Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians.

Physician solicitation of charitable contributions from patients-also known among other things as grateful patient fundraising-raises significant ethical concerns. These include pressure on patients to donate and the effects of this on the patient-physician relationship, potential expectations of donor patients for treatment that is not indicated or preferential care, justice and fairness issues, disclosure and use of confidential patient information for nontreatment purposes, and conflicts of interest. The patient-physician relationship and knowledge of the patient's medical history, clinical status, personal information, and financial circumstances are some of the reasons development and administrative officials might see physicians as strong potential fundraisers. But those are among the reasons grateful patient fundraising is ethically problematic. This American College of Physicians position paper explores these issues and offers guidance.

The Hospital Course of a Successfully Treated Patient with Respiratory Failure: Beginning to End!

The successful treatment of a patient with acute respiratory failure is a complex undertaking that requires clinical competence, evidence-based interventions, seamless coordination of care transitions, and transparent open communication among all members of the health care team. Many of the processes of care in these critically ill patients are reassuringly consistent across services, across hospitals, across health systems, and even across the country. Although the clinical course of such complicated patients can be extremely unpredictable, we are fortunate that the professional, technical, and psychosocial aspects of care for these patients can be relatively orderly, evidence-based, and transparent.

The HCA National Disease Management Program for coronary disease detection and treatment in women.

The diagnosis and treatment of heart disease in women continues to be one of the greatest challenges facing cardiovascular medicine today. Marked reductions in mortality rates during the past 2 decades did not result in improved outcomes for women. A major rate-limiting step to improving mortality rates for women is early diagnosis and initiation of effective lifesaving therapies for women. In 1999, HCA Healthcare Systems, Inc, Nashville, TN, initiated a coordinated effort among 208 hospitals in 26 states to improve the diagnosis of coronary disease and to target women who should receive aggressive risk factor modification and referral to cardiologists. We describe the initial phases of program development, including employee risk factor screening; citywide health risk assessment; nationwide educational programs for clinicians, staff, and consumers; and a dedicated outcomes assessment program for tracking women at risk for coronary disease. We believe that these efforts provide a venue for optimal care and improved outcomes for women served by HCA facilities.

Electron-beam computed tomography: a Bayesian approach to risk assessment.

The epidemic of coronary artery disease continues to affect a large number of individuals who often experience sudden and unexpected events. This underscores the need to develop more effective programs to detect silent atherosclerosis, with the ultimate goal of preventing coronary events. The use of conventional risk factors is helpful in assessing the median risk of a population, but it is often unsatisfactory in estimating the actual risk of an individual patient. As a consequence, newer imaging modalities are being developed to detect atherosclerosis in its early developmental phases. Technologies such as electron-beam computed tomography (EBCT) may render risk stratification more accurate if used in the appropriate patient populations and with the right diagnostic approach. Several studies have already demonstrated the power of coronary calcification as a strong predictor of future cardiovascular events. Nonetheless, the medical literature is currently pervaded by an animated debate, as some investigators still have concerns about the effectiveness of a preventive approach driven by technology. The use of Bayesian models to interpret data acquired with EBCT screening may provide practitioners with valuable evidence to aid in their decision making.

Aggressive versus moderate lipid-lowering therapy in postmenopausal women with hypercholesterolemia: Rationale and design of the Beyond Endorsed Lipid Lowering with EBT Scanning (BELLES) trial.

BACKGROUND: Electron beam tomography (EBT) is a noninvasive technique that allows the study of the entire coronary artery tree during a brief imaging session without the injection of any contrast media. Atherosclerosis is identified vicariously through the visualization of coronary calcific deposits. Quantitative assessments of calcium burden, such as calcium volume scores, have been shown to be a useful means to assess treatment-related changes in the extent of atherosclerotic plaques. Historically, the elderly female population has received less medical recognition regarding the risk and severity of coronary heart disease (CHD). METHODS: In the BELLES (Beyond Endorsed Lipid Lowering with EBT Scanning) trial, the presence of asymptomatic CHD in 600 postmenopausal women will be assessed by EBT. In this 1-year, multicenter, randomized, double-blind, parallel-group study, aggressive lipid-lowering treatment will be compared with moderate lipid-lowering treatment in postmenopausal women with hypercholesterolemia. The hypothesis we will test is that aggressive lipid-lowering therapy with 80 mg/d atorvastatin can produce greater reductions in atherosclerotic plaque burden as assessed by volumetric calcium scores than a moderate treatment with 40 mg/d pravastatin. The primary outcome measure will be the percent change from baseline in total CVS determined by EBT at 12 months. CONCLUSIONS: The results of the BELLES trial will help assess the actual incidence of CHD in postmenopausal women and the relative ability of two different lipid-lowering therapies to halt its progression.

Use of electron beam tomography data to develop models for prediction of hard coronary events.

BACKGROUND: Prediction of hard cardiac events (myocardial infarction and coronary death) remains difficult in spite of the identification of several relevant risk factors for the development of coronary artery disease (CAD). New indicators of risk might add to our predictive ability. We used measures of coronary artery calcification (CAC) found by electron beam tomography (EBT) imaging to develop prediction models for hard cardiac events alone and in association with traditional risk factors for CAD. METHODS: Two groups of patients were studied: group A, 676 asymptomatic patients (mean age 52 years, 51% men) prospectively followed up for 32 +/- 7 months after being referred by primary care physicians for a screening EBT, and group B, 10,122 asymptomatic patients screened by EBT at one center and used as controls for calculation of calcium score nomograms. RESULTS: The occurrence of hard events in group A patients was related to traditional risk factors for CAD, presence of CAC (score >0), Ln (1 + absolute calcium score [CS]), and age- and sex-specific CS percentiles (CS%). Univariate analyses showed that age, smoking, diabetes mellitus, presence of CAC, Ln (1 + absolute CS), and CS% were predictive of hard events (all P <.05). Multiple logistic regression analyses demonstrated that CS% was the only significant predictor of events and provided incremental prognostic value when added to traditional risk factors for CAD (chi-square, P <.001). In a comparison of receiver-operator characteristic curves for prediction of hard events, the area under the curve for CS% plus conventional risk factors and age was significantly larger than that obtained by use of traditional risk factors and age separately as predictors (0.84 vs 0.71, respectively, P <.001). Furthermore, the area under the curve of CS% alone was significantly larger than that of traditional risk factors and age combined (0.82 vs 0.71, P =.028). CONCLUSIONS: Patients are usually selected for EBT screening on the basis of the presence of conventional risk factors for CAD. However, an age- and sex-specific calcium score provides the best predictive model for the occurrence of hard coronary events and adds incremental prognostic information to conventional risk factors for CAD.

Sensitivity of two electron beam tomography protocols for the detection and quantification of coronary artery calcium.

OBJECTIVE: The purpose of this study was to compare the sensitivity of two electron beam tomography protocols for detection and quantification of coronary artery calcium. SUBJECTS AND METHODS: We selected 101 patients (57% men, mean age 53 +/- 10 years) to undergo two consecutive electron beam tomography and acquired imaging with both a 6-mm and a 3-mm slicing protocol. Three pixels (area, 1.03 mm(2)) and a minimal density of 130 H were used for definition of calcified plaque. RESULTS: We found coronary artery calcifications in 46 patients when we used a 6-mm protocol and in 61 patients when we used a 3-mm protocol (p < 0.001). The average total calcium score was 77 (+/-140) with a 6-mm protocol and 251 (+/-395) with a 3-mm protocol (p < 0.005). The average number of calcified lesions per patient was 1.7 for a 6-mm protocol and 3.7 for a 3-mm protocol (p < 0.01). Of 179 individual lesions seen using a 3-mm protocol, 103 (58%) were missed using a 6-mm protocol, and only 27% of the lesions with a calcium score less than or equal to 40 seen with a 3-mm protocol were detected with 6-mm slicing (p < 0.001). The mean lesion attenuation with a 6-mm protocol was 160 (+/-42) H, compared with 218 (+/-44) H with a 3-mm protocol (p < 0.001), indicating a significantly greater partial volume averaging with the former protocol. CONCLUSION: A 6-mm slicing protocol is significantly less sensitive than a 3-mm protocol for the detection and quantification of coronary artery calcium. Since one third of coronary events occur in patients with low calcium scores, a 6-mm protocol might be unreliable for risk assessment because of substantial loss of information in this calcium score range.

Evaluation of chest pain in patients with low to intermediate pretest probability of coronary artery disease by electron beam computed tomography.

Despite its limited sensitivity and specificity in patients with low to intermediate probability of coronary artery disease (CAD), exercise treadmill testing (ETT) is frequently used as the initial test for investigation of chest pain. Although myocardial perfusion imaging is a significantly more accurate test, its added cost to ETT is considerable. The cost of a non-contrast electron beam computed tomography (EBCT) scan is comparable to that of ETT and the calcium score (CS) correlates closely with the volume of atherosclerotic plaque. Therefore, we tested the hypothesis that EBCT might be an effective and cost-beneficial technique for the identification of angiographically obstructive CAD (> or = 50% stenosis) in patients with low to intermediate pretest probability of disease. We calculated the theoretic cost of attaining a diagnosis of CAD based on a Bayesian model that utilizes published sensitivity and specificity levels for ETT, EBCT, and stress myocardial perfusion imaging. We then submitted a cohort of 207 patients with low to intermediate probability of disease both to EBCT and ETT in random order, and estimated the cost of achieving a correct diagnosis by either route based on the number of expected further tests. An EBCT calcium score of 150 was chosen as a cut-point with a sensitivity of 74% and a specificity of 89% for the presence of obstructive CAD. The theoretic Bayesian model predicted substantial cost savings when EBCT was used as the initial test instead of ETT, with decreasing benefit as the prevalence of disease increased (44% saving at 0% prevalence; 15% saving at 100% prevalence). In the patient cohort, the diagnostic pathway starting with EBCT provided a 45% to 65% cost saving over the ETT pathway. We conclude that in patients with low to intermediate pretest probability of disease, a pathway based on EBCT as the initial test to investigate presence of obstructive CAD provides a substantial cost benefit over a pathway based on ETT. Such cost advantages decrease as the prevalence of disease increases.

Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography.

BACKGROUND: There is a clear relationship between absolute calcium scores (CS) and severity of coronary artery disease. However, hard coronary events have been shown to occur across all ranges of CS. METHODS AND RESULTS: We conducted 2 analyses: in group A, 172 patients underwent electron-beam CT (EBCT) imaging within 60 days of suffering an unheralded myocardial infarction. In group B, 632 patients screened by EBCT were followed up for a mean of 32+/-7 months for the development of acute myocardial infarction or cardiac death. The mean patient age and prevalence of coronary calcification were similar in the 2 groups (53+/-8 versus 52+/-9 years and 96% each). In group B, the annualized event rate was 0.11% for subjects with CS of 0, 2.1% for CS 1 to 99, 4.1% for CS 100 to 400, and 4.8% for CS >400, and only 7% of the patients had CS >400. However, mild, moderate, and extensive absolute CSs were distributed similarly between patients with events in both groups (34%, 35%, and 27%, respectively, in group A and 44%, 30%, and 22% in group B). In contrast, the majority of events in both groups occurred in patients with CS >75th percentile (70% in each group). CONCLUSIONS: Coronary calcium is present in most patients who suffer acute coronary events. Although the event rate is greater for patients with high absolute CSs, few patients have this degree of calcification on a screening EBCT. Conversely, the majority of events occur in individuals with high CS percentiles. Hence, CS percentiles constitute a more effective screening method to stratify individuals at risk.

Is mitral valve prolapse due to cardiac entrapment in the chest Cavity? A CT view.

BACKGROUND: Mitral valve prolapse (MVP) is the most frequently diagnosed valvular disease, but its pathophysiology remains elusive. Its complete absence in 1,734 neonatal echocardiographic studies suggests that this may be an acquired rather than a congenital disease. We observed several patients with distorted cardiac and valvular anatomies on electron beam CT (EBCT) images of the chest who reported symptoms reminiscent of MVP. In these patients, the heart is compressed between the spine and the anterior chest wall and it appears trapped in a chest cavity that is too small for its size. METHODS: We performed EBCT in 66 patients with echocardiographically proven MVP and no clinical pectus excavatum (group A; 80% were women; mean age, 48 +/- 12 years) and in 96 control patients without MVP by echocardiography (group B; 72% were women; mean age, 49 +/- 10 years). EBCT alone was also performed on 200 patients who had reported atypical chest discomfort and palpitations to their physicians (group C) and on 200 asymptomatic patients (group D). The EBCT measurements included the following: anteroposterior chest diameter (APD); the angle formed by the confluence of the mitral valve ring with the interatrial septum (ANGLE); and the contact area between the posterior surface of the anterior chest wall and the myocardium (CA). Entrapment was considered present if the individual patient's measurements varied by more than two SDs compared to measurements made in control subjects (group B). RESULTS: EBCT images demonstrated cardiac entrapment in 82% of group A patients and in 4.2% of group B patients (p < 0.001). ANGLE and CA were significantly larger in MVP patients than in group B patients (114 +/- 9 degrees vs 91 +/- 5 degrees and 6,230 +/- 2,020 mm(2) vs 476 +/- 1,009 mm(2), respectively; p < 0.001 for both comparisons), while APD was significantly smaller (91 +/- 16 mm vs 128 +/- 17 mm, respectively; p < 0.001). The prevalence of entrapment was significantly greater in group C patients than in group D patients (22% vs 6.5%; p < 0. 001). CONCLUSIONS: MVP may be an acquired condition caused by a growth disproportion between the heart and the chest cavity, with distortion of the mitral valve annulus and subsequent leaflet prolapse. A narrow APD, a wide ANGLE, and a large CA characterize this condition. Similar findings are found in a sizable proportion of patients with atypical chest pain symptoms and palpitations.

Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography.

BACKGROUND: Angiographic studies of the regression of coronary artery disease are invasive and costly, and they permit only limited assessment of changes in the extent of atherosclerotic disease. Electron-beam computed tomography (CT) is noninvasive and inexpensive. The entire coronary-artery tree can be studied during a single imaging session, and the volume of coronary calcification as quantified with this technique correlates closely with the total burden of atherosclerotic plaque. METHODS: We conducted a retrospective study of 149 patients (61 percent men and 39 percent women; age range, 32 to 75 years) with no history of coronary artery disease who were referred by their primary care physicians for screening electron-beam CT. All patients underwent base-line scanning and follow-up assessment after a minimum of 12 months (range, 12 to 15), and a volumetric calcium score was calculated as an estimate of the total burden of plaque. Treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors was begun at the discretion of the referring physician. Serial measurements of low-density lipoprotein (LDL) cholesterol were obtained, and the change in the calcium-volume score was correlated with average LDL cholesterol levels. RESULTS: One hundred five patients (70 percent) received treatment with HMG-CoA reductase inhibitors, and 44 patients (30 percent) did not. At follow-up, a net reduction in the calcium-volume score was observed only in the 65 treated patients whose final LDL cholesterol levels were less than 120 mg per deciliter (3.10 mmol per liter) (mean [+/-SD] change in the score, -7+/-23 percent; P=0.01). Untreated patients had an average LDL cholesterol level of at least 120 mg per deciliter and at the time of follow-up had a significant net increase in mean calcium-volume score (mean change, +52+/-36 percent; P<0.001). The 40 treated patients who had average LDL cholesterol levels of at least 120 mg per deciliter had a measurable increase in mean calcium-volume score (25+/-22 percent, P<0.001), although it was smaller than the increase in the untreated patients. CONCLUSIONS: The extent to which the volume of atherosclerotic plaque decreased, stabilized, or increased was directly related to treatment with HMG-CoA reductase inhibitors and the resulting serum LDL cholesterol levels. These changes can be determined noninvasively by electron-beam CT and quantified with use of a calcium-volume score.

Coronary artery disease: improved reproducibility of calcium scoring with an electron-beam CT volumetric method.

PURPOSE: To assess the variability and reproducibility of a volumetric calcium score calculated with electron-bean computed tomographic (CT) scans of coronary arteries. MATERIALS AND METHODS: Two sets of electron-beam CT scans were obtained in patients with coronary calcification (group A) or known risk factors for coronary arterial disease (group B). The second set or scans was obtained after a brief interval (group A, n = 52) or after 1 year with no risk modification (group B, n = 27). Traditional (plaque area and attenuation) and volumetric calcium scores were calculated for each patient and lesion. RESULTS: The median percentage change for individual lesions in group A was 13% for the volumetric and 19% for the traditional score. The overall reduction in error with the volumetric score was 40% (P < .001). The median percentage change for group A patient totals was 9% for the volumetric and 15% for the traditional score (P < .001). In group B patients, the median volumetric score increased by 44% after 1 year. CONCLUSION: The volumetric score showed better reproducibility than the traditional score, and its variability was considerably less than the score increase in untreated patients after 1 year. The reproducibility of the volumetric method makes it useful for assessing the progression of coronary arterial disease on serial electron-beam CT studies.

Biochemical and behavioral effects of a sensorimotor cortex injury in rats pretreated with the noradrenergic neurotoxin DSP-4.

The role of the noradrenergic (NE) system in recovery of motor function after sensorimotor cortex (SMCX) injury was investigated. After training on a beam-walking task to assess changes in motor function, animals were given DSP-4 or saline and tested for 2 weeks; both groups then received unilateral SMCX suction ablations. Animals that received DSP-4 were significantly retarded in motor recovery compared with the saline group. At 24 days after injury (after motor recovery), the animals' deficits were significantly reinstated with NE-blocking drugs. DSP-4 significantly depressed NE levels in the hippocampus and cerebellum. A Timm histochemical analysis revealed glutamatergic sprouting in the hippocampus of animals that were pretreated with DSP-4, which suggests the possibility that similar glutamatergic plasticity in other pathways may occur and that excitotoxicity might also play a role after the DSP-4 induced NE deafferentation.