There are challenges in studying and monitoring Alzheimer’s disease (AD) in large patient populations. Clinicians often have insufficient availability of resources to make the diagnosis (e.g. brain scanning, referral to specialists) and clinical inertia may be tied to the perception that there are no clinical benefits in making the differential diagnosis of this stigmatized disease. Consequently, diagnosis codes specifically for AD are underutilized and prevalence is generally underestimated. Our goal was to improve identification of probable AD in a large patient population with the development and application of a refined search algorithm of computerized clinical notes contained in electronic health records. Our methods were developed using records for all Veteran patients in the national Department of Veterans Affairs Healthcare System (VA) in fiscal years 2010-2019. Starting with initial searches for “Alzheimer” and related terms in all clinical notes, the algorithm was optimized through an iterative process. Multiple references to “Alz” in notes were evaluated separately and chunks were excluded when the term referred to family history, care facilities, or negative statements, or when it was part of text in assessment instruments or medication indications. The final algorithm was validated through manual reviews of over 2,400 randomly selected patient charts (predictive value positive = 86.3%; kappa = 0.76 among 2-4 reviewers). When the algorithm was applied to records for the nearly 5 million VA patients over 50 years of age in fiscal year (FY) 2019, we identified 141,816 with probable AD, nearly five times the count based on ICD-10 codes (30,090). Prevalence, standardized to the 2010 census for age and sex, was 2.70%, with higher prevalence in women (3.26%) than in men (2.06%). Median age of probable AD patients was 75 years. As disease modifying treatments for AD enter the market, there will be more focus on proper diagnosis of AD, particularly early in the disease process, emphasizing the importance of better identification of the disease in patient populations. This method, based on searches of clinical notes, appears to be promising to identify patients with probable AD and study its progression in large patient populations.

Background and objectivesLess than 10 percent of the more than one million people vulnerable to HIV are using pre-exposure prophylaxis (PrEP). Practitioners are critical to ensuring the delivery of PrEP across care settings. In this study, we target a group of prescribers focused on providing HIV care and seeking up-to-date information about HIV. We assessed their experiences prescribing PrEP, whether these experiences differed by clinical specialty, and examined associations between willingness to prescribe PrEP as a "best first step" and different hypothetical prescribing scenarios.Setting and methodsBetween March and May 2015, we circulated a paper survey to 954 participants ((652 of whom met our inclusion criteria of being independent prescribers and 519 of those (80%) responded to the survey)) at continuing medical education advanced-level HIV courses in five locations across the US on practitioner practices and preferences of PrEP. We employed multivariable logistic regression analysis for binary and collapsed ordinal outcomes.ResultsAmong this highly motivated group of practitioners, only 54% reported ever prescribing PrEP. Internal medicine practitioners were 1.6 times more likely than infectious disease practitioners to have prescribed PrEP (95% CI: 0.99-2.60, p = .0524) and age, years of training, and sex were significantly associated with prescribing experience. Based on clinical vignettes describing different hypothetical prescribing scenarios, practitioners who viewed PrEP as the first clinical step for persons who inject drugs (PWID) were twice as likely to have also considered PrEP as the first clinical option for safer conception, and vice-a-versa (95% CI: 1.4-3.2, p < .001). Practitioners considering PrEP as the first preventive option for MSM were nearly six times as likely to also consider PrEP as the first clinical step for PWID, and vice-a-versa (95% CI: 2.28-13.56, p = .0002).ConclusionsOur findings indicate that even among a subset of HIV-focused practitioners, PrEP prescribing is not routine. This group of practitioners could be an optimal group to engage individuals that could most benefit from PrEP.

Dense breast tissue is a common finding that decreases the sensitivity of mammography in detecting cancer. Many states have recently enacted dense breast notification (DBN) laws to provide patients with information to help them make better-informed decisions about their health. To test whether DBN legislation affected the probability of screening mammography follow-up by ultrasound and magnetic resonance imaging (MRI), we examined the proportion of times screening mammography was followed by ultrasound or MRI for a series of months pre- and post-legislation. The subjects were women aged 40 to 64 years, covered by private health insurance, undergoing screening mammography from 2007 to 2014. Except for Hawaii, Maryland, and New York, DBN legislation significantly increased the probability of ultrasound follow-up in all states that implemented DBN legislation before December 2014. It also increased the probability of MRI follow-up in California, North Carolina, Pennsylvania, and Texas. The financial and access consequences merit further study.

Background: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies. Objective: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound. Research Design: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws. Subjects: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40–64 years that resided in a state that had implemented relevant legislation during that period. Measures: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators. Results: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect. Conclusions: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Objective: The aim of this study was to investigate the value of coformulated Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) for conception in the U.S. and to identify scenarios in which ‘Undetectable = Untransmittable’ (U = U) may not be adequate, and rather, PrEP or assisted reproduction would improve outcomes. Design: We developed a Markov cohort simulation model to estimate the incremental benefits and cost-effectiveness of PrEP compared with alternative safer conception strategies, including combination antiretroviral therapy (cART) alone for the HIV-infected partner and assisted reproductive technologies. We modelled various scenarios in which HIV RNA suppression in the male partner was less than perfect. Setting: U.S. healthcare sector perspective. Participants: Serodiscordant couples in the U.S. was composed of an HIV-infected male and HIV-uninfected female seeking conception. Intervention: Economic analysis. Main outcome measure(s): Cumulative risks of HIV transmission to women and babies, maternal life expectancy, discounted quality-adjusted life years (QALY), discounted lifetime medical costs and incremental cost-effectiveness ratios. Results: cART with condomless intercourse limited to ovulation was the preferred HIV prevention strategy among women seeking to conceive with an HIV-infected partner who is HIV-suppressed. PrEP was not cost-effective for women who had partners who were virologically suppressed. When the probability of male partner HIV suppression was low and we assumed generic pricing of PrEP, PrEP was cost-effective, and sometimes even cost-saving compared with cART alone. Conclusion: From a U.S. healthcare sector perspective, when the male partner was not reliably suppressed, PrEP became economically attractive, and in some cases, cost-saving.

Objective: To understand the barriers that serodiscordant couples with human immunodeficiency virus (HIV) face in accessing services for risk reduction and infertility using assisted reproductive technology (ART). Design: Two-arm cross-sectional telephone "secret shopper" study. Setting: Infertility clinics designated by the Society for Assisted Reproductive Technology (SART), 140 from 15 American states with the highest prevalence of heterosexual HIV-infected men. Patient(s): Clinical and nonclinical staff at SART-registered clinics. Intervention(s): Standardized telephone calls to SART-registered clinics by investigators in the roles of physician and patient callers. Main Outcome Measure(s): Availability and difference in services offered to callers and the rate of referral if the clinic did not provide these services. Result(s): Of the 140 sampled SART clinics across 15 states, callers in both patient and physician roles spoke to a staff member at greater than 90% of targeted clinics (127 clinics total). Of the physician callers 63% were told that the clinic could offer services, as compared to 40% of patient callers. Of the 55 clinics that were unable to provide services to the patient caller, 51% referred to other clinics with confidence that they could offer these services; 67% of clinics would provide services for both prevention and infertility purposes. Conclusion(s): Risk reduction services for HIV were more available at the sampled fertility clinics than previously reported in the literature. However, the responses depended on the person calling. The clinics demonstrated low rates of concordance with the American Society for Reproductive Medicine's guidelines, which endorse referral of patients to other facilities from sites unable to offer services. (C) 2017 by American Society for Reproductive Medicine.

Background:Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies.Objective:To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound.Research Design:This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws.Subjects:A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40-64 years that resided in a state that had implemented relevant legislation during that period.Measures:The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators.Results:Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect.Conclusions:The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Background: To examine whether inappropriate antibiotic treatment for an initial bout of acute bronchitis in childhood affects patterns of future healthcare utilization and antibiotic prescribing. Methods: We conducted a retrospective analysis of children with at least 1 acute bronchitis episode, defined as the 14-day period after an acute bronchitis visit, born in 2008 and followed through 2015 in a nationally representative commercial claims database. We predicted the likelihood of returning for a subsequent acute bronchitis episode, and being prescribed an antibiotic as part of that episode, as a function of whether or not the child was prescribed an antibiotic as part of the first acute bronchitis episode controlling for patient, provider and practice characteristics. Results: Children prescribed an antibiotic as part of their initial acute bronchitis episode were more likely both to have a subsequent acute bronchitis episode (hazard ratio = 1.23; 95% confidence interval: 1.17–1.30) and to be prescribed an antibiotic as part of that second episode (hazard ratio = 2.13; 95% confidence interval: 1.99–2.28) compared with children who were not prescribed as part of their first episode. Children diagnosed with asthma were more likely to experience a second visit for acute bronchitis, but less likely to receive an antibiotic as part of that second episode. Conclusions: Inappropriate antibiotic prescribing for a child’s initial acute bronchitis episode of care predicted likelihood of subsequent acute bronchitis episodes and antibiotic prescriptions. Providers should consider the downstream effect of inappropriate antibiotic prescribing for acute bronchitis in childhood.

Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.

Aim To examine the risks of all-cause mortality and cardiovascular events associated with adding vs switching to second-line therapies in a comparative safety study of people with Type 2 diabetes mellitus. Methods We conducted a retrospective cohort study using an as-treated analysis of people served by the Veterans Health Administration who were on metformin and subsequently augmented this treatment or switched to other oral glucose-lowering treatments between 1998 and 2012. This study included 145 250 people with long follow-up. Confounding was addressed through several strategies, involving weighted propensity score models with rich confounder adjustment and strict inclusion criteria, coupled with an incident-user design. Results Second-line use of sulfonylureas was related to higher mortality (hazard ratio 1.39, 95% CI 1.14, 1.70) and cardiovascular risks (hazard ratio 1.19, 95% CI 1.09, 1.30) compared with thiazolidinedione therapy. Differential hazards were associated with discontinuing or not discontinuing metformin; switching to sulfonylurea therapy was associated with a higher risk of all-cause mortality and cardiovascular events compared with all other therapies. Furthermore, add-on sulfonylurea therapy was associated with an elevated risk for both outcomes when compared with thiazolidinedione add-on therapy. Conclusions The results of the present study may inform decisions on whether to augment or discontinue metformin; when considering the long-term risks, switching to a sulfonylurea appears unfavourable compared with other therapies. Instead, adding a thiazolidinedione to existing metformin therapy appears to be superior to adding or switching to a sulfonylurea.

ObjectiveTo understand the barriers that HIV serodiscordant couples face in accessing risk reductive Assisted Reproductive Technology (ART) and infertility care.Design“Secret shopper” methodology whereby investigators posed as patient and physicians in standardized, scripted phone calls to a sample of Society for Assisted Reproductive Technology (SART) registered fertility clinics.Materials and MethodsJanuary to March 2016, a “patient” posing as an HIV-negative woman with an HIV-positive male partner and “physician” inquiring on behalf of his/her same patient population conducted scripted phone calls to a sample of 140 fertility clinics. We sampled 15 states with the highest HIV prevalence in the U.S. Call scripts consisted of domains covering access, experience, services offered, and referral patterns. The main outcomes included availability of services to the “patient” caller, a comparison between services offered to “patient” and “physician” callers, and rates of referral. We present the proportion of clinics that offered risk reductive services, and we used McNemar’s test for marginal homogeneity to test discordance between responses. We report services offered at clinics that provided risk reductive services and options provided to patients when clinics did not offer such services.ResultsOf the 140 sampled SART clinics across 15 states, both patient and physician callers reached greater than 90% of targeted clinics. 63% of physician callers were told that the clinic could offer services, as compared to only 40% of patient callers (p<.0001). Of the 55 clinics that denied services to the patient caller, 51% referred to other clinics that offered services, 18% referred but were uncertain whether the clinics offered services, and 31% could not refer to another facility. Of clinics that offered services to the physician caller, 74% offered sperm washing with banking, 81% offered IUI, 96% offered IVF, and 94% offered ICSI. Based on physician inquiries, 67% of clinics would provide services to couples for both prevention and infertility purposes. Of clinics that would provide services for both indications, 19% offered PrEP.ConclusionsThis study provides evidence that risk reductive services are more available than the literature cites; however, there is heterogeneity in responses with answers dependent on the person calling. Clinics also lack compliance with ASRM’s guidelines of referring patients to other facilities. Serodiscordant couples should have access to ART either for the purpose of risk aversion or for supported fertility. Efforts to expand the availability of services and ensure a more uniform experience when seeking care could improve HIV and pregnancy outcomes for women and their children.Reference:1.Medicine Ethics Committee of the American Society for Reproductive. 2015. “Human Immunodeficiency Virus (HIV) and Infertility Treatment: A Committee Opinion.” Fertility and Sterility 104 (1): e1-8. http://dx.doi.org/10.1016/j.fertnstert.2015.04.004. ObjectiveTo understand the barriers that HIV serodiscordant couples face in accessing risk reductive Assisted Reproductive Technology (ART) and infertility care. To understand the barriers that HIV serodiscordant couples face in accessing risk reductive Assisted Reproductive Technology (ART) and infertility care. Design“Secret shopper” methodology whereby investigators posed as patient and physicians in standardized, scripted phone calls to a sample of Society for Assisted Reproductive Technology (SART) registered fertility clinics. “Secret shopper” methodology whereby investigators posed as patient and physicians in standardized, scripted phone calls to a sample of Society for Assisted Reproductive Technology (SART) registered fertility clinics. Materials and MethodsJanuary to March 2016, a “patient” posing as an HIV-negative woman with an HIV-positive male partner and “physician” inquiring on behalf of his/her same patient population conducted scripted phone calls to a sample of 140 fertility clinics. We sampled 15 states with the highest HIV prevalence in the U.S. Call scripts consisted of domains covering access, experience, services offered, and referral patterns. The main outcomes included availability of services to the “patient” caller, a comparison between services offered to “patient” and “physician” callers, and rates of referral. We present the proportion of clinics that offered risk reductive services, and we used McNemar’s test for marginal homogeneity to test discordance between responses. We report services offered at clinics that provided risk reductive services and options provided to patients when clinics did not offer such services. January to March 2016, a “patient” posing as an HIV-negative woman with an HIV-positive male partner and “physician” inquiring on behalf of his/her same patient population conducted scripted phone calls to a sample of 140 fertility clinics. We sampled 15 states with the highest HIV prevalence in the U.S. Call scripts consisted of domains covering access, experience, services offered, and referral patterns. The main outcomes included availability of services to the “patient” caller, a comparison between services offered to “patient” and “physician” callers, and rates of referral. We present the proportion of clinics that offered risk reductive services, and we used McNemar’s test for marginal homogeneity to test discordance between responses. We report services offered at clinics that provided risk reductive services and options provided to patients when clinics did not offer such services. ResultsOf the 140 sampled SART clinics across 15 states, both patient and physician callers reached greater than 90% of targeted clinics. 63% of physician callers were told that the clinic could offer services, as compared to only 40% of patient callers (p<.0001). Of the 55 clinics that denied services to the patient caller, 51% referred to other clinics that offered services, 18% referred but were uncertain whether the clinics offered services, and 31% could not refer to another facility. Of clinics that offered services to the physician caller, 74% offered sperm washing with banking, 81% offered IUI, 96% offered IVF, and 94% offered ICSI. Based on physician inquiries, 67% of clinics would provide services to couples for both prevention and infertility purposes. Of clinics that would provide services for both indications, 19% offered PrEP. Of the 140 sampled SART clinics across 15 states, both patient and physician callers reached greater than 90% of targeted clinics. 63% of physician callers were told that the clinic could offer services, as compared to only 40% of patient callers (p<.0001). Of the 55 clinics that denied services to the patient caller, 51% referred to other clinics that offered services, 18% referred but were uncertain whether the clinics offered services, and 31% could not refer to another facility. Of clinics that offered services to the physician caller, 74% offered sperm washing with banking, 81% offered IUI, 96% offered IVF, and 94% offered ICSI. Based on physician inquiries, 67% of clinics would provide services to couples for both prevention and infertility purposes. Of clinics that would provide services for both indications, 19% offered PrEP. ConclusionsThis study provides evidence that risk reductive services are more available than the literature cites; however, there is heterogeneity in responses with answers dependent on the person calling. Clinics also lack compliance with ASRM’s guidelines of referring patients to other facilities. Serodiscordant couples should have access to ART either for the purpose of risk aversion or for supported fertility. Efforts to expand the availability of services and ensure a more uniform experience when seeking care could improve HIV and pregnancy outcomes for women and their children.Reference:1.Medicine Ethics Committee of the American Society for Reproductive. 2015. “Human Immunodeficiency Virus (HIV) and Infertility Treatment: A Committee Opinion.” Fertility and Sterility 104 (1): e1-8. http://dx.doi.org/10.1016/j.fertnstert.2015.04.004. This study provides evidence that risk reductive services are more available than the literature cites; however, there is heterogeneity in responses with answers dependent on the person calling. Clinics also lack compliance with ASRM’s guidelines of referring patients to other facilities. Serodiscordant couples should have access to ART either for the purpose of risk aversion or for supported fertility. Efforts to expand the availability of services and ensure a more uniform experience when seeking care could improve HIV and pregnancy outcomes for women and their children.

Background. Hepatitis C (HCV) is the most common chronic blood-borne infection in the United States and affects Asian and non-Asian Americans comparably. Injection drug use, the most common national transmission risk, is not as prevalent in Asian-Americans, but prior studies do not include many Cambodian Americans. Lowell, Massachusetts has the second largest population of Cambodian Americans, allowing a direct comparison of HCV-infected Cambodian and non-Cambodian Americans not previously done. Improving our understanding of HCV risks in this unique community may improve their linkage to care. Methods. In this cross-sectional study, medical data were collected regarding HCV risk factors for HCV-infected Cambodian and non-Cambodian Americans seen at Lowell Community Health Center from 2009 to 2012. Results. Cambodian Americans (n = 128) were older (mean age 53 vs 43 years old) and less likely to be male (41% vs 67%, P < .001) compared with non-Cambodians (n = 541). Cambodians had lower rates of injection drug use (1.6% vs 33.6%, P < .001) and any drug use (2.3% vs 82.1%, P < .001). More Cambodians were born between 1945 and 1965 (66.4% vs 44.5%). Within this birth cohort, more Cambodians had no other risk factor (82% vs 69%, P = .02). Fewer Cambodians had chronic HCV (53% vs 74%, P < .001). Conclusions. Birth between 1945 and 1965 was the major HCV risk factor for Cambodian Americans. Cambodians had lower rates of injection drug use or any drug use history. Risk behavior screening fails to describe HCV transmission for Cambodian Americans and creates a barrier to their linkage to care.

With the aging of the population, it is expected that greater demand will be placed on home and community services providers to meet the growing need for long-term services and supports.We analyzed data from the 2002 to 2010 Medicare Current Beneficiary Survey.We identified community-dwelling elderly reporting difficulty with instrumental and basic activities of daily living.Estimates were weighted

Objective To examine inappropriate antibiotic prescribing for acute respiratory tract infections (RTIs) in ambulatory care to help target antimicrobial stewardship interventions. Design and Setting Retrospective analysis of RTI visits within general internal medicine (GIM) and family medicine (FM) ambulatory practices at an inner-city academic medical center from 2008 to 2010. Methods Patient, physician, and practice characteristics were analyzed using multivariable logistic regression to determine factors predictive of inappropriate prescribing; physicians in the highest and lowest antibiotic-prescribing quartiles were compared using χ 2 analysis. Results Visits with FM providers, female gender, and self-reported race/ethnicity as white or Hispanic were significantly associated with inappropriate antibiotic prescribing. Physicians in the lowest quartile prescribed antibiotics for 5%–28% (mean, 21%) of RTI visits; physicians in the highest quartile prescribed antibiotics for 54%–85% (mean, 65%) of RTI visits. High prescribers had fewer African-American patients and more patients who were younger and privately insured. High prescribers had more patients with chronic lung disease. A GIM practice pod with a low prescriber was 3.0 times more likely to have a second low prescriber than other practice pods, whereas pods with a high prescriber were 1.3 times more likely to have a second high prescriber. Conclusions Medical specialty was the only physician factor predictive of inappropriate prescribing when patient gender, race, and comorbidities were taken into account. Possible disparities in care need further study. Stewardship education in medical school, enlisting low prescribers as physician leaders, and targeting interventions to the highest prescribers might be more effective approaches to antimicrobial stewardship. Infect Control Hosp Epidemiol 2014;00(0): 1–7

BACKGROUND There is a paucity of randomized clinical trial data on the use of red blood cell (RBC) transfusion in critically ill patients, specifically in the setting of cardiac disease.OBJECTIVES This study examined how hemoglobin (Hgb) level and cardiac disease modify the relationship of RBC transfusion with hospital mortality. The aim was to estimate the Hgb level threshold below which transfusion would be associated with reduced hospital mortality.METHODS We performed secondary data analyses of Veterans Affairs intensive care unit (ICU) episodes across 5 years. Logistic regression quantified the effect of transfusion on hospital mortality while adjusting for nadir Hgb level, demographic characteristics, admission information, comorbid conditions, and ICU admission diagnoses.RESULTS Among 258,826 ICU episodes, 12.4% involved transfusions. Hospital death occurred in 11.6%. Without comorbid heart disease, transfusion was associated with decreased adjusted hospital mortality when Hgb was approximately < 7.7 g/dl, but transfusion increased mortality above this Hgb level. Corresponding Hgb level thresholds were approximately 8.7 g/dl when comorbid heart disease was present and approximately 10 g/dl when the ICU admission diagnosis was acute myocardial infarction (AMI). Sensitivity analysis using additional adjustment for selected blood tests in a subgroup of 182,792 ICU episodes lowered these thresholds by approximately 1 g/dl.CONCLUSIONS Transfusion of critically ill patients was associated with reduced hospital mortality when Hgb level was < 8 to 9 g/dl in the presence of comorbid heart disease. This Hgb level threshold for transfusion was 9 to 10 g/dl when AMI was the ICU admission diagnosis. (C) 2015 by the American College of Cardiology Foundation.

Objective The aims of this study were to support the standard clinical assumption that preferential right-sided injection (RSI) over left-sided injection (LSI) results in improved head and neck computed tomography angiograms and to determine which patients most benefit from RSIs. Methods Head and neck computed tomography angiograms of 453 RSIs and 419 LSIs were included. Interactions between injection side, age, weight, body mass index, and left ventricular ejection fraction with mean vessel Hounsfield units (HU) were compared. Statistical analysis was performed using 2-tailed Student t tests, Mann-Whitney U tests, and simple linear (SL) and multiple linear regressions. Results Right-sided injection yielded higher HU for patients older than 40 years (eg, RSI of the right common carotid artery [RCCA] vs LSI of the RCCA; P < 0.01). Body mass index (eg, RCCA; r = −0.31, P < 0.01 [SL]) and weight (eg, RCCA; r = −0.39, P < 0.01 [SL]) were negatively correlated with HU. Female had higher HU (mean ± SE, +39.7 ± 7.6 HU; P < 0.01 [multiple linear]). Left ventricular ejection fraction had no interactions with injection side or HU. Conclusions The findings support preferential RSI in patients older than 40 years with higher body mass index and weight, particularly male.

OBJECTIVES:To investigate the location-specific tissue properties and age-related changes of the facial fat and facial muscles using quantitative MRI (qMRI) analysis of longitudinal magnetization (T1) and transverse magnetization (T2) values.METHODS:38 subjects (20 males and 18 females, 0.5-87 years old) were imaged with a mixed turbo-spin echo sequence at 1.5 T. T1 and T2 measurements were obtained within regions of interest in six facial fat regions including the buccal fat and subcutaneous cheek fat, four eyelid fat regions (lateral upper, medial upper, lateral lower and medial lower) and five facial muscles including the orbicularis oculi, orbicularis oris, buccinator, zygomaticus major and masseter muscles bilaterally.RESULTS:Within the zygomaticus major muscle, age-associated T1 decreases in females and T1 increases in males were observed in later life with an increase in T2 values with age. The orbicularis oculi muscles showed lower T1 and higher T2 values compared to the masseter, orbicularis oris and buccinator muscles, which demonstrated small age-related changes. The dramatic age-related changes were also observed in the eyelid fat regions, particularly within the lower eyelid fat; negative correlations with age in T1 values (p<0.0001 for age) and prominent positive correlation in T2 values in male subjects (p<0.0001 for male×age). Age-related changes were not observed in T2 values within the subcutaneous cheek fat.CONCLUSIONS:This study demonstrates proof of concept using T1 and T2 values to assess age-related changes of the facial soft tissues, demonstrating tissue-specific qMRI measurements and non-uniform ageing patterns within different regions of facial soft tissues.