition to palliative care to maximize quality of life, improve symptoms, and ensure continuity of health services. We discuss the clinical determination of utility and futility, explore the current evidence guiding the integration of palliative care in procedure-focused cardiac programs, and outline recommendations for TAVI programs. Recent findings The determination of futility of treatment in elderly patients with aortic stenosis is challenging. There is a paucity of research available to guide best practices when TAVI is not an option. Opportunities exist to build on the evidence gained in the management of end of life and heart failure. TAVI programs and primary care providers can facilitate improved communication and processes of care to provide decision support and transition to palliative care. Summary The increased availability of transcatheter options for the management of valvular heart disease will increase the assessment of people with life-limiting conditions for whom treatment may not be an option. It is pivotal to bridge cardiac innovation and palliation to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR. Methods: We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data. Results: After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P <0.001). Conclusions: Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02287662. [ABSTRACT FROM AUTHOR]

The article discusses a study on the ability and practicability of 3DA to determine the optimal perpendicular valve projection for accurate positioning and deployment of valve prosthesis in transcatheter aortic valve replacement (TAVR) and compared the method with multidetector computed tomography (MDCT). Patient had MDC during the week before and 3DA at the start of TAVR. It suggests that the role of MDCT for patient selection, planning and conducting TAVR is well established.

The article presents case reports on spontaneous coronary dissection (SCAD) and concomitant fibromuscular dysplasia (FMD). The first case involved a 35-year-old African female with no cardiovascular (CV) risk factors with persistent chest pain while doing aerobic exercises. The second involved a 48-year-old female with chest pain after running 10 kilometers (km). Another case involved a white female with chest pain a day after skiing.

Background: The torn hamstring is a common athletic injury. The purpose of the present study was to review the clinical presentation of this injury, the diagnostic imaging findings, the surgical technique of reattachment, and the likely clinical outcome of surgery for the treatment of avulsion of the proximal hamstring origin.Methods: Seventy-two consecutive reconstructions in seventy-one patients with avulsion of the proximal hamstring origin were performed at a single center. The mean age at the time of the operation was 40.2 years. The mean duration of follow-up was twenty-four months, and all patients with a minimum duration of follow-up of six months were included. There were no exclusions. Patients were independently reviewed, and the mean postoperative isotonic hamstring strength was compared with that on the uninjured side.Results: Waterskiing was the most frequent cause of injury (twenty-one cases). The mean time between the injury and the operation was twelve months. The most common pathological finding was a complete avulsion of the proximal hamstring origin (sixty-three cases; 87.5%), with a mean retraction of 7 cm (range, 0 to 20 cm). The mean postoperative isotonic hamstring strength measured 84% (range, 43% to 122%) and the mean postoperative hamstring endurance measured 89% (range, 26% to 161%) when compared with the values on the contralateral side.Conclusions: It is important to distinguish proximal hamstring origin avulsions (for which we recommend early surgical repair) from the majority of hamstring muscle injuries (which respond well to nonoperative treatment). The present study suggests that, in cases of complete avulsion with hamstring retraction, a delay in surgical repair renders the repair more technically challenging, may increase the likelihood of sciatic nerve involvement, increases the need for postoperative bracing, and reduces postoperative outcome in terms of hamstring strength and endurance. Once the nature of the injury has been established, the surgical treatment of hamstring origin avulsions has predictable and satisfactory results. [ABSTRACT FROM AUTHOR]

Background: The torn hamstring is a common athletic injury. The purpose of the present study was to review the clinical presentation of this injury, the diagnostic imaging findings, the surgical technique of reattachment, and the likely clinical outcome of surgery for the treatment of avulsion of the proximal hamstring origin. Methods: Seventy-two consecutive reconstructions in seventy-one patients with avulsion of the proximal hamstring origin were performed at a single center. The mean age at the time of the operation was 40.2 years. The mean duration of follow-up was twenty-four months, and all patients with a minimum duration of follow-up of six months were included. There were no exclusions. Patients were independently reviewed, and the mean postoperative isotonic hamstring strength was compared with that on the uninjured side. Results: Waterskiing was the most frequent cause of injury (twenty-one cases). The mean time between the injury and the operation was twelve months. The most common pathological finding was a complete avulsion of the proximal hamstring origin (sixty-three cases; 87.5%), with a mean retraction of 7 cm (range, 0 to 20 cm). The mean postoperative isotonic hamstring strength measured 84% (range, 43% to 122%) and the mean postoperative hamstring endurance measured 89% (range, 26% to 161%) when compared with the values on the contralateral side. Conclusions: It is important to distinguish proximal hamstring origin avulsions (for which we recommend early surgical repair) from the majority of hamstring muscle injuries (which respond well to nonoperative treatment). The present study suggests that, in cases of complete avulsion with hamstring retraction, a delay in surgical repair renders the repair more technically challenging, may increase the likelihood of sciatic nerve involvement, increases the need for postoperative bracing, and reduces postoperative outcome in terms of hamstring strength and endurance. Once the nature of the injury has been established, the surgical treatment of hamstring origin avulsions has predictable and satisfactory results. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The academic health department, also referred to as the teaching health department, is receiving increased attention as an organizational structure to enhance public health workforce development. Traditionally, academic institutions have been viewed by major funders, and reported in the literature, to be the innovators of these partnerships, in part to extend the academic institution's education role in the workplace. However, the role of the local health department as innovator is emerging with implications beyond workforce development. This report illustrates how a local agency-initiated community-centered approach to an academic health department enhances the core public health function of assessment, a frequently underdeveloped function at the local level. This agency-initiated, community-centered academic health department model builds assessment capacity through a partnership that integrates academic research and public health surveillance capacity to provide comprehensive assessment, including community assessment, community-based participatory research, data analysis, and program evaluation. This organizational structure, focused on systems approaches to building community capacity rather than focusing on disease categories or high-risk populations, illustrates how a local health department can substantially enhance its assessment capacity using available resources. [ABSTRACT FROM AUTHOR]

Farmers in British Columbia (BC), Canada have been shown to have unexplained elevated proportional mortality rates for several cancers. Because agricultural exposures have never been documented systematically in BC, a quantitative agricultural Job-exposure matrix (JEM) was developed containing exposure assessments from 1950 to 1998. This JEM was developed to document historical exposures and to facilitate future epidemiological studies. Available information regarding BC farming practices was compiled and checklists of potential exposures were produced for each crop. Exposures identified included chemical, biological, and physical agents. Interviews with farmers and agricultural experts were conducted using the checklists as a starting point. This allowed the creation of an initial or 'potential' JEM based on three axes: exposure agent, 'type of work' and time. The 'type of work' axis was determined by combining several variables: region, crop, job title and task. This allowed for a complete description of exposures. Exposure assessments were made quantitatively, where data allowed, or by a dichotomous variable (exposed/unexposed). Quantitative calculations were divided into re-entry and application scenarios. 'Re-entry' exposures were quantified using a standard exposure model with some modification while application exposure estimates were derived using data from the North American Pesticide Handlers Exposure Database (PHED). As expected, exposures differed between crops and job titles both quantitatively and qualitatively. Of the 290 agents included in the exposure axis; 180 were pesticides. Over 3000 estimates of exposure were conducted; 50% of these were quantitative. Each quantitative estimate was at the daily absorbed dose level. Exposure estimates were then rated as high, medium, or low based on comparing them with their respective oral chemical reference dose (RfD) or Acceptable Daily Intake (ADI). This data was mainly obtained from the US... [ABSTRACT FROM AUTHOR]

Background: The management of the patella in total knee arthroplasty is still problematic. We aimed to identify differences in the clinical outcome of total knee arthroplasty according to whether or not patellar resurfacing had been performed in a prospective, randomized study of 220 osteoarthritic knees. Methods: Two hundred and twenty total knee arthroplasties in 201 patients were randomly assigned to be per-formed with either resurfacing or retention of the patella, and the results were followed for a mean of forty-eight months (range, thirty-six to seventy-nine months) in a double-blind (both patient and clinical evaluator blinded), prospective study. Evaluation was performed annually by an independent observer and consisted of assess-ment with the Knee Society clinical rating system, specific evaluation of anterior knee pain, a stair-climbing test, and radiographic examination. Results: Fifteen (12%) of the 128 knees without patellar resurfacing and nine (10%) of the ninety-two knees with patellar resurfacing underwent a revision or another type of reoperation related to the patellofemoral artic-ulation. This difference was not significant (chi square with one degree of freedom = 0.206, p = 0.650). At the time of the latest follow-up, there was a significantly higher incidence of anterior pain (chi square with one de-gree of freedom = 5.757, p = 0.016) in the knees that had not had patellar resurfacing. Conclusions: Patients who underwent patellar resurfacing had superior clinical results in terms of anterior knee pain and stair descent. However, anterior knee pain still occurred in patients with patellar resurfacing, and nine (10%) of the ninety-two patients in that group underwent a revision or another type of reoperation involving the patellofemoral joint. Weight but not body mass index was associated with the development of anterior knee pain in the patients without patellar resurfacing, a finding that suggests that patellofemoral dysfunct [ABSTRACT FROM AUTHOR]