Medicine and Health Sciences Commons^™

The United States Army Ocular Teleconsultation Program 2004 Through 2009, Michael J. Mines, Kraig S. Bower, Charles M. Lappan, Robert A. Mazzoli, Ronald K. Poropatich

Uniformed Services University of the Health Sciences

PURPOSE: To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009.

DESIGN: Retrospective, noncomparative, consecutive case series.

METHODS: All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images.

RESULTS: The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; …

Educating Clerkship Students In The Era Of Resident Duty Hour Restrictions, L. James Nixon, Meenakshy Aiyer, Steven Durning, Chris Gouveia, Jennifer R. Kogan, Valerie J. Lang, Olle Ten Cate, Karen E. Hauer

Uniformed Services University of the Health Sciences

In 2003, the Accreditation Council for Graduate Medical Education defined for the first time an upper limit on the number of hours that residents can work. This initial reduction in work hours was made with the goal of improving patient safety, resident education, and resident well-being. Now, 8 years later, further duty hour restrictions are slated to take effect July 1, 2011. These new reductions are largely a response to growing public concern about the effects of sleep deprivation on residents. Educators and residents alike have mixed opinions about the effects of prior and future duty hour restrictions on resident …

Anti-Fcεr1 Antibody Injections Activate Basophils And Mast Cells And Delay Type 1 Diabetes Onset In Nod Mice, Marc P. Hübner, David Larson, Marina N. Torrero, Ellen Mueller, Yinghui Shi, Kristin E. Killoran, Edward Mitre

Uniformed Services University of the Health Sciences

Mounting evidence suggests that helminth infections protect against autoimmune diseases. As helminths cause chronic IgE-mediated activation of basophils and mast cells we hypothesized that continuous activation of these cells could prevent diabetes onset in nonobese diabetic (NOD) mice in the absence of infection. Anti-FcεR1 activated basophils and mast cells and resulted in the release of IL-4 and histamine into the bloodstream. Anti-FcεR1-treated NOD mice showed a type 2 shift in insulin-specific antibody production and exhibited significant delays in diabetes onset. IL-4 responses played a partial role as the protective effect of anti-FcεR1 therapy was diminished in IL-4-deficient NOD mice. In …

Arachidonyl Trifluoromethyl Ketone Ameliorates Experimental Autoimmune Encephalomyelitis Via Blocking Peroxynitrite Formation In Mouse Spinal Cord White Matter, Adam C. Vana, Shihe Li, Rachel Ribeiro, Flaubert Tchantchou, Yumin Zhang

Uniformed Services University of the Health Sciences

Inhibition of phospholipase A₂ (PLA₂) has recently been found to attenuate the pathogenesis of experimental autoimmune encephalomyelitis (EAE), a commonly used animal model of multiple sclerosis (MS). However, the protective mechanisms that underlie PLA₂ inhibition are still not well understood. In this study, we found that cytosolic PLA₂ (cPLA₂) was highly expressed in infiltrating lymphocytes and macrophages/microglia in mouse spinal cord white matter. Although cPLA₂ is also expressed in spinal cord neurons and oligodendrocytes, there were no differences observed in these cell types between EAE and control animals. Arachidonyl trifluoromethyl ketone (AACOCF3), …

Low-Dose Human Chorionic Gonadotropin May Improve In Vitro Fertilization Cycle Outcomes In Patients With Low Luteinizing Hormone Levels After Gonadotropin-Releasing Hormone Antagonist Administration, Anthony M. Propst, Micah J. Hill, Gordon Wright Bates, Michelle Palumbo, Anne K. Van Horne, Matthew G. Retzloff

Uniformed Services University of the Health Sciences

Objective: To evaluate the effect of low levels of endogenous luteinizing hormone (LH) and low-dose human chorionic gonadotropin (hCG) supplementation on in vitro fertilization (IVF) cycle outcomes in a gonadotropinreleasing hormone (GnRH) antagonist protocol.

Design: Retrospective study. Setting: Military medical center. Patient(s): General in vitro fertilization/embryo transfer (IVF-ET) population.

Intervention(s): Addition of low-dose urinary hCG to IVF stimulations using a recombinant follicle-stimulating hormone (FSH) and GnRH antagonist protocol. Main

Outcome Measure(s): Implantation and live-birth rates.

Result(s): As part of a larger cohort of 239 patients, 42 patients with LH levels ≤0.5 mIU/mL were evaluated. In the larger cohort, there were …

Linkages Between Anxiety And Outcomes In Heart Failure, Marla J. De Jong, Misook L. Chung, Jia-Rong Wu, Barbara Riegel, Mary Kay Rayens, Debra K. Moser

Uniformed Services University of the Health Sciences

Objective: We investigated the relationship between anxiety and event-free survival (ie, composite endpoint of death, emergency department visits, or hospitalizations) for patients with heart failure (HF), and examined whether behavioral and physiologic mechanisms mediate any association between anxiety and outcomes.

Methods: In this longitudinal study, patients with HF completed the anxiety subscale of the Brief Symptom Inventory, and heart-rate variability and plasma norepinephrine levels were measured. Dietary adherence and medication adherence were measured according to 24-hour urine sodium level and the Medication Event Monitoring System, respectively. Patients were followed at least 1 year for event-free survival.

Results: In total, 147 …

Suicide In The United States Air Force: Risk Factors Communicated Before And At Death, Daniel W. Cox, Marjan Ghahramanlou-Holloway, Farrah N. Greene, Jennifer L. Bakalar, Christina L. Schendel, M. Elicia Nademin, David A. Jobes, David R. Englert, Michael Kindt

Uniformed Services University of the Health Sciences

Background: Over the last decade, suicide rates in the U.S. military have steadily increased, resulting in a call for suicide-related research with military populations. The present project aimed to describe and evaluate the communications (i.e., verbally and in suicide notes) of 13 suicide risk factors in the suicide death investigation files of 98 active duty U.S. Air Force (USAF) members.

Methods: Two-hundred thirty-seven suicide death investigation files were coded. Ninety-eight decedents left suicide notes and were included in the current analyses. Descriptive statistics were computed to evaluate the types of risk factors most commonly communicated prior to and at the …

P11 Expression And Pet In Bipolar Disorders, Lei Zhang, Cheng-Ta Li, Tung-Ping Su, Xian-Zhang Hu, Ruth A. Lanius, Maree J. Webster, Ming-Yi Chung, Ying-Sheue Chen, Ya-Mei Bai, Jeffery L. Barker, James E. Barrett, Xiao-Xia Li, He Li, David M. Benedek, Robert Ursano

Uniformed Services University of the Health Sciences

Background: Bipolar disorder (BD) is a common mental disorder, subdivided into BD-I and BD-II. Currently, few biomarkers differentiate BD-I from BD-II. However, it is suggested that peripheral blood mononuclear cell (PBMC) mRNA levels of p11 and positron emission tomography (PET) might be potential biomarkers for BD.

Methods: Healthy controls (HCs), BD-I, and BD-II patients in remission (n = 20 in each group) underwent a resting PET study with the radiotracer [¹⁸F]-2-deoxy-2-fluoro-_D-glucose (¹⁸F-FDG). PBMC p11 mRNA levels were determined by quantitative real-time PCR.

Results: Comparing BD patients to HCs, normalized glucose metabolism (NGM) was higher …

Effectiveness Of Battlefield-Ethics Training During Combat Deployment: A Programme Assessment, Christopher H. Warner, George N. Appenzeller, Angela Mobbs, Jessica R. Parker, Carolynn M. Warner, Thomas Grieger, Charles W. Hoge

Uniformed Services University of the Health Sciences

Background Breakdowns in the ethical conduct of soldiers towards non-combatants on the battlefi eld are of grave concern in war. Evidence-based training approaches to prevent unethical conduct are scarce. We assessed the eff ectiveness of battlefi eld-ethics training and factors associated with unethical battlefi eld conduct.

Methods The training package, based on movie vignettes and leader-led discussions, was administered 7 to 8 months into a 15-month high-intensity combat deployment in Iraq, between Dec 11, 2007, and Jan 30, 2008. Soldiers from an infantry brigade combat team (total population about 3500) were randomly selected, on the basis of company and the …

Liposome-Induced Complement Activation And Related Cardiopulmonary Distress In Pigs: Factors Promoting Reactogenicity Of Doxil And Ambisome, János Szebeni, Péter Bedőcs, Zoltán Rozsnyay, Zsóka Weiszhár, Rudolf Urbanics, László Rosivall, Rivka Cohen, Olga Garbuzenko, György Báthori, Miklós Tóth, Rolf Bünger, Yechezkel Barenholz

Uniformed Services University of the Health Sciences

Hypersensitivity reactions to liposomal drugs, often observed with Doxil and AmBisome, can arise from activation of the complement (C) system by phospholipid bilayers. To understand the mechanism of this adverse immune reaction called C activation-related pseudoallergy (CARPA), we analyzed the relationship among liposome features, C activation in human serum in vitro, and liposome-induced cardiovascular distress in pigs, a model for human CARPA. Among the structural variables (surface charge, presence of saturated, unsaturated, and PEGylated phospholipids, and cisplatin vs. doxorubicin inside liposomes), high negative surface charge and the presence of doxorubicin were significant contributors to reactogenicity both in vitro and …

Distinct Role Of Nitric Oxide And Peroxynitrite In Mediating Oligodendrocyte Toxicity In Culture And In Experimental Autoimmune Encephalomyelitis, S. Li, A. C. Vana, R. Ribeiro, Y. Zhang

Uniformed Services University of the Health Sciences

Nitric oxide has been implicated in the pathogenesis of multiple sclerosis. However, it is still unclear whether nitric oxide plays a protective role or is deleterious. We have previously shown that peroxynitrite, a reaction product of nitric oxide and superoxide, is toxic to mature oligodendrocytes (OLs). The toxicity is mediated by intracellular zinc release, phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), activation of 12-lipoxygenase (12-LOX) and the formation of reactive oxygen species (ROS). In this study, we found that the donors of nitric oxide, dipropylenetriamine NONOate (DPT NONOate) and diethylenetriamine NONOate (DETA NONOate), protected OLs from peroxynitrite or zinc-induced toxicity. …

Postoperative Lymphocele After Revision Circumferential Long-Segment Scoliosis Construct For Pseudarthrosis, Ronald A. Lehman Jr.

Uniformed Services University of the Health Sciences

The patient was a 69-year-old female who had previously undergone a T10-ilium posterior spinal fusion for lumbar scoliosis and spinal stenosis. She presented 2 years after the index procedure for new complaints of low back pain and midthoracic pain, and a feeling of ‘‘tipping over.’’ Scoliosis survey and computed tomography (CT) revealed proximal junctional kyphosis with cephalad degeneration and pseudarthrosis at L5–S1 and L3–L4. She subsequently underwent anterior lumbar interbody fusion from L3 sacrum and revision posterior spinal fusion from T3 ilium the same day. She recovered uneventfully until she returned for follow-up approximately 3 weeks after surgery. At that …

Schistosoma Comparative Genomics: Integrating Genome Structure, Parasite Biology And Anthelmintic Discovery, Martin T. Swain, Denis M. Larkin, Conor R. Caffrey, Stephen J. Davies, Alex Loukas, Patrick J. Skelly, Karl F. Hoffmann

Uniformed Services University of the Health Sciences

Schistosoma genomes provide a comprehensive resource for identifying the molecular processes that shape parasite evolution and for discovering novel chemotherapeutic or immunoprophylactic targets. Here, we demonstrate how intragenus and intergenus comparative genomics can be used to drive these investigations forward, illustrate the advantages and limitations of these approaches and review how post-genomic technologies offer complementary strategies for genome characterisation. Although sequencing and functional characterisation of other schistosome/platyhelminth genomes continues to expedite anthelmintic discovery, we contend that future priorities should equally focus on improving assembly quality, and chromosomal assignment, of existing schistosome/platyhelminth genomes.

A Systematic Review Of Experimental Infections With Enterotoxigenic Escherichia Coli (Etec), Chad K. Porter, Mark S. Riddle, David R. Tribble, A. Louis Bougeois, Robin Mckenzie, Sandra D. Isidean, Peter Sebeny, Stephen J. Savarino

Uniformed Services University of the Health Sciences

Volunteer challenge with enterotoxigenic Escherichia coli (ETEC) has been used for four decades to elucidate the pathogenesis and immune responses and assess efficacy of various interventions. We performed a systematic review of these studies and a meta-analysis of individual patient-level data (IPD) from a subset of studies using standard methodology.

We identified 27 studies of 11 ETEC strains administered to 443 naive subjects at doses from 1 × 10⁶ to 1 × 10¹⁰ colony forming units (cfu). Diarrhea attack rates varied by strain, dose and enterotoxin. Similar rates were seen at doses of 5 × 10⁸ to …

International Federation For Emergency Medicine Model Curriculum For Medical Student Education In Emergency Medicine, Cherri Hobgood, Venkataraman Anantharaman, Glen Bandiera, Peter Cameron, Pinchas Halperin, James Holliman, Nicholas Jouriles, Darren Kilroy, Terrence Mulligan, Andrew Singer

Uniformed Services University of the Health Sciences

There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations …

Incidence Of Tricyclic Antidepressant-Like Complications After Cyclobenzaprine Overdose, Vikhyat S. Bebarta, Joseph Maddry, Douglas J. Borys, David L. Morgan

Uniformed Services University of the Health Sciences

Background: The cyclobenzaprine structure is similar to amitriptyline; however, tricyclic antidepressant (TCA)-like wide complex dysrhythmia has not been reported. Our objective was to determine the incidence of TCA-like effects in cyclobenzaprine overdoses as reported to 6 poison centers for 2 years. We compared the incidence of these effects to amitriptyline overdoses collected during the same period.

Methods: We performed a retrospective review of 2 years of cases as reported to the Texas Poison Center Network. We identified sole ingestions of cyclobenzaprine and of amitriptyline. Cases had a recorded clinical outcome and clinical effect. A trained reviewer used a standard data …

The Case For Simulation As Part Of A Comprehensive Patient Safety Program, Cynthia H. Argani, Melissa Eichelberger, Shad Deering, Andrew J. Satin

Uniformed Services University of the Health Sciences

Simulation in obstetrics allows us to practice in a safe environment. Simulations can improve the performance of individuals and obstetric teams. The evidence is overwhelming that, with simulated practice, obstetricians improve their technical and communication skills. Evidence is emerging that simulation ultimately may improve clinical outcomes. It stands to reason that simulation in obstetrics should be incorporated into comprehensive patient safety programs.

Malignant Hyperthermia — Human Stress Triggering, Gerald A. Gronert, Joseph R. Tobin, Sheila Muldoon

Uniformed Services University of the Health Sciences

Letter to the Editor concerns the question of a discussion of awake porcine malignant hyperthermia that erroneously omits the awake human stress reaction of malignant hyperthermia.

How To Develop An Effective Obstetric Checklist, M. Bardett Fausett, Anthony Propst, Karin Van Doren, Benjamin T. Clark

Uniformed Services University of the Health Sciences

Checklists to guide critical procedures are becoming an increasingly important part of medical practice. These tools have proved effective in improving outcome in a variety of medical settings, including obstetrics. In this review, we outline essential principles of successful checklist creation and implementation and review our experience with checklist development in a worldwide, multiinstitutional health care delivery system.

Delineation Of Two Clinically And Molecularly Distinct Subgroups Of Posterior Fossa Ependymoma, Hendrik Witt, Stephen C. Mack, Marina Ryzhova, Sebastian Bender, Martin Sill, Ruth Isserlin, Axel Benner, Thomas Hielscher, Till Milde, Marc Remke, David T. W. Jones, Paul A. Northcott, Livia Garzia, Kelsey C. Bertrand, Andrea Wittmann, Yuan Yao, Stephen S. Roberts, Luca Massimi, Tim Van Meter, William A. Weiss, Nalin Gupta, Wiesia Grajkowska, Boleslaw Lach, Yoon-Jae Cho, Andreas Von Deimling, Andreas E. Kulozik, Olaf Witt, Gary D. Bader, Cynthia E. Hawkins, Uri Tabori, Abhijit Guha, James T. Rutka, Peter Lichter, Andrey Korshunov, Michael D. Taylor, Stefan M. Pfister

Uniformed Services University of the Health Sciences

Despite the histological similarity of ependymomas from throughout the neuroaxis, the disease likely comprises multiple independent entities, each with a distinct molecular pathogenesis. Transcriptional profiling of two large independent cohorts of ependymoma reveals the existence of two demographically, transcriptionally, genetically, and clinically distinct groups of posterior fossa (PF) ependymomas. Group A patients are younger, have laterally located tumors with a balanced genome, and are much more likely to exhibit recurrence, metastasis at recurrence, and death compared with Group B patients. Identification and optimization of immunohistochemical (IHC) markers for PF ependymoma subgroups allowed validation of our findings on a third independent …

Pre-Clinical Screening Of Immunomodulatory Compounds Using The Parent-Into-F1 Model, Charles S. Via

Uniformed Services University of the Health Sciences

Activation of the innate immune system by toll-like receptors (TLR) provides an early response to pathogens and shapes the subsequent antigen-specific adaptive immune response. Unmethylated cytosine-guanine dinucleotide (CpG)motifs present in bacterial DNA, but not vertebrate DNA, can be detected by Toll like receptor 9 (TLR9)—bearing DC and B cells resulting in a pro-inflammatory Th1 response. Synthetic oligodeoxynucleotides (ODN) expressing these CpG motifs exhibit similar in vivo biologic activity and have been shown to reduce disease severity for selected pathogens, to promote vaccine responses and to enhance anti-tumor responses (reviewed in Ref.). Conversely, suppressive DNA sequences have also been identified. TTAGGG …

Morphine-Induced Modulation Of Ltd At Gabaergic Synapses In The Ventral Tegmental Area, Matthieu Dacher, Fereshteh S. Nugent

Uniformed Services University of the Health Sciences

Adaptive behaviors often require the learning of appropriate responses to rewarding stimuli, yet aberrant learning processes can lead to serious diseases such as addiction. Dopamine (DA) neurons of the ventral tegmental area (VTA) play an essential role in the treatment of rewarding stimuli, and they exhibit plasticity in response to such stimuli, but also to drugs of abuse. Previously we discovered a form of presynaptic nitric oxide (NO)-mediated long-term potentiation (LTP_GABA) at GABAergic synapses onto VTA DA neurons that is prevented with morphine in vivo 24 h after exposure. Here we investigated whether the same GABAergic synapses are …

Opiates And Plasticity, Matthieu Dacher, Fereshteh S. Nugent

Uniformed Services University of the Health Sciences

Opiates are among the most powerful analgesics and pain-relieving agents. However, they are potentially extremely addictive thereby limiting their medical use, making them exceedingly susceptible to abuse and adding to the global drug problem. It is believed that positive memories associated with the pleasurable effects of opiates and negative memories associated with dysphoria during opiate withdrawal contribute to compulsive opiate-seeking behavior characterizing addiction. There is a vast amount of available data regarding the neuroadaptations in response to opiates during opiate tolerance, dependence and withdrawal that contribute to opiate addiction, yet it is still a major challenge to identify the neurobiological …

Epithelial To Mesenchymal Transition (Emt) Induced By Bleomycin Or TfgB1/Egf In Murine Induced Pluripotent Stem Cell-Derived Alveolar Type Ii-Like Cells, Zaida A. Alipio, Nathan Jones, Wenbin Liao, Jianchang Yang, Shilpa Kulkarni, K. Sree Kumar, Martin Hauer-Jensen, David C. Ward, Yupo Ma, Louis M. Fink

Uniformed Services University of the Health Sciences

Induced pluripotent stem (iPS) cells are derived from reprogrammed somatic cells and are similar to embryonic stem (ES) cells in morphology, gene/protein expression, and pluripotency. In this study, we explored the potential of iPS cells to differentiate into alveolar Type II (ATII)-like epithelial cells. Analysis using quantitative real time polymerase chain reaction and immunofluorescence staining showed that pulmonary surfactant proteins commonly expressed by ATII cells such as surfactant protein A (SPA), surfactant protein B (SPB), and surfactant protein C (SPC) were unpregulated in the differentiated cells. Microphilopodia characteristics and lamellar bodies were observed by transmission electron microscopy and lipid deposits …

Accelerated Lymphocyte Reconstitution And Long-Term Recovery After Transplantation Of Lentiviral-Transduced Rhesus Cd34+ Cells Mobilized By G-Csf And Plerixafor, Naoya Uchida, Aylin Bonifacino, Allen E. Krouse, Mark E. Metzger, Gyorgy Csako, Agnes Lee-Stroka, Ross M. Fasano, Susan F. Leitman, Joseph J. Mattapallil, Matthew M. Hsieh, John F. Tisdale, Robert E. Donahue

Uniformed Services University of the Health Sciences

Objective. Granulocyte colony-stimulating factor (G-CSF) in combination with plerixafor produces significant mobilization of CD34⁺ cells in rhesus macaques. We sought to evaluate whether these CD34⁺ cells can stably reconstitute blood cells with lentiviral gene marking.

Materials and Methods. We performed hematopoietic stem cell transplantation using G-CSF and plerixafor-mobilized rhesus CD34⁺ cells transduced with a lentiviral vector, and these data were compared with those of G-CSF and stem cell factor mobilization.

Results. G-CSF and plerixafor mobilization resulted in CD34⁺ cell yields that were twofold higher than yields with G-CSF and stem cell factor. CD123 (interleukin-3 receptor) …

Stress Relief To Augment Fertility: The Pressure Mounts, William H. Catherino

Uniformed Services University of the Health Sciences

Current studies have not conclusively demonstrated an objective and consistent marker of an aberrant stress response; an effect of such a stress response on reproductive outcome; or a benefit of counseling on reproductive outcome in such patients.

Print And Digital Media Reviews: Atlas Of Virtual Colonoscopy, 2nd Edition. Abraham H. Dachman And Andrea Laghi, Editors., Brooks D. Cash

Uniformed Services University of the Health Sciences

The format of this eminently readable hardcover volume is logically arranged in 2 sections: Part 1 accounts for about 50% of the book and consists of 12 text-based chapters; part 2 consists of conventional atlas images. All told there are nearly 700 images included throughout the book. Part 1 begins with an overview of the history and development of CTC, placing the technology in historical and clinical context for the reader. This is followed by various first-person reports regarding the global implementation of CTC from a panel of international investigators. Although not necessarily relevant to a US audience, this section …

Racial Disparities In Histopathologic Characteristics Of Uterine Cancer Are Present In Older, Not Younger Blacks In An Equal-Access Environment, Kate E. Oliver, Lindsey R. Enewold, Kangmin Zhu, Thomas P. Conrads, G. Scott Rose, G. Larry Maxwell, John J. Farley

Uniformed Services University of the Health Sciences

Objective. We sought to determine whether racial disparities in tumor characteristics among uterine cancer patients persisted, and varied by age, in an equal-access healthcare population.

Methods. The distributions of tumor histology, stage and grade by race were compared for uterine cancers diagnosed from 1990 to 2003 using data from the U.S. Department of Defense's Automated Central Tumor Registry. Comparisons were conducted overall and stratified by age (<50, ≥50) using the Chi-square test.

Results. Of 2582 uterine tumors identified, 2057 (79.7%) were diagnosed among White women and 183 (7.1%) among Black women. Among all women analyzed, Blacks were more likely than Whites to present with …

Acr Appropriateness Criteria® On Cerebrovascular Disease, Robert L. Delapaz, Franz J. Wippold Ii, Rebecca S. Cornelius, Sepideh Amin-Hanjani, Edgardo J. Angtuaco, Daniel F. Broderick, Douglas C. Brown, Jeffrey L. Creasy, Patricia C. Davis, Charles F. Garvin, Brian L. Hoh, Charles T. Mcconnell Jr, Laszlo L. Mechtler, David J. Seidenwurm, James G. Smirniotopoulos, Paul J. Tobben, Alan D. Waxman, Greg J. Zipfel

Uniformed Services University of the Health Sciences

Stroke is the sudden onset of focal neurologic symptoms due to ischemia or hemorrhage in the brain. Current FDA-approved clinical treatment of acute ischemic stroke involves the use of the intravenous thrombolytic agent recombinant tissue plasminogen activator given >3 hours after symptom onset, following the exclusion of intracerebral hemorrhage by a noncontrast CT scan. Advanced MRI, CT, and other techniques may confirm the stroke diagnosis and subtype, demonstrate lesion location, identify vascular occlusion, and guide other management decisions but, within the first 3 hours after ictus, should not delay or be used to withhold recombinant tissue plasminogen activator therapy after …

Acr Appropriateness Criteria® Chronic Chest Pain—High Probability Of Coronary Artery Disease, James P. Earls, Richard D. White, Pamela K. Woodard, Suhny Abbara, Michael K. Atalay, J. Jeffrey Carr, Linda B. Haramati, Robert C. Hendel, Vincent B. Ho, Udo Hoffman, Arfa R. Khan, Leena Mammen, Edward T. Martin, Anna Rozenshtein, Thomas Ryan, Joseph Schoeph, Robert M. Steiner, Charles S. White

Uniformed Services University of the Health Sciences

Imaging is valuable in determining the presence, extent, and severity of myocardial ischemia and the severity of obstructive coronary lesions in patients with chronic chest pain in the setting of high probability of coronary artery disease. Imaging is critical for defining patients best suited for medical therapy or intervention, and findings can be used to predict long-term prognosis and the likely benefit from various therapeutic options. Chest radiography, radionuclide single photon-emission CT, radionuclide ventriculography, and conventional coronary angiography are the imaging modalities historically used in evaluating suspected chronic myocardial ischemia. Stress echocardiography, PET, cardiac MRI, and multidetector cardiac CT have …