Differences and Disparities Among Self-Referred and Physician-Referred Populations Undergoing Coronary Artery Calcium Scanning.

BACKGROUND: Coronary artery calcium computed tomography (CAC) is an important tool for identifying subclinical atherosclerosis and cardiovascular risk stratification. Despite robust evidence and inclusion in current guidelines, CAC is considered investigational by some US insurance carriers and requires out-of-pocket expenses. CAC can be obtained via self-referral (SR) or physician referral (PR). We aimed to examine differences in patient, socioeconomic, and CAC characteristics between referral groups. METHODS: We evaluated demographic, medical history, and CAC results of consecutive patients with a CAC completed at one of multiple Wisconsin sites from March 1, 2019, to June 30, 2021. We separated patients into SR and PR groups. Through census data, we analyzed socioeconomic variables at the block level including race and ethnicity, median income, average household size, and high school completion in the areas where patients resided at the time of CAC. RESULTS: The final analysis included 19 726 patients: 13 835 (70.1%) PR and 5891 (29.9%) SR. Most patients in both groups were White (95.2% versus 95.1%), with the Black/African American population representing 2.7% (SR) and 2.3% (PR). The PR group had a higher prevalence of cardiovascular risk factors. SR patients were more likely to have a score of 0 (41.2% versus 38.1%; P<0.001); PR patients had a higher prevalence of CAC >300 (16.8% versus 14.8%; P<0.001). SR patients were more likely to be women (55.1% versus 48.9%; P<0.001) and were found to live in higher income areas (19.5% versus 16.4%; P<0.001). Patients from low-income areas comprised the smallest proportion in both groups (7.5%). CONCLUSIONS: Patients who obtain out-of-pocket CAC live predominantly in medium- and high-income areas, and patients from lower income locations are less likely to obtain CAC despite having more cardiovascular disease risk factors. Consideration should be made from a policy perspective to promote health equity and improve utilization of CAC testing among underrepresented groups.

Foraging behavior and age affect maternal transfer of mercury to northern elephant seal pups.

Deep ocean foraging northern elephant seals (Mirounga angustirostris) consume fish and squid in remote depths of the North Pacific Ocean. Contaminants bioaccumulated from prey are subsequently transferred by adult females to pups during gestation and lactation, linking pups to mercury contamination in mesopelagic food webs (200-1000 m depths). Maternal transfer of mercury to developing seal pups was related to maternal mercury contamination and was strongly correlated with maternal foraging behavior (biotelemetry and isotopes). Mercury concentrations in lanugo (hair grown in utero) were among the highest observed worldwide for young pinnipeds (geometric mean 23.01 µg/g dw, range 8.03-63.09 µg/g dw; n = 373); thus, some pups may be at an elevated risk of sub-lethal adverse health effects. Fetal mercury exposure was affected by maternal foraging geographic location and depth; mercury concentrations were highest in pups of the deepest diving, pelagic females. Moreover, pup lanugo mercury concentrations were strongly repeatable among successive pups of individual females, demonstrating relative consistency in pup mercury exposure based on maternal foraging strategies. Northern elephant seals are biosentinels of a remote deep-sea ecosystem. Our results suggest that mercury within North Pacific mesopelagic food webs may also pose an elevated risk to other mesopelagic-foraging predators and their offspring.

Identification and Localization of Cell Types in the Mouse Olfactory Bulb Using Slide-SeqV2.

Spatial transcriptomics maps RNA molecules to the location in a tissue where they are expressed. Here we document the use of Slide-SeqV2 to visualize gene expression in the mouse olfactory bulb (OB). This approach relies on spatially identified beads to locate and quantify individual transcripts. The expression profiles associated with the beads are used to identify and localize individual cell types in an unbiased manner. We demonstrate the various cell types and subtypes with distinct spatial locations in the olfactory bulb that are identified using Slide-SeqV2.

NO2 emissions from oil refineries in the Mississippi Delta.

Of the >17,943 thousand barrels per calendar day (bbl/d) of oil refining capacity located in the US, the Petroleum Administration for Defense District 3 (PADD-3) region has the largest number of refineries and accounts for >53 % (or 9607 tbbl/d) of all US oil refining capacity. Processing facilities in this area are mainly located on the Gulf of Mexico coast in Texas and Louisiana. This study selected a sub-region for analysis within the Mississippi River delta in the state of Louisiana between the cities of New Orleans and Baton Rouge. This region is characterized by intensive industrial activity connected with oil refining and related activities. The TROPOspheric Monitoring Instrument (TROPOMI) detected highly localized NO2 vertical column densities (VCDs) over the two largest US refineries in Baton Rouge (503,000 bbl/d) and Garyville (578,000 bbl/d). TROPOMI NO2 VCD over these stations were 100 µmol/m2 and 80 µmol/m2, respectively. A high correlation coefficient (r = 0.65, p < 0.05) was also found between TROPOMI NO2 and population density. Data from the National Emissions Inventory (NEI) showed high NOx emissions from refineries and other industries including coal-fired power generation, chemical, and aluminum processing plants. The results of the NO2 analysis are of practical interest for a comparative assessment of air pollution, as well as for the exchange of best practices in the field of low-waste fuel combustion technologies.

Differentiating Lung Nodules Due to Coccidioides from Those Due to Lung Cancer Based on Radiographic Appearance.

BACKGROUND: Coccidioidomycosis (cocci) is an endemic fungal disease that can cause asymptomatic or post-symptomatic lung nodules which are visible on chest CT scanning. Lung nodules are common and can represent early lung cancer. Differentiating lung nodules due to cocci from those due to lung cancer can be difficult and lead to invasive and expensive evaluations. MATERIALS AND METHODS: We identified 302 patients with biopsy-proven cocci or bronchogenic carcinoma seen in our multidisciplinary nodule clinic. Two experienced radiologists who were blinded to the diagnosis read the chest CT scans and identified radiographic characteristics to determine their utility in differentiating lung cancer nodules from those due to cocci. RESULTS: Using univariate analysis, we identified several radiographic findings that differed between lung cancer and cocci infection. We then entered these variables along with age and gender into a multivariate model and found that age, nodule diameter, nodule cavitation, presence of satellite nodules and radiographic presence of chronic lung disease differed significantly between the two diagnoses. Three findings, cavitary nodules, satellite nodules and chronic lung disease, have sufficient discrimination to potentially be useful in clinical decision-making. CONCLUSIONS: Careful evaluation of the three obtained radiographic findings can significantly improve our ability to differentiate benign coccidioidomycosis infection from lung cancer in an endemic region for the fungal disease. Using these data may significantly reduce the cost and risk associated with distinguishing the cause of lung nodules in these patients by preventing unnecessary invasive studies.

Warm Season Turfgrass Equine Sports Surfaces: An Experimental Comparison of the Independence of Simple Measurements Used for Surface Characterization.

Turfgrass in equine sports has clear advantages over other types of reinforcement but adds complexity to the management. This study investigates factors that influence the turfgrass' surface performance and how the use of a drainage package and a geotextile reinforcement affect quantitative measurements of turfgrass. The measurements are made using affordable, lightweight testing tools that are readily available or easily constructed. Eight boxes with turfgrass over a mix of the arena with peat at a consistent depth were tested for volumetric moisture content (VMC %) with time-domain reflectometry (TDR), the rotational peak shear device (RPS), the impact test device (ITD), soil cone penetrometer (SCP), and the Going Stick (GS). Results obtained using TDR, RPS, ITD, SCP, and GS indicate that the presence of the geotextile and drainage package was mainly detected by VMC (%), SCP detected geotextile addition, and GS detected the interaction of geotextile × drainage package. Linear regression showed SCP and GS are related to geotextile and was positively correlated between them and negatively with VMC (%). The testing showed some limitations of these devices, mainly related to moisture content and sod composition, but the potential exists to utilize these devices for quality control as well as for the monitoring of maintenance of the surfaces when controlling the range of both VMC (%) and sod constitution.

A framework to quantify flow through coral reefs of varying coral cover and morphology.

Flow velocities within coral reefs are greatly reduced relative to those at the water surface. The in-reef flow controls key processes that flush heat, cycle nutrients and transport sediment from the reef to adjacent beaches, all key considerations in assessments of reef resilience and restoration interventions. An analytical framework is proposed and tested with a suite of high-resolution numerical experiments. We demonstrate a single parameter that describes the total coral frontal area explains variation of horizontally averaged velocity within a reef canopy across morphologies, densities, and flow depths. With the integration of existing data of coral cover and geometry, this framework is a practical step towards the prediction of near-bed flows in diverse reef environments.

Association Between Shared Decision-Making During Family Meetings and Surrogates' Trust in Their ICU Physician.

BACKGROUND: Although trust is central to successful physician-family relationships in ICUs, little is known about how to promote surrogates' trust of ICU physicians in this setting. RESEARCH QUESTION: Does the conduct of family conferences and physicians' use of shared decision-making (SDM) within family conferences impact surrogates' trust in the physician? STUDY DESIGN AND METHODS: A mixed-methods secondary analysis was done of a multicenter prospective cohort study of 369 surrogate decision-makers of 204 decisionally incapacitated patients at high risk of death or severe functional impairment within 13 ICUs at six US medical centers between 2008 and 2012. Surrogates completed the Abbreviated Wake Forest Physician Trust Scale (range, 5-25) before and after an audio-recorded family conference conducted within 5 days of ICU admission. We qualitatively coded transcribed conferences to determine physicians' use of five SDM behaviors: discussing surrogate's role, explaining medical condition and prognosis, providing emotional support, assessing understanding, and eliciting patient's values and preferences. Using multivariable linear regression with adjustment for clustering, we assessed whether surrogates' trust in the physician increased after the family meeting; we also examined whether the number of SDM behaviors used by physicians during the family meeting impacted trust scores. RESULTS: In adjusted models, conduct of a family meeting was associated with increased trust (average change, pre- to post family meeting: 0.91 point [95% CI, 0.4-1.4; P < .01]). Every additional element of SDM used during the family meeting, including discussing surrogate's role, providing emotional support, assessing understanding, and eliciting patient's values and preferences, was associated with a 0.37-point increase in trust (95% CI, 0.08-0.67; P = .01). If all four elements were used, trust increased by 1.48 points. Explaining medical condition or prognosis was observed in nearly every conference (98.5%) and was excluded from the final model. INTERPRETATION: The conduct of family meetings and physicians' use of SDM behaviors during meetings were both associated with increases in surrogates' trust in the treating physician.

A Pilot Study to Assess the Performance of Phase-Sensitive Breast Tomosynthesis.

Background A new modality, phase-sensitive breast tomosynthesis (PBT), may have similar diagnostic performance to conventional breast tomosynthesis but with a reduced radiation dose. Purpose To perform a pilot study of the performance of a novel PBT system compared with conventional digital breast tomosynthesis (DBT) in patients undergoing additional diagnostic imaging workup for breast lesions. Materials and Methods In a prospective study from June 2020 to March 2021, participants with suspicious breast lesions detected at screening DBT or MRI were recruited for additional PBT imaging before additional diagnostic workup or biopsy. In this pilot study, nine radiologists independently evaluated image quality and assessed the likelihood of lesion malignancy by retrospectively evaluating DBT and PBT images in two separate reading sessions. Image quality was rated subjectively using a Likert scale from 1 to 5. Areas under the receiver operating characteristic curve (AUCs) were used to compare the lesion classification (malignant vs benign) performance of the radiologists. Results Images in 50 patients (mean age, 56 years ± 12 [SD]; 49 women) with 52 evaluable lesions (28 malignant) were assessed. For image appearance and general feature visibility, DBT images had a higher total mean image quality score (3.8) than PBT images (2.9), with P < .002 for each comparison. For classification of lesions as benign or malignant, the AUCs were 0.74 for both PBT and DBT. PBT images were acquired at a 24% mean radiation dose reduction (mean, 1.78 mGy vs 2.34 mGy for DBT; P < .001). Conclusion The phase-sensitive breast tomosynthesis system had a 24% lower mean radiation dose compared with digital breast tomosynthesis, although with lower image quality. Diagnostic performance of the system remains to be determined in larger studies. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gao and Moy in this issue.

The 2021 SIIM-FISABIO-RSNA Machine Learning COVID-19 Challenge: Annotation and Standard Exam Classification of COVID-19 Chest Radiographs.

We describe the curation, annotation methodology, and characteristics of the dataset used in an artificial intelligence challenge for detection and localization of COVID-19 on chest radiographs. The chest radiographs were annotated by an international group of radiologists into four mutually exclusive categories, including "typical," "indeterminate," and "atypical appearance" for COVID-19, or "negative for pneumonia," adapted from previously published guidelines, and bounding boxes were placed on airspace opacities. This dataset and respective annotations are available to researchers for academic and noncommercial use.

A Comparison of Devices for Race Day Characterization of North American Turfgrass Thoroughbred Racing Surfaces.

Both pre-race meet and daily turf surface condition measurements are required by regulations adopted as part of the Horseracing Integrity and Safety Act (HISA). The Orono Biomechanical Surface Tester (OBST) is the primary device used for characterizing a racing surface and is used for the pre-meet inspections. Tools that are better suited for the daily testing of turf surfaces are also needed to meet the new federal regulations. The purpose of this study was to compare five simple tools commonly used in turf applications to the OBST. Data were collected with each of the six devices at plots chosen to approximate the current and potential compositions of North American turf racetracks. Correlations and linear regression models were then established between the simple tool measurements and the parameters measured by the OBST. The moisture probe was found to be the primary device for race day characterization due to its strong correlation to OBST measurements. The Longchamp Penetrometer is also prioritized for daily measurements due to its established correlation to horse performance and injuries. The Clegg Impact Hammer provides further improvement of the linear regression model. The Turf Shear Tester and GoingStick® were not found to correlate well to the biomechanically based device.

Upward propagation of gigantic jets revealed by 3D radio and optical mapping.

Occasionally, lightning will exit the top of a thunderstorm and connect to the lower edge of space, forming a gigantic jet. Here, we report on observations of a negative gigantic jet that transferred an extraordinary amount of charge between the troposphere and ionosphere (∼300 C). It occurred in unusual circumstances, emerging from an area of weak convection. As the discharge ascended from the cloud top, tens of very high frequency (VHF) radio sources were detected from 22 to 45 km altitude, while simultaneous optical emissions (777.4 nm OI emitted from lightning leaders) remained near cloud top (15 to 20 km altitude). This implies that the high-altitude VHF sources were produced by streamers and the streamer discharge activity can extend all the way from near cloud top to the ionosphere. The simultaneous three-dimensional radio and optical data indicate that VHF lightning networks detect emissions from streamer corona rather than the leader channel, which has broad implications to lightning physics beyond that of gigantic jets.

Measuring air pollution from the 2021 Canary Islands volcanic eruption.

The eruption of the Cumbre Vieja volcano on the island of La Palma (Canary Islands, Spain) began on September 19, 2021 and ended on December 13, 2021. It lasted continuously for 85 days with short periods of calm when lava did not exit the cone of the volcano. Vast amounts of volcanic material, including ash and gases, were emitted into the environment. This research focuses on these emissions. The main objective is to use available open-source data to examine the impact on regional and local air quality. Data from the following sources were used: 1) Copernicus Atmosphere Monitoring Service (CAMS) data was used to track the transfer of volcanic SO2 in the troposphere in early October over long distances from the source of the eruption, including Western and Eastern Europe, across the Atlantic Ocean and the Caribbean; 2) Data from ground monitoring stations measured the concentrations of SO2 and PM10 near the source; 3) AErosol RObotic NETwork (AERONET) data from the La Palma station that showed high Aerosol Optical Depth (AOD) values (over 0.4) during the active phase of emissions on September 24 and 28, as well as on October 3; 4) Ångström Exponent (AE) values indicated the presence of particles of different sizes. On September 24, high AE values (>1.5), showed the presence of fine-mode fraction scattering aerosols such as sulfates; 5) Cloud Aerosol Lidar and Infrared Pathfinder Satellite Observation (CALIPSO) data additionally confirmed the presence of sulfate and dust aerosols in the atmosphere over the region. However, the influence of Saharan dust on the atmosphere of the entire region could not be excluded. This research helps forecast air pollution resulting from large-scale volcanic eruptions and associated health risks to humans.

Caffeine: What Is Its Role in Pain Medicine?

Caffeine is the world's most widely used psychoactive legal substance. The involvement of caffeine in pain management has gotten minimal attention in the past, but it is getting more attention now. This article provides a brief assessment of the literature to clarify the role of caffeine as a pain reliever and stimulate the interest of researchers. Caffeine affects adenosine receptors, which are involved in nociception, and plays a significant role in pain regulation. Caffeine's usage as an adjuvant therapy has been extensively documented in the literature, and it is now accessible in certain over-the-counter drugs. The mixture of coffee and morphine for pain reduction in individuals with terminal cancer has shown mixed outcomes in studies. Caffeine can be utilized for hypnic headaches and post-dural puncture headaches since it is crucial in pain regulation. Caffeine has the potential to help in pain management. Caffeine's usage for migraines and end-stage cancer disease is not well acknowledged. Further research is essential to focus on caffeine's potential role in various forms of pain, including dosage escalation and outcome assessment standardization.

The Illumination of Thunderclouds by Lightning: 2. The Effect of GLM Instrument Threshold on Detection and Clustering.

Lightning is measured from space using optical instruments that detect transient changes in the illumination of the cloud top. How much of the flash (if any) is recorded by the instrument depends on the instrument detection threshold. NOAA's Geostationary Lightning Mapper (GLM) employs a dynamic threshold that varies across the imaging array and changes over time. This causes flashes in certain regions and at night to be recorded in greater detail than other flashes, and threshold inconsistencies will impose biases on all levels of GLM data products. In this study, we quantify the impact of the varying GLM threshold on event/group/flash detection, flash clustering, and gridded product generation by imposing artificial thresholds on the event data taken from a thunderstorm with a low instrument threshold (∼0.7 fJ). We find that even modest increases in threshold severely impact event (60% loss by 2 fJ, 90% loss by 10 fJ) and group (25% loss by 2 fJ, 81% loss by 10 fJ) detection by suppressing faint illumination of the cloud top from weak sources and scattering. Flash detection is impacted less by threshold increases (4% loss by 2 fJ), but reductions are still significant at higher thresholds (35% loss by 10 fJ, or 44% if single-group flashes are removed). Undetected pulses cause individual flashes to be split and severely impact the construction of gridded products. All of these factors complicate the interpretation of GLM data, particularly when trended over time under a changing threshold.

The Illumination of Thunderclouds by Lightning: 3. Retrieving Optical Source Altitude.

Optical space-based lightning sensors such as the Geostationary Lightning Mapper (GLM) detect and geolocate lightning by recording rapid changes in cloud top illumination. While lightning locations can be determined to within a pixel on the GLM imaging array, these instruments are not individually able to natively report lightning altitude. It has previously been shown that thunderclouds are illuminated differently based on the altitude of the optical source. In this study, we examine how altitude information can be extracted from the spatial distributions of GLM energy recorded from each optical pulse. We match GLM "groups" with Lightning Mapping Array (LMA) source data that accurately report the 3-D positions of coincident Radio-Frequency (RF) emitters. We then use machine learning methods to predict the mean LMA source altitudes matched to GLM groups using metrics from the optical data that describe the amplitude, breadth, and texture of the group spatial energy distribution. The resulting model can predict the LMA mean source altitude from GLM group data with a median absolute error of <1.5 km, which is sufficient to determine the location of the charge layer where the optical energy originated. This model is able to capture changes to the source altitude distribution in response to convective processes in the thunderstorm, and the GLM predictions can reveal the vertical structure of individual flashes - enabling 3-D flash geolocation with GLM for the first time. Future work will account for differences in thunderstorm charge/precipitation structures and viewing angle across the GLM Field of View.

Clinical Characteristics, Risk Factors, and Outcomes Among a Large Midwestern U.S. Cohort of Patients Hospitalized With COVID-19 Prior to Vaccine Availability.

Purpose: The COVID-19 pandemic posed unprecedented demands on health care. This study aimed to characterize COVID-19 inpatients and examine trends and risk factors associated with hospitalization duration, intensive care unit (ICU) admission, and in-hospital mortality. Methods: This retrospective study analyzed patients with SARS-CoV-2 infection hospitalized at an integrated health system between February 2, 2020, and December 12, 2020. Patient characteristics and clinical outcomes were obtained from medical records. Backward stepwise logistic regression analyses were used to identify independent risk factors of ICU admission and in-hospital mortality. Cox proportional hazards models were used to evaluate relationships between ICU admission and in-hospital mortality. Results: Overall, 9647 patients were analyzed. Mean age was 64.6 ± 18 years. A linear decrease was observed for hospitalization duration (0.13 days/week, R2=0.71; P<0.0001), ICU admissions (0.35%/week, R2=0.44; P<0.001), and hospital mortality (0.16%/week, R2=0.31; P<0.01). Bacterial co-infections, male sex, history of chronic lung and heart disease, diabetes, and Hispanic ethnicity were identified as independent predictors of ICU admission (P<0.001). ICU admission and age of ≥65 years were the strongest independent risk factors associated with in-hospital mortality (P<0.001). The in-hospital mortality rate was 8.3% (27.4% in ICU patients, 2.6% in non-ICU patients; P<0.001). Conclusions: Results indicate that, over the pandemic's first 10 months, COVID-19 carried a heavy burden of morbidity and mortality in older patients (>65 years), males, Hispanics, and those with bacterial co-infections and chronic comorbidities. Although disease severity has steadily declined following administration of COVID-19 vaccines along with improved understanding of effective COVID-19 interventions, these study findings reflect a "natural history" for this novel infectious disease in the U.S. Midwest.

Deterioration of air quality associated with the 2020 US wildfires.

The wildfires of August and September 2020 in the western part of the United States were characterized by an unparalleled duration and wide geographical coverage. A particular consequence of massive wildfires includes serious health effects due to short and long-term exposure to poor air quality. Using a variety of data sources including aerosol optical depth (AOD) and ultraviolet aerosol index (UVAI), obtained with the Moderate-Resolution Imaging Spectroradiometer (MODIS), Multi-Angle Implementation of Atmospheric Correction (MAIAC) and Tropospheric Monitoring Instrument (TROPOMI), combined with meteorological information from the European Center for Medium-Range Weather Forecasts (ECMWF) and other supporting data, the impact of wildfires on air quality is examined in the three western US states, California, Oregon, and Washington, and areas to the east. The results show that smoke aerosols not only led to a significant deterioration in air quality in these states but also affected all other states, Canada, and surrounding ocean areas. The wildfires increased the average daily surface concentration of PM2.5 posing significant health risks, especially for vulnerable populations. Large amounts of black carbon (BC) aerosols were emitted into the atmosphere. AOD and UVAI exceeded 1 and 2 over most of the country. In parts of the three western states, those values reached 3.7 and 6.6, respectively. Moreover, a reanalysis based on MERRA-2 (Modern-Era Retrospective Analysis for Research and Applications, version 2) showed that the maximum values of BC surface mass concentration during the wildfires were about 370 µg/m3. These various indicators provide a better understanding of the extent of environmental and atmospheric degradation associated with these forest fires.

The Challenges of Equestrian Arena Surfaces: The Unprecedented Use of a Raised Platform at the 2012 Olympic Games.

The design of equestrian arenas can be challenged by time constraints and specific restrictions at a venue but are nonetheless a critical element to the success and sustainability of equestrian sport. The equestrian arenas for the 2012 Olympic Games were an example of a temporary arena constructed on a raised platform and supported by struts, a design unprecedented for equestrian activities. This study assessed the developmental stages of the Olympic surfaces from 2011 to the actual event in 2012 and aimed to confirm that accelerations and forces experienced by horses were comparable to those on solid ground. Assessment took place at (1) the Olympic test event;(2) a developmental mock-up arena; and (3) the Olympic venue in 2012. A Clegg impact hammer measured peak vertical deceleration and an Orono Biomechanical Surface Tester quantified peak load and peak loading rate. General Linear Models using the arena's structural features as explanatory variables highlighted surface heterogeneity. Peak vertical deceleration (P < .0001) and peak load (P < .0001) were significantly higher and peak loading rate was significantly lower (P < .0001) following iterative testing and modifications to the arena. Data were comparable with surfaces on solid ground by the final testing at the 2012 Olympic Games. Findings highlighted the importance of testing surfaces throughout their development and demonstrated the impact that surface composition, time elapsed since installation, water management, and type of construction have on surface functional properties, with relevance to future temporary arena initiatives.