Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals

Background

Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.

Methods

From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1–49%, 50–69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) – inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) – and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.

Results

Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61–3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75–3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09–1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18–2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29–2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05–1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).

Conclusion

For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.     

Functional balance assessment in recreational college-aged individuals with a concussion history

Objectives

Despite evidence for increased musculoskeletal injury after concussion recovery, there is a lack of dynamic balance assessments that could inform management and research into this increased injury risk post-concussion. Our purpose was to identify tandem gait dynamic balance deficits in recreational athletes with a concussion history within the past 18-months compared to matched controls.

Syringomyelia after decompressive laminectomy for cervical spondylosis

We describe a case of cervical spondylotic myelopathy in which deterioration occurred a month after decompressive laminectomy. Syringomyelia was then in evidence as seen by myelography and delayed metrizamide computed tomography scanning. The etiology of this finding and its possible relation to the course and treatment of cervical spondylotic myelopathy are discussed.     

Replication-competent Lentivirus Analysis of Clinical Grade Vector Products

Lentiviral vectors are now in clinical trials for a variety of inherited and acquired disorders. A challenge for moving any viral vector into the clinic is the ability to screen the vector product for the presence of replication-competent virus. Assay development for replication-competent lentivirus (RCL) is particularly challenging because recombination of vector packaging plasmids and cellular DNA leading to RCL has not been reported with the current viral vector systems. Therefore, the genomic structure of a RCL remains theoretical. In this report, we describe a highly sensitive RCL assay suitable for screening vector product and have screened large-scale vector supernatant, cells used in vector production, and cells transduced with clinical grade vector. We discuss the limitations and challenges of the current assay, and suggest modifications that may improve the suitability of this assay for screening US Food and Drug Administration (US FDA)-licensed products.     

Improving recognition of psychiatric disorders in a primary care practice

A high percentage of patients who seek care from primary care physicians have a psychiatric disorder, either as the primary illness or secondary to a medical illness or drug use. Drs Thompson and Petersen discuss a number of approaches that physicians can take to better recognize psychiatric disorders, so that they may treat or consult on the less complicated conditions and refer complex or resistant conditions to a psychiatrist.     

The receptive fields of cat retinal ganglion cells in physiological and pathological states: where we are after half a century of research

Studies on the receptive field properties of cat retinal ganglion cells over the past half-century are reviewed within the context of the role played by the receptive field in visual information processing. Emphasis is placed on the work conducted within the past 20 years, but a summary of key contributions from the 1950s to 1970s is provided. We have sought to review aspects of the ganglion cell receptive field that have not been featured prominently in previous review articles. Our review of the receptive field properties of X- and Y-cells focuses on quantitative studies and includes consideration of the function of the receptive field in visual signal processing. We discuss the non-classical as well as the classical receptive field. Attention is also given to the receptive field properties of the less well-studied cat ganglion cells-the W-cells-and the effect of pathology on cat ganglion cell properties. Although work from our laboratories is highlighted, we hope that we have given a reasonably balanced view of the current state of the field.