Calcium scoring of the coronary artery by electron beam CT: how to apply an individual attenuation threshold.

OBJECTIVE: Our aim was to assess the inter- and intraindividual variability of the attenuation threshold used to identify coronary artery calcification on electron beam CT and to illustrate a new threshold method. MATERIALS AND METHODS: We measured the soft-tissue attenuation of regions surrounding the coronary arteries at the level of the left main coronary artery ostium (high level) and at the bottom of the heart (low level) in 48 consecutive patients (22 men, 26 women). Mean +/- 2 standard deviations (SD) of soft-tissue attenuation and variance of soft-tissue density and SDs were calculated at each level for every patient. It was assumed that setting an attenuation threshold greater than or equal to 3 SDs above that of soft tissue at each myocardial level would eliminate 99.5% of all scatter artifacts, allowing precise identification of calcific deposits. RESULTS: For the entire patient cohort, the average soft-tissue attenuation was 41 H and 35 H at the high and low levels, respectively (p < 0.01), indicating a large intraindividual variability. The SDs of soft-tissue attenuation measured by the computer software at the high and low levels were not different (26 H at the high level and 28 H at the low level; p = not significant). However, the calculated SD of the individual mean soft-tissue attenuation was 5 H at the high level and 8 H at the low level, again indicating a large intraindividual variability (p < 0.01). The addition of 3 measured SDs above the mean individual soft-tissue attenuation predicted a mean threshold of 120 and 121 H at the high and low levels, respectively, but with a wide interindividual variability (83-193 H at the high level and 79-242 H at the low level). There was a strong correlation between body weight and SD of soft-tissue attenuation at the low level (r = 0.75, p < 0.001) and a weaker but statistically significant correlation between weight and SD of soft-tissue attenuation at the high level (r = 0.51, p < 0.001). CONCLUSION: For the patients in this study, a threshold of 120 H for the detection of coronary calcification by electron beam CT seemed more appropriate than a threshold of 130 H, which is currently in use. However, given the great inter- and intraindividual variability, a biologic threshold tailored to the individual patient and to each individual imaging level should be used instead of a fixed threshold.     

Tracking of high- and low-density-lipoprotein cholesterol from childhood to young adulthood in a single large kindred with familial hypercholesterolemia

Tracking of high- and low-density-lipoprotein cholesterol (HDLC, LDLC) from childhood to young adulthood was assessed in 77 children and in 53 adults from a single large pedigree with familial hypercholesterolemia who were respectively less than or equal to 19 and greater than or equal to 20 years old when first studied in 1973, with reassessment in 1984. No children and only five of the adults had received LDLC lowering therapy from 1973 to 1984. The rank correlations between the 1973 and 1984 measurements for LDLC were 0.73, 0.74, and 0.87; and for HDLC were 0.55, 0.73, and 0.65 (P less than 0.0001 for all correlations), respectively for relatives who were less than or equal to 12, 13 to 19, and greater than or equal to 20 years old in 1973. The 1973:1984 LDLC and HDLC correlations, categorized by relationships to the proband, were as follows: (1) unrelated, LDLC = 0.16, HDLC = 0.56;* (2) first-degree relatives, LDLC = 0.90, HDLC = 0.30; (3) second-degree relatives, LDLC = 0.79, HDLC = 0.39; and (4) other relatives, LDLC = 0.62, HDLC = 0.64. All nine of the probands' first-degree relatives who were above the age-sex specific LDLC 95th percentile in 1973 were also greater than the 95th percentile for LDLC in 1984. Similarly, seven of eight second-degree relatives with LDLC greater than the 95th percentile in 1973 were greater than the 95th percentile in 1984, as were ten of 15 other relatives. LDLC levels in childhood in this extended kindred were highly predictive of adult values.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraoperative hypercyanosis in a patient with pulmonary artery band: case report and review of the literature

A case of intraoperative cyanosis in a patient with a common atrioventricular canal palliated with a pulmonary artery (PA) band is presented. The patient's physiology was consistent with cyanosis due to inadequate pulmonary blood flow, and responded quickly to typical interventions used for a hypercyanotic episode in a patient with unrepaired Tetralogy of Fallot. Differences and similarities in the physiology of PA banding compared with Tetralogy of Fallot are presented, including a rationale for treatment options for hemodynamic decompensation occurring in the setting of anesthesia and surgery.     

Bone Density and Microarchitecture: Relationship Between Hand, Peripheral, and Axial Skeletal Sites Assessed by HR-pQCT and DXA in Rheumatoid Arthritis

We assessed the relationship of bone density and microarchitecture between hand, peripheral, and axial skeletal sites using high-resolution peripheral quantitative computed tomography (HR-pQCT) and dual-energy X-ray absorptiometry (DXA) in patients with rheumatoid arthritis (RA) and which factors influence these parameters. This was a cross-sectional study of 100 female patients (53.4?±?9.3?years) with RA. HR-pQCT scans at distal radius and the second metacarpal head were performed to assess cortical and trabecular volumetric bone mineral density (vBMD) and microarchitecture. DXA scans at the hip, lumbar spine, and ultradistal radius were performed to assess areal BMD. There was significant correlation in vBMD and microarchitectural parameters between the second metacarpal head and distal radius (r?=?0.201?0.628). Areal BMD at the axial skeleton was moderately associated with vBMD at the peripheral sites (r?=?0.354–0.558). Factors related to disease severity/chronicity significantly correlated with vBMD and microarchitecture at the distal radius and the second metacarpal head. Factors related to disease activity were more likely to correlate with vBMD and microarchitecture at the second metacarpal head but not those at the distal radius. HR-pQCT is a promising technique that is capable of providing detailed quantitative assessment of disease-associated periarticular bone loss at both cortical and trabecular bone compartments in patients with RA. Future longitudinal studies will be needed to investigate whether assessment by HR-pQCT can be used as a marker of disease activity and a predictor of disease progression in RA.     

Quality of life improves within 30 days of surgery for Crohn's disease

BACKGROUND: The effect of surgery on quality of life (QOL) in the early postoperative period is important in Crohn's disease because of the multiple surgical procedures that patients undergo and the acute QOL benefits that might occur as a result of modifications of medical treatment. Earlier studies of the effect of surgery on QOL have been retrospective and assessed changes 3 to 24 months after surgery. This study prospectively assesses the effect of surgery on QOL in the early postoperative period. STUDY DESIGN: Patients requiring surgical management of sequelae of Crohn's disease were obtained from a prospectively entered database including data on QOL. Preoperative and 30-day postoperative QOL were determined in 82 patients using Cleveland Global Quality of Life (CGQL) scores (range from 0 [worst] to 10 [best possible] QOL). Preoperative and postoperative scores were compared using a paired t-test to determine the significance of any change in QOL after surgery. The effect of other variables on change in QOL after surgery was assessed using the t-test or analysis of variance. Multifactor analysis of variance was used to assess the effect of several independent variables. RESULTS: Eighty-two patients (41 women) of 142 patients who had had surgery (58%) had complete preoperative and 30-day postoperative scores. The incidence of complications was 23% (11% were major). There was a significant improvement in QOL 30 days after surgery as measured by CGQL (0.6 +/- 0.2 preoperative to 0.7 +/- 0.2 postoperative; mean +/- SD; p < 0.001). The mean preoperative CGQL was 0.56 +/- 0.24 and the mean improvement was 0.11 +/- 0.20 toward a better QOL. Female patients (p < 0.05) and those who did not develop complications within 30 days of surgery (p < 0.05) had a significantly greater improvement in CGQL after surgery than other groups. No other factor was predictive of improved outcomes. CONCLUSIONS: QOL as measured by CGQL improves early after surgery (30 days postoperatively). Improvement in CGQL is greater in female patients and patients who do not develop complications in the postoperative period. It is not affected by other patient characteristics, nature of disease, indication, or procedure performed. Most patients who undergo surgery for Crohn's disease feel that surgery has helped them and would undergo surgery again.     

Health related quality of life patterns in patients treated with interstitial prostate brachytherapy for localized prostate cancer--data from CaPSURE

PURPOSE: We measured the impact brachytherapy monotherapy (BMT) has on general and disease specific health related quality of life (HRQOL) compared to patients treated with radical prostatectomy (RP). MATERIALS AND METHODS: We studied 419 men with newly diagnosed prostate cancer who enrolled in CaPSURE (Cancer of the Prostate Strategic Urological Research Endeavor) data base whose primary treatment was brachytherapy monotherapy (92) or radical prostatectomy (327). The validated RAND 36-Item Health Survey and the UCLA Prostate Cancer Index were used to measure HRQOL before treatment and at 6-month intervals during the first 2 years after treatment. RESULTS: Patients treated with BMT or RP did not differ greatly in general HRQOL after treatment. Both treatment groups showed early functional impairment in most general domains with scores returning to or approaching baseline in most domains 18 to 24 months after treatment. Patients treated with BMT had significantly higher urinary function scores at 0 to 6 months after treatment (84.5, SD 18.7) than patients treated with RP (63.3, SD 26.6). Urinary bother scores at 0 to 6 months after treatment were not significantly different between patients treated with BMT (67.7, SD 31.2) and those treated with RP (67.4, SD 29.1). Both treatment groups had decreases in sexual function that did not return to pretreatment levels. CONCLUSIONS: Overall BMT and RP are well tolerated procedures that cause mild changes in general HRQOL. Disease specific HRQOL patterns are different in patients treated with BMT or RP. Baseline and serial HRQOL measurements after treatment can provide valuable information regarding expected quality of life outcome after treatment for localized prostate cancer.     

Cyclooxygenase-2 Inhibition Improves Macrophage Function in Melanoma and Increases the Antineoplastic Activity of Interferon γ

Background: Melanoma inhibits macrophage tumoricidal activity and increases the expression of cyclooxygenase-2 (COX-2). In this study, we sought to determine whether inhibition of COX-2 could restore macrophage function and hence maximize the antitumor activity of the immune stimulant interferon (IFN).Methods: Peritoneal macrophages were exposed to B16 melanoma-conditioned medium for 24 hours with or without the COX-2 inhibitor NS-398 and then were stimulated with lipopolysaccharide and IFN. Cytotoxic activity, nitrite production, and cytokine production by the stimulated macrophages were measured. In addition, B16 melanoma cells were implanted intradermally into mice treated with IFN (14,000 U on alternate days) alone or with a combination of IFN and a COX-2 inhibitor (NS-398 or nimesulide). Mice were assessed for tumor growth and survival.Results: Macrophage cytotoxicity and nitrite production were significantly suppressed by melanoma-conditioned medium (P < .01). This was prevented by 200 M of NS-398 (P < .05). In vivo, combined treatment with IFN and a COX-2 inhibitor caused a significant inhibition of tumor growth (P < .01) and improved survival (P = .02) compared with controls.Conclusions: COX-2 inhibition reversed melanoma-induced suppression of macrophage function, and combined treatment of IFN plus a COX-2 inhibitor was maximally effective in reducing tumor growth and improving survival.     

Effectiveness of an intensive stress intervention workshop for senior managers

This study investigates the efficacy of an intensive, integrated approach to stress reduction and coping enhancement directed towards an educated, upper level management population. Ninety‐five US governmental senior managers participated in a 35‐h stress management retreat held over a 3.5‐day period. The retreat combined didactic and experiential activities that were designed to increase participants' knowledge of stress liabilities and coping skills. Participants were encouraged to make positive lifestyle changes and to create specific action plans for the year following the workshop. Evaluations of participant satisfaction were completed at the close of the workshop. Eighty‐three participants completed baseline and follow‐up Stress and Coping Inventory (SCI) assessments in order to identify durable changes in these measures. Across 10 months, participants showed significant improvements in their overall Global Balance scores, psychological symptoms, depression symptoms, and all major coping scales, including Health Habits, Social Support, Responses to Stress and Life Satisfactions. Therefore, an intensive, multifaceted approach to stress intervention is a viable option for encouraging sustained behavioural change. Copyright © 2003 John Wiley & Sons, Ltd.