Daniel Lerner

When should doppler-determined valve area be better than the Gorlin formula?: Variation in hydraulic constants in low flow states

In low flow states, underestimation errors occur when the Gorlin formula is used to calculate valve area. A model of valvular stenosis designed to examine changes in the hydraulic discharge coefficient (Cd) and coefficient of orifice contraction (Cc) may explain these errors. Unsteady flow was examined in a pulsatile pump model and in a dog model. Valve areas were calculated from pressure and flow data using: a modified form of the Gorlin formula (assuming constant values for Cd and Cc) and a corrected formula (with values of Cd and Cc obtained from steady state data). Valve area was also calculated using the continuity equation with velocity and flow data (constant Cc). Flow velocities were measured using a newly designed ultrasound Doppler catheter capable of resolving flow velocities of up to 5.5 m/s. Both the corrected formula and continuity equation were highly predictive of actual valve area (r = 0.99, slope or M = 0.96 and r = 0.99, M = 1.06, respectively). The modified Gorlin equation was less accurate and tended to underestimate valve areas (r = 0.87, M = 0.83). This underestimation was most notable at low rates of flow (Gorlin: r = 0.94, M = 0.53; continuity: r = 0.93, M = 0.81 and r = 0.94, M = 0.89, respectively) more accurately than the modified Gorlin formula (r = 0.69, M = 0.49). In patients with low cardiac output, hemodynamic formulas, such as the Gorlin formula, which assume a constant value for the hydraulic discharge coefficient (Cd), may be less accurate than formulas using either a corrected value of Cd or Doppler-determined flow velocity and mean systolic flow.

Implantation success and infection in cardiovascular implantable electronic device procedures utilizing an antibacterial envelope.

Background:  Cardiovascular implantable electronic device (CIED) infection rates are increasing faster than implantation rates. More effective antimicrobial prophylaxis may help reduce CIED infections and improve clinical outcomes. The AIGISRx® antibacterial envelope is a polymer mesh implanted in the generator pocket with the CIED. After implantation it releases two antibiotics, minocycline and rifampin, that have been shown to reduce infections associated with other medical devices. The purpose of this retrospective cohort study is to determine the rate of CIED implantation success and CIED infection in procedures utilizing the antibacterial envelope.

Increased long-term mortality in patients with cardiovascular implantable electronic device infections.

Device infection is associated with increased mortality in patients receiving cardiovascular implantable electronic device (CIED) therapy. However, long‐term mortality associated with CIED infections has not been systematically analyzed in larger studies. This study sought to determine the long‐term mortality associated with CIED infection in a large cohort of Medicare beneficiaries.

Euratlantica: changing perspectives of the European elites

with the theme of Nationalism and Social Communication. Nationalism and Its Alternatives is seriously marred by a confusing use of key terms. What Deutsch calls a people is what Ernest Barker, Rupert Emerson, Carlton Hayes, and others called a nation. Deutsch here reserves the term nation for a people who have control of a state or, at least, an important measure of self-government. A nation-state is defined in the traditional manner as one which has become largely identical with one people. Despite these definitions, nation is often used interchangeably with state, and nation-state and national state are often used to refer to what in fact are multinational states. Thus Spain (actually a multinational state) is referred to as a nation. The Belgians (that is, the Flemish and Walloons who uncomfortably share the territory of Belgium) are likewise referred to as a nation. Such multinational states as Czechoslovakia, Romania, and Yugoslavia are referred to as nationstates. Most surprising, however, is that the central subject, nationalism, is nowhere defined. Sometimes it refers to identification with a state and other times to identification with an ethnic group. There are two other aspects of the work that troubled this reviewer. One is Professor Deutschs treatment of the states of Westem Europe as fully assimilated entities, despite the fact that Belgium, France, Italy, Spain, Switzerland, and the United Kingdom have all been troubled by ethnic discord in recent years. The second objection is to Professor Deutschs emphasis upon the material rewards and services that groups receive from association with the state as a major element in determining whether the state will be troubled by separatist tendencies. This position is seriously questioned by the prevalence of separatist attitudes among ethnic groups even while they were rapidly closing the economic and benefit gap between themselves and the states leading ethnic group. Flemish and Slovaks are recent cases in point. Moreover, separatist desires have grown on the part of the Croats and Slovenes, despite the fact that both people are significantly better off than are the politically dominant Serbs. At least in some instances, then, it would appear that nothing secedes like success.

One-year mortality and costs associated with surgical ablation for atrial fibrillation concomitant to coronary artery bypass grafting†.

OBJECTIVES While surgical ablation (SA) for persistent atrial fibrillation (AF) can reduce recurrence of AF, its impact on longitudinal survival and health‐care costs remains controversial. This study defines the clinical outcomes and costs associated with SA in patients with prior AF undergoing coronary artery bypass grafting (CABG). METHODS A total of 3745 Medicare beneficiaries with prior AF who underwent CABG in 2013 were divided into 2 groups: those with and those without concomitant SA. Risk‐adjusted early (0‐90 days) and late (91‐364 days) postoperative outcomes and inpatient costs were compared. RESULTS SA was performed in 17% of CABG patients with prior AF. Preoperative characteristics favoured patients with SA: emergent presentation (15% vs 22%), heart failure in the 2 weeks prior to CABG (31% vs 36%), chronic lung disease (27% vs 33%) and renal failure (4% vs 7%) (all P < 0.05). Risk‐adjusted operative mortality and perioperative stroke rates were similar in the 2 groups. Risk‐adjusted survival was similar through 90 days, but significantly better with SA after 90 days [hazard ratio (HR) = 0.58; P = 0.03]. At 1 year, the risk‐adjusted incidence of cardiovascular implantable electronic device implantation was greater with SA (HR = 1.20; P = 0.01). Risk‐adjusted costs for the CABG admission (HR = 1.11; P < 0.01) and inpatient care through 1 year (HR = 1.06; P = 0.02) were also greater with SA. CONCLUSIONS In the US Medicare population, SA was performed in 17% of CABG‐AF patients in 2013. Operative risks for mortality and stroke did not increase with SA but costs did. Patients receiving SA, however, had significantly better risk‐adjusted late survival.

Book of the Month

Harold D. Lasswell, Daniel Lerner, and Hans Speier, eds. Propaganda and Communication in World History, Volume 1: The Symbolic Instrument in Early Times (Honolulu: University Press of Hawaii, 1979---S25.00)

The Passing of Traditional Society: Modernizing the Middle East.

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