Predictive value of preoperative tests in discriminating bilateral adrenal hyperplasia from an aldosterone-producing adrenal adenoma

In primary hyperaldosteronism, discriminating bilateral adrenal hyperplasia (BAH) from an aldosterone-producing adenoma (APA) is important because adrenalectomy, which is usually curative in APA, is seldom effective in BAH. We analyzed the results from our most recent 7-yr series to evaluate the predictive value of preoperative noninvasive tests compared with adrenal vein sampling (AVS). Forty-eight patients with hypertensive hyperaldosteronism underwent bedside testing, computed tomography (CT) imaging, and AVS. Those in whom the results of AVS indicated APA underwent adrenalectomy. Twelve (30%) and 14 (34%) of 41 patients with APA had paradoxical falls with ambulation in plasma aldosterone concentration (PAC) and 18-hydroxycorticosterone (18-OH-B), respectively. Twenty-nine (70%) and 26 (65%) APA patients had a rise in PAC and 18-OH-B, respectively, as did all 8 BAH patients. Significant identifiers of BAH were supine PAC values less than 15 ng/dL (P: = 0.04), an increase greater than 60% (P: = 0.02) in PAC with ambulation, and supine 18-OH-B values less than 60 ng/dL (P: = 0.04). CT imaging alone was not predictive for BAH or APA. In our population, patients with a positive bedside test result (e.g. a fall in PAC and/or 18-OH-B) and a unilateral adrenal nodule on CT (10 of 41 patients) could have proceeded directly to adrenalectomy for APA. However, a positive bedside test result with a negative CT or a negative bedside test result regardless of CT findings required AVS to confirm the diagnosis and site of disease.     

Use and referral patterns for 22 complementary and alternative medical therapies by members of the American College of Rheumatology: results of a national survey

BACKGROUND: This study was designed to determine rheumatologists' self-reported knowledge, perceptions of legitimacy, referral patterns, and use in practice of 22 complementary and alternative medicine (CAM) therapies. METHODS: A survey was mailed to a random sample of 2000 physician members of the American College of Rheumatology asking respondents which (if any) CAM therapies they (1) knew enough about to discuss with patients, (2) considered part of "legitimate medical practice," and (3) "personally administered" to patients, or "referred patients to someone else" to administer. The response rate was 47%. RESULTS: On average, the respondents reported knowing enough to discuss 10 of the therapies with patients, considered 9 to be part of legitimate medical practice, and had referred patients to someone else for 8 of the 22 therapies. Correlates of use and/or referral included sex, age, belief in the legitimacy of the therapies, and self-reported knowledge. CONCLUSIONS: These results provide potentially important preliminary data regarding rheumatologists' responses to dramatic increases in the use of CAM therapies among their patients.     

Noninvasive strategies for the estimation of cardiac risk in stable chest pain patients. The Economics of Noninvasive Diagnosis (END) Study Group

Effective allocation of medical resources in stable chest pain patients requires the accurate diagnosis of coronary artery disease and the stratification of future cardiac risk. We studied the relative predictive value for cardiac death of 3 commonly applied noninvasive strategies, clinical assessment, stress electrocardiography, and myocardial perfusion tomography, in a large, multicenter population of stable angina patients. The multicenter observational series comprised 7 community and academic medical centers and 8,411 stable chest pain patients. All patients underwent pretest clinical screening followed by stress (exercise 84% or pharmacologic 16%) electrocardiography and myocardial perfusion tomography. Risk-adjusted multivariable Cox proportional hazards models were developed to predict cardiac death. Kaplan-Meier rates of time to cardiac catheterization were also computed. Cardiac mortality was 3% during the 2.5 +/- 1.5 years of follow-up. The number of infarcted vascular territories and pretest clinical risk factors were strong predictors of cardiac mortality, whereas the number of ischemic vascular territories gained increasing importance when determining post-test resource use requirements (i.e., the decision to perform cardiac catheterization). Exertional ST-segment depression in a population with a high frequency of electrocardiographic abnormalities at rest was not a significant differentiator of cardiac death risk. Stable chest pain patients are accurately identified as being at high risk for near-term cardiac events by both physicians' screening clinical evaluation and by the results of stress myocardial perfusion imaging. Disease management strategies for stable chest pain patients aimed at risk reduction should incorporate knowledge of relevant end points in treatment and guideline development.     

Myocardial salvage by intracoronary thrombolysis in evolving acute myocardial infarction: evaluation using intracoronary injection of thallium-201

Immediate objective assessment of viabillty of reperfused myocardium following intracoronary (IC) thrombolysis by evaluation of ventricular function may be limited due to delay in restoration of function. Thus we assessed myocardial uptake of thallium-201 (TI-201) following IC injection postreperfusion as an index of myocardial salvage in 12 experimental dogs and in five patients with evolving acute myocardial infarction (AMI). In seven dogs with mean of 313 minutes of experimental coronary occlusion, immediate postreperfusion IC TI-201 images revealed absence of myocardial uptake in prevlously occluded zones. These TI-201 defects correlated with presence of necrosis as demonstrated by histochemical staining with triphenyl-tetrazolium chloride (TTC). In contrast, in five dogs with mean of 37 minutes of coronary occlusion, reperfused myocardium showed normal TI-201 uptake following its IC injection; this normal TI-201 uptake pattern correlated with absence of necrosis by TTC technique in all five dogs. In five patients with evolving AMI, control TI-201 images obtained following IV injection prior to IC thrombolysis showed myocardial perfusion defects corresponding to distribution of the occluded vessel. Following reperfusion, 30 to 50 mCi of TI-201 was injected into the reopened coronary artery. In two patients with mean symptom onset of reperfusion time of $\text{2}\text{1}\text{2}\text{hours}$, immediate postreperfusion IC TI-201 images demonstrated normal or improved TI-201 uptake in reperfused myocardium. By radionuclide ventriculography, segmental wall motion remained abnormal in the reperfused regions 6 hours postreperfusion and showed improvement by the time of 10-day study. In the remaining three patients with symptom onset to reperfusion time of 5 hours, immediate postreperfusion IC TI-201 images did not show improvement, correlating with persistent wall motion abnormalities 10 days postreperfusion. In all five patients, repeat 10-day IV TI-201 images were unchanged from the immediate postreperfusion IC TI-201 images. We conclude that (1) prereperfusion TI-201 imaging with repeat TI-201 injection into the reopened coronary artery appears to delineate the extent of myocardial salvage in both experimental and clinical studies and (2) this method of IC TI-201 imaging allows immediate assessment of myocardial viabillty which may facilltate decisions regarding the need for additional myocardial revascularization modalities.     

An economic analysis of an aggressive diagnostic strategy with single photon emission computed tomography myocardial perfusion imaging and early exercise stress testing in emergency department patients who present with chest pain but nondiagnostic electrocardiograms: results from a randomized trial

STUDY OBJECTIVE: Conventional emergency department testing strategies for patients with chest pain often do not provide unequivocal diagnosis of acute coronary syndromes. This study was conducted to determine whether the routine use of single photon emission computed tomography (SPECT) imaging at rest and early exercise stress testing to assess intermediate-risk patients with chest pain and no ECG evidence of acute ischemia will lead to earlier discharges, more discriminate use of coronary angiography, and an overall reduction in average costs of care with no adverse clinical outcomes. METHODS: All patients in this study had technetium 99m tetrofosmin SPECT imaging at rest and were randomly assigned to either a conventional (results of the imaging test blinded to the physician) or perfusion imaging-guided (results of the imaging test unblinded to the physician) strategy. Patients in the conventional arm were treated at their physician's discretion. Patients in the perfusion imaging-guided arm were treated according to a predefined protocol based on SPECT imaging test results: coronary angiography after a positive scan result and exercise treadmill testing after a negative scan result. Study endpoints consisted of total in-hospital costs and length of stay. Hospital costs were calculated using hospital department-specific Medicare cost/charge ratios. Length of stay was calculated as total hospital room days billed (regular and intensive care). RESULTS: We enrolled 46 patients, 9 with acute myocardial infarctions. Patients randomly assigned to the perfusion imaging-guided arm had $1,843 (95% confidence interval [CI] $431 to $6,171) lower median in-hospital costs and 2.0-day (95% CI 1.0 to 3.0 days) shorter median lengths of stay but similar rates of in-hospital and 30-day follow up events as patients in the conventional arm. CONCLUSION: An ED chest pain diagnostic strategy incorporating acute resting (99m)Tc tetrofosmin SPECT imaging and early exercise stress testing may lead to reduced in-hospital costs and decreased length of stay for patients with acute chest pain and nondiagnostic ECGs.     

Amplification of the dihydrofolate reductase gene is a mechanism of acquired resistance to methotrexate in patients with acute lymphoblastic leukemia and is correlated with p53 gene mutations

Although dihydrofolate reductase (DHFR) gene amplification is a common mechanism of resistance to methotrexate (MTX) in tumor cell lines, with the exception of a few case reports, the incidence of this phenomenon as a mechanism of MTX resistance in the clinic has not been reported. We studied 38 untreated patients and 29 patients in relapse with acute lymphoblastic leukemia (ALL) for gene amplification and p53 gene mutations. Three patients were studied both at diagnosis and at each of two relapses after treatment with MTX. Nine of 29 relapsed patients (31%) had low-level DHFR gene amplification (two to four gene copies) associated with increased levels of DHFR mRNA and enzyme activity. Of significance was a correlation of gene amplification with p53 mutations in seven of nine relapsed patients (P < .001). Low-level DHFR gene amplification may be an important cause of MTX resistance in ALL and strengthens the concept that mutations in the p53 gene may lead to gene amplification as a consequence of defective cell cycle control.     

Nurse attitudes towards the use of complementary and alternative therapies in critical care

BACKGROUND: There is increasing demand for complementary/alternative therapies (CAT) in critical care, however, critical care nurses' perspectives regarding CAT are unknown. OBJECTIVES: This study was conducted to determine critical care nurses' knowledge, attitudes, and use of CAT. SAMPLE/SETTING: A total of 348 critical care registered nurses working at least 40% in medical, surgical, cardiac, neurological, and pediatric ICUs at 2 tertiary-level hospitals in a large Midwestern city were surveyed. One hospital is a 926-bed private, urban hospital and the second is an 1868-bed academic-affiliated medical center. METHODS: A survey was distributed to all critical care nurses described above. RESULTS: The level of knowledge reported by 138 nurse respondents was greatest for diet, exercise, massage, prayer, and music therapy. Use of therapies was related to knowledge and training and consistent with beliefs of legitimacy and perceptions of beneficial effects. Despite barriers including lack of knowledge, time, and training, 88% of respondents were open or eager to use CAT, and 60% reported moderate or greater desire to use CAT. CONCLUSIONS: Critical care nurses are open to CAT use and many use them in their own practice. Because use was associated with knowledge, recommendations for future research include increasing the scientific base and enhancing knowledge to promote evidence-based incorporation of CAT in practice.     

Demographic and dietary predictors of urinary bisphenol A concentrations in adults in Israel

Background

To date, there is scarce data on levels of exposure to bisphenol A (BPA) in the general population in Israel and the region. The goal of the current study was to measure urinary levels of BPA in the general adult population in Israel and to determine the demographic and dietary predictors of exposure.

Methods

We recruited 249 individuals (ages 20–74) from five different regions in Israel. We collected urine samples and questionnaire data including detailed dietary data and analyzed urine samples for BPA concentrations.

Results

Eighty nine percent of the study population had urinary BPA concentrations equal to or above the level of quantification (0.3 μg/L). Median creatinine adjusted BPA urinary concentrations in the study population (2.3 μg/g) were slightly higher than those reported for the general population in the US (1.76 μg/g) and Canada (1.47 μg/g), and were comparable to those reported for the general population in Belgium (2.25 μg/g) and Korea (2.09 μg/g). BPA concentrations were higher in Jews compared to Arab and Druze (prevalence ratio (PR) = 2.34; 95%CI 1.56–3.49), in individuals with higher education (PR = 1.70, 1.11–2.62), in individuals consuming mushrooms (PR = 2.08, 1.07–4.05), and in smokers (PR = 1.43, 1.00–2.05).

Conclusions

We found that the general adult population in Israel is widely exposed to BPA. Our findings on higher BPA levels in Jews compared to Arabs and Druze and in individuals with higher education highlights the fact that predictors of BPA exposure vary across populations.     

Can a Minimal Intervention Reduce Secondhand Smoke Exposure Among Children with Asthma from Low Income Minority Families? Results of a Randomized Trial

We report on the results of a low-intensity behavioral intervention to reduce second hand smoke (SHS) exposure of children with asthma from low income minority households in Los Angeles, California. In this study, 242 child/adult dyads were randomized to a behavioral intervention (video, workbook, minimal counseling) or control condition (brochure). Main outcome measures included child’s urine cotinine and parental reports of child’s hours of SHS exposure and number of household cigarettes smoked. Implementation of household bans was also considered. No differences in outcomes were detected between intervention and control groups at follow-up. Limitations included high attrition and low rates of collection of objective measures (few children with urine cotinine samples). There continues to be a need for effective culturally and linguistically appropriate strategies that support reduction of household SHS exposure among children with asthma in low income, minority households.