Comparison of risk stratification with pharmacologic and exercise stress myocardial perfusion imaging: A meta-analysis

BACKGROUND: Although pharmacologic stress myocardial perfusion imaging (MPI) and exercise stress MPI have comparable diagnostic accuracy, their comparative value for risk stratification of patients with known or suspected coronary disease is not known. METHODS AND RESULTS: The data of 14,918 patients were combined from 24 studies evaluating prognosis in patients undergoing either pharmacologic stress or exercise stress MPI. Studies were included if a 2 x 2 table for hard cardiac events (cardiac death and myocardial infarction [MI]) could be constructed from the data available. Excluded were studies performed for post-MI, post-revascularization, or preoperative risk stratification. A weighted t test was used to compare the cardiac events, and a random effects model was used to calculate summary odds ratios. Summary odds ratios for hard cardiac events were similar for pharmacologic stress and exercise stress MPI. Summary receiver operating characteristic curves also showed no difference in discriminatory power between the stressors. The cardiac event rates were significantly higher with normal and abnormal test results with pharmacologic stress MPI than with exercise stress MPI (1.78% vs 0.65% [P < .001] for normal results and 9.98% vs 4.3% [P < .001] for abnormal results). Subgroup analysis revealed that both cardiac death and nonfatal MI were significantly higher with pharmacologic stress MPI. Patients undergoing pharmacologic stress MPI had a significantly higher prevalence of poor prognostic factors, and meta-regression revealed that exercise capacity was the single most important predictor of cardiac events. CONCLUSIONS: This meta-analysis shows that exercise stress MPI and pharmacologic stress MPI are comparable in their ability to risk-stratify patients. However, patients undergoing pharmacologic stress studies are at a higher risk for subsequent cardiac events. This is true even for those with normal perfusion imaging results.     

Plasma Concentrations of Mycophenolic Acid Acyl Glucuronide Are Not Associated with Diarrhea in Renal Transplant Recipients

The aim of this study was to determine whether plasma concentrations of the acyl (AcMPAG) and phenolic (MPAG) glucuronide metabolites of mycophenolic acid (MPA) were related to diarrhoea in renal transplant patients on mycophenolate mofetil (MMF) with cyclosporine (CsA) or tacrolimus (TCL). Blood samples (0, 30, 120 min) were taken at days 3, 10, week 4, months 3, 6 and 12 for determination of MPA, MPAG and AcMPAG. MPA-AUC was estimated using validated algorithms. Two hour AUCs were calculated for MPAG and AcMPAG. Immunosuppressive therapy consisted of CsA/MMF (n= 110) and of TCL/MMF (n= 180). In 70/290 (24%) patients 86 episodes of diarrhoea were recorded during 12 months. Significantly more patients on TCL (31.1%) suffered from diarrhea compared to CsA (12.7%). MMF dose, MPA-AUC and the 2 h AUCs of MPAG and AcMPAG did not differ between patients with and without diarrhoea. Plasma AcMPAG and MPAG concentrations were substantially higher in patients on CsA compared with TCL, while MPA-AUC was lower in the former group. These data support the concept that CsA inhibits the biliary excretion of MPAG and AcMPAG, thereby potentially reducing the risk of intestinal injury through enterohepatic recycling of MPA and its metabolites.     

Experimental vaccination of young chickens with a live, non-pathogenic strain of Escherichia coli

A non-pathogenic, piliated strain of Escherichia coli (BT-7; Frommer et al., 1990), isolated from a meat-type chicken flock, was studied as a candidate for a live vaccine to protect chickens from E. coli infection. Active immunization provided substantial protection of chicks vaccinated at 14 or 21 days of age, resulting in better resistance to challenge than in those vaccinated at 1 or 7 days. Chicks vaccinated at 21 days of age and challenged 1 week later with pathogenic E. coli strains 01-.K1, 02:K1 or 078:K80, exhibited good protection for at least 2 weeks against all strains. Three vaccination routes were found to give the highest resistance to challenge with pathogenic E. coli strain 078:K80. Intramuscular (i.m.) at 7 and 21 days of age, i.m. at 21 days of age and spray at 7, followed by per os at 21 days of age. Vaccination per os once at 7 or twice at 7 and 21 days resulted in good protection. Chicks exhibiting high antibody titres by ELISA were well-protected against challenge.     

Does cardiac SPECT using attenuation and scatter correction accurately predict coronary artery disease in a minority women population?

BACKGROUND: Myocardial perfusion imaging (MPI) is a well-established diagnostic method for evaluation and risk stratification of coronary artery disease (CAD).We undertook this study to validate both the positive predictive value (when compared to cardiac catheterization) and the prognosis afforded by MPI in a group of minority women patients. MATERIAL/METHODS: The database of our Nuclear Imaging and Catheterization Laboratory was retrospectively queried for consecutive minority (African-American, Hispanic and Asian) women patients who underwent MPI and cardiac catheterization within 90 days of each other. Patients with recent revascularization were excluded. Attenuation/scatter correction was utilized in the final interpretation of the study. RESULTS: Of the 54 women patients who underwent MPI, 7 underwent exercise stress testing, 26 had stress testing with adenosine, 18 with dipyridamole and 3 with dobutamine. Eighteen patients (53%) had same number of vessels predicted by MPI and coronary angiography (7 patients with triple vessel disease, 7 with 2-vessel disease and 4 with single vessel disease). Five (3 with intermediate and 2 with high risk scans) out of the 54 patients (9.3%) were dead at 2 years. The sensitivity, specificity and positive predictive value of MPI as compared to angiography were 87.2%, 26.7%, 75.6% and 44.4% respectively. CONCLUSIONS: The sensitivity of MPI in this group of patients is comparable to the general population though the specificity is lower in spite of using attenuation and scatter correction. Low risk perfusion scan signifies favorable prognosis at 2 years with regards to mortality.     

The density, contour, and thickness of the pancreas in diabetics: CT findings in 57 patients.

Insulin has a trophic effect on pancreatic acinar tissue, so the pancreas might be expected to atrophy in persons who have diabetes. Accordingly, we analyzed the density, contour (smooth or lobulated), and thickness of the pancreas on CT scans of diabetic patients and compared the results with those in control subjects. The prevalence of pancreatic lobulation (incisurae deeper than 2 mm) and its correlation with age in diabetic and control subjects were determined. The thickness of the pancreas was measured at three levels (head, body, tail). Three groups of diabetic patients were examined: 20 insulin-dependent patients, 25 patients not treated with nor dependent on insulin, and 12 patients treated with but not dependent on insulin. A control group included 57 nondiabetic patients. The ages of the control subjects were similar to those of the diabetic patients. The statistical significance of the differences between groups of diabetic patients and control subjects was estimated by using Student's t test for the values of density and thickness and the chi 2-test for the prevalence of pancreatic lobulation. The density of the pancreas in diabetic patients and control subjects was not statistically different. Diabetic patients had increased lobulation of the pancreas. All parts of the pancreas tended to be smaller in diabetic patients, but the degree of reduction varied. It was modest in the patients not treated with insulin, pronounced in insulin-dependent patients, and intermediate in non-insulin-dependent, insulin-treated patients. Moreover, the size of the body was significantly reduced in all three groups, whereas the size of the pancreatic head was preserved in patients not treated with insulin. In conclusion, CT of the pancreas shows that although density in diabetic patients is normal, lobulation is increased. Reduction in size involves the body of the pancreas more than other parts of the gland and is more pronounced in insulin-treated diabetic patients. CT of the pancreas might be useful to predict which diabetic patients will require insulin therapy.