Sestamibi SPECT in the detection of myocardial viability in patients with chronic ischemic left ventricular dysfunction: Comparison between visual and quantitative analysis

BACKGROUND: Technetium 99m sestamibi cardiac scintigraphy is widely used as a means of predicting myocardial viability in patients with chronic ischemic left ventricular (LV) dysfunction. No data are available comparing the results of visual and quantitative analysis of tomographic imaging in the assessment of myocardial viability. The aim of this study was to directly compare visual and quantitative analysis of resting sestamibi single photon emission computed tomography in the identification of viable myocardium in patients with chronic LV dysfunction. METHODS AND RESULTS: Sixty-five patients with an earlier myocardial infarction and LV dysfunction that had occurred within 1 week underwent echocardiography and resting sestamibi SPECT. In each patient, regional tracer distribution was visually assessed and quantitatively measured in 13 segments. Regional LV function was evaluated in corresponding segments by means of echocardiography. All patients underwent revascularization, and echocardiography was repeated 12 months later as a means of assessing the recovery of regional LV function. Among all akinetic or dyskinetic revascularized segments, 66 of 112 viable segments (59%) and 85 of 100 nonviable segments (81%) were identified by means of visual analysis. Eighty-two of 112 viable segments (73%; P<.05 vs. visual analysis) and 74 of 100 nonviable segments (74%; P = .3 vs. visual analysis) were identified by means of quantitative analysis, with a threshold of 55%. Receiver operating characteristic curve areas constructed by using visual and quantitative analyses for the detection of myocardial viability in all 212 akinetic or dyskinetic segments were 0.79+/-0.04 and 0.81+/-0.03, respectively (P = not significant). Overall concordance in the detection of myocardial viability between visual and quantitative analysis was observed in 165 of akinetic or dyskinetic dysfunctional segments (78%), with a kappa value of 0.6. CONCLUSIONS: The results of this study demonstrate that, in patients with chronic myocardial infarction and LV dysfunction, visual and quantitative analysis of sestamibi tomographic images at rest have similar overall accuracy in predicting the recovery of LV function after coronary revascularization procedures.     

Adenosquamous lung carcinomas: a histologic subtype with poor prognosis

Introduction

The aim of this study is to evaluate the prognostic factors and outcome of patients operated for adenosquamous (ADS) carcinoma of the lung, in comparison with adenocarcinoma (AD) and squamous cell carcinoma (SCC).

Methods

a retrospective review of our thoracic cancer surgical database for patients operated for ADS, SCC and AD between January, 1995 and December, 2009 was done.

Results

Forty-eight patients (39 males, 81.3%) had ADS; complete tumor resection and lymphadenectomy was accomplished in all patients. A higher stage at presentation was observed in ADS, as compared to AD or SCC (p = 0.0001). Three and 5-year survival rates were 25% and 15%. ADS overall survival was worse than AD or SCC (p = 0.0005). Three and 5-year survival rates of ADS Stage I were similar to those of Stage IIIA AD or SCC. More than half ADS patients developed distant metastases (MTS) or local recurrences. Brain MTS were the most frequent. Median survival for those patients was 8 ± 2.3 months. Postoperative platinum-based chemotherapy statistically improved patients survival (p = 0.02). In the multivariate analysis, the presence of MTS (p = 0.001), the tumor perineural invasion (p = 0.01) and the tumor stage (p = 0.0005) were factors associated with poor prognosis. Adjuvant chemotherapy was a significant positive prognostic factor (p = 0.00001).

Conclusions

ADS are uncommon and extremely aggressive lung tumors. Adjuvant chemotherapy should be administered even in Stage I radically resected tumors. A whole brain postoperative prophylactic radiotherapy could be proposed to reduce risk of developing brain MTS.     

Effects of intra-ventrolateral periaqueductal grey palmitoylethanolamide on thermoceptive threshold and rostral ventromedial medulla cell activity

Palmitoylethanolamide (PEA), a peroxisome proliferator-activated receptor-α (PPAR-α) ligand, exerts antinociceptive and anti-inflammatory effects. PEA (3 and 6 nmol) was microinjected in the ventrolateral periaqueductal grey (VL PAG) of male rats and effects on nociceptive responses and ongoing and tail flick-related activities of rostral ventromedial medulla (RVM) ON and OFF cells were recorded. Intra-PAG microinjection of PEA reduced the ongoing activity of ON and OFF cells and produced an increase in the latency of the nociceptive reaction. These effects were prevented by a selective PPAR-α antagonist, GW6471 and by a large-conductance Ca(2+)-activated K(+) channel inhibitor, charybdotoxin. Cannabinoid 1 (CB(1)) receptor blockade by AM251 increased the PEA-induced effect both on the ongoing activity of the ON cell and on the latency to tail flick without affecting the effect of PEA on the OFF cell. Conversely, a transient receptor potential vanilloid type 1 (TRPV(1)) blocker, I-RTX, had no effect on the ON cell activity and tail flick latency, whereas it blocked the PEA-induced decrease in ongoing activity of the OFF cell. PEA decreased the burst and increased the latency of tail flick-evoked onset of ON cell activity in a manner antagonised by GW6471 and charybdotoxin. AM251 and I-RTX, instead, enhanced these latter effects. In conclusion, intra-VL PAG PEA induces antinociceptive effects associated with a decrease in RVM ON and OFF cell activities. PPAR-α receptors mediate, and CB(1) and TRPV(1) receptors antagonise, PEA-induced effects within the PAG-RVM circuitry.     

Abdominal Angina due to Obstruction of Mesenteric Artery Treated With Spinal Cord Stimulation: A Clinical Case

Introduction: Abdominal angina occurs in patients affected by mesenteric artery obstruction, causing postprandial episodes of visceral pain. The conventional treatment consists of vessels revascularization, but sometimes this is not applicable. Case Report: The authors report a case of a patient with severe abdominal angina caused by mesenteric ischemia, not treatable with surgery and few‐responder to pharmacological therapy (opioids and epidural infusion of local anesthetics). After a successful screening test, the patient underwent implantation of a spinal cord stimulation (SCS) device. Results: The stimulation provided a reduction in pain episodes (number and intensity) and in oral analgesics consumption. Results obtained support the clinical efficacy and durability of the SCS in the management of abdominal angina due to not treatable mesenteric ischemia. Conclusions: Spinal cord stimulation may be considered for abdominal angina, although there is still no evidence provided by controlled studies.     

No longitudinal mitochondrial DNA sequence changes in HIV-infected individuals with and without lipoatrophy

The potential for mitochondrial (mt) DNA mutation accumulation during antiretroviral therapy (ART), and preferential accumulation in patients with lipoatrophy compared with control participants, remains controversial. We sequenced the entire mitochondrial genome, both before ART and after ART exposure, in 29 human immunodeficiency virus (HIV)-infected Swiss HIV Cohort Study participants initiating a first-line thymidine analogue-containing ART regimen. No accumulation of mtDNA mutations or deletions was detected in 13 participants who developed lipoatrophy or in 16 control participants after significant and comparable ART exposure (median duration, 3.3 and 3.7 years, respectively). In HIV-infected persons, the development of lipoatrophy is unlikely to be associated with accumulation of mtDNA mutations detectable in peripheral blood.     

Cardiac involvement in patients with spinal muscular atrophies

The spinal muscular atrophies (SMAs) include a group of disorders characterized by progressive weakness of the lower motor neurons. Several types of SMAs have been described based on age onset of clinical features: Acute infantile (SMA type I), chronic infantile (SMA type II), chronic juvenile (SMA type III), and adult onset (SMA type IV) forms. The incidence is about 1:6,000 live births with a carrier frequency of 1:40 for the severe form and 1:80 for the juvenile form. The mortality and/or morbidity rates of SMAs are inversely correlated with the age at onset. SMAs are believed to only affect skeletal muscles; however, new data on SMA mice models suggest they may also impact the heart. Aim of the study was to retrospectively examine the cardiological records of 37 type molecularly confirmed II/III SMA patients, aged 6 to 65 years, in order to evaluate the onset and evolution of the cardiac involvement in these disorders. All patients had a standard ECG and a routine echocardiography. The parameters analysed were the following: Heart rate (HR), PQ interval, PQ segment, Cardiomyopathic Index (ratio QT/PQs), ventricular and supraventricular ectopic beats, pauses > or = 2,5 msec, ventricle diameters, wall and septum thickness, ejection fraction, fiber shortening. The results showed that HR and the other ECG parameters were within the normal limits except for the Cardiomyopathic Index that was higher than the normal values (2,6-4,2) in 2 patients. Left ventricular systolic function was within the normal limits in all patients. A dilation of the left ventricle without systolic dysfunction was observed in only 2 patients, aged respectively 65 and 63 years; however they were hypertensive and/or affected by coronary artery disease. Data here reported contribute to reassure patients and their clinicians that type II/III SMAs do not present heart dysfunction.