Correction to: Risk stratification with vasodilator stress SPECT myocardial perfusion imaging in patients with elevated cardiac biomarkers.

The following error (highlighted in bold below) appears in the Results section of the Abstract: A total of 503 patients were followed for an average of 33.6 ± 16.2 months, with a mean age of 69.3 years; 53.7% male; and a majority (88.7%) of them undergoing vasodilator stress. A significant increase in all-cause mortality was seen based on the severity of TPD results for all vasodilators (P < .0001) and regadenoson (P < .0001). Similar prognostic ability was seen for all-cause (this should actually be cardiac) mortality. This association was maintained even after adjustment for cardiac risk factors, previous coronary disease, and troponin quartiles. MPI results (stress TPD and LVEF) added to traditional cardiac risk factors, and troponin values resulted in a significant incremental increase in the ability to predict all-cause and cardiac mortality, and stress TPD remained independently predictive for both all-cause and cardiac mortality in a multivariate model.

Risk stratification with vasodilator stress SPECT myocardial perfusion imaging in patients with elevated cardiac biomarkers.

BACKGROUND: Although the diagnostic accuracy and prognostic utility of vasodilator stress MPI have been well established in the non-acute setting, the efficacy of all of the vasodilator stressors in risk stratifying post-MI patients as well as the evaluation of cardiac troponin elevation of unclear etiology is not established. Accordingly, the aim of the present study was to investigate the prognostic efficacy of vasodilator stress MPI in the setting of elevated cardiac troponin to accurately risk stratify these higher-risk patients. METHODS: All patients from two tertiary centers, from 1/1/2010 through 12/31/2012, with elevated cardiac biomarkers within < 7 days and undergoing stress SPECT MPI testing were studied. Results of stress MPI were scored using a 17-segment model based on semiquantitative scoring as normal or abnormal (mild, moderate, or severe) using a total perfusion defect (TPD) of 0%, 1-10%, 10-20%, and > 20%. Mortality data through the year 2014 were obtained from the National Death Index, and survival analyses were performed. The primary endpoint was all-cause mortality with the secondary endpoint being cardiac mortality. RESULTS: A total of 503 patients were followed for an average of 33.6 ± 16.2 months, with a mean age of 69.3 years; 53.7% male; and a majority (88.7%) of them undergoing vasodilator stress. A significant increase in all-cause mortality was seen based on the severity of TPD results for all vasodilators (P < .0001) and regadenoson (P < .0001). Similar prognostic ability was seen for all-cause mortality. This association was maintained even after adjustment for cardiac risk factors, previous coronary disease, and troponin quartiles. MPI results (stress TPD and LVEF) added to traditional cardiac risk factors, and troponin values resulted in a significant incremental increase in the ability to predict all-cause and cardiac mortality, and stress TPD remained independently predictive for both all-cause and cardiac mortality in a multivariate model. CONCLUSION: Vasodilator stress (including regadenoson) MPI effectively risk stratifies patients with recently elevated cardiac biomarkers, with the increasing risk of mortality with the increasing severity of perfusion defects. It provides incremental prognostic value, in addition to clinical factors and degree of troponin elevation.

Safety of vasodilator stress myocardial perfusion imaging in patients with elevated cardiac biomarkers.

BACKGROUND: While adenosine and dipyridamole as myocardial perfusion imaging (MPI) stress agents have literature supporting their safety in the setting of myocardial infarction (MI), regadenoson does not. Studying a high risk cohort of patients with elevated cardiac biomarkers may shed light on potential safety issues of these agents which might also affect lower risk cohorts. METHODS: All patients who had undergone a clinically indicated stress MPI study at two academic centers from 1/1/2010 through 12/31/2012 with elevated troponin ≤7 days prior to testing were included. The primary endpoint was a composite of death, non-fatal MI, congestive heart failure (CHF), stroke, ventricular arrhythmias, atrial fibrillation/flutter, or atrioventricular block requiring intervention within 24 h of testing. RESULTS: Of the 703 stress MPI studies that met inclusion criteria, 360 (51.2%), 199 (28.3%), 74 (10.5%), 9 (1.3%), and 61 (8.7%) underwent regadenoson, dipyridamole, adenosine, dobutamine, and exercise stress, respectively. The primary endpoint occurred in 11 (1.6%) patients with an incidence of 1.4% (n = 5), 1.0% (n = 2), 1.4% (n = 1), 11.1% (n = 1), and 3.3% (n = 2) following regadenoson, dipyridamole, adenosine, dobutamine, and exercise stress, respectively (P = 0.137). The adverse events included non-fatal MI in 7 (1.0%) patients, death in 1 (0.1%) patient, CHF in 1 (0.1%) patient, ventricular arrhythmia in 1 (0.1%) patient, and atrial arrhythmia in 1 (0.1%) patient. CONCLUSION: In the setting of elevated troponin, serious complications associated with either exercise or vasodilator stress testing appear to be relatively rare with no increased risk attributable to a particular vasodilator agent.

A multi-center assessment of the temporal trends in myocardial perfusion imaging.

BACKGROUND: Recent literature suggests that the frequency of abnormal SPECT myocardial perfusion imaging (MPI) has decreased over the past two decades despite an increase in the prevalence of many cardiac risk factors. This study examined the trends in the prevalence of obstructive coronary artery disease (CAD) by abnormal and ischemic MPI and invasive angiography. METHODS: We analyzed all patients who underwent stress MPI or invasive angiography at two academic centers between January 1996 and December 2012, for their demographic data and study results. RESULTS: A total of 108,654 MPI studies were performed. Over time, the percentage of patients with hypertension, hyperlipidemia, diabetes, and a history of smoking increased. There was a decline in the prevalence of abnormal MPI studies in all patients as well as in those with and without known CAD (from 47.2%, 71.8%, and 31.4% in 1996 to 33.9%, 64.8%, and 18.8% in 2012, respectively, all P < .0001). Similarly, there was a decline in the prevalence of ischemic MPI studies in all patients as well as in those with and without known CAD. A total of 142,924 invasive angiograms were performed. There was a decline in the prevalence of one-vessel and multi-vessel coronary disease (from 29.1% and 53.6% in 1996 to 22.4% and 35.9% in 2012, respectively, all P < .0001). CONCLUSIONS: There has been a temporal decline in the prevalence of abnormal and ischemic MPI studies as well as the frequency and extent of obstructive CAD on angiography. However, this decline was not to the same extent as previously reported, and the overall 34% abnormal MPI rate, with 19% in patients with no known CAD and 65% in patients with known CAD, remains a clinically relevant percentage of patients tested.

Conscious sedation for awake fibreoptic intubation: a review of the literature.

PURPOSE: Awake fibreoptic intubation (AFOI) is the gold standard of management of the predicted difficult airway. Sedation is frequently used to make the process more tolerable to patients. It is not always easy to strike a balance between patient comfort and good intubating conditions on the one hand and maintaining ventilation and a patent airway on the other. In the last 30 years, many drugs and drug combinations have been described, but there is very little in the literature to help guide the practitioner to choose between them. The objective of this article is to discuss the evidence supporting the use of the agents described with regard to their efficacy, recommended doses and techniques, and limitations to their use for AFOI. SOURCE: Publication databases were searched for articles published from 1996 to 2012 relating to sedation for AFOI. PRINCIPLE FINDINGS: Benzodiazepines, propofol, opioids, alpha2-adrenoceptor agonists, and ketamine are the main classes of drugs that have been described to facilitate AFOI. Drugs that are most suitable have a combination of both anxiolytic and analgesic properties. The ideal choice of drug may vary depending on the patient and the indication for AFOI. CONCLUSION: There is good evidence to support the use of two drugs in particular, remifentanil and dexmedetomidine. Each has certain unique characteristics that make them an attractive choice for an AFOI.

Patency rates and the role of newer grafts in coronary artery bypass grafting.

Coronary artery bypass grafting (CABG) was one of major surgical advances of the 20th century and it has proven to be one of the most effective and long-lasting therapies in the treatment of ischemic heart disease. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. We seek to review the emerging role and patency rates of newer arterial grafts in comparison with the traditional saphenous vein grafts.

Electrocardiographic changes during vasodilator SPECT myocardial perfusion imaging: does it affect diagnosis or prognosis?

BACKGROUND: Significance of electrocardiographic (ECG) changes during vasodilator stress myocardial perfusion imaging (MPI) is controversial. We examined the diagnostic and prognostic significance of ECG changes during vasodilator single photon emission computerized tomography (SPECT) MPI. METHODS: We studied consecutive patients who underwent vasodilator SPECT MPI from 1995 to 2009. Patients with baseline ECG abnormalities, previous history of coronary artery bypass graft surgery or myocardial infarction (MI) were excluded. Significant coronary artery disease (CAD) was defined as >70% stenosis of any vessel or ≥50% stenosis of left main. Mean follow-up was 2.4 ± 1.5 years for cardiac events (cardiac death and non-fatal MI). RESULTS: Of patients in the diagnostic cohort, ST depression was associated with increased incidence of CAD with abnormal (P = .020 and P <.001) but not in those with normal perfusion (P = .342). Of 3,566 patients with follow-up in the prognostic cohort, including 130 (5.0%) with ST depression and normal perfusion, the presence of ST depression ≥1 mm did not affect the outcomes in any summed stress score category. CONCLUSIONS: ST depression ≥1 mm during vasodilator SPECT MPI is associated with CAD in patients with abnormal perfusion, but provides no additional risk stratification beyond concomitant perfusion imaging, including those with normal studies.

CYP2C19 genotype-guided antiplatelet therapy in a patient with clopidogrel resistance.

We report a switch in antiplatelet medication based on platelet function and CYP2C19 genotype test results in a 74-year-old man with severe coronary arterial disease. Upon bare metal stent implantation at age 66, clopidogrel therapy (75 mg/ day) was initiated to supplement aspirin. Over the next eight years, the patient required multiple percutaneous coronary interventions for de novo coronary stenosis and in-stent restenosis. Platelet reactivity measured while on clopidogrel therapy was high, consistent with clopidogrel resistance. CYP2C19 genotype testing then revealed homozygosity for the *2 null allele. The *2/*2 designation indicates poor metabolizer status, indicating deficient capacity of the cytochrome p450 2C19 enzyme for activation of clopidogrel. A medication switch to prasugrel,which does not rely on activation by the 2C19 enzyme, reduced platelet reactivity by 86%. The patient has suffered no cardiovascular events in the 18 months since initiation of prasugrel therapy.

Recurrent acute pancreatitis and persistent hyperamylasemia as a presentation of pancreatic osteoclastic giant cell tumor: an unusual presentation of a rare tumor.

Giant cell tumors of the pancreas are rare neoplasms divided into three forms: osteoclastic, pleomorphic, and mixed. We report an unusual case of a 62-year-old male presenting with recurrent acute pancreatitis and found to have a mass in the head of the pancreas on routine imaging. Endoscopic retrograde cholangiopancreatography showed a main pancreatic duct stricture, with brush cytology revealing the diagnosis of osteoclastic giant cell tumor of the pancreas. Whipple's procedure was successfully performed for resection of this tumor. and IAP.

Collagenous gastroduodenitis.

Collagenous gastroduodenitis is a rare histopathologic entity characterized by marked subepithelial collagen deposition with associated mucosal inflammatory infiltrate. Only 4 cases have been reported, of which 3 had associated collagenous colitis. Collagenous gastroduodenitis without colonic involvement is exceptionally rare with only 1 case reported so far in the literature. We present a case of a 68-year-old woman with dyspepsia and mild anemia, who was found to have nodular gastric and duodenal mucosa on endoscopic examination. Histopathology showed collagenous gastroduodenitis. To the best of our knowledge, this is the second (and first in English literature) reported case of isolated collagenous gastroduodenitis.

Intracranial hemorrhage from undetected aneurysmal rupture complicating transphenoidal pituitary adenoma resection.

We report a case of a 39-year-old man who presented with a nonfunctioning pituitary macroadenoma which extended into the suprasellar region. He underwent a transcranial resection of the tumor followed eight months later by transsphenoidal surgery for the residual tumor. Postoperatively he developed massive subarachnoid and intraventricular hemorrhage. A cerebral angiogram revealed a leaking anterior communicating artery aneurysm which was not seen on the computed tomography angiography and magnetic resonance angiography before the surgery. Complications of transsphenoidal surgery, particularly vascular hemorrhagic complications, and risk of rupture of undetected aneurysms are discussed.

Meta-analysis of optimal risk stratification in patients >65 years of age.

This meta-analysis evaluated the optimal noninvasive strategy for cardiac risk assessment of patients >65 years of age with known or suspected coronary artery disease using the available literature. Patients >65 years of age constitute a growing proportion of the population and have higher cardiovascular morbidity and mortality, but an optimal strategy to predict the risk of cardiac events in this group is unknown. A systematic search of MEDLINE was performed for cohort studies of ≥100 patients >65 years old with ≥12 months of follow-up that reported cardiac death and/or nonfatal myocardial infarction after any of stress myocardial perfusion imaging (MPI), stress echocardiography, or exercise tolerance testing (ETT) for known or suspected coronary artery disease. Pooled annualized event rates were calculated for each technique. Summary odds ratios (ORs) between normal and abnormal test results were calculated using a random-effects model. Seventeen studies (MPI 7, stress echocardiography 7, ETT 3) in 13,304 patients (mean age 75.5 years) were included. Abnormal compared to normal stress MPI (OR 11.8, 95% confidence interval [CI] 7.5 to 18.7) and stress echocardiography (OR 3.2, 95% CI 2.6 to 3.9) accurately stratified risk in patients. However, patients with abnormal and normal ETT results had similar cardiac event rates (OR 3.1, 95% CI 0.8 to 11.5). In conclusion, stress imaging with MPI or stress echocardiography effectively stratified risk in patients, whereas ETT alone did not.

Therapeutic hypothermia is associated with improved neurologic outcome and survival in cardiac arrest survivors of non-shockable rhythms.

BACKGROUND: Therapeutic hypothermia improves neurologic outcomes in patients resuscitated from cardiac arrest due to ventricular fibrillation. However, its role in patients with cardiac arrest due to non-shockable rhythms (pulseless electrical activity (PEA) and asystole) is unclear. We hypothesized that therapeutic hypothermia favorably impacts neurologic outcome and survival in patients resuscitated from cardiac arrest due to non-shockable rhythms. METHODS: Retrospectively collected data on consecutive adult patients admitted to Hartford Hospital from 1/1/2004 to 11/1/2010 who survived a cardiac arrest due to PEA or asystole were analyzed. Patients who underwent therapeutic hypothermia (1/1/2007-11/1/2010) formed the hypothermia group while patients admitted prior to the institution of therapeutic hypothermia (1/1/2004-1/1/2007) at Hartford Hospital formed the control group. The primary end-point was measured using the Pittsburgh cerebral performance category (CPC) scale and patients were assessed for a good (CPC 1 and 2) or poor (CPC 3-5) neurological outcome prior to discharge from hospital. A secondary end-point was measured as survival at discharge from hospital. RESULTS: Of 100 post-cardiac arrest patients included in the study, 15/52 (29%) patients in the hypothermia group had a good neurologic outcome as compared to 5/43 (10%) patients in the control group (P=0.021). On multivariate analysis, the odds ratio for good neurologic outcome and survival at discharge from the hospital with therapeutic hypothermia as compared to control were 4.35 (95% CI 1.10-17.24, P=0.04) and 5.65 (CI 1.66-19.23, P=0.006) respectively. CONCLUSION: Therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients resuscitated after cardiac arrest due to non-shockable rhythms.

Myths about diabetes and its treatment in North Indian population.

BACKGROUND: Myths prevailing about diabetes in the society have become a major hurdle for its proper treatment and control. AIM: To find out about various myths related to diabetes and its treatment in the population. MATERIALS AND METHODS: A cross sectional study was carried out in a teaching hospital of Delhi in 2008. 124 diabetic patients attending the regular diabetic clinic, 78 people who accompanied these patients and 214 non-diabetic people were included in the study. A pre-tested interview schedule with 48 questions was used to get information about sociodemographic characteristics and myths about diabetes. Data was analyzed by Epi info software version 3.2. RESULTS: The most common myth in the population (22%) was that eating more sugar causes diabetes. Others were: diabetes can only occur in old age, soaking feet in water can help control blood sugar, diabetes is a result of past sins and is cured by spiritual treatment. Myths were significantly more common in females, non-diabetics, less educated group. There was a slightly higher prevalence of myths in Muslim population. 12.1% of diabetics were taking herbal medicines. 15.9% of the diabetics and 26% of non diabetics were unaware that complications could occur if diabetes was uncontrolled. 18.5% of diabetics and 30.1% of non-diabetics were unaware about role of diet and lifestyle measures in control of diabetes. CONCLUSIONS: The prevalence of myths about diabetes is high in North Indian population which could be associated with poor early health seeking behavior and poor compliance with treatment.