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This review focuses on three key noninvasive cardiac imaging modalities-cardiac CT angiography (CTA), MRI, and PET/CT-and summarizes key publications in 2021 relevant to radiologists in clinical practice. Although this review focuses primarily on articles published in

The Ars rhetorica attributed to Apsines of Gadara contains five cryptic references to a speech prosecuting the Athenian politician Aristogeiton for proposing an illegal law to raise state revenue. It is disputed whether Aristogeiton is supposed to have moved to legalize payment (μισθός) for ‘closing one’s eyes’ (μύϵιν, i.e. taking bribes) or for ‘initiating’ (μυϵῖν) into the Mysteries. It also remains a mystery how Aristogeiton’s scheme was to function. I argue that ‘initiate for pay’ is correct and that in fact Apsines wrote the declamation against Aristogeiton. I reason to the best explanation of ‘payment’: neither an entrance fee into the Mysteries nor a tax, but payment made by pilgrims to something like a syndicate empowered by contract to conduct preliminary initiation. Such a scheme would contravene religious norms. The declamation’s speaker therefore must have prosecuted Aristogeiton on an indictment of νόμον μὴ ἐπιτήδϵιον θϵῖναι (‘proposing an inexpedient law’) so far unparalleled in Greek declamation. Moreover, I suggest that Apsines’ marriage ties to the Keryx clan at Eleusis supports his authorship of the Ars. These cryptic references highlight the influence that the Mysteries and the figure of Aristogeiton exerted on composers of declamations in the Imperial period.

BackgroundObstructive sleep apnea (OSA) is an independent risk factor for cardiovascular (CV) morbidity and mortality, but the benefit of continuous positive airway pressure (CPAP) therapy is uncertain. However, most randomized-controlled trials have focused on the role of CPAP in secondary prevention although there is growing evidence of a potential benefit on early CV disease. Weight loss in combination with CPAP may be superior but is difficult to achieve and maintain with conventional measures alone. The aim of this study was to gain insights into the effect of CPAP on early atherosclerotic processes and to compare it to a glucagon-like-peptide (GLP)-1-mediated weight loss regimen in OSA.MethodsWe performed a randomized proof-of-concept study (clinicaltrials.gov:NCT04186494) comparing CPAP, a liraglutide-based weight loss regimen (Lir) alone or both in combination for 24 weeks in 30 non-diabetic patients with moderate to severe OSA (50±7 years, 80% males, apnea-hypopnea index [AHI] 50±19/hr, body mass index [BMI] 35.0 ±3 kg/m2). Baseline characteristics were similar between groups. Beside extensive evaluation for CV risk factors and endothelial function at baseline and end of study, subjects underwent 18F-fluorodeoxyglucose (FDG)-PET-CT for measurement of aortic wall inflammation (target-to-background ratio [TBR]) and coronary CT angiography (CCTA) for semi- automated coronary plaque analysis.ResultsCPAP alone and combination resulted in greater reduction in AHI than Lir alone at 24 weeks (mean difference -45/hr and -43/hr, respectively, vs -12/hr, pLow-attenuation coronary artery plaque volume as marker of unstable plaque also decreased with CPAP (from 571±490 to 334±185mm3) and with combination therapy (from 401±145 to 278±126mm3) but not with Lir.ConclusionThese data suggest that CPAP therapy, but not GLP-1 mediated weight loss, improves vascular inflammation and reduces low-attenuation coronary artery plaque volume in OSA patients. These novel findings support the benefit of CPAP therapy in modifying early CV disease.Clinical PerspectiveWhat is new?This is the first study comparing standard CPAP therapy to a GLP-1 mediated weight loss regimen in obstructive sleep apnea (OSA).The study utilized 18F-FDG PET CT and artificial intelligence-enabled coronary CT quantification of coronary artery plaque subtypes to determine treatment effects on early atherosclerotic disease processes.What are the clinical implications?CPAP in contrast to GLP-1-mediated weight loss may improve early atherosclerotic and potentially modifiable disease processes in obstructive sleep apnea (OSA).These data support the benefit of CPAP in the primary prevention of cardiovascular diseases in OSA.

Background Multisystem inflammatory syndrome in adults (MIS-A) is a severe condition temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention (CDC) case definition to identify diagnosed and undiagnosed MIS-A cases among adults discharged during April 2020–January 2021 from 4 Atlanta, Georgia hospitals affiliated with a single medical center. Non–MIS-A coronavirus disease 2019 (COVID-19) hospitalizations were identified using International Classification of Diseases, Tenth Revision, Clinical Modification encounter code U07.1. We calculated the ratio of MIS-A to COVID-19 hospitalizations, compared demographic characteristics of the 2 cohorts, and described clinical characteristics of MIS-A patients. Results We identified 11 MIS-A cases, none of which were diagnosed by the treatment team, and 5755 COVID-19 hospitalizations (ratio 1:523). Compared with patients with COVID-19, patients with MIS-A were more likely to be younger than 50 years (72.7% vs 26.1%, P < .01) and to be non-Hispanic Black (81.8% vs 50.0%, P = .04). Ten patients with MIS-A (90.9%) had at least 1 underlying medical condition. Two MIS-A patients (18.2%) had a previous episode of laboratory-confirmed COVID-19, occurring 37 and 55 days prior to admission. All MIS-A patients developed left ventricular systolic dysfunction. None had documented mucocutaneous involvement. All required intensive care, all received systemic corticosteroids, 8 (72.7%) required mechanical ventilation, 2 (18.2%) required mechanical cardiovascular circulatory support, and none received intravenous immunoglobulin. Two (18.2%) died or were discharged to hospice. Conclusions MIS-A is a severe but likely underrecognized complication of SARS-CoV-2 infection. Improved recognition of MIS-A is needed to quantify its burden and identify populations at highest risk.

We compared the characteristics of hospitalized and nonhospitalized patients who had coronavirus disease in Atlanta, Georgia, USA. We found that risk for hospitalization increased with a patient's age and number of concurrent conditions. We also found a potential association between hospitalization and high hemoglobin A1c levels in persons with diabetes.

Background Coronavirus disease (COVID-19) can cause severe illness and death. Predictors of poor outcome collected on hospital admission may inform clinical and public health decisions. Methods We conducted a retrospective observational cohort investigation of 297 adults admitted to 8 academic and community hospitals in Georgia, United States, during March 2020. Using standardized medical record abstraction, we collected data on predictors including admission demographics, underlying medical conditions, outpatient antihypertensive medications, recorded symptoms, vital signs, radiographic findings, and laboratory values. We used random forest models to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for predictors of invasive mechanical ventilation (IMV) and death. Results Compared with age Conclusions After adjustment for patient and clinical characteristics, older age was the strongest predictor of death, exceeding comorbidities, abnormal vital signs, and laboratory test abnormalities. That coronary artery disease, but not chronic lung disease, was associated with death among hospitalized patients warrants further investigation, as do associations between certain antihypertensive medications and death.

SARS-CoV-2, the novel coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in the United States during January 2020 (1). Since then, >980,000 cases have been reported in the United States, including >55,000 associated deaths as of April 28, 2020 (2). Detailed data on demographic characteristics, underlying medical conditions, and clinical outcomes for persons hospitalized with COVID-19 are needed to inform prevention strategies and community-specific intervention messages. For this report, CDC, the Georgia Department of Public Health, and eight Georgia hospitals (seven in metropolitan Atlanta and one in southern Georgia) summarized medical record-abstracted data for hospitalized adult patients with laboratory-confirmed* COVID-19 who were admitted during March 2020. Among 305 hospitalized patients with COVID-19, 61.6% were aged

Lutetium peptide receptor radio nuclide therapy (Lu-PRRT) is an effective treatment for progressive, metastatic, somatostatin-receptor-positive, well-differentiated neuroendocrine tumours (WD-NETs). Here, we report a single centre experience of real-world efficacy, long-term side effects, and challenges of this treatment. This was a retrospective analysis. All patients linked with our centre who had Lu-PRRT were included. Clinicopathological data were analysed using descriptive statistics, Kaplan-Meier, and Cox regression. A total of 45 patients had Lu-PRRT, of those 30 (67%) were males, and 13 (29%) were more than 65 years old. The primary site was small intestine in 30 (67%) patients, pancreas in seven (16%) patients, and lung in three (7%) patients. The tumor was grade 1 in 15 (35%) patients, grade 2 in 22 (48%) patients, and grade 3 in six (13%) patients. A total of 41 (91%) patients had liver metastasis, and 20 (44%) patients had carcinoid syndrome. Lu-PRRT was the second-line therapy in all patients. Krenning's score was 4 in 36 (80%) patients and 3 in nine (20%) patients. The median waiting time to start Lu-PRRT therapy was 87 days. The median follow-up was 41 months. A total of 23 (51%) patients had a partial response, 18 (40%) patients had stable disease, and four (9%) patients had progression. None of the patients had a complete response. The median progression-free survival (PFS) was 38 months (95% CI: 25.8-50.1). The median overall survival (OS) was not reached. Nine patients died during follow-up (death from any cause). Prior treatment with targeted therapies or high dose somatostatin analogues were negative predictors of Lu-PRRT outcome (p-values of.001 and.045, respectively). There were two serious haematological toxicities, one patient developed acute myeloid leukaemia (AML), and the other developed chronic myeloid leukaemia (CML). Lu-PRRT is an effective second-line treatment for metastatic WD-NETs. The effect of targeted therapies on Lu-PRRT outcome was significant and needs to be clarified in further studies.

Myocardial fibrosis leads to diastolic dysfunction in patients with hypertrophic cardiomyopathy (HCM).To evaluate a manual method of measuring mitral annular relaxation velocity (termed cardiac MRI e') as a measure of diastolic dysfunction on routine cardiac MRI and its relationship with myocardial late-gadolinium enhancement (LGE) and feature tracking measures of diastolic dysfunction in patients with HCM.CMR e', feature tracking measures of diastolic function, left atrial, left ventricular (LV) parameters and LGE were retrospectively measured in 75 patients with HCM (mean age, 54.7 years ± 15.3, 54 men). Multivariate regression and partial Spearman correlations were performed.Cardiac MRI e' measures correlated with LGE (r = 0.49, P 0.001) and multiple feature tracking measures of diastolic function, adjusted for patient demographics, left atrial and left ventricular parameters. Cardiac MRI e' measures were independently predictive of LGE ≥ 10% (mean total cardiac MRI e': LGE 10% vs LGE ≥ 10% was 3.5 cm/s vs. 1.7 cm/s, P 0.001). Superior CMR e' had an AUC of 0.79 [95%CI 0.66-0.92, P 0.0001]) in predicting patients with LGE ≥ 10% and a cutoff of 1.7 cm/s resulted in a sensitivity and specificity of 81.0% and 78.0% respectively.Cardiac MRI e' is a manual measure of LV diastolic dysfunction acquired on routine cardiac MRI without specialized software and is an independent predictor of LGE ≥ 10% and diastolic dysfunction in HCM.

Since the Pennsylvania oil rush of 1859, petroleum has quickly become the dominant fuel of industrial society. The “Peak Oil” debate focused on whether or not there was an impending production crunch of cheap oil, and whilst there have been no shortages across the globe, a shift from conventional to unconventional oil liquids has occurred. One aspect of this shift was not fully explored in previous discussions–although of some importance in a low-carbon energy transition context: the extent to which the net-energy supply of oil products is affected by the use of lower quality energy sources. To fill this gap, this paper incorporates standard EROI (energy-return-on-investment) estimates and dynamic decline functions in the GlobalShift all-liquids bottom-up model on a global scale. We determine the energy necessary for the production of oil liquids (including direct and indirect energy costs) to represent today 15.5% of the energy production of oil liquids, and growing at an exponential rate: by 2050, a proportion equivalent to half of the gross energy output will be engulfed in its own production. Our findings thus question the feasibility of a global and fast low-carbon energy transition. We therefore suggest an urgent return of the peak oil debate, but including net-energy issues and avoiding a narrow focus on ‘peak supply’ vs ‘peak demand’.

PURPOSE: To assess the prevalence of retinopathy and its association with systemic morbidity and laboratory indices of coagulation and inflammatory dysfunction in severe COVID-19. DESIGN: Retrospective, observational cohort study. METHODS: Adult patients hospitalized with severe COVID-19 who underwent ophthalmic examination from April to July 2020 were reviewed. Retinopathy was defined as one of the following: 1) Retinal hemorrhage; 2) Cotton wool spots; 3) Retinal vascular occlusion. We analyzed medical comorbidities, sequential organ failure assessment (SOFA) scores, clinical outcomes, and laboratory values for their association with retinopathy. RESULTS: Thirty-seven patients with severe COVID-19 were reviewed, the majority of whom were female (n = 23, 62%), Black (n = 26, 69%), and admitted to the intensive care unit (n = 35, 95%). Fourteen patients had retinopathy (38%) with retinal hemorrhage in 7 (19%), cotton wool spots in 8 (22%), and a branch retinal artery occlusion in 1 (3%) patient. Patients with retinopathy had higher SOFA scores than those without retinopathy (8.0 vs. 5.3, p = .03), higher rates of respiratory failure requiring invasive mechanical ventilation and shock requiring vasopressors (p

Natural gas is expected to play an important role in the coming low-carbon energy transition. However, conventional gas resources are gradually being replaced by unconventional ones and a question remains: to what extent is net-energy production impacted by the use of lower-quality energy sources? This aspect of the energy transition was only partially explored in previous discussions. To fill this gap, this paper incorporates standard energy-return-on-investment (EROI) estimates and dynamic functions into the GlobalShift bottom-up model at a global level. We find that the energy necessary to produce gas (including direct and indirect energy and material costs) corresponds to 6.7% of the gross energy produced at present, and is growing at an exponential rate: by 2050, it will reach 23.7%. Our results highlight the necessity of viewing the energy transition through the net-energy prism and call for a greater number of EROI studies.

International audience; Natural gas is expected to play an important role in the coming low-carbon energy transition. However, conventional gas resources are gradually being replaced by unconventional ones and a question remains: to what extent is net-energy production impacted by the use of lower-quality energy sources? This aspect of the energy transition was only partially explored in previous discussions. To fill this gap, this paper incorporates standard energy-return-on-investment (EROI) estimates and dynamic functions into the GlobalShift bottom-up model at a global level. We find that the energy necessary to produce gas (including direct and indirect energy and material costs) corresponds to 6.7% of the gross energy produced at present, and is growing at an exponential rate: by 2050, it will reach 23.7%. Our results highlight the necessity of viewing the energy transition through the net-energy prism and call for a greater number of EROI studies.

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Accurately diagnosing urinary tract infections (UTIs) in hospitalized patients remains challenging, requiring correlation of frequently nonspecific symptoms and laboratory findings. Urine cultures (UCs) are often ordered indiscriminately, especially in patients with urinary catheters, despite the Infectious Diseases Society of America guidelines recommending against routine screening for asymptomatic bacteriuria (ASB).1,2 Positive UCs can be difficult for providers to ignore, leading to unnecessary antibiotic treatment of ASB.2,3 Using diagnostic stewardship to limit UCs to situations with a positive urinalysis (UA) can reduce inappropriate UCs since the absence of pyuria suggests the absence of infection.4–6 We assessed the impact of the implementation of a UA with reflex to UC algorithm (“reflex intervention”) on UC ordering practices, diagnostic efficiency, and UTIs using a quasi-experimental design.

OBJECTIVES: To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES: Source data were obtained from a PubMed literature review. STUDY SELECTION: English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION: Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS: Approximately 30–50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS: The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.

Background Cardiovascular disease is a major cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD). However, the association of NAFLD with coronary microvascular dysfunction is, to our knowledge, unknown. Purpose To determine whether coronary microvascular dysfunction is more prevalent in patients with NAFLD and to determine whether coronary microvascular dysfunction predicts major adverse cardiac events (MACE) independently of NAFLD. Materials and Methods This retrospective study (2006-2014) included patients without evidence of obstructive epicardial coronary artery disease and healthy left ventricular ejection fraction (≥40%) at a clinical rest and stress myocardial perfusion PET/CT. NAFLD was defined by a mean hepatic attenuation of less than 40 HU at CT and coronary microvascular dysfunction as a coronary flow reserve (CFR) of less than 2.0. A composite of all-cause mortality, myocardial infarction, coronary revascularization, and hospitalization because of heart failure comprised MACE (130 of 886 patients; 14.7%). The relation between NAFLD and MACE was assessed by using multivariable Cox regression analysis. Results Among 886 patients (mean age, 62 years ± 12 [standard deviation]; 631 women [mean age, 62 years ± 12 years] and 255 men [mean age, 61 years ± 12]; and ejection fraction, 63% ± 9), 125 patients (14.1%) had NAFLD and 411 patients (46.4%) had coronary microvascular dysfunction. Coronary microvascular dysfunction was more prevalent (64.8% vs 43.4%; P < .001) and CFR was lower (1.9 ± 1.1 vs 2.2 ± 0.7; P < .001) in patients with NAFLD compared with those without NAFLD. NAFLD independently predicted coronary microvascular dysfunction (P = .01). The interaction of NAFLD and male sex predicted MACE (hazard ratio, 1.45; 95% confidence interval: 1.08, 1.69; P = .008) and coronary microvascular dysfunction remained associated with MACE (adjusted hazard ratio, 1.46; 95% confidence interval: 1.02, 2.07; P = .04). Conclusion Coronary microvascular dysfunction was more prevalent in patients with nonalcoholic fatty liver disease and predicted major adverse cardiac events independently of nonalcoholic fatty liver disease. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Ambale-Venkatesh and Lima in this issue.

Sea-Bird Scientific SBE 41CP CTDs are used on autonomous floats in the global Argo ocean observing program to measure the temperature and salinity of the upper ocean. While profiling, the sensors are subject to dynamic errors as they profile through vertical gradients. Applying dynamic corrections to the temperature and conductivity data reduces these errors and improves sensor accuracy. A series of laboratory experiments conducted in a stratified tank are used to characterize dynamic errors and determine corrections. The corrections are adapted for Argo floats, and recommendations for future implementation are presented.

Objective To estimate the cost of infections associated with multidrug-resistant organisms (MDROs) during inpatient hospitalization in the United States. Data sources/study setting 2014 National Inpatient Sample. Study design Multivariable regression models assessed the incremental effect of MDROs on the cost of hospitalization and hospital length of stay among patients with bacterial infections. Data collection/extraction methods We retrospectively identified 6 385 258 inpatient stays for patients with bacterial infection. Principal findings The national incidence rate of inpatient stays with bacterial infection is 20.1 percent. At least 10.8 percent of such stays-and as many as 16.9 percent if we account for undercoded infections-show evidence of one or more MDROs. MRSA, C. difficile, infection with another MDRO, and the presence of more than one MDRO are associated with $1718 (95% CI, $1609-$1826), $4617 (95% CI, $4407-$4827), $2302 (95% CI, $2044-$2560), and $3570 (95% CI, $3019-$4122) in additional costs per stay, respectively. The national cost of infections associated with MDROs is at least $2.39 billion (95% CI, $2.25-$2.52 billion) and as high as $3.38 billion (95% CI, $3.13-$3.62 billion) if we account for undercoded infections. Conclusions Infections associated with MDROs result in a substantial cost burden to the US health care system.