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Rationale and Design of the SAFE-PAD Study.
Secemsky EA, Raja A, Shen C, Valsdottir LR, ... Yeh RW, SAFE-PAD Investigators
Recent evidence from randomized controlled trials has raised concerns about the long-term safety of paclitaxel-coated peripheral devices used for femoropopliteal artery revascularization. In response to a call for more real-world data on the safety of these devices, the SAFE-PAD study (Safety Assessment of Femoropopliteal Endovascular treatment with Paclitaxel-coated Devices) was designed with input from the Food and Drug Administration to provide a long-term, comprehensive evaluation of the mortality risk associated with paclitaxel-coated devices among Medicare beneficiaries. Methods and Results SAFE-PAD is an observational cohort study of fee-for-service Medicare beneficiaries that underwent femoropopliteal artery revascularization with either a drug-coated device or nondrug-coated device from 2015 through 2018. All patients age 66 years or older who underwent revascularization will be identified using a combination ofprocedural codes, Current Procedural Terminology codes, and Healthcare Common Procedure Coding System C-codes. The safety end point of all-cause death will be updated semiannually and continued until the median duration of follow-up surpasses 5 years. Sub-group analyses will be conducted by device type, patient characteristics, and procedural setting. Registration: The SAFE-PAD study has been registered on URL: https://www.clinicaltrials.gov; Unique identifier: NCT04496544.
The SAFE-PAD study will evaluate the long-term safety of drug-coated devices compared with nondrug-coated devices for femoropopliteal artery revascularization among a broad, real-world population of patients with peripheral artery disease.
Circ Cardiovasc Qual Outcomes: 12 Jan 2021:CIRCOUTCOMES120007040; epub ahead of print
Circ Cardiovasc Qual Outcomes: 12 Jan 2021:CIRCOUTCOMES120007040; epub ahead of print | PMID: 33435732
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Comparability of Event Adjudication Versus Administrative Billing Claims for Outcome Ascertainment in the DAPT Study: Findings From the EXTEND-DAPT Study.
Faridi KF, Tamez H, Butala NM, Song Y, ... Strom JB, Yeh RW
Data from administrative claims may provide an efficient alternative for end point ascertainment in clinical trials. However, it is uncertain how well claims data compare to adjudication by a clinical events committee in trials of patients with cardiovascular disease. Methods We matched 1336 patients ≥65 years old who received percutaneous coronary intervention in the DAPT (Dual Antiplatelet Therapy) Study with the National Cardiovascular Data Registry CathPCI Registry linked to Medicare claims as part of the EXTEND (Extending Trial-Based Evaluations of Medical Therapies Using Novel Sources of Data) Study. Adjudicated trial end points were compared with Medicare claims data withcodes from inpatient hospitalizations using time-to-event analyses, sensitivity, specificity, positive predictive value, negative predictive value, and kappa statistics. Results At 21-month follow-up, the cumulative incidence of major adverse cardiovascular and cerebrovascular events (combined mortality, myocardial infarction, and stroke) was similar between trial-adjudicated events and claims data (7.9% versus 7.2%, respectively; =0.50). Bleeding rates were lower using adjudicated events compared with claims (5.0% versus 8.6%, respectively; <0.001). The sensitivity and positive predictive value of comprehensive billing codes for identifying adjudicated events were 65.6% and 85.7% for myocardial infarction, 61.5% and 47.1% for stroke, and 76.8% and 39.3% for bleeding, respectively. Specificity and negative predictive value for all outcomes ranged from 93.7% to 99.5%. All 39 adjudicated deaths were identified using Medicare data. Kappa statistics assessing agreement between events for myocardial infarction, stroke, and bleeding were 0.73, 0.52, and 0.49, respectively.
Claims data had moderate agreement with adjudication for myocardial infarction and poor agreement but high specificity for bleeding and stroke in the DAPT Study. Deaths were identified equivalently. Using claims data in clinical trials could be an efficient way to assess mortality among Medicare patients and may help detect other outcomes, although additional monitoring is likely needed to ensure accurate assessment of events.
Patient-Perceived Versus Actual Risk of Cardiovascular Disease and Associated Willingness to Consider and Use Prevention Therapy.
Navar AM, Wang TY, Li S, Mi X, ... Virani SS, Peterson ED
Cardiovascular prevention guidelines use estimated 10-year atherosclerotic cardiovascular disease (CVD) risk based on the pooled cohort equations to guide treatment decisions and engage patients in shared decision-making. We sought to determine patient perceived versus actual risk of atherosclerotic CVD and associations with willingness for preventive therapy.
We evaluated calculated and perceived CVD risk among 4187 patients across 124 sites in the Patient and Provider Assessment of Lipid Management Registry. Ten-year risk was assessed using the pooled cohort equations; risk relative-to-peers was determined based on age-, sex-, and race-based percentiles; and patient estimates of risk were assessed using patient surveys. Poisson regression models evaluated associations between risk estimates, statin use, and willingness to take prevention therapy.
Overall, there was no correlation between patients\' estimates of their 10-year CVD risk and calculated 10-year risk (ρ=-0.01, =0.46), regardless of age, sex, race, or socioeconomic status. The majority (72.2%) overestimated their 10-year CVD risk relative to the pooled cohorts equation (mean perceived 33.3% versus mean calculated 17.1%, <0.01). Patients\' perceptions of their risk relative-to-peers were slightly correlated with standardized risk percentiles (ρ=0.19, <0.01), although most had overly optimistic views of how risk compared with their peers. Increasing perceived risk was not associated with current statin use (=0.18) but was associated with willingness to consider future prevention therapy (<0.01). Perceived risk relative-to-peers was associated with increased prevalent statin use (risk ratio 1.04 per category increase [95% CI, 1.02-1.06]) and reported willingness for prevention therapy (risk ratio 1.11 [95% CI, 1.07-1.16]).
When asked, most patients overestimate their 10-year risk but hold an optimistic bias of their risk relative to age-, race-, and sex-matched peers. Providing accurate absolute risk assessments to patients without proper context may paradoxically decrease many patients\' perceived risk of CVD, thereby disincentivizing initiation of CVD risk reduction therapy.
Use of ACE (Angiotensin-Converting Enzyme) Inhibitors and Risk of Lung Cancer: A Nationwide Nested Case-Control Study.
Kristensen KB, Hicks B, Azoulay L, Pottegård A
Use of angiotensin-converting enzyme inhibitors (ACEIs) was associated with increased risk of lung cancer in a cohort study from the United Kingdom. We aimed to replicate these findings in a Danish population.
We conducted a nested case-control study using data from 4 Danish national health and administrative registries. New users of ACEIs or angiotensin II receptor blockers in Denmark from January 1, 2000 were followed until December 31, 2015, incident lung cancer, death, or emigration. Each lung cancer case was matched with up to 20 controls on age, sex, duration of follow-up, and year of cohort entry using risk-set sampling. Conditional logistic regression was used to estimate odds ratios (ORs) for incident, histologically verified lung cancer with high use of ACEIs defined as a cumulative dose above 3650 defined daily doses. We examined different cumulative doses of ACEI (≤1800, 1801-3650, >3650 defined daily doses), examined whether the association varied with lung cancer histology, and repeated the analyses using thiazides as active comparator.
We included 9652 lung cancer cases matched to 190 55 controls. High use of ACEIs was associated with lung cancer (adjusted OR, 1.33 [95% CI, 1.08-1.62]). Lower cumulative doses showed neutral associations (≤1800 defined daily doses OR, 1.01 [95% CI, 0.94-1.09]; 1801-3650 defined daily doses OR, 1.03 [95% CI, 0.90-1.19]). CIs were wide and included the null when stratifying on histology. Using thiazides as active comparator yielded comparable results (OR, 1.34 [95% CI, 0.96-1.88]).
Use of high cumulative ACEI doses was associated with modestly increased odds of lung cancer although use of lower doses showed neutral associations. The established benefits of ACEIs should be considered when interpreting these findings.
Perceived Versus Actual Risks of 30-Day Readmission in Patients With Cardiovascular Disease.
Xu H, Farmer HR, Granger BB, Thomas KL, Peterson ED, Dupre ME
Cardiovascular disease (CVD) is the leading cause of hospitalization in the United States, and patients with CVD are at a high risk of readmission after discharge. We examined whether patients\' perceived risk of readmission at discharge was associated with actual 30-day readmissions in patients hospitalized with CVD.
We recruited 730 patients from the Duke Heart Center who were admitted for treatment of CVD between January 1, 2015, and August 31, 2017. A standardized survey was linked with electronic health records to ascertain patients\' perceived risk of readmission, and other sociodemographic, psychosocial, behavioral, and clinical data before discharge. All-cause readmission within 30 days after discharge was examined.
Nearly 1-in-3 patients perceived a high risk of readmission at index admission and those who perceived a high risk had significantly more readmissions within 30 days than patients who perceived low risks of readmission (23.6% versus 15.8%, =0.016). Among those who perceived a high risk of readmission, non-White patients (odds ratio [OR], 2.07 [95% CI, 1.28-3.36]), those with poor self-rated health (OR, 2.30 [95% CI, 1.38-3.85]), difficulty accessing care (OR, 2.72 [95% CI, 1.24-6.00]), and prior hospitalizations in the past year (OR, 2.13 [95% CI, 1.21-3.74]) were more likely to be readmitted. Among those who perceived a low risk of readmission, patients who were widowed (OR, 2.69 [95% CI, 1.60-4.51]) and reported difficulty accessing care (OR, 1.89 [95% CI, 1.07-3.33]) were more likely to be readmitted.
Patients who perceived a high risk of readmission had a higher rate of 30-day readmission than patients who perceived a low risk. These findings have important implications for identifying CVD patients at a high risk of 30-day readmission and targeting the factors associated with perceived and actual risks of readmission.
The Cardiovascular Quality Improvement and Care Innovation Consortium: Inception of a Multicenter Collaborative to Improve Cardiovascular Care.
Bradley SM, Adusumalli S, Amin AP, Borden WB, ... Shreenivas S, Ho PM
Despite decades of improvement in the quality and outcomes of cardiovascular care, significant gaps remain. Existing quality improvement strategies are often limited in scope to specific clinical conditions and episodic care. Health services and outcomes research is essential to inform gaps in care but rarely results in the development and implementation of care delivery solutions. Although individual health systems are engaged in projects to improve the quality of care delivery, these efforts often lack a robust study design or implementation evaluation that can inform generalizability and further dissemination. Aligning the work of health care systems and health services and outcomes researchers could serve as a strategy to overcome persisting gaps in cardiovascular quality and outcomes. We describe the inception of the Cardiovascular Quality Improvement and Care Innovation Consortium that seeks to rapidly improve cardiovascular care by (1) developing, implementing, and evaluating multicenter quality improvement projects using innovative care designs; (2) serving as a resource for quality improvement and care innovation partners; and (3) establishing a presence within existing quality improvement and care innovation structures. Success of the collaborative will be defined by projects that result in changes to care delivery with demonstrable impacts on the quality and outcomes of care across multiple health systems. Furthermore, insights gained from implementation of these projects across sites in Cardiovascular Quality Improvement and Care Innovation Consortium will inform and promote broad dissemination for greater impact.
Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes.
Natsui S, Sun BC, Shen E, Redberg RF, ... Kawatkar AA, Sharp AL
Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians\' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events. Methods We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction. Results Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%).
Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.
Micro-Randomized Trial Design for Evaluating Just-In-Time-Adaptive-Interventions Through Mobile Health Technologies for Cardiovascular Disease.
Golbus JR, Dempsey W, Jackson EA, Nallamothu BK, Klasnja P
Smartphone and wearable device use is rising broadly and can be leveraged for chronic disease management. Just-In-Time Adaptive Interventions (JITAIs) promise to deliver personalized, dynamic interventions directly to patients through use of push notifications from mobile devices. While JITAIs are a powerful tool for shaping health behavior, their application to cardiovascular disease management has been limited as they can be challenging to design. Herein we provide a general overview and conceptual framework for micro-randomized trials, a novel experimental study design that can be used to optimize JITAIs. Micro-randomized trials leverage mobile devices to sequentially randomize participants to types or levels of an intervention to determine the effectiveness of an intervention and time-varying moderators of those effects. Micro-randomized trials are an efficient study design that can be used to determine which intervention components to include in JITAI and to optimize their decision rules while maintaining the strength of causal inference associated with traditional randomized controlled trials.
Circ Cardiovasc Qual Outcomes: 11 Jan 2021; epub ahead of print
Circ Cardiovasc Qual Outcomes: 11 Jan 2021; epub ahead of print | PMID: 33430608
Mendelian Randomization in Cardiovascular Research: Establishing Causality When There Are Unmeasured Confounders.
Bell KJL, Loy C, Cust AE, Teixeira-Pinto A
Mendelian randomization is an epidemiological approach to making causal inferences using observational data. It makes use of the natural randomization that occurs in the generation of an individual\'s genetic makeup in a way that is analogous to the study design of a randomized controlled trial and uses instrumental variable analysis where the genetic variant(s) are the instrument (analogous to random allocation to treatment group in an randomized controlled trial). As with any instrumental variable, there are 3 assumptions that must be made about the genetic instrument: (1) it is associated (not necessarily causally) with the exposure (relevance condition); (2) it is associated with the outcome only through the exposure (exclusion restriction condition); and (3) it does not share a common cause with the outcome (ie, no confounders of the genetic instrument and outcome, independence condition). Using the example of type II diabetes and coronary artery disease, we demonstrate how the method may be used to investigate causality and discuss potential benefits and pitfalls. We conclude that although Mendelian randomization studies can usually not establish causality on their own, they may usefully contribute to the evidence base and increase our certainty about the effectiveness (or otherwise) of interventions to reduce cardiovascular disease.
Economic Evaluation of Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure With Reduced Ejection Fraction.
Chew DS, Loring Z, Anand J, Fudim M, ... Mark DB, Piccini JP
Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes.
We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective.
Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations.
Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
Circ Cardiovasc Qual Outcomes: 06 Dec 2020:CIRCOUTCOMES120007094; epub ahead of print
Circ Cardiovasc Qual Outcomes: 06 Dec 2020:CIRCOUTCOMES120007094; epub ahead of print | PMID: 33280436
Examining Hospital Variation on Multiple Indicators of Stroke Quality of Care.
Austin PC, Fang J, Yu B, Kapral MK
Provider profiling involves comparing the performance of hospitals on indicators of quality of care. Typically, provider profiling examines the performance of hospitals on each quality indicator in isolation. Consequently, one cannot formally examine whether hospitals that have poor performance on one indicator also have poor performance on a second indicator.
We used Bayesian multivariate response random effects logistic regression model to simultaneously examine variation and covariation in multiple binary indicators across hospitals. We considered 7 binary patient-level indicators of quality of care for patients presenting to hospital with a diagnosis of acute stroke. We examined between-hospital variation in these 7 indicators across 86 hospitals in Ontario, Canada.
The number of patients eligible for each indicator ranged from 1321 to 14 079. There were 7 pairs of indicators for which there was a strong correlation between a hospital\'s performance on each of the 2 indicators. Twenty-nine of the 86 hospitals had a probability higher than 0.90 of having worse performance than average on at least 4 of the 7 indicators. Seven of the 86 of hospitals had a probability higher than 0.90 of having worse performance than average on at least 5 indicators. Fourteen of the 86 of hospitals had a probability higher than 0.50 of having worse performance than average on at least 6 indicators. No hospitals had a probability higher than 0.50 of having worse performance than average on all 7 indicators.
These findings suggest that there are a small number of hospitals that perform poorly on at least half of the quality indicators, and that certain indicators tend to cluster together. The described methods allow for targeting quality improvement initiatives at these hospitals.
Circ Cardiovasc Qual Outcomes: 29 Nov 2020; 13:e006968
Circ Cardiovasc Qual Outcomes: 29 Nov 2020; 13:e006968 | PMID: 33238729
Systemic Inflammatory Response Syndrome Is Associated With Increased Mortality Across the Spectrum of Shock Severity in Cardiac Intensive Care Patients.
Jentzer JC, Lawler PR, van Diepen S, Henry TD, ... Holmes DR, Kashani KB
The systemic inflammatory response syndrome (SIRS) frequently occurs in patients with cardiogenic shock and may aggravate shock severity and organ failure. We sought to determine the association of SIRS with illness severity and survival across the spectrum of shock severity in cardiac intensive care unit (CICU) patients.
We retrospectively analyzed 8995 unique patients admitted to the Mayo Clinic CICU between 2007 and 2015. Patients with ≥2/4 SIRS criteria based on admission laboratory and vital sign data were considered to have SIRS. Patients were stratified by the 2019 Society for Cardiovascular Angiography and Interventions (SCAI) shock stages using admission data. The association between SIRS and mortality was evaluated across SCAI shock stage using logistic regression and Cox proportional-hazards models for hospital and 1-year mortality, respectively.
The study population had a mean age of 67.5±15.2 years, including 37.2% women. SIRS was present in 33.9% of patients upon CICU admission and was more prevalent in advanced SCAI shock stages. Patients with SIRS had higher illness severity, worse shock, and more organ failure, with an increased risk of mortality during hospitalization (16.8% versus 3.8%; adjusted odds ratio, 2.1 [95% CI, 1.7-2.5]; <0.001) and at 1 year (adjusted hazard ratio, 1.4 [95% CI, 1.3-1.6]; <0.001). After multivariable adjustment, SIRS was associated with higher hospital and 1-year mortality among patients in SCAI shock stages A through D (all <0.01) but not SCAI shock stage E.
One-third of CICU patients meet clinical criteria for SIRS at the time of admission, and these patients have higher illness severity and worse outcomes across the spectrum of SCAI shock stages. The presence of SIRS identified CICU patients at increased risk of short-term and long-term mortality. Further study is needed to determine whether systemic inflammation truly drives SIRS in this population and whether patients with SIRS respond differently to supportive therapies for shock.
Site-Level Variability in 30-Day Patient Outcomes After Transcatheter Mitral Valve Repair in the United States.
Malik AO, Chhatriwalla AK, Saxon J, Hejjaji V, ... Kosinski A, Spertus JA
Clinical trials have demonstrated health status benefit of transcatheter mitral valve repair (TMVr) with MitraClip in patients with mitral valve regurgitation. Real-world site-level variability in health status outcomes for TMVr, and factors associated with this variability, are unknown.
All patients undergoing TMVr procedure with MitraClip between November 2013 and March 2019 in the Transcatheter Valve Therapy Registry were included. Health status was measured at baseline and 30 days with the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary (OS) score. Site-level variability in 30-day change in KCCQ-OS was examined by calculating the median odds ratio from a hierarchical logistic regression model, with ≥20-point improvement as the dependent variable. To define the extent to which patient characteristics, procedural characteristics (residual mitral valve regurgitation, periprocedural bleeding), site volume, and patients\' baseline health status accounted for variability in outcomes, the proportion of variability () explained by sequentially adding these variables to the model was quantified.
Across 339 sites, 12 415 patients (mean age 79.0±9.5 years, 46.1%. females, 89.5% White) completed baseline and 30-day health status assessments. Mean KCCQ-OS score was 43.0±24.4 at baseline and 67.0±24.9 at 30-day follow-up. Across sites, the proportion of patients achieving a ≥20-point improvement in KCCQ-OS ranged from 12.5% to 100% and the adjusted median odds ratio was 1.58 (95% CI, 1.46-1.69). The greatest contribution to the variability in health status outcomes was from patients\' baseline KCCQ-OS score (=25%) with <1% of the variability explained by patient and procedural characteristics, and annual site volume.
There is moderate variation across sites in their patients\' achievement of health status benefits from TMVr, with patient\'s baseline health status accounting for the largest proportion of this variation. This underscores the importance of patient selection in supporting more consistent health status benefit from TMVr.
Show Me the Money: Patients\' Perspectives on a Decision Aid for Sacubitril/Valsartan Addressing Out-of-Pocket Cost.
Dickert NW, Mitchell AR, Venechuk GE, Matlock DD, ... Speight CD, Allen LA
Out-of-pocket medication costs for patients who have heart failure with reduced ejection fraction may be an important part of shared decision-making, but cost has generally been excluded from clinical discussions. This study reports patients\' perspectives on a decision aid for sacubitril/valsartan that explicitly addresses out-of-pocket costs.
Structured, in-depth interviews were conducted with 20 patients with heart failure with reduced ejection fraction from 2 medical centers to elicit their views on a publicly available decision aid for sacubitril/valsartan that explicitly incorporates considerations related to out-of-pocket costs. Qualitative descriptive analysis was conducted.
Key themes identified were general enthusiasm for decision aids for medication decisions, openness on the part of patients to incorporation of cost into decision-making and the decision aid, requests for greater specificity regarding patient-specific cost, and challenges communicating evidence of benefit in a way that allows patients to make cost-benefit analyses for themselves. Patients also raised questions regarding logistical challenges of incorporating a decision aid into the normal clinical and decision-making workflow.
Patients were receptive to the inclusion of out-of-pocket cost as relevant in a decision aid for sacubitril/valsartan. Key challenges to effective integration of cost in these decisions include developing mechanisms for acquiring reliable patient-specific cost estimates and addressing patients\' difficulties (and sometimes skepticism) applying trial evidence to their own situation. In addition, implementation strategies are important to develop to facilitate decision aid integration for routine medical decisions into clinic workflow.
Show Me the Money: Patients' Perspectives on a Decision Aid for Sacubitril/Valsartan Addressing Out-of-Pocket Cost.
Target: Stroke Was Associated With Faster Intravenous Thrombolysis and Improved One-Year Outcomes for Acute Ischemic Stroke in Medicare Beneficiaries.
Man S, Xian Y, Holmes DN, Matsouaka RA, ... Schwamm LH, Fonarow GC
The benefit of intravenous thrombolytic therapy for acute ischemic stroke is time dependent. To assist hospitals in providing faster thrombolytic treatment, the American Heart Association launched target: stroke quality initiative in January 2010 which disseminated feasible strategies to shorten door-to-needle times for thrombolytic therapy. This study aimed to examine whether target: stroke was associated with improved door-to-needle times and 1-year outcomes.
We analyzed Medicare beneficiaries aged ≥65 years receiving intravenous thrombolytic treatment for acute ischemic stroke at 1490 Get With The Guidelines-Stroke hospitals during January 2006 and December 2009 (preintervention, n=10 804) and January 2010 and December 2014 (postintervention, n=31 249). The median age was 80 years and 42.7% were male.
The median door-to-needle times decreased from 80 minutes for the preintervention to 68 minutes for the postintervention (<0.001). The proportion of patients receiving intravenous thrombolysis with door-to-needle times 45 minutes and 60 minutes increased from 9.6% and 24.8% for preintervention to 17.1% and 40.6% for postintervention, respectively (<0.001). The annual rate of increase in the door-to-needle times of 60 minutes or less accelerated from 0.20% (95% CI, -0.43% to 0.83%) per each 4 quarters for preintervention to 5.68% (95% CI, 5.23%-6.13%) for postintervention (<0.001) which was further confirmed in piecewise multivariable generalized estimating analysis (adjusted odds ratio, 1.27 [95% CI, 1.19-1.35]). Cox proportional hazards analysis, after adjusting for patient and hospital characteristics and within-hospital clustering, showed that target: stroke was associated with lower all-cause readmission (40.4% versus 44.1%; hazard ratio, 0.91 [95% CI, 0.88-0.95]), cardiovascular readmission (19.7% versus 22.9%; hazard ratio, 0.85 [95% CI, 0.80-0.89]), and composite of all-cause mortality or readmission (56.0% versus 58.4%; hazard ratio, 0.96 [95% CI, 0.93-1.00]). The risk decline in all-cause mortality dissipated after risk adjustment (adjusted hazard ratio, 0.98 [95% CI, 0.94-1.02]).
Target: stroke quality initiative was associated with faster thrombolytic treatment times for acute ischemic stroke and modestly lower 1-year all-cause and cardiovascular readmissions.
A Blueprint for Productive Maintenance of Certification, But Is the American Board of Internal Medicine up to the Challenge?
Alyesh D, Gambhir A, Waase M, Remo B, ... Estes NAM, Heist EK
The future of the American Board of Internal Medicine Maintenance of Certification (MOC) program is at a crossroads. The current MOC program lacks a clear visible mission, adds to modern health care\'s onerous bureaucracy, and thus pulls physicians from the most important humanistic aspects of their profession. The aim of the MOC program should be to promote the best patient care by ensuring certified physicians maintain core skills through continuous education and evaluation. The program should focus on education and be designed with the rigorous obligations of practicing physicians in mind. Moving forward, the American Board of Internal Medicine should cocreate MOC with the physician community and apply innovative adult education techniques. Over time, data-driven methods and member feedback should be used to provide continuous program improvement. This review describes the origins of the current state of MOC, explores its evidence base, provides examples of model programs for the maintenance of complex professional skills, and outlines guiding principles for the future of MOC.
Cardiovascular Disease Events and Mortality After Myocardial Infarction Among Black and White Adults: REGARDS Study.
Blackston JW, Safford MM, Mefford MT, Freeze E, ... Brown TM, Levitan EB
Despite improvements in prognosis following myocardial infarction (MI), racial disparities persist. The objective of this study was to examine disparities between Black and White adults in cardiovascular disease (CVD), coronary heart disease, stroke, heart failure (HF), and mortality after MI and characteristics that may explain the disparities.
This prospective cohort study included 1122 REGARDS (Reasons for Geographic and Racial Differences in Stroke) study participants with incident MI between 2003 and 2016. We followed participants for subsequent CVD events (MI, stroke, HF hospitalization, or death from CVD; n=431), coronary heart disease events (MI or death from coronary heart disease; (n=277), stroke (n=68), HF events (HF hospitalization or death from HF; n=191), and all-cause mortality (n=527; 3-year median follow-up after MI).
Among 1122 participants with incident MI, 37.5% were Black participants, 45.4% were women, and mean age was 73.2 (SD, 9.5) years. The unadjusted hazard ratio for CVD events comparing Black to White participants was 1.42 (95% CI, 1.17-1.71). Adjusting for sociodemographic characteristics did not attenuate the association (1.41 [95% CI, 1.14-1.73]), but further adjusting for pre-MI health status (1.25 [95% CI, 1.00-1.56]) and characteristics of the MI (1.01 [95% CI, 0.80-1.27]) resulted in substantial attenuation. Similar patterns were observed for the other outcomes, although the number of strokes was small.
Black individuals had a higher risk of CVD events and mortality after MI than White individuals. The disparities were explained by health status before MI and characteristics of the MI. These findings suggest that both primordial prevention of risk factors and improved acute treatment strategies are needed to reduce disparities in post-MI outcomes.
Examining the Nocebo Effect of Statins Through Statin Adverse Events Reported in the FDA Adverse Event Reporting System (FAERS).
Moon J, Cohen Sedgh R, Jackevicius C
: This study aimed to evaluate whether the high frequency of reported statin adverse effects (AEs) may be associated with the nocebo effect. We compared nocebo-related subjective AEs with objective AEs and investigated factors potentially associated with the nocebo effect. : A retrospective cohort study was conducted using the FDA Adverse Event Reporting System (FAERS) between January 2010 and December 2019 for statins, including, atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Subjective AEs included fatigue, subjective muscular, and nervous system AEs. Objective AEs were defined as hepatic and objective muscular AEs. We compared the number of subjective and objective AEs using the Mann-Whitney U test and examined trends in the frequency of subjective versus objective reports over time using linear regression with interaction terms. We evaluated the association between AEs and gender and country using linear regression. Quantitative detection of signals was estimated using proportional reporting ratio (PRR) and reporting odds ratio (ROR) for simvastatin. : Of 2,994,487 overall AE reports, more subjective than objective AEs were reported per quarter (mean±SD: 4,777±1,375.45 vs 999±276.95; <0.0001), and over time during the study period (<0.001). Females reported more subjective AEs than males per quarter (fatigue: 86.98 more per quarter, =0.035; subjective muscular AE: 417.95, <0.0001; nervous system AE: 273.60, <0.0001), but fewer objective muscular AEs (-125.23 per quarter, <0.0001). More subjective AEs and fewer objective AEs were reported per quarter in the US relative to other countries. Simvastatin-associated reports showed signals for higher objective muscular AEs relative to all other statins (ROR 1.53, 95% CI: 1.49-1.58). : This study found that significantly more subjective than objective AEs are reported for statins. Subjective statin AEs, potentially related to the nocebo effect are reported more often by females than by males, and in the US than in other countries.
Circ Cardiovasc Qual Outcomes: 08 Nov 2020; epub ahead of print
Circ Cardiovasc Qual Outcomes: 08 Nov 2020; epub ahead of print | PMID: 33161769
Association of Medicaid Expansion with Rates of Utilization of Cardiovascular Therapies Among Medicaid Beneficiaries Between 2011 and 2018.
Sumarsono A, Lalani H, Segar MW, Rao S, ... Fonarow GC, Pandey A
: The Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to healthcare. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs. : We used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants (DOAC). We defined expander states as those who expanded Medicaid on January 1, 2014, and non-expander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus non-expander states. : Between 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins [DID estimate (95% CI): 22.5 (16.5 to 28.6), P<0.001], antihypertensives [DID estimate (95% CI): 63.2 (47.3 to 79.1), P<0.001], and P2Y12 inhibitors [DID estimate (95% CI): 1.7 (1.2 to 2.2), P<0.001]. Between 2013 and 2018, more than 75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of non-expander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher DOAC prescription rates [DID estimate (95% CI) 0.9 [-0.3 to 2.1], P=0.142). : The 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.
Evidence-Based Policy Making for Public Health Interventions in Cardiovascular Diseases: Formally Assessing the Feasibility of Clinical Trials.
Foti K, Foraker RE, Martyn-Nemeth P, Anderson CAM, ... Whitsel LP, Appel LJ
Implementation of prevention policies has often been impeded or delayed due to the lack of randomized controlled trials (RCTs) with hard clinical outcomes (eg, incident disease, mortality). Despite the prominent role of RCTs in health care, it may not always be feasible to conduct RCTs of public health interventions with hard outcomes due to logistical and ethical considerations. RCTs may also lack external validity and have limited generalizability. Currently, there is insufficient guidance for policymakers charged with establishing evidence-based policy to determine whether an RCT with hard outcomes is needed before policy recommendations. In this context, the purpose of this article is to assess, in a case study, the feasibility of conducting an RCT of the oft-cited issue of sodium reduction on cardiovascular outcomes and then propose a framework for decision-making, which includes an assessment of the feasibility of conducting an RCT with hard clinical outcomes when such trials are unavailable. We designed and assessed the feasibility of potential individual- and cluster-randomized trials of sodium reduction on cardiovascular outcomes. Based on our assumptions, a trial using any of the designs considered would require tens of thousands of participants and cost hundreds of millions of dollars, which is prohibitively expensive. Our estimates may be conservative given several key challenges, such as the unknown costs of sustaining a long-term difference in sodium intake, the effect of differential cotreatment with antihypertensive medications, and long lag time to clinical outcomes. Thus, it would be extraordinarily difficult to conduct such a trial, and despite the high costs, would still be at substantial risk for a spuriously null result. A robust framework, such as the one we developed, should be used to guide policymakers when establishing evidence-based public health interventions in the absence of trials with hard clinical outcomes.
Circ Cardiovasc Qual Outcomes: 30 Oct 2020; 13:e006378
Circ Cardiovasc Qual Outcomes: 30 Oct 2020; 13:e006378 | PMID: 32981337
Cardiovascular- and Bleeding-Related Hospitalization Rates With Edoxaban Versus Warfarin in Patients With Atrial Fibrillation Based on Results of the ENGAGE AF-TIMI 48 Trial.
Vilain K, Li H, Kwong WJ, Antman EM, ... Magnuson EA,
The ENGAGE AF-TIMI 48 trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) demonstrated noninferiority of once-daily 60 mg (30 mg dose-reduced) edoxaban compared with warfarin for prevention of stroke/systemic embolism in patients with atrial fibrillation. No previous analysis has explored the impact of treatment with edoxaban versus warfarin on rates of hospitalizations. Methods Detailed healthcare resource utilization data from ENGAGE AF-TIMI 48 for the 14 024 randomized patients who received at least one dose of study drug were used to compare the rates of bleeding- and cardiovascular-related hospitalizations for edoxaban versus warfarin. Hospitalization rates were calculated for each treatment group, and relative rates were estimated using Poisson regression. The influence of patient characteristics on the impact of edoxaban versus warfarin was evaluated through the inclusion of interaction terms. Results The overall rate of cardiovascular- or bleeding-related hospitalization was significantly lower for edoxaban than warfarin (relative rate [RR], 0.91 [95% CI, 0.85-0.97], =0.003). Rates of hospitalizations for cardiovascular reasons (RR, 0.91 [95% CI, 0.85-0.97], =0.004), stroke (RR, 0.80 [95% CI, 0.72-0.88], <0.0001), and for each stroke subtype (ischemic: RR, 0.89 [95% CI, 0.81-0.99], =0.03; hemorrhagic: RR, 0.60 [95% CI, 0.54-0.68], <0.0001) were also lower for edoxaban. Notably, significantly greater reductions with edoxaban versus warfarin were seen for ischemic stroke-related hospitalizations in vitamin K antagonist naive patients and patients with CHADS scores 4 to 6, previous stroke or transient ischemic attack, age ≥75, and no previous coronary artery disease. For nonstroke bleeding-related hospitalizations, greater reductions with edoxaban were seen in vitamin K antagonist naive patients, patients with CHADS scores 4 to 6, and patients with moderate renal dysfunction.
Edoxaban 60 mg (30 mg dose-reduced) was associated with a significantly lower overall rate of cardiovascular- or bleeding-related hospitalization and significant reductions in the subcategories of cardiovascular-related, stroke-related, bleed-related, and nonstroke cardiovascular-related hospitalizations, when compared with warfarin. These results suggest the potential for cost offsets with edoxaban, with even greater reductions in higher-risk patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00781391.
Sources of Hospital Variation in Postacute Care Spending After Cardiac Surgery.
Thompson MP, Yost ML, Syrjamaki JD, Norton EC, ... Pagani FD, Likosky DS
Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization.
A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes.
There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.
Cause of Death Among Patients With Peripheral Artery Disease: Insights From the EUCLID Trial.
Kochar A, Mulder H, Rockhold FW, Baumgartner I, ... Patel MR, Jones WS
Peripheral artery disease is common and associated with high mortality. There are limited data detailing causes of death among patients with peripheral artery disease.
EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) was a randomized clinical trial that assigned patients with peripheral artery disease to clopidogrel or ticagrelor. We describe the causes of death in EUCLID using mortality end points adjudicated through a clinical events classification process. The association between baseline factors and cardiovascular death was evaluated by Cox proportional hazards modeling. The competing risk of noncardiovascular death was assessed by the cumulative incidence function for cardiovascular death and the Fine and Gray method to ascertain the association between baseline characteristics and cardiovascular mortality.
A total of 1263 out of 13 885 (9.1%) patients died (median follow-up: 30 months). There were 706 patients (55.9%) with a cardiovascular cause of death and 522 (41.3%) with a noncardiovascular cause of death. The most common cause of cardiovascular death was sudden cardiac death (20.1%); while myocardial infarction (5.2%) and ischemic stroke (3.2%) were uncommon. The most common causes of noncardiovascular death were malignancies (17.9%) and infections (11.9%). The factor most associated with a higher risk of cardiovascular death was age per 5 year increase (HR, 1.26 [95% CI, 1.20-1.32]). Female sex was associated with a lower risk of cardiovascular death (HR, 0.68 [95% CI, 0.56-0.82]). To evaluate the effect of noncardiovascular death as a competing risk, we superimposed the cumulative incidence function curve with the Kaplan-Meier curve. These curves closely approximated each other. After accounting for the competing risk of noncardiovascular death, the magnitude and direction of the factors associated with cardiovascular death were minimally changed.
Among patients with symptomatic peripheral artery disease, noncardiovascular causes of death reflected a high proportion (40%) of deaths. Accounting for noncardiovascular deaths as a competing risk, there was not a significant change in the risk estimation for cardiovascular death. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01732822.
Determinants of Value in Coronary Artery Bypass Grafting.
Brescia AA, Vu JV, He C, Li J, ... Likosky DS,
Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, =0.006), prolonged ventilation (17.6% versus 4.8%, <0.001), and operative mortality (4.8% versus 0.6%, =0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (<0.001), driven by higher readmission ($3675 versus $2177, =0.005), professional ($7462 versus $6090, <0.001), postacute care ($7315 versus $5947, =0.031), and index hospitalization payments ($33 474 versus $30 800, <0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, <0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, <0.001), but lower utilization of home health (66% versus 73%, =0.016) and emergency department services (13% versus 17%, =0.034).
To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.
Comparative Effectiveness of Dual Antiplatelet Therapy With Aspirin and Clopidogrel Versus Aspirin Monotherapy in Mild-to-Moderate Acute Ischemic Stroke According to the Risk of Recurrent Stroke: An Analysis of 15 000 Patients From a Nationwide, Multicenter Registry.
Lee HL, Kim JT, Lee JS, Park MS, ... Lee J, Bae HJ
This study compared the effectiveness of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin with that of aspirin monotherapy (AM) in mild-to-moderate acute ischemic stroke considering the risk of recurrent stroke using the Stroke Prognosis Instrument II (SPI-II) score.
This study is a retrospective analysis of data from a prospective, nationwide, multicenter stroke registry database between January 2011 and July 2018. We included patients with mild-to-moderate (National Institutes of Health Stroke Scale score ≤10), acute (within 24 hours of onset), noncardioembolic ischemic stroke. The primary outcome was a 3-month composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality. Propensity scores using the inverse probability of treatment weighting method were used to mitigate baseline imbalances between the DAPT and AM groups and within each subgroup considering SPI-II scores.
Among the 15 430 patients (age, 66±13 years; men, 62.0%), 45.1% (n=6960) received DAPT and 54.9% (n=8470) received AM. Primary outcome events were significantly more frequent in the AM group (16.7%) than in the DAPT group (15.5%; =0.03). Weighted Cox proportional hazards models showed a reduced risk of 3-month primary vascular events in the DAPT group versus the AM group (hazard ratio, 0.84 [0.78-0.92]; <0.001), with no interaction between acute treatment type and SPI-II risk subgroups (=0.44). However, among the high-risk patients with SPI-II scores >7, a substantially larger absolute benefit was observed for 3-month composite vascular events in the DAPT group (weighted absolute risk differences, 5.4%), whereas smaller absolute benefits were observed among patients in the low- or medium-risk SPI-II subgroups (1.7% and 2.4%, respectively).
Treatment with clopidogrel-aspirin was associated with a reduction in 3-month vascular events compared with AM in mild-to-moderate acute noncardioembolic ischemic stroke patients. Larger magnitudes of the effects of DAPT with clopidogrel-aspirin were observed in the high-risk subgroup by SPI-II risk scores.
Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest.
Malik AO, Nallamothu BK, Trumpower B, Kennedy M, ... Hejjaji V, Chan PS
Identifying actionable resuscitation practices that vary across hospitals could improve adherence to process measures or outcomes after in-hospital cardiac arrest (IHCA). We sought to examine whether hospital debriefing frequency after IHCA varies across hospitals and whether hospitals which routinely perform debriefing have higher rates of process-of-care compliance or survival. Methods We conducted a nationwide survey of hospital resuscitation practices in April of 2018, which were then linked to data from the Get With The Guidelines-Resuscitation national registry for IHCA. Hospitals were categorized according to their reported frequency of debriefing immediately after IHCA; rarely (0%-20% of all IHCA cases), occasionally (21%-80%), and frequently (81%-100%). Hospital-level rates of timely defibrillation (≤2 minutes), epinephrine administration (≤5 minutes), survival to discharge, return of spontaneous circulation, and neurologically intact survival were comparted for patients with IHCA from 2015 to 2017. Results Overall, there were 193 hospitals comprising 44 477 IHCA events. Mean patient age was 65±16, 41% were females, and 68% were of White race. Across hospitals, 84 (43.5%) rarely performed debriefings immediately after an IHCA, 82 (42.5%) performed debriefing sessions occasionally, and 27 (14.0%) performed debriefing frequently. There was no association between higher reported debriefing frequency and hospital rates of timely defibrillation and epinephrine administration. Mean hospital rates of risk-standardized survival to discharge were similar across debriefing frequency groups (rarely 25.6%; occasionally 26.0%; frequently 25.2%, =0.72), as were hospital rates of risk-adjusted return of spontaneous circulation (rarely 72.2%; occasionally 73.0%; frequently 70.0%, =0.06) and neurologically intact survival (rarely 21.9%, occasionally 22.2%, frequently 21.1%, =0.75).
In a large contemporary nationwide quality improvement registry, hospitals varied widely in how often they conducted debriefings immediately after IHCA. However, hospital debriefing frequency was not associated with better adherence to timely delivery of epinephrine or defibrillation or higher rates of IHCA survival.
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IPPB Deputy Manager Recruitment 2019-2020: Once more the India Post Payments Bank has release a recruitment notification to getting online application form for the Deputy Manager Posts. A lot of candidates who has waited to IPPB Deputy Manager Jobs 2019 Notification, now they can apply application form before last date. The recruitment notification has dispatch for the 18Vacanct Posts. As per detail of the IPPB Bank Deputy Manager Recruitment 2019 Notification the process to make application form start from 19 January 21019 and candidates can apply application form till 07 Feb 2019. More detail like as education qualification, Age Limit, Selection Mode and much more is available at below.


Planned Parenthood is just a pure and great organization that loves women, right? Well, unless they are Republican women.
Planned Parenthood paid some of its supporters who threw condoms at GOP presidential candidate Carly Fiorina and at her supporters during an Iowa Hawkeye tailgate on Saturday.
The payments were briefly mentioned in a story by the New York Times. "On Saturday, women wearing pink, some of whom were paid by Planned Parenthood, protested Mrs. Fiorina at a campaign appearance in Iowa, throwing condoms and chanting, 'Women are watching, and we vote,'" reported the New York Times.


text:
The German Naval Archives: Tambach
August 31, 2016 March 20, 2019 by jessiekratz, posted in - World War II, National Archives History
The wreckage at Lunebach, Germany, ca. March 1945. (National Archives Identifier 535977)
Today's post comes from Sonia Kahn in the National Archives History Office. It is part four of a series on the history of some of the seized foreign records housed at the National Archives.
Imagining Germany in April 1945 conjures up images of destruction and despair as the war in Europe drew to a close and the Nazi war machine gasped its final breaths.
That April, Allied troops seized documents of the German Naval Archives, also known as the Tambach documents, named after Tambach Castle in northern Bavaria, where they were captured.
A document from German Naval Files relating to Operation Barbarossa from a collection that was seized at Tambach Castle. (National Archives Identifier 7431812)
The records found at Tambach Castle included German Navy documents from World War II but also some dating back as far as 1850. The Nazis had moved the documents from their home in Berlin to the rural safe haven in November 1943.
After Germany surrendered on May 7, 1945, the U.S. and British forces moved to London the seized documents that they could use for naval intelligence purposes.
They split the documents—some went to the British Admiralty while others were sent to 20 Grosvenor Square, the American military headquarters in London.
U.S. and British officials planned to jointly organize, catalog, and film the intelligence records at each location.
In the midst of filming, Commodore Dudley Knox of the Office of Naval Records and Library, recognizing the great academic and research value of the Tambach records, sought to film the entire collection and to maintain a copy.
Knox persuaded the Director of Naval Intelligence to film the additional documents—a mighty accomplishment considering the postwar reduction in military funds.
A document from German Naval Files relating to Operation Barbarossa from a collection that was seized at Tambach Castle. (National Archives Collection of Foreign Records Seized)
Documents that had remained at Tambach Castle after the seizure—which were now deemed worth filming for historic value—were swiftly shipped to join the rest of the collection in London.
Knox eventually realized that it would be a logistical and costly nightmare to truly film every document of the German Naval Archives. Rather than let his dream of filming a greater portion of the Archive fall apart, he made the call to film only what he deemed the most historically valuable documents.
Microfilming the collection began in London in August 1945.
British naval staff first registered the documents, giving them a "PG" designation followed by a unique number identifier."PG" reportedly stood for "pinched from the Germans."
Once the documents were registered, American translators listed and detailed the items in the series. The documents were then filmed.
In 1946, while the staff were filming records from 1930-45—those considered most vital to be duplicated—they began the additional task of filming some of the more historic, older records.
Piece of a map from German Naval Files relating to Operation Barbarossa from a collection that was seized at Tambach Castle. (National Archives Collection of Foreign Records Seized)
By July 1947, filming was complete, resulting in 3,905 reels of film, of which 40 percent concerned material from before 1930.
Document from the Records of the German Navy, October 1915. (National Archives Identifier 7065546)
In 1962, 17 years after the German Naval Archives had been seized at Tambach Castle, the British Admiralty began the process of returning the original documents to the Federal Republic of Germany.
The original records were sent to the Federal German Military Archives in Freiburg. The entire microfilm collection of German Naval Archives material from before 1930 came to the National Archives in February 1967 from the Naval History Division of the U.S. Navy. The first transfer was completed in 1969. In 1972 the Navy began to transfer reels of unclassified records dating from after 1930.
So in addition to housing United States' federal records, the National Archives had acquired documents relating to the German Navy under the Third Reich and Prussian Navy from the mid-19th century.
But the National Archives doesn't just have German historical records—next Wednesday's post explores records seized from Italy's notorious II Duce.
English translation of a page from a diary of German Naval Staff, Operations Division, that was captured at Tambach, April 8, 1943. (National Archives Identifier 23889434)
Tagged foreign records seized
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redpajama_set_name: RedPajamaCommonCrawl


This concrete shed is on the northeastern corner of the island.
Looking northwest gives us a view of Uunisaari. While Harakka is accessible basically on summer for most people. Uunisaari is better accessible in the winter, because the pontoon bridge to Uunisaari is only in place during winter. However, a boat does go to Uunisaari in summer.
The small bridge in the left is the one connecting the two halves of Uunisaari, which is actually two islands, unless the sea level is very low.
The stairs connect the less steep eastern and more steep western shore in the north. The rusty pulley was there near the stairs, amid wild strawberry plants.
A view towards the mainland and Uunisaari from the cliffs in the north of Harakka. The red boat is a search and rescue boat.
In the summer, the paths here were almost overgrown. To the left is the path to the western shore.
This was a tour of the north of the island Harakka. In the next installment, we are going west, revisiting some familiar places and exploring further on the western cliffs.
Love the fifth for its colour, nice to see that shade of light, too.
Second favourite: last photo. Mysterious yet cheerful path to follow? Yes, please!
I love water, I love woods, I love finding strange objects in the woods. I love these pictures.
The joys of having somewhere that cars can't get at you.
I think the concrete shed has something to do with the undersea cables between Harakka and mainland.
We'll see what's on the other end of the path in the last picture in the next part.
The woods in Harakka are fairly small, it's a small island (8 hectares/20 acres, longest dimension circa 500 m/550 yd), but as you have already seen, there are a lot of different features on that small rocky hill peeking out of the sea.
There is a little tractor on the island and some carts and wheelbarrows, but apart from that, yeah, no vehicles. And the sea ice probably won't be strong enough for walking this winter (if it ever is around Harakka), let alone for cars.
My favourite is the last one, but I also love the stairs with the sunshine in the corner. The light is lovely in all of them.


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Q: How to change color in heatmap api of google calender In one of my project i have setup google map with heatmap api of google and as per database leads i need to change the color of heatmap. can any one help me regarding it.
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redpajama_set_name: RedPajamaStackExchange


Click on the "Create Single Invoice" option under the Billing tab.
Select a customer and enter the invoice settings.
To add lessons, select the "Add Lessons" option and then enter the start and end dates from which to draw lessons, and then click the "Go" button. Only uninvoiced lessons will be added.
If you don't want to make the invoice available to the customer immediately, click the "Save" button. Otherwise click the "Approve" button.


Explore! Challenge yourself! Learn! Outdoor Adventures offers a variety of opportunities for the Loyola community to enjoy the great outdoors.
Want to stay up-to-date with Outdoor Adventures, see pictures, and stay current on outdoor-related news? Like us on Facebook, join our email list, watch our YouTube videos, or view our trip calendar. For more information about Outdoor Adventures, call 410-617-5437 or email oae@loyola.edu.
The climbing wall is located on the first floor of the Fitness and Aquatics Center, is for all levels of climbers, from beginners to advanced, and offers a yearly climbing competition.
A week-long adventure for incoming First-Year students, designed to ease the transition to college. It is offered every August just prior to the start of Fall Welcome Weekend.
This is the place for anyone who wants to sign up for a trip, read a book from our library, or rent basic camping equipment.


PEAK Insight Journal regularly issues calls for articles related to themes for upcoming issues. We also accept submissions on a rolling basis. Please include a 150-200 word overview as well as information on format (narrative, interview, Top 10 list, etc.) and submit to Nikki Powell for more information.
PEAK Insight Journal, the journal of PEAK Grantmaking, begins and informs conversations about issues of interest to grantmakers, grantmaking, grants management professionals, and the philanthropy sector as a whole. Articles should be written in clear, jargon-free English and should include links to online resources for additional learning or explanation. Where possible, PEAK Grantmaking encourages opportunities for interaction between writers and readers through blog posts with comments, Facebook discussions, or Twitter chats. Our goal is to make the journal accessible to a variety of readers: grantmaking practitioners, scholars, policy-makers, thought leaders, and journalists, among others. PEAK Insight Journal follows the AP Stylebook. House style sheets may be sent to authors as part of the revision process.
PEAK Insight Journal publishes articles of varying lengths and encourages writers to fully cover the topic at hand. The following word counts and article formats are recommendations only.
Features Covers a broad range of issues related to the issue theme (if themed) and introduces a variety of perspectives. They include links to online references for more learning. Visuals are important additions to feature articles and include charts and graphs, stock art, infographics, and data visualization imagery.
Point/Counterpoint Presents two sides of the same issue; thought-provoking, discussion generator. Best when followed by interactive online elements like Facebook discussion or Twitter chat.
Interviews One-on-one Q&A with expert, thought leader, or other key practitioner. Includes links to online references for more learning.
How To Instructional articles presenting step-by-step details on performing a specific task. Includes links to online references for more learning.
Best Practices Review and compendium of available tactics and techniques. Includes links to online references for more learning.
Survey and report Employs interviews or questionnaires plus review of findings and commentary on current/future outlook. Includes links to online references for more learning.
Book Reviews Review of new literature covering topics of importance to philanthropy and grants management. Includes links to online references for more learning.
What is the topic that is addressed?
How do you know this is important?
What is the bigger, more general field your article relates to?
What are the implications for the field of grants management or for philanthropy?
What are the practical implications of the topoic (how can the results be utilized by e.g. practitioners, society or companies)?
PEAK Grantmaking will own copyright to all published works and have the right of first publication, both in print and online, unless other arrangements are made with the editors in advance.


The Superman costume worn by actor Christopher Reeve in 1978 during his first "Superman" film sold for $115,000, soaring past its $50,000 to $70,000 estimated sell price according to Superman's costume matches Oz guard's at auction.
The Hollywood memorabilia firm Profiles in History held an auction on Thursday April 5, 2007 and sold over $2 million worth of movie and television items. Among the other items was a "Winkie" costume from the 1939 movie "The Wizard of Oz" that also sold for $115,000. This rare Winkie costume was used by an actor portraying a guard protecting the Wicked Witch of the West in the much beloved "Wizard of Oz." It was within its estimated price range of $100,000 to $120,000.
Get your Superman costume today! Check out Extreme Halloween's collection of Superman costumes for babies, toddlers, children, adults and even for your dog! We also carry a variety of other Superhero costumes to choose from!
Spiderman 3 May 4th - Get Your Spidey Wear Now!
Where will you be on May 4? With the release of Spiderman 3 on May 4, I suspect you'll be at the theater! As a true Spiderman fanatic, make sure you get your "spidey wear" in time for the premier.
Looking for the new Spiderman 3 Black? We have the black/grey raise-web jumpsuit with muscle chest and arms and matching character hood with mesh eyes for good visibility. Available in Small (size 4-6) and Medium (size 7-8). Also available without muscles in in Toddler (size 3T-4T), Small (size 4-6), Medium (size 7-8), Large (size 10-12), and Teen/XLarge (size 14-16).
Are you a classic Spiderman fan? We carry a variety of traditional Spiderman red jumpsuits available with or without muscles. Sizes start from 3 - 6 month old babies to XLarge (size 14-16)!
Check out our extensive collection of Spiderman 3 costumes today!
Is there a little princess in your life? Does she aspire to be a fairytale princess each and everyday? Make all her dreams come true and buy her a princess dress and accessories to wear whenever she wants to dress up!
Whether she thinks she is Cinderella, the Snow Queen, Sleeping Beauty, Snow White, Beauty, or Rapunzel, Annie's Costumes has a wide variety of princess costumes to choose from. And what's the one thing every princess MUST have? Yes a tiara!
We haven't forgotten about the young princes either!
Check out the complete selection of princess, prince, fairy costumes and accessories and order now!
Happy Easter, Underwater Easter Bunny!
One of our customers made it into AOL's Pictures of the Week SCUBA Diving in our open face bunny suit! The Underwater Easter Bunny a.k.a. Wayne Donelson is an intern at the Florida Keys Dive Center. He is hiding hard boiled Easter eggs for a charity hunt to take place in the beautiful waters off of Key Largo, FL in the Florida Keys National Marine Sanctuary. Visit AOL's Pictures of the Week (see photo #7) and Vote for your favorite!
Ordering Deadlines Approaching - Order Now!
With two events just days away we urge you to order now!
Still need a costume for Easter? It's not too late to order! Easter is this Sunday, April 8. To receive your Easter costume by Friday April 6* simply place your order by Thursday April 5* 2pm EST and choose next day air. For those last minute Easter emergencies we offer Saturday delivery! Place your order by Friday April 6* 2pm EST and choose Saturday delivery.
Celebrating Mardi Gras at Universal Studios in Orlando, Fl? The event has two dates till it ends - this Saturday April 7 and next Saturday April 14. This fun event is surely one to dress up for! If you are attending this weekend and want to have your Mardi Gras costume by Friday April 6* place your order by Thursday April 5* 2pm EST and choose next day air. If you are going to Mardi Gras in Orlando next weekend April 14 we have plenty of delivery options available if you order early.
*If your order includes a Special Order Item, delivery time depends on availability and may require an additional day for processing. Contact customer service if you have any questions! 1-877-413-8747.


Describe the process when someone considers working with you.
Our process involves two stages. First, we do a room-by-room home evaluation with the parent(s), citing the potential hazards and problems we see, as well as hearing their concerns. We have a collaborative discussion. Then we do a show and tell of the safety products recommended. We follow with an emailed estimate. After reviewing the estimate, the customer schedules a date for us to implement those safety products. The process to install safety items is always within one day.
What is the benefit that most of your clients experience from using your services?
Customers know their home is safer because they have used an Advanced Certified Professional Childproofer, who has installed safety products correctly and is experienced in balancing safety with aesthetics and functionality. People may not have the time to install the safety products themselves or may be unable to find the right or best products. By working with a professional, they are assured the right product is used and installed correctly. Many safety products are made differently, and we only use the highest quality items, including only certified baby gates.
Describe a typical childproofing job.
Typically, the jobs we do include latches in cabinets/drawers, protective safety outlet covers, safety gates, toilet lid locks, furniture and TV anchoring, door locks, and protective wire covering.
I love making homes safer for children because it's a way of giving back to society. Helping others is a positive reward. The most challenging aspect of my job is explaining to parents that childproofing is more than just installing safety items. Awareness and educating parents about where potential hazards exist in their home, and how quickly accidents can happen overcomes the challenge.


Macy's Sale | 40% off Handbags!
Home / Deals / Online Deals / Macy's Sale | 40% off Handbags!
Macy's Sale | 40% off Handbags!
There is a great Macy's Sale going on right now online!
They have Handbags for 40% off and I found some really great deals and low prices on wristlets, shoulder bags, and more!
This Tote is only $19.99 right now, marked down from $40!
I also found this Red by Marc Ecko Bag for just $29.99, WAY down from $89.99!
Check out all of the hot deals in the Macy's Sale today!
Find all of the hottest Deals at Macy's with Macy's Coupons and more!
Boy's Shirts and Shorts Sets just $3!


text:
Hanna Maria Świda-Ziemba (September 19, 1930 – January 11, 2012) was Polish sociologist, scholar and opposition activist in the Polish People's Republic.

Biography
Her father was professor Witold Świda, and her sister was professor Zofia Świda. She grew up in Vilnius and started keeping a diary from the age of ten, describing life in Soviet-occupied Vilnius, and documenting the post-war period of creating a new socio-political reality in Poland. She became interested in the mechanisms of totalitarian states and would later expand on her observations in her academic studies.

In 1952 she graduated with a degree in sociology from the University of Łódź, in 1960 she obtained a doctoral degree, and in 1969 her habilitation. She began working the University of Warsaw in 1954. She was a member of the presidium of the Polish Academy of Sciences and also lectured at the SWPS University of Social Sciences and Humanities.  She has published a number of academic papers, mainly in the field of sociology on the topic of totalitarian systems. She was co-founder of the Institute of Applied Social Sciences as well as the Institute of Social Prevention and Rehabilitation of the University of Warsaw and in the years 1991-1993 she was member of the State Tribunal.

In 2010 she published Youth of the People's Republic of Poland: portraits of generations in historical context, a culmination of many years of research for which she received the Jan Długosz award in 2011. President Bronisław Komorowski awarded Świda-Ziemba  the Commander's Cross of the Order of Polonia Restituta for outstanding achievements in research and teaching.

She died on January 11, 2012, in Warsaw and was buried at the Powązki Military Cemetery (section D 31-tuje-6).

Publications

 Człowiek wewnętrznie zniewolony. Mechanizmy i konsekwencje minionej formacji – analiza psychologiczna, Warszawa 1997
 Młodzi w nowym świecie, Kraków 2005
 Młodzież licealna: analiza wybranych klas warszawskich w latach 1956–58, Warszawa 1963
 Obraz świata i bycia w świecie. Z badań młodzieży licealnej, Warszawa 2000
 Osobowość jako problem pedagogiki, Wrocław 1970
 Stalinizm i społeczeństwo polskie, Warszawa 1991
 Urwany lot. Pokolenie inteligenckiej młodzieży powojennej w świetle listów i pamiętników z lat 1945–1948, Kraków 2003
 Wartości egzystencjalne młodzieży lat dziewięćdziesiątych, Warszawa 1995
 Młodzież PRL. Portrety pokoleń w kontekście historii, Kraków 2010

References

Polish sociologists
Academic staff of the University of Warsaw
1930 births
2012 deaths
Polish women academics
20th-century Polish women
Commanders of the Order of Polonia Restituta

redpajama_set_name: RedPajamaWikipedia


Our goal is to teach men and women what God has provided to mankind in the books of the Old and New Testament (commonly referred to as the Bible.) While our primary focus will be on the teachings of Jesus and his chosen apostles recorded in the New Testament, we will also familiarize students with the examples and wisdom shared in the Old Testament.
We believe that God (not man) is the sole source of authority. However, for the sake of potential students and interested readers, we provide the following list of viewpoints that are shared among the faculty and staff of JSP.
1. The Bible is the inerrant, infallible inspired word of God.
2. Jesus Christ was born of a virgin.
3. The church is the body of Christ here on earth.
4. Jesus Christ died, was buried and rose again.
5. Baptism is for the remission of sins.
6. Instrumental music is not for use in the assembly of the church of Christ.
7. The second coming of Jesus is taught in the New Testament.
8. Men and women are equal in the church, but each have different roles based on the teachings of the scriptures.


text:
The country was embarrassed by the BJP: Uddhav Thackeray
Mumbai: Maharashtra Chief Minister Uddhav Thackeray has slammed the Bharatiya Janata Party (BJP) over the Prophet Mohammad controversy. The country has been humiliated and embarrassed internationally by the BJP leader's controversial remarks. Arab countries put pressure on India to apologize. On the one hand, inflation is rising and the value of money is declining (against the dollar). Uddhav, on the other hand, addressed a rally in Aurangabad that the BJP was only concerned about finding shibboleths in the mosque.
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Uddhav has also criticized the Center for the recent killings of Hindus in Kashmir. He said that through the CBI and the Directorate of Enforcement, the leaders of the Maharashtra Development Front should be raided there (in Kashmir) instead of harassing them. Commenting on the controversial remarks made by former BJP spokesperson Nupur Sharma against Prophet Mohammad, he said, What was the fault of the country? The whole country is notorious because of the leaders of the BJP and its spokespersons. "
"What the BJP or its spokesperson has to say on any issue will never be India's opinion," Thackeray said. India's image has been tarnished internationally by the BJP spokesperson's remarks (addressed to Prophet Muhammad). It is not the BJP that has tarnished the image of my country. "I want to ask RSS chief Mohan Bhagwat whether he expects such behavior from the BJP," Thackeray said.
InThe country was embarrassed by the BJP
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If you're looking for a place to rent in Cape Town, these are the top 10 areas where Capetonians love living.
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Sandy Scott was born into a family of gardeners. Most of her horticultural knowledge came from following her father around his garden, asking questions, and begging to be allowed to weed. Sandy received a degree in art history at University of California at Berkeley and an MBA from Stanford. She blended her interests while volunteering at Filoli and the Huntington as well as working for Stanford. Sandy retired to Point Arena in 2000 and delights in sharing her garden.


The article reports on the joint venture formed by mining company AREVA and Mongolian state-owned nuclear company MON-ATOM, called AREVA Mines LLC, to develop its mining activities in Mongolia.
Reports that a consortium led by energy firm Areva has won a contract to replace steam generators from 900MW reactors in Europe. Quantity of steam generators to be replaced; Value of the deal; Overview of the deal.
The article reports on the joint venture between the wine energy companies Areva SA and Gamesa Corporación Tecnolóca SA to build 2.8 gigawatts of wind energy and an aim to capture 20% of the European off-shore wind market by 2020.
Reports on the joint ventures of French nuclear group Areva SA and Constellation Energy company to form UniStar Nuclear power plant in Annapolis, Maryland. Division of labor of the companies for the development of the power plant.


You have a big vision for your Rescue Mission, and even bigger hopes for the men, women and children you serve.
Now you have a new partner – with years of experience and a passion for designing fundraising around your organization and your specific needs.
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Delia Martín Agency is named after my mother and a brother. Both died much too young – yet both helped create a passion in me to help those who have exhausted all their options.
In my work over the years with Rescue Missions, I have seen men, women and children who are out of options come through their doors. And the Mission stretched out a hand, welcomed them in the name of Jesus, and gave them help and hope.
My passion is to honor my family by serving your Mission, partnering with you to maximize your direct response income – and your impact on your city.
Helping build Brewer Direct from the ground up. As VP of Client Service, Rod provided oversight on all campaigns and take point on strategic discussions for the agency.
Managing Grizzard Communications Group's largest, most successful Mission clients for nearly ten years as a Senior Account Executive.
Rod is a consummate client service specialist with a Business Administration degree. A graduate of Musicians Institute in Hollywood, he still finds time to play music and has served on worship teams at his church. Rod is also an active board member of Glendora National Little League where he coaches baseball.
Jill has over 17 years of experience in all aspects of direct mail fundraising, including list selections, overseeing all mail and print production, database conversions, and providing direct client support to the agency.
Prior to joining Delia Martin Agency, Jill worked as the Client Support Supervisor at Brewer Direct for 11 years and as a Senior Account Coordinator at Grizzard Communications Group.
"THRILLED!" When Rod Romero told me he was opening an agency to work directly with non-profit organizations, I was delighted. When he asked me to be a part of Delia Martin Agency, I was THRILLED.
I've worked with some really great people over the years.Russ Reid at RRC. Randy Brewer at Brewer Direct. Bob Hemmings at the original Smith/Hemmings. In each case, my greatest thrill has been creating fundraising programs with people who genuinely care about and are directly involved with their clients.
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It's no secret that e-sports are on the rise, becoming more and more popular each year with millions up for grabs in prize money. What would happen then if you could combine the aspects of a physical sport with the open ended options that technology can give? Hado might just have the answer.
Hado uses Augmented Reality and a smart device worn on the arm to bring their game to life. Definitely not one for the living room Hado plays out on a court and looks like a high tech version of dodge ball. Players can charge and throw their energy balls at the opposition who can either dodge or use shields to protect themselves and their team mates. Players can alter their load out in various ways to make them more defensive or attacking. For example attacking players could reduce the time it takes to charge their energy ball but making their shield weaker as a consequence, defensive players can do the opposite having a stronger shield but slower recharge rate for attacks.
Hado has been running events across Asia for a few years now and has already held several world cups and other competitions. In 2019 the first Hado pro league will begin in Japan with plans to expand across the globe by 2020.
When I first saw the promo videos I was blown away at how cool Hado looks to play. I'm not the fittest guy in the world so I don't think I'll manage some (all) of the gymnastics on show in the videos but I can't wait to have a try at this revolutionary game. Whilst there are Hado arenas around the globe there is currently only one in the UK (Birmingham) but hopefully as more people become aware of the sport more arenas will appear. Check out a list of Hado arenas to find your nearest.
As well as dodge ball, Hado have also launched an AR karting game where players race each other to collect as many AR coins as possible.
For more information on Hado you can visit the official site.