18F-FDG PET for detecting myocardial viability: validation of 3D data acquisition.

(18)F-FDG PET is an important diagnostic tool for detecting myocardial viability in patients with coronary artery disease. In combination with perfusion scanning, (18)F-FDG PET allows differentiation between reversibly and irreversibly damaged myocardium and selection of patients likely to benefit from revascularization. Viability PET is usually performed in two-dimensional (2D) mode. Taking into account the rising number of three-dimensional (3D)-only scanners, a validation of 3D acquisition is required. METHODS: Twenty-one patients with coronary artery disease referred for (18)F-FDG PET underwent an imaging protocol of nongated 2D (2D-NG) and gated 2D (2D-G) acquisitions for 15 min each, followed by 3D gated acquisitions for 10 min (3D-10) and 5 min (3D-5), using an ECAT Exact HR+ scanner. Results were analyzed using a 20-segment polar map in terms of activity concentration (Bq/mL), viability (50% uptake threshold), regional activity distribution, visual assessment of viability based on a 3-point rating scale, and left ventricular ejection fraction. RESULTS: Activity concentration measured in each segment with 2D-G, 3D-10, and 3D-5 showed a good linear correlation with 2D-NG. Quantitative viability assessment with 3D-5 gave a sensitivity of 84% and a specificity of 98%, compared with 2D-NG. No differences in regional activity distribution and visual viability assessment were found between the various protocols. Left ventricular ejection fractions obtained with 3D-10 and 3D-5 showed a good linear correlation with those measured with 2D-G. CONCLUSION: An ECG-gated 3D imaging protocol gave results comparable to those of 2D acquisition with regard to absolute and regional myocardial activity distribution, left ventricular function, and visual viability assessment. Sensitivity for viability assessment with a 50% uptake threshold was significantly less with 3D, but specificity was maintained. This protocol delivers a clinical performance nearly equivalent to that of 2D acquisition.     

Periodontal status of a subject sample of Yemen

Abstract From August to October 1991, the periodontal status of 1001 Yemenis representing the age groups 12-14, 15-19, 20-24 and 35-44 years was recorded and evaluated with preference to the CPITN, the calculus index and clinical attachment levels. The impact of chewing khat, the leaves of a cultivated, alkaloid shrub, and of using the traditional miswak chewing stick for oral hygiene purposes were investigated. The results show that 6.9% of the juvenile probands (15-19 years) had healthy periodontal tissue (CPITN 0). whereas bleeding on probing and calculus (CPITN 1+2) were registered in 86.2%. In the 35-44 year age group. 1.7% were periodontally healthy, whereas 84.5% displayed plaque retention or shallow pocketing (CPITN 2-3) and 12.5% deep pocketing (CPITN 4). The treatment needs in all age groups are confined primarily to calculus removal and instruction in oral hygiene. The clinical attachment level and the calculus index revealed age-related attachment loss and calculus formation, primarily among male probands. The higher khat consumption among the male population is reflected in its detrimental effect on the periodontal tissue, especially among younger probands. Oral hygiene aids have also an influence on periodontal status, with a toothbrush proving more efficient than the miswak. WHO efforts directed towards prophylactic programs need to be intensified but can be staffed by dental hygienists.     

Commonalities in fly embryogenesis and mammalian pituitary patterning.

During embryonic development, morphogenetic gradients can specify the formation of gene expression territories. Here, we explore possible commonalities between pattern formation in the Drosophila blastoderm and murine pituitary. Shared principles include the need for positive feedback involving fate-determining genes to maintain a differentiated state, and the existence of intra- or extracellular inhibitory signals that improve spatial resolution of neighboring territories. The precision of spatial segregation is, however, limited by stochastic gene expression. Variability in gene expression at territory boundaries might give rise to a poorly differentiated pool of cells, which could harbor stem-like properties. The ideas outlined here deserve further theoretical and experimental exploration.     

Safety of outpatient tonsillectomy and adenoidectomy

Recent changes in reimbursement for tonsillectomy and adenoidectomy have resulted in a large number of these procedures being done on an outpatient basis. There is still considerable controversy, however, as to the safety of this concept. We reviewed the charts of 1000 consecutive patients who underwent these procedures. Three hundred ninety-six procedures were performed as inpatient surgery and 604 were performed as outpatient surgery. Patients were considered as candidates for outpatient surgery if they met specific criteria, such as good overall medical health, no central apnea, normal bleeding history and profile, and had adequate social considerations. The inpatient group included those patients who did not meet the criteria to be outpatients. We compared the complication rates of these two groups with regard to age, type of procedure performed (tonsillectomy, adenoidectomy, adenotonsillectomy), and indication for surgery in order to determine if there was any increased risk of outpatient surgery, despite strict selection criteria. The two groups were similar in their distribution with regards to age, sex, type of procedure, and indication for surgery. The overall complication rate for the entire group was 7.9%, with an 11.8% complication rate for inpatients and 4.1% complications for outpatients. The higher complication rate among the inpatient group is probably a direct result of the selection process because this group included the higher-risk patients. On the basis of these findings, we believe that surgery of the tonsils and adenoids can be performed safely as an outpatient procedure, regardless of age, indication, or procedure, if the candidates for ambulatory surgery are carefully selected by the surgeon.     

Computerized follow-up of discrepancies in image interpretation between emergency and radiology departments

Radiographs are ordered and interpreted for immediate clinical decisions 24 hours a day by emergency physicians (EP’s). The Joint Commission for Accreditation of Health Care Organizations requires that all these images be reviewed by radiologists and that there be some mechanism for quality improvement (QI) for discrepant readings. There must be a log of discrepancies and documentation of follow up activities, but this alone does not guarantee effective Q.I. Radiologists reviewing images from the previous day and night often must guess at the preliminary interpretation of the EP and whether follow up action is necessary. EP’s may remain ignorant of the final reading and falsely assume the initial diagnosis and treatment were correct. Some hospitals use a paper system in which the EP writes a preliminary interpretation on the requisition slip, which will be available when the radiologist dictates the final reading. Some hospitals use a classification of discrepancies based on clinical import and urgency, and communicated to the EP on duty at the time of the official reading, but may not communicate discrepancies to the EP’s who initial read the images. Our computerized radiology department and picture archiving and communications system have increased technologist and radiologist productivity, and decreased retakes and lost films. There are fewer face-to-face consultations of radiologists and clinicians, but more communication by telephone and electronic annotation of PACS images. We have integrated the QI process for emergency department (ED) images into the PACS, and gained advantages over the traditional discrepancy log. Requisitions including clinical indications are entered into the Hospital information System and then appear on the PACS along with images and readings. The initial impression, time of review, and the initials of the EP are available to the radiologist dictating the official report. The radiologist decides if there is a discrepancy, and whether it is category I (potentially serious, needs immediate follow-up), category II (moderate risk, follow-up in one day), or category III (low risk, follow-up in several days). During the working day, the radiologist calls immediately for category I discrepancies. Those noted from the evening, night, or weekend before are called to the EP the next morning. All discrepancies with the preliminary interpretation are communicated to the EP and are kept in a computerized log for review by a radiologist at a weekly ED teaching conference. This system has reduced the need for the radiologist to ask or guess what the impression was in the ED the night before. It has reduced the variability in recording of impressions by EP’s, in communication back from radiologists, in the clinical follow-up made, and in the documentation of the whole QI process. This system ensures that EP’s receive notification of their discrepant readings, and provides continuing education to all the EP’s on interpreting images on their patients.     

Cholate-dependent killing of Giardia lamblia by human milk.

We showed previously that nonimmune human milk (NHM) kills Giardia lamblia trophozoites in vitro and presented evidence that killing requires the bile salt-stimulated lipase of milk. Since this enzyme is activated by bile salts, killing should be dependent on the presence of bile salts. We now show that killing by fresh NHM or NHM stored at -70 degrees C is totally dependent on sodium cholate (a bile salt). With less than 0.4 mM cholate, no parasites were killed, whereas with 1 mM cholate, greater than 99.7% were killed by 5% NHM in 30 min. Moreover, killing activity was completely heat labile. The G. lamblia-killing activity of human milk was greatly altered by storage at -10 or -20 degrees C. In less than 23 days, the 50% lethal dose decreased, cholate dependence was lost, and killing activity became heat stable. In contrast, the activity of milk stored at -70 degrees C remained unchanged. Milk lipase activity, like killing activity, became cholate independent during storage at -10 or -20 degrees C. On the basis of these results, we hypothesize that killing of G. lamblia by fresh NHM or NHM stored at -70 degrees C depends on bile salt-stimulated lipase, which must be activated by bile salts. In contrast, NHM stored at -20 degrees C accumulated free fatty acids which kill G. lamblia. In support of this thesis, milk stored at -10 degrees C had a concentration of 18.7 mM free fatty acids compared with only 1.1 mM in an identical sample stored at -70 degrees C.     

Should we begin with statin therapy in acute coronary syndrome?

Acute coronary syndrome (ACS) constitutes a unique syndrome with a distinct pathophysiology: rupture of the fibrous cap of unstable atherosclerotic plaques in coronary arteries resulting in subsequent platelet deposition and a thrombus formation that completely or partially occludes the artery. Remarkable therapeutic advances in the treatment of ACS have been made during the past decade with antiplatelet and antithrombotic therapy. However, these therapies alone do not appear to completely stabilize the unstable plaque. Results from several clinical trials suggest that early administration of a statin following an ACS may reduce both short-term and longterm adverse outcomes such as subsequent cardiovascular mortality, myocardial infarction and revascularization. The potential mechanisms of benefit include improvements in endothelial function and vasomotion, reduction of platelet aggregability and thrombus formation, fibrinolytic and antioxidant activity as well as reduction of inflammation within plaques, reducing matrix degradation due to reduction of macrophage metalloproteinase production and increasing collagen content. Based upon the current knowledge, it might be concluded that patients hospitalized for ACS should be given a statin and the treatment should be initiated as soon as possible.