Large Vessel Occlusion Prediction in the Emergency Department with National Institutes of Health Stroke Scale Components: A Machine Learning Approach.

OBJECTIVE: To determine the feasibility of using a machine learning algorithm to screen for large vessel occlusions (LVO) in the Emergency Department (ED). MATERIALS AND METHODS: A retrospective cohort of consecutive ED stroke alerts at a large comprehensive stroke center was analyzed. The primary outcome was diagnosis of LVO at discharge. Components of the National Institutes of Health Stroke Scale (NIHSS) were used in various clinical methods and machine learning algorithms to predict LVO, and the results were compared with the baseline method (aggregate NIHSS score with threshold of 6). The Area-Under-Curve (AUC) was used to measure the overall performance of the models. Bootstrapping (n = 1000) was applied for the statistical analysis. RESULTS: Of 1133 total patients, 67 were diagnosed with LVO. A Gaussian Process (GP) algorithm significantly outperformed other methods including the baseline methods. AUC score for the GP algorithm was 0.874 ± 0.025, compared with the simple aggregate NIHSS score, which had an AUC score of 0.819 ± 0.024. A dual-stage GP algorithm is proposed, which offers flexible threshold settings for different patient populations, and achieved an overall sensitivity of 0.903 and specificity of 0.626, in which sensitivity of 0.99 was achieved for high-risk patients (defined as initial NIHSS score > 6). CONCLUSION: Machine learning using a Gaussian Process algorithm outperformed a clinical cutoff using the aggregate NIHSS score for LVO diagnosis. Future studies would be beneficial in exploring prospective interventions developed using machine learning in screening for LVOs in the emergent setting.

Papillary muscle rupture following acute myocardial infarction: Anatomic, echocardiographic, and surgical insights.

Papillary muscle (PM) rupture is a rare complication of acute myocardial infarction which carries an excessive mortality rate. Optimal outcomes require rapid diagnosis and prompt surgical referral, and in this regard, echocardiography plays a crucial role. Comprehensive echocardiographic examination of the patient with PM rupture consists of identification of the ruptured PM segment, visualization of flail mitral valve segment(s), evaluation of mitral regurgitation severity, and assessment of left ventricular systolic function. This article discusses anatomic and echocardiographic features as well as the surgical management of PM rupture.

Hypertrophic Cardiomyopathy Requiring Myectomy in a Young Patient With Systemic Lupus Erythematosus: A Case Report.

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multiple organ systems. Among these, the heart, including the pericardium, conduction system, myocardium, valves, and coronary arteries, can be affected. Hypertrophic cardiomyopathy (HCM) is a myocardial disease caused mainly by genetic mutation. The association between SLE and HCM is still unclear. We are reporting a case of a 25-year-old female with SLE with end-stage renal disease (ESRD) due to lupus nephritis, who was found to have hypertrophic obstructive cardiomyopathy (HOCM) on the echocardiogram and required septal myectomy. She presented to the hospital with dyspnea and was admitted as a hypertensive emergency with pulmonary edema, which required intubation and admission to the cardiac intensive care unit (CICU). She underwent urgent hemodialysis and blood pressure medication adjustment and then improved and was discharged home. Based on the literature review, 10 cases of SLE and HCM were reported, and the underlying mechanisms linking SLE and HCM remain unclear. Further studies are warranted for a better understanding of the association between SLE and HCM.

Cardiovascular Precision Medicine and Remote Intervention Trial Rationale and Design.

Background: It has recently been shown that excessive fluctuation in blood pressure readings for an individual over time is closely associated with poor outcomes, including increased risk of cardiovascular mortality, coronary heart disease and stroke. Fluctuations may be associated with inconsistent adherence to medical recommendations. This new marker of risk has not yet been incorporated into a monitoring and intervention strategy that seeks to reduce cardiovascular risk by identifying patients through an algorithm tied to their electronic health record (EHR). Methods: We describe the methods used in an innovative "proof of concept" trial using CP&R (Cardiovascular Precision Medicine and Remote Intervention). A blood pressure variability index is calculated for clinic patients via an EHR review. Consenting patients with excessive variability are offered a remote intervention aimed at improving adherence to medical recommendations. The outcomes include the ability to identify and engage the identified patients and the effects of the intervention on blood pressure variability using a pre-post comparison design without parallel controls. Conclusions: Our innovative approach uses a recently identified marker based on reviewing and manipulating EHR data tied to a remote intervention. This design reduces patient burden and supports equitable and targeted resource allocation, utilizing an objective criterion for behavioral risk. This study is registered under ClinicalTrials.gov Identifier: NCT05814562.

Chagas disease in Latin American immigrants with dilated cardiomyopathy in New York City.

Chagas disease-associated cardiomyopathy is clinically similar to other causes of cardiomyopathy and, therefore, the diagnosis can be easily overlooked. We found a 13% point prevalence of Chagas disease in a sample of New York City immigrants with dilated cardiomyopathy.

Beyond Hispanics: sub-ethnic differences in depression, post-traumatic distress, and suicidal ideation among patients with coronary heart disease.

OBJECTIVES: Our study of cardiac outpatients participating in a mental health screening program aimed to explore: a) sub-ethnic differences in the severity and/or prevalence of depression, post-traumatic stress disorder, and suicidal ideation, and b) whether intrusion and avoidance symptoms of distress equally or differentially predict severity of depression among sub-ethnic groups. DESIGN: Five hundred ninety Caucasian (n = 103) and immigrant Hispanic (n = 487) cardiac outpatients were recruited. Participants completed measures of depression and post-traumatic stress symptoms and were categorized into sub-ethnic groups according to regional and national origins. RESULTS: For regional comparisons, South American and Caribbean Hispanic patients exhibited greater symptoms of depression than US born Caucasians (UBC). Significant differences in the proportion of patients screening positive for depression were found among regional subethnic groups. When these groups were further stratified by national origin, Colombian and Dominican patients demonstrated higher levels of depression than UBC patients. Dominican patients reported greater levels of distress than UBC patients. Significant differences in rates of positive depression screens were found among comparisons between UBC and Hispanic national sub-ethnic groups. Finally, stepwise regression analyses revealed that intrusion symptoms predicted depression severity better than avoidance symptoms among all of sub-ethnic groups tested. CONCLUSION: The findings suggest that collapsing ethnic sub-groups into catchall ethnic labels may undermine high resolution screening strategies for concurrent medical and psychiatric conditions.

Anagrelide-induced pericardial effusion in a patient with essential thrombocythemia.

Pericardial effusion leading to cardiac tamponade can occur due to a multitude of etiologies, one of which is medication adverse effects. In patients with comorbid conditions, this can prove to be a challenge in its co-management along with the primary disease. We present a rare case of anagrelide-induced pericardial effusion that is presented with tamponade physiology in a patient with essential thrombocythemia. After cautiously weighing the risks and benefits of further invasive interventions following an unsuccessful pericardiocentesis, the decision was to stop anagrelide while managing the pericardial effusion medically. Therefore, managing pericardial effusion should be tailored to each patient individually through shared decision-making.

Delayed doxorubicin induced cardiomyopathy in a breast cancer patient: A case report.

Heart failure (HF) is a clinical syndrome with a wide spectrum of presentations and an even wider array of etiologies. Anthracyclines such as Doxorubicin, Daunorubicin, Idarubicin, and Epirubicin have demonstrated increased risk of HF with significant morbidity and mortality. We present an interesting case report of a patient with a history of breast cancer treated with Doxorubicin who presented with symptoms of HF who had a comprehensive evaluation that excluded the most common etiologies, narrowing our diagnosis to late onset doxorubicin induced HF with on-going recovery after initiation of guideline-directed medical therapy.

Long term outcomes of percutaneous coronary intervention vs coronary artery bypass grafting in patients with diabetes mellitus with multi vessels diseases: A meta-analysis.

Aims: Long term cardiovascular outcome comparison of multivessel coronary disease among patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) is limited. The objective of this study was to compare the long-term cardiovascular outcome PCI vs CABG among DM patients with multivessel disease. Method and results: Online databases were explored to identify studies that compared cardiovascular outcomes between PCI and CABG among patients with DM. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), rate of revascularization, cardiac death, and cerebrovascular accident (CVA). A total of 27 studies with 37,091 (PCI n = 19,838 (53 %) and CABG n = 17,253 (47 %)) patients were included. The mean age was 64 ± 5.9 years for PCI group and 63.8 ± 5.3 years for CABG group; and, predominantly male (71.22 % vs 74.29 %) for PCI and CABG respectively. The most common comorbidity was hypertension (64.35 % vs 62.88 %) in both PCI and CABG respectively. Compared with CABG, PCI group had a higher odds of overall all-cause mortality (OR 1.18, 95 % CI 1.02-1.37, p = 0.03), MACCE (OR 1.52, 95 % CI 1.31-1.75, p = 0.00), MI (OR 1.85, 95 % CI 1.46-2.36, p = 0.00), repeat revascularization (OR 3.08, 95 % CI 2.34-4.05, p = 0.00) and cardiac death (OR 1.27, 95 % 1.02-1.59, p = 0.04), while CVA (0.57, 95 % CI 0.37-0.86, p = 0.01) was higher with CABG. Conclusion: Diabetic patients with multivessel coronary artery disease have worse outcomes undergoing PCI as compared to CABG. However, CVA was significantly higher with CABG. CABG remains the preferred management among eligible patients with multivessel disease and DM.

Intracranial meningioma surveillance using volumetrics from T2-weighted MRI.

BACKGROUND AND PURPOSE: The gold standard for imaging of meningiomas is MRI with gadolinium-based contrast agent. Due to increased costs, time, and uncertain chronic effects of gadolinium exposure, use of noncontrast T2-weighted imaging (T2WI) in lieu of contrast-enhanced MRI has been an increasing focus of research across various diagnostic scenarios. The purpose of this study was to evaluate the diagnostic accuracy of T2WI in detecting changes in meningioma tumor volume. METHODS: Imaging and clinical data were reviewed for 82 consecutive patients undergoing MR-surveillance of intracranial meningioma. Using volumetric-T2WI, two neuroradiologists independently calculated tumor volumes. Measurements were compared to a baseline study contrast-enhanced T1 tumor volume. Using contrast-enhanced sequences as the reference standard, statistical analysis was performed to determine the accuracy of T2WI in detecting changes of meningioma volume. RESULTS: Using only T2WI, readers detected meningioma volume change ≥ 20% in 19/82 patients and volume change <20% in 63/82 patients. Reader accuracy for detecting change in tumor volume on T2WI ≥ 20% was 0.85, sensitivity 0.65, specificity 0.93, positive predictive value (PPV) 0.79, and negative predictive value (NPV) 0.87. For meningiomas >1 ml, reader accuracy for detecting change in tumor volume on T2WI ≥20% was 0.90, sensitivity 0.78, specificity 0.95, PPV 0.88, and NPV 0.91. Change in tumor volume on T2WI ≥20% was detected with 100% accuracy for posterior fossa meningiomas. Inter-reader agreement for all meningiomas was moderate (κ = 0.45) improving to substantial agreement (κ = 0.77) with tumor volumes >1 ml. CONCLUSION: Volumetric-T2WI detects changes in meningioma volume with comparable accuracy to gold standard T1 postcontrast imaging, particularly with higher tumor volumes and posterior fossa locations.

Osteochondroma of the convexity: pathologic-neuroimaging correlates of a lesion that mimics high-grade meningioma.

Intracranial chondromas are uncommon benign lesions usually attached to dura and located over the convexity of the skull. Osteochondromas are even rarer and additionally contain a benign bony component. Both lesions are reportedly difficult to distinguish from meningiomas on pre-operative neuroimaging studies, although few detailed pathologic-neuroimaging correlation studies have appeared in the literature, particularly for intracranial osteochondromas. A 33-year-old woman with a 4-year history of headaches presented with recent onset of left-sided muscle spasms and weakness. Two days prior to admission to our hospital, neuroimaging studies had shown a large right convexity mass with unusual multifocal bright signal intensities throughout an otherwise isointense mass. The bright signals were interpreted as showing multifocal hemorrhage and the mass was felt to be a convexity meningioma. However, subsequent catheter angiography characterized the lesion as being avascular. The mass was resected en bloc. Extensive histological sectioning revealed a benign osteochondroma predominantly composed of lobules of hypocellular cartilage. Microdissection of the different components revealed that the multifocal, spicule-like bright foci interpreted as hemorrhage on neuroimaging studies were instead foci of benign bone containing metaplastic bone marrow with trilineage hematopoietic cell populations and adipose tissue. Centrally, the hilum of the lesion contained avascular loose connective tissue. No recent or remote hemorrhage was identified anywhere in the lesion. Rare convexity osteochondromas may be mistaken for high-grade meningiomas on neuroimaging studies; their avascular nature, coupled with their complex signal pattern can serve as clues to the correct pre-operative diagnosis.

Psychiatric symptom presentation in ethnically diverse cardiology patients.

OBJECTIVES: The purpose of our study was to examine rates of depression and distress among different ethnic groups receiving care in an outpatient cardiology clinic. DESIGN: Cross sectional study. SETTING: Participants were recruited from an urban cardiology clinic. PARTICIPANTS: Data are presented for 1003 patients screened between June 2005 and November 2007. The ethnic groups represented were Hispanics (504 patients or 50% of the sample), Southeast Asians (229 patients or 23%), Caucasians (114 patients or 11%), East Asians (89 patients or 9%), Africans (53 patients or 5%), and 14 patients (2%) of unknown or other ethic backgrounds. MAIN OUTCOME MEASURES: All patients registered for an outpatient visit received questionnaires, in English or Spanish, screening for depression (Patient Health Questionnaire [PHQ-9]) and distress (the impact of Events Scale [IES]). RESULTS: Overall, significantly more patients screened positive for distress than depression (33% vs 27%, X2 = 130.11, P = .00). The ANOVA comparing PHQ scores by ethnic group was significant, F(4, 867) = 4.46, P = .01 with Hispanics and Southeast Asians scoring significantly higher than East Asians. An ANOVA comparing IES scores by ethnic group was also significant, F (4, 760) = 3.63, P = .01.with Southeast Asians scoring significantly higher than Caucasians. CONCLUSIONS: Elevated levels of psychiatric symptoms are common across ethnic groups in medical settings, particularly in patients of Hispanic and Southeast Asian origin. Devising culturally sensitive procedures is imperative to successful screening and evaluation.

Site matters: winning the hearts and minds of patients in a cardiology clinic.

BACKGROUND: In medical care settings, mental health symptoms of depression and distress are associated with poor medical outcomes, yet they are often underrecognized. OBJECTIVE: Authors sought to examine the effect of having immediate mental-health screening in the cardiology clinic. METHOD: The Patient Health Questionnaire and the Impact of Event Scale were used to screen for depression and distress in 316 patients at an urban cardiology clinic. Because of poor follow-up rates, a psychiatrist was placed on the premises of the cardiology clinic to facilitate referrals. RESULTS: Placing a psychiatrist within the cardiology clinic significantly improved the rate of successful referrals. CONCLUSION: Because 45 patients (14%) endorsed suicidal thoughts, authors conclude that mental health screening programs should include an immediate evaluation by a clinician.

Posttraumatic stress disorder: a missed link between psychiatric and cardiovascular morbidity?

Posttraumatic stress disorder (PTSD) symptoms may develop as a result of an acute, life-threatening traumatic event. Such acute events are quite common in patients with cardiovascular illnesses (ie, a myocardial infarction, acute exacerbations of heart failure or edema). Indeed, PTSD symptoms have been described in a substantial minority of patients who had such events (10% to 25%), and have been shown to be associated with medical morbidity and with non-adherence to medications. This review summarizes available information about these symptoms in patients with cardiovascular illnesses. It also describes the importance of recognizing PTSD as a distinct psychiatric disorder (that can be addressed by specific treatments) and as an important compounding factor in studies of psychopathology in cardiovascular patients. In particular, an argument is made that the understanding of depressive disorders in patients with cardiovascular illnesses should incorporate conceptual and treatment information from the emotional trauma literature if indeed depressive and anxiety disorders are to be successfully treated in these patients. The authors conclude with a description of the challenges and promise of an effort to implement a clinical program to screen for PTSD symptoms in patients with cardiovascular illnesses, and with recommendations for future efforts.

Imaging of oral cancer.

This article reviews imaging modalities commonly used to evaluate oral cavity cancers and their metastases to lymph nodes. It discusses how the studies are performed and their relative merits. It also presents new techniques for evaluating these neoplasms.

Technical Innovation: The Automated Residency Match Rank List.

The creation of the final rank list for the National Residency Matching Program every year is a laborious task requiring the time and input of numerous faculty members and residents. This article describes the creation of an automated visual rank list to efficiently organize and guide discussion at the yearly rank meeting so that the task may be efficiently and fairly completed. The rank list was created using a PowerPoint (Microsoft) macro that can pull information directly from a spreadsheet to generate a visual rank list that can be modified on-the-fly during the final rank list meeting. An automatically created visual rank list helps facilitate an efficient meeting and creates an open and transparent process leading to the final ranking.

Coronary artery disease in patients with body mass index ≥30 kg/m(2): a retrospective chart analysis.

OBJECTIVE: In this study, we evaluated obesity as a single risk factor for coronary artery disease (CAD), along with the synergistic effect of obesity and other risk factors. METHODS: A retrospective study of 7,567 patients admitted to hospital for chest pain from 2005 to 2014 and underwent cardiac catheterization. Patients were divided into two groups: obese and normal with body mass index (BMI) calculated as ≥30 kg/m(2) and <25, respectively. We assessed the modifiable and non-modifiable risk factors in obese patients and the degree of CAD. RESULTS: Of the 7,567 patients who underwent cardiac catheterization, 414 (5.5%) had a BMI ≥30. Of 414 obese patients, 332 (80%) had evidence of CAD. Obese patients displayed evidence of CAD at the age of 57 versus 63.3 in non-obese patients (p<0.001). Of the 332 patients with CAD and obesity, 55.4% had obstructive CAD versus 44.6% with non-obstructive CAD. In obese patients with CAD, male gender and history of smoking were major risk factors for development of obstructive CAD (p=0.001 and 0.01, respectively) while dyslipidemia was a major risk factor for non-obstructive CAD (p=0.01). Additionally, obese patients with more than one risk factor developed obstructive CAD compared to non-obstructive CAD (p=0.003). CONCLUSION: Having a BMI ≥30 appears to be a risk factor for early development of CAD. Severity of CAD in obese patients is depicted on non-modifiable and modifiable risk factors such as the male gender and smoking or greater than one risk factor, respectively.

Advances in head and neck imaging.

This article discusses new techniques in head and neck imaging.

Utilizing correspondence analysis to characterize the mental health of cardiac patients with diabetes.

The aim of this study was to examine the mental health of cardiac patients with diabetes and whether symptoms varied by gender and/or age. Screening for depression and posttraumatic stress symptoms was conducted on 1003 patients with cardiovascular disease. Correspondence analysis was utilized to identify clinical core profiles. Results suggested that cardiovascular disease patients with diabetes, particularly males, experience high rates of depression, suicide ideation, and posttraumatic stress symptoms. Clinical implications of these findings include targeted mental health screening options as well as offering a closer look at the specific concerns of cardiovascular disease patients with diabetes.