2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease: A Summary for JASE

This report provides a descriptive summary of the ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease with an emphasis on the role of stress echocardiography.

ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease

The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting1-4.This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD4. Key changes beyond the updated ratings based on new evidence include the following: 1. Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document under development. 2. Some clinical scenarios and tables were removed in an effort to simplify the selection of clinical scenarios. Additionally, the flowchart of tables has been reorganized, and all clinical scenario tables can now be reached by answering a limited number of clinical questions about the patient, starting with the patient's symptom status. 3. Several clinical scenarios have been revised to incorporate changes in other documents such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessment, syncope, and others. ASCVD risk factors that are not accounted for in contemporary risk calculators have been added as modifiers to certain clinical scenarios. The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.5 These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD.Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented, midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely appropriate.

18F-FDG/13N-ammonia cardiac PET findings in ATTR cardiac amyloidosis

18F-flurodeoxyglycose (FDG)/13N-ammonia positron emission tomography/computed tomography (PET/CT) is frequently utilized to evaluate cardiac sarcoidosis (CS) but findings can reflect other forms of myocardial inflammation or altered myocardial metabolic activity. Herein, we present five cases where cardiac PET findings suggested CS, but right ventricular endomyocardial biopsy samples revealed ATTR-type cardiac amyloidosis.

Utility of the Serum Free Light Chain Assay in the Diagnosis of Light Chain Amyloidosis in Patients With Heart Failure

OBJECTIVE

To determine the utility of the serum free light chain (FLC) assay for routine screening of light chain amyloidosis (AL) in patients with heart failure.

PATIENTS AND METHODS

We studied consecutive new patients referred to the Heart Failure Clinic who had the FLC assay performed for routine screening at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 2011, through December 31, 2015. An FLC ratio between 0.26 and 1.65 was considered normal.

RESULTS

Of the 1173 patients in the study (mean age, 64±15 years), 207 had an abnormal FLC ratio. Light chain amyloidosis was diagnosed in 0.5% of all patients (6 of 1173) and in 2.9% of those with an abnormal FLC ratio (6 of 207). To increase the pretest probability of an abnormal FLC ratio in predicting AL, we considered patients with an N-terminal pro B-type natriuretic peptide level of 5000 pg/mL or greater (to convert to pmol/L, multiply by 0.1182) and a left ventricular posterior wall thickness of 13 mm or greater; this increased the diagnostic yield to 66.7% (6 of 9).

CONCLUSION

The prevalence of AL in patients with heart failure could be 0.5% or higher. Compared with the use of the serum FLC assay for routine screening, a targeted approach of the serum FLC assay in those with higher N-terminal pro B-type natriuretic peptide level (≥5000 pg/mL) and increased posterior wall thickness (≥13 mm) has a markedly higher yield for the diagnosis of AL.

Morphology and function of gill mitochondria-rich cells in fish acclimated to different environments

The objective of this study is to test the hypothesis that morphologically different mitochondria-rich (MR) cells may be responsible for the uptake of different ions in freshwater-adapted fish. Tilapia (Oreochromis mossambicus) were acclimated to high-Ca, mid-Ca, low-Ca, and low-NaCl artificial freshwater, respectively, for 2 wk. Cell densities of wavy-convex, shallow-basin, and deep-hole types of gill MR cells as well as whole-body Ca(2+), Na(+), and Cl(-) influxes were measured. Low-Ca fish developed more shallow-basin MR cells in the gills and a higher Ca(2+) influx than those acclimated to other media. However, fish acclimated to low-NaCl artificial freshwater predominantly developed wavy-convex cells, and this was accompanied by the highest Na(+) and Cl(-) influxes. Relative abundance of shallow-basin and wavy-convex MR cells appear to be associated with changes in Ca(2+) and Na(+)/Cl(-) influxes, suggesting that shallow-basin and wavy-convex MR cells are mainly responsible for the uptake of Ca(2+) and Na(+)/Cl(-), respectively.

Using sustainable development indicators as a supplementary measure for the integrated management of environmental information system in Taiwan

Environmental Information System (EIS) transfers environmental data and information to audiences in any field of knowledge or activity interested in environmental problems. Currently, numerous conventional EISs or Environmental Databases (EDs) are available in Taiwan. However, they fail to adequately address the strong correlations among the environmental, social and economic components. Notably, Sustainable Development Indicators (SDIs) combine environmental, social and economic dimensions, as well as illustrate the links among systems. Subsequently, developing a set of SDIs will provide an excellent opportunity to systematically consolidate the information scattered among many archives, as well as promoting an integrated EIS. This work presents an experimental model referred to as the 'Sustainable Development Information System of the Island Taiwan' (SDISIT). This system was developed to assist the integrated management of either EIS or ED. The Factor Analysis Method (FAM) is one tool that may prove useful in easing the developing process. Furthermore, by examining the correlations between the indicators, this method can apply existing SDIs to identify the structure of interrelationships among indicators.

Protective effects of partially purified antigens of Actinobacillus pleuropneumoniae on experimentally infected mice

Three different models of protection experiments in mice using partially purified Actinobacillus pleuropneumoniae antigens such as crude culture supernatant extract (CCSE) and partially purified cell extract (PPCE) were attempted. Biochemical analysis showed that these two immunogens had protein concentration of 0.17-0.2 mg/mL and pentose concentration of 0.012-0.014 mg/mL. In the first model intranasal (IN) vaccination with different doses (from 0.01-10 IN-LD50) against IN challenge with the dose of 20 IN-LD50 containing 1.2 x 10(9) colony forming unit (CFU)/50 microL showed that only those with the dose more than 1 IN-LD50 had slight protection in terms of survival index (SI). In the second model of protection experiment, in which subcutaneous vaccination (s.c.) with the immunogens plus soybean oil against IN challenge with 10 IN-LD50 containing 6 x 10(8) CFU/50 microL, showed that formalin-killed bacteria (bacterin) and CCSE plus PPCE had only a slight protection whereas vaccination with CCSE or PPCE immunogen alone had no protection. In the third model of protection experiment, in which the intramuscular (i.m.) vaccination with the immunogens plus aluminum hydroxide [Al(OH3)] gel against intraperitoneal (i.p.) challenge with the dose of either 2 or 6 i.p.-LD50 containing 1.2-3.6 x 10(8) CFU/0.5 mL of 0.3% mucin saline showed highly effective.

[A study on behavior towards injection among residents and physicians in Kaohsiung & Ping-tung area]

To understand why people in Taiwan preferred iatrogenic injection as their medical therapy, we surveyed the knowledge, attitude, and behavior of iatrogenic injection for people and doctors in Kaohsiung and Ping-tung area by questionnaire. The results of the survey are drawn below: 1. More than 91.7% of the interviewed people would like to receive iatrogenic injection as their medical therapy, and 78.1% of the parents would choose iatrogenic injection for their children. The reason majority were because doctors suggested that and the parents believed iatrogenic injection is a quicker way of recovery. 2. In this study, 72.1% of the people received injection as their usual mode of medical treatment, and 74.9% of them had received injection during the previous month. When they brought their children to the clinics, the percentages of the above two conditions were 60.4% and 59.7% respectively. The factors influencing the reception of injection for people were the efficacy of the injection, education level and medical insurance. The influencing factors for children were the parents' medical behavior and the parents' willingness to accept injection. 3. About 83% of the interviewed doctors preferred iatrogenic injection as treatment for their patients. Almost 60% of them agreed that more patients would receive injection after National Health Insurance. About 72% of the doctors would not change the treatment for their patients, no matter how the system of the medical insurance changes. They would choose the right treatment for the distinct disease.

Pulmonary function and respiratory symptoms of Portland cement workers in southern Taiwan

Respiratory symptoms and pulmonary function were studied in a cross-sectional survey of Portland cement workers in southern Taiwan. The study cohort consisted of 661 cement workers who were classified into low, medium, and high exposure groups with mean exposure values of 0.22, 0.55 and 1.24 mg/m3 of respirable dust concentrations, respectively. The prevalence of respiratory symptoms was not found to be significantly related to exposure, with the exception of a higher prevalence of coughing found among the heavy exposure group (OR = 1.55, P < 0.05). Both non-smoking and smoking cement workers showed no significant differences in the pulmonary function indices among the three exposure groups.

Nosocomial Legionnaire's disease--a case report and review of the literature

We report a case of nosocomial legionellosis in a 63 year-old man who was managed with neurosurgery under the diagnosis of subarachnoidal hemorrhage and complicated pneumonia in the intensive care unit. A legionella species was reported from sputum culture and direct immunofluorescent antibody test revealed L. pneumophila (serogroup 2). Our patient's pneumonia was cured with medical therapy including erythromycin and was the first case of microbiologically confirmed legionellosis in Korea.

[The study of Apgar score and infant birth weight in the central Taiwan]

The objective of this study was to assess the relationship between birth weight and the Apgar Score. We collected data on the birth weights and the 1 min and 5 min Apgar Score of new born infants between 1982 and 1987 at a teaching hospital in Central Taiwan. Compared to babies with normal Apgar Score, infants with low Apgar Scores were found to born with low and very low birth weights. In the 1 min of life test, the relative risks of low birth weights among infants with Apgar Scores of 0 to 3 and 4 to 6 were 115.0 and 5.9 times higher than those of normal infants, respectively. In the very low birth weight category, the relative risks of the above score were 252.5 and 51.1, in this order. In the 5 min of life test, the relative risks of the above scores were 16.2 and 12.1 in the low birth weight category, respectively. However, among babies of very low birth weight, the relative risks of the same scores were 121.2 and 84.9, in this order. In conclusion, the 5 min Apgar Score might be a useful prognostic index for the relationship between health and birth weight of new born infants.

[A study of weight and weight/birth at birth by gestational week]

A study of 35,919 live neonates was conducted from 1976 to 1987 (excluding 1980) at a teaching hospital in Central Taiwan. Our goal was to determine the proportions of low birth weight (LBW) and very low birth weight (VLBW) and birth weight/birth length ratios by gestational week. The results showed that LBW and VLBW neonates were 6.3% and 1.1%, respectively. In LBW neonates groups, there was a rapid decline after the 33rd gestational week, then as low as 6.9% by the 38th gestational week. After the 28th gestational week, there was a rapid decline in VLBW proportion, then a further decline to 9.3% at the 32nd gestational week. Birth weight/birth length ratios were 2.94 and 6.25 at the 28th and 39th gestational weeks, respectively. There were no differences in birth weight/birth length ratios between male and female babies. Based on the above findings, we tried to set a norm from birth weight/birth length ratios by gestational week.

Expression of growth-related genes and drug-resistance genes in HTLV-I-positive and HTLV-I-negative post-thymic T-cell malignancies

This study was designed to investigate the biologic and molecular basis of the aggressive behavior of high-grade post-thymic T-cell malignancies. Freshly frozen tumor tissues from (1) human T-cell leukemia/lymphoma virus type I (HTLV-I)-positive adult T-cell lymphoma (ATL) (7 cases), (2) HTLV-I-negative aggressive T-cell lymphoma (12 cases), and (3) HTLV-I-negative nonaggressive T-cell lymphoma (11 cases) were studied for the expression of several growth-related genes or proliferation antigens including interleukin-2 receptor (IL-2R), Ki-67, transforming growth factor-beta (TGF-beta), topoisomerase, and the multidrug resistance (MDR) gene by immunohistochemistry and Northern blot hybridization. Our results showed that tumor cells associated with HTLV-I and anaplastic morphology had an enhanced expression of Ki-67, TGF-beta, and topoisomerase, as compared to nonaggressive T-cell lymphoma. The expression of IL-2R was limited to ATL and one Ki-1 lymphoma. The MDR gene was frequently expressed in ATL, but only infrequently in other, HTLV-I-negative, malignancies. Clinical progression or relapse was associated with the expression of MDR, in addition to an increased expression of Ki-67. We therefore conclude that the aggressive clinical behavior of high-grade T-cell lymphoma may result mainly from the high proliferative activity of tumor cells, but the association with HTLV-I and clinical relapse is further complicated by the development of drug resistance.

Attack rate of dengue-like illness among teachers in Kaohsiung City, 1988

The present study is based on a questionnaire evaluating 2,770 school teachers, including those from elementary, junior-high, senior-high, and occupational schools, in Kaohsiung city. The response rate was 91.1% (2,626/2,770). The self-reported cumulative incidence of dengue-like illness was 7.9% (207/2,626) and the physician-diagnosed cumulative incidence was 5.6% (148/2,626). There is no significant difference between distribution of infections among subjects' gender, educational background, and the associated school regardless of self-reported cases or diagnosed cases. Among those self-reported dengue infected teachers, 60.1% (119/207) required sick leaves. The difference of sick leaves among subjects by either education background or associated school was not significant. However, more females stayed home because of the illness than males did.

Allograft reconstruction for the treatment of long bone defects: report of 9 cases

From April 1980 to December 1987, we experienced 18 cases of frozen intercalary allografts including 13 cases of bone tumor, 3 cases of congenital pseudoarthrosis of the tibia and 2 cases of traumatic bone defect. Nine cases were followed up for more than 2 years. The average allograft of length was 10.5cm (ranging from 3.5cm to 22cm). All cases had supplemental autografts in combination with intercalary allografts. The average time of radiographic union was 5 months (ranging from 4 months to 8 months) between allograft and autogenous cancellous bone graft, and 11.3 months (ranging from 7 months to 18 months) between allograft and host bone. We use the bone scan for early determination of the fate of allografts. The bone scan usually becomes positive at about 6 months after transplantation. The functional result was 89% "excellent" and "good" according to Henry J. Mankin's grading. One non-union and 3 leg length discrepancies of more than 2cm were encountered. In this study, we found that the deep frozen allograft for the treatment of large bone defects is very encouraging.

Enhancement of acousto-optic filter resolution using birefringence dispersion in CdS

A CdS acousto-optic tunable filter has been constructed and operated near the band gap. The filter exhibits a large enhancement of spectral resolution that is due to birefringence dispersions. Over the wavelength range 530 to 545 nm, a half-power bandwidth of 20 A was obtained with an angular aperture of 38 degrees.

Controlling factors in the development of ceruloplasmin in pigs during the neonatal growth period

The sequence of ceruloplasmin development and limiting factors controlling this process in neonatal piglets was studied in a randomized block design. Guided by the change in serum ceruloplasmin levels, the liver copper concentrations of piglets fed copper-deficient and copper-supplemented diets were compared in three different periods. The plasma of piglets was devoid of both apo- and holo-ceruloplasmin at birth. The system responsible for the synthesis of apoceruloplasmin developed shortly after birth as indicated by a steady increase in serum ceruloplasmin activity during the first week without being affected by the diet. Copper apparently was not the limiting factor at this stage since very high concentrations of copper were found in the livers of newborn piglets. However, the liver copper was depleted quickly within 1 to 2 weeks and became the limiting factor if the diet was deficient in copper. The livers of these piglets were fractionated by differential centrifugation to compare the liver copper distribution in the two dietary groups with and without copper supplementation. The treatments did not affect the copper distribution on a percentage of total liver copper basis. However, fractionation study revealed that, unlike adult pig livers, about 70% to 80% of copper was present in the heavier particle fractions of piglet livers.

Development of ceruloplasmin in pigs during the neonatal period

Colostrum-free newborn pigs were raised artificially to investigate the appearance of ceruloplasmin in the serum of piglets. The sensitivity of the p-phenylenediamine oxidase activity assay, commonly used as a measure of ceruloplasmin, has been increased 10-fold. Based on this activity, no evidence was found that this copper protein was present in the serum of baby pigs at birth, although some evidence was obtained that the protein moiety (apoceruloplasmin) was present. Holoceruloplasmin usually became detectable in the serum 10-15 hours after birth. Its concentration increased slowly at first and then at an accelerated rate. The ceruloplasmin in the sera of 2-3-day-old piglets was isolated and compared with that isolated from the serum of adults. Contrary to a previous report, the physical and chemical properties of ceruloplasmin synthesized during the first 3 days of life of the piglet showed no significant difference from that synthesized by the adult.

Semi-commercial-scale production of Japanese B encephalitis virus vaccines from tissue culture

This study was undertaken to modify and develop procedures for tissue culture-inactivated Japanese B encephalitis (JBE) virus vaccine production in large quantities. Various types of glass bottles were tried and, considering many advantages, long cylindrical roller (CR) bottles were selected. Several variables were investigated including number and volume of trypsinized cells to be seeded, volume of growth medium required for optimum cell growth, amount of calf serum, and volume of harvest medium for a high-titer virus yield. A good confluent cell sheet in CR bottles was obtained within a week by increasing the calf serum from 4 to 10% and when such tissue in a CR bottle was inoculated with 45,000 viral mean tissue culture infective doses directly into the medium, the cytopathological effects (CPE) appeared on day 5. High-titer virus yields were obtained when the harvests were made at 4(+) CPE using medium 199 with 2% human albumin at pH 8.3 to 8.5. No appreciable gain in titer was found from such harvests by blending to release intracellular virions. The production methods finally adopted gave consistently good results, and several inactivated JBE virus vaccine lots with minimum immunizing doses, ranging from 0.005 to 0.017 ml, were prepared using a large number of CR bottles in a simulated commercial-scale production system.

Sensitization of mice by inhalation of antigen after infection with Bordetella pertussis

Intranasal infection of mice with Bordetella pertussis or injection of pertussis vaccine previous to administration of an albumin aerosol augments sensitivity toward albumin. Sensitization was demonstrated by provocation of anaphylactic reactions following intravenous injection of antigen.

Light Activation of Mg-dependent Adenosine 5'-Triphosphatase in Isolated Euglena Chloroplasts

Enhancement of Mg(2+)-dependent ATPase activity in Euglena gracilis chloroplasts by light in the presence of a sulfhydryl compound has been demonstrated. A number of uncouplers and energy transfer inhibitors were studied for their effects on the light enhancement of ATPase activity simultaneously with their effects on photophosphorylation. Results suggest that the light-enhanced ATPase activity in Euglena chloroplasts is an energy-initiated process and that the energy is supplied through electron flow upon illumination of the chloroplasts. However, by studying the difference in their response toward the various uncouplers and inhibitors, it seems that the two processes (photohydrolysis of ATP and photophosphorylation) share only the latter part of their energy-transferring pathway.