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Background Chronic kidney disease (CKD) is a predictor of morbidity and mortality in patients undergoing percutaneous coronary interventions (PCIs), and African American (AA) patients have been reported to have worse outcomes after PCI. Methods We assessed whether CKD affects the rate of death and major adverse cardiovascular events (MACE = myocardial infarction, revascularization, and death) differently in AA and white (CC) patients 1 year after PCI. Accordingly, we reviewed the database of all patients referred for PCI in the Emory Healthcare System between January 2001 and December 2004. Results We identified 800 CC and 116 AA patients with CKD among 4,372 patients referred for PCI. Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) 2 ) calculated by means of the Cockcroft-Gault equation. The AA patients with CKD were younger and had a larger number of comorbidities than the CC subjects. However, neither mortality nor MACE differed between races (14.7% vs 13.1%, P = .65 and 31.9% vs 31.3%, P = .89, respectively). In multivariable models, eGFR and emergency PCI were the best predictors of any adverse event, whereas prior PCI or coronary artery bypass surgery was a predictor of MACE alone. A test for interaction failed to show a significant effect of race and CKD on outcome. Conclusions In a tertiary referral center, AA and CC patients with CKD had a similar mortality rate and MACE at 1 year after PCI. Race was not a determinant of outcome, whereas CKD was.

Although patient participation in the medical encounter confers significant benefits, many patients are reluctant to ask questions of their physicians. Patients' literacy level may affect their level of participation and question-asking behaviors.To examine the effect of literacy on the number and types of questions asked by patients during primary care office visits.Convenience sample recruited between April and November 2004. Physician-patient visits were audiotaped, and patient questions from complete encounters (N = 57) were coded using an adaptation of the Roter Interaction Analysis System.Participants were predominantly middle-aged (mean age = 56.7 years), female (75.4%), and African American (94.7%). Low literacy skills (or = 6th grade reading level) were present in 38.6%.We hypothesized prospectively that low-literacy patients would ask fewer total questions and fewer questions about key aspects of their medical care.Low-literacy adults asked significantly fewer questions about medical care issues (median = 4 vs 6 among patients with higher literacy levels, p = .014). They also tended to ask fewer questions overall (median = 7 vs 10, p = .070). Low-literacy patients were more likely to ask the physician to repeat something (p = .013), indicating an initial lack of understanding. They were less likely to use medical terminology, refer to medications by name, request additional services, or seek new information. Question-asking behavior was not significantly related to patient gender, age, years of education, or physician-patient gender concordance.Literacy level appears to be an important determinant of patients' participation in the medical encounter. Low-literacy patients ask fewer questions about their medical care, and this may affect their ability to learn about their medical conditions and treatments.

Increased aortic stiffness, as measured by pulse wave velocity (PWV) and augmentation index (Aix), and vascular calcification have been associated with an unfavourable cardiovascular outcome in hemodialysis patients. However, the majority of data have been published in white patients and epidemiological data are discordant on the fate of patients of different races. In this cross sectional study we measured PWV and Aix by applanation tonometry and coronary artery and thoracic aorta calcium score (CAC and AoC) by electron beam tomography (EBT) in 81 Blacks and 61 Whites on maintenance hemodialysis. Vascular stiffness measurements and EBT scans were performed within a week of each other. There was no difference between races in age, systolic blood pressure or gender distribution. Blacks had a more frequent history of hypertension (100% versus 89%; P=0.002), lower prevalence of dyslipidemia (30% versus 66%; P0.001), higher PTH levels (geometric mean 607 pg/ml versus 245 pg/ml; P=0.039), received calcium based phosphate binders less frequently (37% versus 60%, P=0.007) and calcium antagonists more frequently than Whites (54% versus 28%; P=0.003). Nonetheless, the unadjusted and risk adjusted PWV and Aix, as well as CAC and AoC were not statistically different between races. In this dialysis cohort there was no difference in markers of vasculopathy between black and white patients despite differences in baseline clinical characteristics. Epidemiological data from the general population indicate that Blacks have lower calcium scores and stiffer vessels than Whites. Some studies in the renal populations suggest a better and others a similar survival of Blacks and Whites on hemodialysis. Our findings raise the important question of the prognostic significance of markers of vasculopathy in patients of different races and with different risk profiles.

Healthcare is experiencing significant global changes in the organization of delivery services, leading to a quest for ways to enhance providers' work and the quality of their patient care. Organiz...

Background Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes. Objective We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi. Methods A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts. Results The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (−0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (−1.209, P P = .029), and increased number of biopsies before the initial PLC (−0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC. Limitations This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period. Conclusion Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.

Background Recent experimental and clinical data suggest that lowering serum lipid levels with statins may prevent or delay the process of restenosis. The purpose of this trial is to determine whether lipid levels relate to restenosis and/or whether statin therapy can prevent or delay the process of restenosis after intracoronary stenting. Methods One hundred thirty-six patients who underwent single coronary artery stenting from June 1995 to June 1997 in our institution were included in the study. All these patients were followed for at least 9months (mean 392 ± 148days) for major adverse cardiac events (MACE). We defined as MACE the occurrence of death, myocardial infarction, or need for target lesion revascularization. From this cohort, 103 patients had at least one lipid parameter from the lipid profile evaluated within 2months from the date of the procedure. Patients who had the stent because of an acute myocardial infarction were included in the study only if their lipid profile was evaluated before or at least 6weeks after the event. Patients with triglyceride levels above 500 had both triglyceride and low-density lipoprotein cholesterol levels excluded from the statistical analysis. Patients were divided into two groups based on lipid levels: normal (Group I; n=31) and elevated (Group II; n=72). Patient outcomes were also analyzed by statin therapy use. Results There was no significant difference in MACE rates between the two groups when outcomes were analyzed by lipid levels (22.6% versus 20.8% P = 0.8). Furthermore, outcomes were analyzed by use of statin therapy (Group III, n=53, on statin versus Group IV, n=50, on no statin). There was also no difference in MACE rates between the two groups (20.8% versus 22%; P = 0.8). Conclusion The process of restenosis has unique features that differentiate it from atherosclerosis. Although lipid-lowering therapy is crucial in delaying the process of atherosclerosis, its role in the prevention of restenosis is yet to be proven.

The aim of this study was to evaluate the differences in 5-year outcomes among diabetic and nondiabetic patients undergoing saphenous vein graft (SVG) percutaneous coronary intervention (PCI) prior to the era of distal protection and drug-eluting stents.PCI of native coronary arteries is known to be associated with higher rates of adverse outcomes in diabetic patients compared to nondiabetic patients. However, the impact of diabetes on long-term outcomes after SVG interventions is not as well established. We conducted an evaluation of 5-year outcomes after SVG PCI in the two decades prior to the availability of distal protection devices and drug-eluting stents.Data on 2,556 subjects (1,780 nondiabetic and 776 diabetic) undergoing SVG PCI at Emory Hospital from 1981 to 2001 were collected and entered into a computerized database and analyzed for adverse cardiovascular outcomes.Compared to the nondiabetic group, the diabetic group had worse 1-year (87.7% vs. 94.9%; p0.0001) and 5-year survival rates (62.9% vs. 78.5%; p0.0001). In the subset of patients receiving stents, 5-year survival remained significantly worse in the diabetic group (78.2% vs. 87.1%; p = 0.009). After multivariate analysis, diabetes was an independent predictor of 5-year mortality (hazard ratio = 1.8; 95% CI = 1.5-2.5; p0.0001).Diabetic patients undergoing vein graft PCI prior to the distal protection and drug-eluting stent era had significantly worse long-term outcomes compared to nondiabetic patients. The effect on long-term outcomes using these newer devices in diabetic subjects undergoing SVG PCI must be established for a true assessment of their impact.

Percutaneous coronary intervention (PCI) remains a major therapeutic option for the treatment of chronic coronary artery disease. In the COURAGE trial, 2287 patients with chronic coronary disease were randomized between PCI with medical management and medical management alone. Embedded within the COURAGE trial is a detailed economic analysis being conducted in three health care systems: the US Veterans Administration (VA), Canada, and the US non-VA. Resource use and costs are being collected for each system and overall. Survival is assessed internally in the trial with mean follow-up of 4.5 years. Long-term mean survival will be estimated by projecting survival beyond the trial period by extrapolating the in-trial hazard rates. Utility is being assessed at baseline and at 1, 3, and 6 months and annually thereafter, using a computer-administered standard gamble. Quality-adjusted life years are calculated by multiplying survival by utility. The incremental cost-effectiveness ratio of PCI will be defined as the additional cost of PCI divided by the gain in life years and quality-adjusted life years. The 95% confidence regions of efficacy and costs will be determined by bootstrap over a range of acceptability thresholds, which will then be displayed in the cost-effectiveness plane and as a cost-effectiveness acceptability curve. A multilevel regression model will assess cost-effectiveness from a net benefit perspective. These approaches should provide the most detailed assessment available of the cost-effectiveness of PCI for coronary artery disease.

Purpose Panel reactive antibody (PRA) is used to screen patients being evaluated for heart transplantation (HT). Whether there are significant racial or ethnic differences in PRA among adults awaiting HT is poorly characterized. Our purpose was to investigate wait list characteristics and graft survival as a function of race and PRA. Methods and Materials All White, Black or Hispanic subjects age ≥18 (N=26,090) listed for their first HT between 1986 and 2012 were identified in the OPTN database. A PRA value of >10 was used to define clinically meaningful sensitization. Results Compared to whites and Hispanics, blacks were younger at listing and there was a higher proportion of females. Blacks had a higher peak PRA, and were more likely to be sensitized. Blacks were more likely to have graft failure than Whites or Hispanics (68% vs. 60% vs. 56%, p figure 1 ] Conclusions Race and level of sensitization are important predictors of graft survival. White N=21477 Black N=3021 Hispanic N=1258 p Age, yrs 52±11 46±12 49±12 Male (%) 17,171 (80) 1942 (64) 956 (76) Days on Wait List 210±293 191±300 164±270 Most recent PRA 3.6±12.8 4.3±14.0 3.9±13.1 0.006 Peak PRA 6.2±17.3 7.4±18.7 5.9±16.1 0.001 PRA >10% 2910 (14) 496 (16) 175 (14)

This study sought to evaluate the long-term cost effectiveness of a clopidogrel loading strategy before percutaneous coronary intervention (PCI) followed by continued treatment for one year.The Clopidogrel for the Reduction of Events During Observation (CREDO) trial, a randomized trial of 2,116 patients, showed the effectiveness of antiplatelet therapy with clopidogrel 300 mg before PCI and 75 mg daily for one year afterward compared with placebo load and placebo days 29 to 365 in reducing the combined risk of death, myocardial infarction, and stroke. All patients received clopidogrel on days 1 to 28 and aspirin on days 1 to 365.All hospitalizations were assigned a diagnosis-related group. Associated costs were estimated three ways (including professional costs): 1) Medicare costs, 2) MEDSTAT costs, and 3) blend with Medicare for those ageor = 65 years and MEDSTAT for those age65 years. Clopidogrel 75 mg cost 3.22 dollars. Life expectancy in trial survivors was estimated using external data. Confidence intervals were assessed by bootstrap.The primary composite end point occurred in 89 (8.45%) clopidogrel patients and in 122 (11.48%) placebo patients (relative risk reduction [RRR] 26.9%; 95% confidence interval [CI] 3.9% to 44.4%). The number of life-years gained (LYG) with clopidogrel was 0.1526 (95% CI 0.0263 to 0.2838) using Framingham data and 0.1920 (95% CI 0.054 to 0.337) using Saskatchewan data. Average total costs were 664 dollars higher for the clopidogrel arm (95% CI -461 dollars to 1,784 dollars). The incremental cost-effectiveness ratios (ICERs) based on Framingham data ranged from 3,685 dollars/LYG to 4,353 dollars/LYG, with over 97% of bootstrap-derived ICER estimates below 50,000 dollars/LYG. The ICERs based on Saskatchewan data were 2,929 dollars/LYG to 3,460 dollars/LYG, with over 98% of estimates below 50,000 dollars/LYG.Platelet inhibition with clopidogrel loading before PCI followed by therapy for one year is highly cost effective.

Objective To determine the clinical features in HIV-positive patients with and without infective endocarditis (IE). Patients and Methods All bacteremic, HIV-positive patients with suspected IE admitted over a four-year period who underwent either transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE) were retrospectively reviewed with regard to clinical, laboratory, and demographic characteristics. Results Ten (11.5%) of 87 HIV-positive patients had a clinical diagnosis of IE based on the Duke Criteria. The mean age of patients with IE was 37.8 years and without IE 39.9 years ( P = NS). Both patient groups were similar with respect to gender, race, IVDA, renal failure requiring hemodialysis, history of predisposing heart disease, origin of infection, and causative organism of infection. The mean CD4 count (cells/ μ L) was 200.7 in patients with IE and 95.9 in patients without IE ( P = NS). Of 10 HIV-positive patients with IE, seven had left-sided heart involvement, two had complications related to IE, three required cardiothoracic surgery, and three died. Conclusions There were no differences found with regard to the clinical characteristics of HIV-positive patients with and without IE. No correlation could be drawn between mortality and the degree of immunosuppression in patients from this study. The high incidence of IE (11.5%) and mortality rate (30%) in this study suggests that IE in HIV-positive patients, including non-intravenous drug abusers, represents a real concern for clinicians and their management of these patients.

To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC).Prospective cost analysis with each patient serving as his or her own control.Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center.A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears.The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure(because this outcome affects overall cost).Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs (937 vs 1029 US dollars; P =.16) or a subsequent TSE (937 vs 944 US dollars; P =.53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly (956 vs 1399 US dollars; P.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen.If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.

Studies of the effects of menopausal hormone therapy on coronary artery disease (CAD) in postmenopausal women have provided contradictory results. Although recent experimental studies have revealed no beneficial effect of combination therapy with estrogen (E) and progesterone (P), the effect of monotherapy with E remains unknown. We retrospectively examined the medical records of 843 consecutive women aged > or =55 years who underwent their first cardiac catheterization between January 1996 and December 1998. We compared the presence and severity of CAD, defined as > or =1 diseased coronary vessel (with stenosis > or =50%), in women who only took E, E+P, or no menopausal hormone therapy. In all, 210 women (33%) took hormones, of whom 47 (22%) used E+P and 163 (78%) used E only. Women who used any hormones tended to be healthier than nonusers, but E+P users had a lower prevalence of risk factors and co-morbidities than E users. In unadjusted analyses, both the E and E+P groups were significantly less likely to have CAD than nonusers (relative risk [RR] 0.71, 95% confidence interval [CI] 0.58 to 0.84 for the E group; RR 0.76, 95% CI 0.54 to 0.99 for the E+P group). Demographic factors, CAD risk factors, co-morbidities, and primary prevention medication use explained the association between E+P and the presence of CAD (RR 1.14, 95% CI 0.74 to 1.39). In contrast, adjustment for these factors had a minimal effect on the association between E and CAD compared with nonusers (RR 0.79, 95% CI 0.59 to 0.98). Thus, the apparent protective effect of combination menopausal hormone therapy with E+P on CAD is due to differences in other patient characteristics. In contrast, unopposed E therapy may have a protective effect on CAD.

Objectives This study evaluated the cost-effectiveness of administering prophylactic intravenous (IV) amiodarone therapy to patients undergoing cardiac surgery according to their predicted risk of postoperative atrial fibrillation. Background Atrial fibrillation (AF) is a common complication of cardiovascular surgery that is associated with a significant increase in hospitalization costs. Intravenous amiodarone has been shown to decrease the incidence of postoperative AF. Methods All 8,709 patients who underwent coronary artery bypass grafting (CABG), 1,217 patients who underwent valve replacement and 624 patients who underwent CABG and valve replacement procedures (CABG + valve) from January 1, 1994, to June 30, 1999, at Emory University Hospitals were studied. Models predicting the risk of AF were developed using logistic regression; linear regression was used to estimate the influence of AF on hospitalization costs. Cost-effectiveness was evaluated for patient subsets identified according to their predicted risk of AF. Results Postoperative AF rates were 17.7% for CABG, 24.6% for valve and 33.8% for CABG + valve. Using $5,000 as an acceptable cost per episode of atrial fibrillation averted, prophylactic IV amiodarone in CABG patients was not found to be cost-effective. Therapy would be recommended for roughly 5% of valve patients with a predicted risk of atrial fibrillation >45%, and roughly two thirds of CABG + valve patients who have a predicted risk of >30%. Conclusions Cost-effectiveness of prophylactic IV amiodarone varies according to type of surgery and the predicted risk of atrial fibrillation. Older patients undergoing valve replacement, particularly those with a history of chronic obstructive pulmonary disease, and those undergoing concomitant CABG are likely to be the most appropriate candidates for IV amiodarone therapy in the perioperative period.

Importance There is an increasing demand for a limited number of pigmented lesion clinic (PLC) visits at dermatology centers. Objective To determine the proportion of visits to PLCs that are more frequent (“additional screening”) than the recommended (“standard”) follow-up schedule and to determine if certain patient characteristics correlate with the demand for these visits. Design, Setting, and Participants A retrospective medical chart review of all PLC visits at an academic dermatology center from October 2010 to January 2012. A total of 609 patients associated with 1756 visits were identified. Of these, 25 patients associated with 26 visits were excluded owing to lack of melanoma diagnosis or risk factors, leaving 584 patients and 1730 visits. Diagnoses of these patients included in situ and invasive melanoma, dysplastic nevi, Spitz nevi, atypical nevus syndrome, family history of melanoma only, and other risk factors. The mean (SD) age was 48 (16) years, and 235 (40.2%) of the patients were male. Main Outcomes and Measures The proportion of additional screening visits compared with standard visits. Standard visits were defined as occurring at the following frequencies: annually for mildly dysplastic nevi, Spitz nevi, or solely family history of melanoma; biannually for the first year, then annually thereafter for moderately dysplastic nevi or atypical nevus syndrome; biannually for up to 3 years, then annually thereafter for severely dysplastic nevi or melanomas in situ; every 3 months for 2 years, biannually for the following 2 years, then annually thereafter for invasive melanoma. Results A total of 1400 visits (80.9%) were standard, 257 (14.9%) were for additional screening, and 73 (4.2%) were “problem focused.” Thirty percent of patients had at least 1 additional screening visit. The distribution of diagnoses among standard vs additional screening visits differed significantly, with “family history only” and “other risk factors” taking up a larger percentage of standard visits (15.1%) than the percentage of additional screening visits (8.9%), and all other diagnoses being better represented among additional screening visits ( P = .04). No particular patient characteristic described those who sought additional screening visits. Conclusions and Relevance A substantial proportion of additional screening PLC visits exist and are desired by all patients with pigmented lesions. We propose alternative clinic models, such as diagnosis-specific, adjunctive fee-for-additional-service, and teledermatology clinics to meet patient needs while creating resources to expand PLC visits.

Importance Neocollagenesis can be achieved using a dermal rolling needle device, thereby reducing the appearance of acne scars. Objective To determine the efficacy of a needling device for treatment of acne scars. Design, Setting, and Participants We performed a single-center, rater-blinded, balanced (1:1), split-face, placebo-controlled, parallel-group randomized clinical trial at an urban academic institution. The study took place from November 30, 2009, through July 27, 2010. Twenty healthy adults (age range, 20-65 years) with acne scars on both sides of the face were enrolled. Fifteen individuals completed the study, and no enrolled participants were withdrawn for adverse effects. Interventions For each participant, one side of the face was randomized for needling. Three needling treatments were performed at 2-week intervals. Main Outcomes and Measures Two blinded dermatologists separately rated participants’ acne scars based on standard digital photographs obtained at baseline and at the 3-month and 6-month follow-up visits on the quantitative global scarring grading system. Results Mean scar scores were significantly lower in the treatment group compared with baseline at 6 months (mean difference, 3.4; 95% CI, 0.2-6.5; P = .03) and nominally but not significantly lower compared with baseline at 3 months (mean difference, 2.4; 95% CI, −0.01 to 4.8; P = .052). In the control group, mean scar scores did not vary significantly from baseline at 3 months (mean difference, 1.0; 95% CI, −1.4 to 3.4; P = .96) and at 6 months (mean difference, 0.4; 95% CI, −2.3 to 3.5; P > .99). The needling procedure was not particularly painful, with a mean pain rating of 1.08 of 10. Participants perceived a 41% mean improvement in overall scar appearance on the treated side. No adverse events were reported. Conclusions and Relevance After 3 needling treatments, there was improvement in the appearance of acne scars over time compared with the control group, with minimal pain reported. Trial Registration clinicaltrials.gov Identifier:NCT00974870

Importance Evidence-based treatment guidelines are not available for primary cutaneous mucinous carcinoma (PCMC). Objective To assess outcomes associated with surgical treatment of PCMC. Data Sources MEDLINE, Cumulative Index to Nursing and Allied Health, and Embase from 1952 to 2010. Search terms were “primary cutaneous mucinous carcinoma,” “primary mucinous adenocarcinoma of the skin,” “primary mucinous sweat-gland carcinoma,” and “endocrine mucin-producing sweat gland carcinoma.” Study Selection Articles describing primary data on treatment (ie, case reports, case series, and cohort studies) of any patients with PCMC. A total of 116 articles were identified, with 90 of these assessed for eligibility and 87 used for final analysis. Data Extraction and Synthesis Each case was verified to be of primary cutaneous origin by 2 observers. Histopathologic descriptions were confirmed to be consistent with PCMC. Extracted fields included age, sex, race, lesion duration, tumor diameter, method of treatment, follow-up, and whether the lesion recurred or metastasized. Main Outcomes and Measures Outcomes were dichotomized into good and bad depending on the presence of recurrence or metastasis during follow-up. Multivariate logistic regression analysis was performed to determine significant factors for predicting bad outcomes. Results One hundred fifty-nine cases of PCMC, of whom 54.7% were male and 77.2% were white, with mean (SD) age 63.5 (13.2) years, were analyzed. Most had been treated with traditional surgical excision (85.5%), with only 9.4% of cases treated with Mohs surgery. Older (odds ratio [OR], 0.93;P = .04) and Asian (OR, 0.02;P = .01) patients had relatively better postsurgical outcomes. Larger tumors (OR, 6.71;P = .14), those persistent for longer prior to surgery (OR, 1.02;P = .11), and those located on the trunk (OR, 103.24;P = .005) also were associated with poorer outcomes. Limitations included reliance on case report data. Conclusions and Relevance Patient demographic characteristics and tumor-specific features may provide predictive information regarding the risk of postsurgical recurrence and metastasis after treatment of PCMC.

been reviewed in detail. 1 With recent changes in performing PCI, especially with the introduction of intracoronary stents, older data may not adequately reflect contemporary levels of risk. The present study examines the risk of in-hospital mortality following PCI in octogenarians in the stent era using a multiinstitutional database. ••• From January 1998 to June 1999, 2,968 patients 80 years of age underwent PCI in 17 of the National Cardiovascular Network of hospitals; all of these patients were included in this study. The National Cardiovascular Network is an alliance of hospitals that performs a minimum of 500 PCI procedures and 500 coronary artery bypass procedures annually. National Cardiovascular Network physicians meet or exceed American College of Cardiology volume requirements. All PCI procedures were performed using the standard techniques employed during the period of time in which the procedure took place. PCI procedures included balloon dilations, stent implantation, and the use of other new devices. Patients were considered to have diabetes based on a physician’ s diagnosis (nonstressed blood sugar 140 mg/dl on 2 occasions, although this could not reasonably be verified), or if they had received oral hypoglycemic agents or insulin, or were on diet therapy. Patients were considered to have narrowing of the coronary arteries if they had 70% diameter luminal narrowing in the left anterior descending, left circumflex, or right coronary arteries, or of a major branch. Patients had left main disease if there was 70% diameter luminal narrowing in the left main coronary artery. Patients experienced angiographic success if there was a decrease in postprocedure diameter stenosis to 50% and a decrease in percent stenosis by 20%. They were diagnosed with myocardial infarction if new Q waves were seen after the procedure. The variables defined by patient history were hypertension, severity of angina, and prior myocardial infarction. Angina was defined by the Canadian Cardiovascular Society Classification. Heart failure was defined by the New York Heart Association criteria. Demographic, clinical, angiographic, and procedural data, including complications, were recorded at the clinical sites and entered into a local computerized database. Data were sent to the data coordinating center at Emory semi-annually. All fields were defined in a data dictionary. Data are expressed as proportions or as mean SD. Categorical data were compared by chi-square and continuous by analysis of variance. Missing covariate data were imputed using an S-Plus (Mathsoft, Seattle, Washington) procedure that performs multiple imputation using relations among all variables to predict the missing observations. Multivariate correlates of discrete end points were analyzed with logistic regression. Potential nonlinear effects of each of the continuous predictor variables were checked using restricted cubic splines. Statistical modeling and testing were performed using S-Plus. The ability of the models to discriminate among patients with respect to their outcomes was measured using the c-index, which is equivalent to the area under the receiver-operating characteristic curve. Bootstrap validation and calibration of a singly imputed dataset were carried out using the “ validate”and “ calibrate”functions in the “ Design”library of S-Plus statistical functions. There were 2,968 patients with 105 deaths (3.54%). Demographic and clinical characteristics of the 2,485 patients with (13%) and without (87%) an acute myocardial infarction are listed in Table 1. Mean age was 84 years, most of the patients were women, and diabetes was common. Most of the patients had systemic hypertension, a minority had heart failure, and approximately half had unstable angina. Previous coronary artery bypass graft surgeries and PCIs were more common in patients without acute myocardial infarction. Comorbidities of cerebrovascular disease, peripheral vascular disease, renal insuf ficiency, and chronic obstructive pulmonary disease were each noted in a minority of patients. Angiographic characteristics and outcomes according to presentation with and without an acute myocardial infarction are listed in Table 2. Multivessel disease was noted in most of the patients. The mean ejection fraction was 50% and left ventricular end-diastolic pressure was 19 7 mm Hg. Most of the cases underwent elective procedures and stent usage was common. The need for coronary artery bypass grafts, and the occurrence of Q-wave myocardial infarction, and stroke occurred in a small minority of patients. The unadjusted relative risk of death for patients with an

Importance Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. Objectives To quantify adverse events associated with MMS and detect differences relevant to safety. Design, Setting, and Participants Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. Exposure Mohs micrographic surgery. Main Outcomes and Measures Intraoperative and postoperative minor and serious adverse events. Results Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. Conclusions and Relevance Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

The handheld umbrella (HU) is a commonly employed method of sun protection by women in many countries in Asia (45% in China1) and the Middle East. In Turkey, hats and umbrellas were found to be the most common photoprotection accessories.2

Objectives To establish the effect of sunless tanning products on tanning behaviors and to determine characteristics of sunless tanning product users. Design A cross-sectional survey study conducted between May 30, 2007, and December 4, 2007. Setting The Emory University campus and surrounding locations in Atlanta, Georgia. Participants Four hundred fifteen community and university-affiliated women. Main Outcome Measures Self-reported use of sunless tanning products and UV radiation tanning methods. Results Forty-eight percent of participants had used sunless tanning products, 70.6% had tanned in the sun, and 26.0% had used tanning beds at least once in the past year. Most participants (92.7%) believed that tanned skin is more attractive than untanned skin, and 79.2% reported feeling better about themselves when tan. Many sunless tanning product users reported decreased frequency of tanning in the sun (36.8%) or in tanning beds (38%) because of product use. Frequent users were more likely to have decreased their UV radiation exposure. Lighter complexion, frequent use of UV radiation tanning methods, feeling better about oneself when tan, and having a history of skin cancer were independently associated with sunless tanning product use. Conclusions The desire for tanned skin remains strong despite growing awareness of the dangers of UV radiation exposure. In some women, sunless tanning product use is associated with decreased UV radiation tanning frequency, especially in women who use them repeatedly. Improvements in the appearance of sunless tanning product tans may allow wider acceptance by the public and further decreases in UV radiation tanning practices.

RAS inhibitors (RASIs/ACE inhibitors & ARBs) have reduced mortality in SHF (EF 45p) in randomized controlled trials. Since, AAs are underrepresented in these trials, whether these results are applicable to AAs with HFPEF is uncertain All cause mortality was

Tuberous sclerosis (TS) is a common autosomal-dominant disorder characterized by tumors of the skin, lung, brain, and kidneys. Monotherapy with rapamycin however resulted in partial regression of tumors, implying the involvement of additional pathways. We have previously implicated platelet-derived growth factor-BB in TS-related tumorigenesis, thus providing a rationale for a combination of mTOR/PDGF blockade using rapamycin and imatinib. Here, we test this combination using a well-established preclinical model of cutaneous tumorigenesis in TS, tsc2ang1 cells derived from a skin tumor from a mouse heterozygous for tsc2. Treatment of tsc2ang1 cells with a combination of rapamycin and imatinib led to an inhibition of proliferation compared with either vehicle treatment or treatment with rapamycin or imatinib monotherapy. Combination therapy also led to a decrease in Akt activation. Potent in vivo activity in animal experiments by combination therapy was noted, without toxicity to the animals. Our findings provide a rationale for the combined use of rapamycin and imatinib, both FDA approved drugs, for the treatment of TS.

Context Although depression is associated with increased cardiovascular morbidity and mortality, there is virtually no information on whether it also increases the risk in young populations. Objectives We sought to determine the association of unipolar and bipolar depression and a history of attempted suicide with mortality due to ischemic heart disease (IHD) and cardiovascular disease (CVD) in young US adults and to examine potential sex differences. Design Longitudinal epidemiologic study. Setting Nationally representative sample of US adults. Participants A total of 7641 US adults aged 17 to 39 years from the 1988-1994 Third National Health and Nutrition Examination Survey. Main Outcome Measures Cardiovascular disease and IHD mortality. Unipolar/bipolar depression and a history of attempted suicide were assessed via the Diagnostic Interview Schedule. Results After a median follow-up of 14.9 years, a total of 51 subjects (0.67%) died of CVD causes and 28 (0.37%) died of IHD. Depression (538 individuals [7.04%]) and history of attempted suicide (419 [5.48%]) were each associated with an increased risk of IHD death, with adjusted hazard ratios of 3.70 (95% CI, 1.32-10.35) for depression and 7.12 (2.67-18.98) for a history of attempted suicide. Women with depression or a history of attempted suicide had a 3-fold adjusted risk of CVD (adjusted hazard ratio, 3.20 [95% CI, 1.12-9.17]) and a 14-fold adjusted risk of IHD (14.57 [2.65-80.10]). Corresponding figures for men were 2.37 (0.85-6.58) and 3.52 (1.05-11.76). Conclusion In adults younger than 40 years, depression and history of attempted suicide are significant independent predictors of premature CVD and IHD mortality in both sexes.

ObjectivesThis study sought to determine an aggregate, pathway-specific risk score for enhanced prediction of death and myocardial infarction (MI).BackgroundActivation of inflammatory, coagulation, and cellular stress pathways contribute to atherosclerotic plaque rupture. We hypothesized that an aggregate risk score comprised of biomarkers involved in these different pathways—high-sensitivity C-reactive protein (CRP), fibrin degradation products (FDP), and heat shock protein 70 (HSP70) levels—would be a powerful predictor of death and MI.MethodsSerum levels of CRP, FDP, and HSP70 were measured in 3,415 consecutive patients with suspected or confirmed coronary artery disease (CAD) undergoing cardiac catheterization. Survival analyses were performed with models adjusted for established risk factors.ResultsMedian follow-up was 2.3 years. Hazard ratios (HRs) for all-cause death and MI based on cutpoints were as follows: CRP ≥3.0 mg/l, HR: 1.61; HSP70 >0.625 ng/ml, HR; 2.26; and FDP ≥1.0 μg/ml, HR: 1.62 (p < 0.0001 for all). An aggregate biomarker score between 0 and 3 was calculated based on these cutpoints. Compared with the group with a 0 score, HRs for all-cause death and MI were 1.83, 3.46, and 4.99 for those with scores of 1, 2, and 3, respectively (p for each

ObjectivesThis study sought to determine and compare the prognostic and incremental value of positron emission tomography (PET) in normal, overweight, and obese patients.BackgroundCardiac rubidium 82 (Rb-82) PET is increasingly being used for myocardial perfusion imaging (MPI). A strength of PET is its accurate attenuation correction, thereby potentially improving its diagnostic accuracy in obese patients. The prognostic value of PET in obese patients has not been well studied.MethodsA total of 7,061 patients who had undergone Rb-82 PET MPI were entered into a multicenter observational registry. All patients underwent pharmacologic Rb-82 PET and were followed for cardiac death and all-cause mortality. Based on body mass index (BMI), patients were categorized as normal (