Jones Institute

Background: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in patients with atrial fibrillation (AF); however, inappropriate dosages may increase risk for adverse events. Using data from the American Heart Association’s Get with the Guidelines-Stroke registry (GWTG-Stroke) linked with Medicare data, we evaluated the association of DOAC dosing with risk of stroke/systemic embolism, major bleeding, and all-cause mortality in older ischemic stroke patients with AF. Methods: We included ischemic stroke patients admitted to a GWTG-Stroke hospitals in Oct. 2012-Dec. 2019 who were > 66 years, had a history of AF/flutter, and were discharged on a DOAC (dabigatran, rivaroxaban, or apixaban). DOAC dosing was defined as appropriate (standard dose or appropriately adjusted dose), underdose (reduced dose without indications for dose reduction or dose lower than recommended), or overdose (standard dose in patients with indications for dose reduction or dose higher than recommended). Normalized inverse probability weighted generalized boosted models were used to estimate 1-year outcomes after discharge. Results: Of the 37,464 ischemic stroke survivors (median age: 81 years; 53% female; 7% non-Hispanic Black), 68% were discharged with the appropriate DOAC dose, 22% were underdosed and 10% were overdosed. Apixaban was the most common DOAC (68%), followed by rivaroxaban (23%) and dabigatran (9%). The cumulative 1-year incidence of stroke/systemic embolism were 7.1%, 7.0%, and 7.9% among patients who were appropriate dosed, underdosed, and overdosed. After multivariable adjustments, there was no significant association between DOAC dose and stroke/systemic embolism ( Table ). However, patients who were overdosed (aHR 1.11 [1.01-1.23]) were associated with greater risk of major bleeding compared with appropriately dosed patients. Furthermore, patients who were underdosed were associated with greater risk of all-cause mortality (aHR 1.12 [1.06-1.18]). No significant association with mortality risk was observed in those who were overdosed. Conclusion: In a nationwide registry of ischemic stroke survivors with AF, approximately one-third of patients were prescribed a non-recommended DOAC dose. Patients who were overdosed had greater risk of major bleeding, while those underdosed had a greater risk of all-cause mortality. Strategies, including medical education, to ensure appropriate DOAC dosing at discharge are needed to reduce risk of adverse outcomes.

Introduction/Background: Hospital at Home (HaH) is an emerging, patient-centered clinical model by which patients receive inpatient-level care at home. HaH may be particularly well-suited to the care of patients with worsening heart failure (WHF). Research Questions: Our study sought to examine, if implemented widely, what proportion of US patients hospitalized with WHF would be eligible for HaH care. We also sought to determine the clinical and demographic differences between HaH eligible and ineligible populations. Methods/Approach: Among US patients hospitalized for WHF in the Get With The Guidelines – Heart Failure (GWTG-HF) registry from 2021-2024, we applied generally accepted and/or required (by Medicare) social and clinical criteria for HaH to estimate the proportion of patients potentially eligible for HaH. We then further compared the demographics, vital signs and laboratory findings, comorbidities, mortality, and length of stay for the HaH eligible and ineligible groups. Results/Data: Among 81,610 patients hospitalized across 204 sites, 49,544 (60.7%) were projected as eligible for HaH (Table 1) . Eligibility rates were >50% across demographic and geographic subgroups but tended to be higher among patients age >75 years, women, and Hispanic patients, as well as among patients hospitalized in urban areas and the Northeast US (Figure) . Eligible patients were less likely to have a history of chronic kidney disease and had a lower median GWTG-HF risk score (Table 2) . Patients eligible for HaH had lower in-hospital mortality and shorter length of stay (Table 2) . Conclusions: In this nationwide cohort of US patients hospitalized for WHF, approximately 6 out of 10 patients were projected as potentially eligible for HaH, with modest variability across demographic and geographic subgroups. Patients eligible for HaH demonstrated a lower risk clinical profile. HaH could conceivably be a viable treatment strategy for the majority of US patients with WHF, and national efforts to continue or expand HaH have the potential to substantially impact WHF care delivery.

This paper highlights findings from a targeted survey of aerial pesticide applicators who specialize in mosquito control space sprays. The questionnaire captured location and site details, aircraft types, and use scenarios, as well as spray system configurations, operational protocols, and pesticide use. By identifying common application settings across different platforms, the survey offers a vital benchmark for ensuring that current and future gathering of empirical data for AGriculturalDISPersal™ (AGDISP) refinement aligns with real-world conditions. These data are discussed in relation to the current mechanistic model AGDISP and relevance to the design of the field trials already underway at Lee County Mosquito Control District, Florida.

In their recent publication, Rosenberg et al. conclude the following: “Visual recovery and cystoid macular edema rates were significantly better in patients who underwent cataract surgery assisted by the 3D digital visualization without an increase in complications or surgical time.”1 Our letter argues that the analysis conducted by Rosenberg et al. lacks rigor, casting doubt on the reliability of their findings. We believe that the current form of their study does not provide robust evidence that 3D-assisted cataract surgery is associated with better visual recovery and lower cystoid macular edema rates compared with cataract surgery performed using a traditional analog operating microscope. The study's findings are drawn from comparisons of postoperative outcomes between groups with differing rates of diabetes—37% in the traditional group vs 28% in the digital group. While the P value of .16 suggests no statistical significance, it is crucial to recognize that P values can be influenced by sample sizes, which in this case are relatively small (118 vs 96). This could mask potential underlying differences that are clinically relevant.2 A more appropriate approach would be to report the standardized difference for baseline characteristics, which provides a measure of effect size that is not contingent upon sample size.2 This would offer a clearer understanding of whether the baseline difference in diabetic status between the groups could be contributing to the observed outcomes. Furthermore, given the clinical significance of diabetes in the development of cystoid macular edema, a multivariate analysis, such as logistic regression, adjusting for diabetic status and other relevant confounders, would provide a more accurate estimation of the effect of 3D digital visualization on postoperative outcomes. Several studies have indicated that preoperative factors, such as Black race, preexisting comorbidities such as epiretinal membrane or central retinal vein occlusion, a history of pseudophakic cystoid macular edema in the fellow eye, and preoperative use of topical prostaglandin analogs, are associated with a higher risk of postoperative cystoid macular edema after cataract surgery.3–5 In the study by Rosenberg et al., patients with complex cases requiring additional manipulation and those with preoperative corneal pathologies were excluded. However, no information was provided about the preexisting comorbidities mentioned above in both groups. It is conceivable that the higher rate of cystoid macular edema in the traditional group could be attributed, at least in part, to their higher diabetic status and other co-existing confounding comorbidities. In addition, as diabetes can manifest with varying degrees of retinal involvement, the analysis would benefit from stratifying by the severity of diabetic retinopathy, which is a known risk factor of cystoid macular edema. This stratification could elucidate the extent to which diabetic retinopathy contributes to the risk of cystoid macular edema after cataract surgery.3,4 We have previously shown that even in the absence of diabetic retinopathy preoperatively, the relative risk (RR) of pseudophakic cystoid macular edema is increased (RR, 1.8). The presence of any form of diabetic retinopathy significantly increases the risk of developing pseudophakic cystoid macular edema (RR, 6.2), and the RR is proportional to the DR severity, ranging from 2 to 6 in nonproliferative diabetic retinopathy to 10 in proliferative retinopathy.4 While the study by Rosenberg et al. provides valuable insights, a more rigorous statistical analysis that includes standardized differences and adjustment for baseline imbalances/covariates is crucial. Without these considerations, it remains uncertain whether the differences in visual recovery and cystoid macular edema rates can be confidently attributed to the use of 3D digital visualization systems.

Introduction: Patients with tetralogy of Fallot (TOF) from disadvantaged racial and ethnic groups are reported to have worse outcomes, including worse exercise performance. The underlying mechanisms are not fully understood. Hypothesis: We hypothesize that the association of exercise performance with race is mediated by socioeconomic factors. Methods: We conducted a single center retrospective cohort study of TOF patients aged 8 - 30 years who underwent maximal exercise stress testing (EST) from 2007 - 2020. The primary outcome was percent-predicted maximum oxygen consumption (VO2). Addresses were geocoded. The Childhood Opportunity Index (COI) and its three domains represented neighborhood socioeconomic status. Generalized linear models and mediation analysis were used (Figure). Results: We included 154 subjects who underwent 273 ESTs (Table). Correcting for age at EST, sex, outflow tract repair type, and body mass index, those of non-Hispanic Black race had an 8.6% lower percent-predicted VO2 (95% CI -15.0, -2.2) than those of non-Hispanic white race. Mediation analysis showed that the COI mediates 90% of this relationship. By domain, Education is the strongest mediator and alone can account for 75% of this relationship. Conclusions: Disparities exist in exercise performance after TOF repair. Neighborhood-level factors, in particular related to Education, are significant mediators of the relationship between race and exercise performance in TOF. A detailed understanding of the driving mechanisms underlying health disparities, particularly those that are modifiable, is critical to eliminating those disparities at both the patient and societal levels.

Introduction: High-bleeding risk (HBR) patients undergoing percutaneous coronary intervention (PCI) are often at high risk for thrombotic complications following coronary stenting. We sought to evaluate the frequency and predictors of myocardial infarction (MI) or stent thrombosis (ST) events in HBR patients at 1 year after PCI. Methods: We included HBR patients undergoing PCI with drug-eluting stent implantation at a tertiary-care center, between 2012 and 2019. HBR status was defined as the presence of ≥1 major or ≥2 minor Academic Research Consortium-HBR criteria. Clinical and angiographic baseline characteristics were analyzed after stratifying patients by the occurrence of MI/ST. Independent predictors of MI/ST at 1-year follow-up were assessed using Cox multivariate regression analysis. Results: Among 7,806 HBR patients undergoing PCI, 245 (3.1%) experienced MI/ST within one year of the index procedure. These patients were more frequently female (42.6% vs. 35.7%, p=0.03), had a higher prevalence of insulin-dependent diabetes mellitus (62.3% vs. 40.5%, p<0.001), peripheral artery disease (18.4% vs. 13.4%, p=0.03), chronic kidney disease (57.1% vs. 52.1%, p=0.006), and a history of prior PCI (57.1% vs. 45.7%, p<0.001). Furthermore, they were more likely to undergo complex PCI (43.3% vs. 32.3%, p<0.001) and had a higher mean syntax score (20.6±12.5 vs. 14.2±10.8, p<0.001). Multivessel disease was the most prevalent and strongest predictor of MI/ST at 1-year follow-up, followed by acute coronary syndrome and diabetes mellitus ( Figure ). Conclusions: MI/ST events frequently occur in HBR patients undergoing PCI. Predictors of MI/ST must be accounted for while deciding on the optimal antithrombotic therapy strategy in these patients.