Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease.

BACKGROUND: The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy. METHODS: Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis. RESULTS: A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]). CONCLUSIONS: In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Source and Chemistry of Hydroxymethanesulfonate (HMS) in Fairbanks, Alaska.

Fairbanks, Alaska, is a subarctic city with fine particle (PM2.5) concentrations that exceed air quality regulations in winter due to weak dispersion caused by strong atmospheric inversions, local emissions, and the unique chemistry occurring under the cold and dark conditions. Here, we report on observations from the winters of 2020 and 2021, motivated by our pilot study that showed exceptionally high concentrations of fine particle hydroxymethanesulfonate (HMS) or related sulfur(IV) species (e.g., sulfite and bisulfite). We deployed online particle-into-liquid sampler-ion chromatography (PILS-IC) in conjunction with a suite of instruments to determine HMS precursors (HCHO, SO2) and aerosol composition in general, with the goal to characterize the sources and sinks of HMS in wintertime Fairbanks. PM2.5 HMS comprised a significant fraction of PM2.5 sulfur (26-41%) and overall PM2.5 mass concentration of 2.8-6.8% during pollution episodes, substantially higher than what has been observed in other regions, likely due to the exceptionally low temperatures. HMS peaked in January, with lower concentrations in December and February, resulting from changes in precursors and meteorological conditions. Strong correlations with inorganic sulfate and organic mass during pollution events suggest that HMS is linked to processes responsible for poor air quality episodes. These findings demonstrate unique aspects of air pollution formation in cold and humid atmospheres.

Prospective randomized double-blinded trial comparing 2 anti-MRSA agents with supplemental coverage of cefazolin before lower extremity revascularization.

OBJECTIVE: To compare with antibiotics with methicillin-resistant microbial coverage in a prospective fashion. BACKGROUND: Current antibiotic prophylaxis for vascular procedures includes a first generation cephalosporin. No changes in recommendations have occurred despite changes in reports of incidence of MRSA related surgical site infections. Does supplemental anti-MRSA prophylactic coverage provide a significant reduction in Gram-positive or MRSA infections? METHODS: Single center prospective double blinded randomized study of patients undergoing lower extremity vascular procedures from 2011 to 2014. One hundred seventy-eight (178) patients were evaluated at 90 days for surgical site infection. Infections were categorized as early infections less than 30 days of the index procedure and late after 90 days. RESULTS: Early vascular surgical site infection occurred in 7(8.24%) of patients in the Vancomycin arm, and 11 (11.83%) in the Daptomycin arm (P = 0.43). Gram-positive related infections and MRSA infections occurred in 1(1.18%)/0(0%) of Vancomycin patients and 9 (9.68%)/1 (1.08%) of Daptomycin patients, respectively (P < 0.02 and P = 1.00). Readmissions related to surgical site infections occurred in 4(4.71%) in the Vancomycin group and 11 (11.8%) in the Daptomycin group (P = 0.11). Patients undergoing operative exploration occurred in 5 (5.88%) in the Vancomycin group and 10 (10.75%) of the Daptomycin group (P = 0.17). Late infections were reported in 3 patients, 2 of which were in the combined Daptomycin group. Median hospital charges related to readmissions due to a surgical site infection was $50,823 in the combination Vancomycin arm and $110,920 in the combination Daptomycin group; however, no statistical significance was appreciated (P = 0.11). CONCLUSIONS: Vancomycin supplemental prophylaxis seems to reduce the incidence of Gram-positive infection compared with adding supplemental Daptomycin prophylaxis. The Incidence of MRSA-related surgical site infections is low with the addition of either anti-MRSA agents compared with historical incidence of MRSA-related infection.

An alternative database approach for management of SNOMED CT and improved patient data queries.

OBJECTIVE: SNOMED CT is the international lingua franca of terminologies for human health. Based in Description Logics (DL), the terminology enables data queries that incorporate inferences between data elements, as well as, those relationships that are explicitly stated. However, the ontologic and polyhierarchical nature of the SNOMED CT concept model make it difficult to implement in its entirety within electronic health record systems that largely employ object oriented or relational database architectures. The result is a reduction of data richness, limitations of query capability and increased systems overhead. The hypothesis of this research was that a graph database (graph DB) architecture using SNOMED CT as the basis for the data model and subsequently modeling patient data upon the semantic core of SNOMED CT could exploit the full value of the terminology to enrich and support advanced data querying capability of patient data sets. METHODS: The hypothesis was tested by instantiating a graph DB with the fully classified SNOMED CT concept model. The graph DB instance was tested for integrity by calculating the transitive closure table for the SNOMED CT hierarchy and comparing the results with transitive closure tables created using current, validated methods. The graph DB was then populated with 461,171 anonymized patient record fragments and over 2.1 million associated SNOMED CT clinical findings. Queries, including concept negation and disjunction, were then run against the graph database and an enterprise Oracle relational database (RDBMS) of the same patient data sets. The graph DB was then populated with laboratory data encoded using LOINC, as well as, medication data encoded with RxNorm and complex queries performed using LOINC, RxNorm and SNOMED CT to identify uniquely described patient populations. RESULTS: A graph database instance was successfully created for two international releases of SNOMED CT and two US SNOMED CT editions. Transitive closure tables and descriptive statistics generated using the graph database were identical to those using validated methods. Patient queries produced identical patient count results to the Oracle RDBMS with comparable times. Database queries involving defining attributes of SNOMED CT concepts were possible with the graph DB. The same queries could not be directly performed with the Oracle RDBMS representation of the patient data and required the creation and use of external terminology services. Further, queries of undefined depth were successful in identifying unknown relationships between patient cohorts. CONCLUSION: The results of this study supported the hypothesis that a patient database built upon and around the semantic model of SNOMED CT was possible. The model supported queries that leveraged all aspects of the SNOMED CT logical model to produce clinically relevant query results. Logical disjunction and negation queries were possible using the data model, as well as, queries that extended beyond the structural IS_A hierarchy of SNOMED CT to include queries that employed defining attribute-values of SNOMED CT concepts as search parameters. As medical terminologies, such as SNOMED CT, continue to expand, they will become more complex and model consistency will be more difficult to assure. Simultaneously, consumers of data will increasingly demand improvements to query functionality to accommodate additional granularity of clinical concepts without sacrificing speed. This new line of research provides an alternative approach to instantiating and querying patient data represented using advanced computable clinical terminologies.

C-reactive protein and brain natriuretic peptide as predictors of adverse events after lower extremity endovascular revascularization.

BACKGROUND: High-sensitivity C-reactive protein (hsCRP) and brain natriuretic peptide (BNP) have been shown to be independent predictors of adverse cardiovascular outcomes and increased risk of secondary interventions or limb loss in patients with peripheral arterial disease (PAD). To assist clinicians in decision-making about treatment approaches and predicting postprocedure mortality and morbidity, we retrospectively examined patients with preprocedure hsCRP and BNP levels who underwent elective angioplasty or stent placement for lower extremity PAD. METHODS: The study period was from January 1, 2007, to December 31, 2012, and patients were included who had angioplasty or stenting for PAD. Minimal required follow-up for study inclusion was at least one postoperative ankle-brachial index, contrast angiography, or duplex imaging of the treated limb. Events of interest included major adverse limb events (MALE), defined as target vessel revascularization, amputation, or disease progression by 1 year, and major adverse cardiovascular events (MACE; stroke, myocardial infarction, or death) by 2 years. Elevated/abnormal values for our biomarkers of interest were established by the upper limits of our institution's clinical laboratory reference range (hsCRP, >0.80 mg/dL; BNP, >100 pg/mL). RESULTS: A total of 159 limbs in 118 patients were included in analysis (42% men; median age [range], 64 [42-87] years). All limbs were symptomatic (Rutherford classification: 1-6). Iliac artery revascularization without other adjunct lower extremity intervention was performed in 60% of the limbs. High hsCRP levels (>0.80 mg/dL) were present in 32 patients (27%) and high BNP values (>100 pg/mL) in 24 patients (20%). Kaplan-Meier analysis with log-rank comparison demonstrated that elevated hsCRP levels were associated with MALE but only in limbs receiving interventions distal to the iliac arteries (P = .005). High BNP levels did not affect MALE rates (P = .821). Conversely, both elevated BNP levels (hazard ratio, 5.6; 95% confidence interval [CI], 2.0-5.8; P = .001) and hsCRP levels (hazard ratio, 2.9; 95% CI, 1.1-7.6; P = .034) predicted MACE at 2 years in the presence of confounders in Cox proportional hazards multivariate analysis. Patients with high preintervention values of hsCRP and BNP were 10.6 times (95% CI, 2.6-42.9; P = .001) more likely to experience MACE than were patients with normal hsCRP and BNP values. CONCLUSIONS: After lower extremity endovascular interventions, elevated preprocedural hsCRP levels are associated with MALE (femoral-popliteal interventions), and elevated levels of hsCRP and BNP are associated with late cardiovascular events.

Napa Valley Cabernet Sauvignon Proanthocyanidin Changes During Fruit Ripening: A Multi-Appellation Survey.

In 2015, an experiment was designed to investigate the distribution and variance of in winegrape flavonoids across the ripening phase in the Napa Valley. This Cabernet Sauvignon experiment was intended to evaluate the polyphenol differences across Napa Valley in order to understand parameters controlling "proanthocyanidin activity." This method has shown promise in understanding proanthocyanidin (PA) astringency based on size distribution, pigmentation, conformation, and composition. Results from whole berry partial extractions showed that seed PA material was driving PA activity early in the ripening phase, while the formation of the pigmented polymer led to a decrease later in the growing season. Multivariate analysis showed that the main drivers of changes across the ripening phase were the molecular masses of PAs and the amount of pigmentation. Given the high amount of variability seen in the experiment between sites in such a small geographical area, the results suggest that manipulation of PA activity may be possible in the vineyard, perhaps explaining variations in wine mouthfeel attributes between locations. These results can be used to develop furthermore controlled experiments targeting the variables responsible for PA activity changes.

Assessing the Oxidative Potential of Outdoor PM2.5 in Wintertime Fairbanks, Alaska.

The oxidative potential (OP) of outdoor PM2.5 in wintertime Fairbanks, Alaska, is investigated and compared to those in wintertime Atlanta and Los Angeles. Approximately 40 filter samples collected in January-February 2022 at a Fairbanks residential site were analyzed for OP utilizing dithiothreitol-depletion (OPDTT) and hydroxyl-generation (OPOH) assays. The study-average PM2.5 mass concentration was 12.8 µg/m3, with a 1 h average maximum of 89.0 µg/m3. Regression analysis, correlations with source tracers, and contrast between cold and warmer events indicated that OPDTT was mainly sensitive to copper, elemental carbon, and organic aerosol from residential wood burning, and OPOH to iron and organic aerosol from vehicles. Despite low photochemically-driven oxidation rates, the water-soluble fraction of OPDTT was unusually high at 77%, mainly from wood burning emissions. In contrast to other locations, the Fairbanks average PM2.5 mass concentration was higher than Atlanta and Los Angeles, whereas OPDTT in Fairbanks and Atlanta were similar, and Los Angeles had the highest OPDTT and OPOH. Site differences were observed in OP when normalized by both the volume of air sampled and the particle mass concentration, corresponding to exposure and the intrinsic health-related properties of PM2.5, respectively. The sensitivity of OP assays to specific aerosol components and sources can provide insights beyond the PM2.5 mass concentration when assessing air quality.

Indoor-Outdoor Oxidative Potential of PM2.5 in Wintertime Fairbanks, Alaska: Impact of Air Infiltration and Indoor Activities.

The indoor air quality of a residential home during winter in Fairbanks, Alaska, was investigated and contrasted with outdoor levels. Twenty-four-hour average indoor and outdoor filter samples were collected from January 17 to February 25, 2022, in a residential area with high outdoor PM2.5 concentrations. The oxidative potential of PM2.5 was determined using the dithiothreitol-depletion assay (OPDTT). For the unoccupied house, the background indoor-to-outdoor (I/O) ratio of mass-normalized OP (OPmDTT), a measure of the intrinsic health-relevant properties of the aerosol, was less than 1 (0.53 ± 0.37), implying a loss of aerosol toxicity as air was transported indoors. This may result from transport and volatility losses driven by the large gradients in temperature (average outdoor temperature of -19°C/average indoor temperature of 21 °C) or relative humidity (average outdoor RH of 78%/average indoor RH of 11%), or both. Various indoor activities, including pellet stove use, simple cooking experiments, incense burning, and mixtures of these activities, were conducted. The experiments produced PM2.5 with a highly variable OPmDTT. PM2.5 from cooking emissions had the lowest OP values, while pellet stove PM2.5 had the highest. Correlations between volume-normalized OPDTT (OPvDTT), relevant to exposure, and indoor PM2.5 mass concentration during experiments were much lower compared to those in outdoor environments. This suggests that mass concentration alone can be a poor indicator of possible adverse effects of various indoor emissions. These findings highlight the importance of considering both the quantity of particles and sources (chemical composition), as health metrics for indoor air quality.

Overview of the Alaskan Layered Pollution and Chemical Analysis (ALPACA) Field Experiment.

The Alaskan Layered Pollution And Chemical Analysis (ALPACA) field experiment was a collaborative study designed to improve understanding of pollution sources and chemical processes during winter (cold climate and low-photochemical activity), to investigate indoor pollution, and to study dispersion of pollution as affected by frequent temperature inversions. A number of the research goals were motivated by questions raised by residents of Fairbanks, Alaska, where the study was held. This paper describes the measurement strategies and the conditions encountered during the January and February 2022 field experiment, and reports early examples of how the measurements addressed research goals, particularly those of interest to the residents. Outdoor air measurements showed high concentrations of particulate matter and pollutant gases including volatile organic carbon species. During pollution events, low winds and extremely stable atmospheric conditions trapped pollution below 73 m, an extremely shallow vertical scale. Tethered-balloon-based measurements intercepted plumes aloft, which were associated with power plant point sources through transport modeling. Because cold climate residents spend much of their time indoors, the study included an indoor air quality component, where measurements were made inside and outside a house to study infiltration and indoor sources. In the absence of indoor activities such as cooking and/or heating with a pellet stove, indoor particulate matter concentrations were lower than outdoors; however, cooking and pellet stove burns often caused higher indoor particulate matter concentrations than outdoors. The mass-normalized particulate matter oxidative potential, a health-relevant property measured here by the reactivity with dithiothreiol, of indoor particles varied by source, with cooking particles having less oxidative potential per mass than pellet stove particles.

Estimating surface visibility at Hong Kong from ground-based LIDAR, sun photometer and operational MODIS products.

Hong Kong's surface visibility has decreased in recent years due to air pollution from rapid social and economic development in the region. In addition to deteriorating health standards, reduced visibility disrupts routine civil and public operations, most notably transportation and aviation. Regional estimates of visibility solved operationally using available ground and satellite-based estimates of aerosol optical properties and vertical distribution may prove more effective than standard reliance on a few existing surface visibility monitoring stations. Previous studies have demonstrated that such satellite measurements correlate well with near-surface optical properties, despite these sensors do not consider range-resolved information and indirect parameterizations necessary to solve relevant parameters. By expanding such analysis to include vertically resolved aerosol profile information from an autonomous ground-based lidar instrument, this work develops six models for automated assessment of surface visibility. Regional visibility is estimated using co-incident ground-based lidar, sun photometer visibility meter and MODerate-resolution maging Spectroradiometer (MODIS) aerosol optical depth data sets. Using a 355 nm extinction coefficient profile solved from the lidar MODIS AOD (aerosol optical depth) is scaled down to the surface to generate a regional composite depiction of surface visibility. These results demonstrate the potential for applying passive satellite depictions of broad-scale aerosol optical properties together with a ground-based surface lidar and zenith-viewing sun photometer for improving quantitative assessments of visibility in a city such as Hong Kong.

Outcomes of Hospitalized Patients With Fecal Occult Positive Stool Prior to Cardiac Catheterization in Acute Coronary Syndrome (ACS).

Introduction Cardiac catheterization is an essential component of patient care in Acute Coronary Syndrome (ACS). Fecal occult blood testing (FOBT) has been used in the inpatient setting to evaluate the risk of bleeding with dual anti-platelet therapy prior to cardiac catheterization although no guidelines exist for this indication and FOBT testing in the inpatient setting is not recommended for evaluation of GI blood loss. We sought to assess the outcomes of patients with fecal occult positive stool prior to cardiac catheterization compared to those that did not undergo FOBT during admission for non-ST-elevation myocardial infarction (NSTEMI). Methods We identified patients between 18 and 90 years old with admission for NSTEMI in the Trinetx Research Network from January 1, 2019 to December 31, 2020. Patients were then divided into those who had an FOBT prior to cardiac catheterization and those that did not have an FOBT. We compared all-cause mortality, bleeding, troponin levels, and length of stay between propensity-matched (PSM) pairs of patients. Results We identified 46,349 that met inclusion criteria, of which 1,728 had an FOBT (3.7%) and 44,621 (96.3%) had no FOBT prior to cardiac catheterization. Patients in the FOBT group were older and had a higher prevalence of hypertension, coronary artery disease, heart failure, diabetes, chronic obstructive pulmonary disease, and higher BMI. Two well-matched groups of n=1,728/1,728 were used for comparing outcomes. The FOBT group had similar 30-day mortality (4.45% vs 4.01, P=0.56) as well as similar bleeding events (0.98% vs 0.69%, P=0.35). Troponin levels in the FOBT group were on average lower (0.41 vs 0.95, P=0.04). The FOBT groups also had a similar average length of stay of (14.1 days vs 14.2 days, P=0.42). 233 patients who received FOBT underwent endoscopic evaluation with either upper endoscopy or colonoscopy (13.5%), and there was no significant difference in 30-day mortality (6.86% vs 4.7%, P=0.321). Among patients who underwent endoscopy, 72 had some form of endoscopic intervention (30.9%). There was no difference in 30-day mortality between patients undergoing endoscopy with intervention and without intervention (14.49%/14.49%) P=1.00. Readmission was similar between patients undergoing endoscopy with and without intervention. Conclusions In a large multi-center national database, we observed similar outcomes in patients who were admitted with NSTEMI and had FOBT and those not receiving FOBT in terms of all-cause mortality and bleeding events. In patients with positive FOBT, endoscopy with and without intervention we observed no significant difference in 30-day mortality. We conclude that there is no compelling evidence for FOBT testing in patients with NSTEMI.

Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections.

OBJECTIVE: This study assessed the efficacy of antibiotic-loaded polymethylmethacrylate (PMMA) beads in the treatment of lower extremity vascular surgical site infections (VSSIs). METHODS: This was a retrospective review of all patients with a VSSI of a lower extremity bypass treated with antibiotic-loaded PMMA beads and culture-specific antibiotics during a 4.5-year period. Data collected included patient demographics, comorbidities, site of initial graft infection, symptoms and signs at presentation, initial and additional surgical debridement, wound culture results, type of antibiotic beads implanted, and graft treatment strategy, comprising conduit preservation or in situ replacement, with associated soft tissue management by muscle flap or vacuum-assisted closure. Primary outcome measures included death, recurrent infection, and limb salvage. RESULTS: Forty patients developed 42 extracavitary lower extremity VSSIs (bilateral groin infections in two). Patients were treated according to our treatment algorithm with antibiotic-impregnated PMMA beads. Previous reconstructions included nine aortofemoral bypasses (groin infection only), 20 infrainguinal bypasses, five extra-anatomic bypasses, five femoral interpositions, two combined inflow-outflow bypass procedures, and one patch angioplasty with VSSI. Cultures isolated 59 pathogens (39 gram-positive, 18 gram-negative, 2 Candida spp). Methicillin-resistant Staphylococcus aureus was cultured from 10 VSSs (23.8%) overall and from 27.7% of those patients with attempted graft preservation or in situ reconstructions. Two patients (4.8%) had no growth despite clinical signs of infection. Repeat VSS exploration and culture results led to an average of 1.4 bead replacements before definitive treatment. Final treatment strategy included graft preservation of patent bypasses in 28, partial graft excision with in situ replacement in eight, graft removal only with residual graft remaining at implant site (ie, incorporated anastomotic conduit, 11.9%) in five, and extra-anatomic reconstruction in one. Sartorius muscle flap was performed in 14 groin infections (37.8%). The 30-day mortality was 0%, and limb loss was 7.1% (n = 3). At the median follow-up of 17 months, the limb loss was 21.4% and the recurrent infection rate was 19.4% (seven of 36) in those with attempted graft preservation or in situ replacement. CONCLUSIONS: Antibiotic-loaded PMMA beads may serve as an adjunct in the management of VSSIs and may also expand treatment options for graft preservation or in situ reconstruction, with expected recurrent infection rate approaching 20%. Further experience with this adjunct may help elucidate its role in the management of this complicated problem, including the need for bead exchanges, until perigraft cultures are free of microbes.

Critical analysis of renal duplex ultrasound parameters in detecting significant renal artery stenosis.

BACKGROUND: Several published studies have reported differing results of renal duplex ultrasound (RDU) imaging in detecting significant renal artery stenosis (RAS) using different Doppler parameters. This study is the largest to date to compare RDU imaging vs angiography and assess various published Doppler criteria. METHODS: RDU imaging and angiography were both done in 313 patients (606 renal arteries). RAS was classified as normal, <60%, ≥ 60% to 99%, and occlusion. Main outcome measurements included renal peak systolic velocity (PSV), systolic renal-to-aortic ratio (RAR), end-diastolic velocity (EDV), and kidney lengths. RESULTS: The mean PSVs and RARs for normal, <60%, and ≥ 60% stenosis were 173, 236, and 324 cm/s (P < .0001), and 2.2, 2.9, and 4.5, respectively (P < .0001). The PSV cutoff value that provided the best overall accuracy for ≥ 60% stenosis was 285 cm/s, with a sensitivity, specificity, and overall accuracy of 67%, 90%, and 81%, respectively. The RAR cutoff value with the best overall accuracy for ≥ 60% stenosis was 3.7, with a sensitivity, specificity, and overall accuracy of 69%, 91%, and 82%, respectively. A PSV of ≥ 180 cm/s and RAR of ≥ 3.5 had a sensitivity, specificity, and overall accuracy of 72%, 81%, and 78% in detecting ≥ 60% stenosis. A PSV of ≥ 200 cm/s with an RAR of ≥ 3.5 had a sensitivity, specificity, and overall accuracy of 72%, 83%, and 78% in detecting ≥ 60% stenosis. A receiver operator characteristic (ROC) curve analysis showed that the PSV and RAR were better than the EDV in detecting ≥ 60% stenosis: PSV area under the curve (AUC) was 0.85 (95% confidence interval [CI], 0.81-0.88), EDV AUC was 0.71, and RAR AUC was 0.82 (PSV vs EDV, P < .0001; PSV vs RAR, P = .075; EDV vs RAR, P < .0001). A PSV of 285 cm/s or RAR of 3.7 alone were better than any combination of PSVs, EDVs, or RARs in detecting ≥ 60% stenosis. The mean kidney length was 10.4 cm in patients with ≥ 60% stenosis vs 11.0 cm in patients with <60% stenosis (P < .0001). Twelve percent of patients with ≥ 60% stenosis had a kidney length of ≤ 8.5 cm vs 4% in patients with <60% stenosis (P = .0003), and 5.6% (34 of 606) had accessory renal arteries on angiography, with six detected on RDU imaging. The presence of accessory renal arteries, solitary kidneys, or renal fibromuscular dysplasia had no influence on overall accuracy of using PSV values for detecting ≥ 60% stenosis. CONCLUSIONS: A PSV of 285 cm/s or an RAR of 3.7 alone can be used in detecting ≥ 60% RAS. Previously published data must be validated in individual vascular laboratories.

Blood lead levels of refugee children resettled in Massachusetts, 2000 to 2007.

OBJECTIVES: We described elevated blood lead level (BLL; ≥ 10 µg/dL) prevalence among newly arrived refugee children in Massachusetts. We also investigated the incidence of BLL increases and BLLs newly elevated to 20 µg/dL or higher in the year following initial testing, along with associated factors. METHODS: We merged data from the Massachusetts Department of Public Health's Refugee and Immigrant Health Program and the Childhood Lead Poisoning Prevention Program on 1148 refugee children younger than 7 years who arrived in Massachusetts from 2000 to 2007. RESULTS: Elevated BLL prevalence was 16% among newly arrived refugee children. The rate ratio for BLL elevation to 20 µg/dL or higher after arrival was 12.3 (95% confidence interval [CI] = 6.2, 24.5) compared with children in communities the state defines as high-risk for childhood lead exposure. Residence in a census tract with older housing (median year built before 1950) was associated with a higher rate of BLL increases after resettlement (hazard ratio = 1.7; 95% CI = 1.2, 2.3). CONCLUSIONS: Refugee children are at high risk of lead exposure before and after resettlement in Massachusetts. A national surveillance system of refugee children's BLLs following resettlement would allow more in-depth analysis.

Anthocyanin Addition Alters Tannin Extraction from Grape Skins in Model Solutions via Chemical Reactions.

Condensed tannin extraction and stable color formation are two of the cornerstones of red wine production. Without condensed tannin, red wine would lack the tactile feeling of astringency, and without the formation of modified pigments, it would lack color stability for long-term aging. To understand how malvidin-3,5-diglucoside interacts with condensed tannin under nonoxidative conditions, an experiment was designed conducting model-wine skin extractions of Sauvignon blanc grapes harvested at various dates of maturity. Monomeric malvidin-3,5-diglucoside was isolated from color concentrate and added during these extractions. Following a 72 h extraction, solutions were evaluated for recovery of monomeric anthocyanins, skin tannin concentration, skin tannin extractability, and impact of anthocyanins on condensed tannin size. Anthocyanins showed a significant impact on the extraction of flavan-3-ol material in the early stages of ripening that declined in the latter stages of ripening. Furthermore, anthocyanins significantly decreased the size of the condensed tannin extracted. These results suggest that anthocyanins are not only enhancing the extractability of condensed tannin but also readily incorporating into the polymeric material, leading to a decrease in the average molecular mass of the condensed tannin polymer. The extent of reaction in 72 h suggests that the rate of interflavan bond cleavage may be higher than previously reported and merits closer scrutiny.

Exploration of PCORnet Data Resources for Assessing Use of Molecular-Guided Cancer Treatment.

PURPOSE: Examine the ability of PCORnet data resources to investigate molecular-guided cancer treatment. PATIENTS AND METHODS: Patients (N = 86,154) had single primary solid tumors (diagnosed 2013-2017) from hospital oncology registries linked to the PCORnet Common Data Model (CDM) at 11 medical institutions. Molecular and anatomic test procedures and oral and infused therapies were identified with Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, RxNorm Concept Unique Identifier, and National Drug Codes from CDM tables. Chart review (2 institutions, n = 213) for advanced colorectal cancer and Medicare claims linkages (7 institutions, n = 1,731) for breast cancer explored options for increasing electronic data capture. RESULTS: Molecular testing prevalence detected via analyte-specific molecular CPT/HCPCS codes was 5.5% (n = 4,784); for the nonspecific anatomic pathology codes, for which only some testing is performed to guide therapy selection, it was an additional 44.8% (n = 38,610). Molecular-guided therapy prevalence was 5% (n = 4,289). Testing and treatment were most common with stage IV disease and varied across cancer types and study institutions (testing, 0%-10.4%; treatment, 0.8%-8.4%). Therapy-concordant test results were found in charts for all 36 treated patients with colorectal cancer at the 2 institutions, 3 (8.3%) of whom received treatment outside the institution. Breast cancer Medicare claims linkage increased rates of identified testing from 62.7%-98.9% and treatment from 3.9%-8.2%. CONCLUSION: Although a minority of patients received molecular-guided therapies, the majority had testing that could guide cancer treatment. Claims data extended electronic data capture for therapies and test orders but often was uninformative for types of test ordered. Test results continue to require text data curation from narrative pathology reports.

Using SNOMED CT-encoded problems to improve ICD-10-CM coding-A randomized controlled experiment.

OBJECTIVE: Clinical problems in the Electronic Health Record that are encoded in SNOMED CT can be translated into ICD-10-CM codes through the NLM's SNOMED CT to ICD-10-CM map (NLM Map). This study evaluates the potential benefits of using the map-generated codes to assist manual ICD-10-CM coding. METHODS: De-identified clinic notes taken by the physician during an outpatient encounter were made available on a secure web server and randomly assigned for coding by professional coders with usual coding or map-assisted coding. Map-assisted coding made use of the problem list maintained by the physician and the NLM Map to suggest candidate ICD-10-CM codes to the coder. A gold standard set of codes for each note was established by the coders using a Delphi consensus process. Outcomes included coding time, coding reliability as measured by the Jaccard coefficients between codes from two coders with the same method of coding, and coding accuracy as measured by recall, precision and F-score according to the gold standard. RESULTS: With map-assisted coding, the average coding time per note reduced by 1.5 min (p = 0.006). There was a small increase in coding reliability and accuracy (not statistical significant). The benefits were more pronounced in the more experienced than less experienced coders. Detailed analysis of cases in which the correct ICD-10-CM codes were not found by the NLM Map showed that most failures were related to omission in the problem list and suboptimal mapping of the problem list terms to SNOMED CT. Only 12% of the failures was caused by errors in the NLM Map. CONCLUSION: Map-assisted coding reduces coding time and can potentially improve coding reliability and accuracy, especially for more experienced coders. More effort is needed to improve the accuracy of the map-suggested ICD-10-CM codes.

Quantifying the direct radiative effect of absorbing aerosols for numerical weather prediction: a case study.

We conceptualize aerosol radiative transfer processes arising from the hypothetical coupling of a global aerosol transport model and a global numerical weather prediction model by applying the US Naval Research Laboratory Navy Aerosol Analysis and Prediction System (NAAPS) and the Navy Global Environmental Model (NAVGEM) meteorological and surface reflectance fields. A unique experimental design during the 2013 NASA Studies of Emissions and Atmospheric Composition, Clouds and Climate Coupling by Regional Surveys (SEAC4RS) field mission allowed for collocated airborne sampling by the high spectral resolution Lidar (HSRL), the Airborne Multi-angle SpectroPolarimetric Imager (AirMSPI), up/down shortwave (SW) and infrared (IR) broadband radiometers, as well as NASA A-Train support from the Moderate Resolution Imaging Spectroradiometer (MODIS), to attempt direct aerosol forcing closure. The results demonstrate the sensitivity of modeled fields to aerosol radiative fluxes and heating rates, specifically in the SW, as induced in this event from transported smoke and regional urban aerosols. Limitations are identified with respect to aerosol attribution, vertical distribution, and the choice of optical and surface polarimetric properties, which are discussed within the context of their influence on numerical weather prediction output that is particularly important as the community propels forward towards inline aerosol modeling within global forecast systems.

A Model Information Management Plan for Molecular Pathology Sequence Data Using Standards: From Sequencer to Electronic Health Record.

Incorporating genetic variant data into the electronic health record (EHR) in discrete computable fashion has vexed the informatics community for years. Genetic sequence test results are typically communicated by the molecular laboratory and stored in the EHR as textual documents. Although text documents are useful for human readability and initial use, they are not conducive for data retrieval and reuse. As a result, clinicians often struggle to find historical gene sequence results on a series of oncology patients within the EHR that might influence the care of the current patient. Second, identification of patients with specific mutation results in the EHR who are now eligible for new and/or changing therapy is not easily accomplished. Third, the molecular laboratory is challenged to monitor its sequencing processes for nonrandom process variation and other quality metrics. A novel approach to address each of these issues is presented and demonstrated. The authors use standard Health Level 7 laboratory result message formats in conjunction with international standards, Systematized Nomenclature of Medicine Clinical Terms and Human Genome Variant Society nomenclature, to represent, communicate, and store discrete gene sequence data within the EHR in a scalable fashion. This information management plan enables the support of the clinician at the point of care, enhances population management, and facilitates audits for maintaining laboratory quality.

A computable pathology report for precision medicine: extending an observables ontology unifying SNOMED CT and LOINC.

BACKGROUND: The College of American Pathologists (CAP) introduced the first cancer synoptic reporting protocols in 1998. However, the objective of a fully computable and machine-readable cancer synoptic report remains elusive due to insufficient definitional content in Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) and Logical Observation Identifiers Names and Codes (LOINC). To address this terminology gap, investigators at the University of Nebraska Medical Center (UNMC) are developing, authoring, and testing a SNOMED CT observable ontology to represent the data elements identified by the synoptic worksheets of CAP. METHODS: Investigators along with collaborators from the US National Library of Medicine, CAP, the International Health Terminology Standards Development Organization, and the UK Health and Social Care Information Centre analyzed and assessed required data elements for colorectal cancer and invasive breast cancer synoptic reporting. SNOMED CT concept expressions were developed at UNMC in the Nebraska Lexicon© SNOMED CT namespace. LOINC codes for each SNOMED CT expression were issued by the Regenstrief Institute. SNOMED CT concepts represented observation answer value sets. RESULTS: UNMC investigators created a total of 194 SNOMED CT observable entity concept definitions to represent required data elements for CAP colorectal and breast cancer synoptic worksheets, including biomarkers. Concepts were bound to colorectal and invasive breast cancer reports in the UNMC pathology system and successfully used to populate a UNMC biobank. DISCUSSION: The absence of a robust observables ontology represents a barrier to data capture and reuse in clinical areas founded upon observational information. Terminology developed in this project establishes the model to characterize pathology data for information exchange, public health, and research analytics.