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Monkeypox (Mpox), an uncommon zoonotic Orthopoxvirus, is commonly manifested by blisters on the skin and has a mortality rate of approximately 0-10%. Approximately two decades after the cessation of global smallpox vaccination, the number of confirmed cases of Mpox has been growing, making it the most common Orthopoxvirus infection. Therefore, in this narrative review, we aimed to shed light on recent advancements in the pathophysiology, transmission routes, epidemiology, manifestations, diagnosis, prevention, and treatment of Mpox, as well as the application of artificial intelligence (AI) methods for predicting this disease. The clinical manifestations of Mpox, including the onset of symptoms and dermatologic characteristics, are similar to those of the infamous smallpox, but Mpox is clinically milder. Notably, a key difference between smallpox and Mpox is the high prevalence of lymphadenopathy. Human-to-human, animal-to-human, and animal-to-animal transmission are the three main pathways of Mpox spread that must be considered for effective prevention, particularly during outbreaks. PCR testing, as the preferred method for diagnosing Mpox infection, can enhance early detection of new cases and thereby improve infection control measures. JYNNEOS and ACAM2000 are among the vaccines most commonly recommended for the prevention of Mpox. Brincidofovir, Cidofovir, and Tecovirimat are the primary treatments for Mpox cases. Similar to other viral infections, the best approach to managing Mpox is prevention. This can, in part, be achieved through measures such as reducing contact with individuals displaying symptoms, maintaining personal safety, and adhering to practices commonly used to prevent sexually transmitted infections., Competing Interests: None.

The heterogeneity of the solid tumor microenvironment (TME) impairs the therapeutic efficacy of standard therapies and also reduces the infiltration of antitumor immune cells, all of which lead to tumor progression and invasion. In addition, self-renewing cancer stem cells (CSCs) support tumor dormancy, drug resistance, and recurrence, all of which might pose challenges to the eradication of malignant tumor masses with current therapies. Natural forms of oncolytic viruses (OVs) or engineered OVs are known for their potential to directly target and kill tumor cells or indirectly eradicate tumor cells by involving antitumor immune responses, including enhancement of infiltrating antitumor immune cells, induction of immunogenic cell death, and reprogramming of cold TME to an immune-sensitive hot state. More importantly, OVs can target stemness factors that promote tumor progression, which subsequently enhances the efficacy of immunotherapies targeting solid tumors, particularly the CSC subpopulation. Herein, we describe the role of CSCs in tumor heterogeneity and resistance and then highlight the potential and remaining challenges of immunotherapies targeting CSCs. We then review the potential of OVs to improve tumor immunogenicity and target CSCs and finally summarize the challenges within the therapeutic application of OVs in preclinical and clinical trials., (© 2024 John Wiley & Sons Ltd.)

Introduction: Acute exposure to e-cigarette aerosol has been shown to have potentially deleterious effects on the cardiovascular system. However, the cardiovascular effects of habitual e-cigarette use have not been fully elucidated. Therefore, we aimed to assess the association of habitual e-cigarette use with endothelial dysfunction and inflammation - subclinical markers known to be associated with increased cardiovascular risk., Methods: In this cross-sectional study, we analyzed data from 46 participants (23 exclusive e-cigarette users; 23 non-users) enrolled in the VAPORS-Endothelial function study. E-cigarette users had used e-cigarettes for ≥6 consecutive months. Non-users had used e-cigarettes <5 times and had a negative urine cotinine test (<30 ng/mL). Flow-mediated dilation (FMD) and reactive hyperemia index (RHI) were used to assess endothelial dysfunction, and we assayed high-sensitivity C-reactive protein, interleukin-6, fibrinogen, p-selectin, and myeloperoxidase as serum measures of inflammation. We used multivariable linear regression to assess the association of e-cigarette use with the markers of endothelial dysfunction and inflammation., Results: Of the 46 participants with mean age of 24.3 ± 4.0 years, the majority were males (78%), non-Hispanic (89%), and White (59%). Among non-users, 6 had cotinine levels <10 ng/mL while 17 had levels 10-30 ng/mL. Conversely, among e-cigarette users, the majority (14 of 23) had cotinine ≥500 ng/mL. At baseline, the systolic blood pressure was higher among e-cigarette users than non-users (p=0.011). The mean FMD was slightly lower among e-cigarette users (6.32%) compared to non-users (6.53%). However, in the adjusted analysis, current e-cigarette users did not differ significantly from non-users in their mean FMD (Coefficient=2.05; 95% CI: -2.52-6.63) or RHI (Coefficient= -0.20; 95% CI: -0.88-0.49). Similarly, the levels of inflammatory markers were generally low and did not differ between e-cigarette users and non-users., Conclusions: Our findings suggest that e-cigarette use may not be significantly associated with endothelial dysfunction and systemic inflammation in relatively young and healthy individuals. Longer term studies with larger sample sizes are needed to validate these findings., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. E. Boakye, O. El-Shahawy, J. Erhabor, A. Bhatnagar, and M. Blaha report that since the initial planning of the work this study was supported by Awards P50HL120163 and U54HL120163 from National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) and the FDA Center for Tobacco Products (CTP). S.S. Biswal reports that since the initial planning of the work this study was supported by R01 grant DE026031 from the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH)., (© 2023 Boakye E. et al.)

Surveillance of e-cigarette use among different population groups is important for the timely implementation and evaluation of tobacco regulatory policies. In this review, we identified 13 nationally representative, repeatedly conducted epidemiologic surveys that assess e-cigarette use among U.S. youth and/or adults and have been instrumental in e-cigarette surveillance. These surveys included National Youth Tobacco Survey, Youth Risk Behavior Surveillance System, Monitoring the Future Survey, International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey, Behavioral Risk Factor Surveillance System, National Health Interview Survey, Tobacco Use Supplement of the Current Population Survey, Health Information National Trends Survey, Tobacco Products and Risk Perception Surveys, ITC Four Country Smoking and Vaping Survey, National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, and Population Assessment of Tobacco and Health. These surveys vary in scope and detail, with their unique strengths and the regulatory questions that can be answered using each survey data. We also highlighted the gaps in these surveys and made recommendations for improvement., Competing Interests: We declare no competing interests., (© 2023 The Authors.)

We evaluated whether wrist circumference (WrC), as a novel anthropometric measure, is associated with incidences of any fractures. The study population included 8288 adults (45.3% men) aged ≥30 years, who were followed for incidences of any fractures from 31 January 1999 to 16 March 2016. We used Cox proportional hazard models adjusted for well-known risk factors to evaluate the association of WrC, both as continuous and categorical variables (bottom tertile as reference), with incidences of any fractures and major osteoporotic fractures (MOF). Over 15 years of follow-ups, 348 fractures occurred (men = 162). For a 1 cm increase in WrC, hazard ratios (HRs) were 1.18 (95% CI: 1.03-1.35) for incident any fractures and 1.22 (1.01-1.49) for incident MOF. In addition to WrC, age, female sex, lower BMI, higher WC, current smoking, and usage of steroidal medications were significantly associated with the incidences of any fractures. Moreover, participants in the middle and top tertiles of WrC had a higher risk of incidence for any fractures [HR = 1.62 (1.19-2.20) and 1.70 (1.14-2.55), respectively, p -value for trend = 0.012]. We presented WrC as a strong and independent risk factor for incidences of any fractures that might be considered in the risk prediction of bone fracture in Iranian adults.

Absolute coronary artery calcium (CAC) scores and CAC percentiles can identify different patient groups, which could be confusing in clinical practice. We aimed to create a simple "rule of thumb" for identifying the American College of Cardiology/American Heart Association endorsed 75th CAC percentile based on age, gender, and the absolute CAC score. Using the Multi-Ethnic Study of Atherosclerosis, we calculated the age and gender-specific percent likelihood that a guideline-based absolute CAC score group (1 to 100, 100 to 300, &gt;300) will place a patient above the 75th percentile. Also, we derived gender-specific age cutoffs by which 95% of participants with any (&gt;0), moderate (≥100), or severe (≥300) CAC score would be over the 75th percentile. We repeated the analysis using the 90th percentile threshold and also conducted sensitivity analyses stratified by race. Any CAC &gt;0 places 95% of women younger than 60 years and over 90% of men younger than 50 years over the 75th percentile. Moderate absolute CAC scores (&gt;100) place nearly all men &lt;60 years and all women &lt;70 years over the 75th percentile. Confirmatory analysis for age cutoffs was consistent with primary analysis, with cutoffs of 48 years for men and 59 years for women indicating a 95% likelihood that any CAC would place patients over the 75th percentile. In conclusion, our study provides a simple rule of thumb (men &lt;50 years and women &lt;60 years with any CAC, men &lt;60 years and women &lt;70 years with CAC &gt;100) for identifying CAC &gt;75th percentile that might be readily adopted in clinical practice., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Breast cancer is the most frequently diagnosed cancer and the leading reason for cancer-related death among women. Neoadjuvant treatment with dual-HER2 (human epidermal growth factor receptor 2) blockade has shown promising effects in this regard. The present study aimed to compare the efficacy and safety of a proposed pertuzumab biosimilar with the reference pertuzumab., Methods: This randomized, phase III, multicenter, equivalency clinical trial was conducted on chemotherapy-naive women with HER2-positive breast cancer. Patients were randomly assigned (1:1) to receive six cycles of either P013 (CinnaGen, Iran) or the originator product (Perjeta, Roche, Switzerland) along with trastuzumab, carboplatin, and docetaxel every 3 weeks. Patients were stratified by cancer type (operable, locally advanced, inflammatory) and hormone receptor status. The primary endpoint was breast pathologic complete response (bpCR). Secondary endpoints included comparisons of total pCR, overall response rate (ORR), breast-conserving surgery (BCS), safety, and immunogenicity., Results: Two hundred fourteen patients were randomized to treatment groups. bpCR rate in the per-protocol population was 67.62% in the P013 and 71.57% in the reference drug groups. Based on bpCR, P013 was equivalent to the reference pertuzumab with a mean difference of - 0.04 (95% CI: - 0.16, 0.09). Secondary endpoints were also comparable between the two groups., Conclusions: The proposed biosimilar P013 was equivalent to the reference product in terms of efficacy. The safety of both medications was also comparable., (© 2022. The Author(s).)

Detailed description of the prevalence and sources of e-cigarettes among youth is needed to inform effective regulatory policies. We used the Youth Risk Behavior Surveillance System data (2015-2019) to assess trends in current (past-30-day-use) and frequent (≥10 days in past-30-days) e-cigarette use among United States high schoolers before the COVID-19 pandemic. First, we assessed trends overall and then stratified by participants' sociodemographic characteristics, use of other tobacco products, and experiences of psychosocial stress. We also evaluated past year quit attempts and the changing sources of e-cigarettes. Our sample size was 41,021 (15,356-2015; 12,873-2017; 12,792-2019). The prevalence of current e-cigarette use increased from 24.0% (95%CI:21.9%-26.3%) in 2015 to 32.7% (30.4%-35.1%) in 2019. The proportion of current users who reported frequent use also increased significantly from 22.6% (20.4%-24.8%) to 45.4% (42.7%-48.2%). Thus, an increasing proportion of US high school students who use e-cigarettes reported frequent use, indicating greater nicotine dependence. The increase in current and frequent e-cigarette use was more pronounced in youth who reported other substance use and psychosocial stressors such as bullying. Between 2017 and 2019, there was a decline in the proportion of youth who bought e-cigarettes online (6.9% to 3.2%) or from convenience stores (22.0% to 16.6%). Conversely, there was an increase in the proportion who borrowed (34.5% to 40.1%) or purchased e-cigarettes through other people (10.7% to 18.0%), indicating that most youth are evading age-related restrictions by obtaining e-cigarettes from other people. Finally, a considerable proportion of youth tobacco users are making quit attempts; 47.6% (45.1%-50.1%) in 2019., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Importance: Updated data on the patterns of e-cigarette use among adults in the US are needed., Objective: To examine recent patterns in current and daily e-cigarette use among US adults., Design, Setting, and Participants: This repeated cross-sectional study used data from the 2017, 2018, and 2020 Behavioral Risk Factor Surveillance System, a nationally representative state-based survey of noninstitutionalized US adults. A total of 994 307 adults 18 years and older who were living in states and territories that provided data on e-cigarette use in 2017 (53 states and territories), 2018 (36 states and Guam), and 2020 (42 states and Guam) were included., Main Outcomes and Measures: The weighted prevalence of current (past 30 days) and daily e-cigarette use was estimated for each year, and changes in prevalence from 2017 to 2020 were assessed, first overall and then stratified by participant characteristics, including state or territory of residence., Results: Among 994 307 adults from states with data on e-cigarette use, 429 370 individuals (weighted 51.3% female) were participants in the 2017 survey, 280 184 (weighted 52.1% female) were participants in the 2018 survey, and 284 753 (weighted 52.1% female) were participants in the 2020 survey. The weighted proportions of young adults aged 18 to 24 years were 12.6% in 2017, 11.8% in 2018, and 11.9% in 2020. Across all 3 years, 17 035 participants (weighted, 1.0%) were American Indian or Alaska Native, 22 313 (weighted, 4.6%) were Asian, 75 780 (weighted, 12.2%) were Black, 72 190 (weighted, 15.1%) were Hispanic, 4817 (weighted, 0.2%) were Native Hawaiian, 757 140 (weighted, 65.1%) were White, 20 332 (weighted, 1.3%) were multiracial, and 6245 (weighted, 0.5%) were of other races and/or ethnicities. The prevalence of current e-cigarette use was 4.4% (95% CI, 4.3%-4.5%) in 2017, which increased to 5.5% (95% CI, 5.4%-5.7%) in 2018 and decreased slightly to 5.1% (95% CI, 4.9%-5.3%) in 2020. The recent decrease, though modest, was observed mainly among young adults aged 18 to 20 years (from 18.9% [95% CI, 17.2%-20.7%] to 15.6% [95% CI, 14.1%-17.1%]; P = .004). However, the prevalence of daily e-cigarette use increased consistently from 1.5% (95% CI, 1.4%-1.6%) in 2017 to 2.1% (95% CI, 2.0%-2.2%) in 2018 and 2.3% (95% CI, 2.2%-2.4%) in 2020. Among young adults aged 21 to 24 years, there was a slight, albeit insignificant, increase in the prevalence of current e-cigarette use (from 13.5% [95% CI, 12.3%-14.7%] to 14.5% [95% CI, 13.2%-15.9%]; P = .28) but a significant increase in the prevalence of daily e-cigarette use (from 4.4% [95% CI, 3.8%-5.1%] to 6.6% [95% CI, 5.6%-7.6%]; P < .001) between 2018 and 2020. State-level patterns in the prevalence of current e-cigarette use were heterogeneous, with states like Massachusetts (from 5.6% [95% CI, 4.8%-6.5%] to 4.1% [95% CI, 3.1%-5.3%]; P = .03) and New York (from 5.4% [95% CI, 4.9%-5.9%] to 4.1% [95% CI, 3.5%-4.7%]; P = .001) recording significant decreases between 2018 and 2020. In contrast, Guam (from 5.9% [95% CI, 4.5%-7.9%] to 11.4% [95% CI, 8.7%-14.8%]; P = .002) and Utah (from 6.1% [95% CI, 5.5%-6.7%] to 7.2% [95% CI, 6.5%-8.0%]; P = .02) recorded significant increases in current e-cigarette use over the same period., Conclusions and Relevance: In this study, a slight decrease in the prevalence of current e-cigarette use was found between 2018 and 2020; this decrease was mainly observed among young adults aged 18 to 20 years. In contrast, daily e-cigarette use consistently increased, particularly among young adults aged 21 to 24 years. This increase in daily use suggests greater nicotine dependence among those who use e-cigarettes, warranting continued surveillance.

Aims: By 2030, we seek to reduce premature deaths from non-communicable diseases, including ischaemic heart disease (IHD), by one-third to reach the sustainable development goal (SDG) target 3.4. We aimed to investigate the quality of care of IHD across countries, genders, age groups, and time using the Global Burden of Diseases Study (GBD) 2017 estimates., Methods and Results: We did a principal component analysis on IHD mortality to incidence ratio, disability-adjusted life-years (DALYs) to prevalence ratio, and years of life lost to years lived with disability ratio using the results of the GBD 2017. The first principal component was scaled from 0 to 100 and designated as the quality of care index (QCI). We evaluated gender inequity by the gender disparity ratio (GDR), defined as female to male QCI. From 1990 to 2017, the QCI and GDR increased from 71.2 to 76.4 and from 1.04 to 1.08, respectively, worldwide. In the study period, countries of Western Europe, Scandinavia, and Australasia had the highest QCIs and a GDR of 1 to 1.2; however, African and South Asian countries had the lowest QCIs and a GDR of 0.8 to 1. Moreover, the young population experienced more significant improvements in the QCI compared to the elderly in 2017., Conclusion: From 1990 to 2017, the QCI of IHD has improved; nonetheless, there are remarkable disparities between countries, genders, and age groups that should be addressed. These findings may guide policymakers in monitoring and modifying our path to achieve SDGs., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Introduction: Smoking is independently associated with erectile dysfunction and cardiovascular disease. Given existing similarities in the constituents of e-cigarettes or ENDS and cigarettes, this study examines the association between ENDS use and erectile dysfunction., Methods: Data from Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health study were analyzed in 2020. Male participants aged ≥20 years who responded to the erectile dysfunction question were included. Multivariable logistic regression models examined the association of ENDS use with erectile dysfunction within the full sample and in a restricted sample (adults aged 20-65 years with no previous cardiovascular disease diagnosis) while adjusting for multiple risk factors., Results: The proportion of erectile dysfunction varied from 20.7% (full sample) to 10.2% (restricted sample). The prevalence of current ENDS use within the full and restricted samples was 4.8% and 5.6%, respectively, with 2.1% and 2.5%, respectively, reporting daily use. Current daily ENDS users were more likely to report erectile dysfunction than never users in both the full (AOR=2.24, 95% CI=1.50, 3.34) and restricted (AOR=2.41, 95% CI=1.55, 3.74) samples. In the full sample, cardiovascular disease history (versus not present) and age ≥65 years (versus age 20-24 years) were associated with erectile dysfunction (AOR=1.39, 95% CI=1.10, 1.77; AOR= 17.4, 95% CI=12.15, 24.91), whereas physical activity was associated with lower odds of erectile dysfunction in both samples (AOR range=0.44-0.58)., Conclusions: The use of ENDS seems to be associated with erectile dysfunction independent of age, cardiovascular disease, and other risk factors. While ENDS remain under evaluation for harm reduction and smoking-cessation potential, ENDS users should be informed about the possible association between ENDS use and erectile dysfunction., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Thoracic aortic calcium(TAC) is an important marker of extracoronary atherosclerosis with established predictive value for all-cause mortality. We sought to explore the predictive value of TAC for stroke mortality, independent of the more established coronary artery calcium (CAC) score. The CAC Consortium is a retrospectively assembled database of 66,636 patients aged ≥18 years with no previous history of cardiovascular disease, baseline CAC scans for risk stratification, and follow-up for 12 ± 4 years. CAC scans capture the adjacent thoracic aorta, enabling assessment of TAC from the same images. TAC was available in 41,066 (62%), and was primarily analyzed as present or not present. To account for competing risks for nonstroke death, we utilized multivariable-adjusted Fine and Gray competing risk regression models adjusted for traditional cardiovascular risk factors and CAC score. The mean age of participants was 53.8 ± 10.3 years, with 34.4% female. There were 110 stroke deaths during follow-up. The unadjusted subdistribution hazard ratio (SHR) for stroke mortality in those who had TAC present compared with those who did not was 8.80 (95% confidence interval [CI]: 5.97, 12.98). After adjusting for traditional risk factors and CAC score, the SHR was 2.21 (95% CI:1.39,3.49). In sex-stratified analyses, the fully adjusted SHR for females was 3.42 (95% CI: 1.74, 6.73) while for males it was 1.55 (95% CI: 0.83, 2.90). TAC was associated with stroke mortality independent of CAC and traditional risk factors, more so in women. The presence of TAC appears to be an independent risk marker for stroke mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background The optimal method for communicating coronary heart disease (CHD) risk to individual patients is not yet clear. Recent research supports the concept of "coronary age" for more effective risk communication. We defined an individual's coronary age as the age at which an average healthy individual would have an equivalent estimated CHD risk as that calculated for the index individual, building on our previously validated MESA (Multi-Ethnic Study of Atherosclerosis) 10-year CHD Risk Score equations with and without coronary artery calcium (CAC). Methods and Results We derived a coronary age by (1) calculating the MESA 10-year CHD risk; (2) mathematically setting this equal to an equation describing risk of an average healthy MESA participant, as a function of age; and (3) solving for age. The risk discrimination of the resultant coronary age was compared with that of chronological age, the MESA CHD Risk Score, and CAC alone. Approximately 95% of coronary age values ranged from 30 years less to 30 years higher than chronological age. Although the mean chronological age of individuals experiencing CHD events compared with those free of events was 67.4 versus 61.8 years, the difference in coronary age including CAC was larger (80.6 versus 62.8 years). Coronary age with CAC had identical predictive ability to that of MESA CHD Risk Score and outperformed chronological age and CAC alone. Conclusions The newly derived coronary age is a convenient transformation of MESA CHD Risk, retaining very good risk discrimination. This easy-to-communicate tool will be available for patients and clinicians, potentially facilitating risk communication in routine care.

Background and Aims: Statins do not decrease coronary artery calcium (CAC) and may increase existing calcification or its density. Therefore, we examined the prognostic significance of CAC among statin users at the time of CAC scanning., Methods: We included 28,025 patients (6151 statin-users) aged 40-75 years from the CAC Consortium. Cox regression models were used to assess the association of CAC with coronary heart disease (CHD) and cardiovascular disease (CVD) mortality. Models were adjusted for traditional CVD risk factors. Additionally, we examined the predictive performance of CAC components including CAC area, volume, and density using an age- and sex-adjusted Cox regression model., Results: Participants (mean age 53.9 ± 10.3 years, 65.0% male) were followed for median 11.2 years. There were 395 CVD and 182 CHD deaths. One unit increase in log CAC score was associated with increased risk of CVD mortality (hazard ratio (HR), 1.2; 95% CI = 1.1-1.3) and CHD mortality (HR, 1.2; 95% CI = 1.1-1.4)) among statin users. There was a small but significant negative interaction between CAC score and statin use for the prediction of CHD (p-value = 0.036) and CVD mortality (p-value = 0.025). The volume score and CAC area were similarly associated with outcomes in statin users and non-users. Density was associated with CVD and CHD mortality in statin naïve patients, but with neither in statin users., Conclusion: CAC scoring retains robust risk prediction in statin users, and the changing relationship of CAC density with outcomes may explain the slightly weaker relationship of CAC with outcomes in statin users., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: The prevalence of e-cigarette use among lesbian, gay, bisexual, and transgender (LGBT) individuals and its association with risk behaviors was studied., Methods: Using data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, self-reported sexual orientation, e-cigarette use, cigarettes, marijuana, smokeless tobacco, and high-risk behavior (using non-prescribed drugs, treatment for sexually transmitted disease, or receiving monetary or drug compensation in exchange for sex in the previous year) were assessed. Multivariable-adjusted logistic regression models were used to study the association between LGBT and risk behaviors., Results: The prevalence of e-cigarette use among LGBT adults was 13%, nearly twice that of heterosexual adults. LGBT adults were more likely [Odds Ratio (95% Confidence Interval)] to report current use of e-cigarettes 1.84 (1.64, 2.06), cigarettes 1.61 (1.49, 1.73), marijuana 2.37 (1.99, 2.82), and high-risk behavior 3.69 (3.40, 4.01) compared to heterosexual adults. Results for smokeless tobacco were not significant., Conclusion: There are disparities in e-cigarette and other risk behaviors among LGBT adults, which may increase risk of adverse health effects in this vulnerable population., (© 2020 The University of Kansas Medical Center.)

Use of substances other than nicotine in e-cigarettes, especially marijuana, is becoming increasingly popular in the US. However, population-representative data on such poly-use (nicotine and marijuana) remains limited. We therefore conducted a cross-sectional logistic regression analysis of the 2018 Behavioral Risk Factor Surveillance System among 16 US states/territories with data on past 30-day marijuana use to describe the emerging dual nicotine and marijuana vaping population. We additionally examined trends in marijuana use, including marijuana vaping, from 2016 to 2018. Of the 131,807 participants studied, 3068 were current e-cigarette users, among whom 7.1% also vaped marijuana. Prevalence of nicotine-predominant, dual nicotine marijuana, and marijuana-predominant vaping was 3.36%, 0.38% and 1.09%, respectively. Compared to nicotine-predominant vapers, dual and marijuana-predominant vapers were older, had greater proportions of non-Whites, particularly Hispanics, and less likely to be current smokers (nicotine-predominant vs dual vs marijuana-predominant vaping: current tobacco use 44.7 vs 23.7 vs 11.1%). Proportion of dual vapers among current e-cigarette users was 8.6%, 2.6% and 7.1% for 2016, 2017 and 2018, respectively. Prevalence of marijuana use increased from 8.97% (2016) to 13.1% (2018) while no clear trend was observed for marijuana vaping. Dual nicotine and marijuana vaping is prevalent in the US, and compared to predominantly nicotine vapers such users have higher mean ages, and are more likely to be Blacks, Hispanics, and never cigarette smokers. Marijuana use overall increased from 2016 to 2018. Dual vapers represent a large and important emerging population that will require dedicated study of health effects and tailored regulatory strategies., Competing Interests: Declaration of competing interest Emelia J. Benjamin has received research grant from the NIH and American Heart Association (2U54HL120163). S. M. Iftekhar Uddin has received T32 grant from NIH (T32-HL-7227-44). All other authors have no financial disclosures or conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The prevalence of e-cigarette use has increased dramatically in the last decade in the U.S. Understanding the prevalence, patterns of use, and risk factor associations of e-cigarette use in pregnant women is particularly important, as this could have potential health implications for the mother and the developing child., Methods: Using Behavioral Risk Factor Surveillance System Survey data from 2016 to 2018, adult women of reproductive age (18-49 years) who reported being pregnant (n=7,434) were studied. Self-reported current e-cigarette use was the main exposure. Other measures included combustible cigarette smoking status and high-risk behaviors (including other tobacco, marijuana, or heavy alcohol use; binge drinking; and others). All analyses were done in 2019., Results: Approximately 2.2% of pregnant women reported current e-cigarette use, of whom 0.6% reported daily use. The highest prevalence of e-cigarette use was observed in the youngest age group of pregnant women (3.2%), with 41.7% of all pregnant current e-cigarette users being aged 18-24 years. There was a marked increase in the prevalence of current use of e-cigarettes among pregnant women from 1.9% in 2016 to 3.8% in 2018. Approximately 46% of pregnant current e-cigarette users reported concomitant cigarette smoking. Compared with pregnant never e-cigarette users, pregnant current e-cigarette users had a higher prevalence of other tobacco product use, marijuana use, heavy alcohol intake, binge drinking, and other high-risk behaviors., Conclusions: These findings underscore the need to strengthen prevention and policy efforts, specifically in the vulnerable subgroup of pregnant women., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the association and burden of coronary artery calcium (CAC) with long-term, cause-specific mortality across the spectrum of baseline risk., Background: Although CAC is a known predictor of short-term, all-cause mortality, data on long-term and cause-specific mortality are inadequate., Methods: The CAC Consortium cohort is a multicenter cohort of 66,636 participants without coronary heart disease (CHD) who underwent CAC testing. The following risk factors (RFs) were considered: 1) current cigarette smoking; 2) dyslipidemia; 3) diabetes mellitus; 4) hypertension; and 5) family history of CHD., Results: During the 12.5-years median follow-up, 3,158 (4.7%) deaths occurred; 32% were cardiovascular disease (CVD) deaths. Participants with CAC scores ≥400 had a significantly increased risk for CHD and CVD mortality (hazard ratio [HR]: 5.44; 95% confidence interval [CI]: 3.88 to 7.62; and HR: 4.15; 95% CI: 3.29 to 5.22, respectively) compared with CAC of 0. Participants with ≥3 RFs had a smaller increased risk for CHD and CVD mortality (HR: 2.09; 95% CI: 1.52 to 2.85; and HR: 1.84; 95% CI: 1.46 to 2.31, respectively) compared with those without RFs. Across RF strata, CAC added prognostic information. For example, participants without RFs but with CAC ≥400 had significantly higher all-cause, non-CVD, CVD, and CHD mortality rates compared with participants with ≥3 RFs and CAC of 0., Conclusions: Across the spectrum of RF burden, a higher CAC score was strongly associated with long-term, all-cause mortality and a greater proportion of deaths due to CVD and CHD. Absence of CAC identified people with a low risk over 12 years of follow-up, with most deaths being non-CVD in nature, regardless of RF burden., (Copyright © 2020. Published by Elsevier Inc.)

Background and Aims: We sought to understand the risk factor correlates of very early coronary artery calcium (CAC), and the potential investigational value of CAC phenotyping in adults aged 20-30 years., Methods: We studied all participants aged 20-30 years at baseline (N = 373) in the Coronary Artery Calcium Consortium, a large multi-center cohort study of patients aged 18 years or older without known atherosclerotic cardiovascular disease (ASCVD) at baseline, referred for CAC scoring for clinical risk stratification. We described the prevalence of CAC in men and women, the frequency of risk factors by the presence of CAC (CAC = 0 vs CAC >0), and assessed the association between traditional non-demographic CVD risk factors (hypertension, hyperlipidemia, smoking, family history of CHD, and diabetes) and prevalent CAC, using age- and sex-adjusted logistic regression models., Results: The mean age of the study participants was 27.5 ± 2.4 years; 324 (86.9%) had CAC = 0, and 49 (13.1%) had CAC >0. Among the 49 participants with CAC, 38 (77.6%) were men, and median CAC score was low at 4.6. In age- and sex-adjusted models, there was a graded increase in the odds of CAC >0 with increasing traditional cardiovascular disease (CVD) risk factor burden (p = 0.001 for linear trend). Participants with ≥3 traditional risk factors had a statistically significant higher odds of having prevalent CAC (OR 5.57, 95% CI; 1.82-17.03) compared to participants with no risk factors., Conclusions: Our study demonstrates the non-negligible prevalence of CAC among very high-risk young US adults, reinforcing the critical importance of traditional risk factors in the earliest development of detectable subclinical ASCVD., Competing Interests: Declaration of competing interest The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The 2018 and 2019 guidelines from the American College of Cardiology and American Heart Association reflect the complexity of individualized cholesterol management. The documents address more detailed risk assessment, newer nonstatin cholesterol-lowering drugs, special attention to patient subgroups, and consideration of the value of therapy, all with the aim of creating personalized treatment plans for each patient. Overall, the guidelines recommend shared decision-making to meet the individual needs of each patient., (Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.)

Background: To assess the impact of changes in different glucose tolerance states on risk of incident cardiovascular disease (CVD)/coronary heart disease (CHD)., Methods: A total of 4094 Iranians (43.9% men) aged ≥ 30 years, without diabetes and CVD at enrolment were included. The following categories were defined both at baseline visit and 3 years later (second visit): normal fasting glucose (NFG), normal glucose tolerance (NGT), NFG and NGT (NFG/NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and IFG and/or IGT (IFG/IGT). Changes in the categories, i.e. regression to normoglycemia, remaining in previous status and progression to diabetes were assessed. We used Cox's proportional hazard models adjusted for traditional risk factors and their changes, to estimate the hazard ratio (HR) with 95% confidence interval (CI) of different changing categories for incident CVD/CHD., Results: During a median follow-up of 12.42 years, 428 subjects (men = 265) experienced CVD. Considering persistent NFG/NGT as reference, participants who shifted from NFG/NGT to IFG/IGT showed a lower hazard of CVD in the fully adjusted model, HR 0.72 [95% CI 0.52-0.996, P = 0.048]. Moreover, subjects who shifted from IFG, IGT and IFG/IGT to diabetes had an increased risk of CVD/CHD. The risk however, was only statistically significant for those with IFG/IGT, 1.61 [(1.03-2.51), P = 0.04] for CVD and 1.75 [(1.10-2.78), P = 0.02] for CHD; considering IFG/IGT at both visits as reference. Furthermore, those who regressed from IFG/IGT to normoglycemia were at the same risk as those remained in IFG/IGT state, 1.12 [(0.79-1.60), P = 0.52] for CVD and 1.04 [(0.70-1.53), P = 0.85] for CHD. Among a subgroup of population with insulin data (n = 803) those with insulin resistance (IR) that converted to diabetes showed a higher risk for CVD, 3.68 [(1.49-9.06), P = 0.01] and CHD, 2.76 [(1.00-7.60), P = 0.05] events in the fully adjusted model., Conclusions: Among participants with IFG, IGT or IFG/IGT at baseline, only those who developed diabetes had a higher risk of developing CVD/CHD. Persistent IFG/IGT was not associated with higher risk, compared with those reverted to normoglycemia. Moreover, subjects who converted from NFG/NGT to incident IFG/IGT showed a signal for lower risk of CVD/CHD.

Introduction: The association between e-cigarette use and chronic bronchitis, emphysema, and chronic obstructive pulmonary disease has not been studied thoroughly, particularly in populations defined by concomitant combustible smoking status., Methods: Using pooled 2016 and 2017 data from the Behavioral Risk Factor Surveillance System, investigators studied 705,159 participants with complete self-reported information on e-cigarette use, combustible cigarette use, key covariates, and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Current e-cigarette use was the main exposure, with current use further classified as daily or occasional use. The main outcome was defined as reported ever having a diagnosis of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. For all the analyses, multivariable adjusted logistic regression was used, with the study population stratified by combustible cigarette use status (never, former, or current). All the analyses were conducted in 2019., Results: Of 705,159 participants, 25,175 (3.6%) were current e-cigarette users, 64,792 (9.2%) current combustible cigarette smokers, 207,905 (29.5%) former combustible cigarette smokers, 432,462 (61.3%) never combustible cigarette smokers, and 14,036 (2.0%) dual users of e-cigarettes and combustible cigarettes. A total of 53,702 (7.6%) participants self-reported chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Among never combustible cigarette smokers, current e-cigarette use was associated with 75% higher odds of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease compared with never e-cigarette users (OR=1.75, 95% CI=1.25, 2.45), with daily users of e-cigarettes having the highest odds (OR=2.64, 95% CI=1.43, 4.89). Similar associations between e-cigarette use and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease were noted among both former and current combustible cigarette smokers., Conclusions: The results suggest possible e-cigarette-related pulmonary toxicity across all the categories of combustible cigarette smoking status, including those who had never smoked combustible cigarettes., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction Individuals who use electronic cigarettes (e-cigarettes) may have a poor perception of physical and mental health. We, therefore, studied the association of e-cigarettes with subjectively reported health domains. Methods We utilized cross-sectional data from the 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative U.S. telephone-based survey. All variables were self-reported. E-cigarette use was characterized as never, former, or current. Health domains included overall health, physical health, and mental health, which was assessed as the frequency of emotional support, life satisfaction, and feeling stressed. Weighted multivariable-adjusted logistic regression models were used to examine the association between e-cigarette use and these health domains. Results Our study population consisted of 755,355 (79%) never e-cigarette users, 111,940 (16%) former users, and 28,917 (5%) current users. There was a significant association between e-cigarette use and the less favorable perceived state of overall health, physical health, or mental health. For example, the OR (95% CI) for the association of current e-cigarette use with health domains was as follows: good perception of overall health: 0.78 (0.74,0.83), physical health: 0.69 (0.66,0.73), adequate emotional support: 0.89 (0.79,0.99), feeling satisfied: 0.83 (0.71,0.96), or being free of stress: 0.64 (0.53,0.76). Similar results were obtained in younger individuals (aged 18-34 years). Conclusions E-cigarette use is associated with a less favorable perception of physical and mental health as compared to never use, particularly among younger adults. These results have important implications for clinicians for patient counseling and regulatory agencies to regulate e-cigarette sales., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Al Rifai et al.)

Background and Aims: Cardiovascular disease (CVD) and cancer are the two leading causes of death in smokers. Lung cancer screening is recommended in a large proportion of smokers. We examined the implication of coronary artery calcium (CAC) score (quantitative and qualitative) for cardiovascular disease (CVD), coronary heart disease (CHD), and cancer mortality risk prediction among current smokers., Methods: We included current smokers without known heart disease from the CAC Consortium. Cox regression (for all-cause mortality) and Fine-and-Gray competing-risk regression (for CVD, CHD, and cancer mortality) models, adjusted for traditional CVD risk factors, were used to assess the association between CAC and each mortality outcome, with CAC as a continuous (log2-transformed) or categorical variable (CAC = 0, CAC = 1-99, CAC = 100-399, and CAC ≥400). We used number of vessels with CAC as a surrogate for the qualitative measure of CAC and mortality outcomes. Analyses were repeated for lung cancer screening-eligible population (defined as ever smokers with >30 pack years smoking history) (n = 1,149). Hazard ratios (HR) for all-cause mortality and Subdistribution HRs (sHR) with 95% confidence intervals (CI) were reported., Results: Over a median of 11.9 years (25th-75th percentile: 10.2-13.3) of follow-up, of 5,147 current smokers (mean age 52.5 ± 9.4, 32.4% women) 337 died (102 of CVD, 54 of CHD, and 123 of cancer). A doubling of CAC score was associated with increased HRs of all-cause mortality (1.10 (1.06-1.14)), and sHRs for CVD (1.15 (1.07-1.24)), CHD (1.26 (1.11-1.42)) and cancer mortality (1.06 (1.00-1.13)). Those with CAC ≥400 had increased sHR of CVD (3.55 (1.70-7.41)), CHD (8.80 (2.41-32.10)), and cancer mortality (1.85 (1.07-3.22)), compared with those with CAC = 0. A diffuse CAC pattern significantly increased the risk of all-cause, CVD, and CHD mortality among smokers. Results were consistent for the lung cancer screening-eligible population., Conclusions: Qualitative and quantitative CAC scores can prognosticate risk of all-cause, CVD, CHD, and cancer mortality beyond traditional risk factors among all smokers as well as those eligible for lung cancer screening., Competing Interests: Declaration of competing interest The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: This study thoroughly explored the demographic and imaging characteristics, as well as the all-cause and cause-specific mortality risks of patients with a coronary artery calcium (CAC) score ≥1,000 in the largest dataset of this population to date., Background: CAC is commonly used to quantify cardiovascular risk. Current guidelines classify a CAC score of >300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with a CAC score ≥1,000., Methods: A total of 66,636 asymptomatic adults were included from the CAC consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for patients with cardiovascular disease (CVD), coronary heart disease (CHD), cancer, and all-cause mortality. Multivariate Cox proportional hazards regression models adjusted for age, sex, and conventional risk factors were used to assess the relative mortality hazard of individuals with CAC ≥1,000 compared with, first, a CAC reference of 0, and second, with patients with a CAC score of 400 to 999., Results: There were 2,869 patients with CAC ≥1,000 (86.3% male, mean 66.3 ± 9.7 years of age). Most patients with CAC ≥1,000 had 4-vessel CAC (mean: 3.5 ± 0.6 vessels) and had greater total CAC area, higher mean CAC density, and more extracoronary calcium (79% with thoracic artery calcium, 46% with aortic valve calcium, and 21% with mitral valve calcium) than those with CAC scores of 400 to 999. After full adjustment, those with CAC ≥1,000 had a 5.04- (95% confidence interval [CI]: 3.92 to 6.48), 6.79- (95% CI: 4.74 to 9.73), 1.55- (95% CI:1.23 to 1.95), and 2.89-fold (95% CI: 2.53 to 3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC score of 0. The CAC ≥1,000 group had a 1.71- (95% CI: 1.41 to 2.08), 1.84- (95% CI: 1.43 to 2.36), 1.36- (95% CI:1.07 to 1.73), and 1.51-fold (95% CI: 1.33 to 1.70) increased risk of CVD, CHD, cancer, and all-cause mortality compared to those with CAC scores 400 to 999. Graphic analysis of CAC ≥1,000 patients revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau., Conclusions: Patients with extensive CAC (CAC ≥1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC ≥1,000 patients to be a distinct risk group who may benefit from the most aggressive preventive therapy., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The Coronary Artery Calcium Data and Reporting System (CAC-DRS), which takes into account the Agatston score category (A) and the number of calcified vessels (N) has not yet been validated in terms of its prognostic significance., Methods: We included 54,678 patients from the CAC Consortium, a large retrospective clinical cohort of asymptomatic individuals free of baseline cardiovascular disease (CVD). CAC-DRS groups were derived from routine, cardiac-gated CAC scans. Cox proportional hazards regression models, adjusted for traditional CVD risk factors, were used to assess the association between CAC-DRS groups and CHD, CVD, and all-cause mortality. CAC-DRS was then compared to CAC score groups and regional CAC distribution using area under the curve (AUC) analysis., Results: The study population had a mean age of 54.2 ± 10.7, 34.4% female, and mean ASCVD score 7.3% ± 9.0. Over a mean follow-up of 12 ± 4 years, a total of 2,469 deaths (including 398 CHD deaths and 762 CVD deaths) were recorded. There was a graded risk for CHD, CVD and all-cause mortality with increasing CAC-DRS groups ranging from an all-cause mortality rate of 1.2 per 1,000 person-years for A0 to 15.4 per 1,000 person-years for A3/N4. In multivariable-adjusted models, those with CAC-DRS A3/N4 had significantly higher risk for CHD mortality (HR 5.9 (95% CI 3.6-9.9), CVD mortality (HR4.0 (95% CI 2.8-5.7), and all-cause mortality a (HR 2.5 (95% CI 2.1-3.0) compared to CAC-DRS A0. CAC-DRS had higher AUC than CAC score groups (0.762 vs 0.754, P < 0.001) and CAC distribution (0.762 vs 0.748, P < 0.001)., Conclusion: The CAC-DRS system, combining the Agatston score and the number of vessels with CAC provides better stratification of risk for CHD, CVD, and all-cause death than the Agatston score alone. These prognostic data strongly support new SCCT guidelines recommending the use CAC-DRS scoring., (Copyright © 2020 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: The popularity of electronic cigarettes (E-cigarettes) has risen considerably. Several studies have suggested that nicotine may affect insulin resistance, however, the impact of E-cigarette exposure on insulin resistance, an early measure of cardiometabolic risk, is not known., Methods and Results: Using experimental animals and human data obtained from 3,989 participants of the United States National Health and Nutrition Examination Survey (NHANES), respectively, we assessed the association between E-cigarette and conventional cigarette exposures and insulin resistance, as modelled using the homeostatic model assessment of insulin resistance (HOMA-IR) and glucose tolerance tests (GTT). C57BL6/J mice (on standard chow diet) exposed to E-cigarette aerosol or mainstream cigarette smoke (MCS) for 12 weeks showed HOMA-IR and GTT levels comparable with filtered air-exposed controls. In the NHANES cohort, there was no significant association between defined tobacco product use categories (non-users; sole E-cigarette users; cigarette smokers and dual users) and insulin resistance. Compared with non-users of e-cigarettes/conventional cigarettes, sole E-cigarette users showed no significant difference in HOMA-IR or GTT levels following adjustment for age, sex, race, physical activity, alcohol use and BMI., Conclusion: E-cigarettes do not appear to be linked with insulin resistance. Our findings may inform future studies assessing potential cardiometabolic harms associated with E-cigarette use., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Disclosure: The authors receive research funding from the US Food and Drug Administration.

Importance: The prevalence of the use of electronic cigarettes (e-cigarettes) in the United States has grown rapidly since their introduction to the market more than a decade ago. While several studies have demonstrated an association between combustible cigarette smoking and depression, the association between e-cigarette use and depression has not been thoroughly studied., Objective: To examine the association between e-cigarette use and depression in a nationally representative sample of the adult population in the United States., Design, Setting, and Participants: Cross-sectional study of the Behavioral Risk Factor Surveillance System database, 2016 to 2017. The Behavioral Risk Factor Surveillance System is the largest national telephone-based survey of randomly sampled adults in the United States. A total of 892 394 participants with information on e-cigarette use and depression were included. Data analysis was conducted in May 2019., Exposures: Electronic cigarette use status defined by self-report as never, former, or current use., Main Outcomes and Measures: Self-reported history of a clinical diagnosis of depression., Results: Of the 892 394 participants (414 326 [29.0%] aged ≥60 years; 502 448 [51.3%] women), there were 28 736 (4.4%) current e-cigarette users, of whom 13 071 (62.1%) were aged between 18 and 39 years. Compared with never e-cigarette users, current e-cigarette users were more likely to be single, male, younger than 40 years, and current combustible cigarette smokers (single, 120 797 [24.3%] vs 10 517 [48.4%]; men, 318 970 [46.6%] vs 14 962 [60.1%]; aged 18-39 years, 129 085 [32.2%] vs 13 071 [62.1%]; current combustible cigarette use, 217 895 [7.9%] vs 8823 [51.8%]). In multivariable adjusted models, former e-cigarette users had 1.60-fold (95% CI, 1.54-1.67) higher odds of reporting a history of clinical diagnosis of depression than never users, whereas current e-cigarette users had 2.10 (95% CI, 1.98-2.23) times higher odds. Additionally, higher odds of reporting depression were observed with increased frequency of use among current e-cigarette users compared with never users (daily use: odds ratio, 2.39; 95% CI, 2.19-2.61; occasional use: odds ratio, 1.96; 95% CI, 1.82-2.10). Similar results were seen in subgroup analyses by sex, race/ethnicity, smoking status, and student status., Conclusions and Relevance: This study found a significant cross-sectional association between e-cigarette use and depression, which highlights the need for prospective studies analyzing the longitudinal risk of depression with e-cigarette use. If confirmed by other study designs, the potential mental health consequences may have regulatory implications for novel tobacco products.

Background: Coronary artery calcium (CAC) has been shown in multiple populations to predict atherosclerotic cardiovascular disease. However, its predictive value in Asian-Americans is poorly described., Patients and Methods: We studied 1621 asymptomatic Asian-Americans in the CAC Consortium, a large multicenter retrospective cohort. CAC was modeled in categorical (CAC = 0; CAC = 1-99; CAC = 100-399; CAC ≥ 400) and continuous [ln (CAC + 1)] forms. Participants were followed over a mean follow-up of 12 ± 4 years for coronary heart disease (CHD) death, cardiovascular disease (CVD) death, and all-cause mortality. The predictive value of CAC for individual outcomes was assessed using multivariable-adjusted Cox regression models adjusted for traditional cardiovascular risk factors and reported as hazard ratios (95% confidence interval)., Results: The mean (SD) age of the population was 54 (11.2) years and 64% were men. The mean 10-year atherosclerotic cardiovascular disease risk score was 8%. Approximately half had a CAC score of 0, whereas 22.5% had a CAC score of greater than 100. A total of 56 deaths (16 CVD and 8 CHD) were recorded, with no CVD or CHD deaths in the CAC = 0 group. We noted a significantly increased risk of CHD [hazard ratio (HR): 2.6 (1.5-4.3)] and CVD [HR: 2.3 (1.8-2.9)] mortality per unit increase in In (CAC + 1). Compared to those with CAC scores of 0, individuals with CAC scores of at least 400 had over a three-fold increased risk of all-cause mortality [HR: 3.3 (1.3-8.6)]., Conclusion: Although Asian-Americans are a relatively low-risk group, CAC strongly predicts CHD, CVD, and all-cause mortality beyond traditional risk factors. These findings may help address existing knowledge gaps in CVD risk prediction in Asian-Americans.

Background: E-cigarette use prevalence has grown rapidly in the US. Despite the popularity of these products, few acute exposure toxicity studies exist, and studies on long-term pulmonary health effects are limited. E-cigarette users who are never combustible cigarette smokers (sole users) constitute a unique group of young adults that may be at increased risk of bronchial hyperreactivity and development of asthma. Given the public health concern about the potential pulmonary health effects of sole e-cigarette use, we aimed to examine the association between e-cigarette use and asthma among never combustible cigarette smokers., Methods: We pooled 2016 and 2017 data of the Behavioral Risk Factor Surveillance System (BRFSS), a large, cross-sectional telephone survey of adults aged 18 years and older in the U.S. We included 402,822 participants without any history of combustible cigarette smoking (defined as lifetime smoking < 100 cigarettes) and with complete self-reported information on key variables. Current e-cigarette use, further classified as daily or occasional use, was the primary exposure. The main outcome, asthma, was defined as self-reported history of asthma. We assess the relationship of sole e-cigarette use with asthma using multivariable logistic regression adjusting for age, sex, race, income, level of education and body mass index., Results: Of 402,822 never combustible cigarette smokers, there were 3103 (0.8%) current e-cigarette users and 34,074 (8.5%) with asthma. The median age group of current e-cigarette users was 18-24 years. Current e-cigarette use was associated with 39% higher odds of self-reported asthma compared to never e-cigarette users (Odds Ratio [OR], 1.39; 95% confidence interval: 1.15, 1.68). There was a graded increased odds of having asthma with increase of e-cigarette use intensity. The odds ratio of self-reported asthma increased from 1.31 (95% confidence interval: 1.05, 1.62) in occasional users to 1.73 (95% confidence interval: 1.21, 2.48) in daily e-cigarette users, compared to never e-cigarette users., Conclusion: Our findings from a large, nationally representative survey suggest increased odds of asthma among never combustible smoking e-cigarette users. This may have potential public health implications, providing a strong rationale to support future longitudinal studies of pulmonary health in young e-cigarette-using adults.

Background: The prevalence of e-cigarette use in the United States has increased rapidly. However, the association between e-cigarette use and cardiovascular disease remains virtually unknown. Therefore, we aimed to examine the association between e-cigarette use and cardiovascular disease among never and current combustible-cigarette smokers., Methods: We pooled 2016 and 2017 data from the Behavioral Risk Factor Surveillance System (BRFSS), a large, nationally representative, cross-sectional telephone survey. We included 449,092 participants with complete self-reported information on all key variables. The main exposure, e-cigarette use, was further divided into daily or occasional use, and stratified by combustible-cigarette use (never and current). Cardiovascular disease, the main outcome, was defined as a composite of self-reported coronary heart disease, myocardial infarction, or stroke., Results: Of 449,092 participants, there were 15,863 (3.5%) current e-cigarette users, 12,908 (2.9%) dual users of e-cigarettes + combustible cigarettes, and 44,852 (10.0%) with cardiovascular disease. We found no significant association between e-cigarette use and cardiovascular disease among never combustible-cigarette smokers. Compared with current combustible-cigarette smokers who never used e-cigarettes, dual use of e-cigarettes + combustible cigarettes was associated with 36% higher odds of cardiovascular disease (odds ratio 1.36; 95% confidence interval, 1.18-1.56); with consistent results in subgroup analyses of premature cardiovascular disease in women <65 years and men <55 years old., Conclusion: Our results suggest significantly higher odds of cardiovascular disease among dual users of e-cigarettes + combustible cigarettes compared with smoking alone. These data, although preliminary, support the critical need to conduct longitudinal studies exploring cardiovascular disease risk associated with e-cigarette use, particularly among dual users., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Aims: Left main (LM) coronary artery disease is associated with greater myocardial infarction-related mortality, however, coronary artery calcium (CAC) scoring does not account for disease location. We explored whether LM CAC predicts excess mortality in asymptomatic adults., Methods: Cause-specific cardiovascular and all-cause mortality was studied in 28,147 asymptomatic patients with non-zero CAC scores in the CAC Consortium. Multivariate regression was performed to evaluate if the presence and burden of LM CAC predict mortality after adjustment for clinical risk factors and the Agatston CAC score. We further analyzed the per-unit hazard associated with LM CAC in comparison to CAC in other arteries., Results: The study population had mean age of 58.3 ± 10 years and CAC score of 301 ± 631. LM CAC was present in 21.7% of the cases. During 312,398 patient-years of follow-up, 1,907 deaths were observed. LM CAC was associated with an increased burden of clinical risk factors and total CAC, and was independently predictive of increased hazard for all-cause (HR 1.2 [1.1, 1.3]) and cardiovascular disease death (HR 1.3 [1.1, 1.5]). The hazard for death increased proportionate to the percentage of CAC localized to the LM. On a per-100 Agatston unit basis, LM CAC was associated with a 6-9% incremental hazard for death beyond knowledge of CAC in other arteries., Conclusions: The presence and high burden of left main CAC are independently associated with a 20-30% greater hazard for cardiovascular and total mortality in asymptomatic adults, arguing that LM CAC should be routinely noted in CAC score reports when present., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The 2018 American Heart Association and American College of Cardiology (AHA/ACC) cholesterol management guideline considers current evidence on coronary artery calcium (CAC) testing while incorporating learnings from previous guidelines. More than any previous guideline update, this set encourages CAC testing to facilitate shared decision making and to individualize treatment plans. An important novelty is further separation of risk groups. Specifically, the current prevention guideline recommends CAC testing for primary atherosclerotic cardiovascular disease (ASCVD) prevention among asymptomatic patients in borderline and intermediate risk groups (5-7.5% and 7.5-20% 10-year ASCVD risk). This additional sub-classification reflects the uncertainty of treatment strategies for patients broadly considered to be "intermediate risk," as treatment recommendations for high and low risk groups are well established. The 2018 guidelines, for the first time, clearly recognize the significance of a CAC score of zero, where intensive statin therapy is likely not beneficial and not routinely recommended in selected patients. Lifestyle modification should be the focus in patients with CAC = 0. In this article, we review the recent AHA/ACC cholesterol management guideline and contextualize the transition of CAC testing to a guideline-endorsed decision aid for borderline-to-intermediate risk patients who seek more definitive risk assessment as part of a clinician-patient discussion. CAC testing can reduce low-value treatment and focus primary prevention therapy on those most likely to benefit., Competing Interests: The authors declare that they have no conflicts of interest.

Background: The Society of Cardiovascular Computed Tomography (SCCT) recommends consideration of coronary artery calcium (CAC) scoring among individuals with a family history (FH) of coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD) risk <5%. No dedicated study has examined the prognostic significance of CAC scoring among this population., Methods: The CAC Consortium is a multi-center observational cohort study from four clinical centers linked to long-term follow-up for cause-specific mortality. All CAC scans were physician referred and performed in patients without a history of CHD. Our analysis includes 14,169 patients with ASCVD scores <5% and self-reported FH of CHD., Results: This cohort had a mean age of 48.1 (SD 7.4), was 91.3% white, 47.4% female, had an average ASCVD score of 2.3% (SD 1.3), and 59.4% had a CAC = 0. The event rate for all-cause mortality was 1.2 per 1000 person-years, 0.3 per 1000 person-years for CVD-specific mortality, and 0.2 per 1000 person-years for CHD-specific mortality. In multivariable Cox proportional hazard models, those with CAC>100 had a 2.2 (95% CI 1.5-3.3) higher risk of all-cause mortality, 4.3 (95% CI 1.9-9.5) times higher risk of CVD-specific mortality, and a 10.4 (95% CI 3.2-33.7) times higher risk of CHD-specific mortality compared to individuals with CAC = 0. The NNS to detect CAC >100 in this sample was 9., Conclusion: In otherwise low risk patients with FH of CHD, CAC>100 were associated with increased risk of all-cause and CHD mortality with event rates in a range that may benefit with preventive pharmacotherapy. These data strongly support new SCCT recommendations regarding testing of patients with a family history of CHD., (Copyright © 2019. Published by Elsevier Inc.)

We examined the utility of coronary artery calcium (CAC) for cardiovascular risk stratification among hypertensive adults, including those fitting eligibility for SPRINT (Systolic Blood Pressure Intervention Trial). Additionally, we used CAC to identify hypertensive adults with cardiovascular disease (CVD) mortality rates equivalent to those observed in SPRINT who may, therefore, benefit from the most intensive blood pressure therapy. Our study population included 16 167 hypertensive patients from the CAC Consortium, among whom 6375 constituted a "SPRINT-like" population. We compared multivariable-adjusted hazard ratios of coronary heart disease and CVD deaths by CAC category (0, 1-99, 100-399, ≥400). Additionally, we generated a CAC-CVD mortality curve for patients aged >50 years to determine what CAC scores were associated with CVD death rates observed in SPRINT. Mean age was 58.1±10.6 years. During a mean follow-up of 11.6±3.6 years, there were 409 CVD deaths and 207 coronary heart disease deaths. Increasing CAC scores were associated with increased coronary heart disease and CVD mortality (coronary heart disease-CAC 100-399: hazard ratio [95% CI] 1.88 [1.04-3.40], CAC ≥400: 4.16 [2.34-7.39]; CVD-CAC 100-399: 1.93 [1.31-2.83], CAC ≥400: 3.51 [2.40-5.13]). A similar increased risk was observed across 10-year atherosclerotic CVD risk categories and in the SPRINT-like population. A CAC score of 220 (confidence range, 165-270) was associated with the CVD mortality rate observed in SPRINT. CAC risk stratifies adults with hypertension, including those who are SPRINT eligible. A CAC score of 220 can identify hypertensive adults with SPRINT-level CVD mortality risk and, therefore, may be reasonable for identifying candidates for aggressive blood pressure therapy.

Importance: The interplay of self-rated health (SRH), coronary artery calcium (CAC) scores, and cardiovascular risk is poorly described., Objectives: To assess the degree of correlation between SRH and CAC, to determine whether these measures are complementary for risk prediction, and to assess the incremental value of the addition of SRH to established risk tools., Design, Setting, and Participants: The Multi-Ethnic Study of Atherosclerosis (MESA) is a large population-based prospective cohort study of adults aged 45 to 84 years who were recruited from 6 US communities. A total of 6764 participants without baseline cardiovascular disease (CVD) were included in the analysis. Data were collected from July 2000 through August 2002. Follow-up was completed by December 2013, and data were analyzed from October 2018 to December 2018., Exposures: The EVGGFP (excellent, very good, good, fair, and poor) self-assessment of overall health (assessed before the baseline study examination) and CAC score. The EVGGFP rating was categorized as poor/fair, good, very good, or excellent., Main Outcomes and Measures: Hard coronary heart disease (CHD) events, hard CVD events, and all-cause mortality during a median follow-up of 13.2 years (interquartile range, 12.7-13.7 years)., Results: Among the study population of 6764 participants, the mean (SD) age was 62.1 (10.2) years, and 52.9% were women. The EVGGFP rating was strongly associated with age, sex, race/ethnicity, educational and income levels, healthy diet and physical activity, and cardiovascular risk factors. Despite encapsulating many risk variables, no correlation (r = -0.007; P = .57) or association between EVGGFP and the presence (χ2 = 0.84; P = .84) or severity (χ2 = 4.64; P = .86) of CAC was found. During follow-up, 1161 deaths, 637 hard CVD events, and 405 hard CHD events were recorded. In models adjusted for age, sex, race/ethnicity, and CAC, participants who reported excellent health had a 45% lower risk of CVD (hazard ratio [HR], 0.55; 95% CI, 0.39-0.77) and a 42% lower risk of CHD (HR, 0.58; 95% CI, 0.37-0.90) compared with those who reported poor/fair health. Participants in the excellent SRH category who had any CAC had markedly elevated risk of hard CHD (HR, 6.19; 95% CI, 2.1-18.3) and CVD (HR, 6.50; 95% CI, 2.7-15.6) events compared with those with a CAC score of 0. The addition of the EVGGFP rating to CAC improved the area under the curve (C statistic) for CHD events (0.725 vs 0.734; P = .007), CVD events (0.693 vs 0.706; P < .001), and all-cause mortality (0.685 vs 0.707; P < .001). However, the addition of the EVGGFP rating to the combination of CAC and atherosclerotic CVD risk score did not significantly improve C statistics for CHD events (0.751 vs 0.753; P = .39), CVD events (0.739 vs 0.741; P = .18), or all-cause mortality (0.779 vs 0.781; P = .13)., Conclusions and Relevance: Although SRH and CAC integrate many risk variables, this study suggests that they are poorly correlated and have complementary predictive utility. A perception of excellent health does not obviate the need for definitive assessment of CVD risk, whereas fair/poor perceived health may serve as a risk enhancer, arguing for advanced risk assessment in selected clinical scenarios.

Purpose: Women in radiology are known to be underrepresented in academic leadership positions. We sought to determine if women are appropriately represented on editorial boards and editor-in-chief positions compared with their authorship contributions., Materials and Methods: We assessed the first and senior authorship male versus female gender breakdown of manuscripts published in nine high-impact American radiology journals 1 month per year from 2002 to 2017. We looked at the gender of the first authors, senior authors, editorial board members, and editors-in-chief of these journals to see if there was a gender discrepancy., Results: We assessed 3,702 first authors, 3,702 senior authors, and 9,400 editorial board members. Women were underrepresented on the editorial boards compared with their first-authored manuscript contribution in our sample of articles from every journal for every year and were underrepresented compared with their senior-authored manuscript contributions in 119 of 139 (85.6%) journal-years. The percentage of women as first authors (mean = 29.3 ± 9.9), senior authors (mean = 20.7 ± 8.1), and editorial board members (mean = 13.4 ± 6.5) showed major differences (P < .001). This gap did not significantly narrow over the 16 years of study. Notably, there was no woman as editor-in-chief for any of the journal-years., Conclusion: There is a gender gap in the composition of editorial boards in radiology compared with authorship contributions by women. Given the implications of editorial board assignment and editorship on women's academic advancement, journals may wish to consider strategies that will narrow the gap., (Copyright © 2018. Published by Elsevier Inc.)

In the recently published review "Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines," the following author name was inadvertently misspelled as Alison Peng. The correct spelling of the author's name is: Allison Peng as shown above.

Background Coronary artery calcium (CAC) predicts cardiovascular disease (CVD) events; however, less is known about how its prognostic implications vary by race/ethnicity. Methods and Results A total of 38 277 whites, 1621 Asians, 977 blacks, and 1349 Hispanics from the CAC Consortium (mean age 55 years, 35% women) were followed over a median of 11.7 years. Modeling CAC in continuous and categorical (CAC=0; CAC 1-99; CAC 100-399; CAC ≥400) forms, we assessed its predictive value for all-cause and CVD mortality by race/ethnicity using Cox proportional hazards and Fine and Gray competing-risk regression, respectively. We also assessed the impact of race/ethnicity on risk within individual CAC strata, using whites as the reference. Models were adjusted for traditional cardiovascular risk factors. Increased CAC was associated with higher total and CVD mortality risk in all race/ethnicity groups, including Asians. However, the risk gradient with increasing CAC was more pronounced in blacks and Hispanics. In Fine and Gray subdistribution hazards models adjusted for traditional cardiovascular risk factors and CAC (continuous), blacks (subdistribution hazard ratio 3.4, 95% confidence interval, 2.5-4.8) and Hispanics (subdistribution hazard ratio 2.3, 95% confidence interval, 1.6-3.2) showed greater risk of CVD mortality when compared with whites, while Asians had risk similar to whites. These race/ethnic differences persisted when CAC=0. Conclusions CAC predicts all-cause and CVD mortality in all studied race/ethnicity groups, including Asians and Hispanics, who may be poorly represented by the Pooled Cohort Equations. Blacks and Hispanics may have greater mortality risk compared with whites and Asians after adjusting for atherosclerosis burden, with potential implications for US race/ethnic healthcare disparities research.

Background: Contemporary data on the prevalence of e-cigarette use in the United States are limited., Objective: To report the prevalence and distribution of current e-cigarette use among U.S. adults in 2016., Design: Cross-sectional., Setting: Behavioral Risk Factor Surveillance System, 2016., Participants: Adults aged 18 years and older., Measurements: Prevalence of current e-cigarette use by sociodemographic groups, comorbid medical conditions, and states of residence., Results: Of participants with information on e-cigarette use (n = 466 842), 15 240 were current e-cigarette users, representing a prevalence of 4.5%, which corresponds to 10.8 million adult e-cigarette users in the United States. Of the e-cigarette users, 15% were never-cigarette smokers. The prevalence of current e-cigarette use was highest among persons aged 18 to 24 years (9.2% [95% CI, 8.6% to 9.8%]), translating to approximately 2.8 million users in this age range. More than half the current e-cigarette users (51.2%) were younger than 35 years. In addition, the age-standardized prevalence of e-cigarette use was high among men; lesbian, gay, bisexual, and transgender (LGBT) persons; current combustible cigarette smokers; and those with chronic health conditions. The prevalence of e-cigarette use varied widely among states, with estimates ranging from 3.1% (CI, 2.3% to 4.1%) in South Dakota to 7.0% (CI, 6.0% to 8.2%) in Oklahoma., Limitation: Data were self-reported, and no biochemical confirmation of tobacco use was available., Conclusion: E-cigarette use is common, especially in younger adults, LGBT persons, current cigarette smokers, and persons with comorbid conditions. The prevalence of use differs across states. These contemporary estimates may inform researchers, health care policymakers, and tobacco regulators about demographic and geographic distributions of e-cigarette use., Primary Funding Source: American Heart Association Tobacco Regulation and Addiction Center, which is funded by the U.S. Food and Drug Administration and National Heart, Lung, and Blood Institute.

Purpose of Review: In this review, we evaluate the coronary artery calcium (CAC) score as a biomarker for advanced atherosclerotic cardiovascular disease (ASCVD) risk assessment., Recent Findings: We summarize the evidence from multiple epidemiological studies, which show a clear advantage of CAC compared to traditional and non-traditional cardiovascular risk factors. We then compare the recommendations included in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and in the 2017 Society of Cardiovascular Computed Tomography (SCCT) guidelines for the use of CAC in ASCVD risk assessment, and examine the recent 2018 US Preventive Services Task Force (USPSTF) document. Finally, based on the currently available evidence, we provide constructive input for the upcoming ACC/AHA guidelines, regarding the population in whom CAC is most likely to be informative, the level of evidence that we believe should be assigned to CAC as an advanced ASCVD risk assessment tool, and the special populations in whom CAC might be beneficial for further risk assessment. We support a pragmatic approach that combines the pooled cohort equations (PCE) for initial ASCVD risk stratification, followed by CAC for refining ASCVD risk assessment among a broad range of intermediate risk patients and other special groups.