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Objective: To assess the impact of informing women about the presence of breast arterial calcification (BAC) on mammography by determining whether those notified about the presence of BAC would seek cardiovascular evaluation., Methods: This IRB-approved prospective study included 494 patients who underwent screening mammography between June 8, 2021, and April 22, 2022. Mammograms were reviewed by a radiologist, and patients were notified via e-mail about the presence or absence of BAC. Patients with BAC were advised to discuss the results with their physicians and were surveyed 3 months later. Frequencies and proportions were calculated for study participation, presence of BAC, survey participation, health actions, and perceptions. Confidence intervals were calculated for proportions of health actions and perceptions., Results: Of 494 study participants, 68/494 (13.8%; 95% CI: 10.9%-17.1%) had BAC detected on mammography and 42/68 (61.8%; 95% CI: 61.1%-62.1%) with BAC completed the follow-up survey at 3 months. Of these 42 survey respondents, 24/42 (57.1%; 95% CI: 41.1%-72.3%) reported discussing results with their primary care physician (PCP) or a cardiologist. In addition, 34/42 (81.0%; 95% CI: 65.9%-91.4%) reported finding it helpful to receive information about BAC and 32/42 (76.2%; 95% CI: 60.6%-88.0%) believed all women should be informed about BAC after mammography., Conclusion: After notification about the presence of BAC on screening mammography, the majority (57.1%) of survey respondents reported discussing the results with a PCP or cardiologist. These results suggest that providing mammography patients with information about BAC may promote preventive cardiovascular health., (© Society of Breast Imaging 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To evaluate awareness about cardiovascular (CVD) risk among a racially and ethnically diverse cohort of health system employees., Design: Cross-sectional study., Setting: Voluntary survey of health system employees during an annual CVD awareness and screening event., Subjects: 759 health system employees., Measures: We performed initial CVD screening measurements (blood pressure, body mass index) and collected patient-reported answers to questions about their own CVD risk factors (hypertension, high cholesterol, diabetes, overweight, smoking, physical inactivity and family history of CVD) and whether or not they believed that CVD is preventable. Subjects were offered in-depth follow-up CVD screening (lipid panel, hs-CRP, hemoglobin A1c), if interested., Analysis: Continuous measures were compared across sex and racial/ethnic subsets using a t test and analysis of variance technique. Univariable and multivariable logistic regression models were used to estimate the employee's willingness to undergo further comprehensive screening., Results: African American, Hispanic, and Asian employees were younger than white employees ( P < .0001). More than one-quarter of African Americans reported a history of hypertension, a higher rate than for other subgroups ( P = .001). The rate of self-reported diabetes was highest in African American and Asian employees ( P = .001). African Americans had a 54% reduced odds of electing to pursue follow-up CVD screening (odds ratio: .46, 95% confidence interval = .24-.91, P = .025)., Conclusion: Presence of CVD risk factors and knowledge of their importance differ among racial and ethnic groups of health system employees in our cohort as does interest in pursuing follow-up screening once risk factors are identified. Development of evidence-based customization strategies by racial and ethnic group may improve understanding of and interest in CVD risk factors and advance prevention. The data from this study will inform future research and strategies for employee health promotion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: This study evaluates a large cohort of college students after the 2009-2010 pandemic H1N1 influenza season. The objective was to assess influenza vaccination status, influenzalike illnesses (ILIs), and other characteristics associated with attaining immunizations., Methods: This study was conducted during the summer 2010 the Reserve Officer Training Corps Leadership Development and Assessment Course involving 6272 college students. A voluntary, anonymous questionnaire was administered to assess study objectives., Results: Vaccination rates were 39.9% for pandemic H1N1, 40.6% for seasonal influenza, and 32.6% for receiving both vaccinations. Age less than 25 and having a Reserve Officer Training Corps scholarship were associated with lower odds of receiving vaccinations, whereas entering the nursing field and simultaneous membership in the Army reserve forces were associated with higher odds of vaccination. There are 11.2% of respondents reported having an ILI, including 4.3% with severe ILI. There were 4184 reasons indicated for not attaining influenza vaccinations, which are listed in categorical groupings., Conclusions: A historical anchor for vaccination rates and ILI is provided in a large cohort of college students following the 2009 H1N1 influenza pandemic. Influenza immunization locations were determined, as was self-reported obstacles to receiving vaccinations. These are important results for public health leaders seeking to increase vaccination rates during future influenza seasons., (© The Author 2020. Published by Oxford University Press Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: The American Heart Association and the American College of Obstetricians and Gynecologists make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

In the past two decades, focused research on women at risk for cardiovascular disease (CVD) has helped to clarify our understanding of some of the sex-specific factors that are important in the prevention and early detection of coronary atherosclerosis with a resultant 30 % decrease in the number of women dying from CVD. In spite of these advances, CVD, specifically, ischemic heart disease due to coronary atherosclerosis is the leading cause of cardiovascular death of women in the USA. The 2010 landmark Institute of Medicine (IOM) report, "Women's Health Research--Progress, Pitfalls and Promise," highlighted the fact that although major progress had been made in reducing cardiovascular mortality in women, there were disparities in disease burden among subgroups of women, particularly those women who are socially disadvantaged because of race, ethnicity, income level, and educational attainment [1]. The IOM recommended targeted research on these subpopulations of women with the highest risk and burden of disease. Causes of disparities are multifactorial and are related to differences in risk factor prevalence, access to care, use of evidence-based guidelines, and social and environmental factors. In this article, we review a few of the contributing factors to the disparities in ischemic heart disease in women with a focus on the subgroups of women of Black, Latino, and South Asian descent who are at high risk for morbidity and mortality from CVD.

Evolving knowledge regarding sex differences in coronary heart disease has demonstrated that the prevalence, symptomatology, and pathophysiology of coronary atherosclerosis vary between genders. Women experience higher mortality rates and more adverse outcomes after acute myocardial infarction than men, despite a lower prevalence of obstructive coronary artery disease. Based on recent insights into the complex pathophysiology of coronary heart disease which includes a spectrum of obstructive coronary artery disease and dysfunction of the coronary microvasculature and endothelium, the term ischemic heart disease is a more accurate term for discussion of coronary atherosclerosis specific to women. In women, with clinical features and risk factors for ischemic heart disease, the detection and evaluation of ischemic heart disease is challenging due to the diverse pathogenic mechanisms of ischemic heart diseases in women. In this article, we discuss noninvasive imaging tests, provocative tests, including exercise testing in women with suspected ischemic heart disease.

Significant advances in medical treatment, medical technology, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, coronary artery disease (CAD) is the leading cause of cardiovascular death of women in the Western world. In the past 2 decades, the focused research on women at risk for CAD has helped to clarify our understanding of some of the sex-specific factors that are important in the detection of CAD. In women, the detection and evaluation of physiologically significant CAD can be challenging. Many of the traditional tests that are designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients, who have a greater burden of symptoms, higher atherosclerotic burden, and lower prevalence of obstructive coronary disease. In this article, we review the available evidence on the role of contemporary noninvasive diagnostic techniques in the evaluation of women with symptoms of CAD. The authors have no funding, financial relationships, or conflicts of interest to disclose., (© 2012 Wiley Periodicals, Inc.)

Background: In the United States, women have attained near gender equity at the entry stages in academic medicine; however, progress has been much slower at senior leadership levels. The paucity of women leaders inhibits the ability of academic medicine to adequately meet the needs of an increasingly diverse body of students, faculty, staff, and patients. Research indicates that until a critical mass of women with sustained success as leaders is achieved, it is unlikely that this deficit will be corrected., Methods: To promote the attainment of a critical mass of women leaders, the authors integrate two approaches to advancing women--the concept of a leadership continuum and a framework of practical approaches for moving toward gender equity at all ranks., Results: An institutional guide is presented that can be used to promote dialogue about gender equity, noting areas of success and opportunities for additional improvement as well as an assessment of progress. A corresponding checklist has been developed that women faculty can use as a reflection guide for their career planning and to assess their position and progress along the leadership continuum., Conclusions: Proactive, ongoing use of these frameworks can promote reflective dialogue and provide direction and accountability for institutions working to advance women into leadership positions.

The aim of this study is to prospectively evaluate the clinical value of electrocardiographically gated single-photon emission computed tomographic myocardial perfusion scintigraphy (MPS) imaging in a cohort of postmenopausal women with symptoms suggestive of ischemic heart disease. Forty-six postmenopausal women with no history of coronary artery disease (CAD), but with typical or atypical angina and >or=1 risk factor for CAD, were enrolled and underwent both coronary angiography and technetium-99m sestamibi MPS with exercise (n = 36) or pharmacologic stress (n = 10). All women were followed up for 5.0 +/- 3 years for the occurrence of hospitalization for acute coronary syndrome, myocardial infarction, and/or new-onset or worsening angina. CAD prevalence (>or=50% diameter stenosis) was 62% (26 of 42 patients). Fifteen patients (36%) had 1-vessel disease, 7 (17%) had 2-vessel disease, and 4 (10%) had 3-vessel disease. Diagnostic sensitivity and specificity of the exercise electrocardiogram were 67% and 69%, respectively. By comparison, sensitivity of MPS was 88% and specificity was 87.5% (p <0.0001). Cox survival analysis showed 3- and 5-year cumulative event-free survival rates of 97% and 94% for patients with normal MPS results compared with 60% and 48% for those with abnormal MPS findings (p <0.001). In conclusion, results of this study indicate high diagnostic and prognostic accuracy for MPS in symptomatic postmenopausal women.

We present the case of a 36-year-old woman who was diagnosed with severe mitral stenosis in the 30th week of a pregnancy that was complicated by complete placenta previa and placenta percreta. With medical management, she successfully carried the pregnancy to fetal viability and was delivered by cesarean section before undergoing percutaneous balloon mitral valvuloplasty.

Penetrating chest wounds leading to damage of thoracic structures are common. A rare sequelae of chest trauma is a contained rupture of the left ventricle of the heart leading to the development of a pseudoaneurysm. This complication needs prompt recognition and repair because of the high likelihood of rupture and death. We report the case of a 47-year-old man who underwent repair of a stab wound to the heart 25 years ago and subsequently developed a large left ventricular pseudoaneurysm and presented with angina.

A coronary artery aneurysm is defined as coronary dilatation that exceeds the diameter of normal adjacent artery segments, or is 1.5 times the diameter of the largest coronary artery. Coronary artery aneurysms are rare with an incidence of between 1.5% to 5%. The aneurysm is caused by destruction of the vessel media, thinning of the arterial wall, increased wall stress, and progressive dilatation of a segment of the coronary artery. The most common cause is atherosclerotic coronary artery disease. These aneurysms occasionally rupture but more commonly develop thrombus and hematoma leading to the appearance of the presence of an intramyocardial mass. We present the case of a 60-year-old man with hypertension who presented with a mass that was identified initially by transthoracic echocardiography in the setting of an inferior wall myocardial infarction, which was later recognized to be a thrombosed right coronary artery aneurysm.

Myocardial contrast echocardiography (MCE) has been used with increasing frequency and is considered a safe way to improve left ventricular border opacification. Studies have consistently documented that MCE can improve the ability to assess both global and regional left ventricular function by echocardiography. We report the case of an 83-year-old female who developed immediate and sustained hemodynamic instability after the injection of Perflutren for a contrast echocardiogram. We reviewed the literature and found no such previous reactions with Perflutren. Based on the temporal sequence of hypotension following Perflutren injection along with other clinical data, we concluded that our patient's hemodynamic instability was most likely secondary to an anaphylactic reaction.

Tetralogy of Fallot is the most common cyanotic congenital heart defect during infancy. It is composed of a ventricular septal defect, an overriding aorta, obstruction of right ventricular outflow, and right ventricular hypertrophy. Most patients experience cyanosis at birth and die in childhood without surgical intervention. The rate of survival at 40 years without surgical correction is only 3%. We present the case of a man with tetralogy of Fallot who survived until the age of 52 years without surgical intervention.

Systematic, prospective data regarding phenotypic features, including echocardiographic findings, in pediatric patients with the Marfan syndrome are lacking. In addition, limited and conflicting information exists regarding the impact of pharmacologic therapy on aortic growth rate in children. Fifty-three children and adolescents with the Marfan syndrome underwent physical examination, anthropometric evaluation, and echocardiography. The relation of pharmacologic therapy to aortic growth rate was examined in the 44 subjects in whom serial echocardiograms were recorded. Although boys and girls did not differ in ocular, skeletal, or cardiovascular manifestations, aortic dilatation tended to be more common in boys (86% vs 72%). Children with aortic dilatation at baseline (42 of 53 or 79%) were more likely to also have scoliosis and mitral prolapse (both p <0.005). The medicated patients had slower aortic growth than the unmedicated patients with regard to both absolute aortic growth rate (p <0.01) and aortic growth rate adjusted for age and body size (p <0.005). Nevertheless, major cardiovascular complications developed in 5 patients despite long-term pharmacologic therapy. In conclusion, beta-blocker and calcium antagonist therapy retards aortic growth rate in children and adolescents with the Marfan syndrome.

Study Objective: Patent foramen ovale (PFO) is present in 10 to 35% of people and has been reported to be an important risk factor for cardioembolic cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs), especially in younger patients. While contrast transthoracic echocardiography has been used to detect PFO, contrast transesophageal echocardiography (TEE) has a greater sensitivity. Prior studies reported the incidence of PFO in patients presenting with a CVA or TIA., Design: To determine the incidence of PFO in a more general population, we reviewed 1,000 consecutive TEEs performed with contrast and color Doppler for the presence of PFO and other cardioembolic risk factors, including atrial septal aneurysm (ASA), aortic plaque, atrial fibrillation (AFib), and atrial thrombi. While imaging with monoplane or biplane TEE, multiple injections of agitated saline solution were injected during cough or Valsalva maneuver to detect flow through a PFO., Patients: There were 482 male and 518 female patients with mean age of 60 +/- 17 years (range 11 to 93 years)., Results: Patent foramen ovale was found in 9.2% of all patients and, though seen in all age groups divided by decade, the incidence in patients aged 40 to 49 years was greater than those aged 70 to 79 years (12.96% vs 6.15%, p = 0.03). Contrast TEE had a much higher detection rate than color Doppler alone. Importantly, there was no greater incidence of PFO in patients with CVA vs those without CVA, or in male vs female patients. Also, there was a very strong correlation between the presence of ASA and PFO (p < .001)., Conclusion: Thus, PFO detected by TEE, frequently seen with ASA, is seen in all age groups and does not in itself present a risk factor for CVA. The association of PFO with peripheral thrombosis and CVA needs further study.

The natural history of patients with severe nonischemic mitral regurgitation (MR) from mitral valve prolapse, who are asymptomatic or minimally symptomatic and have normal right ventricular (RV) and left ventricular (LV) performance, has not been evaluated previously. To define natural history in this population and to determine if any objective variables could predict disease progression, 31 patients were followed annually with severe MR due to prolapse, who at entry were asymptomatic or minimally symptomatic and had normal RV and LV performance at rest by radionuclide cineangiography. Average follow-up in patients not reaching surgical end point was 4.7 years. The Kaplan-Meier product limit estimates were used to determine the rate of progression to either "operable" symptoms or to previously defined "high risk" ventricular performance descriptors, if the latter occurred first. Univariate comparisons of Kaplan-Meier curves and multivariate Cox proportional hazards analyses were used to define prognostically important variables measured at entry. Fourteen patients developed symptoms warranting referral for operation; none developed high-risk ventricular performance descriptors. The annual end point risk was 10.3%. Of all covariates, only change in RV ejection fraction from rest to exercise was significantly associated with disease progression. Annual risk of progression to surgical end point was 4.9% in the subgroup in which this parameter increased with exercise and 14.7% in the subgroup without an increase (p = 0.04). Patients with severe MR due to mitral valve prolapse, who are asymptomatic or minimally symptomatic with normal ventricular performance, can be expected to progress to surgical indications at an annual rate of 10.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives: The present study examines the incidence of aortic complications (dissection, marked dilation requiring surgery or progressive moderate to severe aortic regurgitation) and their relation to clinical features and aortic root morphology in patients with the Marfan syndrome., Background: Considerable phenotypic variability exists in the Marfan syndrome, and the prospective prediction of the risk for aortic complications in individual patients remains elusive., Methods: One hundred thirteen patients with the Marfan syndrome underwent anthropometric and echocardiographic evaluation and were followed-up for 49 +/- 24 (mean +/- SD) months. Aortic root dilation was defined as localized when confined to the sinuses of Valsalva (based on two-dimensional echocardiographic confidence limits utilizing age and body size) and generalized if dilation additionally involved the supraaortic ridge and proximal ascending aorta., Results: Aortic root dilation was present in 80% of patients and was localized in 28% and generalized in 51%. Aortic complications occurred during follow-up in none of 23 patients with normal initial aortic size, in 2 (6%) of 32 patients with initially localized dilation and in 19 (33%) of 58 patients with generalized dilation (p < 0.0005). Complications were associated with larger initial aortic size (p < 0.00005), higher systolic blood pressure (p < 0.005), height (p < 0.05), aortic growth rate (p < 0.05) and older age (p < 0.01). The only independent predictor of aortic complications was initial aortic root size (p < 0.005). However, when aortic size, one of the indications for surgical referral, was excluded from analyses, the only independent predictor of aortic complications was generalized aortic dilation (p < 0.005)., Conclusions: The present study indicates that generalized aortic root dilation is a potent marker of an increased risk for subsequent aortic complications in Marfan syndrome.

Imaging and color flow Doppler echocardiography are an integral part of any evaluation of a patient with the Marfan syndrome. The major cardiovascular manifestations of this condition are aortic dilation, which may involve the proximal and distal aorta, aortic regurgitation, aortic dissection, mitral valve prolapse, and mitral regurgitation. Patients who have the Marfan syndrome should have serial echocardiograms to measure aortic root diameter carefully at the sinuses of Valsalva and subsequent levels (sinotubular junction, arch, descending and abdominal aorta). Additionally, color Doppler echocardiography assists in the diagnosis of aortic dissection and facilitates evaluation of the severity of aortic and mitral regurgitation that commonly complicate the Marfan syndrome. The risk of aortic dissection, which is the most serious manifestation of the Marfan syndrome, increases as the aorta enlarges. Therefore, elective composite graft surgery is recommended when the aortic root size reaches 60 mm, regardless of symptom status, or 55 mm in the presence of severe aortic regurgitation. Surgical replacement of the aortic root with a composite graft does not end the disease process. Color flow Doppler is useful in the diagnosis of dehiscence of the conduit sewing ring, coronary artery aneurysm, distal aortic dissections, and prosthetic valve dysfunction.

We documented hypothalamic-pituitary dysfunction in three patients with congenital herniation of the brain through the base of the skull (basal encephalocele). All had growth hormone deficiency, although one has attained normal height. One had diabetes insipidus. Two had hypogonadotropic hypogonadism. Prolactin secretion was elevated in one, normal in another, and borderline low in the third. Two patients were euthyroid, but in response to thyrotropin-releasing hormone (TRH) injection, one patient's thyrotropin (TSH) level increased to levels exceeding normal while the other's did not attain normal levels. In the third patient, TSH response to TRH went from subnormal to normal after treatment with growth hormone and thyroxine. No patient had evidence of ACTH deficiency. These heterogeneous findings do not permit assignment of an unequivocal anatomic or functional site to the endocrine defect(s). Pituitary function should be evaluated in all patients with basal encephalocele, and this entity should be considered in the differential diagnosis of central endocrine malfunction.

Intrathoracic involvement with cutaneous T-cell lymphoma (CTCL) was documented in eight patients with mycosis fungoides and two patients with Sĕzary syndrome. The radiographic findings consisted of multiple bilateral parenchymal nodular densities (five patients), patchy areas of consolidation (two patients), diffuse reticulonodular or interstitial infiltration (two patients), and pleural effusion without underlying parenchymal disease (one patient). Dyspnea on exertion and nonproductive cough were the most frequent presenting symptoms, and physical examination of the lungs was usually normal. In one patient a partial Pancoast's syndrome developed from a pulmonary apical mass. Results of blood gas studies and pulmonary function tests indicated an alveolar-capillary block in gas diffusion. Although the antemortem diagnosis was often suggested on cytopathologic preparations or on tissue obtained by transbronchial or percutaneous needle aspiration biopsy, a definitive diagnosis of CTCL usually required an open-lung biopsy. The response of pulmonary infiltrates to various systemic chemotherapeutic agents was variable, and the mean survival after initiation of drug therapy was 9.5 months. The findings suggest that combined modality therapy should be considered for patients with extracutaneous CTCL.

A study was undertaken to evaluate the utility of the skin imprint technique and the Papanicolaou stain in the diagnosis of cutaneous T-cell lymphomas (CTCL), to better characterize cytologic findings in CTCL and to establish criteria for the cytologic diagnosis of CTCL. Differential cell counts of 17 specimens, including 12 cases of CTCL and 5 of benign skin infiltrates, were performed. There appear to be some significant differences between the groups in terms of cellularity, number of cerebriform mononuclear cells and presence of mitotic figures. The skin imprint technique, using Papanicolaou staining, seems to facilitate recognition of diagnostically important cells. The usefulness of skin imprint cytology resides in its potential for diagnosing early lesions of CTCL when diagnosis by other methods may be difficult.

A case of pulmonary cryptococcosis initially diagnosed by cytologic examination of sputum is presented. The cytologic findings are reviewed, with a brief discussion of the clinical settings in which pulmonary cryptococcosis occurs. The role of the cytologist in the early detection of this important and often clinically occult pulmonary mycotic disease is emphasized.

The cytologic presentation of a case of extraskeletal chondrosarcoma diagnosed by fine needle aspiration in a 57-year-old asymptomatic female is described. A mass detected on routine chest X ray and defined by CAT scan was subjected to a preoperative percutaneous fine needle aspiration under fluoroscopic guidance; a core biopsy was also obtained. Cytologic findings included pleomorphic malignant cells, with occasional spindle-shaped forms and binucleated and multinucleated cells having various degrees of nuclear atypia. The sarcomatous nature of this neoplasm was readily recognized in the cytologic material, although histologic and ultrastructural studies, which are also illustrated, were necessary to establish its specific histologic type. The biopsy was interpreted as a probable chondrosarcoma, and an exploratory laparotomy revealed a soft tissue tumor arising in the retroperitoneum. A diagnosis of soft tissue chondrosarcoma was rendered. In retrospect, the distinctive cytologic findings in the aspirated material suggest that extraskeletal chondrosarcoma should be considered in the differential diagnosis of soft tissue tumors.

In order to define the cytologic features of pulmonary involvement by mycosis fungoides, 15 respiratory cytology specimens from four patients with biopsy-proven pulmonary mycosis fungoides were reviewed. The presence in sputum smears of occasional small or large cerebriform mononucleated cells against a background of numerous atypical lymphocytic cells permitted an antemortem cytologic diagnosis of probable or definite dissemination of mycosis fungoides with pulmonary involvement. Similar cells were seen in aspiration smears. The lymphocytic infiltrates were similar to those in corresponding skin biopsies in each case. The distinctive cytologic findings in these cases may therefore help to determine the underlying etiology of pulmonary lesions and may contribute to the antemortem diagnosis of visceral dissemination of mycosis fungoides.

As examples of unusually indolent behavior of pancreatic carcinoma, two cases are discussed in which the diagnosis was made serendipitously, without symptoms referable to the pancreas. In both cases dystrophic calcification was noted, and pleomorphic giant cells were aspirated from the tumor. In one case, the patient survived 2 yr after diagnosis, dying from unrelated causes. Findings from ultrasound, computed tomography, and magnetic resonance imaging are discussed. Incidental discovery of a pancreatic carcinoma does not preclude a protracted asymptomatic course.