The assessment of low-risk acute chest pain is a dilemma in the emergency department. CT coronary angiography is used as an important "rule-out" tool in these cases, enabling safe discharges for patients who may have occult life-threatening coronary artery disease (CAD). We analyze legal cases since the incidence of CAD began to rise in the United States to examine how the courts view physicians' diagnostic approaches in low-risk patients, including the use of CT coronary angiography and accelerated diagnostic pathways such as the HEART score.

Pulmonary embolism (PE) is a common emergency presentation that can lead to death if left untreated. While catheter pulmonary angiography was the gold standard, ventilation/perfusion studies were the preferred non-invasive diagnostic test for PE. Lawsuits from this era focused on the diagnostic uncertainty created by V/Q scan reports, which are graded by probability of PE. After multidetector computed tomography (MDCT) became widespread, the focus of lawsuits shifted away from the content of the report and towards implying negligence for not ordering imaging. Due to a confluence of factors, including the evolving medicolegal environment, clinicians chose CT as the modality of choice.

There is limited data on new-generation stent outcomes in patients with previous coronary artery bypass graft (CABG) and the associated risk of gender and race/ethnicity is unclear. We investigated 1-year outcomes after platinum chromium everolimus-eluting stent implantation in a diverse population of men, women, and minorities with previous CABG pooled from the PLATINUM Diversity (NCT02240810) and PROMUS Element Plus (NCT01589978) registries. Our primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR) at 1-year post percutaneous coronary intervention (PCI). Secondary end points included all-cause death, MI, TVR, target vessel failure, and stent thrombosis. A total of 4,175 patients were included in the analysis, including 1,858 women (44.5%), 1,057 minorities (25.3%), and 662 (15.9%) with previous CABG. Patients with previous CABG were older, included more men and White patients, and had more comorbidities compared with patients without previous CABG. At 1 year, patients with previous CABG had a higher risk of MACE (12.6% vs 7.5%, hazard ratio 1.70, 95% confidence interval 1.32 to 2.19, p <0.001) and end points, including death/MI, TVR, and target vessel failure. After multivariate adjustment, no differences were observed in MACE (adjusted hazard ratio 1.11, 95% confidence interval 0.82 to 1.49, p = 0.506) or any secondary end points. No interaction was observed between previous CABG and gender or minority status. In conclusion, in a contemporary PCI population, patients with previous CABG remain at high risk for PCI because of their elevated risk profile. Previous CABG status was however not independently associated with worse outcomes after adjustment, nor was any interaction observed with gender or race/ethnicity. & COPY; 2023 Elsevier Inc. All rights reserved. (Am J Cardiol 2023;200:204-211)

BackgroundHow diabetes mellitus (DM), race/ethnicity, and sex impact ischemic events following coronary artery stent procedures is unknown.MethodsUsing the PLATINUM Diversity and PROMUS Element Plus Post-Approval Pooled Study (N = 4184), we examined the impact of race/ethnicity, sex, and DM on coronary stent outcomes. Primary outcome was 1-year major adverse cardiac events (MACE) (MACE composite: death, myocardial infarction [MI], and target vessel revascularization).ResultsThe study sample included 1437 diabetic patients (501 White men, 470 White women, 246 minority men, 220 minority women) and 2641 patients without medically treated DM (561 minority, 1090 women). Mean age (years) ranged from 61 in minority men to 65 in White women. Diabetic patients had a higher prevalence of atherosclerotic risk factors and comorbidities. Diabetic minority women (DMW; 70% Black, 27% Hispanic) had similar atherosclerotic risk factors to other diabetics, but experienced higher 1-year MACE (14.4% vs 7.5%, P <.01) and MI (4.3% vs 1.6%, P <.01) rates compared with patients without medically treated DM. No other diabetic cohort (White men, White women, minority men) showed an increased risk of MACE vs patients without medically treated DM. The incremental risk of MACE in DMW was associated with insulin use and persisted after risk adjustment (adjusted odds ratio 1.6 vs patients without medically treated DM; 95% CI, 1.0-2.5). Independent predictors of 1-year MACE included insulin use, hyperlipidemia, renal disease, and prior MI.ConclusionsDMW face the highest risk of ischemic events following coronary stenting, driven, in part, by insulin use. Aggressive secondary prevention and strict glycemic control are imperative in this cohort, and further research is warranted to elucidate the biologic mechanisms underpinning these observations.Clinical Trial RegistrationNCT02240810 (http://clinicaltrials.gov/)

Behavioral problems are commonly associated with complete denture therapy. There are easily satisfied patients at one end, while at the other end are patients who become office fixtures, complaining of excessive discomfort, poor function and visit repeatedly for adjustments. Some patients are maladaptive because neurological or neuromuscular deficits preclude successful wearing of dentures. Others are emotionally maladaptive. For these patients, effective verbal and nonverbal communication in the form of an iatrosedative interview is significant in maximizing an effective doctor/patient relationship and minimizing the maladaptive response. Keywords: Maladaptive, Iatrosedation, Doctor patient communication, Doctor’s behavior

A 66-year-old gentleman presented for a cardiovascular evaluation secondary to chest discomfort, right knee pain, and intractable hiccups. The patient also had type 2 diabetes mellitus, hypercholesterolemia, aortic atherosclerosis, and ascending aortic aneurysm. His family history was also significant for premature coronary artery disease in the father. The patient had been compliant with his medical therapy, which included subcutaneous 200 units/mL insulin degludec, 18 mg/3 mL subcutaneous liraglutide, daily oral 500 mg metformin hydrochloride, daily oral 100 mg sitagliptin, daily oral 12.5 mg zolpidem, daily oral 5 mg tadalafil, and 20 mg tablet rosuvastatin daily. He was initially referred for an upper gastrointestinal (GI) endoscopy due to his persistent hiccups, but no GI etiology was found for his persistent symptoms. A cardiac stress test was conducted roughly three months after. There was no significant evidence of ischemia, though the patient complained of dyspnea (unstable angina) at the end of the exercise treadmill stress test. He underwent a transthoracic echocardiogram, which suggested a preserved ejection fraction with no other abnormalities. Afterwards, a coronary calcium score study was immediately taken and revealed that the patient had an Agatson calcium score of 1 185, categorizing him as high risk for future cardiovascular events. The noninvasive cardiovascular workup was inconclusive and all the other differentials considered were not suggestive of any particular etiology. Thus, we decided to do a cardiac catheterization four months after the initial consultation to confirm the patient's suspected diagnosis of occlusive coronary artery disease. The study revealed that multiple arteries were severely calcified, with the left main artery having a 10% stenosis, the left anterior descending artery (LAD) having a 99% stenosis, the circumflex artery having a 20% stenosis, and the right coronary artery (RCA) having a 30% stenosis; the initial LAD is shown in Figure 1. The patient underwent successful revascularization with a drug eluting stent placed in the mid-segment of the LAD, the culprit lesion. This result is seen in Figure 2. Patient was discharged the same day and was followed up in the office in the same week. He was compliant with his dual antiplatelet therapy, which included 81 mg aspirin and 90 mg ticagrelor twice a day. The patient had post-interventional followups after 30 days, 6 months, and a year. The patient neither reported or nor displayed the return of intractable hiccups. When intractable hiccups occur in hospitalized patients, digestive tract problems should be suspected, as they account for around 62.5% of clinical cases. However, in our patient, the etiology was not gastrointestinal. Due to his lack of traditional symptoms associated with severe atherosclerotic plaque, cardiac catheterization was delayed.

Objective We evaluated 1-year outcomes after platinum chromium everolimus-eluting stents (PtCr-EES) in small versus non-small coronary arteries within a large, diverse sample of men, women, and minorities. Background There exists limited outcomes data on the use of second-generation drug-eluting stent to treat small diameter coronary arteries. Methods We pooled patients from the PLATINUM Diversity and PROMUS Element Plus stent registries. Small-vessel percutaneous coronary intervention (SV-PCI) was defined as >= 1 target lesion with reference vessel diameter (RVD) <= 2.5 mm. Endpoints included major adverse cardiac event (MACE; death, myocardial infarction [MI] or target vessel revascularization [TVR]), target vessel failure (TVF; death related to the target vessel, target vessel MI or TVR) and definite/probable stent thrombosis (ST). Multivariable Cox regression was used to risk-adjust outcomes. Results We included 4,155/4,182 (99%) patients with available RVD, of which 1,607 (39%) underwent small-vessel PCI. SV-PCI was not associated with increased MACE (adjHR 1.02; 95%CI 0.81-1.30) or TVF (adjHR 1.07; 95%CI 0.82-1.39). MI risk was lower in white men compared to women and minorities, both in the setting of SV-PCI (adjHR 0.41; 95%CI 0.23-0.74 and adjHR 0.39; 95%CI 0.20-0.75, respectively) and for non-SV-PCI (adjHR 0.61; 95%CI 0.38-0.99 and adjHR 0.45; 95%CI 0.27-0.74, respectively). There was no significant interaction between RVD and sex or minority status for any endpoint. Conclusion In a large diverse contemporary PCI outcomes database, SV-PCI with PtCr-EES was not associated with increased MACE or TVR and did not account for the increased MI risk noted in women and minorities compared to white men.

Communication between different IP cores in MPSoCs and HMPs often results in clock domain crossing. Asynchronous network on chip (NoC) support communication in such heterogeneous set-ups. While there are a large number of tools to model NoCs for synchronous systems, there is very limited tool support to model communication for multi-clock domain NoCs and analyse them. In this article, we propose the Pluggable Asynchronous NEtwork on Chip (PANE) simulator, which allows system-level simulation of asynchronous network on chip (NoC). PANE allows design space exploration of synchronous, asynchronous, and mixed synchronous-asynchronous(heterogeneous) NoC for various system-level NoC parameters such as packet latencies, throughput, network saturation point and power analysis. PANE supports a large range of NoC configurations—routing algorithms, topologies, network sizes, and so on—for both synthetic and real traffic patterns. We demonstrate the application of PANE by using synchronous routers, asynchronous routers, and a mix of asynchronous and synchronous routers. One of the key advantages of PANE is that it allows a seamless transition from synchronous to asynchronous NoC simulators while keeping pace with the developments in synchronous NoC tools as they can be integrated with PANE.

New benchmark suites are constantly being released, with each one providing a much larger set of benchmarks, representing an ever-growing variety of workloads. Contemporary workloads are increasingly more complex in their computational and memory footprints. Most computer architecture research is based on the ability of researchers to simulate novel ideas with a variety of workloads representing the domain being researched. However, bigger and complex benchmarks suites have made it extremely impractical to simulate complete benchmarks from start to finish. As a result, architects are becoming increasingly dependent on statistical sampling techniques like SimPoints, which identify long, repetitive execution phases in benchmarks, and limit simulations to a few instances of these phases. These techniques present an inherent trade-off between simulation speed and accuracy. This work presents results and insights for determining the accuracy of simulation points for the SPEC CPU2017 suite, using Pin and PinPoints, which is an implementation of SimPoints for the ×86 ISA. Our analysis concludes that carefully chosen simulation points faithfully represent the workload; we observe <; 1% variance in the instruction distribution between full runs and the ones using SimPoints, while reducing simulation time by ~750×. We also show that on average, just 12 phases can faithfully represent the 90 th percentile of a benchmark's behavior, which can help reduce the overall simulation time by up to ~1297×. In addition, using performance statistics with native binaries on real hardware and from an architectural model of the same machine using SimPoints, we report good co-relations between the two on metrics such as CPI. Finally, we present cases like memory hierarchy explorations, where SimPoints should be used judiciously and with extreme caution in order to derive correct conclusions - inappropriately chosen SimPoint configurations can show large deviations in memory hierarchy behavior as compared to full runs, as reported by prior studies.

The association between sodium-glucose co transporter 2 (SGLT2) inhibitors and Major Adverse Cardiovascular Events in individuals with type 2 diabetes remain uncertain. This meta-analysis aimed to evaluate the cardiovascular outcomes of FDA approved SGLT2 inhibitors for treatment of diabetes

Importance There exist limited outcomes data for women and minorities after contemporary percutaneous coronary intervention (PCI). Objective To examine 1-year outcomes in women and minorities vs white men after PCI with everolimus-eluting stents. Design, Settings, and Participants The PLATINUM Diversity study was a single-arm study enrolling women and minorities. Patient-level pooling with the PROMUS Element Plus Post-Approval Study was prespecified. Data on social determinants of health and language were collected in the PLATINUM Diversity cohort, which included 1501 patients at 52 US sites. The PROMUS Element Plus Post-Approval study enrolled 2681 patients at 52 US sites with some site overlap and included an "all-comers" population. All patients were enrolled beginning in October 2014 and were followed for 12 months. Analyses began in August 2016. Interventions Patients received 1 or more everolimus-eluting stent implantation. Main Outcomes and Measures The primary end point was 1-year major adverse cardiac events (MACE), which included death/myocardial infarction (MI)/target vessel revascularization. Secondary ischemic end points were also evaluated. Results The pooled study consisted of 4182 patients: 1635 white men (39.1%), 1863 women (white and minority) (44.5%), and 1059 minority patients (women and men) (25.3%). Women and minorities had a higher prevalence of diabetes, prior stroke, hypertension, renal disease, and congestive heart failure than white men but lower rates of multivessel disease, prior coronary artery bypass graft surgery, prior MI, and smoking. Unadjusted 1-year MACE rates (white men, 7.6%; women, 8.6%; minorities, 9.6%) were similar between groups with no significant differences after risk adjustment. The adjusted risk of death/MI was higher among women (odds ratio, 1.6; 95% CI, 1.1-2.4) and minorities (odds ratio, 1.9; 95% CI, 1.2-2.8) compared with white men and the adjusted risk of MI was higher in minorities (odds ratio, 2.6; 95% CI, 1.4-4.8). These differences were driven primarily by nonstent-related MIs. Within the PLATINUM Diversity cohort, the independent predictors of MACE were cardiogenic shock, renal disease, history of peripheral vascular disease, multivessel disease, widowhood, and lack of private insurance. Conclusions and Relevance After contemporary everolimus-eluting stent implantation, women and minorities experience a similar risk of 1-year MACE but a higher adjusted risk of recurrent ischemic events primarily because of nonstent-related MIs. Both clinical and angiographic factors and social determinants of health, including widowhood and insurance status, contribute to 1-year MACE among women and minorities.

To determine the effect of patient off-centering on point organ radiation dose measurements in a human cadaver scanned with routine abdominal CT protocol. A human cadaver (88 years, body-mass-index 20 kg/m2) was scanned with routine abdominal CT protocol on 128-slice dual source MDCT (Definition Flash, Siemens). A total of 18 scans were performed using two scan protocols (a) 120 kV-200 mAs fixed-mA (CTDIvol 14 mGy) (b) 120 kV-125 ref mAs (7 mGy) with automatic exposure control (AEC, CareDose 4D) at three different positions (a) gantry isocenter, (b) upward off-centering and (c) downward off-centering. Scanning was repeated three times at each position. Six thimble (in liver, stomach, kidney, pancreas, colon and urinary bladder) and four MOSFET dosimeters (on cornea, thyroid, testicle and breast) were placed for calculation of measured point organ doses. Organ dose estimations were retrieved from dose-tracking software (eXposure, Radimetrics). Statistical analysis was performed using analysis of variance. There was a significant difference between the trends of point organ doses with AEC and fixed-mA at all three positions (p < 0.01). Variation in point doses between fixed-mA and AEC protocols were statistically significant across all organs at all Table positions (p < 0.001). There was up to 5-6% decrease in point doses with upward off-centering and in downward off-centering. There were statistical significant differences in point doses from dosimeters and dose-tracking software (mean difference for internal organs, 5-36% for fixed-mA & 7-48% for AEC protocols; p < 0.001; mean difference for surface organs, >92% for both protocols; p < 0.0001). For both protocols, the highest mean difference in point doses was found for stomach and lowest for colon. Measured absorbed point doses in abdominal CT vary with patient-centering in the gantry isocenter. Due to lack of consideration of patient positioning in the dose estimation on automatic software-over estimation of the doses up to 92% was reported.

Interdisciplinary teamwork is a complex process in which different specialties work together to share expertise, knowledge, and skills to impact on patient care. This article describes the interdisciplinary management of a patient with a new innovative method of using endodontic post and core in orthodontics for three-dimensional root control of a root stump.

Since its introduction into dentistry in 1998, cone-beam computed tomography (CBCT) has become an increasingly important source of three-dimensional volumetric data in clinical orthodontics. CBCT should be used only in specific cases in which conventional radiography cannot supply satisfactory diagnostic information; these include patients with cleft palate, assessment of position of unerupted tooth, supernumerary teeth, identification of root resorption, and for planning of orthognathic surgery. Two-dimensional diagnostic imaging, such as traditional radiographs, cephalometric tracings, photographs, and video imaging have been routinely used as orthodontic diagnostic records since many years. The limitations of these imaging modalities include geometric distortion, magnification, superimposition of structures, projective displacements, rotational errors, and linear projective transformation. These errors can be easily overcome by the CBCT. The purpose of this is to highlight the significance of CBCT in diagnosis and treatment planning in the orthodontics.

Background Lowering radiation dose in computed tomography (CT) scan results in low quality noisy images. Iterative reconstruction techniques are used currently to lower image noise and improve the quality of images. Purpose To evaluate lesion detection and diagnostic acceptability of chest CT images acquired at CTDI vol of 1.8 mGy and processed with two different iterative reconstruction techniques. Material and Methods Twenty-two patients (mean age, 60 ± 14 years; men, 13; women, 9; body mass index, 27.4 ± 6.5 kg/m 2 ) gave informed consent for acquisition of low dose (LD) series in addition to the standard dose (SD) chest CT on a 128 - multidetector CT (MDCT). LD images were reconstructed with SafeCT C 4 , L 1 , and L 2 settings, and Safire S 1 , S 2 , and S 3 settings. Three thoracic radiologists assessed LD image series (S 1 , S 2 , S 3 , C 4 , L 1 , and L 2 ) for lesion detection and comparison of lesion margin, visibility of normal structures, and diagnostic confidence with SD chest CT. Inter-observer agreement (kappa) was calculated. Results Average CTDI vol was 6.4 ± 2.7 mGy and 1.8 ± 0.2 mGy for SD and LD series, respectively. No additional lesion was found in SD as compared to LD images. Visibility of ground-glass opacities and lesion margins, as well as normal structures visibility were not affected on LD. CT image visibility of major fissure and pericardium was not optimal in some cases ( n = 5). Objective image noise in some low dose images processed with SafeCT and Safire was similar to SD images ( P value > 0.5). Conclusion Routine LD chest CT reconstructed with iterative reconstruction technique can provide similar diagnostic information in terms of lesion detection, margin, and diagnostic confidence as compared to SD, regardless of the iterative reconstruction settings.