Interobserver variability in upgraded and non-upgraded BI-RADS 3 lesions.

AIM: To evaluate interobserver variability in the assessment of Breast Imaging-Reporting and Data System (BI-RADS) 3 mammographic lesions, and to determine if the initial evaluation of upgraded BI-RADS 3 lesions was appropriate. MATERIALS AND METHODS: Retrospective review of the mammography database (1/1/2004-12/31/2008) identified 1,188 screen-detected BI-RADS 3 lesions, 60 (5.1%) were upgraded to BI-RADS 4/5 during surveillance (cases). Cases were matched to 60 non-upgraded BI-RADS 3 lesions (controls) by lesion type, laterality, and year. Available studies were assessed separately by two radiologists blinded to outcomes. RESULTS: Eighty-two studies were available (43 cases, eight malignancies, and 39 controls). Reader 1 assessed 18/82 (22%) as BI-RADS 0, 13 cases, five controls; 35/82 (42.7%) as BI-RADS 2, 11 cases, 24 controls; 7/82 (8.5%) BI-RADS 3, four cases, three controls; 22/82 BI-RADS 4, 15 cases, seven controls. Reader 2 assessed 8/82 (9.8%) as BI-RADS 0, four cases, four controls; 27 (32.9%) BI-RADS 2, 11 cases, 16 controls; 33 (40.2%) BI-RADS 3, 19 cases, 14 controls; 14 (17%) BI-RADS 4, nine cases, five controls. For cancers, reader 1 assessed two BI-RADS 0, one BI-RADS 2, one BI-RADS 3, and four BI-RADS 4; reader 2 assessed two BI-RADS 2, four BI-RADS 3, and two BI-RADS 4. Reasons for BI-RADS 0 assessment included incomplete mammographic views, lack of ultrasound, and failure to include the lesion on follow-up imaging. Reasons for BI-RADS 4 assessment included suspicious morphology or instability. CONCLUSION: There is much interobserver variability in the assessment of BI-RADS 3 lesions. Many BI-RADS 3 lesions were judged as incompletely evaluated on blinded review.

Computerized acoustic cardiography correlates with echocardiography and invasive haemodynamics after percutaneous transvenous mitral commissurotomy.

BACKGROUND: Rheumatic mitral stenosis severity has been assessed by the systolic time interval between the QRS onset and the first heart sound (QS1) by phonocardiography. We hypothesized that non-invasive computerized acoustic cardiography could evaluate mitral stenosis severity compared with echocardiography and invasive haemodynamics in patients undergoing percutaneous transvenous mitral commissurotomy (PTMC). METHODS: 27 patients underwent computerized acoustic cardiography, echocardiography, and invasive haemodynamic measurements prior to and after PTMC. RESULTS: The mean age was 31 ± 10 years, and 21 (78%) were female. By echocardiography, mitral valve area increased from 0.82 ± 0.14 to 1.50 ± 0.24 cm(2) (p < 0.0001). The QS1 interval decreased from 101.7 ± 12.9 to 93.2 ± 9.2 ms (p < 0.0001). The change in the QS1 interval correlated with the change in mitral valve area by echocardiography (p = 0.037), right ventricular systolic pressure (p < 0.0001), and the invasive mitral valve gradient (p = 0.076). CONCLUSIONS: Acoustic cardiography may be used as an adjunctive non-invasive diagnostic tool to assess mitral stenosis severity.

Use of a percutaneous arterial suture device (Perclose) in patients undergoing percutaneous balloon aortic valvuloplasty.

Percutaneous balloon aortic valvuloplasty has been used as a therapeutic option for patients with severe aortic stenosis who are not candidates for aortic valve replacement. This procedure has been limited by both the high rate of aortic valve restenosis and high procedural morbidity related chiefly to the large femoral arteriotomies required. The purpose of this study was to assess the feasibility and vascular complication rate using the "Preclose" technique in patients undergoing balloon aortic valvuloplasty. We evaluated the immediate and 30-day results in 18 consecutive patients undergoing this procedure. Angiographically significant peripheral vascular disease was present in 39% of cases. Aortic balloon dilation produced significant decreases in the mean aortic valve pressure gradient from 55 +/- 20 mmHg to 30 +/- 22 mmHg (P < 0.001). Closure of the arteriotomy with an 8F (10F in 1 case) Perclose device led to immediate hemostasis in all patients. Perclose of the contralateral femoral arterial site with a 6F device was attempted in 50%, all of which were successful. The mean length of bed rest was 4.5 +/- 0.9 hr. No procedural was observed. No patient had a local vascular complication, and no patient required blood product transfusion after the procedure. The use of the "Preclose" technique for closure of femoral arteriotomies after balloon aortic valvuloplasty is feasible and associated with a low rate of periprocedural and short-term vascular complications.

Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation?: Data from the International EECP Patient Registry (IEPR).

BACKGROUND: Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of EECP are maximized when the ratio of diastolic to systolic pressure area is in the range of 1.5 to 2.0. HYPOTHESIS: It is hypothesized that patients undergoing EECP who are able to achieve higher diastolic augmentation (DA) ratios may derive greater clinical benefit. This study examines the relationship between the DA ratio and clinical outcomes in patients undergoing EECP. METHODS: We analyzed demographic, noninvasive hemodynamic, and clinical outcome data on 1,004 patients enrolled in the International EECP Patient Registry (IEPR) for treatment of chronic angina between January 1998 and August 1999. Blood pressure waveforms were recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview. RESULTS: At the end of EECP treatment, 370 (37%) patients had a higher DA ratio (defined as > or = 1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age > or =65 years (p <0.001), female gender (p < 0.001), left ventricular ejection fraction < 35% (p < 0.05), hypertension (p < 0.01), prior coronary bypass surgery (p < 0.01), noncardiac vascular disease (p < 0.001), multivessel disease (p < 0.01), congestive heart failure (p < 0.01), current smoking (p < 0.01), unsuitability for further revascularization (p < 0.001), and higher baseline angina class (p < 0.001). There were no significant differences regarding diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication use between patients with higher or lower DA ratios. Based on a multiple logistic regression model, independent predictors of a DA ratio < 1.5 at the end of EECP included current smoking (odds ratio 3.3; 95% confidence intervals 2.0-5.4); multivessel disease (1.7; 1.3-2.3); female gender (2.2; 1.7-3.0); no prior EECP (1.9; 1.1-3.3); noncardiac vascular disease (2.3; 1.7-2.9); age > or = 65 years (1.7; 1.4-2.2), and patients not suitable for revascularization (1.6; 1.2-2.0). By the end of therapy, there were no significant differences in myocardial infarction, revascularization rates, or nitroglycerin use with respect to higher DA ratios. At 6-month follow-up, patients with higher DA had a trend toward a greater reduction in angina class compared with those with lower DA (p = 0.069). There was a significantly higher rate of unstable angina and congestive heart failure in the group not achieving higher augmentation (p < 0.05). CONCLUSIONS: Patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have higher DA with EECP. Patients with higher DA tended to have a greater reduction in angina class at 6-month follow-up compared with those with lower DA ratios. There is evidence that higher DA ratios are associated with improved short- or long-term clinical outcomes, suggesting that clinical benefit from EECP is associated with the magnitude of DA.

Traditional injury scoring underestimates the relative consequences of orthopedic injury.

OBJECTIVE: To demonstrate that patients with multiple injuries who have orthopedic injuries (ORTHO) face greater challenges regarding functional outcome than those without, to identify domains of postinjury dysfunction, and to illustrate the increasing discordance of functional recovery over time for ORTHO patients in relation to nonORTHO patients. METHODS: A convenience sample of adult blunt force trauma patients admitted to a Level I trauma center was evaluated at admission, and at 6 and 12 months after injury. Data were collected from the trauma registry (Trauma One), chart review, and interviews. Mailed surveys were completed 6 and 12 months after injury. The Short Form 36 (SF36) general health survey and the Sickness Impact Profile work scale (SIPw) were administered at both time points. Data are presented as mean +/- SEM or percent (%). To compare means, t tests were conducted, and Injury Severity Score (ISS) was controlled by linear regression before the evaluation of the role of ORTHO injury pattern on outcome measures. Significance is noted at the 95% confidence level (p < 0.05). RESULTS: The 165 patients studied averaged 37.2 +/- 1.1 years in age and were 67% men. The mean ISS was 14.4 +/- 0.6 and 61% had ORTHO injury. ORTHO patients were no different from nonORTHO in any measure of baseline status including the SIPw score and all domains of the SF36, except that the ISS was greater in the ORTHO group (15.6 +/- 0.96 vs. 12.7 +/- 0.73, p = 0.017). Baseline SF36 values were similar to national norms. Follow-up was 75% at 6 months, and 51% at 12 months. Those lost to follow-up differed only in that they were more likely to be men. Sixty-four percent had returned to work 12 months after injury. After controlling for ISS with linear regression, the ORTHO patients had worse scores on all physical measures of the SF36 (bodily pain, physical function, and role-physical). By 12 months after injury, the relative dysfunction of the ORTHO patients had expanded to include the SIPw score (p = 0.016) and six of eight SF36 domains (bodily pain, physical function, role-physical, mental health, role-emotional, and social function, all p < 0.05). CONCLUSION: Injury severity affects both mortality and the potentially more consequential issues of long-term morbidity. Patients with ORTHO injury have relatively worse functional recovery, and this worsens with time. As trauma centers approach the limits of achievable survival, new advances in trauma care can be directed more toward the quality of recovery for our patients. This will be contingent on further development of screening, scoring, and treatment systems designed to address issues of functional outcome across injury boundaries for those who survive.

Microvascular dysfunction in acute myocardial infarction: focus on the roles of platelet and inflammatory mediators in the no-reflow phenomenon.

Recent interest has shifted from infarct artery patency to microvascular perfusion in the evaluation of patients with acute myocardial infarction (AMI). Microvascular dysfunction occurs in a substantial proportion of patients, despite aggressive therapy with thrombolytic agents and/or percutaneous mechanical revascularization techniques. Patients with impaired microvascular perfusion after immediate reperfusion therapy have an adverse clinical prognosis. Recent studies have extended our understanding of the pathophysiology of this so-called no-reflow phenomenon, focusing on the critical roles of platelet and inflammatory mediators leading to microvascular obstruction and reperfusion injury. Moving beyond the Thrombolysis in Myocardial Infarction (TIMI) flow grade system, new techniques have been developed to assess microvascular perfusion, including TIMI frame counting, angiographic myocardial perfusion grading, myocardial contrast echocardiography, Doppler flow wire studies, nuclear scintigraphy, and magnetic resonance imaging. Armed with a greater understanding of the primary mediators of microvascular dysfunction, these tools may identify improved therapy directed at optimizing myocardial perfusion in patients with AMI.

Intracoronary measurement of pulsus alternans.

Pulsus alternans is typically found in patients with left ventricular systolic dysfunction. We describe a woman with biventricular systolic dysfunction and pulsus alternans in the right ventricle, pulmonary artery, and aorta. Coronary angiography revealed an intermediate stenosis in the proximal left anterior descending (LAD) coronary artery. Pulsus alternans was demonstrated in the mid LAD using a 0.014" guidewire-mounted pressure sensor. An abnormal fractional flow reserve was measured in the LAD. Cathet. Cardiovasc. Intervent. 51:335-338, 2000.

Effects of the repeated administration of adenosine and heparin on myocardial perfusion in patients with chronic stable angina pectoris.

The mechanism by which ischemia stimulates angiogenesis is unknown. Adenosine is released during myocardial ischemia and may be a mediator of this process. Experimental data suggest that heparin may enhance this effect. The purpose of this open-labeled, placebo-controlled trial was to determine whether repeated intravenous administration of adenosine and heparin could mimic physiologic angiogenesis and reduce the amount of exercise-induced myocardial ischemia in patients with coronary artery disease. Subjects with chronic stable angina refractory to conventional medical therapy and not suitable for revascularization received either adenosine (140 microg/kg/min for 6 minutes) and heparin (10,000 U bolus), (n = 14), or placebo, (n = 7) daily for 10 days. All patients underwent baseline and follow-up exercise testing with thallium-201 single-photon emission computed tomography myocardial perfusion imaging. A semiquantitative assessment of the extent and severity of the perfusion abnormalities was calculated by 2 blinded investigators. There was no significant change in exercise duration or in the peak heart rate systolic blood pressure product associated with adenosine and heparin compared with placebo treatment. There was, however, a 9% reduction in the extent (60.6 +/- 4.0 vs 54.9 +/- 4.1, p = 0.03) and a 14% improvement in severity (41.5 +/- 3.2 vs 35.7 +/- 2.9, p = 0.01) of the myocardial perfusion abnormalities seen in patients who received adenosine and heparin compared with placebo. Thus, in this pilot study, repeated administration of adenosine and heparin reduced the amount of exercise-induced ischemia in patients with chronic stable angina refractory to conventional treatment.

Prophylactic vena caval filters in trauma: the rest of the story.

OBJECTIVE: The purpose of this study was to describe outcomes for patients with trauma who had vena caval filters placed in the absence of venous thromboembolic disease (group P) and compare them with outcomes for patients with trauma who had filters placed after either deep venous thrombosis or pulmonary embolism (group T). DESIGN: The study is a case series of consecutive patients who received vena caval filters after traumatic injury. Data were collected prospectively at the time of filter placement from reports of diagnostic studies obtained for clinical indications and during the annual follow-up examinations. Event rate findings are based on objective tests. Data were obtained from the Michigan Vena Cava Filter Registry. RESULTS: Filters were placed in 385 patients with trauma; 249 of these filters were prophylactic (group P). Event rates were similar in the two groups. New pulmonary embolism was diagnosed in 1.5% of the patients in group P and 2% of the patients in group T. Caval occlusion rates were 3.5% for group P and 2.3% for group T. In all, 15.6% of the patients in group P had deep venous thrombosis or pulmonary embolism after placement. The frequencies of lower extremity swelling and use of support hose were higher in group T than in group P (43% vs 25% and 25% vs 3.5%, respectively; P <.005). Outcomes were comparable in the two groups with respect to mechanical stability of the filter. CONCLUSIONS: The prophylactic indication for vena caval filter placement in patients with trauma is associated with a low incidence of adverse outcomes while providing protection from fatal pulmonary embolism. The current challenge is to limit the number of unnecessary placements through improved methods of risk stratification.

Outcome from injury: general health, work status, and satisfaction 12 months after trauma.

OBJECTIVE: We evaluated outcomes 12 months after trauma in terms of general health, satisfaction, and work status. METHODS: Two hundred forty-seven patients without severe neurotrauma were evaluated by interview during admission and by mailed self-report 6 and 12 months after trauma. Data were obtained from the Trauma Registry, interviews, and survey instruments. Baseline assessment was obtained with the Short Form 36 (SF36) and the Sickness Impact Profile (SIP) work scale. Outcome measures were the SF36, SIP work scale, Brief Symptom Inventory (BSI) depression scale, the Civilian Mississippi Scale for Posttraumatic Stress Disorder (PTSD), and a satisfaction questionnaire. Three regressions were determined for outcome. The dependent variables were general health and work status (linear) and satisfaction (logistic). Each regression controlled for baseline status and mental health, Injury Severity Score (ISS), and 12-month SF36 physical function before evaluating the effect of outcome mental health. RESULTS: Follow-up data were available for 75% of the patients at 6 months and 51% at 12 months. The mean age of patients was 37.2 +/- 0.9 years (+/-SEM), and 73% were male. Their average ISS was 13.9 +/- 0.6. Seventy percent of injuries were blunt force, 13.5 % were penetrating, and 16.5 % were burn injuries (mean total body surface area, 13.3 +/- 1.5%). Sixty-four percent of the patients had returned to work at 12 months. Follow-up SF36 mental health was associated with the dependent outcome in each regression. After controlling for baseline status and mental health, ISS, and outcome SF36 physical function, outcome mental health was associated with outcome SF36 general health (p < 0.001), SIP work status (p = 0.017), and satisfaction with recovery (p = 0.005). Outcome SF36 mental health was related to baseline mental health, 12-month PTSD and BSI depression scores, and increased drug and alcohol use. CONCLUSIONS: Twelve months after trauma, patients' work status, general health, and overall satisfaction with recovery are dependent on outcome mental health. This dependency persists despite measured baseline status, ISS, or physical recovery. The mental disease after trauma is attributable to poor mental health, the development of symptoms of PTSD and depression, and increased substance abuse. Trauma centers that fail to recognize, assess, and treat these injury-related mental health outcomes are not fully assisting their patients to return to optimal function.

Risk stratification after acute myocardial infarction in the reperfusion era.

Historically, risk stratification for survivors of acute myocardial infarction (AMI) has centered on 3 principles: assessment of left ventricular function, detection of residual myocardial ischemia, and estimation of the risk for sudden cardiac death. Although these factors still have important prognostic implications for these patients, our ability to predict adverse cardiac events has significantly improved over the last several years. Recent studies have identified powerful predictors of adverse cardiac events available from the patient history, physical examination, initial electrocardiogram, and blood testing early in the evaluation of patients with AMI. Numerous studies performed in patients receiving early reperfusion therapy with either thrombolysis or primary angioplasty have emphasized the importance of a patent infarct related artery for long-term survival. The predictive value of a variety of noninvasive and invasive tests to predict myocardial electrical instability have been under active investigation in patients receiving early reperfusion therapy. The current understanding of the clinically important predictors of clinical outcomes in survivors of AMI is reviewed in this article.

Posttraumatic stress disorder in injured adults: etiology by path analysis.

OBJECTIVE: Posttraumatic Stress Disorder (PTSD) impairs outcome from injury. We present a path analysis of factors related to the development of PTSD in injured adults. METHODS: A prospective cohort of 250 patients without severe neurotrauma was evaluated by interview during admission and by mailed self-report 6 months later. Data were gathered from the trauma registry (age, injury mechanism, and Injury Severity Score), social history (gender, income, education, and social support), and survey instruments. Baseline assessment used the Michigan Critical Events Perception Scale (peritraumatic dissociation and subjective threat to life), the Life Experience Survey (stressful exposure history), and the SF36 (general and mental health). PTSD at 6 months was identified with the civilian Mississippi Scale for PTSD. Data are listed as mean +/- SEM or percent (%). Path analysis was conducted by linear regression and significant (p<0.05) variables are shown. Factors are listed with the standardized beta. A negative beta suggests a protective effect. RESULTS: The 176 patients (72%) who completed the 6-month follow-up were 37.7+/-0.88 years old; 75% were men; and blunt (70%), penetrating (13.5%), and burn (16.4%) mechanisms caused the injuries. Assault was involved in 14.5% of the cases. Average income was $44,300+/-2,700/yr, education was 13.0+/-0.15 years, and Injury Severity Score was 13.9+/-0.50. A total of 42.3% of the patients developed PTSD. The 39.7% of the variance in PTSD explained by the model was due to intentional injury (beta = 0.27), male gender (beta = -0.21), age (beta = -0.20), peritraumatic dissociation (beta = 0.174), baseline mental health (beta = -0.21), and prior life-threatening illness (beta = -0.29). Peritraumatic dissociation was due to the patient's sense of threat to life (beta = -0.47), and threat was related to Injury Severity Score (beta = 0.2), assault(beta = 0.14), education (beta = -0.15), and age (beta = -0.19). Baseline SF36 mental health was related to social support (beta = 0.27) and income (beta = 0.21). Income was contingent on education (beta = 0.21). CONCLUSION: PTSD occurred in 42.3% of injured adults 6 months after trauma and was related to assault, dissociation, female gender, youth, poor mental health, and prior illness. By modeling PTSD, we may learn more of the etiology, risk stratification, and potentials for the treatment of this common and important morbidity of injury.

Early use of ACE inhibitors in the treatment of acute myocardial infarction in the United States: experience from the National Registry of Myocardial Infarction 2. National Registry of Myocardial Infarction 2 participants.

This study was undertaken to examine recent trends in the use of angiotensin-converting enzyme (ACE) inhibitors within 24 hours of admission in patients hospitalized for acute myocardial infarction (AMI) and to identify clinical factors associated with ACE inhibitor-prescribing patterns. Demographic, procedural, and acute medication use from 202,438 patients with AMI were collected at 1,470 US hospitals participating in the National Registry of Myocardial Infarction 2 from June 1994 through June 1996. Acute ACE inhibitor use increased from 14.0% in 1994 to 17.3% in 1996. After controlling for all important clinical variables, we found that there was a significant increase in the odds of acute ACE inhibitor treatment over time (odds ratio [OR]1.07 for each 180-day period; 95% confidence intervals [CI] 1.06 to 1.08; p<0.0001). Univariate data suggested that patients treated acutely with ACE inhibitors tended to be older (70.9 vs. 67.2 years) and had lower rates of in-hospital mortality (8.8% vs. 11.0%). Independent predictors of receiving an ACE inhibitor acutely included anterior wall infarction (OR 1.36; 95% CI 1.32 to 1.40), Killip class 2 or 3 (OR 1.77; 95% CI 1.72 to 1.83), prior myocardial infarction (OR 1.33; 95% CI 1.30 to 1.37), prior history of congestive heart failure (OR 1.88; 95% CI 1.82 to 1.95), and diabetes mellitus (OR 1.34; 95% CI 1.30 to 1.38). Physicians are prescribing ACE inhibitors acutely in patients with AMI with increasing frequency. Patients with evidence of congestive heart failure and those with anterior myocardial infarction have the greatest expected benefit from such therapy, and these persons receive such treatment most often. However, most patients hospitalized with AMI do not receive this potentially life-saving therapy.

Posttraumatic stress disorder after injury: impact on general health outcome and early risk assessment.

OBJECTIVE: To evaluate prospectively components of general health outcome after trauma and to report on the further validation of the Michigan Critical Events Perception Scale (MCEPS), an instrument that predicts increased risk for posttraumatic stress disorder (PTSD). METHODS: Adults without neurologic injury admitted to a Level I trauma center in 1997 were interviewed during hospitalization. Baseline data included demographics, injury mechanism, Injury Severity Score, the Short Form 36 (SF36), and the MCEPS, which measures peri-traumatic dissociation (the sense of depersonalization or derealization during an injury event). Surveys sent by mail and completed 6 months later included the SF36 and civilian Mississippi Scale for PTSD. RESULTS: A total of 140 patients were interviewed; the 70% (n = 100 patients) who completed the 6-month assessment form the study group. Injuries were categorized as 71% blunt, 13% penetrating, and 16% burn. Mean Injury Severity Score was 13.7+/-0.52. PTSD at 6 months occurred in 42% of the patients and was directly related to MCEPS dissociation (p = 0.001; odds ratio = 3.1; 95% confidence interval, 1.6, 5.9). A stepwise linear regression explains 40% of the variance in 6-month SF36 general health outcome (adjusted R2 = 0.402). The model controls for individual factors related to dissociation, PTSD, and general health outcome. Development of PTSD was independently and inversely related to general health outcome as measured by the SF36 at 6 months (p < 0.001, beta = -0.404). The R2 change of 0.132 for PTSD (vs. 0.082 for 6-month physical function) illustrates that PTSD contributes more to the patient's perceived general health at 6 months than the degree of physical function or injury severity. CONCLUSIONS: Within hours of injury, the MCEPS identifies patients who are three times more likely to develop PTSD. PTSD compromises self-reported general health outcome in injured adults independent of baseline status, Injury Severity Score, or degree of physical recovery. These data suggest that psychological morbidity is an important part of the patient's perceived general health.