Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes

BACKGROUND

Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis.

OBJECTIVES

The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods.

METHODS

Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations.

RESULTS

Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0.

CONCLUSIONS

Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.

Incidental Coronary Artery Calcium: Opportunistic Screening of Previous Nongated Chest Computed Tomography Scans to Improve Statin Rates (NOTIFY-1 Project)

BACKGROUND

Coronary artery calcium (CAC) can be identified on nongated chest computed tomography (CT) scans, but this finding is not consistently incorporated into care. A deep learning algorithm enables opportunistic CAC screening of nongated chest CT scans. Our objective was to evaluate the effect of notifying clinicians and patients of incidental CAC on statin initiation.

METHODS

NOTIFY-1 (Incidental Coronary Calcification Quality Improvement Project) was a randomized quality improvement project in the Stanford Health Care System. Patients without known atherosclerotic cardiovascular disease or a previous statin prescription were screened for CAC on a previous nongated chest CT scan from 2014 to 2019 using a validated deep learning algorithm with radiologist confirmation. Patients with incidental CAC were randomly assigned to notification of the primary care clinician and patient versus usual care. Notification included a patient-specific image of CAC and guideline recommendations regarding statin use. The primary outcome was statin prescription within 6 months.

RESULTS

Among 2113 patients who met initial clinical inclusion criteria, CAC was identified by the algorithm in 424 patients. After chart review and additional exclusions were made, a radiologist confirmed CAC among 173 of 194 patients (89.2%) who were randomly assigned to notification or usual care. At 6 months, the statin prescription rate was 51.2% (44/86) in the notification arm versus 6.9% (6/87) with usual care (P<0.001). There was also more coronary artery disease testing in the notification arm (15.1% [13/86] versus 2.3% [2/87]; P=0.008).

CONCLUSIONS

Opportunistic CAC screening of previous nongated chest CT scans followed by clinician and patient notification led to a significant increase in statin prescriptions. Further research is needed to determine whether this approach can reduce atherosclerotic cardiovascular disease events.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04789278.

Nebulized Ketamine Used for Managing Ankle Fracture in the Prehospital Emergency Setting: A Case Report

INTRODUCTION

Acute traumatic limb injury is a common complaint of patients presenting to the emergency department (ED). Ketamine is an effective analgesic administered via intravenous (IV), intranasal (IN), intramuscular (IM), and nebulized routes in the ED. It has also been used in the prehospital setting via IV, IM, and IN routes. Recent studies have proposed the prehospital use of nebulized ketamine via breath-actuated nebulizer (BAN) as a noninvasive and effective method of analgesic delivery, as well as an alternative to opioid analgesia.

CASE REPORT

We present a case of a patient with right ankle fracture after a 12-foot fall who subsequently received 0.75 milligrams per kilogram of nebulized ketamine via BAN in the prehospital setting. The patient reported improvement of pain from 8/10 to 3/10 on the pain scale without need for additional pain medication during prehospital transport. This report supports the use of nebulized ketamine via BAN in the prehospital setting for acute traumatic limb injuries.

CONCLUSION

The use of nebulized ketamine via BAN in the prehospital setting may be an effective analgesic option for the management of patients with acute traumatic limb injuries, particularly in those with difficult IV access, where mucosal atomization devices are not accessible, or where opioid-sparing treatments are preferable.

Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting

Introduction

Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regard to preference as well as the barriers to its preparation and administration.

Methods

A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus “push-dose” epinephrine (PD-E). Data collection was carried out from June to September 2021.

Results

A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in “using” and “preparing” it. Participants felt less confident with “using” and “preparing” vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding. 

Conclusion

This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting. 

Automated coronary calcium scoring using deep learning with multicenter external validation

Coronary artery disease (CAD), the most common manifestation of cardiovascular disease, remains the most common cause of mortality in the United States. Risk assessment is key for primary prevention of coronary events and coronary artery calcium (CAC) scoring using computed tomography (CT) is one such non-invasive tool. Despite the proven clinical value of CAC, the current clinical practice implementation for CAC has limitations such as the lack of insurance coverage for the test, need for capital-intensive CT machines, specialized imaging protocols, and accredited 3D imaging labs for analysis (including personnel and software). Perhaps the greatest gap is the millions of patients who undergo routine chest CT exams and demonstrate coronary artery calcification, but their presence is not often reported or quantitation is not feasible. We present two deep learning models that automate CAC scoring demonstrating advantages in automated scoring for both dedicated gated coronary CT exams and routine non-gated chest CTs performed for other reasons to allow opportunistic screening. First, we trained a gated coronary CT model for CAC scoring that showed near perfect agreement (mean difference in scores = -2.86; Cohen's Kappa = 0.89, P < 0.0001) with current conventional manual scoring on a retrospective dataset of 79 patients and was found to perform the task faster (average time for automated CAC scoring using a graphics processing unit (GPU) was 3.5 ± 2.1 s vs. 261 s for manual scoring) in a prospective trial of 55 patients with little difference in scores compared to three technologists (mean difference in scores = 3.24, 5.12, and 5.48, respectively). Then using CAC scores from paired gated coronary CT as a reference standard, we trained a deep learning model on our internal data and a cohort from the Multi-Ethnic Study of Atherosclerosis (MESA) study (total training n = 341, Stanford test n = 42, MESA test n = 46) to perform CAC scoring on routine non-gated chest CT exams with validation on external datasets (total n = 303) obtained from four geographically disparate health systems. On identifying patients with any CAC (i.e., CAC ≥ 1), sensitivity and PPV was high across all datasets (ranges: 80-100% and 87-100%, respectively). For CAC ≥ 100 on routine non-gated chest CTs, which is the latest recommended threshold to initiate statin therapy, our model showed sensitivities of 71-94% and positive predictive values in the range of 88-100% across all the sites. Adoption of this model could allow more patients to be screened with CAC scoring, potentially allowing opportunistic early preventive interventions.

Foreign body injuries in children: Are the younger siblings doomed?

Background and objectives

Foreign body injury (FBI) is a considerable public health issue for children. Although the relationships of FBI with age, gender, and objects of injury have been studied, the extent to which other demographic factors influence FBI is unclear. We hypothesized that the risk for FBI increases with the number of children in the household.

Design and settings

This was a retrospective analysis of 223 patients aged 2-10 years who presented to the emergency department of an inner-city pediatric hospital and who were found to have FBI.

Patients and methods

The guardians were contacted via phone to examine the associations of FBI with income, parental educational level, number of children in the household, and birth order while controlling with a matched population of 250 patients. Statistical analyses using frequencies and univariate and multivariate analyses were performed.

Results

For each increase in the number of children, the risk of FBI increased 1.44-fold (OR = 1.442). With each increase in the number of caregivers, the risk of a FBI decreased 33% (OR = 0.673). With each increase in income category, the risk of a FBI decreased 59% (OR = 0.413).

Conclusion

The results suggest that an increase in the number of children in a household is associated with a greater risk of FBI.

The needs of persons with lupus and health care providers: a qualitative study aimed toward the development of the Lupus Interactive Navigator™

Objective

Systemic lupus erythematosus is an inflammatory autoimmune disease associated with high morbidity and unacceptable mortality. A major challenge for persons with lupus is coping with their illness and complex care. Our objective was to identify the informational and resource needs of persons with lupus, rheumatologists, and allied health professionals treating lupus. Our findings will be applied toward the development of an innovative web-based technology, the Lupus Interactive Navigator (LIN™), to facilitate and support engagement and self-management for persons with lupus.

Methods

Eight focus groups were conducted: four groups of persons with lupus ( n = 29), three groups of rheumatologists ( n = 20), and one group of allied health professionals ( n = 8). The groups were held in British Columbia, Ontario, and Quebec. All sessions were audio-recorded and transcribed verbatim. Qualitative analysis was performed using grounded theory. The transcripts were reviewed independently and coded by the moderator and co-moderator using 1) qualitative data analysis software developed by Provalis Research, Montreal, Canada, and 2) manual coding.

Results

Four main themes emerged: 1) specific information and resource needs; 2) barriers to engagement in health care; 3) facilitators of engagement in health care; and 4) tools identified as helpful for the self-management of lupus.

Conclusion

These findings will help guide the scope of LIN™ with relevant information topics and specific tools that will be most helpful to the diverse needs of persons with lupus and their health care providers.

Comparative study of torsional and bending properties for six models of nickel-titanium root canal instruments with different cross-sections

This study investigated the influence of cross-section profile on the mechanical behaviors of six commercial nickel-titanium (NiTi) root canal instruments using the finite element method. The nonlinear mechanical characteristics of the NiTi alloy were taken into account. The six root canal instruments studied were ProTaper, Hero642, Mtwo, ProFile, Quantec, and NiTiflex. Mathematical models for these instruments were constructed and their performances were analyzed under equal torque conditions. The ProTaper and Hero642 models achieved the lowest stress levels that made them the most torque-resistant while the NiTiflex model was the poorest. The maximum stress value and the stress distribution in a model were found strongly influenced by the cross-section profile. Factors affecting the stress distribution include the cross-sectional inertia, depth of the flute, area of the inner core, radial land, and peripheral surface ground. As the area of the inner core of the cross-section increased, the model was more torque-resistant.

Hyaluronan facilitates invasion of colon carcinoma cells in vitro via interaction with CD44

Hyaluronan (HA) and its biosynthetic enzymes, HA synthases (HAS1, 2, and 3) are thought to participate in cancer progression. We have shown previously that HA production and HAS3 expression are increased in metastatic colon carcinoma cells (SW620) when compared with cells isolated from a primary tumor (SW480). Because invasion of the extracellular matrix is a fundamental event in tumor growth and metastasis, we hypothesized that SW620 cells would show greater invasive capability than SW480 cells, that invasion is HA dependent, and that HA mediates invasion via interaction with a cell-surface receptor. Invasion into artificial basement membrane (Matrigel) was assessed in vitro. To assess HA functionality, HAS expression was inhibited in SW620 cells by transfection with antisense HAS constructs. Decreased HA secretion and retention in the transfectants were confirmed using competitive binding and particle exclusion assays. SW620 cells demonstrated greater invasion through Matrigel than did SW480 cells. Antisense transfection decreased Matrigel invasion by SW620 cells by >60%; addition of exogenous HA restored invasion. Because the cell-surface HA receptor CD44 has been implicated in cancer progression, HA-CD44 interaction was then inhibited by incubation with an anti-CD44 antibody. Anti-CD44 antibody impaired invasion into Matrigel by 95%. Taken together, these data suggest that pericellular HA is critical for colon carcinoma cell invasion and that this invasive capability is dependent on interaction with CD44.

Brachial plexus catheter reservoir for the treatment of upper-extremity cancer pain: technical case report

OBJECTIVE AND IMPORTANCE

Infiltration of the brachial plexus with anesthetics can provide relief of upper-extremity pain from invasive cancer. Because the analgesia is short-lived, however, repeated invasive treatments are necessary. We describe the implantation of a catheter reservoir system, in which anesthetic injections through a subcutaneous port resulted in anesthetic infiltration of the brachial plexus.

CLINICAL PRESENTATION

A 47-year-old Hispanic man with squamous cell carcinoma of the larynx had undergone surgical resection, radiation treatment, and chemotherapy. Two years later, he had locally recurrent disease involving the brachial plexus, neck, and chest wall. The patient's pain was minimally responsive to narcotics, which also caused severe nausea and anorexia.

TECHNIQUE

The brachial plexus was localized percutaneously with a needle electrode stimulator. Contrast injection under fluoroscopy confirmed entry into the plexus sheath. With use of the Seldinger technique, two Silastic catheters were placed within the brachial plexus and attached with a "Y" connector to a reservoir. The patient experienced complete relief of upper-extremity pain after a test injection with xylocaine. Thereafter, serial injections of bupivacaine with triamcinolone at 1-week intervals provided complete pain relief. After the treatments were initiated, the patient reported improved sleep and an improvement in his quality of life.

CONCLUSION

A catheter reservoir system for brachial plexus analgesia can provide safe and effective analgesia for upper-extremity pain. This technique negates the need for repeated invasive procedures and avoids the complications of neurolysis.

Tumor response to interferon inducer and radiation effect of serum interferon levels

The effect of interferon inducing complex of polyriboinosinic, polyribocytidylic acid with poly-L-lysine and carboxymethylcellulose - Poly (ICLC) - on the response of Lewis lung carcinoma in C57B1 mice to radiation treatments was studied. Improved tumor response was obtained in mice receiving 1.5 mg/m2 or higher of Poly (ICLC). Such doses have induced more than 1000 mu/ml of serum interferon. The same doses of Poly (ICLC) potentiated the epilation effect of radiation. The injection of 0.15 mg/m2 of Poly (ICLC) led to protection of the tumor and the stimulation of it's growth. It also did not potentiate the epilation effect. In this study, one weekly administration of Poly (ICLC) was as effective as three times per week treatment. The cellular mechanism of the increased radiosensitivity caused by Poly (ICLC) was reflected in the reduction of the width of the shoulder on the cell survival curve, which was dependent on the dose of the drug. In cell cultures, doses of 100 micrograms/ml synchronized the cell division, thus contributing to the increase in radiosensitivity.

A simple quantitative analysis system for coronary cineangiograms using a personal computer

We have developed a simple quantitative analysis system for coronary cineangiograms using a personal computer and a standard projector-video camera system. The selected frame of cinefilm was projected onto the target area of a CCD video camera. To decrease spatial fluctuations due to quantum noise, the digital data were smoothed spatially by applying a moving averaged filter and a median filter. Following the smoothing process, the digital data with gray level were transformed to binary data by quantifying the threshold property of their gray level. To minimize the geometric influence, mainly pincushion effect, a cinefilm of a 1 cm grid was placed against the input screen of the image intensifier to correct the distortion by using 3rd degree polynomials. The accuracy of the contour detection procedure was validated on the basis of phantom models filled with a contrast medium. Despite the potential influence of many radiographic variables on computerized diameter measurements, the overall accuracy was found to be 0.26-0.33 mm over a wide range of clinically relevant artery diameters and radiographic conditions. Using this system we demonstrated one method of examining the effects of acetylcholine and nitroglycerin on coronary artery diameter in adult humans.

Neonatal narcotic abstinence: Effects of pharmacotherapeutic agents and maternal drug usage on nutritive sucking behavior

An uncoordinated and ineffectual sucking reflex is a major manifestation of neonatal narcotic abstinence and may have important consequences for the infant's subsequent well being. Measures of nutritive sucking were used to monitor the severity of neonatal narcotic abstinence in a series of infants born to narcotic-dependent mothers who were either attending the methadone clinic or else were "street addicts." In all these infants, sucking measures were significantly reduced relative to normal control subjects. Furthermore, the sucking behavior of infants born to mothers attending the methadone clinic was significantly more depressed than that of infants born to street addicts. In regard to the salutary effects of pharmacotherapy for neonatal narcotic abstinence, infants treated with paregoric approached normal control levels and showed significantly better sucking than those treated with phenobarbital or diazepam. The latter drug practically eliminated all spontaneous nutritive sucking behavior.