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Solid state cameras (D-SPECT) have superior spatial resolution compared to Anger (A-SPECT) cameras. Furthermore, protocols for D-SPECT typically involve upright and supine scanning. We sought to determine the effect of resolution and position on left ventricular ejection fraction (LVEF) and volumes

Don't let dummy codes get the better of you, says Andrew D. Althouse, a biostatistician at the University of Pittsburgh Medical Center

The Bypass Angioplasty Revascularization Investigation 2 Diabetes trial demonstrated similar long-term clinical effectiveness of revascularization (REV) and intensive medical (MED) therapy. Comparisons of post-intervention ischemic burden have not been explored but are relevant to treatment decisions. This study examined differences in 1-year stress myocardial perfusion SPECT (MPS) abnormalities by randomized treatment.MPS was performed in 1,505 patients at 1-year following randomization. MPS images were analyzed (masked to treatment) by a Nuclear Core Laboratory using a quantitative percent (%) of total, ischemic, and scarred myocardium. Cox proportional hazards models were used to estimate the relationship between MPS variables and trial endpoints.At 1-year, nearly all REV patients underwent the assigned procedure; while 16% of those randomized to MED received coronary REV. Patients randomized to REV exhibited fewer stress perfusion abnormalities than MED patients (P.001). CABG patients had more frequent ischemic and scarred myocardium encumbering ≥ 5% of the myocardium when compared to those receiving PCI. Patients randomized to MED had more extensive ischemia and the median % of the myocardium with perfusion abnormalities was lower following REV (3% vs 9%, P = .01). A total of 59% of REV patients had no inducible ischemia at 1-year compared to 49% of MED patients (P.001). Within the CABG stratum, those randomized to MED had the greatest rate of ischemic (P = .032) and scarred (P = .017) perfusion abnormalities. At 1-year, more extensive and severe stress myocardial perfusion abnormalities were associated with higher 5-year rates of death and a combined endpoint of cardiac death or myocardial infarction (MI) rates (11.3%, 8.1%, 6.8%, for ≥ 10%, 5%-9.9%, and 1-4.9% abnormal myocardium at stress, respectively, P.001). In adjusted models, selected MPS variables were significantly associated with an increased hazard of cardiac death or MI (hazard ratio = 1.11 per 5% increase in abnormal myocardium at stress, P = .004).Patient management strategies that focus on ischemia resolution can be useful to guide the efficacy of near-term therapeutic approaches. A 1-year post-therapeutic intervention myocardial perfusion scan provides important information regarding prognosis in stable CAD patients with diabetes.

151 Background: The “surprise question” – “Would you be surprised if this patient died in the next year?” has been validated in non-gynecologic cancer as highly predictive of 12-month mortality. It has been used as a major inclusion criterion in studies showing benefit to specialized palliative care. It has not been studied in the gynecologic oncology (GO) population or with non-physician providers. Our objectives were to (1) evaluate the prognostic significance of the surprise question in GO patients and (2) compare the performance of the surprise question among different provider groups. Methods: The surprise question was asked of a group of 18 GO providers from a single academic institution (7 physicians, 7 advanced practice providers (APP) and 4 chemotherapy nurses (RN)) regarding their patients currently receiving radiation or chemotherapy. Demographic and clinical data were abstracted from chart review and mortality data was collected 12 months later. Results: The 263 patients included had a median age of 64 and the majority were white (94%). The most common cancer was ovary (50%), 58% had stage III/IV disease and 46% had recurrent disease. There were 54 deaths (20.5% one-year mortality). Risk of mortality was significantly higher for patients with a response of “No” to the surprise question from the MD (40% vs 10.6%, p < 0.01), APP (43.2% vs 7.6%, p < 0.01) and RN (50.8% vs 13.1%, p < 0.01). The unadjusted odds ratio for death within a year associated with a “No” answer to the surprise question by provider were as follows: MD OR 5.6 (p < 0.001), APP 9.21 (p < 0.001), RN 6.86 (p < 0.001). The APP group had the highest sensitivity (79.5%), while the RN group had the best specificity (75.6%). Conclusions: The surprise question is a simple, feasible and effective tool to identify patients with gynecologic cancer who have a greatly increased risk of 12-month morality when administered by physicians, advanced practice providers or chemotherapy nurses. This one question screen could be used to identify patients appropriate for early referral to specialized palliative care or patients in whom to consider initiating conversations about goals of care and advanced care planning.

Objective The objective of the study was to compare the pharmacokinetics of 2 g and 3 g doses of cefazolin when used for perioperative prophylaxis in obese gravidae undergoing cesarean delivery. Study Design We performed a double-blinded, randomized controlled trial from August 2013 to April 2014. Twenty-six obese women were randomized to receive either 2 or 3 g intravenous cefazolin within 30 minutes of a skin incision. Serial maternal plasma samples were obtained at specific time points up to 8 hours after drug administration. Umbilical cord blood was obtained after placental delivery. Maternal adipose samples were obtained prior to fascial entry, after closure of the hysterotomy, and subsequent to fascial closure. Pharmacokinetic parameters were determined via noncompartmental analysis. Results The median area under the plasma concentration vs time curve was significantly greater in the 3 g group than in the 2 g group (27204 μg/mL per minute vs 14058 μg/mL per minute; P = .001). Maternal plasma concentrations had an impact by body mass index. For every 1 kg/m 2 increase in body mass index at the time of the cesarean delivery, there was an associated 13.77 μg/mL lower plasma concentration of cefazolin across all time points ( P = .01). By the completion of cesarean delivery, cefazolin concentrations in maternal adipose were consistently above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria with both the 2 g and 3 g doses. The median umbilical cord blood concentrations were significantly higher in the 3 g vs the 2 g group (34.5 μg/mL and 21.4 μg/mL; P = .003). Conclusion Cefazolin concentrations in maternal adipose both at time of hysterotomy closure and fascial closure were above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria when either 2 g or 3 g cefazolin was administered as perioperative surgical prophylaxis. Maternal cefazolin concentrations in plasma and maternal adipose tissue are related to both dose and body mass index.

Objective The purpose of this study was to identify differences of early-pregnancy body fat percentage and body mass index (BMI) between obese women that experienced preeclampsia and those who did not. Study Design We performed an analysis of the Prenatal Exposures and Preeclampsia Prevention 3 longitudinal cohort study of preeclampsia mechanisms in obese and overweight women. Women completed questionnaires regarding their health behaviors; had hematocrit level, weight and height, and waist and hip circumferences measured, and had resistance and reactance measured by bioelectric impedance analysis machine during the first, second, and third trimesters. Total body water, fat mass, and percent body fat were calculated with the use of pregnancy-specific formulas. Preeclampsia was assessed with the clinical definition and a research definition (clinical preeclampsia plus hyperuricemia). Logistic regression models were constructed to analyze early-pregnancy BMI and body fat percentage (measured at 10.2 ± 3.0 weeks of gestation) as predictors of preeclampsia outcomes. Results Three hundred seventy-three women were included in the analysis: 30 women had preeclampsia by clinical definition (8.0%), and 14 women had preeclampsia by the research definition (3.8%). There was no relationship between BMI and preeclampsia risk in obese women; however, body fat percentage was associated significantly with increased risk of both the clinical definition of preeclampsia and the research definition. In 239 obese women, a 1% increase in body fat was associated with approximately 12% increased odds of clinical preeclampsia and 24% increased risk of preeclampsia by the research definition. Conclusion Early-pregnancy body fat appears to be important in the pathophysiologic condition of preeclampsia in obese women.

Background Chronic arterial stiffness contributes to the negative health effects of obesity and insulin resistance, which include hypertension, stroke, and increased cardiovascular and all-cause mortality. Weight loss and improved insulin sensitivity are individually associated with improved central arterial stiffness; however, their combined effects on arterial stiffness are poorly understood. The purpose of this study was to determine how insulin levels modify the improvements in arterial stiffness seen with weight loss in overweight and obese young adults. Methods To assess the effects of weight loss and decreased fasting insulin on vascular stiffness, we studied 339 participants in the Slow the Adverse Effects of Vascular Aging (SAVE) trial. At study entry, the participants were aged 20–45, normotensive, non-diabetic, and had a body-mass index of 25–39.9 kg/m2. Measures of pulse wave velocity (PWV) in the central (carotid-femoral (cfPWV)), peripheral (femoral-ankle (faPWV)), and mixed (brachial-ankle (baPWV)) vascular beds were collected at baseline and 6 months. The effects of 6-month change in weight and insulin on measures of PWV were estimated using multivariate regression. Results After adjustment for baseline risk factors and change in systolic blood pressure, 6-month weight loss and 6-month change in fasting insulin independently predicted improvement in baPWV but not faPWV or cfPWV. There was a significant interaction between 6-month weight change and change in fasting insulin when predicting changes in baPWV (p baPWV. Conclusions Young adults with excess weight who both lower their insulin levels and lose weight see the greatest improvement in vascular stiffness. This improvement in vascular stiffness with weight loss and insulin declines may occur throughout the vasculature and may not be limited to individual vascular beds. Trial registration NCT00366990