24) However, the indication for surgical correction of mild to moderate functional MR is still a controversial issue. As a surgical procedure, STA-4783 molecular weight mitral valve repair or mitral valve replacement is also controversial.25-29) NEED FOR SUBMITRAL APPROACH Undersized annuloplasty has been widely accepted as a simple and at the same tine effective procedure.30),31) However it sometimes fails to ameliorate MR in patient with severely tethered mitral leaflet.32) A simple annuloplasty sometimes

worsen the tethering of posterior leaflet and it induces recurrent MR33-36) and has a possibility to induce functional mitral stenosis.37-39) With these facts, Inhibitors,research,lifescience,medical additional procedures should be considered for patients with severely tethered valve or Inhibitors,research,lifescience,medical dilated left ventricle. SUBMITRAL PROCEDURE Several submitral targeted surgical procedures for functional MR have been produced (Fig. 4).40-45) Relocation of PMs is effective for improving the mitral tethering; however, relocation of PM head for anterior leaflet alone has a possibility to remain the tethering of posterior leaflet. To overcome this problem, novel surgical procedure for functional MR named “papillary heads Inhibitors,research,lifescience,medical optimization” has been developed

(Fig. 5). In this method, the PM head for posterior leaflet was connected to the PM head for anterior leaflet by using a polytetrafluoroethylene suture in each PM. After annuloplasty by a semi-rigid ring, its arms were re-suspended towards the mid-anterior mitral annulus and the sutures were passed through it and tied after the length adjustment. This method aims physiological relocation of both PM head for anterior leaflet and for posterior leaflet towards

Inhibitors,research,lifescience,medical physiological position to avoid residual tethering of both leaflet after annuloplasty and prevention of further left ventricular Inhibitors,research,lifescience,medical remodeling by the sutures. Fig. 4 Surgical procedures for subvalvular apparati or left ventricle. Undersized annuloplasty sometimes fails to ameliorate mitral regurgitation (MR) in patient with severely tethered mitral leaflet and worsen the tethering of posterior leaflet, resulting GSK461364 concentration recurrent … Fig. 5 Papillary heads optimization method. In Papillary heads optimization method, the papillary muscle (PM) head for posterior leaflet was connected to the PM head for anterior leaflet by using a PTFE suture in each PM. After annuloplasty by a semi-rigid ring, … VISUALIZING THE SUBVALVULAR STRUCTURE In the setting of submitral-targeted surgery such as papillary heads optimization, a detailed understanding of the submitral apparatus is essential for successful repair and for evaluating results of surgery. Adequate imaging is necessary for precise quantitative evaluation of the mitral valve structure. Three dimensional TEE has become widely available recently and it plays an essential role in understanding the status of the mitral valve apparatus.

Consistent SZ scored significantly worse than HC on all RBANS scales except for language. It should be noted that laboratory DD results, demographic characteristics, and cognitive assessments for all imaging participants of this study (except one inconsistent SZ) were included in the larger samples of HC and SZ in R. E. Weller, K. B. Avsar, J. E. Cox, M. A. Reid, D. M. White, A. C. Lahti (unpubl. ms). The inconsistent SZs for whom Pacritinib FLT3 quality scans were available (n = 9) did not differ from the consistent SZ group on any of the demographic variables, BPRS or RBANS scores, with the exception of the Delayed Memory score of the Inhibitors,research,lifescience,medical RBANS where inconsistent SZ scored worse than

Consistent SZ (Table S4). By definition, inconsistent SZ had lower R2 (mean = 0.26) than consistent SZ and HC but also significantly higher log(k)

(mean = −0.019). Inhibitors,research,lifescience,medical However, the validity of the computed k values for this group is suspect. Inspection of Figure ​Figure5,5, left, reveals that percentage of Now responses (%Now) by inconsistent SZ was significantly higher for k5 trials than for the other groups, consistent with greater DD, but %Now was also significantly lower versus HC for k1 trials, contrary to what would be expected for more impulsive individuals. Furthermore, %Now values from individual inconsistent SZ (Fig. ​(Fig.5,5, right) reveal that a large percentage failed to show the expected pattern of decreasing Inhibitors,research,lifescience,medical %Now as trial k’s increased, suggesting that the task

was Inhibitors,research,lifescience,medical too difficult and/or that the participants were not meaningfully engaged in the task. Figure 5 Mean (± standard error) percentage of Now (%Now) choices as a function of the five trial k’s for the consistent healthy controls (HC), consistent SZ, and inconsistent SZ (INCON) (left) and for individual inconsistent SZ (n = 9; right). a, P = … It should be noted that in our behavioral study of performance on the laboratory version of the DD task (R. E. Weller, K. B. Avsar, J. E. Cox, M. A. Reid, D. M. White, A. C. Lahti, unpubl. ms.), almost all (21/23) the SZ participants Inhibitors,research,lifescience,medical in this study had met the same criterion level of consistency used in this study, R2 Brefeldin_A > 0.60. However, the laboratory task is undoubtedly easier than the magnet task, consisting of fewer trials and with a higher percentage of easy trials, on which the subjective values of the two choices are markedly different. In addition, participants often find the magnet environment to be stressful. The inability of approximately 40% of previously consistent SZ to appropriately perform the task in the magnet may be attributable to this combination of greater difficulty and stress (Mazure 1995). Those SZ who switched from consistent in the laboratory to inconsistent in the magnet had significantly lower R2, as well as higher log(k) in the laboratory session than those who remained consistent.

9 In 2006, they reported the first three live patients to undergo TORS for base of tongue neoplasms in a prospective

clinical trial.10 From there, research in TORS gained momentum. Two larger studies, with 49 and 54 patients respectively, were published in the next few years suggesting the use of TORS as a feasible and efficacious alternative to traditional operative methods, with good functional outcomes.11–13 Growing interest in transoral robotic surgery ultimately culminated in the US Food and Drug Etoposide Administration (FDA) approval of the use of TORS for management of select benign and malignant tumors of the head and neck in 2009.14 CURRENT APPLICATIONS IN OROPHARYNGEAL CANCER Transoral robotic Inhibitors,research,lifescience,medical surgery is currently available at most tertiary medical centers in the United States. It is also actively being adopted at major medical centers in Europe.15 At centers where the technology and expertise are available, many oropharyngeal cancers are amenable to transoral robotic resection. Important considerations when deciding on the use of TORS Inhibitors,research,lifescience,medical include tumor characteristics,

such as deep neck invasion and involvement Inhibitors,research,lifescience,medical of major blood vessels, and also anatomical factors such as clinically significant trismus.11,13 Most transoral robotic oropharyngeal resections are within the tonsillar fossa and tongue base, reflecting the relatively higher clinical prevalence of these tumors compared to soft palate, uvula, and posterior pharyngeal wall neoplasms. The majority of studies published include both early and advanced-stage cancers. A few studies to date have evaluated TORS specifically for advanced-stage oropharyngeal cancers. In 2010, Weinstein et al. looked prospectively at 47 Inhibitors,research,lifescience,medical patients with stage

III and IV oropharyngeal cancer treated with primary TORS. Staged neck dissection and adjuvant therapy were included in patient management as clinically indicated. They found that disease-specific survival was 90% at 2 years and comparable to previously published data on chemoradiotherapy studies. They also noted good functional outcomes, including Inhibitors,research,lifescience,medical low rates of feeding tube dependence and permanent Luminespib solubility dmso tracheostomy.12 Tonsillar Fossa Studies have shown that surgery is highly effective in treating tonsillar cancer and provides accurate staging information for adjuvant therapy;16 however, the morbidity of an open surgical approach can be significant. It frequently requires a mandibulectomy, tracheostomy, feeding tube, and long-term speech therapy for dysphagia. Additionally, transoral resection of tonsillar lesions has previously been restricted to tumors that are limited to the tonsillar fossa, with minimal involvement of surrounding structures, due to limited visualization. In 2007, Weinstein et al. described TORS for radical tonsillectomy in 27 patients with invasive squamous cell carcinoma of the tonsil.

Phone follow-up A phone follow up data collection form will be created to collect data on: •Adverse events following the ED episode •Additional ED or acute care hospital admissions •Time spent in residential care (respite or newly admitted as permanent resident) •Pain and medication management following the ED episode •Patient satisfaction Inhibitors,research,lifescience,medical •Patient perception of clinical decision making and privacy Phone follow up will occur at 7 and 28 days but data will be combined to provide a summary of the total 28-day period. Two phone calls are scheduled to ensure continuity of contact with the

patient Inhibitors,research,lifescience,medical and to assist in more reliable recall of information over shorter selleck products periods of time. Emergency department information system (EDIS) data extraction A data collection form will be created to identify key information stored on the system relevant to the patient and to compare this with data collection from the patient. The EDIS data will also be used to provide general demographic data relating to patients Inhibitors,research,lifescience,medical both included and excluded (gender, age, triage category, residential

setting). Patient medical record This record will vary between institutions, being either electronic, paper based or a combination of both. A chart review tool will be designed which focuses on abstraction of data, and minimises the need for ‘interpretation’ of data during the audit process. Where possible, existing chart abstraction tools will be utilized. The final chart review tool will undergo preliminary pilot testing. Data custodian information Inhibitors,research,lifescience,medical on ED episodes and acute care admissions Data on the index ED episode, subsequent acute care admission and any additional hospital interactions in the 28 days post ED departure will be sought from the data custodian in each State. International Classification of Diseases (10th revision) [57] codes, Inhibitors,research,lifescience,medical primary diagnoses, length

of stay and classification of care for each episode of care during the study time period will be requested. Each data collection set (comprises all the data collection sheets for AV-951 each phase of data collection) will be matched against the original data matrix to ensure that all required variables are being collected. A database for data entry will be created. Each variable item, coded to match the data collection sheet and carrying a unique variable name, will be recorded in the manual alongside each QI in preparation for analysis of the data set. Research staff A registered nurse with geriatric assessment expertise(site nurse) will be employed for prospective data collection, including the phone follow-up, at each site.

g. turning bed, buying hats, bringing dog) to help, as illustrated below: “We were trying to get one patient to get up and walk in the halls so that he wouldn’t get weak cause he was going to be going home soon. He was just like, ‘is there something to do? You know, I like to walk on the beach, but, just walking in the hall is kind of boring’. So the nurses and I actually brought in a little mat, we put some sand down, we put like a little beach chair and had like a little poster of like a beach scene and Inhibitors,research,lifescience,medical some water and finally got him out to kinda walk over there and at least sit and pretend like he was on the beach for a while. We all had fun doing

it.” These employees combined fun, caring, and creativity in their efforts to help a patient, out of concern for his physical and emotional health. Going above and beyond narratives were focused on doing things that are more than expected in the job requirements to help the patients or their

family members. This included mediating between patients Inhibitors,research,lifescience,medical and other institutions (e.g. financial assistance), being creative in finding ways to assist the individual Inhibitors,research,lifescience,medical or to bring joy to patients’ and families’ hospitalization experience. Valuing Patients’ Well-Being Valuing patients’ well-being included an attitude or way of behaving marked by unselfish concern for the needs and welfare of others. These stories were about being compassionate and/or showing concern. Stories included employees being generous, willing to give money, help, or time freely (magnanimity), as well as being VRT752271 diligent, by

working hard and investing effort in doing something for patients’ well-being. Valuing patients’ well-being is focused on a holistic look at people’s needs Inhibitors,research,lifescience,medical rather than focused on the medical need, as illustrated in the following WLN: “We had a two-and-a-half-year-old patient who had been here his whole life … He had to be in isolation, due to an infection. I would go in there every night before I left and rock him to Inhibitors,research,lifescience,medical sleep, because his mom was a single mom; she couldn’t be here a lot and I couldn’t stand the thought of him always going to sleep by himself … And there was this Sunday BAY 80-6946 research buy night before he passed away, … and work called and said, ‘You know he’s not doing real well, we’re really, really busy, I think he needs to be rocked to sleep, and we were wondering if you would come in’. And I said, ‘Absolutely’. So I got in my car and came … he was just sitting there awake. He grabbed the bars and just kind of looked outside and so I went in there and rocked him to sleep.” When employees described caring for patients they mentioned such issues as: willingness to sacrifice their own comfort to provide the highest-quality care (e.g. coming in on their day off), working late hours, assisting in other units without their own team, and performing services not included in their professional job description (e.g. rocking the child to sleep).

4). The patient had an uneventful postoperative course apart from an atrial fibrillation which disappeared after the use of amiodarone. He was discharged 7 days after the operation. Fig. 3 Whitish, round, and soft mass (arrow) was found on the anterior mitral valve leaflet (A) and it was completely excised from the mitral valve (B). Fig. 4 Histologic examination showed spindle-shaped cells and stellate cells in a myxoid stroma (H&E stain, × 100). Discussion Cardiac myxoma is a rare disease, Inhibitors,research,lifescience,medical with an incidence between 0.0017 and 0.03% in autopsy series.3),4) Myxoma can occur in nearly all age groups

but occurs frequently between the third and sixth decades of life.5),6) Sixty-five percent of cardiac myxoma occurs in women.7) About 75% of myxomas originate from the left atrium, 18% in the right atrium, and 4% in the ventricle.8) The exact incidence of myxomas originating from the mitral valve is not clear. In one study, it was reported as 1.5% (1 case

among 68 myxoma cases).9) Inhibitors,research,lifescience,medical Myxoma originating from the heart valve Inhibitors,research,lifescience,medical was first reported by Jaleski10) in 1934, and the first premortem diagnosis of mitral valve myxoma was reported by Sandrasagra et al.11) in 1979. In Korea, only 2 cases were reported since 1994.12),13) Clinical manifestations of myxoma are determined by the location, size, mobility, and friability. Clinical manifestations can be divided into three general categories: systemic symptoms, embolism, and intracardiac obstruction. Systemic symptoms such as general weakness, fever, weight loss, arthralgia, and erythematous rash have been observed, and laboratory abnormalities such as anemia, elevations in CRP, ESR, and Inhibitors,research,lifescience,medical globulin levels have also been reported in patients with

myxoma.6),14),15) Myxoma can cause an embolism by way of the tumor emboli or thromboemboli that are released from or formed on the surface of the tumor. As most myxomas are located in the left atrium, systemic embolism frequently occurs. In most cases, the cerebral arteries are affected, and embolization into Inhibitors,research,lifescience,medical the renal, visceral, and coronary arteries has also been reported.8) Symptoms due to intracardiac obstruction depend on the size, mobility, Brefeldin_A and selleck Pazopanib location of the tumor. These symptoms include dyspnea, orthopnea, dizziness, syncope, and pulmonary edema. Whether myxoma of the mitral valve causes an embolism more frequently than a myxoma originating from the left atrium is not known. Echocardiography is the most important and widely available method in the diagnosis of myxoma. Echocardiography can provide information on the location, size, shape, and mobility of a myxoma. When abnormal mass lesions are found on the heart valve, it is important to distinguish tumorous conditions from valvular vegetations. The characteristic narrow stalk is the most important feature of cardiac myxoma, and it is helpful when diagnostic confusion exists.

The sleep LEG recordings following an adaptation night, of 130 patients were compared to those of 147 normal controls in the age range 20 to 65 years (mean 37 years). Regarding sleep continuity, the results indicate that GAD is mostly associated with sleep maintenance insomnia, and to a lesser extent, with sleep initiation difficulties. Five studies found a significant, decrease in total sleep time, four an increase of waking after sleep onset, while only two studies showed a. significant prolongation of sleep onset, latency. As regards NREM and REM sleep structures, results are inconsistent. Stage 4 was significantly decreased in three Inhibitors,research,lifescience,medical studies, all six studies showed nonsignificant,

decrease in REM sleep, and one study a significant, shortening of REM latency. Treatment GAD is often responsive to BZDs, buspirone, and antidepressants. Anxiolytic BZDs provide

a prompt, relief of the GAD symptoms belonging to the motor and the vigilance-scanning clusters. However, psychic symptoms such as worry and ruminations are Inhibitors,research,lifescience,medical less affected by these compounds and respond better to antidepressants such as TCAs, SSRIs, or norepinephrine and serotonin selective Inhibitors,research,lifescience,medical antidepressant (NaSSA), such as venlafaxine.58 Adjunctive psychotherapy with a. cognitive focus can be beneficial. In this regard, studies have shown that cognitive-behavioral techniques are better than control conditions or to either Inhibitors,research,lifescience,medical cognitive or behavior therapy alone.58 The alleviation of the sleep disturbance can often greatly improve the condition: therefore a low-dose, intermediate-acting BZD at Belinostat ptcl bedtime may be temporarily indicated early in the treatment. Sedative antidepressant could also help improve sleep. Obsessive-compulsive disorder According to DSM-IV,34 the essential features of the OCD are recurrent, obsessions or compulsions that are sufficiently severe to cause a signification disruption

of a person’s daily routine. The most, common obsessional thoughts are fears of contamination, of being aggressive, and of a sexual nature; the most common compulsions AV-951 Inhibitors,research,lifescience,medical relate to checking, cleaning, and counting. The sufferer knows that, it is his or her own thought (or act), that it. arises from within him- or herself, and that it. is subject, to the sufferer’s own will. Anxiety is provoked by the fear of what may happen if the compulsive rituals arc disturbed, the need to both perform the action and preserve social acceptability, or the fearful nature of the obsessional thoughts themselves. The person usually functions satisfactorily in other areas of life not, contaminated by the obsessional thoughts, but. as the obsessions become more severe there is increasing social incapacity. Patients often complain of disrupted sleep and sleep delay due to compulsive behaviors. In one epidemiological survey,55 insomnia related to OCD had a prevalence of 0.

The tariff for the no indication modality was higher or lower than the correct answer. In both situations the imposed cost was calculated as the tariff for the no indication for any modality because these modalities did not apply for diagnosis in the practice. In cases where participants marked the medical imaging modality that was appropriate for diagnosis however they did not recommend imaging as the top priority, if the tariff of the wrong answer was higher than the correct answer we considered the difference of the two tariffs’ as the imposed cost. If the tariff of the wrong answer was lower than the correct answer, the imposed cost was calculated as zero. For “I don’t know” responses, the median of the

costs of all mentioned Inhibitors,research,lifescience,medical choices was calculated as the imposed cost. We added all the imposed costs together and calculated the total which was subsequently divided by the total number of

respondents. The result was considered Inhibitors,research,lifescience,medical to be the imposed cost per medical student. Finally, we converted Iranian rials into US dollars. Results were reported in US dollars according to the mean of the Inhibitors,research,lifescience,medical contemporary declared currencies reported by the Central Bank of the Islamic Republic of Iran during the study period.11 Results Of the 270 medical students invited to participate, 200 (74%) responded and completed the questionnaires. Participants included 68 female externs, 44 male externs, 52 female interns and 36 male interns. Mean selleck scores and categories of knowledge of indications for each modality and the total for the imaging modalities are shown in table 1. The mean knowledge score was 9.7 (fail) for all modalities. Similar scores were excellent for X-ray, acceptable Inhibitors,research,lifescience,medical for Doppler ultrasonography, and fail for ultrasonography, CT scan and MRI. Table 1 Knowledge of indications for imaging modalities in medical students at Shiraz University of Medical Sciences, Iran during Inhibitors,research,lifescience,medical 2011-2012 In this study, 16.5% of participants chose CT scan or MRI instead of ultrasonography for their answers. A total of 29% selected CT scan with contrast although the true answer was a scan without contrast. Approximately 14.5%

of participants selected CT scan or MRI instead Dacomitinib of X-ray modalities. Cost analysis for the non-indicated requests of imaging modalities is presented in table 2. Table 2 Cost analysis of non-indicated requests for imaging modalities prescribed by medical students of Shiraz University of Medical Sciences, Iran during 2011-2012 Discussion Medical imaging is a support for clinical workups that can improve patient outcome.1 Due to the importance of economy in modern medicine, physicians should pay attention to the high cost burden of medical imaging for health care systems and communities.4 It is noted that in our setting, the only radiology course for medical students is presented during the externship period. Students’ knowledge during the externship period directly impacts both their practice as interns and the imposed costs.

While a repeat polymorphism, the DRD4 gene has been associated with a related dimension, novelty-seeking,53 there have been few explicit studies of the genetics of affective instability and none in personality disorders. Emotional information processing While emotional lability and reactivity, discussed in the previous section, generally refer to alterations in the threshold of emotional reactivity, the processing and recognition of emotional information may be a partially discriminable dimension that enables appropriate social interaction. Impairment in neuronal circuits involving orbital frontal ventral medial prefrontal

cortex and anterior cingulate Inhibitors,research,lifescience,medical may mediate the abnormal emotional information processing. Psychometric measures that might be used to identify intermediate phenotypes of this dimension include the Emotion Attribution Questionnaire (EAQ) (Coccaro et al, personal communication) identifying a subject’s ability to identify Inhibitors,research,lifescience,medical the emotion of another person in a vignette such as anger, sadness, fear, and disgust. These

are similar to the emotions Inhibitors,research,lifescience,medical expressed in the Ekman Facial Emotional Recognition Task (EFERT). Indeed, the EFERT can be used to directly assess emotional information processing in the laboratory67 The Emotional Stroop Task68 may also be useful in assessing emotional information processing, as may be the Bechara Gambling Task (BGT) where subjects need to discriminate advantageous from disadvantageous decks of card.69 The EFERT is sensitive to ventral medial prefrontal cortical dysfunction.

The Emotional Stroop Task test asks subjects to name the color of a word presented and BPD subjects exhibit a delay in naming Inhibitors,research,lifescience,medical the color when emotionally charged words are presented. The stability of these measures, their discriminability for specific personality disorders such as BPD, and Inhibitors,research,lifescience,medical their underlying genetics are not yet clear, but are a focus of current studies. The schizophrenia spectrum personality disorders (SPD) A number of critical dimensions underlie the schizophrenia spectrum or www.selleckchem.com/products/dorsomorphin-2hcl.html cluster A personality disorders. Cognitive disorganization, as exemplified in disturbed thinking patterns, Carfilzomib odd speech or language, and even eccentric appearance, is a hallmark of SPD and may parallel the more massive cognitive disorganization observed in schizophrenia. Deficit-like or negative symptoms are prominent in SPD and to a lesser degree in schizoid personality disorder, and seem to represent attenuated versions of the more severe deficit symptoms of schizophrenia. The cognitive/perceptual distortions of SPD represent psychotic-like or positive symptoms analogous to the positive symptoms of schizophrenia and, while not meeting criteria for actual hallucinations and delusions, may reflect the same underlying dimension.

Along with these observations, mice that were engineered to overexpress the β-adrenoreceptor or Gα protein displayed initial sustained increases in heart rate and ventricular contractile function, followed by ventricular dilation, myocardial fibrosis, and heart failure.33 In contrast, there were distinct differences in mice with Nilotinib Leukemia cardiac-directed expression of AC6—despite 20-fold excess cardiac AC6 protein, there was no increase in heart rate or left ventricular function in unstimulated Inhibitors,research,lifescience,medical animals. Moreover, the animals displayed improved responsiveness to β-adrenoreceptor stimulation by showing marked increases in heart rate and contractile function. Most importantly,

unlike mice with cardiac-directed β-adrenoreceptor or Gα, there was no decline in function or abnormalities of cardiac

Inhibitors,research,lifescience,medical structure or histology even in old mice. The precise mechanisms for these striking differences in effect were not determined. Exogenous gene transfer will be required if AC6 is ever to be applied in the treatment of clinical heart failure, and so far clinical trials are lacking. Istaroxime is a non-cardiac glycoside that has inhibitory effects on the Na+/K+-ATPase pump, and it is suggested to possess SERCA-stimulatory abilities.34 The inhibition of the Na+/K+-ATPase pump increases intracellular sodium, Inhibitors,research,lifescience,medical which reduces the driving force for the sodium calcium exchanger (NCX) and decreases calcium extrusion

from the cell. The increased sodium may actually stimulate the NCX to function in the reverse mode and transport calcium into the cell in exchange for sodium. Inhibitors,research,lifescience,medical The calcium influx into the cytosol is expected to increase contractility, but may also be harmful in the failing heart which already has elevated diastolic calcium levels. This mechanism likely explains the modest benefit of drugs such as digoxin in heart Inhibitors,research,lifescience,medical failure. Therefore the additional capability to promote SERCA activity and the uptake of calcium to the sarcoplasmic reticulum may be thing crucial to the success of an inotropic agent that blocks the Na+/K+-ATPase pump. In several animal studies, istaroxime increased the maximum rates of rise and fall in left ventricular pressure and decreased end-diastolic pressure and volume without a change in heart Drug_discovery rate and blood pressure. Most importantly, these inotropic and lusitropic (relaxation) effects were different from those of digoxin and have not been associated with an increase in myocardial oxygen consumption.35 In the HORIZON trial (a randomized, double-blind, placebo-controlled study that recruited 120 patients with relatively mild heart failure that did not require inotropes), an intravenous infusion of istaroxime resulted in an increase in systolic blood pressure and a transient increase in cardiac index, without a change in ejection fraction.