Background: Type 2 myocardial infarction (T2MI) occurs because of an acute imbalance in myocardial oxygen supply and demand in the absence of atherothrombosis. Despite being frequently encountered in clinical practice, the population-based incidence and trends remain unknown, and the long-term outcomes are incompletely characterized. Methods: We prospectively recruited residents of Olmsted County, Minnesota, who experienced an event associated with a cardiac troponin T >99th percentile of a normal reference population (≥0.01 ng/mL) between January 1, 2003, and December 31, 2012. Events were retrospectively classified into type 1 myocardial infarction (T1MI, atherothombotic event), T2MI, or myocardial injury (troponin rise not meeting criteria for myocardial infarction [MI]) using the universal definition. Outcomes were long-term all-cause and cardiovascular mortality and recurrent MI. T2MI was further subclassified by the inciting event for supply/demand mismatch. Results: A total of 5460 patients had at least one cardiac troponin T ≥0.01 ng/mL; 1365 of these patients were classified as index T1MI (age, 68.5±14.8 years; 63% male) and 1054 were classified as T2MI (age, 73.7±15.8 years; 46% male). The annual incidence of T1MI decreased markedly from 202 to 84 per 100 000 persons between 2003 and 2012 ( P <0.001), whereas the incidence of T2MI declined from 130 to 78 per 100 000 persons ( P =0.02). In comparison with patients with T1MI, patients with T2MI had higher long-term all-cause mortality after adjustment for age and sex, driven by early and noncardiovascular death. Rates of cardiovascular death were similar after either type of MI (hazard ratio, 0.8 [95% CI, 0.7–1.0], P =0.11). Subclassification of T2MI by cause demonstrated a more favorable prognosis when the principal provoking mechanism was arrhythmia, in comparison with postoperative status, hypotension, anemia, and hypoxia. After index T2MI, the most common MI during follow-up was a recurrent T2MI, whereas the occurrence of a new T1MI was relatively rare (estimated rates at 5 years, 9.7% and 1.7%). Conclusions: There has been an evolution in the type of MI occurring in the community over a decade, with the incidence of T2MI now being similar to T1MI. Mortality after T2MI is higher and driven by early and noncardiovascular death. The provoking mechanism of supply/demand mismatch affects long-term survival. These findings underscore the healthcare burden of T2MI and provide benchmarks for clinical trial design.

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Background: There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection (LoD) of 5 ng/L to exclude acute myocardial infarction. Per the United States (US) Food and Drug Administration (FDA), hs-cTnT can only report to the limit of quantitation (LoQ) of 6 ng/L, a threshold for which there is limited data. Our goal was to determine whether a single hs-cTnT below the LoQ of 6 ng/L is a safe strategy to identify patients at low-risk for acute myocardial injury and infarction. Methods: The efficacy (proportion identified as low-risk based on baseline hs-cTnT<6 ng/L) of identifying low-risk patients was examined in a multicenter (n=22 sites) US cohort study of emergency department patients undergoing at least one hs-cTnT (CV Data Mart Biomarker cohort). We then determined the performance of a single hs-cTnT<6 ng/L (biomarker alone) to exclude acute myocardial injury (subsequent hs-cTnT >99 th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic electrocardiogram with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling-out acute myocardial infarction and safety (myocardial infarction or death at 30-days) were evaluated. Results: A total of 85,610 patients were evaluated in the CV Data Mart Biomarker cohort, amongst which 24,646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% vs. 20%, p<0.0001). Among 11,962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI 98.6, 99.0) and sensitivity of 99.6% (95% CI 99.5, 99.6). In the adjudicated cohort, a nonischemic electrocardiogram with hs-cTnT<6 ng/L identified 33% of patients (610 of 1849) as low-risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for 30-day myocardial infarction or death. Conclusions: A single hs-cTnT below the LoQ of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction.

Summary A multiyear study of pallid sturgeon distribution and relative abundance was conducted in the lower and middle Mississippi river (LMR and MMR, respectively). The LMR and MMR comprise the free‐flowing Mississippi River extending 1857 river kilometers (rkm) from its mouth at the Gulf of Mexico upstream to the mouth of the Missouri River. A total of 219 pallid sturgeon and 6018 shovelnose sturgeon was collected during the periods 1996–1997 and 2000–2006. Trotlines baited with worms were the primary collecting gear. The smallest pallid sturgeon captured on trotlines was 405 mm FL and the largest was 995 mm FL. Mean size of pallid sturgeon was statistically smaller in the Mississippi River below the Atchafalaya River near Baton Rouge, LA (621 mm FL). Mean abundance (catch per trotline night) of pallid sturgeon was highest at water temperatures around 10°C. There was a latitudinal trend in mean abundance of pallid and shovelnose sturgeon, but the pattern differed between species. Pallid sturgeon abundance was statistically (P < 0.05) higher (0.3 fish per trotline night) in the lower reach between the Atchafalaya River and New Orleans (rkm 154–507), and at the Chain of Rocks (COR), a low water dam near the mouth of the Missouri River. Pallid sturgeon abundance between these two locations was statistically the same (0.12–0.23). Shovelnose sturgeon abundance increased going upstream, but was disproportionally higher at the COR (22 fish per line compared with <6 fish per line in other reaches). Overall, the ratio between pallid and shovelnose sturgeon varied from a high of 1 : 6 at the lower reach, and gradually decreased upstream to a low of 1 : 77 at the COR. Based on differences in sturgeon abundance, size and habitat characteristics, the free‐flowing Mississippi River can be divided into two reaches in the MMR (i.e. COR is a separate location), and four reaches (i.e., including the Atchafalaya River) in the LMR where management goals may differ.

Background: Risks and mechanisms of extension of conservatively managed spontaneous coronary artery dissection (SCAD) remain incompletely understood. Study objectives were to (1) evaluate mechanisms of early SCAD evolution through serial angiographic analysis, and (2) determine predictors of early SCAD progression. Methods and Results: Retrospective registry study of patients with SCAD managed with an initial conservative strategy (n=240). Patients who experienced significant SCAD progression within 14 days, defined as clinical worsening plus new critical coronary obstruction on repeat angiography, were compared with remaining controls. A total of 42 of 240 (17.5%) experienced significant SCAD progression after index conservative approach; 91% by day 6. Isolated intramural hematoma (IMH) at baseline (no intimal dissection) was observed more frequently in those experiencing progression compared with controls (69.1% versus 44.4%; P =0.004). Multivariable predictors of SCAD progression included lesion severity, multivessel involvement, and isolated IMH. To investigate mechanisms of SCAD evolution, all repeat angiograms ≤14 days were compared with corresponding baselines (n=82 patient angiogram pairs). Of those with isolated IMH at baseline, 20% developed intimal dissection at repeat study. IMH was associated with greater longitudinal lesion extension (11.5 versus 2.8 mm; P =0.01), worsening Thrombolysis in Myocardial Infarction flow (−0.8 versus 0.1; P =0.003), and a nonsignificant lower rate of angiographic improvement (20.0% versus 31.3%; P =0.16) compared with the group with baseline intimal dissection. Optical coherence tomography subgroup analysis (n=17) indicated intimo-medial thickness to be lowest at the midpoint of IMH. Conclusions: Conservatively managed SCAD carries a 1:6 hazard for serious deterioration within 6 days. The risk was higher in those with isolated IMH at baseline. IMH often precedes development of intimal dissection, which has implications for mechanisms of SCAD.

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Trotlines were used to capture pallid sturgeon in the freeflowing Mississippi River, which extends from the Gulf of Mexico to the mouth of the Missouri River. Trotlines were baited with worms, and set overnight usually along the channel border. The pectoral fin rays of 165 pallid sturgeon caught in the Mississippi River were aged; 118 were from the lower Mississippi River (LMR) between the Gulf and mouth of the Ohio River, and 47 were from the middle Mississippi River (MMR) between the mouths of the Ohio and Missouri rivers. Initial agreement within ±1 year between two readers ranged from 53% for the LMR specimens, which were read first, to 84% for the MMR. Final age was agreed upon by both readers. For LMR pallid sturgeon, final age estimates ranged from 3 to 21 years with a mean (±SD) of 11.0 ± 4.7. For MMR pallid sturgeon, final age estimates ranged from 5 to 14 years with a mean of 9.5 ± 2.1. Seven pallid sturgeon marked with coded wire tags (CWT), indicating hatchery origin, were collected in the MMR. Age estimates for CWT fish were 7-8 years representing 1997 stocked fish, and 11-12 years representing 1992 progeny stocked in 1994. Von Bertalanffy growth equations for length indicated that pallid sturgeon in the MMR had higher growth rates for a given age than pallid sturgeon in the LMR. However, there were no significant differences (ANOVA ANOVA, P > 0.5) in the length-weight relationships between reaches. In the LMR, pallid sturgeon fully recruited to trotlines at age 11 and instantaneous total mortality (Z; slope of catch curve) was estimated at )0.12 (n ¼ 10 year classes, r 2 ¼ 0.55, P ¼ 0.01). Of the 118 sectioned rays from the LMR, 28 could not be reliably aged (only one section from the MMR could not be aged). Therefore, age was predicted from length using the von Bertalanffy equation. The catch curve was re-calculated using the predicted ages of the 28 pallid sturgeon in the LMR resulting in Z ¼ )0.07. In the MMR, pallid sturgeon fully recruited to trotlines at age 9 and Z was estimated at )0.36 (n ¼ 6 year classes, r 2 ¼ 0.67, P ¼ 0.04), which was significantly higher (ANOVA ANOVA, P ¼ 0.04) than the LMR estimate. Higher mortality in the MMR may be due to habitat limitations compared to a larger, more diverse channel in the LMR, and incidental take of larger, older individuals during commercial harvesting of shovelnose sturgeon. Commercial take of shovelnose does not occur in the LMR except in the northern portion of the reach. Considering the presence of pallid sturgeon with CWT, recruitment of older individuals in the MMR may have been influenced by stocking a decade earlier. Management strategies for this endangered species should consider the differences in mortality rates among reaches, the impacts of commercial fishing on recovery of pallid sturgeon in the MMR, and the long-term effects of hatchery fish now recruiting into the free-flowing Mississippi River.

Musculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.