Biography:

Brojendra Agarwala has completed his MBBS from University of Kolkata, India and completed Pediatric Cardiology fellowship from New York University Medical Center New York, NY, USA. He is a Pediatric Cardiologist and Professor of Pediatrics at the University of Chicago. He has received Best Teacher Award by the pediatric residents and the medical students. He has published 68 papers in reputed journals. He is named as one of the top doctors and best pediatricians in Chicago magazine for many years.

Abstract:

Competitive athletes are those who participates in an organized team or individual sports that requires regular competition against others. Athletic activities substantially increase the sympathetic drive resulting in surge in catecholamine level that increases blood pressure, heart rate, myocardial contractility and oxygen demand. This can cause myocardial ischemia and arrhythmia that may lead to sudden death in athletes with known and unrecognized heart conditions during athletic activities. It is estimates that 1-2/100,000 SCD/year happens worldwide. According to the International Olympic Committee, SCD rate in athletes is ~ three times higher than in the normal population. There are many structural and acquired heart conditions that are not clinically manifested. Many physicians are involved in medical clearance of children for participations in school sports activities. Physicians have to recognize them to protect athletes from catastrophic events. In order to prevent sudden cardiac death physicians should be aware of cardiac conditions that may cause problem. Also physicians should be familiar with general guidelines for evaluation of an athlete and clearance for participation in athletic activities. Guidelines vary in different parts of the world. In this presentation I will discuss guidelines for European, Italian and in USA outlined by American heart Association. In this presentation the causes of congenital and acquired heart conditions and arrhythmias that can cause sudden cardiac death will be discussed with authors experience and literature review.

Biography:

Abstract:

Eosinophilic coronary periarteritis (EPCA) was recently reported by Kajihara and his co-workers as a new pathologic entity, and clinically showed a vasospastic angina and sudden cardiac death (SCD). The patients were relatively young (mainly 30 to 50 years old) and predominantly male. The characteristic clinical findings of this disease include a) vasospastic angina (Prinzmetal’s variant angina) appearing usually from evening to early in the morning, b) all patients experienced SCD early in the morning, and c) allergy or history of allergy was hard to identify in the patients with this disease. Histological findings include a) eosinophilic inframmatory infiltration limited to the adventitia and periadventitial soft tissue is recognized in the epicardial large coronary arteries, b) all 3 main coronary artery branches are affected, with the left anterior descending artery most frequently affected, c) medial smooth muscle cells of the affected coronary artery and both internal and external elastic laminae are well preserved, d) fibrinoid necrosis or granuloma as seen in polyarteritis nodosa (PN) or allergic granulomatous angiitis (AGA) are not found in or around the inflammatory areas, and e) no findings of any type of vasculitis in any other tissue or organs. Spontaneous coronary artery dissection (SCAD) is frequently accompanied by eosinophilic inflammatory infiltration limited to the adventitia and periadventitial soft tissue in the dissected portion of the epicaldial coronary arteries, i.e., same as the findings of EPCA, and the patients usually die suddenly. EPCA was recently reported in the patient with cocaine abuse. The diagnosis of ECPA is very difficult to make at the clinical examination stage and is made almost exclusively at autopsy. However, vasospastic angina appearing mainly from the evening to early in the morning (Prinzmetal’s variant angina) is the most important symptom of this disease.

Biography:

Jean Pierre Usdin MD., is a Former Internal of the Hospitals of Paris, Former Head of clinic, Assistant of the Hospitals of Paris, Former consultant in scientific committee of medical Journal CONSENSUS and previous Chief of the cardiologic department of American Hospital of Paris (2006-2012). He is currently renowned Cardiologist at American Hospital of Paris, Member of European Society of Cardiology, Member of French Society of Cardiology. Being a Journalist and Blogger in Medscape France (From 2010) he has blogs dedicated to general cardiology: reports discussions and notes about trials, cardiology congresses, live-comments on 2015 ESC congress in London.

Abstract:

In February 2004 the emblematic journal of American Heart Association « Circulation” did a special issue focused on cardiovascular disease in women. It was time to inform female population about the burden of stroke, myocardial infarction. Women were aware of cancer especially Breast but ignore the price they paid to cardiovascular disease: the worldwide leading cause of women’s death. Active associations like women in Red spread the information in USA. European Society Cardiology was not in rest with the campaign Women at Heart. So what, 15 years passed and cardiovascular disease are still the first cause of death in women, ahead all form of cancer. What happened? Why? This persevering situation in spite of many efforts done by Media, university, care of physicians, cardiologists? Among numerous reasons, two main seem to emerge: Number one: In doctors minds the concept of women cardiovascular disease still remain far from their awareness. Women’s cardiovascular disease specificity is now a part of our training but preconceived ideas have a long life. Number two: the warning of cardiovascular disease does not work. Justified women’ fears of breast cancer are at the tip of their preoccupation. Cardiovascular diseases does not afraid women (men too) and cancerous tumour done. We continue to see women smoking, being obese, pursuing a sedentary life, and not informing their daughter about the danger of this attitude. Women accept cancer screening but they rarely perform blood sugar and cholesterol test. We cardiologists, attending physician, medical society, government, media have to be vigilant, specifickly in women who suffered from preeclampsia, gestational diabetes, healed from a breast cancer and continuously repeat cardiovascular diseases kill more people than cancer.

Biography:

Takao Konishi is a Medicine Doctor (MD-Medicine), is a Clinical Fellow of Department of Cardiology, Hokkaido Cardiovascular Hospital, the Japanese Circulation Society certified Specialist, the Japanese Society of Internal Medicine certified Specialist, the Japanese Association of Cardiovascular Intervention and Therapeutics certified Physician, the Fellow of the Japanese Society of Ultrasonics in Medicine, AHA ACLS Instructor and AHA BLS Instructor. He also belongs to Department of Cancer Pathology, Hokkaido University School of Medicine. He is involved in a clinical research in the graduate school of medicine.

Abstract:

A 78-year-old man presented to our hospital complaining of shortness of breath on exertion, 1 week after the onset of chest pain. Coronary angiography determined a severely stenosed, long diffuse lesion of the proximal-mid (segment 6-7) left anterior descending (LAD) coronary artery. Using a left radial approach, a 6 Fr 6Fr TAIGA EBU 3.5 guiding catheter (Medtronic Inc.) was used to engage the left coronary artery (LCA). An XT-R guidewire with a support of Corsair, to which was exchanged from SION blue guidewire (Asahi Intecc) could cross through the LAD artery. Intravascular ultrasound (IVUS) imaging determined fully circumferential fibrocalcified plaque or thrombus from the segment 6 to 7. A 3.0 x 13 mm Lacrosse NSE ALPHA balloon was selected for predilatation of segment 6, but was not easily able to cross the highly calcified and stenosed lesion. Using so-called leopard-crawl technique, NSE balloon could successfully reach the lesion site, and subsequent dilatation of the lesion was performed at 12 atm from distal to proximal segment 6. The tip pressure of guiding catheter suddenly showed 0 mmHg in the monitor. Angiography revealed a large thrombus in the left main trunk and left circumflex artery. After aspiration thrombectomy, using Export Advance^TM Aspiration Catheter (Medtronic Inc.), several red thrombi were aspirated, resulting in disappearance of thrombus in angiography. The ACT was 293 sec. After stent implantation of Resolute Integrity 3.0/26mm for segment 6, the patient was free from symptoms with TIMI grade 3 flow. Histopathological examination showed that the thrombus was slightly organized, which suggested that the thrombus was probably formed not during the procedure, but several days before the admission. This case highlights that non-slip element balloon provides a useful scoring effect, but infrequently causes thrombus shift when extracting the balloon catheter because of its unique design.

Biography:

Juan Jose Martinez Rivas is a fourth year Geriatric Specialist Resident with special interest in geriatric stroke and cardiovascular diseases. He did his graduation from University Los Andes in Merida, Venezuela with specialist rotation underway in Granollers Spain. He is interested in medical innovation and research with 6 oral communications presented in the Geriatrics national conference of Spain during the residency.

Abstract:

Introduction: The interatrial block (IAB) is a delay in atrial conduction defined as a wide p-wave (wpw) on electrocardiogram (ECG) but has low specificity for supraventricular tachycardia (SVA) and ischemic stroke (IS) prediction. New criteria for IAB appeared as the biphasic morphology of p wave in the inferior leads, which has increased its predictive value. The objective of this study is to find relationship between new IAB’s criteria (NIAB) and IS of undetermined cause (ISUC).

Method: retrospective study of 188 cases admitted to hospital for ISUC (A group) without prior arrhythmias, compared to 180 controls admitted for other causes (B group). NIAB finding on the ECG (biphasic p≥120ms in II, III and AVF) was assessed in both groups. Data analysis was made to find IAB differences between groups in relation to age (<75; ≥75) and comorbidities.

Results: 368 patients (47% women; mean age 72,7+15,2; Barthel index 79,5+24,9) were included. wpw and NIAB findings were significantly more prevalent in A group (p≤0.000), with no other differences observed. Significant differences were found considering age: stronger association wpw-IS vs NIAB-IS in the youngest group (OR 24,1(12,4-46,7) vs 20,5(4,8-87,3) in contrast with a stronger association NIAB-IS vs wpw-IS in the oldest group (OR 33,8(4,3-264,7 vs 7,4(2,1-26,8).

Conclusions: wpw and NIAB were significantly related to ISUC. Relevant differences were found considering age, being more prevalent the presence of wpw in younger with IS of UC and NIAB in elder. Although more studies are needed, these outcomes could justify primary prophylaxis with anticoagulation before SVA appears.

Biography:

Josephine Achan is a young Researcher with special interest in cardiovascular disease. She is currently practising in Uganda Heart Institute as a Physician and second year adult cardiology fellow. She is involved in the local research in her country and currently part of the acute myocardial infarction in Uganda.

Abstract:

Myocardial infarction is one of the leading causes of mortality worldwide with decreasing incidence in developed countries and increasing incidences in developing countries, Uganda inclusive. This increasing trend has been attributed to urbanization and changing life styles in developing countries. There is high burden of risk factors like hypertension and diabetes mellitus in our setting. The purpose of this study is to describe the clinical presentation and in-hospital outcome among patients admitted with myocardial infarction in Mulago hospital. This was a prospective cohort study that was conducted in Mulago Hospital complex and Uganda Heart Institute in 2013. 54 subjects were recruited during the eight months study period. Data on collected through standardized questionnaire and blood samples obtained. Participants were followed for minimum of two weeks and maximum of one month. A total of 54 patients were recruited, 29/54 (63%) had ST segment elevation myocardial infarction (STEMI) and 17/54(37%) had non-ST segment elevation myocardial infarction. Chest pain (66.7%) was the common presentation. Most patients in this study came to the hospital more than 72hours with median time of presentation to the hospital from onset of symptoms 93.5hours (SD 57.09, OR=1.002 95%CI 0.9-1.0). The mean age for the study participants was 58.7(SD=+/-10) with more males 38/54 (70.4%) than females 16/54 (29.6%). Common associated symptoms were breathlessness 39/54(54.7%), palpitations 21/54 (38.9%). Symptoms occurred at rest, with exercise and emotional stress. Only 7/59 (13%) of the participants had low systolic and 11/54(20.4%) low diastolic blood pressure. 18/54 (33.3%) had high systolic and 20/54(37%) diastolic pressure at admission. 19/54(35.2%) of participants had significant pulmonary rales at admission. 34/54(63%) had New York Heart Association class I and 40/54(74.1%) were in Killip class I. Risk factors include past medical history of hypertension 35/54 (OR=1.53, 95% CI=0.48-4.90), diabetes mellitus (OR=1.52, 95% CI=0.46-4.95), dyslipidaemia 7/54 (OR=1.73, 955CI=0.29-10.10), high LDL Cholesterol were higher risk for myocardial infarction. Low HDL (OR=1.9, 95% CI=0.55-6.58) confers higher risk for myocardial infarction compared to normal and high HDL cholesterol levels. Also similar patterns are seen in family history as positive for hypertension (59.3%) (OR=1.1, 955CI=0.35-3.88) and diabetes mellitus (37%). Over all 10/54(24.1%) developed shock, 10/54(18.5%) had pulmonary oedema and congestive heart failure, 6/54(11.1%) developed arrhythmia, 6/54(11.1%) died in the hospital, and 2/54(3.7%) had ventricular wall aneurysm formation. 1/54(1.9%) had stroke, re infarction and thrombus formation. Majority of patients admitted with myocardial infarction had STEMI and present with chest pain. Most patients are males. Hypertension, Diabetes Mellitus and dyslipidaemia were high risk factors. Almost half of the patients with STEMI developed pulmonary edema, shock, congestive heart failure and arrhythmia.

Biography:

Kamalika Roy Choudhury did her PhD from SINP, India on Cell Biology and Proteomics of Huntington’s disease. She is currently working on cardiovascular translational research; looking for proteomic alterations and post translational modifications during acute coronary syndrome.

Abstract:

Statement of the Problem: Atherosclerotic lesions in humans typically develop over years to decades; one of the longest incubation periods of disease onset in humans. Acute coronary syndrome (ACS) includes unstable angina and acute myocardial infarction. Atherosclerosis is the major source of mortality in the developed countries, claiming more lives than all types of cancer combined. WHO predicts atherosclerosis to become an epidemic in developing countries like India in coming years as it acquires western lifestyles. Only few reports are available on the plasma proteome profile of ACS. In this study, we used STEMI patients and age and sex matched control subjects.

Methodology & Theoretical Orientation: We used nano LC-MS orbitrap mass spectrometer and SWATH-MS to annotate proteins and identify differential expressions between control and ACS samples respectively. We used GeneCodis 3.0 and PANTHER for pathway enrichment analysis.

Findings: Using nano LC-MS orbitrap mass spectrometer we identified ~3000 proteins from control and STEMI patients respectively. We also performed SWATH-MS to identify differential expressions of proteins, if any. 65 proteins (27 downregulated, 38 upregulated) show differential expressions between control and STEMI patients. Some protein expression patterns were validated using western blotting and ELISA to look into the molecular detail. Here we intend to focus on the reverse cholesterol transport (RCT) pathway.

Conclusion & Significance: We found downregulation of ZAG, a novel adipokine in ACS patients from SWATH and validated using western and ELISA. Upregulation of a novel ATP binding cassette transporter, ABCA5, was observed in STEMI using orbitrap-MS. We show here that these might be responsible for the alteration in reverse cholesterol transport pathway during ACS which has a great impact on atherosclerotic pathway.

Biography:

Jay Risk is the National Spokesman for the Tetralogy of Fallot Foundation Inc. – a non-profit organization focused on growing the fields of adult congenital medicine, bridging the congenital gap, giving the condition a voice, providing a national institution for patients and families suffering from TOF and building a National TOF network for awareness. He is also a Comedian, Producer, Technical Director and has appeared on the soap opera ‘The Guiding Light’, the TLC Channel, ‘People Are Talking’ with Matt Lauer from ‘The Today Show’, Regis and Kathy Lee, ABC pilot ‘Florida’s Last Call’ performed at the IMPROV Comedy Clubs, recently worked with Renee Taylor from the sitcom ‘The Nanny’ and just filmed a commercial with Judy Gold from True TV and Rosie O’Donnell from the ‘Rosie ’Donnell Show’.

Abstract:

Within congenital medicine, heart patients suffering from Congenital Heart Defects (Specifically referencing Tetraogy of Fallot patients in our presentation)…There is a universal medical system disconnect within medical care (either preventative, emergency or routine treatment) which operates with a large hole underlying systematic patient care which compromises patient safety. The effects of this gap range from small complications during treatment to the worst outcome being the death of a patient. The lack of continuing education for General Cardiologists, the miniscule number of properly trained and certified Adult Congenital Doctors, the undersized fields of Adult Congenital Medicine and the current practices of using a Pediatric Cardiologist teamed with a General Cardiologist to try and properly treat an Adult Congenital Heart Patient (Tetralogy of Fallot Specific) has shown to help but, the data contrary to the success of these combined efforts shows the need for a serious overhaul and restructuring of present and future medical practices. Medical mandates proposing continuing education and a greater awareness needed by doctors treating such CHD/TOF patients to avoid such preventable negative occurrences are needed, detrimental to the overall health and longevity of a CHD patient and the data that is recorded shows mild complications, to progressive complications during treatment or, ultimately the death of the patient. Jay Risk, a CHD/TOF patient is speaking about his own experiences, research through his foundation and his views are non-bias. According to the US National Library of Medicine 47% of patients are successful” when transferring from pediatric to adult congenital medicine. Thus, 53% of overall patients experience mild to serious complications, even death. 53% is more than half of the CHD patient population, warranting a new and serious focus and stronger efforts being concentrated in solutions?

Biography:

Raghav Lumb graduated from Kurukshetra University, Haryana, India and a post graduate Internal Medicine from Bharati Vidyapeeth University Medical College, Pune , India, presently an aspiring resident of DM Cardiology. Believes in sheer hard work and has passion learning best of cardiology prioritizing patient care. Has few publications in his name , looking forward for more research and work in cardiology in upcoming years.

Abstract:

Introduction: Left atrial compliance (LAC) is an important determinant of cardiac function, both in the normal and pathological state. The basic hemodynamic features of mitral stenosis (MS) are an elevation of left atrial (LA) pressure, resulting from antegrade flow across the mitral valve (MV). The severity of MS and extent of narrowing of MV orifice determine the degree of LA pressure.

Aim: To study the Left atrial compliance in patients with Rheumatic Mitral Stenosis, to analyse the predictors of LA pressure in rheumatic MS, to study effects of successful Balloon mitral Valvuloplasty (BMV) on left atrial compliance.

Methodology: 50 patients undergoing BMV by Inoue technique where included in this study. Doppler echocardiography was performed in all before BMV. Left atrial size, left ventricular end diastolic dimension, left ventricular end systolic dimension and left ventricular ejection fraction were calculated. Mitral valve area (MVA) was measured by 2-D echo planimetry and pressure half time method from continuous mitral flow velocity profile. Mean mitral valve gradient (MVG) was also measured by continuous wave Doppler echocardiography. During BMV procedure right heart catheterization was performed with balloon tipped catheter. Pulmonary capillary wedge pressure, systolic, diastolic and means pulmonary artery pressures were measured with fluid filled catheters. Trans-septal puncture was done from right femoral vein with Brocken brought needle and Mullins transeptal sheath. Left heart catheterization was performed through it. The left atrial ‘a’ and ‘v’ waves amplitude were measured at end-expiration Cardiac output was determined by Fick’s method. LAC was calculated by dividing the systolic rise in LA pressure by stroke volume.

Results: Though LAC was depressed in patients with rheumatic MS, and improved dramatically (from 2.5±0.51 to 7.11±1.71cm³/mm Hg) following successful BMV. Those with higher LA mean pressure had lower LAC. Those with higher PA pressure, higher TMG, Lower MVA and lower LAC had higher mean LA Presssure with strongest negative relationship noted with LAC. However in multivariate analysis only TMG and LAC were predictors of LA pressure.

Conclusion: LAC is important determinant of left atrial pressure in patients of rheumatic mitral stenosis and which correlates with symptomatology. Rheumatic MS has markedly depressed LAC.This depressed compliance improves immediately following successful balloon mitral valvuloplasty. This improvement in compliance occurs irrespective of left atrial mean pressure.

Biography:

Madhumanti Panja is a final year student in the course of DNB Cardiology (Degree course), from the National Board of Examination under the Government of India

Abstract:

AIM: Coronary stents in PCI were designed to reduce abrupt vessel closure and restenosis. Despite pharmacological and technical advances, complication like; late thrombosis and restenosis are of concern for coronary revascularization procedure. The objective is to analyze the long-term follow-up information especially the late complication over several years in consecutive procedures.

Method & Results:  A single center observational study was conducted from August 1996 to July 2004, in the department of Cardiology, IPGME&R, Kolkata, West Bengal, India. Till 2002 all had Bare Metal Stents (BMS) and then onwards majority (60%) underwent BMS and 40% were treated with Drug Eluting Stents (DES).  A total of (* cases with first stent implantation and turned up for regular follow –up were included in this study. Over 15 years patients were strictly observed clinically 1, 2, 3 months initially and there after every 3 month or any time in between when symptoms experienced.

Mean age of the population was 55 + or – 2 years and 85% were male. Before the procedure, 34% had unstable angina. 28% had prior event of myocardial infraction and rest had chronic stable angina. Clinical profile showed diabetes mellitus in 1/3^rd of the patients and 605 had hypertension. Majority (75%) revealed one vessel disease. Among 98 cases 80 had BMS and 18 had DES. During the follow-up (range 1 to 15 years), the incidence of major adverse cardiac event (MACE) in 12 cases with BMS and two with DES.  Ten patient with BMS and two patient with DES had instent restenosis and late stent thrombosis in one with BMS and 2 with DES. Whereas coronary aneurysm was noted only in one patient with DES.

Conclusion: Bare metal stent is effective and safe. All complication except restenosis were higher in DES.

Biography:

Ayshat Yandieva is a graduate student of the Department of Hospital Therapy â„–1 of Moscow State University of Medicine and Dentistry. Along with the research work and teaching activities, she is actively engaged in medical practice, heading the sleep laboratory of Eurasian Clinic in Moscow and developing the direction of sleep medicine in Russia.

Abstract:

Statement of the Problem:  The combination of metabolic syndrome (MetS) and obstructive sleep apnea (OSA) is characterized by a significant increase in cardiovascular risks. Some factors, such as systemic inflammation and arterial stiffening may mediate cardiovascular diseases in these patients. Arterial stiffness is widely accepted as early marker of atherosclerosis and cardiovascular outcomes. Systemic inflammation also plays an important role in the development of cardiovascular complications. The purpose of this study is to determine the effect of continuous positive airway pressure (CPAP) on arterial stiffness and plasma CRP levels in patients with MetS and OSA. Materials and methods: total of 74 patients with MetS and moderate-to-severe OSA were randomized to CPAP (n = 36) and non-CPAP (n = 38) treatment groups for 12 weeks to investigate the effects of CPAP-treatment on arterial stiffness and plasma CRP levels. Findings: Initially, there were no significant differences between the two groups for all the studied parameters. After 12 weeks of therapeutic CPAP, there was registered decrease in R/L-PWV (from 12,7±2,6 m/s to 11,1±3,4 m/s, p <0.05), CAVI (from 8,2±1,8 to 6,5 ±1,8, p <0.05), AIx (from 1,66±0,15 to 0,96±0,12, p<0,05), although change of ABI was not statistically significant. In non-CPAP patients, there was no reliable dynamic in parameters of arterial stiffness. Also, the CPAP-treatment patients presented lower circulating levels of CRP after 3 months of therapy: 6,17±0,52 mg/L vs. 8,32±0,44mg/L at the baseline (p<0,01). On the other hand, no significant differences were found in the control group of patients. Conclusions and significance: appropriate CPAP therapy in patients with MetS and OSA improves both vascular stiffness and chronic systemic inflammation, that leads to reducing general cardiovascular risks.

Biography:

Ghadeer Dawwas is a PhD student at the Department of Pharmaceutical Outcomes and Policy at the University of Florida. Her research is focusing on assessing the effectiveness and safety of medications using population based data with a special focus on cardiovascular diseases.

Abstract:

Background: Patients with diabetes and concomitant heart failure are at higher risk of readmission but few studies evaluated predictors of hospital readmission among this population.

Purpose: To identify predictors of hospital readmission among diabetic patients with heart failure using data from 130 United States Hospitals.

Methods: A retrospective cohort analysis using data from 130 United States hospitals was conducted. Patients who had a diagnosis of diabetes based on primary or secondary diagnosis codes (ICD-9-CM): 250.x0 or 250.x2) and heart failure (ICD-9- CM codes 402.×1, 404.×1, 404.×3, and 428.××) between 1998-2008 were identified. The multivariable logistic regression model was used to identify predictors of hospital readmission.

Results: A total of 18,603 patients were identified (81.6% were 60 years or older, 55% female, mean length of stay: 4.8 days, 75% Caucasian). Predictors of higher risk of hospital readmission were females compared to males (odds ratio (OR): 1.1, 95% CI [1.0, 1.13], total number of outpatients visits (OR: 1.1, 95% CI [1.1, 1.11]), total number of emergency room visits (OR:1.2, 95% CI [1.13, 1.27]), total number of inpatients visits (OR:1.34, 95% CI [1.30, 1.37]), and HBA1C measurement >8 (OR:1.25, 95% CI[ 1.1, 1.50]). The use of insulin, however, had protective effect (OR: 0.89, 95% CI [0.81, 0.98].

Conclusion: Among patients with diabetes and concomitant heart failure, females, a higher number of outpatients’ visits, emergency room visits, inpatients visits, and a higher HBA1C measurement were predictors of higher hospital readmission. Identifying patients at higher risk of hospital readmission can aid in targeting selected subgroups who might be at greater risk of future readmissions. Thus targeting intervention toward higher risk populations can reduce future healthcare utilization.