Course of depressive symptoms and medication adherence after acute coronary syndromes: an electronic medication monitoring study.

OBJECTIVES: We tested whether improvements in depressive symptoms precede improved adherence to aspirin in patients with acute coronary syndromes (ACS). BACKGROUND: Depression is associated with medication nonadherence in patients with ACS, but it is unclear whether changes in depression impact on adherence. METHODS: Electronic medication monitoring was used to measure adherence to aspirin during a 3-month period in a consecutive cohort of 172 patients (25 to 85 years) recruited within 1 week of hospitalization for ACS. Depressive symptom severity was assessed using the Beck Depression Inventory (BDI) during hospitalization and at 1 and 3 months after hospitalization. Adherence was defined as the percentage of days aspirin was taken as prescribed. RESULTS: Depression severity in hospital was associated with nonadherence in a gradient fashion: 15% of non-depressed patients (BDI score 0 to 4), 29% of mildly depressed patients (BDI score 10 to 16), and 37% of patients with moderately-to-severely depressive symptoms (BDI score >16) took aspirin less than 80% of the time (p = 0.03). A cross-lagged path analytic model revealed that improvements in depressive symptoms in the first month after the ACS were associated with improvements in adherence rates in the subsequent 2 months (standardized direct effect -0.32, p = 0.016). CONCLUSIONS: Diagnosis and treatment of depressive symptoms may improve medication adherence in patients after ACS.     

Use of stereotactic PET images in dosimetry planning of radiosurgery for brain tumors: clinical experience and proposed classification.

We developed a technique that allows the routine integration of PET in stereotactic neurosurgery, including radiosurgery. We report our clinical experience with the combined use of metabolic (i.e., PET) and anatomic (i.e., MRI and CT) images for the radiosurgical treatment of brain tumors. We propose a classification describing the relative role of the information provided by PET in this multimodality image-guided approach. METHODS: Between December 1999 and March 2003, 57 patients had stereotactic PET as part of their image acquisition for the planning of gamma knife radiosurgery. Together with stereotactic MRI and CT, stereotactic PET images were acquired on the same day using either (18)F-FDG or (11)C-methionine. PET images were imported in the planning software for the radiosurgery dosimetry, and the target volume was defined using the combined information of PET and MRI or CT. To analyze the specific contribution of the PET findings, we propose a classification that reflects the strategy used to define the target volume. RESULTS: The patients were offered radiosurgery with PET guidance when their tumor was ill-defined and we anticipated some limitation of target definition on MRI alone. This represents 10% of the radiosurgery procedures performed in our center during the same period of time. There were 40 primary brain lesions, 7 metastases, and 10 pituitary adenomas. Abnormal PET uptake was found in 62 of 72 targets (86%), and this information altered significantly the MRI-defined tumor in 43 targets (69%). CONCLUSION: The integration of PET in radiosurgery provides additional information that opens new perspectives for the optimization of the treatment of brain tumors.     

Long-term risk of second malignant neoplasm after a cancer in childhood

The risk of subsequent second malignant neoplasm was studied in a cohort of 634 patients, treated for a childhood cancer at the Gustave Roussy Institute between 1942 and 1969, and in complete remission five years after diagnosis. The most frequent types of first primary cancers (FPC) were Wilms' tumours (28% of the children), neuroblastomas (16%), lymphomas (12%) and soft tissue sarcomas (11%). Median follow-up duration after FPC was 19 years. Thirty-two patients (obs = 32) developed a total of 35 second cancers. Bone, thyroid, connective tissues and skin were the most frequent types of second cancer, with six patients for each type. The average annual incidence of second cancer was 0.36%. The average annual incidence for the periods 5-9, 10-14, 15-19, 20-24 and 25+ years after FPC was respectively 0.16%, 0.34%, 0.36%, 0.71% and 1.18%. The cumulative incidence of second cancer for the periods 5-20, 5-25 and 5-30 years after FPC was, respectively, 4.3% (95% CI: 2.8-6.6%), 7.8% (95% CI: 5.1-11.8%) and 13.0% (95% CI: 8.2-20.0%). The expected number of cancers in the cohort, computed from Danish cancer incidence data, was exp = 2.2. When compared to this expected number, the average annual excess incidence of second cancer, defined as obs-exp divided by the number of person years of observation, was 0.33%. This rose from 0.15% for the period 5-9 years after FPC to 1.09% for the period beginning 25 years after FPC. The standardised incidence ratio of second cancer (i.e. obs/exp) was 15 (95% CI: 10-21), and was fairly constant in the period extending from 15 to 20 years after FPC diagnosis. Obs/exp was equal to 25 for the patients who had had chemotherapy and equal to 9 for those who had not. Cyclophosphamide seemed less carcinogenic than the other alkylating agents. Obs/exp was similar for the patients who had received radiotherapy and for those who had not. The risk of cancer increased with age in the reference population and increased faster in the cohort, because the standardised incidence ratio is constant over a long period.     

Sex-dependence of the relative number of elastic fibres in human heart valves.

The aim of the current study was to find out whether there are sex-dependent differences in the relative number of elastic fibres in human heart valves. Twenty-six aortic valves, 26 mitral valves, 33 pulmonary valves and 28 tricuspid valves of both sexes were obtained at autopsy from newborn to 89-year-old patients who died of noncardiac diseases. The quantitatively morphometric investigations were carried out on conventionally stained (Resorcinfuchsin) histological sections. The results were qualitatively examined with immuno-histochemically marked (anti-elastin antibodies) histological sections. Earlier examinations by Leutert [1976. Z. Gesamte Inn. Med. 31, 97-104] showed that the atrioventricular valves have the following layers: endothelium, atrial fibroelastic tissue (S1), fibrous tissue, ventricular fibroelastic tissue (S2) and endothelium. In our study, the ventricular side of the semilunar valves corresponds to side S1, whereas the vessel side corresponds to side S2. Three regions of interest were examined on each side of the valves: base, mid and tip. The number of elastic fibres per measuring area for all four human heart valves was significantly higher (p < 0,001) in fibroelastic tissue of side S1 than in fibroelastic tissue of side S2. Neither on side S1 nor on side S2 were there significant gender-related differences in the relative number of elastic fibres per measuring area. The results suggest a characteristic distribution of the elastic fibre system which is not sex-dependent but closely related to the function of the heart valves.     

Looking for resilience: Understanding the longitudinal trajectories of responses to stress

Taking advantage of two large, population-based, and longitudinal datasets collected after the 1999 floods in Mexico (n = 561) and the September 11, 2001 terrorist attacks in New York (n = 1267), we examined the notion that resilience may be best understood and measured as one member of a set of trajectories that may follow exposure to trauma or severe stress. We hypothesized that resistance, resilience, recovery, relapsing/remitting, delayed dysfunction, and chronic dysfunction trajectories were all possible in the aftermath of major disasters. Semi-parametric group-based modeling yielded the strongest evidence for resistance (no or mild and stable symptoms), resilience (initially moderate or severe symptoms followed by a sharp decrease), recovery (initially moderate or severe symptoms followed by a gradual decrease), and chronic dysfunction (moderate or severe and stable symptoms), as these trajectories were prevalent in both samples. Neither Mexico nor New York showed a relapsing/remitting trajectory, and only New York showed a delayed dysfunction trajectory. Understanding patterns of psychological distress over time may present opportunities for interventions that aim to increase resilience, and decrease more adverse trajectories, after mass traumatic events.     

Selective laser trabeculoplasty in phakic and pseudophakic eyes.

BACKGROUND AND OBJECTIVE: To evaluate the effect of pseudophakia on the success of selective laser trabeculoplasty in lowering intraocular pressure (IOP). PATIENTS AND METHODS: In this retrospective, nonrandomized clinical trial, a chart review of all patients who underwent selective laser trabeculoplasty from September 2002 to June 2004 using a frequency-doubled Q-switched 532-nm Nd:YAG laser was performed. Changes in IOP and statistical significance were determined at each follow-up period. Average decrease in IOP and success rates for phakic and pseudophakic eyes were compared statistically at each time period. RESULTS: In the phakic group, mean IOP decreased from 18.1 to 15.5 mm Hg (P < .0005) and mean glaucoma medication use decreased from 2.1 to 1.6 medications after 24 months of follow-up. In the pseudophakic group, mean IOP decreased from 18.3 to 15.2 mm Hg (P < .005) and mean glaucoma medication use decreased from 2.2 to 1.6 medications. Success rates ranged from 54% to 67% in the phakic group and 52% to 65% in the pseudophakic group. No statistically significant difference between phakic and pseudophakic eyes in decreased IOP or success rates was seen at any time point (P > .05). No significant complications occurred in either group. CONCLUSIONS: Selective laser trabeculoplasty is effective in lowering IOP in both phakic and pseudophakic patients.     

Radionuclide imaging in the diagnosis of hernias related to peritoneal dialysis

Abdominal hernias are noted with increasing frequency in association with peritoneal dialysis as this mode of dialysis becomes increasingly popular. These hernias often present as localized groin edema, without evidence of a mass, on physical examination. Diagnosis is more difficult when the edema encompasses both groins. Radionuclide imaging peritoneography offers a safe, simple, well-tolerated, highly accurate method of localizing peritoneal defects. We used this method to locate and lateralize inguinal hernias in three patients receiving continuous ambulatory peritoneal dialysis who presented with bilateral scrotal edema and who had unrevealing physical examination findings. All three had unilateral, indirect inguinal herniorrhaphies under local anesthesia and have returned successfully to peritoneal dialysis without complication.