Post-intensive cardiac care outpatient long-term outreach clinic (PICCOLO clinic): Defining health care needs and outcomes among coronary care unit survivors.

Objective: Patients who survive critical illness endure complex physical and mental health conditions, referred to as post-intensive care syndrome (PICS). The University of Michigan's post-intensive cardiac care outpatient long-term outreach (PICCOLO) clinic is designed for patients recently admitted to the coronary care unit (CCU). The long-term goal of this clinic is to understand post-CCU patients' needs and design targeted interventions to reduce their morbidity and mortality post-discharge. As a first step toward this goal, we aimed to define the post-discharge needs of CCU survivors. Design setting particpants: We retrospectively reviewed case-mix data (including rates of depression, PTSD, disability, and cognitive abnormalities) and health outcomes for patients referred to the PICCOLO clinic from July 1, 2018, through June 30, 2021 at Michigan Medicine. Results: Of the 134 referred patients meeting inclusion criteria, 74 (55 %) patients were seen in the PICCOLO clinic within 30 days of discharge. Patients seen in the clinic frequently screened positive for depression (PHQ-2 score ≥3, 21.4 %) and cognitive impairment (MOCA <26, 38.8 %). Further, patients also reported high rates of physical difficulty (mean WHODAS 2.0 score 28.4 %, consistent with moderate physical difficulty). Consistent with medical intensive care unit (ICU) patients, CCU survivors experience PICS. Conclusion: This work highlights the feasibility of an outpatient care model and the need to leverage information gathered from this care model to develop treatment strategies and pathways to address symptoms of PICS in CCU survivors, including depression, cognitive impairment, and physical disability.

Cardiac Metastatic Melanoma Causing Ventricular Arrhythmias Through Impaired Coronary Artery Vasodilation.

Melanoma is an aggressive malignant disease with a high rate of cardiac metastasis. There is a reported association between myocardial tumor invasion and ventricular arrhythmias. We present a case of cardiac metastatic melanoma causing ventricular arrhythmias through a novel mechanism of encasement of coronary arteries leading to reduced myocardial perfusion. (Level of Difficulty: Intermediate.).

Road sediment, an underutilized material in environmental science research: A review of perspectives on United States studies with international context.

Road sediment is a pervasive environmental medium that acts as both source and sink for a variety of natural and anthropogenic particles and often is enriched in heavy metals. Road sediment is generally understudied in the United States (U.S.) relative to other environmental media and compared to countries such as China and the United Kingdom (U.K.). However, the U.S. is an ideal target for these studies due to the diverse climates and wealth of geochemical, socioeconomic, demographic, and health data. This review outlines the existing U.S. road sediment literature while also providing key international perspectives and context. Furthermore, the most comprehensive table of U.S. road sediment studies to date is presented, which includes elemental concentrations, sample size, size fraction, collection and analytical methods, as well as digestion procedure. Overall, there were observed differences in studies by sampling time period for elemental concentrations, but not necessarily by climate in the U.S. Other key concepts addressed in this road sediment review include the processes controlling its distribution, the variety of nomenclature used, anthropogenic enrichment of heavy metals, electron microscopy, health risk assessments, remediation, and future directions of road sediment investigations. Going forward, it is recommended that studies with a higher geographic diversity are performed that consider smaller cities and rural areas. Furthermore, environmental justice must be a focus as community science studies of road sediment can elucidate pollution issues impacting areas of high need. Finally, this review calls for consistency in sampling, data reporting, and nomenclature to effectively expand work on understudied elements, particles, and background sediments.

Impact of a pharmacist in an interdisciplinary post-cardiac intensive care unit clinic.

BACKGROUND: The complex needs of cardiac patients shortly after discharge from a cardiac intensive care unit (CICU) provides a unique opportunity for a pharmacist to help optimize medication management and guideline-directed medical therapy (GDMT). OBJECTIVE: This study describes the impact of a pharmacist in a multidisciplinary post-CICU clinic. METHODS: We performed a retrospective cohort study of patients ≥18 years of age who completed a visit in the University of Michigan Post Intensive Cardiac Care Outpatient Long-Term Outreach (PICCOLO) Clinic from July 2018 to May 2020. RESULTS: One hundred and six CICU survivors were referred. Of these 12 chose to follow-up with long term care providers. A total of 70 of the remaining 94 (74%) completed a visit. The median age was 65 (54-72) years, 71.4% were male, and 85.7% were Caucasian. The median number of pharmacist interventions at each visit was 4 (3-5), all patients had at least 1 intervention. Interventions included medication dose adjustment (n = 46); GDMT optimization (n = 42); medication change (n = 18); medication addition (n = 23) and cessation (n = 21); lab monitoring (n = 97); refill assistance (n = 16); pillbox provision (n = 8); and medication cost assistance (n = 8). CONCLUSIONS: Pharmacist led interventions in a post CICU clinic resulted in medication changes to optimize therapy, increased laboratory monitoring, medication cost savings for patients, and interventions to facilitate GDMT adherence.

Lead Pollution, Demographics, and Environmental Health Risks: The Case of Philadelphia, USA.

Lead (Pb) soil contamination in urban environments represents a considerable health risk for exposed populations, which often include environmental justice communities. In Philadelphia, Pennsylvania (PA), Pb pollution is a major concern primarily due to extensive historical Pb-smelting/processing activity and legacy use of Pb-based paints and leaded gasoline. The U.S. Environmental Protection Agency (USEPA) organized and/or compiled community-driven soil sampling campaigns to investigate Pb content in surface soils across Philadelphia. Using these data (n = 1277), combined with our own dataset (n = 1388), we explored the spatial distribution of Pb content in soils across the city using ArcGIS. While assessing Zone Improvement Plan (ZIP)-code level data, we found strong correlations between factors, such as the percentage of children with elevated blood lead levels (% EBLL) and % minority population as well as between % EBLL and % children in poverty. We developed a "Lead Index" that took demographics, median measured Pb-in-soil content, and % EBLLs into account to identify ZIP codes in need of further assessment. Our results will be used to help lower the Pb-exposure risk for vulnerable children living in disproportionately burdened communities.

Regulatory variants in TCF7L2 are associated with thoracic aortic aneurysm.

Thoracic aortic aneurysm (TAA) is characterized by dilation of the aortic root or ascending/descending aorta. TAA is a heritable disease that can be potentially life threatening. While 10%-20% of TAA cases are caused by rare, pathogenic variants in single genes, the origin of the majority of TAA cases remains unknown. A previous study implicated common variants in FBN1 with TAA disease risk. Here, we report a genome-wide scan of 1,351 TAA-affected individuals and 18,295 control individuals from the Cardiovascular Health Improvement Project and Michigan Genomics Initiative at the University of Michigan. We identified a genome-wide significant association with TAA for variants within the third intron of TCF7L2 following replication with meta-analysis of four additional independent cohorts. Common variants in this locus are the strongest known genetic risk factor for type 2 diabetes. Although evidence indicates the presence of different causal variants for TAA and type 2 diabetes at this locus, we observed an opposite direction of effect. The genetic association for TAA colocalizes with an aortic eQTL of TCF7L2, suggesting a functional relationship. These analyses predict an association of higher expression of TCF7L2 with TAA disease risk. In vitro, we show that upregulation of TCF7L2 is associated with BCL2 repression promoting vascular smooth muscle cell apoptosis, a key driver of TAA disease.

Investigation of Pb-contaminated soil and road dust in a polluted area of Philadelphia.

A multi-analytical geochemical investigation of Pb-contaminated collocated road dust and soils, at two size fractions, was performed in Fishtown, Philadelphia, PA, USA. The combinations of methods employed in this case study were chosen to better characterize the contamination, enhance identification of pollution sources, improve understanding of the impact of former Pb smelters, and to study the relationships between two media and between two size fractions. High concentrations of Cu and Sn were observed in both bulk and finer road dust, whereas large concentrations of Zn and Pb were found in both bulk and finer soil samples, implying pollution. There were no obvious associations between Pb soil concentrations and former smelter locations. Therefore, the primary source of the high mean Pb content in bulk (595 ppm) and fine soils (687 ppm) was likely legacy lead paint and/or leaded-gasoline products. Using electron microscopy, we found that Pb particles were mainly 0.1-10 µm in diameter and were ubiquitous in both soil and dust samples. Two-way analysis of variance tests revealed that, for most chemical elements explored here, there were statistically significant differences in concentrations based on media and size fractions, with finer sizes being more polluted than the bulk. The mineralogical composition and the sources of several pollutant elements (Cr, Cu, Zn, Pb), however, were similar for both soil and dust, pointing to material exchange between the two media. We suggest that future investigations of collocated road dust and soils in urban environments use the methodologies applied in this study to obtain detailed insights into sources of roadside pollution and the relationships between neighboring media.

Multi-scale characterization of glaucophane from Chiavolino (Biella, Italy): implications for international regulations on elongate mineral particles.

In this paper, we present the results of a multi-analytical characterization of a glaucophane sample collected in the Piedmont region of northwestern Italy. Investigation methods included optical microscopy, powder X-ray diffraction, Fourier-transform infrared spectroscopy, µ-Raman spectroscopy, Mössbauer spectroscopy, electron probe microanalysis, environmental scanning electron microscopy and energy-dispersive X-ray spectroscopy, and scanning/transmission electron microscopy combined with energy-dispersive X-ray spectroscopy and electron energy-loss spectroscopy. In addition to the crystal-chemical characterization of the sample from the mesoscale to the near-atomic scale, we have also conducted an extended study on the morphology and dimensions of the mineral particles. The main finding is that studying the same particle population at different magnifications yields different results for mineral habit, dimensions, and dimensional distributions. As glaucophane may occur as an elongate mineral particle (e.g., asbestiform glaucophane occurrences in California and Nevada), the observed discrepancies therefore need to be considered when assessing potential breathability of such particles, with implications for future regulations on elongate mineral particles. While the sample preparation and particle counting methods are not directly investigated in this work, our findings suggest that different magnifications should be used when characterizing an elongate mineral particle population, irrespective of whether or not it contains asbestiform material. These results further reveal the need for developing improved regulation for elongate mineral particles. We thus propose a simple methodology to merge the datasets collected at different magnifications to provide a more complete description and a better risk evaluation of the studied particle population.

Alteration of yellow traffic paint in simulated environmental and biological fluids.

Pollution from heavy metals in urban environments is a topic of growing concern because many metals, including Pb and Cr, are a human health hazard. Exposure to Pb and Cr has been linked to the inhibition of neurological development as well as toxic effects on many organs. Yellow traffic paint (YTP) is a mixture that contains organic polymers, binders, and pigments, which in some cases consist of crocoite (PbCrO4) that may be coated by silica. The primary aim of this study was to investigate the behavior of the crocoite pigment grains within YTP and their silica coatings in simulated environmental and human body conditions. To do this, both YTP and asphalt were collected in Philadelphia, PA, USA. These samples as well as a standard PbCrO4 were investigated with powder X-ray diffraction, X-ray fluorescence, environmental scanning electron microscopy (ESEM), transmission electron microscopy, and energy-dispersive X-ray spectroscopy. Using this multi-analytical approach, mineral phases were determined in the YTP, their shape, dimensional distributions, crystallinity, and chemical composition, as well as elemental distributions before and after experimental interactions. Three batch dissolution experiments with YTP, asphalt, and standard PbCrO4 were performed to simulate ingestion, inhalation, and environmental interaction with rainwater. Elemental releases were determined with inductively coupled plasma-optical emission spectrometry, and results indicated that little (ingestion) to no (environmental and inhalation) Pb and Cr were leached from the YTP during the three experimental procedures. This is likely due to the silica coating that encapsulates the crocoite particles, which persisted during all interactions. The ESEM results for YTP showed dimensional reductions after interactions with all three fluids. The silica coating must be further explored to determine how it breaks down in real environmental conditions.

A mineralogical and chemical investigation of road dust in Philadelphia, PA, USA.

Road dust was investigated within Philadelphia, a major United States city with a long history of industrial activities, in order to determine pollution levels. Almost all of the investigated minor elements were enriched relative to the continental crust. Furthermore, mean concentrations of Cr, Co, Cu, and Pb were high compared with those reported in cities in other countries. Lead pollution should be investigated further in Philadelphia, where 8 of the 30 sample sites, including those heavily trafficked by civilians, were at or above the EPA's child safety threshold for Pb in bare soil. High Spearman correlations between Zn and Cu, Zn and Cr, Cu and Cr, and Sn and V, as well as factor analysis of minor elements suggests that the primary sources of these elements were anthropogenic. Potential sources included the breakdown of alloys, non-exhaust traffic emissions, paint, smelting, and industry. We found that higher organic content in road dust may be related to higher traffic densities, which could be due to tire-wear particles. Additionally, higher mean concentrations of Fe, Cr, Cu, and Zn were found at sites with elevated traffic densities. Land use impacted some of the elements not influenced by traffic density, including Co, Sn, and Pb. Bulk mineral content was similar across different land uses and traffic densities and, thus, did not appear to be influenced by these factors. Our research emphasized the complexity of road dust and utilized a more comprehensive approach than many previous studies. This study established fundamental groundwork for future risk assessment in Philadelphia, as it identified several key pollutants in the city. Overall, this assessment serves as an informative reference point for other formerly heavily industrialized cities in the USA and abroad.

Mineralogical Characterization and Dissolution Experiments in Gamble's Solution of Tremolitic Amphibole from Passo di Caldenno (Sondrio, Italy).

In nature, asbestos is often associated with minerals and other non-asbestiform morphologies thought to be harmless, but not much is known about the potential toxic effects of these phases. Therefore, the characterization of natural assemblages should not be limited to asbestos fibers only. This paper combines a multi-analytical characterization of asbestos from Valmalenco (Italy) with data from dissolution experiments conducted in a simulated interstitial lung fluid (Gamble's solution), and a detailed dimensional study that compares the particle population before and after this interaction. The sample is identified as a tremolitic amphibole, exhibiting a predominance of fiber and prismatic habits at lower magnification, but a bladed habit at higher magnification. The results show that at different magnification, the dimensional and habit distributions are notably different. After the dissolution experiments, the sample showed rounded edges and pyramid-shaped dissolution pits. Chemical analyses suggested that a nearly stoichiometric logarithmic loss of Si and Mg occurred associated with a relatively intense release of Ca in the first 24 h, whereas Fe was probably redeposited on the fiber surfaces. A rearrangement of the more frequent habits and dimensions was recorded after the dissolution experiment, with a peculiar increase of the proportion of elongated mineral particles.

Healthcare provider compliance with the 2013 ACC/AHA Adult Cholesterol Guideline recommendation for high-intensity dose statins for patients with coronary artery disease.

BACKGROUND: Atherosclerotic cardiovascular disease is the foremost cause of death for U.S. adults. The 2013 ACC/AHA Adult Cholesterol Guidelines recommend high-intensity dose statins for individuals with coronary artery disease (CAD). OBJECTIVE: To determine healthcare provider compliance with the Cholesterol Guideline recommendation specific to high-intensity dose statins for patients with CAD. METHODS: A retrospective chart review was conducted to determine compliance rate. A questionnaire was developed to evaluate healthcare provider beliefs, attitudes, and self-confidence toward this recommendation. RESULTS: Of the 473 patients with CAD, 67% were prescribed a high-intensity dose statin. Patients with non-ST segment myocardial infarction and ST segment myocardial infarction were more likely to be prescribed a high-intensity dose statin versus a moderate or low-intensity dose. Healthcare providers strongly agreed with this guideline recommendation. CONCLUSION: There exists a dichotomy between intention to prescribe and actual prescribing behaviors of high-intensity dose statin for patients with CAD.

Aneurysms of medium-sized arteries in Marfan syndrome.

Marfan syndrome is a relatively common connective tissue disorder that causes skin, ocular, skeletal, and cardiovascular abnormalities. High morbidity and mortality occur with aortic aneurysm and dissection. Other large-artery aneurysms, including carotid, subclavian, and iliac artery aneurysms, have also been associated with Marfan syndrome. It is not clear whether small- to medium-sized artery aneurysms are associated with Marfan syndrome. This report describes 4 patients with Marfan syndrome who have associated small- to medium-sized artery aneurysms with several complications. Additional investigations are needed to determine whether Marfan syndrome can cause small- to medium-sized artery aneurysms and how patients with these aneurysms should be treated.

Cardiovascular risk among university students from developed and developing nations.

BACKGROUND: A key aspect in halting global increase in cardiovascular events is prevention and especially prevention at an early age. Unfortunately, global data regarding cardiovascular risk factors in the young are limited. Therefore the objectives of this study were to identify the most common cardiovascular risk factors among young adults in a university setting in both developed and developing countries. METHODS: Lifestyle and cardiovascular risk factors (smoking status, rates of physical activity, alcohol use, family history, blood pressure, fasting lipid panel, fasting blood glucose) were prospectively evaluated in young adults at three different university settings [University of Michigan (Ann Arbor, USA), University of Kalamoon (Deratiah, Syria), and Kakatiya University (Warangal, India)]. RESULTS: A total of 296 subjects (mean age and standard deviation 22 ± 3 years) were evaluated. Rates of current smoking were markedly higher (p < 0.001) in Syria (43%) compared with the USA (6.2%) and India (1.7%). Subjects in India were significantly (p < 0.001) less likely to engage in physical activity (20.2%) compared with the USA (90.7%) and Syria (68.8%). Fasting blood glucose levels and body mass index were significantly higher (p < 0.001) in Syria as compared to other countries. Significant differences were also noted in LDL, HDL, and triglycerides among the three sites. CONCLUSIONS: Cardiovascular risk factors among young adults in a university setting vary depending on global setting. Based upon the results of this study, targeted interventional programs based on risk findings from individual countries may be a reasonable future strategy to help reduce long term cardiovascular morbidity and mortality.

Lack of interaction between the peptidomimetic substrates captopril and cephradine.

Intestinal peptide transporters, including hPEPT1, facilitate the absorption of cephalosporins and angiotensin-converting enzyme inhibitors, and have been investigated as a means to improve oral drug absorption. Renal peptide transporters including hPEPT2, may also facilitate renal reabsorption of such compounds. In vitro and animal studies suggest that co-administration of peptidomimetic compounds may alter oral pharmacokinetics, although this has not been well studied in humans. The purpose of this study was to determine whether co-administration of the hPEPT substrates captopril and cephradine alters the oral pharmacokinetics of either agent. Nine healthy male volunteers received a single oral 25-mg dose of captopril, a single oral 500-mg dose of cephradine, or concurrent ingestion of captopril and cephradine in a cross-over manner. Venous blood samples were taken and captopril and cephradine pharmacokinetics were determined using noncompartmental analyses. No significant differences were observed in captopril or cephradine pharmacokinetics when administered together as compared to each agent alone (a marginal decrease in C(max) was observed for both captopril and cephradine during co-administration [5-15%]; however, differences were not statistically significant). The results of our study suggest that hPEPT1 and hPEPT2 are unlikely to contribute to clinically important drug interactions in humans.