The topical application of telbermin 72 microg/cm2 three times a week for up to six weeks appeared to be well tolerated. Further studies are required to characterise the safety/efficacy of telbermin more completely.
Aims Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in-hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF. Methods and results We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007-2015 and stratified patients by age and SCAI shock stage. The association between age and in-hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co-morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In-hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2-1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2-1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage. Conclusions Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in-hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.
Background Abnormal serum sodium levels have been associated with higher mortality among patients with acute coronary syndromes and heart failure. We sought to describe the association between sodium levels and mortality among unselected cardiac intensive care unit ( CICU ) patients. Methods and Results We retrospectively reviewed consecutive adult patients admitted to our cardiac intensive care unit from 2007 to 2015. Hyponatremia and hypernatremia were defined as admission serum sodium <135 and >145 mE q/L, respectively. In‐hospital mortality was assessed by multivariable regression, and postdischarge mortality was evaluated by Cox proportional‐hazards analysis. We included 9676 patients with a mean age of 68±15 years (37.5% females). Hyponatremia occurred in 1706 (17.6%) patients, and hypernatremia occurred in 322 (3.3%) patients; these groups had higher illness severity and a greater number of comorbidities. Risk of hospital mortality was higher with hyponatremia (15.5% versus 7.5%; unadjusted odds ratio, 2.41; 95% CI , 2.06–2.82; P <0.001) or hypernatremia (17.7% versus 8.6%; unadjusted odds ratio, 2.82; 95% CI , 2.09–3.80; P <0.001), with a J‐shaped relationship between admission sodium and mortality. After multivariate adjustment, only hyponatremia was significantly associated with in‐hospital mortality (adjusted odds ratio, 1.42; 95% CI, 1.14–1.76; P =0.002). Among hospital survivors, risk of postdischarge mortality was higher in patients with hyponatremia (adjusted hazard ratio, 1.28; 95% CI , 1.17–1.41; P <0.001) or hypernatremia (adjusted hazard ratio, 1.36; 95% CI, 1.12–1.64; P =0.002). Conclusions Hyponatremia and hypernatremia on admission to the cardiac intensive care unit are associated with increased unadjusted short‐ and long‐term mortality. Further studies are needed to determine whether correcting abnormal sodium levels can improve outcomes in cardiac intensive care unit patients.
To achieve reductions in the power consumption of the data center cooling infrastructure, the current strategy in data center design is to increase the inlet temperature to the rack, while the current strategy for energy-efficient system thermal design is to allow increased temperature rise across the rack. Either strategy, or a combination of both, intuitively provides enhancements in the coefficient of performance (COP) of the data center in terms of computing energy usage relative to cooling energy consumption. However, this strategy is currently more of an empirically based approach from practical experience, rather than a result of a good understanding of how the impact of varying temperatures and flow rates at rack level influences each component in the chain from the chip level to the cooling tower. The aim of this paper is to provide a model to represent the physics of this strategy by developing a modeling tool that represents the heat flow from the rack level to the cooling tower for an air cooled data center with chillers. This model presents the performance of a complete data center cooling system infrastructure. After detailing the model, two parametric studies are presented that illustrate the influence of increasing rack inlet air temperature, and temperature rise across the rack, on different components in the data center cooling architecture. By considering the total data center, and each component's influence on the greater infrastructure, it is possible to identify the components that contribute most to the resulting inefficiencies in the heat flow from chip to cooling tower and thereby identify the components in need of possible redesign. For the data center model considered here it is shown that the strategy of increasing temperature rise across the rack may be a better strategy than increasing inlet temperature to the rack. Part II of this work expands on this paper with further parametric studies to evaluate the robustness of this data center cooling strategy, with conditions for optimal strategy deployment.
ObjectivesTo examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS).Methods1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed.ResultsAge was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40–1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42–1.69), p<0.0001), dyspnoea (HR=1.58 (1.33–1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22–2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52–2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07–1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38–0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84–1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62–0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS.ConclusionAF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.
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