Coronary Artery Calcium Scoring to Guide Statin Therapy

A paper published in JAMA Cardiology reports on findings of a multicenter, population based, prospective study that included 1,688 participants aged 45 to 75 years with no baseline ASCVD (Atherosclerotic Vascular Disease) or diabetes  who were at intermediate risk for ASCVD and with LDL levels of 70 mg/dl.  

The authors found that among the participants with CAC scores of 0, the presence of risk-enhancing factors was not associated with overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy.  

The results of this study support the use of CAC scoring as a tool in the evaluation of risk and to more accurately classify individuals with intermediate risk for ASCVD who might benefit from statin therapy.

In conclusion the use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. 

Major Increase in Telehealth during Covid-19 Pandemic

 A cohort study published in JAMA of more than 36 million individuals in the US found a dramatic increase in telehealth use during the first four months of the Covid-19 pandemic.  In this study, in-person visits decreased by 37% while telehealth visits accounted for 23% of all interactions, compared with 0.3% in 2019.  Behavioral health encounters were far more likely than medical contacts to take place virtually (46% vs 22%).  Persons living in areas with limited resources were less likely to use telehealth (27% vs 20%).  The costs also decreased by 15%.  The findings of this study are relevant to physicians, administrators, and payers regarding telehealth's potential role during the pandemic and afterward. 

MRI in Cirrhotic Patients at High Risk for Hepatocellular Carcinoma

Kim at al reported in JAMA Oncology their experience regarding the accuracy of MRI with liver specific contrast versus ultrasonography in the surveillance of patients with cirrhosis who are at high risk in developing hepatocellular carcinoma.

Ultrasonography (US) is considered the study of choice for screening patients with cirrhosis at risk of hepatocellular carcinoma.  The current recommendation is for US to be performed every 6 months.

Liver MRI was performed on a 1.5Tesla scanner and Gadoxetic acid (Primovist) was administered at a dose of 0.025 mmol/kg.  Axial T1 weighted images of the arterial, portal, delayed and hepatobilliary phases at 4-mm thickness sections were obtained.   

The authors conducted a prospective study of 407 cirrhotic patients who underwent semi-annual US and MRI studies.  The patients were followed with dynamic computed tomography 6 months after the screening imaging studies.

A total of 407 patients received 1100 screenings with both MRI and US.  Hepatocellular carcinomas were diagnosed in 43 patients.  Ultrasound diagnosed only one HCC, MRI detected 26, 11 by both, and 5 were missed by both.

The HCC detection rate of the MRI was 86%, higher than the 27.9% of US.  MRI showed significantly lower false-positive findings than US, 3% versus 5.6% of US.  Of the 43 patients with HCC 32 had a single less than 2 cm nodule and received curative treatments.  The 3-year survival of the patients with HCC (86%) was at par to those without HCC.

The 5-year survival rate of HCC is lower than 20%, and early diagnosis is essential for the possibility of a cure.  The current recommendation for patients at high risk of developing HCC is US needs to be reviewed as the  accuracy of US is low.

The authors conclude that screening of patients with cirrhosis with MRI and liver specific contrast resulted in higher HCC detection rate and fewer false positive findings when compared with US.

JAMA Oncology, Online First, September 22, 2016

In Pursuit of Slaves

Captain John Gabriel Stedman (1744-1797) was a professional soldier who fought to suppress an 18th-century slave rebellion in Suriname and subsequently published the March Through a Swamp in Pursuit of Slaves. Although slavery was not abolished in Suriname until 1873, the publication of Stedman’s narrative in 1790 helped to erode public support for the slave trade in Europe and its colonies. The book was translated into several languages and published in more than 25 editions. Stedman’s descriptions of the brutality of plantation life debunked the myth that slavery was a benign, civilizing influence. By his own admission, Stedman was a mercenary, who also told the truth, and his narrative endures as a case study of violence and human rights abuses. To counter the argument that slaves were better off on New World plantations than living under comparatively primitive conditions in their native lands, Stedman storied that in the Maroon rebellion the slaves preferred to endure hardships and fight in order to escape get their freedom.

JAMA. 2015;314(5):434-435

Do-Si-Do

Dan Christensen a painter whose paintings were known for their festivity and bright colors was born in Nebraska.  He completed his studies at the Kansas City Art Institute in 1964 and moved to New York shortly thereafter.

Although his brilliant spray-painted bands were well received; he strived to find new ways to express his fascination with color.   Thus his paintings of rectangular blocks came to be known as his “plaid” series. The plaid series evolved into another technique in which he layered different colors thus he created a sense of depth, a technique he called “slab” paintings.   In the 1990s, his work evolved to the “circle” paintings of radiant rounded forms.

An example of the glowing disks that characterized his circle technique is “Do-Si-Do”, in which a series of concentric circles was depicted and shows his long obsession with color.  In this painting Christensen was recalling childhood memories of hot summer days dominated by a relentless sun in the sky. An alternate interpretation of the work involves consideration of the “Do-Si-Do” dance maneuver in which participants move around one another or as the planets rotate around the sun in our solar system occasionally exhibiting paradoxical travels like they are intoxicated from the overpowering brilliance of Ηλιος the Sun-God.

   

Dan Christensen (1942-2007), Do-Si-Do, 1991, American. Acrylic on canvas. 177.8 × 177.8 cm. Courtesy of the Wichita Art Museum (https://www.wichitaartmuseum.org/), Wichita, Kansas.

Excerpt from the article by Jeanette M. Smith, MD JAMA. 2015;313(11):1084-1085

The Sea at Le Havre

Impressionist painter Claude Monet (1840-1926), was born in Paris, but spent his childhood near the coast of Le Mer de la Manche in the north of France.  In Le Havre he met a seascape painter Eugene Boudin and from that time he started painting and showing nature full of in light.  Monet painted The Sea at le Havre in 1868.  Small waves caused by the breeze travel on the surface of the sea, which color, is a reflection of the sky.  Impressionists painted nature having as an objective to express light patterns and depict the hues and luminance of the out-of-doors. Monet with his use of light and color created moments of loveliness and serenity understood only by those who have spent time with loved ones near the water.

Claude Monet (1840-1926), The Sea at Le Havre, 1868, French. Oil on canvas. 60.01 × 81.60 cm. Courtesy of the Carnegie Museum of Art (http://www.cmoa.org/), Pittsburgh, Pennsylvania; purchase, 53.22.

Excerpt from the article by Jeanette M. Smith, MD  JAMA. 2015;313(9):878-879