Background: Heart failure is a clinical syndrome occurring from the heart’s inability to effectively fill and or pump blood, it is the most common reason for admission in elderly patients. Guideline directed medical therapy refers to implementation of all class I agents to reduce patient morbidity and mortality, unless there is an appropriate contraindication. Appropriate beta blocker (BB), angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and aldosterone antagonist (AA) are recommended to be prescribed together prior to discharge for a hospital admission for decompensated heart failure with reduced ejection fraction (HFrEF). Get With The Guidelines – Heart Failure (GWTG- HF) is an online quality improvement project that assists hospitals in providing guideline directed care. Objective: The purpose of this study was to determine if implementation of the GWTG-HF program, increases provider adherence to guideline directed medical therapy (GDMT) for patients admitted with a primary diagnosis of decompensated HFrEF at Banner University Medical Center Tucson (BUMCT). Design: This is a quality improvement project with a pre and post test descriptive design. Setting: BUMCT from 10/04/17 – 11/08/17 Participants: Fifty-five patients discharged with the primary diagnosis of decompensated HFrEF Measurements: Baseline guideline adherence for a 30-day period was compared to guideline adherence after the initiation of the GWTG-HF program. Results: The 24 patients pre intervention were compared to 31 patients post intervention. The following results were found when comparing pre and post adherence rates: BB adherence 92% versus 100%, ACEI/ARB adherence 100% versus 94%, AA adherence 67% versus 84%, and guideline directed medical therapy 58% versus 81%. There were no statistically significant differences for the pre and post adherence rates. Conclusion: Although, there were no statistically significant differences found to support that implementation of the GWTG-HF program, increases providers adherence to GDMT for patients admitted with a primary diagnosis of decompensated HFrEF, the trends were clear. In three out of four class I agents, there was an increase in appropriate provider prescribing per the guidelines.

A vancomicina (VANCO) é a primeira opção terapêutica para o tratamento de infecções por estafilococos meticilina-resistentes. Recomenda-se a manutenção de seus níveis séricos entre 15 e 20 <font face=\"Symbol\">mg/mL para eficácia e segurança dos tratamentos. Foi realizado estudo transversal retrospectivo com 15 pacientes dialítcos em tratamento com doses de 1 g VANCO. As freqüências de administrações de VANCO foram comparadas aos seus níveis séricos. A correlação entre nível sérico com o tempo de tratamento e tempo de omissão de dose foi analisada. Quarenta determinações séricas (43%) se mostravam inferiores a 15 <font face=\"Symbol\">mg/mL enquanto vinte e quatro (25,8%) revelaram níveis superiores a 20<font face=\"Symbol\">mg/mL. Este estudo nos permite sugerir que doses de VANCO utilizadas no tratamento de pacientes dialíticos devem ser calculadas em função de sua massa corpórea real, considerando os resultados dos níveis séricos de amostras colhidas no vale, antes da sessão de diálise. Sugerimos que a vancocinemia seja realizada no vale, a cada 48 horas, em pacientes com clearance de creatinina inferior a 20 mL/min. / Vancomycin (VANCO) has been considered the first therapeutic option for treatment of MRSA infections. In order to achieve efficacy and safety, it is recommended VANCO therapeutic plasma levels range between 15 and 20 <font face=\"Symbol\">mg/mL. Retrospective cross-sectional study of 15 dialyitc patients who received several doses of 1g of VANCO and the serum levels were analysed. The administration frequencies were compared to VANCO plasma levels. The correlation between VANCO plasma levels and treatment period and missed doses period was got. The most VANCO serum levels were out of the therapeuic range. Forty serum levels (43%) were below 15 <font face=\"Symbol\">mg/mL while twenty four (25.8%) were above 20 <font face=\"Symbol\">mg/mL. This sutdy allows us tosuggest that VANCO doses must be prescribed according to the patient Actual Body Weight (ABW), considering results of trough plasma concentrations obtained before hemodialysis session. Our results suggest that through plasma levels are obtained every 48 hours in patients with creatinine clearance below 20 mL/min.

Thesis (MBA.) --University of Limpopo, 2009 / The delivery of quality service is a challenging area in both private and government sectors. The purpose of this research study was to determine if Modiba KO Speech and Audiology Services deliver services as per clients’ expectations and perceptions. It also aimed at determining if there is/are a gap/s between clients expectations’ and what was offered at the clinic. In order to achieve these aims, questionnaires were administered to clients seen at the clinic. The sample was comprised of clients seen at Modiba KO Speech and Audiology Services only. The participants were asked to indicate their expectations and perceptions about the service offered at the clinic. Findings from the research showed that there are gaps between clients’ expectations and perceptions of quality service delivery. KEY WORDS Quality Service, Speed, Flexibility, Dependability, Costs, Quality, Gaps

This thesis deals with a medical and social view of taking healing hemp (cannabis). It is a theoretical thesis elaborated based on the analysis of the available Czech and foreign information sources and professional publications. The thesis target is to map the issue of taking healing hemp by means of the information from the available foreign and Czech literature. The thesis focuses on the most important issues dealt with by the professional as well as lay public and on the development of the solution of this issue. I was captured by this issue after my internship in Belgium, where I had the opportunity to travel through neighbouring Netherlands and to get to know, from the viewpoint of a foreigner, the opinions and access of the inhabitants to the hemp as healing and relaxing mean. The first chapter deals with using the healing hemp in the historical context. Hemp represents one of the oldest crops and for this reason the history of hemp in the period of antiquity, Middle Ages and modern times is described. The following chapter focuses on the individual substances contained in hemp. In this chapter, the endo-cannabinoid system and three kinds of substances contained in hemp strains are analysed canabinoids (THC), canabidiols (CBD), canabinols (CBN). The chapter presents the profile of one of the most important personalities associated with hemp, professor Raphael Mechoulam, the main icon and discoverer of THC. The chapter three devotes to toxicology and addiction when taking hemp, which occurs quite rarely among users of hemp drugs. In this chapter, influence of hemp on the memory of user is treated, as well as the influence of hemp on the occurrence of lungs diseases discussed constantly in connection with smoking and in the last part of this chapter, the addiction and influence of hemp on users psyche is analysed. The following chapter is devoted to the issue of the drug policy, especially defining the status of healing hemp in the law, research of healing hemp and legalization of hemp in the Czech Republic. This chapter is devoted in detail to the legalization of hemp in the world, especially in the states like California, Israel, Canada and Netherlands where the hemp was legalized for healing purposes many years ago. The present science brings a wide spectrum of clinical research examining the effects of hemp during the treatment of many diseases. For this reason, the chapter dealing with hemp in connection with medicine is present in the thesis. Six areas were chosen from individual medicine branches on which this chapter is focused. The reader learns about the healing effects of hemp in the area of oncological diseases, psychiatric diseases, palliation of pain, dermatological diseases, multiple sclerosis and HIV/AIDS. In the last chapter, the opinions and experiences of the professional public in connection with hemp are described. This part deals with the contribution of the newest knowledge presented at the Prague conference about healing hemp. In this part of thesis, also the international hemp Cannafest Trade Fair is mentioned held in 2015 in Prague. It follows clearly from the thesis that the health and social issues connected with healing hemp is the topic of extensive and long-lasting discussions at present. In the area of the lay public, there is interest in this form of medical treatment which is supported quite a lot. The thesis may be used as information source by medical/paramedical and social employees and organizations supporting the legal use of healing hemp. It could represent the base of a professional article for the journal dealing with this topic as e.g. professional journals "Legalization" or "Health." Last but not least, the thesis should serve as complex of information for the persons who decided to take the hemp or consider this possibility.

A vancomicina (VANCO) é a primeira opção terapêutica para o tratamento de infecções por estafilococos meticilina-resistentes. Recomenda-se a manutenção de seus níveis séricos entre 15 e 20 <font face=\"Symbol\">mg/mL para eficácia e segurança dos tratamentos. Foi realizado estudo transversal retrospectivo com 15 pacientes dialítcos em tratamento com doses de 1 g VANCO. As freqüências de administrações de VANCO foram comparadas aos seus níveis séricos. A correlação entre nível sérico com o tempo de tratamento e tempo de omissão de dose foi analisada. Quarenta determinações séricas (43%) se mostravam inferiores a 15 <font face=\"Symbol\">mg/mL enquanto vinte e quatro (25,8%) revelaram níveis superiores a 20<font face=\"Symbol\">mg/mL. Este estudo nos permite sugerir que doses de VANCO utilizadas no tratamento de pacientes dialíticos devem ser calculadas em função de sua massa corpórea real, considerando os resultados dos níveis séricos de amostras colhidas no vale, antes da sessão de diálise. Sugerimos que a vancocinemia seja realizada no vale, a cada 48 horas, em pacientes com clearance de creatinina inferior a 20 mL/min. / Vancomycin (VANCO) has been considered the first therapeutic option for treatment of MRSA infections. In order to achieve efficacy and safety, it is recommended VANCO therapeutic plasma levels range between 15 and 20 <font face=\"Symbol\">mg/mL. Retrospective cross-sectional study of 15 dialyitc patients who received several doses of 1g of VANCO and the serum levels were analysed. The administration frequencies were compared to VANCO plasma levels. The correlation between VANCO plasma levels and treatment period and missed doses period was got. The most VANCO serum levels were out of the therapeuic range. Forty serum levels (43%) were below 15 <font face=\"Symbol\">mg/mL while twenty four (25.8%) were above 20 <font face=\"Symbol\">mg/mL. This sutdy allows us tosuggest that VANCO doses must be prescribed according to the patient Actual Body Weight (ABW), considering results of trough plasma concentrations obtained before hemodialysis session. Our results suggest that through plasma levels are obtained every 48 hours in patients with creatinine clearance below 20 mL/min.

INTRODUÇÃO: Historicamente, os procedimentos de revascularização do miocárdio (cirúrgicos ou percutâneos) foram admitidos como opções terapêuticas efetivas para a proteção, em curto e médio prazo, do miocárdio isquêmico em pacientes portadores de doença arterial coronária. Todavia, não está estabelecido se tais procedimentos são essenciais para a preservação da função ventricular, nem se a ausência dos mesmos contribui para sua piora. OBJETIVOS: Avaliar a evolução da fração de ejeção (FEVE) em pacientes portadores de doença multiarterial coronariana crônica estável, e com função ventricular esquerda preservada, dez anos após terem sido submetidos a três diferentes estratégias terapêuticas: revascularização cirúrgica do miocárdio (RM), angioplastia coronária percutânea (ATC) ou tratamento medicamentoso (TM) isoladamente (subestudo do MASS II). MÉTODOS: Realizou-se o ecocardiograma transtorácico com doppler para avaliação da FEVE em pacientes portadores de DAC multiaterial estável no início do estudo e após dez anos das intervenções. O cálculo da FEVE foi realizado pelos métodos de Teichholz ou bidimensional. RESULTADOS: Dos 611 pacientes integrantes do estudo MASS II, 422 pacientes estavam vivos ao término de 10,32 (±1,43) anos de seguimento; destes, 108 pacientes do grupo TM, 111 do RM e 131 do ATC realizaram reavaliação ecocardiográfica da função ventricular. As principais características demográficas, clínicas e angiográficas foram semelhantes nos 3 grupos, bem como a ocorrência de infarto agudo do miocárdico (IAM). A FEVE foi semelhante entre os grupos no início do estudo (0,61 + 0,07, 0,61 + 0,08 e 0,61 + 0,09, respectivamente, para os grupos ATC, RM e TM [p=0,675]) e ao término do seguimento (0,56 + 0,11, 0,55 + 0,11 e 0,55 + 0,12, respectivamente, para os grupos ATC, RM e TM [p=0,675]). Observou-se redução da função ventricular (p<0,001) nos três grupos terapêuticos de forma semelhante (p=0,641). Outras variáveis, como gênero, diabetes, idade, padrão arterial, necessidade de ATC ou RM adicionais, não influenciaram a evolução da FEVE. Porém, a ocorrência de IAM foi responsável por acentuada queda da FEVE (delta de decréscimo de 18,29 + 21,22% e 6,63 + 18,91% para pacientes com e sem IAM, respectivamente [p=0,001]). Além disso, a presença de IAM prévio à randomização e IAM durante o seguimento foram associadas a desenvolvimento de disfunção ventricular, definida como FEVE < 45%. CONCLUSÃO: Pacientes do grupo clínico portadores de DAC multiarterial desprotegida pelas estratégias de revascularização não apresentaram prejuízo adicional na função ventricular em comparação ao observado nos grupos cirúrgico e angioplastia. Além disso, qualquer que tenha sido a estratégia terapêutica aplicada, a função ventricular permaneceu preservada na ausência de infarto agudo do miocárdio / BACKGROUND: Historically, myocardial revascularization procedures, either by coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), are assumed as effective therapeutic options for the protection of the ischemic myocardium. However, it is not established if those procedures are responsible for left ventricular function preservation, or even if their absence may contribute for the deterioration of left ventricular ejection fraction (LVEF). OBJECTIVES: to evaluate the evolution of LVEF in patients with chronic multivessel coronary heart disease and left ventricular function initially preserved, submitted to CABG, PCI or medical treatment (MT), after ten years of follow-up (MASS II substudy). METHODS: Transthoracic echocardiography was performed in patients with multivessel coronary heart disease, participants of MASS II trial, previously to randomization for one of the three possible therapeutic strategies (CABG, PCI and MT), and after 10 years of follow-up. LVEF was measured by the biplane method (Simpson) or alternatively by the Teichholz method. RESULTS: Of the 611 patients participants of MASS II trial, 422 were alive after a follow-up of 10.32 (±1.43) years. 350 had LVEF reassessed: 108 patients in MT group, 111 in CABG group and 131 in PCI group. Main baseline characteristics were similar among the three groups, including demographic, angiographic and laboratorial findings. The occurrence of acute myocardial infarction (AMI) was also similar among the 3 groups. There was no difference of LVEF either at the beginning (0.61 + 0.07, 0.61 + 0.08 e 0.61 + 0.09 respectively for PCI, CABG and MT, p=0.675) and the end of follow up (0.56 + 0.11, 0.55 + 0.11 e 0.55 + 0.12 respectively for PCI, CABG and MT groups, p=0.675). However, there was a slight, but significant reduction (P<0.001) of LVEF, similar on the three therapeutic groups (p=0.641). The impact of other variables over LVEF evolution, such as gender, age, diabetes, arterial pattern (including, left anterior descending coronary artery commitment) and additional revascularization, were also analyzed, with no influence on the evolution of LVEF. However, the presence of previous AMI (OR 2.50, 95% CI 1.40-4.45; p= 0.0007) and the occurrence of AMI during follow up (OR 2.73, 95% IC 1.25- 5.92; p=0.005) were associated with an increased risk of developing LVEF < 45%. Also, AMI during follow-up was responsible for a greater reduction of LVEF (reduction delta of 18.29 ± 21.22% and 6.63 ± 18.91%, respectively for patients with and without AMI during follow-up, p=0.001). CONCLUSION: Compared with PCI or CABG, the Medical group, with unprotected coronary disease by mechanical revascularization, showed no differences in left ventricular function after 10 years of follow-up. Moreover, regardless of therapeutic strategy applied, ventricular function remained preserved without AMI

INTRODUÇÃO: Historicamente, os procedimentos de revascularização do miocárdio (cirúrgicos ou percutâneos) foram admitidos como opções terapêuticas efetivas para a proteção, em curto e médio prazo, do miocárdio isquêmico em pacientes portadores de doença arterial coronária. Todavia, não está estabelecido se tais procedimentos são essenciais para a preservação da função ventricular, nem se a ausência dos mesmos contribui para sua piora. OBJETIVOS: Avaliar a evolução da fração de ejeção (FEVE) em pacientes portadores de doença multiarterial coronariana crônica estável, e com função ventricular esquerda preservada, dez anos após terem sido submetidos a três diferentes estratégias terapêuticas: revascularização cirúrgica do miocárdio (RM), angioplastia coronária percutânea (ATC) ou tratamento medicamentoso (TM) isoladamente (subestudo do MASS II). MÉTODOS: Realizou-se o ecocardiograma transtorácico com doppler para avaliação da FEVE em pacientes portadores de DAC multiaterial estável no início do estudo e após dez anos das intervenções. O cálculo da FEVE foi realizado pelos métodos de Teichholz ou bidimensional. RESULTADOS: Dos 611 pacientes integrantes do estudo MASS II, 422 pacientes estavam vivos ao término de 10,32 (±1,43) anos de seguimento; destes, 108 pacientes do grupo TM, 111 do RM e 131 do ATC realizaram reavaliação ecocardiográfica da função ventricular. As principais características demográficas, clínicas e angiográficas foram semelhantes nos 3 grupos, bem como a ocorrência de infarto agudo do miocárdico (IAM). A FEVE foi semelhante entre os grupos no início do estudo (0,61 + 0,07, 0,61 + 0,08 e 0,61 + 0,09, respectivamente, para os grupos ATC, RM e TM [p=0,675]) e ao término do seguimento (0,56 + 0,11, 0,55 + 0,11 e 0,55 + 0,12, respectivamente, para os grupos ATC, RM e TM [p=0,675]). Observou-se redução da função ventricular (p<0,001) nos três grupos terapêuticos de forma semelhante (p=0,641). Outras variáveis, como gênero, diabetes, idade, padrão arterial, necessidade de ATC ou RM adicionais, não influenciaram a evolução da FEVE. Porém, a ocorrência de IAM foi responsável por acentuada queda da FEVE (delta de decréscimo de 18,29 + 21,22% e 6,63 + 18,91% para pacientes com e sem IAM, respectivamente [p=0,001]). Além disso, a presença de IAM prévio à randomização e IAM durante o seguimento foram associadas a desenvolvimento de disfunção ventricular, definida como FEVE < 45%. CONCLUSÃO: Pacientes do grupo clínico portadores de DAC multiarterial desprotegida pelas estratégias de revascularização não apresentaram prejuízo adicional na função ventricular em comparação ao observado nos grupos cirúrgico e angioplastia. Além disso, qualquer que tenha sido a estratégia terapêutica aplicada, a função ventricular permaneceu preservada na ausência de infarto agudo do miocárdio / BACKGROUND: Historically, myocardial revascularization procedures, either by coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), are assumed as effective therapeutic options for the protection of the ischemic myocardium. However, it is not established if those procedures are responsible for left ventricular function preservation, or even if their absence may contribute for the deterioration of left ventricular ejection fraction (LVEF). OBJECTIVES: to evaluate the evolution of LVEF in patients with chronic multivessel coronary heart disease and left ventricular function initially preserved, submitted to CABG, PCI or medical treatment (MT), after ten years of follow-up (MASS II substudy). METHODS: Transthoracic echocardiography was performed in patients with multivessel coronary heart disease, participants of MASS II trial, previously to randomization for one of the three possible therapeutic strategies (CABG, PCI and MT), and after 10 years of follow-up. LVEF was measured by the biplane method (Simpson) or alternatively by the Teichholz method. RESULTS: Of the 611 patients participants of MASS II trial, 422 were alive after a follow-up of 10.32 (±1.43) years. 350 had LVEF reassessed: 108 patients in MT group, 111 in CABG group and 131 in PCI group. Main baseline characteristics were similar among the three groups, including demographic, angiographic and laboratorial findings. The occurrence of acute myocardial infarction (AMI) was also similar among the 3 groups. There was no difference of LVEF either at the beginning (0.61 + 0.07, 0.61 + 0.08 e 0.61 + 0.09 respectively for PCI, CABG and MT, p=0.675) and the end of follow up (0.56 + 0.11, 0.55 + 0.11 e 0.55 + 0.12 respectively for PCI, CABG and MT groups, p=0.675). However, there was a slight, but significant reduction (P<0.001) of LVEF, similar on the three therapeutic groups (p=0.641). The impact of other variables over LVEF evolution, such as gender, age, diabetes, arterial pattern (including, left anterior descending coronary artery commitment) and additional revascularization, were also analyzed, with no influence on the evolution of LVEF. However, the presence of previous AMI (OR 2.50, 95% CI 1.40-4.45; p= 0.0007) and the occurrence of AMI during follow up (OR 2.73, 95% IC 1.25- 5.92; p=0.005) were associated with an increased risk of developing LVEF < 45%. Also, AMI during follow-up was responsible for a greater reduction of LVEF (reduction delta of 18.29 ± 21.22% and 6.63 ± 18.91%, respectively for patients with and without AMI during follow-up, p=0.001). CONCLUSION: Compared with PCI or CABG, the Medical group, with unprotected coronary disease by mechanical revascularization, showed no differences in left ventricular function after 10 years of follow-up. Moreover, regardless of therapeutic strategy applied, ventricular function remained preserved without AMI

Purpose of Review: This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD). Recent Findings: A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. Summary: An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.

The initial treatment options for patients with stable coronary artery disease include optimal medical therapy alone, or coronary revascularization with optimal medical therapy. The most common revascularization modality is percutaneous coronary intervention (PCI) with either bare metal stents (BMS) or drug-eluting stents (DES). PCI is believed to reduce recurrent angina and thereby decrease the need for additional procedures compared to optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset the increased costs and small increase in adverse events associated with PCI. The objectives of this thesis were to determine the degree of angina relief afforded by PCI and develop a tool to provide contemporary estimates of the impact of angina on quality of life. In addition, we sought to develop a comprehensive state-transition model, calibrated to real world costs and outcomes to compare the cost-effectiveness of initial medical therapy versus PCI with either BMS or DES in patients with stable coronary artery disease. ii We performed a systematic search and meta-analysis of the published literature. Although PCI was associated with an overall benefit on angina relief (odds ratio [OR] 1.69; 95% Confidence Interval [CI] 1.24-2.30), this benefit was largely attenuated in contemporary studies (OR 1.13; 95% CI 0.76-1.68). Our meta-regression analysis suggests that this observation was related to greater use of evidence-based medications in more recent trials. Using simple linear regression, we were able to create a mapping tool that could accurately estimate utility weights from data on the Seattle Angina Question, the most common descriptive quality of life instrument used in the cardiovascular literature. In our economic evaluation, we found that an initial strategy of PCI with a BMS was cost- effective compared to medical therapy, with an incremental cost-effectiveness ratio (ICER) of $13,271 per quality adjusted life year gained. In contrast, DES had a greater cost and lower survival than BMS and was therefore a dominated strategy.

The initial treatment options for patients with stable coronary artery disease include optimal medical therapy alone, or coronary revascularization with optimal medical therapy. The most common revascularization modality is percutaneous coronary intervention (PCI) with either bare metal stents (BMS) or drug-eluting stents (DES). PCI is believed to reduce recurrent angina and thereby decrease the need for additional procedures compared to optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset the increased costs and small increase in adverse events associated with PCI. The objectives of this thesis were to determine the degree of angina relief afforded by PCI and develop a tool to provide contemporary estimates of the impact of angina on quality of life. In addition, we sought to develop a comprehensive state-transition model, calibrated to real world costs and outcomes to compare the cost-effectiveness of initial medical therapy versus PCI with either BMS or DES in patients with stable coronary artery disease. ii We performed a systematic search and meta-analysis of the published literature. Although PCI was associated with an overall benefit on angina relief (odds ratio [OR] 1.69; 95% Confidence Interval [CI] 1.24-2.30), this benefit was largely attenuated in contemporary studies (OR 1.13; 95% CI 0.76-1.68). Our meta-regression analysis suggests that this observation was related to greater use of evidence-based medications in more recent trials. Using simple linear regression, we were able to create a mapping tool that could accurately estimate utility weights from data on the Seattle Angina Question, the most common descriptive quality of life instrument used in the cardiovascular literature. In our economic evaluation, we found that an initial strategy of PCI with a BMS was cost- effective compared to medical therapy, with an incremental cost-effectiveness ratio (ICER) of $13,271 per quality adjusted life year gained. In contrast, DES had a greater cost and lower survival than BMS and was therefore a dominated strategy.