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During social interactions, people use auditory, visual, and haptic cues to convey their thoughts, emotions, and intentions. Due to weight, energy, and other hardware constraints, it is difficult to create devices that completely capture the complexity of human touch. Here we explore whether a sparse representation of human touch is sufficient to convey social touch signals. To test this we collected a dataset of social touch interactions using a soft wearable pressure sensor array, developed an algorithm to map recorded data to an array of actuators, then applied our algorithm to create signals that drive an array of normal indentation actuators placed on the arm. Using this wearable, low-resolution, low-force device, we find that users are able to distinguish the intended social meaning, and compare performance to results based on direct human touch. As online communication becomes more prevalent, such systems to convey haptic signals could allow for improved distant socializing and empathetic remote human-human interaction., Comment: Copyright 2021 IEEE. Personal use of this material is permitted. Permission from IEEE must be obtained for all other uses, in any current or future media, including reprinting/republishing this material for advertising or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works

This is a survey article on the information transmission capability of haptic devices and ways of maximizing it. It is intended for readers who are engineering professionals interested in developing novel haptic interfaces for a variety of applications but are not necessarily trained in haptic science or human user research. We posit that the ultimate goal of any interface is the exchange of information between a machine and a user, and as such, the evaluation should involve estimating the information-transmission capability with human users. We conducted a literature survey on studies of haptic devices evaluated with human users using an information theoretic framework. Our goal was to discover and summarize best practices that can lead to high information transmission. The results confirmed findings from our own previous studies, uncovered new ways to effectively increase information transmission, and pointed to the need for broader dissemination of proper experimental methodology. We, therefore, present a concise yet comprehensive tutorial on psychophysical methodology for estimating information transfer (IT) and IT rate with humans, survey results on the typical IT achievable with haptic devices, and guidelines for maximizing information transmission with any human–machine interfaces. Although we focus on haptic systems, the information-theoretic framework, the psychophysical methods, and the guidelines presented in this article are applicable to other sensory modalities and multimodal interface systems also.

Wearable haptic systems offer portable, private tactile communication to a human user. To date, advances in wearable haptic devices have typically focused on the optimization of haptic cue transmission using a single modality, or have combined two types of cutaneous feedbacks, each mapped to a particular parameter of the task. Alternatively, researchers have employed arrays of haptic tactile actuators to maximize information throughput to a user. However, when large cue sets are to be transmitted, such as those required to communicate language, perceptual interference between transmitted cues can decrease the efficacy of single-sensory systems, or require large footprints to ensure salient spatiotemporal cues are rendered to the user. In this paper, we present a wearable, multi-sensory haptic feedback system, MISSIVE (Multi-sensory Interface of Stretch, Squeeze, and Integrated Vibration Elements), that conveys multi-sensory haptic cues to the user's upper arm. We present experimental results that demonstrate that rendering haptic cues with multi-sensory components-specifically, lateral skin stretch, radial squeeze, and vibrotactile stimuli-improved perceptual distinguishability in comparison to similar cues with all-vibrotactile components. These results support the incorporation of diverse stimuli, both vibrotactile and nonvibrotactile, for applications requiring large haptic cue sets.

Touch is a powerful communication tool, but we have a limited understanding of the role played by particular physical features of interpersonal touch communication. In this study, adults living in Sweden performed a task in which messages (attention, love, happiness, calming, sadness, and gratitude) were conveyed by a sender touching the forearm of a receiver, who interpreted the messages. Two experiments (N = 32, N = 20) showed that within close relationships, receivers could identify the intuitive touch expressions of the senders, and we characterized the physical features of the touches associated with successful communication. Facial expressions measured with electromyography varied by message but were uncorrelated with communication performance. We developed standardized touch expressions and quantified the physical features with 3D hand tracking. In two further experiments (N = 20, N = 16), these standardized expressions were conveyed by trained senders and were readily understood by strangers unacquainted with the senders. Thus, the possibility emerges of a standardized, intuitively understood language of social touch. Funding Agencies|Facebook; Swedish Research Council

Background The intravenous, rapidly acting P2Y12 inhibitor cangrelor reduces the rate of ischemic events during PCI with no significant increase in severe bleeding. However, the efficacy and safety of cangrelor compared with clopidogrel in patients treated with single vessel (SV)-percutaneous coronary intervention (PCI) or multivessel (MV)-PCI remains unexplored. Methods We studied the modified intention-to-treat population of patients from the CHAMPION PHOENIX trial who were randomized to either cangrelor or clopidogrel. We used logistic regression and propensity score matching to evaluate the effect of cangrelor compared with clopidogrel on the primary efficacy outcome (composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) at 48 hours. The safety outcome was moderate or severe Global Utilization of Streptokinase and tPA for Occluded Arteries bleeding at 48 hours. Hypothesis Cangrelor is as efficacious and safe as clopidogrel in both SV and MV PCI. Results Among 10 854 patients, 9204 (85%) underwent SV- and 1650 (15%) MV-PCI. After adjustment, cangrelor was associated with similar reductions vs clopidogrel in the primary efficacy outcome in patients undergoing SV-PCI (4.5% vs 5.2%; odds ratio [OR] 0.81 [0.66-0.98]) or MV-PCI (6.1% vs 9.8%, OR 0.59 [0.41-0.85]; Pint 0.14). Similar results were observed after propensity score matching (SV-PCI: 5.5% vs 5.9%, OR 0.93 [0.74-1.18]; MV-PCI: 6.2% vs 8.9%, OR 0.67 [0.44-1.01]; Pint 0.17). There was no evidence of heterogeneity in the treatment effect of cangrelor compared with clopidogrel for the safety outcome. Conclusions In patients undergoing SV- or MV-PCI, cangrelor was associated with similar relative risk reductions in ischemic complications and no increased risk of significant bleeding compared with clopidogrel, which highlights the expanding repertoire of options for use in complex PCI.

Suicide is a leading cause of death that defies prediction and challenges prevention efforts worldwide. Artificial intelligence (AI) and machine learning (ML) have emerged as a means of investigating large datasets to enhance risk detection. A systematic review of ML investigations evaluating suicidal behaviors was conducted using PubMed/MEDLINE, PsychInfo, Web-of-Science, and EMBASE, employing search strings and MeSH terms relevant to suicide and AI. Databases were supplemented by hand-search techniques and Google Scholar. Inclusion criteria: (1) journal article, available in English, (2) original investigation, (3) employment of AI/ML, (4) evaluation of a suicide risk outcome. N = 594 records were identified based on abstract search, and 25 hand-searched reports. N = 461 reports remained after duplicates were removed, n = 316 were excluded after abstract screening. Of n = 149 full-text articles assessed for eligibility, n = 87 were included for quantitative synthesis, grouped according to suicide behavior outcome. Reports varied widely in methodology and outcomes. Results suggest high levels of risk classification accuracy (>90%) and Area Under the Curve (AUC) in the prediction of suicidal behaviors. We report key findings and central limitations in the use of AI/ML frameworks to guide additional research, which hold the potential to impact suicide on broad scale.

Objective To examine the safety and efficacy of cangrelor in patients with single-vessel disease (SVD) and multi-vessel disease (MVD). Background Cangrelor, an intravenous, rapidly acting P2Y 12 inhibitor, is superior to clopidogrel in reducing ischemic events among patients receiving percutaneous coronary intervention (PCI). Methods We studied a modified intention to treat population of patients with SVD and MVD from the CHAMPION PHOENIX trial. The primary efficacy outcome was the composite of death, myocardial infarction (MI), ischemia-driven revascularization (IDR), and stent thrombosis (ST) at 48hours. The key safety outcome was non–coronary artery bypass grafting GUSTO severe bleeding at 48hours. Results Among 10,921 patients, 5,220 (48%) had SVD and 5,701 (52%) had MVD. MVD patients were older and more often had diabetes, hyperlipidemia, hypertension, prior stroke, and prior MI. After adjustment, MVD patients had similar rates of 48-hour death/MI/IDR/ST (6.3% vs 4.2%, adjusted odds ratio [OR] 1.6 [95% CI 0.42-6.06]) and GUSTO severe bleeding (0.1% vs 0.2%, P =.67) compared with SVD patients. Consistent with overall trial findings, cangrelor use reduced ischemic complications in patients with both SVD (3.9% vs 4.5%; OR 0.86, 95% CI 0.65-1.12) and MVD (5.5% vs 7.2%; OR 0.74, 95% CI 0.6-0.92, P -interaction=.43). GUSTO severe bleeding outcomes were not significantly increased with cangrelor or clopidogrel in either SVD or MVD patients. Conclusion In the CHAMPION PHOENIX trial, MVD and SVD patients had similar ischemic outcomes at 48hours and 30days. Cangrelor consistently reduced ischemic complications in both SVD and MVD patients without a significant increase in GUSTO severe bleeding. Clinical perspectives What's known? Cangrelor is a novel, intravenous, potent, and rapidly acting P2Y 12 inhibitor that has been demonstrated to reduce the rate of ischemic events at 48hours in patients who received PCI compared with clopidogrel. What's new? In contrast to prior studies, we found that in this modern cohort, patients with SVD and MVD had a similar risk of ischemic complications and GUSTO severe bleeding after PCI. We also found that cangrelor consistently reduced ischemic complications in both SVD and MVD patients without a significant increase in GUSTO severe bleeding. What's next? To assess the impact of single vessel PCI versus multivessel PCI in patients with SVD and MVD.

Current remote monitoring devices for heart failure have been shown to reduce hospitalizations but are invasive and costly; accurate non-invasive options remain limited. The EuleriAn Video Magnification ApPLications In Heart Failure StudY (AMPLIFY) pilot aimed to evaluate the accuracy of a novel noninvasive method that uses Eulerian video magnification. Video recordings were performed on the neck veins of 50 patients who were scheduled for right heart catheterization at the Palo Alto VA Medical Center. The recorded jugular venous pulsations were then enhanced by applying Eulerian phase-based motion magnification. Assessment of jugular venous pressure was compared across three categories: (1) physicians who performed bedside exams, (2) physicians who reviewed both the amplified and unamplified videos, and (3) direct invasive measurement of right atrial pressure from right heart catheterization. Motion magnification reduced inaccuracy of the clinician assessment of central venous pressure compared to the gold standard of right heart catheterization (mean discrepancy of −0.80 cm H2O; 95% CI −2.189 to 0.612, p = 0.27) when compared to both unamplified video (−1.84 cm H2O; 95% CI −3.22 to −0.46, p = 0.0096) and the bedside exam (−2.90 cm H2O; 95% CI −4.33 to 1.40, p = 0.0002). Major categorical disagreements with right heart catheterization were significantly reduced with motion magnification (12%) when compared to unamplified video (25%) or the bedside exam (27%). This novel method of assessing jugular venous pressure improves the accuracy of the clinical exam and may enable accurate remote monitoring of heart failure patients with minimal patient risk.

Objectives The purpose of this study was to examine the safety and efficacy of cangrelor in patients with stable angina (SA) or acute coronary syndrome (ACS). Background The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) trial demonstrated that cangrelor significantly reduced periprocedural ischemic events in all-comer percutaneous coronary intervention with a modest increase in mild and moderate bleeding. Whether this benefit is consistent across SA and ACS has not been explored fully. Methods The CHAMPION PHOENIX trial compared periprocedural administration of cangrelor or clopidogrel, with either a 300- or 600-mg loading dose for the prevention of periprocedural complications in patients undergoing percutaneous coronary intervention. Among the 10,942 patients in the modified intention to treat population, 6,358 patients were classified as having SA, and 4,584 patients had ACS (including unstable angina, non ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction) at randomization. The primary composite endpoint was death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h. A key secondary endpoint was stent thrombosis, and the primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) severe bleeding. Results Cangrelor consistently reduced the primary endpoint in SA and ACS (odds ratio [OR]: 0.83 [95% confidence interval (CI): 0.67 to 1.01] and OR: 0.71 [95% CI: 0.52 to 0.96], respectively; interaction p = 0.41). Cangrelor also consistently reduced stent thrombosis in SA and ACS (OR: 0.55 [95% CI: 0.30 to 1.01] and OR: 0.67 [95% CI: 0.42 to 1.06], respectively; interaction p = 0.62). The impact of cangrelor on GUSTO severe/moderate bleeding was also similar for SA and ACS (OR: 1.49 [95% CI: 0.67 to 3.33] and OR: 1.79 [95% CI: 0.79 to 4.07], respectively; interaction p = 0.75). Conclusions The benefits and risks of cangrelor were consistent in patients with SA and ACS. (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]; NCT01156571)

The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p0.001); 64% of whites and 49% of blacks had long-term TTR55% (p0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.

In our daily lives, we rely heavily on our visual and auditory channels to receive information from others. In the case of impairment, or when large amounts of information are already transmitted visually or aurally, alternative methods of communication are needed. A haptic language offers the potential to provide information to a user when visual and auditory channels are unavailable. Previously created haptic languages include deconstructing acoustic signals into features and displaying them through a haptic device, and haptic adaptations of Braille or Morse code; however, these approaches are unintuitive, slow at presenting language, or require a large surface area. We propose using a multi-sensory haptic device called MISSIVE, which can be worn on the upper arm and is capable of producing brief cues, sufficient in quantity to encode the full English phoneme set. We evaluated our approach by teaching subjects a subset of 23 phonemes, and demonstrated an 86% accuracy in a 50 word identification task after 100 minutes of training.

Despite a long history of research, the development of synthetic tactual aids to support the communication of speech has proven to be a difficult task. The current paper describes a new tactile speech device based on the presentation of phonemic-based tactile codes. The device consists of 24 tactors under independent control for stimulation at the forearm. Using properties that include frequency and waveform of stimulation, amplitude, spatial location, and movement characteristics, unique tactile codes were designed for 39 consonant and vowel phonemes of the English language. The strategy for mapping the phonemes to tactile symbols is described, and properties of the individual phonemic codes are provided. Results are reported for an exploratory study of the ability of 10 young adults to identify the tactile symbols. The participants were trained to identify sets of consonants and vowels, before being tested on the full set of 39 tactile codes. The results indicate a mean recognition rate of 86 percent correct within one to four hours of training across participants. Thus, these results support the viability of a phonemic-based approach for conveying speech information through the tactile sense.

The authors sought to determine the factors that influence fellows-in-training (FITs) to pursue a career in interventional cardiology (IC) and how these differ by sex.Despite increases in the proportion of women across numerous medical and surgical specialties over the last decade, IC still ranks at the bottom in terms of representation of women. It is unclear why this maldistribution persists.An online survey of cardiovascular FITs was conducted under the direction of the American College of Cardiology Women in Cardiology Leadership Council to assess FIT perspectives regarding subspecialty choices.Of 574 respondents, 33% anticipated specializing in IC. Men were more likely to choose IC than women (39% men, 17% women, odds ratio: 3.98 [95% confidence interval: 2.38 to 6.68]; p 0.001). Men were more likely to be married (p = 0.005) and have children (p = 0.002). Among married FITs, male IC FITs were more likely to have spouses who do not work (p = 0.003). Although men were more likely to be influenced by positive attributes to pursue IC, women were significantly more likely to be influenced negatively against pursuing the field by attributes including greater interest in another field (p = 0.001), little job flexibility (p = 0.02), physically demanding nature of job (p = 0.004), radiation during childbearing (p 0.001), "old boys' club" culture (p 0.001), lack of female role models (p 0.001), and sex discrimination (p 0.001).Many factors uniquely dissuade women from pursuing IC compared with men, largely related to the culture of IC as a subspecialty. Targeted resolution of these specific factors may provide the most impact in reducing sex imbalances in the field.

We present a study to examine one's learning and processing capacity of broadband tactile information, such as that derived from speech. In Study 1, we tested a user's capability to recognize tactile locations and movements on the forearm in the presence of masking stimuli and determined 9 distinguishable tactile symbols. We associated these symbols to 9 phonemes using two approaches, random and articulation associations. Study 2 showed that novice participants can learn both associations. However, performance for retention, construction of words and knowledge transfer to recognize unlearned words was better with articulation association. In study 3, we trained novel participants to directly recognize words before learning phonemes. Our results show that novel users can retain and generalize the knowledge to recognize new words faster when they were directly train on words. Finally, Study 4 examined optimal presentation rate for the tactile symbols without compromising learning and recognition rate.

In this paper, we realize a wearable tactile device that delivers smooth pleasant strokes, those resemble of caressing and calming sensations, on the forearm. In Study 1, we develop a psychophysical model of continuous illusory motion on a discrete vibrotactile array. We use this model to generate a variety of tactile strokes that vary in frequency (quality), amplitude (strength) and duration (speed), and test them on a hedonic scale of pleasant-unpleasant in Study 2. Our results show that low frequency (

Touch is an essential method for communicating emotions between individuals. Humans use a variety of different gestures to convey these emotions, including squeezes, pats, and strokes. This paper presents a device for creating a continuous lateral motion on the arm to mimic a subset of the gestures used in social touch. The device is composed of a linear array of voice coil actuators that is embedded in a fabric sleeve. The voice coils are controlled to sequentially press into the user's arm to create the sensation of linear travel up the arm. We evaluate the device in a human-subject study to confirm that a linear lateral motion can be created using only normal force, and to determine the optimal actuation parameters for creating a continuous and pleasant sensation. The results of the study indicated that the voice coils should be controlled with a long duration for each indentation and a short delay between the onset of indentation between adjacent actuators to maximize both continuity and pleasantness.

This paper presents a novel, wearable, and multi-sensory haptic feedback system intended to support the transmission of large sets of haptic cues that are accurately perceived by the human user. Previous devices have focused on the optimization of haptic cue transmission using a single modality and have typically employed arrays of haptic tactile actuators to maximize information throughput to a user. However, when large cue sets are to be transmitted, perceptual interference between transmitted cues can decrease the efficacy of single-sensory systems. Therefore, we present MISSIVE (Multi-sensory Interface of Stretch, Squeeze, and Integrated Vibration Elements), a wearable system that conveys multi-sensory haptic cues to the user’s upper arm, allowing for increased perceptual accuracy compared to a single-sensory vibrotactile array of a comparable size, conveying the same number of cues. Our multi-sensory haptic cues are comprised of concurrently rendered, yet perceptually distinct elements: radial squeeze, lateral skin stretch, and localized cutaneous vibration. Our experiments demonstrate that our approach can increase perceptual accuracy compared to a single-sensory vibrotactile system of comparable size and that users prefer MISSIVE.

Communication of natural language via the skin has seen renewed interest with the advent of mobile devices and wearable technology. Efficient evaluation of candidate haptic encoding algorithms remains a significant challenge. We present 4 algorithms along with our methods for evaluation, which are based on discriminability, learnability, and generalizability. Advantageously, mastery of an extensive vocabulary is not required. Haptic displays used 16 or 32 vibrotactile actuators arranged linearly or as a grid on the arm. In Study 1, a two-alternative, forced-choice protocol tested the ability of 10 participants to detect differences in word pairs encoded by 3 acoustic algorithms: Frequency Decomposition (FD), Dominant Spectral Peaks (DSP), and Autoencoder (AE). Detection specificity was not different among the algorithms, but sensitivity was significantly worse with AE than with FD or DSP. Study 2 compared the performance of 16 participants randomized to DSP vs a phoneme-based algorithm (PH) using a custom video game for training and testing. The PH group performed significantly better at all test stages, and showed better recognition and retention of words along with evidence of generalizability to new words.

Past research has demonstrated that speech communication on the skin is entirely achievable. However, there is still no definitive conclusion on the best training method that minimizes the time it takes for users to reach a prescribed performance level with a speech communication device. The present study reports the design and testing of two learning approaches with a system that translates English phonemes to haptic stimulation patterns (haptic symbols). With the phoneme-based learning approach, users learned the haptic symbols associated with the phonemes before attempting to acquire words made up of the phonemes. With the word-based approach, users learned words on day one. Two experiments were conducted with the two learning approaches, each employing twelve participants who spent 100 min each learning 100 English words made up of 39 phonemes. Results in terms of the total number of words learned show that performance levels vary greatly among the individuals tested (with the best learners in both methods achieving word-recognition scores > 90%-correct on a 100-word vocabulary), both approaches are feasible for successful acquisition of word through the skin, and the phoneme-based approach provides a more consistent path for learning across users in a shorter period of time.

Evidence for successful communication through the sense of touch is provided by the natural methods of tactual communication that have been used for many years by persons with profound auditory and visual impairments. However, there are still currently no wearable devices that can support speech communication effectively without extensive learning. The present study reports the design and testing of learning protocols with a system that translates English phonemes to haptic stimulation patterns (haptic symbols). In one pilot study and two experiments, six participants went through the learning and testing of phonemes and words that involved different vocabulary sizes and learning protocols. We found that with a distinctive set of haptic symbols, it was possible for the participants to learn phonemes and words in small chunks of time. Further, our results provided evidence of the memory consolidation theory in that recognition performance improved after a period of inactivity on the part of a participant. Our findings pave the way for future work on improving the haptic symbols and on protocols that support the learning of a tactile speech communication system in hours as opposed to the much longer periods of time that are required to learn a new language.

In recent years, fractional flow reserve (FFR) has become accepted as a clinically effective tool for guiding decisions about percutaneous coronary intervention (PCI). FFR poses a unique alternative to stress testing or angiography-guided PCI, in that it can interrogate the ischemic potential of an individual vessel on an impromptu basis once an angiogram is in progress, offering immediate data for decision making. With its recent greater adoption across the USA, its cost–effectiveness has become an important consideration. There have been a few key analyses over the last decade demonstrating the cost–effectiveness of FFR-guided PCI; we review the major cost–effectiveness analyses, showing the economic utility of FFR-guided PCI for the modern interventionalist.

Background Frequency-domain optical coherence tomography (FD-OCT) is an intravascular imaging technique now available in the United States. However, the importance of level of training required for analysis using intravascular ultrasound (IVUS) and FD-OCT is unclear. The aim of this study was to evaluate inter- and intra-observer variability between expert and beginner analysts interpreting IVUS and FD-OCT images. Methods and Results Two independent expert analysts and two independent beginner analysts evaluated a total of 226 ± 2 stent cross-sections with IVUS and 232 ± 2 stent cross-sections with FD-OCT in 14 patients after stenting. Inter- and intra-observer variability for determining stent volume index (VI), as well as identifying incomplete stent apposition and dissection were assessed. The inter- and intra-observer variability of stent VI was minimal for both beginner and expert analysts regardless of imaging technology (random variability: 0.38 vs. 0.05 mm3/mm for IVUS, 0.26 vs. 0.08 mm3/mm for FD-OCT). Although qualitative IVUS analysis at the patient level revealed no significant difference between beginners and experts, this was not the case for FD-OCT. The number of overall qualitative findings noted by beginner and expert analysts were more variable (overestimated or underestimated) with FD-OCT. Conclusion Despite varying levels of training, the increased resolution of FD-OCT compared to IVUS provides better detection and less variability in quantitative image analysis. On the contrary, this increased resolution not only increases the rate but also the variability of detection of qualitative image analysis, especially for beginner analysts. © 2013 Wiley Periodicals, Inc.

Aims: The purpose of this study was to test whether different results between Cangrelor versus standard therapy to acHieve optimal Management of Platelet InhibitiON (CHAMPION) PCI/PLATFORM and PHOENIX trials are due in part to different definitions of percutaneous coronary intervention (PCI)-related myocardial infarction (MI). Methods and results: In patients with acute coronary syndrome (ACS), the definition of MI was identical in CHAMPION PCI and PLATFORM and did not require an assessment of baseline cardiac biomarker status, while in PHOENIX specific MI criteria were associated with different patient presentations. The same MI criteria were used in PCI, PLATFORM, and PHOENIX for patients with stable angina. Logistic regression assessed the effect of cangrelor on MI (PCI- and non-PCI related) in the combined PCI/PLATFORM population and in PHOENIX. Consistency of cangrelor’s effect in PCI/PLATFORM and in PHOENIX in patients with stable angina and in those with an ACS (with or without ST elevation) was evaluated. Overall, the incidence of PCI-related MI at 48 h was 6.3% in PCI/PLATFORM and 4.0% in PHOENIX. In patients with ACS, MI incidence was 6.4% in PCI/PLATFORM and 1.7% in PHOENIX, and 6.3% and 5.6%, respectively in stable angina patients. Cangrelor’s effect on PCI-related MI differed between PCI/PLATFORM (odds ratio (OR) 1.03, 95% confidence interval (CI) 0.90–1.17) and PHOENIX (OR 0.80, 95% CI 0.66–0.98) with pINT=0.04. This difference was mostly evident in patients with ACS ( pINT= 0.06) while the effect was consistent in patients with stable angina ( pINT=0.81). Results were similar when all MIs were analyzed. Conclusions: The definition of PCI-related MI has important implications for event rates, treatment effect, and study results. This illustrates the importance of a rigorous assessment of PCI-related MI in clinical trials of patients with an ACS.

The purpose of this study was to examine the safety and efficacy of cangrelor in patients with stable angina (SA) or acute coronary syndrome (ACS).The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) trial demonstrated that cangrelor significantly reduced periprocedural ischemic events in all-comer percutaneous coronary intervention with a modest increase in mild and moderate bleeding. Whether this benefit is consistent across SA and ACS has not been explored fully.The CHAMPION PHOENIX trial compared periprocedural administration of cangrelor or clopidogrel, with either a 300- or 600-mg loading dose for the prevention of periprocedural complications in patients undergoing percutaneous coronary intervention. Among the 10,942 patients in the modified intention to treat population, 6,358 patients were classified as having SA, and 4,584 patients had ACS (including unstable angina, non ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction) at randomization. The primary composite endpoint was death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h. A key secondary endpoint was stent thrombosis, and the primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) severe bleeding.Cangrelor consistently reduced the primary endpoint in SA and ACS (odds ratio [OR]: 0.83 [95% confidence interval (CI): 0.67 to 1.01] and OR: 0.71 [95% CI: 0.52 to 0.96], respectively; interaction p = 0.41). Cangrelor also consistently reduced stent thrombosis in SA and ACS (OR: 0.55 [95% CI: 0.30 to 1.01] and OR: 0.67 [95% CI: 0.42 to 1.06], respectively; interaction p = 0.62). The impact of cangrelor on GUSTO severe/moderate bleeding was also similar for SA and ACS (OR: 1.49 [95% CI: 0.67 to 3.33] and OR: 1.79 [95% CI: 0.79 to 4.07], respectively; interaction p = 0.75).The benefits and risks of cangrelor were consistent in patients with SA and ACS. (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]; NCT01156571).

The optimal preoperative cardiac evaluation strategy for patients with end-stage liver disease (ESLD) undergoing liver transplantation remains unknown. Patients are frequently referred for cardiac catheterization, but the effects of coronary artery disease (CAD) on posttransplant mortality are also unknown. We sought to determine the contribution of CAD and multivessel CAD in particular to posttransplant mortality. We performed a retrospective study of ESLD patients undergoing cardiac catheterization before liver transplant surgery between August 1, 2004 and August 1, 2007 to determine the effects of CAD on outcomes after transplantation. Among 83 patients who underwent left heart catheterization, 47 underwent liver transplantation during the follow-up period. Twenty-one of all ESLD patients who underwent liver transplantation (45%) had CAD. Fifteen of the transplant patients with CAD (71%) had multivessel disease. Among transplant patients, the presence of multivessel CAD (versus no CAD) was predictive of mortality (27% versus 4%, P = 0.046), increased length of stay (22 versus 15 days, P = 0.050), and postoperative pressor requirements (27% versus 4%, P = 0.029). Interestingly, neither the presence of any CAD nor the severity of stenosis in any single coronary artery predicted mortality. Furthermore, none of the traditional clinical predictors (age, gender, diabetes, creatinine, ejection fraction, and Model for End-Stage Liver Disease score) were predictive of mortality among transplant recipients. In conclusion, multivessel CAD is associated with higher mortality after liver transplantation when it is documented angiographically before transplantation, even in the absence of severe coronary artery stenosis. This study provides preliminary evidence showing that there may be significant prognostic value in coronary angiography as a part of the pretransplant workup. Liver Transpl 16:1242-1248, 2010. © 2010 AASLD.

The intravenous, rapidly acting P2Y12 inhibitor cangrelor reduces the rate of ischemic events during percutaneous coronary intervention (PCI) with no significant increase in severe bleeding. This study aimed to evaluate the efficacy and safety of cangrelor in patients treated with single vessel (SV

Proper recognition and treatment of pathological conditions of the suprapatellar pouch of the knee is dependent on the knowledge of normal pouch anatomy and of the various conditions which affect this area of the knee and contribute to knee pain. This article includes a comprehensive review of the surgical anatomy of the pouch, current surgical techniques and review of the common conditions that have a predilection for this often overlooked area of the knee.

Temporary percutaneous mechanical circulatory support (MCS) devices were introduced in the 1960s and have developed into a diverse portfolio of options currently available for left, right, and biventricular support. Patients undergoing high-risk percutaneous coronary interventions (PCI), patients with acute myocardial infarction (AMI), and patients with cardiogenic shock in particular may benefit from these options. In this review, we will discuss the currently available devices and the evidence supporting their use in cardiogenic shock.

Guideline adherence and variation in acute coronary syndrome (ACS) outcomes by race in the modern era of drug-eluting stents (DES) are not well understood. Previous studies also fail to capture rapidly growing minority populations, such as Asians. A retrospective analysis of 689,238 hospitalizations for ACS across all insurance types from 2008 to 2011 from the Healthcare Cost and Utilization Project database was performed to determine whether quality of ACS care and mortality differ by race (white, black, Asian, Hispanic, or Native American), with adjustment for patient clinical and demographic characteristics and clustering by hospital. We found that black patients had the lowest in-hospital mortality rates (5% vs 6% to 7% for other races, p 0.0001, odds ratio [OR] 1.02, 95% confidence interval [CI] 0.97 to 1.07), despite low rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and lower use of DES (30% vs 38% to 40% for other races, p 0.0001). In contrast, Asian patients had the highest in-hospital mortality rates (7% vs 5% to 7% for other races, p 0.0001, odds ratio 1.13, 95% CI 1.08 to 1.20, relative to white patients), despite higher rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and the highest use of DES (74% vs 63% to 68% for other races, p 0.0001). Asian patients had the worst in-hospital mortality outcomes after ACS, despite high use of early invasive treatments. Black patients had better in-hospital outcomes despite receiving less guideline-driven care.

Background The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents ( DES ). Methods and Results We analyzed 835 070 hospitalizations for acute coronary syndrome ( ACS ) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower‐income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction ( STEMI ) (69.5% for IQ 1 versus 73.7% for IQ 4, P OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non‐ STEMI (47.6% for IQ 1 versus 51.8% for IQ 4, P OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ 1 versus 71.2% for IQ 4, P OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower‐income patients also had slightly increased adjusted mortality rates (10.8% for IQ 1 versus 9.4% for IQ 4, P OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased. Conclusions For the most well accepted procedural treatments for ACS , income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI , suggesting an important target for understanding why these inequalities persist.

Secretan's disease is a rare disorder that has, to date, only been reported in the hand. After minor trauma, edema and hyperplasia of the hand may result, and pathological evaluation demonstrates thick fibrous tissue. We present the first report of Secretan's disease involving the foot in a 15-year-old athletic teenage girl with a remote history of blunt trauma, and review the relevant literature.

Frequency-domain optical coherence tomography (FD-OCT) is an intravascular imaging technique now available in the United States. However, the importance of level of training required for analysis using intravascular ultrasound (IVUS) and FD-OCT is unclear. The aim of this study was to evaluate inter- and intra-observer variability between expert and beginner analysts interpreting IVUS and FD-OCT images.Two independent expert analysts and two independent beginner analysts evaluated a total of 226 ± 2 stent cross-sections with IVUS and 232 ± 2 stent cross-sections with FD-OCT in 14 patients after stenting. Inter- and intra-observer variability for determining stent volume index (VI), as well as identifying incomplete stent apposition and dissection were assessed. The inter- and intra-observer variability of stent VI was minimal for both beginner and expert analysts regardless of imaging technology (random variability: 0.38 vs. 0.05 mm(3) /mm for IVUS, 0.26 vs. 0.08 mm(3) /mm for FD-OCT). Although qualitative IVUS analysis at the patient level revealed no significant difference between beginners and experts, this was not the case for FD-OCT. The number of overall qualitative findings noted by beginner and expert analysts were more variable (overestimated or underestimated) with FD-OCT.Despite varying levels of training, the increased resolution of FD-OCT compared to IVUS provides better detection and less variability in quantitative image analysis. On the contrary, this increased resolution not only increases the rate but also the variability of detection of qualitative image analysis, especially for beginner analysts.

Heparin-induced thrombocytopenia (HIT) is a life-threatening immune-mediated adverse effect of chemoprophylaxis for venous thromboembolic events. We present the case of a 44-year-old man who developed bilateral adrenal hemorrhage (BAH) as a sequela of HIT after bilateral total knee arthroplasty. In our review of clinical management of HIT-induced BAH, we discuss the 21 published cases of this phenomenon, 14 of which occurred after orthopedic surgery. Given the potentially fatal consequences and the importance of early intervention, physicians should be on the alert for recognizing HIT-induced BAH in patients experiencing shock unresponsive to fluid resuscitation. In addition, chemoprophylaxis with alternative agents such as a synthetic pentasaccharide factor Xa inhibitor and oral direct thrombin inhibitors that are associated with lower risks of HIT in orthopedic patients merits exploration.

Background: Currently, there is no standardized, comprehensive method to assess surgical scars after breast cancer surgery. This article evaluates the application of the Vancouver Scar Scale, in conjunction with patients' scar self-rating and scar-related pain, in a cohort of breast cancer patients. Methods: Data were prospectively collected in 59 women with breast cancer. Scar assessment comprised: 1. objective rating by pairs of independent observers using the Vancouver Scar Scale; 2. patient's ratings of the scar's physical parameters and overall satisfaction; and 3. pain assessment using the Short-Form McGill Pain Questionnaire. A total of 212 scar scores (59 pairs of breast/chest wall and 47 pairs of axillary scar scores) were generated by 13 observers: three physicians, five radiation therapists, and five nurses. Internal consistency was tested using Cronbach's alpha statistics. Interobserver reliability was evaluated with Spearman's rho and intraclass correlation coefficient computations. Convergent validity of the observer and patient ratings was examined with Spearman's correlation statistics. Linear regression analysis was performed to identify significant factors associated with Vancouver Scar Scale scores and patient satisfaction. Results: The Vancouver Scar Scale, patient self-rating scale, and Short-Form McGill Pain Questionnaire had acceptable internal consistency (Cronbach's alpha 0.79, 0.64, and 0.72 respectively). Interobserver reliability using the Vancouver Scar Scale was significant with Spearman's correlation coefficients of 0.53 for pliability, 0.47 for scar height, 0.49 for vascularity, 0.54 for pigmentation, and 0.66 for overall score (all p values < 0.001). Significant agreement between observer and patient ratings of scar pliability (p = 0.01) and color (p = 0.001) was demonstrated. Mild to moderate pain was reported by more than 40 percent of patients. Patient satisfaction was significantly associated with self-rating of scar pliability and pain, but not Vancouver Scar Scale scores. Conclusions: The Vancouver Scar Scale is a reliable and valid tool to objectively evaluate scars after breast cancer surgery. Evaluation of scar-related pain and patients' scar rating and satisfaction provide additional information relevant to scar assessment This integrated approach is feasible in a busy clinical setting to advance care and research in scar management for breast cancer patients.

Background The impact of lymphovascular invasion (LVI) on postmastectomy locoregional relapse (LRR) and its use in guiding locoregional therapy in node-negative breast cancer are unclear. This study evaluates the association of LVI with relapse and survival in a cohort of women with early-stage breast cancer. Study design The study cohort comprised 763 women with pT1-2, pN0 breast cancer referred from 1989 to 1999 and treated with mastectomy and adjuvant systemic therapy without radiotherapy. Kaplan-Meier LRR, distant relapse, and overall survival rates at 7 years were compared between patients with and without LVI. Cox regression analyses were performed to evaluate the prognostic significance of LVI for relapse and survival. Results Median followup was 7.0 years (range 0.34 to 14.9 years). LVI was present in 210 (27.5%) patients. In log-rank comparisons of Kaplan-Meier curves stratified by LVI status, LVI-positive disease was associated with significantly higher risks of LRR (p = 0.006), distant relapse (p = 0.04), and lower overall survival (p = 0.02). In the multivariable Cox regression analysis, LVI was significantly associated with LRR (relative risk [RR] = 2.32; 95% CI, 1.26–4.27; p=0.007), distance relapse (RR = 1.53; 95% CI, 1.00–2.35; p=0.05), and overall survival (RR = 1.46; 95% CI, 1.04–2.07; p=0.03). In patients with one of the following characteristics: age younger than 50 years, premenopausal status, grade III histology, or estrogen receptor-negative disease, 7-year LRR risks increased threefold from 3% to 5% when LVI was absent, to 15% to 20% in the presence of LVI. Conclusions LVI is an adverse prognostic factor for relapse and survival in node-negative patients treated with mastectomy and systemic therapy. LVI, in combination with age older than 50 years, premenopausal status, grade III histology, or estrogen receptor-negative disease, identified patient subsets with 7-year LRR risks of approximately 15% to 20%. Prospective research is required to define the role of adjuvant radiotherapy in these patients.