White, Richard D.

Abstract Introduction The evaluation of diastolic function in diabesity patients undergoing incretin-based therapy could facilitate early detection and help prevent progression to heart failure. Methodology A group of 15 diabesity cases with chest x-ray examinations (< 1 month) before and after ≥ 12 months of incretin-based therapy (absent ventricular/valvular dysfunction) were identified. Standard diabesity descriptors and predictions of pulmonary venous hypertension (aka “pulmonary congestion”) [None; Stage 1: vascular distention/redistribution but minimal interstitial edema; or Stage ≥ 2: vascular congestion with ≥ mild interstitial or alveolar edema] by validated AI-enabled chest x-ray staging, representing mean left atrial pressure in diastolic dysfunction, were evaluated pre- and post-therapy. Results By weight loss, cases clustered into equal-sized subgroups: 1. Significant Responders (9–30% decreases); 2. Insignificant Responders (0–2% decreases); and 3. Non-Responders (2–12% increases). Regarding hemoglobin A1c changes: 1. Significant Responders collectively decreased; 2. Insignificant Responders varied; and 3. Non-Responders were largely stable. Pre-therapy, all 15 cases demonstrated AI-enabled chest x-ray evidence of diastolic dysfunction; post-therapy, 4 improved (especially cases of greatest weight loss or hemoglobin A1c reduction), 5 were stable, and 6 worsened. Per subgroup, AI-enabled chest x-ray indications therapeutic response were: 1. Significant Responders (all demonstrating unequivocally decreased obesity and improved diabetes) collectively showed stable-decreased dysfunction; 2. Insignificant Responders (all demonstrating minimally decreased obesity but stable-worsening diabetes in most) reflected stable-increased dysfunction in 60%; and 3. Non-Responders (all demonstrating increased obesity but stable-improved diabetes) showed increased dysfunction in 80%. Conclusion AI-enabled CXR staging detects background subclinical diastolic dysfunction in diabesity and monitors its response to incretin-based therapy.

Objective: Pulmonary air trapping is critical for diagnosing and prognostication of various lung diseases. Expiratory CT imaging serves as an accessible method to assess air trapping, which correlates with small airway disease outcomes. Air trapping manifests as mosaic attenuation on inspiratory chest CT that is difficult for visual estimation. The primary aim of this study was to develop an automated tool to quantify mosaic attenuation on inspiratory CT and air trapping on paired expiratory CT. Secondary aims included comparing CT-derived parameters with PFT measurements and dyspnea scores. Methods: This retrospective analysis of noncontrast chest CTs from 2 academic hospitals was conducted between January 1, 2018, and December 31, 2019. Patients with paired inspiratory and expiratory CT chest scans and PFTs performed on the same day were included. A chest radiologist manually annotated lung parenchyma in a reference cohort. Several histogram-based metrics were computed from lung parenchymal CT values, with the maximum peak position showing the strongest correlation with manually determined thresholds. This threshold, derived from the histogram peak, was applied in the adaptive thresholding process to quantify mosaic attenuation and air trapping. Results: We analyzed 267 patients (65.5% female, median age 68). Most exhibited normal physiological patterns (44.0%). Patients with elevated residual volume (RV) by PFTs (28.1%) had significantly higher inspiratory CT mosaic attenuation (1629.6 vs. 1311.5 mL, P <0.01) and expiratory CT air trapping volumes (1413.7 vs. 886.2 mL, P <0.01). Correlation analyses demonstrated strong relationships between CT-derived mosaic attenuation and air trapping measures and RV. The correlation with PFT parameters was even stronger in subgroup analyses in patients with obstructive PFT patterns. These models had good predictive ability for an abnormal RV (AUC of 0.92, sensitivity of 72.4%, and specificity of 92.0%) and clinical utility based on good correlation with the mMRC dyspnea score ( r =0.71; 95% CI: 0.65-0.77). Conclusions: This automated adaptive thresholding on inspiratory and expiratory chest CT scans showed a high correlation of lung volume and air trapping parameters with PFTs, revealing that measures of lung function have a complex interplay with air trapping.

The growing adoption of advanced imaging modalities, such as transesophageal echocardiography (TEE), has led to more frequent detection of cardiac structural abnormalities. While intracardiac cardiac tumors and shunts are infrequent and typically asymptomatic, their existence can precipitate severe outcomes, including stroke, myocardial infarction and sudden death. Case Description: A 69-year-old female presented with left sided facial droop, slurred speech and left arm weakness. A computed tomography angiography revealed focal occlusion of the distal right middle cerebral artery. She was initiated on thrombolytic therapy and experienced resolution of symptoms. Transthoracic echocardiogram revealed right to left shunting consistent with a patent foramen ovale (PFO). Further workup with TEE confirmed the presence of a PFO but also detected a mobile echogenic mass on the aortic valve leaflet, indicative of papillary fibroelastoma (PFE). Cerebral infarction was attributed to an embolic event, with the PFO and PFE being likely culprits. Discussion: Current guidelines give a conditional recommendation, low certainty of evidence, for PFO closure in adults older than 60 years, although some observational studies have shown some risk reduction in older patients. The key trials showing clinical benefit of PFO closure were in adults younger than the age of 60. For left sided cardiac tumors, such as PFE, guidelines give a 2A recommendation for resection. Addressing the risk for recurrent stroke in this 69-year-old patient was an essential part of stroke care, as such, a multi-disciplinary team of experts including cardiology, neurology, and cardiothoracic surgery was conveyed. The decision was to proceed with surgical intervention in addition to antiplatelet therapy to achieve optimal risk reduction. The patient subsequently underwent successful surgical removal of the PFE with native valve preservation and PFO closure. Conclusion: Cardiac PFEs and PFOs can be associated with increased stroke risk. Employing appropriate imaging techniques and timely interventions are of utmost importance in stroke management.

Abstract Pharmacogenomic (PGx) biomarkers integrated using machine learning can be embedded within the electronic health record (EHR) to provide clinicians with individualized predictions of drug treatment outcomes. Currently, however, drug alerts in the EHR are largely generic (not patient‐specific) and contribute to increased clinician stress and burnout. Improving the usability of PGx alerts is an urgent need. Therefore, this work aimed to identify principles for optimal PGx alert design through a health‐system‐wide, mixed‐methods study. Clinicians representing multiple practices and care settings ( N = 1062) in urban, rural, and underserved regions were invited to complete an electronic survey comparing the usability of three drug alerts for citalopram, as a case study. Alert 1 contained a generic warning of pharmacogenomic effects on citalopram metabolism. Alerts 2 and 3 provided patient‐specific predictions of citalopram efficacy with varying depth of information. Primary outcomes included the System's Usability Scale score (0–100 points) of each alert, the perceived impact of each alert on stress and decision‐making, and clinicians' suggestions for alert improvement. Secondary outcomes included the assessment of alert preference by clinician age, practice type, and geographic setting. Qualitative information was captured to provide context to quantitative information. The final cohort comprised 305 geographically and clinically diverse clinicians. A simplified, individualized alert (Alert 2) was perceived as beneficial for decision‐making and stress compared with a more detailed version (Alert 3) and the generic alert (Alert 1) regardless of age, practice type, or geographic setting. Findings emphasize the need for clinician‐guided design of PGx alerts in the era of digital medicine.

Abstract Background and introduction Cardioversion is commonly used to terminate cardiac arrhythmias. Some previous reports have suggested that cardioversion results in myocardial injury as evidenced by increased levels of cardiac troponin. However, many of these studies were done years ago with less sensitive troponin assays and monophasic waveform defibrillators. Purpose To determine if external direct current (DC) cardioversion with biphasic rectilinear waveform shocks results in myocardial injury as assessed by high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI). Methods Patients scheduled for elective DC cardioversion for atrial fibrillation or atrial flutter were recruited. Plasma samples for measurement of hs-cTnT and hs-cTnI were obtained pre-cardioversion and as late as feasible but at least 6 hours post-cardioversion [median of 9 (7–11) hours]. Results A total of 96 patients were recruited. One patient was excluded because the pre-cardioversion sample was hemolysed. Median (25th–75th interquartile range) cumulative energy delivered was 121.6J (62.4–277.4J) and median highest energy individual shock was 121.0J (62.1–146.2J). A total of 39 (41.1%) patients received more than 1 shock, 23 (24.2%) patients received a cumulative energy of 300J or higher and 5 (5.3%) patients received a cumulative energy of 1,000J or more. The median pre-cardioversion hs-cTnT value was 11.48 (7.19–18.38) ng/L and the median hs-cTnI value was 5.1 (2.0–9.4) ng/L. Median post-cardioversion hs-cTnT value were 12.46 (7.98–20.28) ng/L and hs-cTnI value were 6.3 (3.5–10.0) ng/L. Wilcoxon-Signed ranks test showed a statistically significant change between the pre-and-post cardioversion hs-cTnT values (Z=−4.237, p&lt;0.001) and hs-cTnI values (Z=−4.822, p&lt;0.001). In only 5 (hs-cTnT) and 4 patients (hs-cTnI) was there an increase of &gt;5 ng/L. There were 5 cases where the post-cardioversion values of both hs-cTnT and hs-cTnI were above the 50% reference change value. There was no relation between the change in hs-cTn values and sex, number of shocks, total energy delivered (even in those who received more than 1,000J), highest energy per shock, total current delivered, highest current delivered per shock or transthoracic impedance. Conclusion(s) There is a statistically significant but very small change in median hs-cTnT and hs-cTnI values (1 ng/L and 1.2 ng/L respectively) after DC cardioversion. The results were similar even in patients where high energy shocks were delivered and did not vary based on the pre cardioversion baseline value. Patients who have marked troponin elevations after cardioversion should be assessed for other causes of myocardial injury. It should not be assumed that they have myocardial injury from the cardioversion alone. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): Dr. Allan Jaffe has substantial research funds from both grants and private industry. Funds were used to pay for blood sample collection and analysis of high sensitivity cardiac troponin T at Mayo Clinic. Abbott Laboratories donated reagents for the high sensitivity cardiac troponin I analysis.