Impact of ethnic variation and residential segregation on long-term survival following myocardial perfusion SPECT.

BACKGROUND: Ethnic characteristics of a neighborhood may impact upon all-cause mortality (ACM). It is not known whether this consideration remains a risk modifier among those being evaluated for CAD. METHODS: 6,477 pts (60 ± 13 years, male 38%) residing in NYC with normal or abnormal stress SPECT studies were assessed for ACM during a mean follow-up of 9 ± 3.8 years. Baseline CAD risk factors and ethnic characteristics of patient neighborhoods were considered. Zip-codes with >70% of one ethnicity was considered to be predominant of that ethnicity. RESULTS: There were 573 (20%) Hispanics (HS), 765 (27%) African-Americans (AA), and 250 (30%) Caucasians (CC) residing in areas >70% of their own ethnicity. Compared to CC, the risk for ACM was lower in HS (hazard ratio (HR) 0.68, 95% CI 0.57-0.8, P < .0001) and similar among AA (HR 1.1, 95% CI 0.95-1.41, P = .2). Among HS, there was a lower ACM among those residing in HS areas compared to those residing in a non-HS areas (HR 0.7 95% CI 0.56-0.9, P = .03) despite a lower median household income ($27,838 ± 3,328 vs $37,751 ± 17,036; P < .0001). This survival difference was not seen in CC and AA. CONCLUSION: Among patients referred for nuclear SPECT studies for suspected CAD, HS ethnicity was an independent predictor of a favorable prognosis. Among HS, the ethnic characteristic of patients' neighborhoods was an independent predictor of ACM. These results imply that ethnic social support is a potentially powerful modifier of patient outcomes among certain patient groups.

Erosive osteoarthritis: A systematic analysis of definitions used in the literature.

BACKGROUND: Erosive osteoarthritis (EOA) is a commonly invoked diagnosis representing an important variant of hand osteoarthritis (OA). There is increasing literature on the prevalence, risk factors, etiology, and management of EOA. METHODS: We systematically reviewed the literature to assess variability in the diagnostic definitions used to define EOA in these studies. RESULTS: We reviewed 336 articles and found 62 articles citing diagnostic definitions for EOA. Radiographic appearance was the most commonly used criterion, but there was little agreement on the details or extent of the radiographic changes. Overall, 56 of the 62 studies included clinical features in the diagnostic definitions, yet these features varied considerably. Exclusion criteria were mentioned in 43 of the studies. CONCLUSION: Based on the widely disparate definitions of EOA, we urge caution in interpretation of this literature, and propose that further understanding of EOA will require consensus on its definition.

Pauci-Immune Crescentic Glomerulonephritis in Connective Tissue Disease.

Pauci-immune crescentic glomerulonephritis is commonly seen in ANCA-associated vasculitis but it is rarely seen during the course of other connective tissue diseases like lupus or Sjogren's syndrome or MCTD. We report 3 cases of pauci-immune crescentic glomerulonephritis in patients with connective tissue disease other than vasculitis. We reviewed literature and made summary of previously reported cases of this rare entity. Clinical and laboratory features of these patients varied widely, but most of patients have met criteria for lupus. In this small population of patients there is no correlation with ANCAs. Most of the patients were treated with aggressive immunosuppression and did well if they were treated early in the course of their disease. One of our patients required renal transplant, but she presented late in the course of her disease, as evidenced by chronicity on her renal biopsy. Whether these patients are overlap of vasculitis and other connective tissue diseases or to be considered as a separate entity is yet to be described. Clinicians must be aware of these presentations because initial presentation can be severe.

Clinical outcomes following a strategy of optimized medical management and selective "downstream" procedures following coronary computed tomography angiography.

BACKGROUND: Prior studies have shown a consistent relationship between coronary artery calcium (CAC) scores or the degree of coronary stenoses on coronary computed tomography angiography (CCTA) and all-cause mortality. Whether CCTA-targeted therapy, including intensive medical management, stress testing and/or invasive coronary angiography (ICA), can lead to a substantial reduction in adverse outcomes is not yet known. METHODS: We retrospectively analyzed 691 patients (55±13 years, male=63%) from a single medical practice who underwent a CAC scan and CCTA and were followed for a mean of 2.9±1.0 years. Of these, 416 (60%) patients were asymptomatic. All changes in medications, coronary risk factors (including lipids profiles), downstream testing, revascularization procedures, and clinical events (myocardial infarction and death) were recorded. RESULTS: Among our patients cohort 279 (40%) had no coronary artery disease. The most severe stenosis was <50% in 314 (46%) patients, 50-70% in 76 (11%) patients, and >70% in 22 (3%) patients. A high frequency of medical therapy was employed for those patients with any degree of stenosis, while stress testing was primarily applied for patients with >50% stenosis and ICA was primarily performed in those with >70% stenosis. Only two non-cardiovascular deaths and no cardiovascular deaths occurred during the follow-up period. CONCLUSIONS: Our findings support the hypotheses that among patients undergoing CCTA, comprehensive medical management, including targeted percutaneous coronary interventions and increasingly intensive medical therapy with progressively worse CCTA findings, can reduce event rates among patients with abnormal CCTA studies.