All-cause and cause-specific mortality in individuals with zero and minimal coronary artery calcium: A long-term, competing risk analysis in the Coronary Artery Calcium Consortium.

Background and aimsThe long-term associations between zero, minimal coronary artery calcium (CAC) and cause-specific mortality are currently unknown, particularly after accounting for competing risks with other causes of death.MethodsWe evaluated 66,363 individuals from the CAC Consortium (mean age 54 years, 33% women), a multi-center, retrospective cohort study of asymptomatic individuals undergoing CAC scoring for clinical risk assessment. Baseline evaluations occurred between 1991 and 2010.ResultsOver a mean of 12 years of follow-up, individuals with CAC = 0 (45% prevalence, mean age 45 years) had stable low rates of coronary heart disease (CHD) death, cardiovascular disease (CVD) death (ranging 0.32 to 0.43 per 1000 person-years), and all-cause death (1.38-1.62 per 1000 person-years). Cancer was the predominant cause of death in this group, yet rates were also very low (0.47-0.79 per 1000 person-years). Compared to CAC = 0, individuals with CAC 1-10 had an increased multivariable-adjusted risk of CVD death only under age 40. Individuals with CAC>10 had multivariable-adjusted increased risks of CHD death, CVD death and all-cause death at all ages, and a higher proportion of CVD deaths.ConclusionsCAC = 0 is a frequent finding among individuals undergoing CAC scanning for risk assessment and is associated with low rates of all-cause death at 12 years of follow-up. Our results support the emerging consensus that CAC = 0 represents a unique population with favorable all-cause prognosis who may be considered for more flexible treatment goals in primary prevention. Detection of any CAC in young adults could be used to trigger aggressive preventive interventions

Feasibility study of electrocardiographic and respiratory gated, gadolinium enhanced magnetic resonance angiography of pulmonary veins and the impact of heart rate and rhythm on study quality

Background: We aimed to assess the feasibility of 3 dimensional (3D) respiratory and ECG gated, gadolinium enhanced magnetic resonance angiography (MRA) on a 3 Tesla (3 T) scanner for imaging pulmonary veins (PV) and left atrium (LA). The impact of heart rate (HR) and rhythm irregularity associated with atrial fibrillation (AF) on image and segmentation qualities were also assessed. Methods: 101 consecutive patients underwent respiratory and ECG gated (ventricular end systolic window) MRA for pre AF ablation imaging. Image quality (assessed by PV delineation) was scored as 1 = not visualized, 2 = poor, 3 = good and 4 = excellent. Segmentation quality was scored on a similar 4 point scale. Signal to noise ratios (SNRs) were calculated for the LA, LA appendage (LAA), and PV. Contrast to noise ratios (CNRs) were calculated between myocardium and LA, LAA and PV, respectively. Associations between HR/rhythm and quality metrics were assessed. Results: 35 of 101 (34.7%) patients were in AF at time of MRA. 100 (99%) patients had diagnostic studies, and 91 (90.1%) were of good or excellent quality. Overall, mean ± standard deviation (SD) image quality score was 3.40 ± 0.69. Inter observer agreement for image quality scores was substantial, (kappa = 0.68; 95% confidence interval (CI): 0.46, 0.90). Neither HR adjusting for rhythm [odds ratio (OR) = 1.03, 95% CI = 0.98,1.09; p = 0.22] nor rhythm adjusting for HR [OR = 1.25, 95% CI = 0.20, 7.69; p = 0.81] demonstrated association with image quality. Similarly, SNRs and CNRs were largely independent of HR after adjusting for rhythm. Segmentation quality scores were good or excellent for 77.3% of patients: mean ± SD score = 2.91 ± 0.63, and scores did not significantly differ by baseline rhythm (p = 0.78). Conclusions: 3D respiratory and ECG gated, gadolinium enhanced MRA of the PVs and LA on a 3 T system is feasible during ventricular end systole, achieving high image quality and high quality image segmentation when imported into electroanatomic mapping systems. Quality is independent of HR and heart rhythm for this free breathing, radiation free, alternative strategy to current MRA or CT based approaches, for pre AF ablation imaging of PVs and LA

Development of the (d,n) proton-transfer reaction in inverse kinematics for structure studies

Transfer reactions have provided exciting opportunities to study the structure of exotic nuclei and are often used to inform studies relating to nucleosynthesis and applications. In order to benefit from these reactions and their application to rare ion beams (RIBs) it is necessary to develop the tools and techniques to perform and analyze the data from reactions performed in inverse kinematics, that is with targets of light nuclei and heavier beams. We are continuing to expand the transfer reaction toolbox in preparation for the next generation of facilities, such as the Facility for Rare Ion Beams (FRIB), which is scheduled for completion in 2022. An important step in this process is to perform the (d,n) reaction in inverse kinematics, with analyses that include Q-value spectra and differential cross sections. In this way, proton-transfer reactions can be placed on the same level as the more commonly used neutron-transfer reactions, such as (d,p), (9Be,8Be), and (13C,12C). Here we present an overview of the techniques used in (d,p) and (d,n), and some recent data from (d,n) reactions in inverse kinematics using stable beams of 12C and 16O.Comment: 9 pages, 4 figures, presented at the XXXV Mazurian Lakes Conference on Physics, Piaski, Polan

Obtaining high resolution excitation functions with an active thick-target approach and validating them with mirror nuclei

Measurement of fusion excitation functions for stable nuclei has largely been restricted to nuclei with significant natural abundance. Typically, to investigate neighboring nuclei with low natural abundance has required obtaining isotopically enriched material. This restriction often limits the ability to perform such measurements. We report the measurement of a high quality fusion excitation function for a $^{17}$O beam produced from unenriched material with 0.038\% natural abundance. The measurement is enabled by using an active thick-target approach and the accuracy of the result is validated using its mirror nucleus $^{17}$F and resonances. The result provides important information about the average fusion cross-section for the oxygen isotopic chain as a function of neutron excess.Comment: 4 pages, 4 figure

Beyond BMI: The “Metabolically healthy obese” phenotype & its association with clinical/subclinical cardiovascular disease and all-cause mortality -- a systematic review

Background: A subgroup has emerged within the obese that do not display the typical metabolic disorders associated with obesity and are hypothesized to have lower risk of complications. The purpose of this review was to analyze the literature which has examined the burden of cardiovascular disease (CVD) and all-cause mortality in the metabolically healthy obese (MHO) population. Methods: Pubmed, Cochrane Library, and Web of Science were searched from their inception until December 2012. Studies were included which clearly defined the MHO group (using either insulin sensitivity and/or components of metabolic syndrome AND obesity) and its association with either all cause mortality, CVD mortality, incident CVD, and/or subclinical CVD. Results: A total of 20 studies were identified; 15 cohort and 5 cross-sectional. Eight studies used the NCEP Adult Treatment Panel III definition of metabolic syndrome to define “metabolically healthy”, while another nine used insulin resistance. Seven studies assessed all-cause mortality, seven assessed CVD mortality, and nine assessed incident CVD. MHO was found to be significantly associated with all-cause mortality in two studies (30%), CVD mortality in one study (14%), and incident CVD in three studies (33%). Of the six studies which examined subclinical disease, four (67%) showed significantly higher mean common carotid artery intima media thickness (CCA-IMT), coronary artery calcium (CAC), or other subclinical CVD markers in the MHO as compared to their MHNW counterparts. Conclusions: MHO is an important, emerging phenotype with a CVD risk between healthy, normal weight and unhealthy, obese individuals. Successful work towards a universally accepted definition of MHO would improve (and simplify) future studies and aid inter-study comparisons. Usefulness of a definition inclusive of insulin sensitivity and stricter criteria for metabolic syndrome components as well as the potential addition of markers of fatty liver and inflammation should be explored. Clinicians should be hesitant to reassure patients that the metabolically benign phenotype is safe, as increased risk cardiovascular disease and death have been shown

Contextual and Granular Policy Enforcement in Database-backed Applications

Database-backed applications rely on inlined policy checks to process users' private and confidential data in a policy-compliant manner as traditional database access control mechanisms cannot enforce complex policies. However, application bugs due to missed checks are common in such applications, which result in data breaches. While separating policy from code is a natural solution, many data protection policies specify restrictions based on the context in which data is accessed and how the data is used. Enforcing these restrictions automatically presents significant challenges, as the information needed to determine context requires a tight coupling between policy enforcement and an application's implementation. We present Estrela, a framework for enforcing contextual and granular data access policies. Working from the observation that API endpoints can be associated with salient contextual information in most database-backed applications, Estrela allows developers to specify API-specific restrictions on data access and use. Estrela provides a clean separation between policy specification and the application's implementation, which facilitates easier auditing and maintenance of policies. Policies in Estrela consist of pre-evaluation and post-evaluation conditions, which provide the means to modulate database access before a query is issued, and to impose finer-grained constraints on information release after the evaluation of query, respectively. We build a prototype of Estrela and apply it to retrofit several real world applications (from 1000-80k LOC) to enforce different contextual policies. Our evaluation shows that Estrela can enforce policies with minimal overheads

Life\u27s Simple 7 and Incident Heart Failure: The Multi‐Ethnic Study of Atherosclerosis

Background The American Heart Association introduced the Life\u27s Simple 7 (LS7) metrics to assess and promote cardiovascular health. We sought to examine the association between the LS7 metrics and incident heart failure (HF) in a multiethnic cohort. Methods and Results We analyzed data from 6506 participants of the Multi‐Ethnic Study of Atherosclerosis free of cardiovascular disease at baseline. The LS7 metrics (smoking, physical activity, body mass index, diet, blood pressure, total cholesterol, and blood glucose) were graded on a scale of 0 to 2, with 2 indicating “ideal” status, 1 “intermediate” status, and 0 “poor” status. Points were summed, thus the LS7 score ranged from 0 to 14. Cox proportional hazard ratios and incidence rates of HF per 1000 person‐years were calculated. During a median follow‐up of 12.2 years, 262 (4%) participants developed HF. Incidence of HF decreased as the number of ideal LS7 metrics increased; 5.9 per 1000 person‐years for participants with 0 to 1 ideal metrics and 0.6 per 1000 person‐years for those with 6 to 7 ideal metrics. Compared with inadequate scores (0–8 points), hazard ratios for HF were 0.57 (0.43–0.76) and 0.31 (0.19–0.49) for average (9–10 points) and optimal (11–14 points) scores, respectively. A similar pattern was observed when the results were stratified by 4 racial/ethnic groups: white, Chinese American, black, and Hispanic. Conclusions A lower risk of HF with more favorable LS7 status regardless of race/ethnicity suggests that efforts to achieve ideal cardiovascular health may reduce the burden of HF, a major source of morbidity and mortality

What factors increase revision surgery risk when treating displaced femoral neck fractures with arthroplasty: a secondary analysis of the HEALTH trial

Objectives: HEALTH was a randomized controlled trial comparing total hip arthroplasty with hemiarthroplasty in low-energy displaced femoral neck fracture patients aged >= 50 years with unplanned revision surgery within 24 months of the initial procedure being the primary outcome. No significant short-term differences between treatment arms were observed. The primary objective of this secondary HEALTH trial analysis was to determine if any patient and surgical factors were associated with increased risk of revision surgery within 24 months after hip fracture. Methods: We analyzed 9 potential factors chosen a priori that could be associated with revision surgery. The factors included age, body mass index, major comorbidities, independent ambulation, type of surgical approach, length of operation, use of femoral cement, femoral head size, and degree of femoral stem offset. Our statistical analysis was a multivariable Cox regression using reoperation within 24 months of index surgery as the dependent variable. Results: Of the 1441 patients included in this analysis, 8.1% (117/1441) experienced reoperation within 24 months. None of the studied factors were found to be predictors of revision surgery (P > 0.05). Conclusion: Both total and partial hip replacements are successful procedures in low-energy displaced femoral neck fracture patients. We were unable to identify any patient or surgeon-controlled factors that significantly increased the need for revision surgery in our elderly and predominately female patient population. One should not generalize our findings to an active physiologically younger femoral neck fracture population.Orthopaedics, Trauma Surgery and Rehabilitatio

Development, implementation, and evaluation of a competency-based didactic and simulation-focused boot camp for incoming urology residents: Report of the first three years

Introduction: The Royal College of Physicians and Surgeons of Canada’s Competence by Design (CBD) initiative presents curricula challenges to ensure residents gain proficiency while progressing through training. To prepare first-year urology residents (R1s), we developed, implemented, and evaluated a didactic and simulation-focused boot camp to implement the CBD curriculum. We report our experiences and findings of the first three years. Methods: Urology residents from two Canadian universities participated in the two-day boot camp at the beginning of residency. Eleven didactic and six simulation sessions allowed for instruction and deliberate practice with feedback. Pre-and post-course multiple-choice questionnaires (MCQs) and an objective structured clinical exam (OSCE) evaluated knowledge and skills uptake. For initial program evaluation, three R2s served as historical controls in year 1. Results: Nineteen residents completed boot camp. The mean age was 26.4 (±2.8) and 13 were male. Participants markedly improved on the pre- and post-MCQs (year 1: 62% and 91%; year 2: 55% and 89%; year 3: 58% and 86%, respectively). Participants scored marginally higher than the controls on four of the six OSCE stations. OSCE scores remained \u3e88% over the three cohorts. All participants reported higher confidence levels post-boot camp and felt it was excellent preparation for residency. Conclusions: During its first three years, our urology boot camp has demonstrated high feasibility and utility. Knowledge and technical skills uptake were established via MCQ and OSCE results, with participants’ scores near or above those of R2 controls. This boot camp will remain in our CBD curriculum and can provide a framework for other urology residency programs