Economic analysis of the use of coronary calcium scoring as an alternative to stress ECG in the non-invasive diagnosis of coronary artery disease.

OBJECTIVE: To conduct an economic analysis (EA) of coronary calcium scoring (CCS) using a 0 score, as alternative to stress electrocardiography (sECG) in diagnosing coronary artery disease (CAD). METHOD: A decision tree was constructed to compare four strategies for investigation of suspected CAD previously assessed in the formulation of clinical guidelines for the United Kingdom (UK) to two new strategies incorporating CCS. Sensitivity (96%; 95% CI 95.4-96.4%) and specificity (40%; 95% CI 38.7-41.4%) values for CCS were derived from a meta-analysis of 10,760 patients. Other input variables were obtained from a previous EA and average prices for hospital procedures in the UK. A threshold of £30,000/Quality-adjusted Life Year (QALY) was considered cost-effective. RESULTS: Using net monetary benefit calculations, CCS-based strategies were found to be cost-effective compared to sECG equivalents at all assessed prevalence of CAD. Using CCS prior to myocardial perfusion scintigraphy (MPS) and catheter angiography (CA) was found to be cost-effective at pre-test probabilities (PTP) below 30%. CONCLUSIONS: Adoption of CCS as an alternative to sECG in investigating suspected stable angina in low PTP population (<30%) would be cost-effective. In patients with PTP of CAD >30%, proceeding to MPS or CA would be more cost-effective than performing either CCS or sECG. KEY POINTS: Coronary calcium scoring (CCS) is useful for assessing coronary artery atherosclerosis It can be performed with multi-detector CT, which is now widely available It plays a role in excluding disease in suspected stable angina Our study assesses its role in this setting as alternative to stress-ECG Adoption of CCS as an alternative to sECG could prove cost-effective.

St. Louis Encephalitis Virus in the Southwestern United States: A Phylogeographic Case for a Multi-Variant Introduction Event.

Since the reemergence of St. Louis Encephalitis (SLE) Virus (SLEV) in the Southwest United States, identified during the 2015 outbreak in Arizona, SLEV has been seasonally detected within Culex spp. populations throughout the Southwest United States. Previous work revealed the 2015 outbreak was caused by an importation of SLEV genotype III, which had only been detected previously in Argentina. However, little is known about when the importation occurred or the transmission and genetic dynamics since its arrival into the Southwest. In this study, we sought to determine whether the annual detection of SLEV in the Southwest is due to enzootic cycling or new importations. To address this question, we analyzed 174 SLEV genomes (142 sequenced as part of this study) using Bayesian phylogenetic analyses to estimate the date of arrival into the American Southwest and characterize the underlying population structure of SLEV. Phylogenetic clustering showed that SLEV variants circulating in Maricopa and Riverside counties form two distinct populations with little evidence of inter-county transmission since the onset of the outbreak. Alternatively, it appears that in 2019, Yuma and Clark counties experienced annual importations of SLEV that originated in Riverside and Maricopa counties. Finally, the earliest representatives of SLEV genotype III in the Southwest form a polytomy that includes both California and Arizona samples. We propose that the initial outbreak most likely resulted from the importation of a population of SLEV genotype III variants, perhaps in multiple birds, possibly multiple species, migrating north in 2013, rather than a single variant introduced by one bird.

Bloodmeal Host Selection of Culex quinquefasciatus (Diptera: Culicidae) in Las Vegas, Nevada, United States.

St. Louis encephalitis virus (SLEV) and West Nile virus (WNV) have recently emerged in the southwestern United States. Surveillance for arboviruses in Las Vegas, NV, detected a surge of SLEV activity in the southern house mosquito (Culex quinquefasciatus Say) during 2016. To identify candidate avian amplifiers, we assessed the identification, viral infection, and immune status of vertebrate hosts for 195 blood-engorged Cx. quinquefasciatus mosquitoes collected in August and September 2016. Bloodmeals were identified from 164 engorged abdomens, representing 19 species of birds and three species of mammals. No SLEV or WNV viremia was detected, but one mosquito tested positive for Culex flavivirus. House finch (Haemorhous mexicanus) (Muller) was the most common bloodmeal, followed by domestic chicken (Gallus gallus) (Linnaeus), American robin (Turdus migratorius) L., house sparrow (Passer domesticus) (L.), great-tailed grackle (Quiscalus mexicanus) (Gmelin), northern mockingbird (Mimus polyglottos) (L.) and mourning dove (Zenaida macroura) (L.). SLEV-reactive antibodies were detected in six identified bloodmeals and WNV-reactive antibodies were detected in 33. House sparrow and house finch were the most likely hosts to show previous exposure to SLEV and WNV, respectively. Over-utilization by Cx. quinquefasciatus for bloodmeal hosts was observed primarily among robin, finch and sparrow, all species that roost communally. House finch stands out as a candidate important amplifier for both SLEV and WNV because of its preference by mosquito vectors, and high competence for closely related virus strains. While implicated in previous outbreaks as an important mosquito vector, Cx. quinquefasciatus feeds infrequently on mammals in Las Vegas, indicating a low risk for bridge transmission to humans.

Origin of Aedes aegypti In Clark County, Nevada.

Aedesaegypti is the primary vector for serious diseases, including those caused by chikungunya, dengue, and Zika viruses. In 2017, the Southern Nevada Health District first detected this invasive species in Clark County, NV, including in the city of Las Vegas. We analyzed Ae. aegypti from the city of North Las Vegas to determine the likely source of the invasion. We genotyped a sample of Ae. aegypti at 12 highly variable microsatellites and analyzed the data in reference to published data from 25 sites in the southern USA. We found that the Ae. aegypti in Las Vegas most likely invaded from southern California. Knowing the source of new invasions may provide information about the invading population (e.g., previous insecticide exposure) and can help prevent future invasions from the region.

Aortic root abscess: multimodality imaging with computed tomography and gallium-67 citrate single-photon emission computed tomography/computed tomography hybrid imaging.

Culture negative endocarditis and aortic root abscess can prove difficult diagnostic challenges. Computed tomography can be extremely useful in this setting. We report a case of an aortic root abscess 3 months after elective aortic valve replacement in which cardiac CT and hybrid imaging with Gallium-67 SPECT complemented workup with transesophageal echocardiography in establishing the diagnosis of an abscess.

Brachial neuritis caused by varicella-zoster diagnosed by changes in brachial plexus on MRI.

Brachial neuritis is a rare disorder affecting the brachial plexus. It is characterized by the acute onset of shoulder and arm pain followed by weakness, sensory loss and atrophy. Diagnosis is essentially clinical with electrophysiological investigations and imaging useful in excluding other differentials and supporting the diagnosis. Magnetic resonance imaging (MRI) usually does not show any pathology in the brachial plexus or spinal cord. We present a case of a patient who had brachial neuritis preceded by varicella zoster infection. This was supported by MRI which showed abnormal signal consistent with inflammatory changes in the brachial plexus.

A33 antigen displays persistent surface expression.

The A33 antigen is a cell surface glycoprotein of the small intestine and colonic epithelium with homology to tight junction-associated proteins of the immunoglobulin superfamily, including CAR and JAM. Its restricted tissue localization and high level of expression have led to its use as a target in colon cancer immunotherapy. Although the antigen is also present in normal intestine, radiolabeled antibodies against A33 are selectively retained by tumors in the gut as well as in metastatic lesions for as long as 6 weeks. Accordingly, we have studied the trafficking and kinetic properties of the antigen to determine its promise in two-step, pretargeted therapies. The localization, mobility, and persistence of the antigen were investigated, and this work has demonstrated that the antigen is both highly immobile and extremely persistent-retaining its surface localization for a turnover halflife of greater than 2 days. In order to explain these unusual properties, we explored the possibility that A33 is a component of the tight junction. The simple property of surface persistence, described here, may contribute to the prolonged retention of the clinically administered antibodies, and their uncommon ability to penetrate solid tumors.