The binding of learning to action in motor adaptation.

In motor tasks, errors between planned and actual movements generally result in adaptive changes which reduce the occurrence of similar errors in the future. It has commonly been assumed that the motor adaptation arising from an error occurring on a particular movement is specifically associated with the motion that was planned. Here we show that this is not the case. Instead, we demonstrate the binding of the adaptation arising from an error on a particular trial to the motion experienced on that same trial. The formation of this association means that future movements planned to resemble the motion experienced on a given trial benefit maximally from the adaptation arising from it. This reflects the idea that actual rather than planned motions are assigned 'credit' for motor errors because, in a computational sense, the maximal adaptive response would be associated with the condition credited with the error. We studied this process by examining the patterns of generalization associated with motor adaptation to novel dynamic environments during reaching arm movements in humans. We found that these patterns consistently matched those predicted by adaptation associated with the actual rather than the planned motion, with maximal generalization observed where actual motions were clustered. We followed up these findings by showing that a novel training procedure designed to leverage this newfound understanding of the binding of learning to action, can improve adaptation rates by greater than 50%. Our results provide a mechanistic framework for understanding the effects of partial assistance and error augmentation during neurologic rehabilitation, and they suggest ways to optimize their use.

Integrating Web Services/Applications to Improve Pediatric Functionalities in Electronic Health Records.

The past decade has seen a substantial increase in the use of electronic health records (EHRs) by health care providers caring for children. However, gaps in pediatric-specific functionalities continue to exist in some EHR systems, including population-specific growth curves, immunization clinical decision support, weight-based medication dosing with rounding, calculation of pediatric hypertension percentiles, age-specific developmental assessment, newborn bilirubin nomograms, anticipatory guidance reminders, and other functionalities described elsewhere. Implementing pediatric functionalities into EHRs is critical to the provision of safe pediatric care. As an alternative to direct implementation in EHRs, EHR vendor agnostic Web applications, Web services, and application programming interfaces offer an opportunity to provide pediatric functionalities and eliminate the need for each vendor to develop these functionalities. Successful implementation of Web services and related technologies requires responsible attention from both EHR vendors and developers of Web services, Web applications, and application programming interfaces to the use of data terminology standards, adherence to privacy and security requirements, rigorous testing, change management processes, and robust system support and maintenance. Education of health care providers about opportunities to improve pediatric functionalities in EHRs by using these services can facilitate discussions in EHR user groups in which vendors can be lobbied to implement them. This policy statement emphasizes the need to address pediatric-specific functionalities in EHRs by providing insight and recommendations into the development, maintenance, integration, and support of these novel solutions.

Web Services and Cloud Computing in Pediatric Care.

Electronic health record (EHR) systems do not uniformly implement pediatric-supportive functionalities. One method of adding these capabilities across EHR platforms is to integrate Web services and Web applications that may perform decision support and store data in the cloud when the EHR platform is able to integrate Web services. Specific examples of these services are described, such as immunization clinical decision support services, consumer health resources, and bilirubin nomograms. Health care providers, EHR vendors, and developers share responsibilities in the appropriate development, integration, and use of Web services and Web applications as they relate to best practices in the areas of data security and confidentiality, technical availability, audit trails, terminology and messaging standards, compliance with the Health Insurance Portability and Accountability Act, testing, usability, and other considerations. It is desirable for health care providers to have knowledge of Web services and Web applications that can improve pediatric capabilities in their own EHRs because this will naturally inform discussions concerning EHR features and facilitate implementation and subsequent use of these capabilities by clinicians caring for children.

Measuring the Value of a Practical Text Mining Approach to Identify Patients With Housing Issues in the Free-Text Notes in Electronic Health Record: Findings of a Retrospective Cohort Study.

Introduction: Despite the growing efforts to standardize coding for social determinants of health (SDOH), they are infrequently captured in electronic health records (EHRs). Most SDOH variables are still captured in the unstructured fields (i.e., free-text) of EHRs. In this study we attempt to evaluate a practical text mining approach (i.e., advanced pattern matching techniques) in identifying phrases referring to housing issues, an important SDOH domain affecting value-based healthcare providers, using EHR of a large multispecialty medical group in the New England region, United States. To present how this approach would help the health systems to address the SDOH challenges of their patients we assess the demographic and clinical characteristics of patients with and without housing issues and briefly look into the patterns of healthcare utilization among the study population and for those with and without housing challenges. Methods: We identified five categories of housing issues [i.e., homelessness current (HC), homelessness history (HH), homelessness addressed (HA), housing instability (HI), and building quality (BQ)] and developed several phrases addressing each one through collaboration with SDOH experts, consulting the literature, and reviewing existing coding standards. We developed pattern-matching algorithms (i.e., advanced regular expressions), and then applied them in the selected EHR. We assessed the text mining approach for recall (sensitivity) and precision (positive predictive value) after comparing the identified phrases with manually annotated free-text for different housing issues. Results: The study dataset included EHR structured data for a total of 20,342 patients and 2,564,344 free-text clinical notes. The mean (SD) age in the study population was 75.96 (7.51). Additionally, 58.78% of the cohort were female. BQ and HI were the most frequent housing issues documented in EHR free-text notes and HH was the least frequent one. The regular expression methodology, when compared to manual annotation, had a high level of precision (positive predictive value) at phrase, note, and patient levels (96.36, 95.00, and 94.44%, respectively) across different categories of housing issues, but the recall (sensitivity) rate was relatively low (30.11, 32.20, and 41.46%, respectively). Conclusion: Results of this study can be used to advance the research in this domain, to assess the potential value of EHR's free-text in identifying patients with a high risk of housing issues, to improve patient care and outcomes, and to eventually mitigate socioeconomic disparities across individuals and communities.

Algorithmic Detection of Boolean Logic Errors in Clinical Decision Support Statements.

OBJECTIVE: Clinical decision support (CDS) can contribute to quality and safety. Prior work has shown that errors in CDS systems are common and can lead to unintended consequences. Many CDS systems use Boolean logic, which can be difficult for CDS analysts to specify accurately. We set out to determine the prevalence of certain types of Boolean logic errors in CDS statements. METHODS: Nine health care organizations extracted Boolean logic statements from their Epic electronic health record (EHR). We developed an open-source software tool, which implemented the Espresso logic minimization algorithm, to identify three classes of logic errors. RESULTS: Participating organizations submitted 260,698 logic statements, of which 44,890 were minimized by Espresso. We found errors in 209 of them. Every participating organization had at least two errors, and all organizations reported that they would act on the feedback. DISCUSSION: An automated algorithm can readily detect specific categories of Boolean CDS logic errors. These errors represent a minority of CDS errors, but very likely require correction to avoid patient safety issues. This process found only a few errors at each site, but the problem appears to be widespread, affecting all participating organizations. CONCLUSION: Both CDS implementers and EHR vendors should consider implementing similar algorithms as part of the CDS authoring process to reduce the number of errors in their CDS interventions.

Risk factors for major bleeding and for minor bleeding after percutaneous coronary intervention in 634 consecutive patients with acute coronary syndromes.

Of 634 consecutive patients who had percutaneous coronary intervention (PCI) for acute coronary syndromes, 34 (5%) had major bleeding after PCI, 253 (40%) had minor bleeding after PCI, and 347 (55%) had no bleeding after PCI. Significant independent risk factors for major bleeding after PCI were increased troponin I level (P = 0.004; odds ratio [OR] = 4.7), prior coronary artery disease (P = 0.029; OR = 3.7), platelet glycoprotein IIb/IIIa inhibitors (P = 0.002; OR = 9.8), glomerular filtration rate (GFR) <30 versus >or=60 mL/min/1.73 m(2) (P < 0.0001; OR = 39.7), GFR 30-59 versus >or=60 mL/min/1.73 m(2) (P = 0.0001; OR = 9.4), and clopidogrel loading dose >300 mg (P = 0.0001; OR = 8.9). Significant independent risk factors for minor bleeding after PCI were increased troponin I level (P = 0.0004; OR = 2.1), platelet glycoprotein IIb/IIIa inhibitors (P = 0.039; OR = 2.4), GFR 30-59 versus >or=60 mL/min/1.73 m(2) (P < 0.0001; OR = 2.5), thrombolytics (P = 0.01; OR = 2.7), clopidogrel loading dose >300 mg (P < 0.0001; OR = 4.2), and systolic blood pressure during PCI (P < 0.0001; OR = 1.03 per mm Hg). In-hospital deaths included 5 of 34 patients (15%) with major bleeding, none of 253 patients (0%) with minor bleeding, and none of 347 patients (0%) with no bleeding (P < 0.0001). Hospital duration was 11.0 days in patients with major bleeding, 3.4 days in patients with minor bleeding, and 1.8 days in patients with no bleeding (P < 0.0001).

Interhospital transfer of patients with ST-segment elevation myocardial infarction for percutaneous coronary intervention.

We investigated in 277 consecutive patients, mean age 63 years, with ST-segment elevation acute myocardial infarction transferred from 25 community hospitals to a tertiary percutaneous coronary intervention (PCI) center from a median distance of 21 miles the incidences of in-hospital mortality, stroke, and recurrent myocardial infarction associated with transfer times. Of the 277 patients, 158 (57%) had thrombolytic therapy at the referring hospital. Of the 277 patients, 63 (23%) had adjunctive PCI, 119 (43%) had primary PCI, and 95 (34%) had rescue PCI. Of the 277 patients, 42 (15%) were hemodynamically unstable. Median transfer times were 102 minutes with primary PCI, 119 minutes with rescue PCI, and 144 minutes for adjunctive PCI (P < 0.0001 for adjunctive PCI versus primary PCI; P = 0.011 for adjunctive PCI versus rescue PCI). Median transfer time was 98 minutes for hemodynamically unstable patients and 121 minutes for hemodynamically stable patients (P = 0.005). In-hospital death occurred in eight of 277 patients (3%). In-hospital stroke occurred in three of 277 patients (1%). In-hospital recurrent myocardial infarction occurred in none of 277 patients (0%). There was no association of transfer times with in-hospital mortality or stroke. In-hospital mortality occurred in three of 112 patients (3%) who had bare metal stents and in five of 165 patients (3%) who had drug-eluting stents.

Prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention treated with heparin 5000 IU administered systemically versus 500 age-matched and sex-matched patients treated with heparin 70 IU/kg administered systemically.

We investigated the prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention (PCI) treated with heparin 5000 IU administered systemically (group 1) at the time of PCI versus in 500 age-matched and sex-matched patients undergoing PCI treated with heparin 70 IU/kg administered systemically (group 2) at the time of PCI. There was no significant difference in baseline characteristics, indications for PCI, cardiovascular drug therapy at the time of PCI, prevalence of 1-vessel, 2-vessel, and 3-vessel obstructive coronary artery disease, and in-hospital complications between the 2 groups. In-hospital death occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Non-ST-segment elevation myocardial infarction occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. Stroke occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Stent thrombosis occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Occlusion of a side branch occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. A hematoma needing intervention occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Regression analysis showed that none of the differences between the 2 groups were significant. The sample size was adequate to conclude that a fixed low dose of heparin 5000 IU administered systemically at the time of PCI is noninferior to standard therapy with heparin.

Mortality at long-term follow-up of patients with no, nonobstructive, and revascularized 1-, 2-, and 3-vessel obstructive coronary artery disease.

BACKGROUND: To investigate the 5-year survival of patients with coronary angiographic evidence of no coronary artery disease (CAD), nonobstructive CAD, and revascularized 1-vessel, 2-vessel, and 3-vessel obstructive CAD. MATERIAL/METHODS: Coronary angiography was performed in 2,057 unselected patients, mean age 69 years (57% men and 43% women), with an acute coronary syndrome (50%) or anginal chest pain.(50%). RESULTS: Of 2,057 patients, 760 (37%) had obstructive CAD with >50% obstruction of at least 1 major coronary artery (left anterior descending, left circumflex, and right coronary) and were revascularized, 695 (34%) had nonobstructive CAD (<50% obstruction), and 602 (29%) had normal coronary arteries. At 60+/-16-month follow-up, all-cause mortality occurred in 41 of 602 patients (7%) with no CAD (group 1), in 80 of 695 patients (12%) with nonobstructive CAD (group 2), in 50 of 302 patients (17%) with revascularized 1-vessel obstructive CAD (group 3), in 47 of 201 patients (23%) with 2-vessel revascularized obstructive CAD (group 4), and in 72 of 257 patients (28%) with 3-vessel revascularized obstructive CAD (group 4). Log-rank tests to compare survival curves among the 5 groups showed p=0.004 for groups 1 versus 2; p<0.0001 for groups 1 versus 3, 1 versus 4, 1 versus 5, 2 versus 4, and 2 versus 5; and p=0.007 for groups 3 versus 5. CONCLUSIONS: Patients with nonobstructive CAD had a worse survival than those with no CAD, a nonsignificant difference in survival than those with revascularized 1-vessel obstructive CAD, and a better survival than those with revascularized 2-vessel or 3-vessel obstructive CAD.

Predicting hospitalizations from electronic health record data.

OBJECTIVES: Electronic health record (EHR) data have become increasingly available and may help inform clinical prediction. However, predicting hospitalizations among a diverse group of patients remains difficult. We sought to use EHR data to create and internally validate a predictive model for clinical use in predicting hospitalizations. STUDY DESIGN: Retrospective observational cohort study. METHODS: We analyzed EHR data in patients 18 years or older seen at Atrius Health from June 2013 to November 2015. We selected variables among patient demographics, clinical diagnoses, medications, and prior utilization to train a logistic regression model predicting any hospitalization within 6 months and validated the model using a separate validation set. We performed sensitivity analysis on model performance using combinations of EHR-derived, claims-derived, or both EHR- and claims-derived data. RESULTS: After exclusions, 363,855 patient-months were included for analysis, representing 185,388 unique patients. The strongest features included sickle cell anemia (odds ratio [OR], 52.72), lipidoses and glycogenosis (OR, 8.44), heart transplant (OR, 6.12), and age 76 years or older (OR, 5.32). Model testing showed that EHR-only data had an area under the receiver operating characteristic curve (AUC) of 0.84 (95% CI, 0.838-0.853), which was similar to the claims-only data (AUC, 0.84; 95% CI, 0.831-0.848) and combined claims and EHR data (AUC, 0.846; 95% CI, 0.838-0.853). CONCLUSIONS: Prediction models using EHR-only, claims-only, and combined data had similar predictive value and demonstrated strong discrimination for which patients will be hospitalized in the ensuing 6 months.

Major adverse cardiac events at long-term follow-up in patients treated with single versus multiple stents during single-vessel percutaneous coronary intervention.

BACKGROUND: Although insertion of multiple stents into a single coronary vessel during single-vessel percutaneous coronary intervention (PCI) is common, there are no data on long-term occurrence of major adverse cardiac events (MACE) in patients treated with multiple stents versus a single stent. METHODS: The incidence of MACE (death, myocardial infarction, or target vessel revascularization) during long-term follow-up was investigated in 634 patients who underwent single-vessel PCI. Of the 634 patients, 319 (50%) had a single stent, and 315 (50%) had multiple stents inserted. Stepwise Cox regression analyses were performed to identify significant independent prognostic factors for MACE. RESULTS: At 47-month follow-up, MACE occurred in 61 of 319 patients (19%) who had a single stent versus in 57 of 315 patients (18%) who had multiple stents (P not significant). Significant independent predictors of MACE were use of vein grafts (hazard ratio = 1.94; 95% CI, 1.24-3.03; P = 0.0038) and use of drug-eluting stents (hazard ratio = 0.49; 95% CI, 0.34-0.72; P = 0.0002). CONCLUSIONS: At long-term follow-up of single-vessel PCI, the incidence of MACE was similar in patients with multiple or single stents inserted even after controlling for the length of stents.

A planar QRS-T angle >90 degrees is associated with multivessel coronary artery disease in patients undergoing coronary angiography.

BACKGROUND: The aim of the study was to investigate the severity of coronary artery disease (CAD) in patients who had a planar QRS-T angle >90 degrees versus 50% obstruction of >or=1 major coronary artery. All QRS-T angle measurements were made from a 12-lead electrocardiogram by 2 authors who agreed on the measurement and who were blinded to the coronary angiographic findings. A QRS-T angle >90 degrees was considered abnormal. RESULTS: Obstructive CAD of 2 or 3 vessels was present in 309 of 495 patients (62%) with a planar QRS-T angle >90 degrees and in 250 of 734 patients (34%) with a planar QRS-T angle or=30 kg/m2 (odds ratio =1.5). CONCLUSIONS: The prevalence of 2- or 3-vessel obstructive CAD was significantly higher in patients with a planar QRS-T angle >90 degrees than in patients with a planar QRS-T angle

The effect of medication cost transparency alerts on prescriber behavior.

OBJECTIVE: The purpose of this study was to determine if medication cost transparency alerts provided at time of prescribing led ambulatory prescribers to reduce their use of low-value medications. MATERIALS AND METHODS: Provider-level alerts were deployed to ambulatory practices of a single health system from February 2018 through April 2018. Practice sites included 58 primary care and 152 specialty care clinics totaling 1896 attending physicians, residents, and advanced practice nurses throughout western Washington. Prescribers in the randomly assigned intervention arm received a computerized alert whenever they ordered a medication among 4 high-cost medication classes. For each class, a lower cost, equally effective, and safe alternative was available. The primary outcome was the change in prescribing volume for each of the 4 selected medication classes during the 12-week intervention period relative to a prior 24-week baseline. RESULTS: A total of 15 456 prescriptions for high-cost medications were written during the baseline period including 7223 in the intervention arm and 8233 in the control arm. During the intervention period, a decrease in daily prescribing volume was noted for all high-cost medications including 33% for clobetasol propionate (p < .0001), 59% for doxycycline hyclate (p < .0001), 43% for fluoxetine tablets (p < .0001), and a non-significant 3% decrease for high-cost triptans (p = .65). Prescribing volume for the high-cost medications overall decreased by 32% (p < .0001). CONCLUSION: Medication cost transparency alerts in an ambulatory setting lead to more cost-conscious prescribing. Future work is needed to predict which alerts will be most effective.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Relation of bone mineral density to frequency of coronary heart disease.

Coronary angiography was performed because of chest pain in 198 patients (146 women, 52 men; mean age 66 years) who had dual-energy x-ray absorptiometry scans of the spine and left hip because of suspected osteoporosis or osteopenia. Of the 198 patients, 53 (27%) had osteoporosis, 79 (40%) had osteopenia, and 66 (33%) had normal bone mineral density (BMD). Obstructive coronary artery disease with >50% narrowing of > or =1 major coronary artery was present in 40 of 53 patients (76%) with osteoporosis, in 54 of 79 patients (68%) with osteopenia, and in 31 of 66 patients (47%) with normal BMD (p <0.005 comparing osteoporosis with normal BMD, p <0.01 comparing osteopenia with normal BMD). In conclusion, in patients who undergo coronary angiography because of chest pain, patients with osteoporosis or osteopenia have a higher prevalence of obstructive coronary artery disease than those with normal BMD.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease.

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

A Novel Information Retrieval Tool to Find Hospital Care Team Members: Development and Usability Study.

BACKGROUND: Hospital communication among members of a patient's care team is a central part of clinical workflow and consumes a large amount of a health care provider's time. Oftentimes the complexity of hospital care leads to difficulty in finding the appropriate contact, which can lead to inefficiencies and frustration. Squire is a Web-based information retrieval app created to improve the speed and efficiency in reaching the appropriate team member during the care of a hospitalized patient. OBJECTIVE: The objective of the study was to design and develop Squire and to evaluate the usage, usability, and perceived effect of the app on finding the correct contact within a hospital. METHODS: We used a mixed-methods design using a before-after survey methodology combined with one-on-one interviews to understand the perceived effect of Squire. The study took place at an academic medical center with internal medicine resident physicians. We surveyed residents on demographics, as well as time and efficiency of hospital communication before and after the use of Squire. After using Squire, participants were also asked to evaluate Squire's Net Promoter Score (NPS). A subset of voluntary participants participated in one-on-one interviews and completed the System Usability Scale (SUS). We performed descriptive statistics on participant characteristics, app usage data, and responses to surveys. Survey results were compared before and after Squire adoption using the Wilcoxon rank-sum test and a general linear model. Interview data were analyzed using content analysis with a qualitative description approach to review and categorize feedback from participants. RESULTS: There was a 67.9% (74/109) response rate to the pre-Squire survey and 89.9% (98/109) response rate to the post-Squire survey. At baseline, there was an average of 22.2 (95% CI 18.4-26.0) minutes/day spent searching for the right contact, and this decreased to 16.3 (95% CI 13.9-18.7) minutes/day after Squire was launched (P=.01). There were favorable usability scores, with an average SUS of 84.7, and a marginal NPS of +6.1. Overall, the use of Squire included 22,283 page views, most commonly to contact the admissions office or portable chest x-ray technician. Interviews highlighted common benefits of Squire, including decreased perceived time spent on hold with operators and improvement in connecting with the appropriate contact in specialized, complex departments. Future opportunities were also identified to improve Squire including adding a two-way communication between physician and nursing staff and providing offline access. CONCLUSIONS: Squire decreased the perceived time required to find an appropriate contact and had a favorable usability score; however, the NPS was marginal and several opportunities were identified to improve Squire for future use.

Cycling Induced Spontaneous Coronary Artery Dissection in a Healthy Male.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare but important cause of acute coronary syndrome with a spectrum of disease that can include unstable angina, acute myocardial infarction, or sudden cardiac death. It has also been found in case reports to be caused by shear stress from physical exertion. We present a rare cycling induced SCAD that occurred in our institution in an otherwise healthy male with no cardiac risk factors. CASE PRESENTATION: A 36-year-old male presented to the emergency department with complaints of lightheadedness and diaphoresis after a bicycle fall. In the emergency department, he complained of feeling lightheaded and diaphoretic and having mid back pain. Patient had an ECG performed which showed lateral ST segment elevation and troponin I that was positive. A coronary angiography was subsequently performed demonstrating a spontaneous coronary artery dissection of left anterior descending coronary artery. CONCLUSION: SCAD is a rare cause of myocardial infarction, occurring in healthy individuals, which is rarely reported in the literature. Nearly 70% are diagnosed in postmortem studies after sudden cardiac death. Only 12 cases have been reported from activities involving physical exertion and no studies to our knowledge demonstrate this.

Comparison of age, body mass index, and frequency of systemic hypertension and diabetes mellitus in patients having coronary angioplasty in 1996 versus in 2006.

The data submitted to the New York State Department of Health Coronary Angioplasty Reporting System Database on coronary angioplasties performed at Westchester Medical Center/New York Medical College from 1996 to 2005 were analyzed. Compared with 1996, during 2005, more coronary angioplasties were performed (1,624 vs 1,122), and the patients were older (mean age 64.5 vs 61.0 years, p <0.001), weighed more (84.2 vs 82.0 kg, p <0.001), had a higher mean body mass index (28.8 vs 28.3 kg/m(2), p <0.001), and had a higher prevalence of diabetes mellitus (27% vs 17%, p <0.001). The prevalence of systemic hypertension was significantly higher in 2005 (76%) than in 1996 (54%) (p <0.001). In conclusion, in 2005 compared with 1996, patients who underwent coronary angioplasty at Westchester Medical Center/New York Medical College were older, had higher body mass indexes, and had higher prevalences of diabetes mellitus and systemic hypertension.

In-hospital mortality and time from onset of symptoms of acute myocardial infarction in 540 patients undergoing primary coronary angioplasty. Comparison between blacks, whites and patients of other races, and between men and women.

The time from the onset of symptoms of acute myocardial infarction to primary coronary angioplasty was 18 +/- 23 h in 386 men and 19 +/- 24 h in 154 women (p not significant) and 14 +/- 19 h in 27 blacks, 19 +/- 23 h in 493 whites, and 13 +/- 11 h in 20 patients of different races (p not significant). In-hospital mortality was 6% in 144 patients aged > or =70 years and 1% in 396 patients <70 years (p < 0.005). In-hospital mortality was 2% in 386 men and 4% in 154 women (p not significant). In-hospital mortality was 2% in 493 whites, 4% in 27 blacks, and 0% in 20 patients of other races (p not significant). In-hospital mortality was 6% in 143 patients with a left ventricular ejection fraction (LVEF) <40% and 1% in 397 patients with a LVEF > or =40% (p < 0.005). In-hospital mortality was 5% in 223 patients with a glomerular filtration rate (GFR) <90 ml/min and 1% in 317 patients with a GFR > or =90 ml/min (p < 0.005).