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.

An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis.

BACKGROUND: Increasing numbers of patients are undergoing transcatheter aortic valve replacement, which often involves assessment of coronary artery disease ischemic burden. The safety and diagnostic accuracy of vasodilator stress agents in patients with severe aortic stenosis (AS) undergoing SPECT myocardial perfusion imaging (MPI) has not been established. METHODS: Patients with severe AS (valve area <1 cm2) on echocardiography who underwent vasodilator stress SPECT MPI at two centers were identified. Patients with aortic valve intervention prior to MPI or who underwent concurrent exercise during stress testing were excluded. AS patients were matched to controls without AS based on age, gender, BMI, ejection fraction, and stress agent. Symptoms, serious adverse events, hemodynamic response, and correlation to invasive angiography were assessed. RESULTS: A total of 95 cases were identified with 45% undergoing regadenoson, 31% dipyridamole, and 24% adenosine stress. A significant change in systolic blood pressure (BP), cases vs controls, was observed with adenosine [-17.9 ± 20.1 vs -2.6 ± 24.9 P = .03)], with a trend toward significance with regadenoson [-16.8 ± 20.3 vs -9.4 ± 17.9 (P = .08)] and dipyridamole [-17.8 ± 20.6 vs -9.0 ± 12.1 (P = .05)]. The change in heart rate was significantly different only for adenosine [5.3 ± 16.8 vs 14.2 ± 10.8 (P = .04)]. Overall, 45% of cases vs 24% of controls (P = .004) had a >20 mmHg decrease in systolic BP. Age, BMI, and resting systolic BP were related to a >20 mmHg decrease in systolic BP on univariate analysis, although only higher resting systolic BP was a predictor on multivariate analysis. In 33 patients who underwent angiography, the sensitivity, specificity, and diagnostic accuracy of vasodilator stress MPI was 77%, 69%, and 73%, respectively. No serious adverse events occurred in the severe AS patients. CONCLUSION: Severe AS patients are more likely to have a hemodynamically significant decrease in systolic BP with vasodilator stress. There were no serious adverse events in this severe AS cohort with good diagnostic performance of MPI compared to angiography.

Pericardiocentesis followed by thoracotomy and repair of penetrating cardiac injury caused by nail gun injury to the heart.

INTRODUCTION: Work site injuries involving high projectile tools such as nail guns can lead to catastrophic injuries. Generally, penetrating cardiac injuries are associated with a high mortality rate. PRESENTATION OF CASE: A construction worker was brought to the emergency room having sustained a nail gun injury to the chest. The patient was hypotensive, tachycardic with prominent jugular venous distention, and had a profound lactic acidosis. Bedside ultrasound confirmed the presence of pericardial fluid. Pericardiocentesis was performed twice using a central venous catheter inserted into the pericardial space, resulting in improvement in the patient's hemodynamics. Thereafter he underwent left anterolateral thoracotomy and repair of a right atrial laceration. He recovered uneventfully. DISCUSSION: Penetrating cardiac injuries caused by nail guns, although rare, have been previously described. However, pericardiocentesis, while retaining a role in the management of medical causes of cardiac tamponade, has been reported only sporadically in the setting of trauma. We report a rare case of penetrating nail gun injury to the heart where pericardiocentesis was used as a temporizing measure to stabilize the patient in preparation for definitive but timely operative intervention. CONCLUSION: We propose awareness that percardiocentesis can serve as a temporary life saving measure in the setting of trauma, particularly as a bridge to definitive therapy. To our knowledge, this represents the first reported case of catheter pericardiocentesis used to stabilize a patient until definitive repair of a penetrating cardiac injury caused by a nail gun.

Prospective evaluation of a new protocol for the provisional use of perfusion imaging with exercise stress testing.

PURPOSE: Previous literature suggests that myocardial perfusion imaging (MPI) adds little to the prognosis of patients who exercise >10 metabolic equivalents (METs) during stress testing. With this in mind, we prospectively tested a provisional injection protocol in emergency department (ED) patients presenting for the evaluation of chest pain in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. METHODS: All patients who presented to the ED over a 5-year period who were referred for stress testing as part of their ED evaluation were included. Patients considered for a provisional protocol were: exercise stress, age <65 years, no known coronary artery disease, and an interpretable rest ECG. Criteria for not injecting included a maximal predicted heart rate ≥85%, ≥10 METs of exercise, no anginal symptoms during stress, and no ECG changes. Groups were compared based on stress test results, all-cause and cardiac mortality, follow-up cardiac testing, subsequent revascularization, and cost. RESULTS: A total of 965 patients were eligible with 192 undergoing exercise-only and 773 having perfusion imaging. After 41.6 ± 19.6 months of follow-up, all-cause mortality was similar in the exercise-only versus the exercise plus imaging group (2.6% vs. 2.1%, p = 0.59). There were no cardiac deaths in the exercise-only group. At 1 year there was no difference in the number of repeat functional stress tests (1.6% vs. 2.1%, p = 0.43), fewer angiograms (0% vs. 4.0%, p = 0.002), and a significantly lower cost ($65 ± $332 vs $506 ± $1,991, p = 0.002; values are in US dollars) in the exercise-only group. The radiation exposure in the exercise plus imaging group was 8.4 ± 2.1 mSv. CONCLUSIONS: A provisional injection protocol has a very low mortality, few follow-up diagnostic tests, and lower cost compared to standard imaging protocols. If adopted it would decrease radiation exposure, save time and decrease health-care costs without jeopardizing prognosis.

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department.

BACKGROUND: Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population. METHODS: In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups. RESULTS: A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P = .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P = .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P = .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort. CONCLUSIONS: Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing.

Gastric duplication cyst: two case reports and review of the literature.

Background. Duplication of the alimentary tract is a rare congenital anomaly. Gastric duplication cysts (GDCs) represent 4% of all alimentary tract duplications, and approximately 67% manifest within the first year of life. Duplication cysts in adults are generally encountered as incidental findings at endoscopy or laparotomy. Herein, we report two rare cases of symptomatic GDC presenting in adults. Case 1. A 27-year-old male presented with a five-month history of back pain. Exam revealed mild epigastric tenderness with a vague palpable mass in left upper abdomen. CT scan showed 8 × 7.4 × 6 cm homogenous, nonseptated cystic mass posterosuperior to pancreatic tail. On laparotomy, a cystic mass measuring 11 × 8 cm was found, which was densely adherent to posterior wall of stomach suggestive of GDC. Case 2. A 28-year-old woman presented with epigastric pain associated with vomiting for 2 months. Exam revealed mild epigastric tenderness. CT scan showed four cystic lesions in the medial wall of distal stomach measuring approximately one cm each suggestive of duplication cysts. Exploratory laparotomy with antrectomy and truncal vagotomy with Billroth II reconstruction were performed. Pathology in both patients was diagnostic of GDC. Conclusion. GDC is a rare anomaly, and its presentation in adults is even rarer.

Evolution of the chronic congestive heart failure paradigm.

Paradigms are a part of our human nature. In the world of medicine and science, they allow investigators to work within a particular, previously accepted framework that provides certain constraints. This is the crux of Newton's quote, "If I've seen so far it's because I stood upon the shoulders of giants." However, in the same way that it allows us to build, it can constrain our thought processes if we fail to accept new data that are ill suited to an accepted paradigm. The physiological mechanisms to explain the phenomenon of chronic congestive heart failure are similar to other paradigms of science, in that they have undergone several shifts throughout their history, and continue to change with new evidence. Here, we seek to explore how our understanding of congestive heart failure has changed.

Babesiosis as a cause of fever in patients undergoing a splenectomy.

Babesiosis is an emerging infection most commonly acquired from a tick bite. We describe three hospitalized patients with fever attributable to babesiosis after a splenectomy. Splenectomy was done because of splenic enlargement due to unsuspected babesia infection in one patient and because of splenic perforation due to babesiosis in a second patient. The third patient underwent splenectomy for trauma and acquired babesiosis postoperatively from a blood transfusion. Our cases demonstrate the need to be vigilant for babesiosis in patients undergoing splenectomy.

Multi-institutional validation of a web-based core competency assessment system.

OBJECTIVE: The Association of Program Directors in Surgery and the Division of Education of the American College of Surgeons developed and implemented a web-based system for end-of-rotation faculty assessment of ACGME core competencies of residents. This study assesses its reliability and validity across multiple programs. METHODS: Each assessment included ratings (1-5 scale) on 23 items reflecting the 6 core competencies. A total of 4241 end-of-rotation assessments were completed for 332 general surgery residents (> or =5 evaluations each) at 5 sites during the 2004-2005 and 2005-2006 academic years. The mean rating for each resident on each item was computed for each academic year. The mean rating of items representing each competency was computed for each resident. Additional data included USMLE and ABSITE scores, PGY, and status in program (categorical, designated preliminary, and undesignated preliminary). RESULTS: Coefficient alpha was greater than 0.90 for each competency score. Mean ratings for each competency increased significantly (p < 0.01) as a function of PGY. Mean ratings for professionalism and interpersonal/communication skills (IPC) were significantly higher than all other competencies at all PGY levels. Competency ratings of PGY 1 residents correlated significantly with USMLE Step I, ranging from (r = 0.26, p < 0.01) for Professionalism to (r = 0.41, p < 0.001) for Systems-Based Practice. Ratings of Knowledge (r = 0.31, p < 0.01), Practice-Based Learning & Improvement (PBLI; r = 0.22, p < 0.05), and Systems-Based Practice (r = 0.20, p < 0.05) correlated significantly with 2005 ABSITE Total Percentile. Ratings of all competencies correlated significantly with the 2006 ABSITE Total Percentile Score (range: r = 0.20, p < 0.05 for professionalism to r = 0.35, p < 0.001 for knowledge). Categorical and designated preliminary residents received significantly higher ratings (p < 0.05) than nondesignated preliminaries for knowledge, patient care, PBLI, and systems-based practice only. CONCLUSIONS: Faculty ratings of core competencies are internally consistent. The pattern of statistically significant correlations between competency ratings and USMLE and ABSITE scores supports the postdictive and concurrent validity, respectively, of faculty perceptions of resident knowledge. The pattern of increased ratings as a function of PGY supports the construct validity of faculty ratings of resident core competencies.

Multiple, disparate roles for calcium signaling in apoptosis of human prostate and cervical cancer cells exposed to diindolylmethane.

Diindolylmethane (DIM), derived from indole-3-carbinol in cruciferous vegetables, causes growth arrest and apoptosis of cancer cells in vitro. DIM also induces endoplasmic reticulum (ER) stress, and thapsigargin, a specific inhibitor of the sarcoplasmic reticulum/ER calcium-dependent ATPase, enhances this effect. We asked whether elevated cytosolic free calcium [Ca2+]i is required for cytotoxicity of DIM and thapsigargin in two cancer cells lines (C33A, from cervix, and DU145, from prostate). [Ca2+]i was measured in real-time by FURA-2 fluorescence. We tested whether DIM, thapsigargin, and DIM + thapsigargin cause apoptosis, measured by nucleosome release, under conditions that prevented elevation of [Ca2+]i, using both cell-permeable and cell-impermeable forms of the specific calcium chelator BAPTA. DIM, like thapsigargin, rapidly mobilized ER calcium. C33A and DU145 responded differently to perturbations in Ca2+ homeostasis, suggesting that DIM induces apoptosis by different mechanisms in these two cell lines and/or that calcium mobilization also activates different survival pathways in C33A and DU145. Apoptosis in C33A was independent of increased [Ca2+]i, suggesting that depletion of ER Ca2+ stores may be sufficient for cell killing, whereas apoptosis in DU145 required elevated [Ca2+]i for full response. Inhibitor studies using cyclosporin A and KN93 showed that Ca2+ signaling is important for cell survival but the characteristics of this response also differed in the two cell lines. Our results underscore the complex and variable nature of cellular responses to disrupted Ca2+ homeostasis and suggest that alteration Ca2+ homeostasis in the ER can induce cellular apoptosis by both calcium-dependent and calcium-independent mechanisms.

Injury prevention priority score: a new method for trauma centers to prioritize injury prevention initiatives.

BACKGROUND: Trauma centers are expected to develop injury prevention programs that address needs of the local population. A relatively simple, objective, and quantitative method is needed for prioritizing local injury prevention initiatives based on both injury frequency and severity. STUDY DESIGN: Pediatric trauma patients (16 years or younger; n= 7,958) admitted to two Level I regional trauma centers (Johns Hopkins Children Center and Westchester Medical Center) from 1993 to 1999 were grouped by injury causal mechanism according to ICD-9 external cause codes. An Injury Prevention Priority Score (IPPS), balancing the influences of severity (based on the Injury Severity Score) and frequency, was calculated for each mechanism and mechanisms were ranked accordingly. RESULTS: IPPS-based rank lists differed across centers. The highest ranked mechanism of injury among children presenting to Johns Hopkins Children Center was "pedestrian struck by motor vehicle," and at Westchester Medical Center it was "motor vehicle crash." Different age groups also had specific injury prevention priorities, eg, "child abuse" was ranked second highest among infants at both centers. IPPS was found to be stable (r = 0.82 to 0.93, p < 0.05) across alternate measures of injury severity. CONCLUSIONS: IPPS is a relatively simple and objective tool that uses data available in trauma center registries to rank injury causes according to both frequency and severity. Differences between two centers and across age groups suggest IPPS may be useful in tailoring injury prevention programs to local population needs.

Assessing educational validity of the Morbidity and Mortality conference: a pilot study.

PURPOSE: To assess inter-rater agreement in perceptions of cases presented during Morbidity & Mortality conference (M&M) and changes associated with initiation of a modified M&M. METHODS: Faculty, residents, fellows, and students at weekly M&M between June 2001 and March 2002 voluntarily completed an anonymous questionnaire after each M&M case presentation, which asked: if the complication was avoidable (yes/no/not sure), if consensus was reached among participants (yes/no/not sure), the primary cause of the complication (diagnostic error, technical error, judgment error, nature of disease, other), when the primary cause occurred (preoperatively, intraoperatively, postoperatively), and which, if any, of 16 listed actions could prevent similar future problems. On September 24, 2001, the conference was lengthened and modified. Data collected before (n = 30 cases) and after M&M modification (n = 46 cases) were compared. RESULTS: A total of 76 cases were evaluated for a total of 860 completed forms. In 57 cases (75%), majority opinion (ie, > or =50% of participants) indicated that the complication resulted from either nature of disease (n = 32, 41%), or error in diagnosis (n = 5, 7%), technique (n = 8, 11%) or judgment (n = 12, 17%). There was no clear majority for the remainder of the cases. Relative to cases presented prior to M&M modification, for those presented post-modification, the majority perceived that consensus was reached more often (96% of cases vs. 70% of cases, p<.01), and that complications were more often avoidable (54% of cases vs. 23% of cases, p <.05), more likely caused during the preoperative period (26% of cases vs. 7% of cases, p <.01) and less likely caused during the postoperative period (28% of cases vs. 67% of cases, p <.01). CONCLUSIONS: The variability in questionnaire responses suggests that an evaluation instrument such as that reported here can be useful in assessing educational needs, quantifying the efficacy of case presentations, and assessing the effects of modifications to conference content and structure. Modifying M&M in accordance with published recommendations appears to improve case analysis and consensus among participants.