Showing papers by "Robert J. Goldberg published in 2019"

Anticoagulant Prescribing for Non-Valvular Atrial Fibrillation in the Veterans Health Administration.

Abstract: Background Direct acting oral anticoagulants (DOACs) theoretically could contribute to addressing underuse of anticoagulation in non‐valvular atrial fibrillation (NVAF). Few studies have examined t...

The Kathmandu Declaration on Global CVD/Hypertension Research and Implementation Science: A Framework to Advance Implementation Research for Cardiovascular and Other Noncommunicable Diseases in Low- and Middle-Income Countries

Abstract: Highlights NCD represent a serious challenge globally, particularly in LMIC Implementation research capacity building are critical to inform the prevention and control of NCD in LMIC Sustainable evidence-based strategies can reduce mortality and prevent avoidable illness from NCD Strategic change agents (ie, key stakeholders, institutions, communities, health systems, patients, and families) should work collaboratively to make the necessary advancements to reducing the burden of NCD in LMIC

Decade Long Trends (2001–2011) in the Incidence Rates of Initial Acute Myocardial Infarction

Abstract: Despite the magnitude and impact of acute coronary disease, there are limited population-based data in the United States describing relatively recent trends in the incidence rates of acute myocardial infarction (AMI). The objectives of this study were to describe decade long (2001–2011) trends in the incidence rates of initial hospitalized episodes of AMI, with further stratification of these rates by age, sex, and type of AMI, in residents of central Massachusetts hospitalized at 11 area medical centers. The study population consisted of 3,737 adults hospitalized with a first AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The median age of this study population was 70 years, 57% were men, and 90% were white. Patients hospitalized during the most recent study years (2009/11) were younger, more likely to be men, have more co-morbidities, and less in-hospital complications as compared with those in the earliest study years (2001/03). The overall age-adjusted hospital incidence rates (per 100,000 persons) of initial AMI declined (from 319 to 163), for men (from 422 to 219), women (from 232 to 120), for patients with a ST segment elevation (129 to 56), and for those with an non-ST segment elevation (190 to 107) between 2001 and 2011, respectively. In conclusion, the incidence rates of initial AMI declined appreciably in residents of central Massachusetts who were hospitalized with AMI during the years under study.

Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF.

Abstract: Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC). Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions. Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA2DS2VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records. Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA2DS2VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18-0.59) and social isolation (OR = 0.38, 95%CI 0.14-0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05-4.29) in patients aged 65-74 years. Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Impact of cardiac- and noncardiac-related conditions on adverse outcomes in patients hospitalized with acute myocardial infarction:

Abstract: Background:To examine the impact of cardiac- and noncardiac-related conditions on the risk of hospital complications and 7- and 30-day rehospitalizations in older adult patients with an acute myoca...

Religious practices and changes in health-related quality of life after hospital discharge for an acute coronary syndrome.

Abstract: Religious beliefs and practices influence coping mechanisms and quality of life in patients with various chronic illnesses. However, little is known about the influence of religious practices on changes in health-related quality of life (HRQOL) among hospital survivors of an acute coronary syndrome (ACS). The present study examined the association between several items assessing religiosity and clinically meaningful changes in HRQOL between 1 and 6 months after hospital discharge for an ACS. We recruited patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011–2013). Participants reported making petition prayers for their health, awareness of intercessory prayers by others, and deriving strength/comfort from religion. Generic HRQOL was assessed with the SF-36®v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated using the Seattle Angina Questionnaire Quality of Life subscale (SAQ-QOL). We separately examined the association between each measure of religiosity and the likelihood of experiencing clinically meaningful increase in disease-specific HRQOL (defined as increases by ≥10.0 points) and Generic HRQOL (defined as increases by ≥3.0 points) between 1- and 6-months post-hospital discharge. Participants (n = 1039) were, on average, 62 years old, 33% were women, and 86% were non-Hispanic White. Two-thirds reported praying for their health, 88% were aware of intercessions by others, and 85% derived strength/comfort from religion. Approximately 42, 40, and 26% of participants experienced clinically meaningful increases in their mental, physical, and disease-specific HRQOL respectively. After adjustment for sociodemographic, psychosocial, and clinical characteristics, petition (aOR:1.49; 95% CI: 1.09–2.04) and intercessory (aOR:1.72; 95% CI: 1.12–2.63) prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL respectively. Most ACS survivors in a contemporary, multiracial cohort acknowledged praying for their health, were aware of intercessory prayers made for their health and derived strength and comfort from religion. Patients who prayed for their health and those aware of intercessions made for their health experienced improvement in their generic physical and disease-specific HRQOL over time. Healthcare providers should recognize that patients may use prayer as a coping strategy for improving their well-being and recovery after a life-threatening illness.

Influence of Multimorbidity on Burden and Appropriateness of Implantable Cardioverter-Defibrillator Therapies.

Abstract: OBJECTIVE To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN Retrospective cohort study. SETTING Seven US healthcare delivery systems. PARTICIPANTS Adults with left ventricular systolic dysfunction receiving an implantable cardioverter-defibrillator (ICD) for primary prevention. MEASUREMENTS Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0-3, 4-5, 6-7 and 8-16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4-8), with 98% having at least two comorbidities. During a mean 2.2 years of follow-up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14-3.31] for 4-5 comorbidities; HR = 2.25 [95% CI = 1.25-4.05] for 6-7 comorbidities; and HR = 2.91 [95% CI = 1.54-5.50] for 8-16 comorbidities). Participants with 8-16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43-3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67-6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07-2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation.

Predicting 30-day mortality and 30-day re-hospitalization risks in Medicare patients with heart failure discharged to skilled nursing facilities: development and validation of models using administrative data

Abstract: Background Despite the growing importance of skilled nursing facility care for Medicare patients hospitalized with heart failure, no risk prediction models for these patients exist. Objectives To develop and validate separate predictive models for 30-day all-cause mortality and 30-day all-cause re-hospitalization. Design Retrospective cohort study using a nationwide Medicare claims data cross-linked with Minimum Data Set 3.0. Setting 11,529 skilled nursing facilities in the United States (2011-2013). Participants 77,670 hospitalized heart failure patients discharged to skilled nursing facilities (randomly split into development (2/3) and validation (1/3) cohorts). Measurements Using data on patient sociodemographic and clinical characteristics, health service use, functional status, and facility-level factors, we developed separate prediction models for 30-day mortality and 30-day re-hospitalization using logistic regression models in the development cohort. Results Within 30 days, 6.8% died and 24.2% were re-hospitalized. Thirteen patient-level factors remained in the final model for 30-day mortality and 10 patient-level factors for re-hospitalization with good calibration. The area under receiver operating characteristic curves were 0.71 for 30-day mortality and 0.63 for re-hospitalization in the validation cohort. Conclusions Among Medicare patients with heart failure discharged to skilled nursing facilities, predicting 30-day mortality and re-hospitalization using administrative data is challenging. Further work identifying factors for re-hospitalization remains needed.

Religious Practices and Long-Term Survival After Hospital Discharge for an Acute Coronary Syndrome

Abstract: Background Prior studies of healthy populations have found religious practices to be associated with survival. However, no contemporary studies have examined whether religiosity influences survival among patients discharged from the hospital after an acute coronary syndrome (ACS). The present study examined the relationship between religious practices and 2-year all-cause mortality among hospital survivors of an ACS. Methods Patients hospitalized for an ACS were recruited from 6 medical centers in Massachusetts and Georgia between 2011 and 2013. Study participants self-reported three items assessing religiosity: strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. All cause-mortality within 2-years of hospital discharge was ascertained by review of medical records at participating study hospitals and from death certificates. Cox proportional hazards models were used to estimate the multivariable adjusted risk of 2-year all-cause mortality. Results Participants (n = 2,068) were on average 61 years old, 34% were women, and 81% were non-Hispanic White. Approximately 85% derived strength/comfort from religion, 61% prayed for their health, and 89% were aware of intercessions. Overall, 6% died within 2 years post-discharge. After adjusting for sociodemographic variables (age, sex, and race/ethnicity), petition prayers were associated with an increased risk of 2-year all-cause mortality (HR: 1.64; 95% CI: 1.01–2.66). With further adjustment for several clinical and psychosocial measures, this association was no longer statistically significant. Strength and comfort from religion and intercessory prayers were not significantly associated with mortality. Conclusions Most ACS survivors acknowledge deriving strength and comfort from religion, praying for their health, and intercessions made by others for their health. Although the reported religious practices were not associated with post-discharge survival after multivariable adjustment, acknowledging that patients utilize their religious beliefs and practices as strategies to improve their health would ensure a more holistic approach to patient management and promote cultural competence in healthcare.

Characteristics, Management, and Short-Term Outcomes of Adults ≥65 Years Hospitalized With Acute Myocardial Infarction With Prior Anemia and Heart Failure.

Abstract: Our study objectives were to examine the impact of anemia and heart failure (HF) on in-hospital complications, and postdischarge outcomes (7 and 30-day rehospitalizations and mortality) in adults ≥65 years hospitalized with acute myocardial infarction (AMI). We used multivariable-adjusted logistic regression models to examine the association between the presence of anemia and/or HF, and the examined outcomes. The study population consisted of 3,863 patients ≥65 years hospitalized with AMI at the 3 major medical centers in Worcester, MA, during 6 annual periods between 2001 and 2011. Individuals were categorized into 4 groups based on the presence of previously diagnosed anemia (hemoglobin ≤10 mg/dl) and/or HF: Those without these conditions (n = 2,300), those with anemia only (n = 382), those with HF only (n = 837), and those with both conditions (n = 344). The median age of the study population was 79 years and 49% were men. Individuals who had been previously diagnosed with anemia and HF had the highest proportion of older adults (≥85 years) and the lowest proportion of those who had received any cardiac interventional procedure during hospitalization. After multivariable adjustment, individuals who presented with both previously diagnosed conditions were at the greatest risk for experiencing adverse events. Patients who presented with HF only were at higher risk for developing several clinical complications during hospitalization, whereas those with anemia only were at slightly higher risk of being rehospitalized within 7-days of their index hospitalization. In conclusion, anemia and HF are prevalent chronic conditions that increased the risk of adverse events in older adults hospitalized with AMI.

Re: "Permanent Versus Bioresorbable Implants in Orbital Floor Blowout Fractures".

Abstract: To the Editor: We thank Drs. Ramesh and Goldberg for their letter. We agree with their points and acknowledge their concerns. We also enjoyed reading their systematic review of bioresorbable implants for orbital fracture repair, and appreciate their observation on the various stresses that different orbital fractures can withstand. In addition to the points mentioned in our article, it should be noted that orbital walls are typically and routinely not impact bearing bones, although in the face of trauma, the rims and strut do bear impact and offer significant support to the orbital soft tissue structures. Second, while the ultimate implant choice is dependent on several factors, we generally choose to use bioresorbable implants for combined floor and medial wall fractures in patients who are not at high risk for repetitive orbital injury, e.g., sedentary patients, those not involved in contact sports, etc. For those who are at increased risk of impacts or further trauma, e.g., contact sports, industrial workers, etc., we fully agree that an anatomically correct, prefabricated permanent implant would be ideal. As pointed out, bioresorbable implants vary immensely regarding their chemical constitution, resorption rates, induced inflammatory reaction, proximity to fractured bone fragments, imaging characteristics on imaging and their mechanical properties at the time of placement, and various stages of resorption. Our earlier publication on the use of bioresorbable implants in orbital fractures demonstrated, with late To the Editor: I would like to congratulate the authors of the manuscript, “Permanent versus bioresorbable implants in orbital floor blowout fractures,” on their excellent case series of resorbable implants for orbital floor fractures. We have just published a systematic review of bioresorbable implants for orbital fracture repair, and have one important observation based on our research. The orbital floor or the lamina papyracea can withstand stress of roughly 300 megapascals (MPa), or 43,511 psi, while the inferior orbital rim and the inferomedial strut can bear loads of up to 1.2 gigapascals (GPa), or 174,045 psi. While different commercially available resorbable polymers have different characteristics (Fig. 1) as the authors astutely point out, none are able to maintain a strength of 1.2 GPa for longer than 6 months, while the critical periods of osteogenesis can take up to 24 months. As such, we suggest that while resorbable implants are well suited for isolated floor or medial fractures, permanent material may reduce late enophthalmos in load-bearing applications after fracture of the inferomedial strut or inferior rim.

Stakeholder Engagement in Late-Stage Translation Phase 4 Research for Noncommunicable Diseases in Low- and Middle-Income Countries: What Works and Why—The Vietnam Experience (UMMS–Vietnam Team)

Abstract: Background: Stakeholder engagement is crucial for conducting high-quality implementation research as well as for the incorporation and adoption of health interventions and policies in the community Objectives: This study sought to build a mutually rewarding collaboration between stakeholders in Vietnam and investigators in the United States Methods: A collaboration was established between investigators from several institutions in Vietnam and the University of Massachusetts Medical School that was built on mutual trust, cross-cultural learning, and shared experiences This collaborative arrangement has led to sustainable stakeholder engagement in Vietnam We formed a multidisciplinary transnational research team and maintained regular contact both online and in person We also conducted a needs assessment study, in which several focus group discussions and in-depth interviews of stakeholders in Vietnam were carried out Results: The formal collaboration between investigators in Vietnam and the University of Massachusetts Medical School began in 2011 and has strengthened over time The US team provided expertise in study and intervention design, data collection and analysis, and trial implementation, whereas the team in Vietnam brought a deep understanding of local health care delivery systems and expertise in the delivery of health care interventions at the grassroots level Our initial partnership has now grown to include committed individuals at the government, academic, and community levels including the Vietnam Ministry of Health, key governmental and nongovernmental research institutions and agencies, medical and public health universities, and communities in rural settings The needs assessment study found that there are important gaps in the delivery of hypertension management practices in many rural communities in Vietnam and that stakeholders are fully engaged in our ongoing, community-based, hypertension-control project Conclusions: Multiple layers of stakeholders and communities in Vietnam are fully engaged with, and have contributed significantly to, our ongoing hypertension control research project in Northern Vietnam Highlights The formal collaboration between investigators in Vietnam and the UMMS began in 2011 and has strengthened over time The US team provided expertise in study and intervention design, data collection and analysis, and trial implementation, whereas the team in Vietnam brought a deep understanding of local health care delivery systems and expertise in the delivery of health care interventions at the grassroots level Our initial partnership has now grown to include committed individuals at the government, academic, and community levels including the Vietnam Ministry of Health, key governmental and nongovernmental research institutions and agencies, medical and public health universities, and communities in rural settings The needs assessment study found that there are important gaps in the delivery of HTN management practices in many rural communities in Vietnam and that stakeholders are fully engaged in our ongoing, community-based, HTN-control project

Reply Re: "Bony Regrowth After Deep Lateral Orbital Decompression".

Abstract: We commend the authors on exploring a subject that may impact surgical prognosis in addition to postoperative planning of patients requiring repeat orbital decompression for thyroid eye disease. As the authors discussed, bony regrowth has been observed in other sites in the orbit, such as after conservatively treated orbital fractures (radiologically) and after dacryocystorhinostomy (microscopically). While this subject is important, the evidence provided in this manuscript may be problematic in proving the claims that bony regrowth may occur after deep lateral wall decompression. For Case 1, CT scans in Figure 1A, B are being directly compared, but they are of different radiologic windows. Comparing the 2 may be misleading when interpreting the presence or absence of a very thin layer of bone growth. In Figure 1C, without intraoperative stereotactic navigation as described by Wu and Kahana, or without histologic specimens of the area, it is difficult to ascertain if this area corresponds to the exact location of bony regrowth as presumed on CT and if there is actual microscopic evidence of bony regrowth. In Case 2, Figure 2B, C, comparing the initial postoperative CT to a later postoperative CT, are of a different axial cut. Therefore, radiologically comparing these 2 figures for bony regrowth is challenging. We welcome the authors to submit a reply including updated figures with similar window and axial cuts of the CT scans. This will help support the postulations of the manuscript better. In addition, we encourage further research in this field, including histologic sampling of the surgical sites in repeat decompression surgery.

Anatomic variation of the entrance of the optic canal into the orbit.

Abstract: Purpose: To characterise variations in the location of the optic canal and its entry into the orbit in relation to the sphenoid sinus.Methods: In this observational study, patients with hig...