Combining cardiac magnetic resonance and computed tomography coronary calcium scoring: added value for the assessment of morphological coronary disease?

To investigate prospectively, in patients with suspicion of coronary artery disease (CAD), the added value of coronary calcium scoring (CS) as adjunct to cardiac magnetic resonance (CMR) for the diagnosis of morphological coronary stenosis in comparison to catheter angiography (CA). Sixty consecutive patients (8 women; 64 ± 10 years) referred to CA underwent CMR (1.5 T) including perfusion and late gadolinium-enhancement imaging as well as CS with computed tomography. Diagnostic performance was evaluated for CMR and CS separately, and for both methods combined, with CA as reference standard. Best CS threshold combined with a specificity >90% to predict significant stenosis in patients without abnormalities on CMR was determined from receiver operator characteristics (ROC) analysis. Abnormal CMR results were considered to indicate significant stenosis regardless of CS; CS above threshold reclassified patients to have CAD regardless of CMR. CA identified 104/960 (11%) coronary segments with coronary artery stenosis >50% in 36/60 (60%) patients. ROC revealed an area-under-the-curve of 0.83 (95%CI: 0.68-0.99) with the best CS threshold of 495 Agatston score (sensitivity 50%). CMR depicted 128/960 (13%) myocardial segments with abnormalities in 31/60 (52%) patients. Sensitivity, specificity, negative (NPV) and positive predictive value (PPV) of CMR were 78, 88, 72 and 90%. When adding CS to CMR, sensitivity and NPV increased to 89 and 83%, while specificity and PPV slightly decreased to 83 and 89%. Accuracy of the combined approach (87%) was significantly (P < 0.05) higher than that of CMR (82%) alone. Adding CS to CMR improves the accuracy for the detection of morphological CAD.     

The clinical value of single photon emission computed tomography myocardial perfusion imaging in cardiac risk stratification of very elderly patients (≥80 years) with suspected coronary artery disease

Background  

The role of single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) in cardiac evaluation of the very elderly patients is unclear. We investigated the clinical value of SPECT MPI in very elderly patients (≥80 years) with suspected coronary artery disease (CAD) as well as in comparison to younger patients.     

An Examination of Parenting Variables and Child Self-Care Behavior Across Disease Groups

The present study examined the relationship of three parent-related variables, namely, perceived child vulnerability, parental overprotection, and parenting stress to child self-care behaviors among 200 children with Type 1 diabetes, asthma, or cystic fibrosis. A related goal of the study was to examine for illness- and age-related differences among the same variables of interest. Results indicated that higher levels of parenting stress were associated with lower parent ratings of their child’s self-care behaviors. Additional analyses of individual illness groups demonstrated that age was significantly related to both child and parent ratings of self-care only for the diabetes group, with older children engaging in lower levels of self-care. Such results support continued investigation of parent behaviors and beliefs as they relate to child self-care outcomes at different ages in pediatric chronic illness populations.     

Advantages and disadvantages of PET and SPECT in a busy clinical practice

The continued high utilization of rest-stress single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) is supported by its known clinical benefits, established reimbursement, and wide availability of cameras and radiopharmaceuticals. However, traditional rest-stress SPECT protocols tend to be lengthy and inefficient, and the prevalence of equivocal studies continues to be a problem. The use of stress-only SPECT protocols in selected patients, and a new generation of ultrafast SPECT cameras have led to improved image quality, reduced dosimetry and shorter, more efficient MPI protocols. The utilization of positron emission tomographic (PET) MPI has been accelerated by the availability of radiopharmaceuticals that can be generated on-site, and by the availability of more PET cameras. Emerging evidence consistently demonstrates that PET provides improved image quality, greater interpretive certainty, higher diagnostic accuracy, lower patient dosimetry, and shorter imaging protocols as compared to SPECT. Importantly, PET imaging allows assessment of left ventricular function at peak-stress, and evaluation of microvascular function through the measurement of absolute myocardial blood flow at rest and at peak-stress. Wider utilization of PET MPI is hindered by a high cost of entry, high on-going costs, and an immature reimbursement structure.     

Physical attributes,limitations, and future potential for PET and SPECT

Background  

Cadmium Zinc Telluride (CZT) SPECT camera technology has the potential to reduce patient’s radiation exposure and shorten imaging time. This study evaluated the correlation of low stress tracer dose, rapid CZT SPECT myocardial perfusion imaging (MPI) to coronary angiography in a <200-lbs population to further validate its ability to achieve both goals while preserving diagnostic accuracy.     

Reliability and Factor Structure of the Autism Spectrum Disorders—Diagnosis Scale for Intellectually Disabled Adults (ASD—DA)

Most of the scale development work in autism spectrum disorders (ASD) to date has focused on instrumentation designed for one disorder, autism, and mainly focused on young children. Three hundred seventy-one staff were administered a newly developed assessment scale for adults with ID. The Autism Spectrum Disorders—Diagnosis Scale for Intellectually Disabled Adults (ASD—DA) was designed to quickly provide relevant information to establish a diagnosis for the most common ASD (autism, PDD-NOS, and Asperger’s syndrome). Staff completed the assessment for adults with ID (n = 192) some of which had a diagnosis of either autism or PDD-NOS (n = 107) or ID alone (n = 85). Inter-rater and test-retest reliability data were obtained. Item analysis reduced the scale to 31 items that were found to be both reliable and significantly differentiate between groups. A factor analysis with a three-factor solution was identified. The internal consistency of factor and total scale scores were found to be excellent.     

The effects of the extent of spinal block on the BIS score and regional cerebral oxygen saturation in elderly patients: A prospective,randomized, and double-blinded study

Backgrounds Patients may become sedated with␣spinal anesthesia; however, the effect of the extent of␣spinal block on the Bispectral index (BIS), a processed electroencephalographic variable, has not been fully investigated. We evaluated the influence of the extent of spinal block on BIS values and on regional cerebral oxygen saturation (rSO₂) in elderly patients. Methods A prospective, randomized, double-blinded study was performed in 55 ASA II patients undergoing urological surgery. The patients were randomly allocated into one of two groups to receive 2.7 ml of 0.5% hyperbaric bupivacaine or 1.5 ml, and then divided into two groups according to level of spinal blockade: high spinal group (Th6 and above) or low spinal group (Th12 and below). Systolic blood pressure (SBP), heart rate (HR), cardiac output (CO), stroke volume (SV), BIS values, and rSO₂ were measured for 30 min. CO and SV were evaluated using impedance cardiograph methods. Results The level of spinal blockade was Th4.7 ± 1.0 in high spinal group (n = 20) and L2.5 ± 2.2 in low spinal group (n = 20). High spinal anesthesia produced a significant decrease in SBP (p < 0.01) and SV (p < 0.01), but had no effect on CO. High spinal anesthesia significantly decreased BIS values (p < 0.01) without affecting rSO₂. There was relationship between level of spinal blockade and BIS values (r = 0.566). In contrast, no changes in above parameters were found in low spinal group. Conclusions This study provides evidence that the extent of spinal block may have significant influence on BIS values without affecting rSO₂ in elderly patients. A part of the present study was presented at the Annual Meeting of the Japan Society of Anesthesiologists, June 02–04, 2005 at Kobe, Japan. Nishikawa K,Hagiwara R, Nakamura K, Ishizeki J, Kubo K, Saito S, Goto F. The effects of the extent of spinal block on the BIS score and regional cerebral oxygen saturation in elderly patients: A prospective, randomized, and double-blinded study.     

Clinical review: Long-term noninvasive ventilation

Noninvasive positive ventilation has undergone a remarkable evolution over the past decades and is assuming an important role in the management of both acute and chronic respiratory failure. Long-term ventilatory support should be considered a standard of care to treat selected patients following an intensive care unit (ICU) stay. In this setting, appropriate use of noninvasive ventilation can be expected to improve patient outcomes, reduce ICU admission, enhance patient comfort, and increase the efficiency of health care resource utilization. Current literature indicates that noninvasive ventilation improves and stabilizes the clinical course of many patients with chronic ventilatory failure. Noninvasive ventilation also permits long-term mechanical ventilation to be an acceptable option for patients who otherwise would not have been treated if tracheostomy were the only alternative. Nevertheless, these results appear to be better in patients with neuromuscular/-parietal disorders than in chronic obstructive pulmonary disease. This clinical review will address the use of noninvasive ventilation (not including continuous positive airway pressure) mainly in diseases responsible for chronic hypoventilation (that is, restrictive disorders, including neuromuscular disease and lung disease) and incidentally in others such as obstructive sleep apnea or problems of central drive.     

Assessment of the extension and the inflammatory activity in Crohn’s disease: comparison of ultrasound and MRI

Objective  The purpose of this prospective study was twofold: to examine the efficacy of MRI and sonography in the assessment of Crohn’s disease (CD) activity in comparison with clinical scoring and biologic tests and to compare both techniques in the evaluation of extension and transmural complications. Material and methods  Thirty patients with histologically proven Crohn’s disease were prospectively examined the same day first with sonography and after MRI. Sonographic exam included evaluation of bowel wall thickness, vascularity pattern, and perienteric changes. Thirty minutes prior to MRI imaging, patients were given 250 mL of dilute sodium phosphate solution and additional 750 mL of water orally. MRI images evaluation included bowel wall thickening, bowel wall enhancement, and perienteric changes. The gastrointestinal tract was divided into five segments. Findings and extension of the both techniques were verified by means of barium studies, surgery, or/and colonoscopy. The sonographic and MR findings were compared with clinical and laboratory data. Results  About 53 of 119 (45%) bowel segments showed pathological changes in gold standard tests. Sonography was superior to MRI in the localization of affected bowel segments (sensitivity: US 91%; MRI 83%; intertechniques agreement, kappa: 0.905) and in recognizing transmural complications (sensitivity: US 80%; MRI 72%), although significant differences were not found (p > 0.05). A statistically significant correlation between color Doppler flow and MR bowel wall enhancement (segment-by-segment analysis and per patient analysis; p > 0.5), and between perienteric changes in both techniques (p > 0.5) were found. Wall thickness measured on sonography was significantly greater in the group of patients with clinical activity (p = 0.023) or with clinical-biologic activity (p = 0.024). Grades of hyperemia and MR contrast enhancement of patients with clinical–biologic activity was higher than in patients without clinical–biologic activity (p = 0.019; p = 0.023). Conclusion  In summary, both ultrasound and MRI are sensitive to localize the affected bowel segments and to detect transmural complications in patients with Crohn’s disease. A significant correlation between color Doppler flow and bowel wall enhancement on MRI was found. Sonographic wall thickness, color Doppler flow, and bowel wall enhancement on MRI are related with clinical or biologic activity.