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We quantified confidence intervals (CIs) for T-scores for the lumbar spine and hip and determined the practical effect (impact on diagnosis) of variability around the T-score cutpoint of -2.5. Using precision data from the literature for GE Lunar Prodigy dual-energy X-ray absorptiometry (DXA) systems, the 95% CI for the T-score was +/-0.23 at the lumbar spine (L1-L4), +/- 0.20 at the total hip, and +/-0.41 at the femoral neck. Thus, T-score variations of +/-0.23 or less at the spine, +/-0.20 at the total hip, and +/-0.41 at the femoral neck are not statistically significant. When diagnosing osteoporosis, T-scores in the interval -2.3 to -2.7 for spine or total hip (after rounding to conform to guidelines from the International Society for Clinical Densitometry) and -2.1 to -2.9 for femoral neck are not statistically different from -2.5. Better precision values resulted in smaller 95% CIs. This concept was applied to actual clinical data using Hologic DXA systems. The study cohort comprised 2388 white women with either normal or osteopenic spines in whom the densitometric diagnosis of osteoporosis would be determined by hip T-scores. When evaluating actual patient T-scores in the range -2.5+/-95% CI, we found that the diagnosis was indeterminate in approximately 12% of women when T-scores for femoral neck were used and in 4% of women when T-scores for total hip were used, with uncertainty as to whether the classification was osteopenia or osteoporosis. We conclude that precision influences the variability around T-scores and that this variability affects the reliability of diagnostic classification.

Clinical risk factors are associated with increased probability of fracture in postmenopausal women. We sought to compare prediction models using self-reported clinical risk factors, excluding BMD, to predict incident fracture among postmenopausal women. The GLOW study enrolled women aged 55 years or older from 723 primary-care practices in 10 countries. The population comprised 19,586 women aged 60 years or older who were not receiving antiosteoporosis medication and were followed annually for 2 years. Self-administered questionnaires were used to collect data on characteristics, fracture risk factors, previous fractures, and health status. The main outcome measure compares the C index for models using the WHO Fracture Risk (FRAX), the Garvan Fracture Risk Calculator (FRC), and a simple model using age and prior fracture. Over 2 years, 880 women reported incident fractures including 69 hip fractures, 468 "major fractures" (as defined by FRAX), and 583 "osteoporotic fractures" (as defined by FRC). Using baseline clinical risk factors, both FRAX and FRC showed a moderate ability to correctly order hip fracture times (C index for hip fracture 0.78 and 0.76, respectively). C indices for "major" and "osteoporotic" fractures showed lower values, at 0.61 and 0.64. Neither algorithm was better than the model based on age + fracture history alone (C index for hip fracture 0.78). In conclusion, estimation of fracture risk in an international primary-care population of postmenopausal women can be made using clinical risk factors alone without BMD. However, more sophisticated models incorporating multiple clinical risk factors including falls were not superior to more parsimonious models in predicting future fracture in this population.

Background: Little data exist regarding interreader variability of diastolic measurements and their application by the 2016 American Society of Echocardiography left ventricular (LV) diastolic function guidelines. Methods: Volunteers (n = 49) were recruited from an outpatient cardiology practice. The presence and grade of diastology dysfunction (DD) was determined by the 2016 LV diastology guideline algorithm. We determined the mean, standard deviation, coefficient of variation, and intraclass correlation coefficient (ICC) for each measurement and Fleiss K‐statistic to define differences in grading DD. We determined predictors associated with disagreement of DD grade using odds ratios. Results: The mean LVEF was 56%, LAVI 32 ml/m2, and peak TR velocity was 2.3 m/s. The ICC for mitral inflow and tissue Doppler velocities were >.90, for LV volumes were.80–.86, and for LA volume was.56. The Fleiss K‐value for the agreement of the presence of DD was.68 and for DD grade was.59. Variables with increased odds of disagreement were (1) at least one reader considering a TR signal uninterpretable (OR 12.0; 95% CI 1.3–109.6), (2) at least one reader assessing both LVEF 50%–55% and LAVI 29–39 ml/m2 (OR 9.3; 95% CI 1.0–87), and (3) at least one reader assessing LVEF 50–55% (OR 3.8; 95% CI 1.1–13.4). Conclusions: Using the 2016 ASE/EACVI diastology guidelines, we found excellent interrater reliability of Doppler measurements, moderate‐good interrater reliability of volumetric measurements, and moderate‐good but not excellent agreement for diastology grade. [ABSTRACT FROM AUTHOR]

Background: Transient ischemic dilation of the left ventricle (LV) during stress echocardiography indicates extensive myocardial ischemia. It remains unclear whether the change of LV end‐systolic volume (ESV) or end‐diastolic volume (EDV) better correlated with significant coronary artery disease (CAD). Meanwhile, the clinical significance of the extent of the volumetric change post‐stress has not been investigated. Methods: One hundred and five individuals (62 ± 12 years and 75% men) who underwent coronary angiography following exercise treadmill echocardiography were enrolled retrospectively. An additional 30 age‐ and sex‐matched healthy subjects were included for comparison. LV dilation was defined as any increase in LV volume from rest to peak exercise. Patients who had at least two coronary arteries with significant stenosis were considered as having multi‐vessel CAD. Results: Thirty‐four patients had ESV dilation during exercise echocardiography. On the contrary, ESV decreased at peak exercise in all healthy subjects. Forty‐one patients had multi‐vessel CAD, and its prevalence was higher in patients with ESV dilation (65% vs 27%, p = 0.001). The extent of ESV increase correlated with CAD severity. ESV dilation is associated with multi‐vessel CAD (Odds ratio [OR] 5.02, 95% confidence interval [CI] 2.09 – 12.07, p < 0.001). After adjustment for EDV increase, clinical, electrocardiographic, and echocardiographic variables, the association remained significant (adjusted OR 5.57, 95% CI 1.37‐22.64; p = 0.02). Conclusions: ESV dilation independently correlated with multi‐vessel CAD, whereas EDV dilation did not. The amount of ESV increase correlated with the severity of CAD. Our findings provide a rationale for incorporating volume measurements into stress echocardiography practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: ARDS is a highly morbid condition characterized by diffuse pulmonary inflammation, which results in hypoxemic respiratory failure. Approximately 25% of patients with ARDS develop right ventricular dysfunction, with cor pulmonale being a common final pathway in a significant number of non-survivors. ARDS-related right ventricular dysfunction occurs due to acute elevation in ventricular afterload caused by mechanisms that are associated with increased pulmonary dead space fraction. Thus, we hypothesized that changes in pulmonary dead space fraction may reflect changes in pulmonary hemodynamics. METHODS: This was a prospective single-center study of 21 subjects with ARDS who underwent serial determination of pulmonary dead space fraction and pulmonary hemodynamics via transthoracic echocardiography. Linear mixed-effects modeling was performed to test for an association between a change in pulmonary dead space and a change in pulmonary hemodynamics. RESULTS: The tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio, an echocardiographic surrogate for pulmonary vascular resistance, increased by 0.16 Wood units (Coefficient 0.16, 95% CI 0.09 - 0.23; P < .001), and the tricuspid regurgitation pressure gradient increased by 3.7 mm Hg (Coefficient 3.7, 95% CI 1.74 -5.63, P < .001) for every 10% increase in pulmonary dead space fraction. CONCLUSIONS: Increases in the pulmonary dead space fraction were associated with relative increases in both the tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio and the tricuspid regurgitation pressure gradient, which likely contributed to the high incidence of ARDS-related right ventricular dysfunction encountered in clinical practice. Pulmonary dead space monitoring may serve as a clinical indicator to identify patients with ARDS at risk of developing right ventricular dysfunction and acute cor pulmonale. [ABSTRACT FROM AUTHOR]

BackgroundCannabis use shows a robust dose-dependent relationship with psychosis risk among the general population. Despite this, it has been difficult to link cannabis use with risk for transitioning to a psychotic disorder among individuals at ultra-high risk (UHR) for psychosis. The present study examined UHR transition risk as a function of cannabis use characteristics which vary substantially between individuals including age of first use, cannabis abuse severity and a history of cannabis-induced attenuated psychotic symptoms (APS).MethodParticipants were 190 UHR individuals (76 males) recruited at entry to treatment between 2000 and 2006. They completed a comprehensive baseline assessment including a survey of cannabis use characteristics during the period of heaviest use. Outcome was transition to a psychotic disorder, with mean time to follow-up of 5.0 years (range 2.4–8.7 years).ResultsA history of cannabis abuse was reported in 58% of the sample. Of these, 26% reported a history of cannabis-induced APS. These individuals were 4.90 (95% confidence interval 1.93–12.44) times more likely to transition to a psychotic disorder (p = 0.001). Greater severity of cannabis abuse also predicted transition to psychosis (p = 0.036). However, this effect was mediated by higher abuse severity among individuals with a history of cannabis-induced APS.ConclusionsFindings suggest that cannabis use poses risk in a subpopulation of UHR individuals who manifest cannabis-induced APS. Whether this reflects underlying genetic vulnerability requires further study. Nevertheless, findings reveal an important early marker of risk with potentially significant prognostic utility for UHR individuals. [ABSTRACT FROM PUBLISHER]

Background While changes in the left ventricular end-diastolic pressure-volume relationship ( LV- EDPVR) can be estimated using echocardiography, their prognostic utility in stable coronary artery disease ( CAD) is unknown. Methods Using echo-estimated LV end-diastolic volume index and diastolic function category, the relative position of the LV- EDPVR was defined in 901 participants with stable CAD as: (1) left-shifted, (2) right-shifted, or (3) intermediate. We then evaluated the association of LV- EDPVR position relative to the intermediate category with time to hospitalization for heart failure ( HF) or cardiovascular ( CV) death using Cox proportional hazards models. Results During 7.0 ± 3.1 years of follow-up, there were 207 admissions for HF or CV deaths. Both leftward and rightward shifts of LV- EDPVR were associated with a significantly higher risk of HF or CV death ( HR 1.73, 95% CI 1.15-2.62 and HR 6.75, 95% CI 4.02-11.31, respectively). In multivariable-adjusted models, these associations were attenuated but remained significant ( HR 1.66, 95% CI 1.08-2.55 for left-shifted and HR 4.19, 95% CI 2.32-7.55 for right-shifted). The association of LV- EDPVR with HF or CV death was no longer significant after inclusion of N-terminal pro-brain natriuretic peptide level as a covariate. Conclusions In stable CAD, echo-estimated leftward and rightward shifts in the LV- EDPVR are associated with HF and CV death. The loss of these associations after adjustment for N-terminal pro-brain natriuretic peptide level suggests that echo-estimated LV- EDPVR captures changes in LV filling pressure at any given LV end-diastolic volume. [ABSTRACT FROM AUTHOR]

Background Diastolic dysfunction is common and associated with higher mortality in the end-stage renal disease ( ESRD) population. E/E′, a measure derived from tissue Doppler imaging ( TDI), is a correlate of left ventricular ( LV) filling pressures. E/E′ may be viewed as a confirmatory marker of diastolic dysfunction, but it is not routinely used to quantify diastolic dysfunction. Whether E/E′ is associated with N-terminal brain natriuretic peptide ( NT-pro BNP) or high sensitivity troponin T (hs-TnT) in this population is not known. Methods We performed echocardiograms and serology prior to the 2nd or 3rd dialysis session of the week on 35 chronic hemodialysis patients. We compared TDI parameters (E/E′ and E′ alone), traditional categories of diastolic function (normal, impaired, pseudonormal or restrictive), and ejection fraction ( EF) as potential predictors of the outcomes NT-pro BNP and hs-TnT. Results Higher E/E′ was associated with higher NT-pro BNP ( rho 0.48, P = 0.004) and hs-TnT ( rho 0.37, P = 0.03). EF did not have statistically significant associations with NT-pro BNP ( rho −0.2, P = 0.4) or hs-TnT ( rho −0.24, P = 0.16). As compared to patients with normal diastolic function, those with impaired or pseudonormal filling patterns did not have significantly different levels of NT-pro BNP (P = 0.46); patients in traditional categories of worsened diastolic function actually had lower hs-TnT (P = 0.02). The associations of E/E′ with higher NT-pro BNP and hs-TnT persisted after multivariate adjustment for EF, LV mass, and volume status. Conclusions Tissue Doppler imaging may be more useful in evaluating cardiac function than traditional measures of diastolic dysfunction in the ESRD population. [ABSTRACT FROM AUTHOR]

BackgroundIndividuals at ultra-high risk (UHR) for psychosis show reduced neurocognitive performance across domains but it is unclear which reductions are associated with transition to frank psychosis. The aim of this study was to investigate differences in baseline neurocognitive performance between UHR participants with (UHR-P) and without transition to psychosis (UHR-NP) and a healthy control (HC) group and examine neurocognitive predictors of transition over the medium to long term.MethodA sample of 325 UHR participants recruited consecutively from the Personal Assessment and Crisis Evaluation (PACE) Clinic in Melbourne and 66 HCs completed a neurocognitive assessment at baseline. The UHR group was followed up between 2.39 and 14.86 (median = 6.45) years later. Cox regression was used to investigate candidate neurocognitive predictors of psychosis onset.ResultsThe UHR group performed more poorly than the HC group across a range of neurocognitive domains but only performance on digit symbol coding and picture completion differed between the groups. The risk of transition was only significantly associated with poorer performance on visual reproduction [hazard ratio (HR) 0.919, 95% confidence interval (CI) 0.876–0.965, p = 0.001] and matrix reasoning (HR 0.938, 95% CI 0.883–0.996, p = 0.037). These remained significant even after controlling for psychopathology at baseline.ConclusionsThis study is the longest follow-up of an UHR sample to date. UHR status was associated with poorer neurocognitive performance compared to HCs on some tasks. Cognition at identification as UHR was not a strong predictor of risk for transition to psychosis. The results suggests the need to include more experimental paradigms that isolate discrete cognitive processes to better understand neurocognition at this early stage of illness. [ABSTRACT FROM PUBLISHER]

BackgroundSubclinical psychotic experiences during adolescence may represent liability for developing psychotic disorder. Both coping style and the degree of persistence of psychotic experiences may play a role in the progression to clinical psychotic disorder, but little is known about the causal relationship between the two.MethodPath modelling was used to examine longitudinal relationships between subclinical positive psychotic experiences and three styles of coping (task-, emotion- and avoidance-oriented) in an adolescent general population sample (n=813) assessed three times in 3 years. Distinct developmental trajectories of psychotic experiences, identified with growth mixture modelling, were compared on the use of these coping styles.ResultsOver time, emotion-oriented coping in general was bi-directionally related to psychotic experiences. No meaningful results were found for task- or avoidance-oriented coping. Females reported using a wider range of coping styles than males, but the paths between coping and psychotic experiences did not differ by gender. Persistence of psychotic experiences was associated with a greater use of emotion-oriented coping, whereas a decrease in experiences over time was associated with an increased use of task-orientated coping.ConclusionsEmotion-oriented coping is the most important coping style in relation to psychotic experiences, as it may contribute to a ‘vicious cycle’ and is associated with persistence of experiences. In addition, more task-oriented coping may result in a decrease in psychotic experiences. Results suggest that opportunities for intervention may already be present at the level of subclinical psychosis. [ABSTRACT FROM PUBLISHER]

Objectives: This study investigated changes in left atrial (LA) volumes and phasic atrial function, by deciles, with normal aging. Background: LA volume increase is a sensitive independent marker for cardiovascular disease and adverse outcomes. To use this variable more effectively as a marker of pathology and a gauge of outcome, physiological changes due to aging alone need to be quantitated. Methods: A detailed transthoracic echocardiogram was performed in 220 normal subjects; 89 (41%) were male and their age ranged from 20 to 80 years (mean 45 ± 17 years). Maximum (end-ventricular systole), minimum (end-ventricular diastole), and pre–a-wave volumes were measured using the biplane method of disks. LA filling, passive emptying, conduit and active emptying volumes, and fractions were calculated. Transmitral inflow, pulmonary vein flow, and pulsed-wave Doppler tissue imaging parameters were measured as expressions of left ventricular diastolic function. For purposes of analysis, subjects were divided by age deciles. Results: LA indexed maximum (0.05 ml/m2 per year) and minimum (0.06 ml/m2 per year) volume increased with age but only became significant in the eighth decade (26.0 ± 6.3 ml/m2, p = 0.02, and 13.5 ± 3.9 ml/m2, respectively; p < 0.001). Impaired left ventricular diastolic relaxation was apparent in decade 6 and was associated with a shift in phasic LA volumes so that LA expansion index and passive emptying decreased with increasing age, whereas active emptying volume increased. Conclusions: In normal healthy subjects, LA indexed volumes remain nearly stable until the eighth decade when they increase significantly. Therefore, an increase in LA size that occurs before the eighth decade is likely to represent a pathological change. Changes in phasic atrial volumes develop earlier consequent to age-related alteration in LV diastolic relaxation. [ABSTRACT FROM AUTHOR]

Background: Quantitative stress echocardiography enables calculation of left-ventricular power-to-mass ratio (LVPMR) at peak exercise, a novel measure of cardiac performance per unit mass of myocardial tissue. We hypothesized that LVPMR at peak exercise provides prognostic information beyond established echocardiographic indices such as left-ventricular ejection fraction (LVEF) and left-ventricular mass index (LVMI). Methods: LVPMR (watts/kilogram) at peak exercise was defined as (k × heart rate × mean arterial pressure × stroke volume)/LV mass. We measured LVPMR in 918 adults with stable ambulatory coronary artery disease recruited for the Heart and Soul Study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for all-cause mortality, cardiovascular death, nonfatal myocardial infarction, heart failure hospitalization, and combined adverse cardiovascular events. Multivariate adjustments were made for established risk factors including LVEF and LVMI. The prognostic value of LVPMR was also compared with established exercise parameters using receiver-operating characteristic curve analysis. Results: Compared with patients in the highest LVPMR quartile, those in the lowest quartile were at increased risk of all-cause mortality (adjusted HR 1.9; 95% CI 1.1–3.3), heart failure hospitalization (adjusted HR 2.9; 95% CI 1.2–6.9), and combined adverse cardiovascular events (adjusted HR 1.9; 95% CI 1.1–3.4). In comparison with the rate-pressure product and the Duke treadmill score, LVPMR did not add significant prognostic value (p > 0.1 for c-statistic comparisons). Conclusions: In patients with stable ambulatory coronary artery disease, LVPMR at peak exercise predicts mortality, heart failure hospitalization, and adverse cardiovascular events. However, LVPMR does not add significant prognostic information beyond established exercise test parameters. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD.Methods: We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible.Results: 7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples.Limitations: Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms.Conclusions: Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state. [ABSTRACT FROM AUTHOR]

: ObjectivesWe sought to test whether the ratio of peak tricuspid regurgitant velocity (TRV, ms) to the right ventricular outflow tract time-velocity integral (TVIRVOT, cm) obtained by Doppler echocardiography (TRV/TVIRVOT) provides a clinically reliable method to determine pulmonary vascular resistance (PVR).: BackgroundPulmonary vascular resistance is an important hemodynamic variable used in the management of patients with cardiovascular and pulmonary disease. Right-heart catheterization, with its associated disadvantages, is required to determine PVR. However, a reliable noninvasive method is unavailable.: MethodsSimultaneous Doppler echocardiographic examination and right-heart catheterization were performed in 44 patients. The ratio of TRV/TVIRVOT was then correlated with invasive PVR measurements using regression analysis. An equation was modeled to calculate PVR in Wood units (WU) using echocardiography, and the results were compared with invasive PVR measurements using the Bland-Altman analysis. Using receiver-operating characteristics curve analysis, a cutoff value for the Doppler equation was generated to determine PVR >2WU.: ResultsAs calculated by Doppler echocardiography, TRV/TVIRVOT correlated well (r = 0.929, 95% confidence interval 0.87 to 0.96) with invasive PVR measurements. The Bland-Altman analysis between PVR obtained invasively and that by echocardiography, using the equation: PVR = TRV/TVIRVOT × 10 + 0.16 , showed satisfactory limits of agreement (mean 0 ± 0.41). A TRV/TVIRVOT cutoff value of 0.175 had a sensitivity of 77% and a specificity of 81% to determine PVR >2WU.: ConclusionsDoppler echocardiography may provide a reliable, noninvasive method to determine PVR. [Copyright &y& Elsevier]

: BackgroundWhether B-type natriuretic peptide (BNP) levels can be used to screen for ventricular dysfunction in patients at risk of heart failure but without overt symptoms is not known. We examined the characteristics of a BNP test for identifying systolic and diastolic dysfunction in outpatients with stable coronary disease.: MethodsIn a cross-sectional study of 293 outpatients who had stable coronary disease and no history of heart failure, we compared elevations in plasma BNP levels with echocardiography for the diagnosis of systolic dysfunction (ejection fraction <55%) and diastolic dysfunction (diastolic dominant pulmonary vein flow with ejection fraction ≥55%).: ResultsA total of 48 patients (16%) had systolic dysfunction, and among the remaining 245 with preserved systolic function, 31 (13%) had diastolic dysfunction. At the standard cutpoint of >100 pg/mL, an elevated BNP level was 38% sensitive (80% specific) for systolic dysfunction and 55% sensitive (85% specific) for diastolic dysfunction. Negative likelihood ratios were 0.8 (95% confidence interval [CI]: 0.6 to 1.0) for systolic dysfunction and 0.5 (95% CI: 0.4 to 0.8) for diastolic dysfunction. Positive likelihood ratios were 1.9 (95% CI: 1.2 to 2.9) for systolic dysfunction and 3.8 (95% CI: 2.4 to 5.9) for diastolic dysfunction. Areas under the receiver operating characteristic curves were 0.59 (95% CI: 0.49 to 0.69) for systolic dysfunction and 0.79 (95% CI: 0.71 to 0.87) for diastolic dysfunction.: ConclusionThese data suggest that BNP is not a useful screening test for asymptomatic ventricular dysfunction in patients with stable coronary disease. [Copyright &y& Elsevier]