Detection of defects in myocardial perfusion imaging in patients with early breast cancer treated with radiotherapy.

BACKGROUND AND PURPOSE: To evaluate radiation-induced defects in myocardial perfusion imaging in early breast cancer patients treated with modern technique radiotherapy. PATIENTS AND METHODS: Twenty-four patients with left-breast tumours and 12 control patients with right-breast tumours, relapse-free since treatment for primary disease, who had undergone radiotherapy at least 5 years previously and with no history of ischaemic heart disease prior to radiotherapy underwent study. In left-breast patients, at least 1 cm of heart was required to have been in the treatment field. Patients underwent cardiac assessment and single photon emission computerized tomography myocardial perfusion imaging. RESULTS: Myocardial perfusion tracer uptake was abnormal in 17 (70.8%) left-breast and two (16.7%) right-breast patients (P = 0.002). Of the 17 abnormal scans in left-breast patients, abnormalities were confined to the cardiac apex in 16 patients, and perfusion defects were reversible (n = 7), fixed (n = 7) or mixed (n = 3). Reversible perfusion defects that were not confined to the cardiac apex were observed in two right-breast patients. Left ventricular ejection fraction was normal in all 33 patients in whom it was measured, and no myocardial perfusion abnormalities were judged to require treatment or follow-up. CONCLUSIONS: In this selected study population modern technique radiotherapy to the left breast was associated with a significantly greater number of myocardial perfusion abnormalities than radiotherapy to the right breast. These abnormalities were both reversible and irreversible, suggesting that radiotherapy can lead to both myocardial damage and to epicardial coronary disease. With a minimum of 5 years follow-up since treatment, no abnormalities were considered to be clinically significant.     

Association of CFH Y402H and LOC387715 A69S with progression of age-related macular degeneration

Context  Studies have reported that single-nucleotide polymorphisms in the genes CFH and LOC387715 are associated with age-related macular degeneration (AMD). Objective  To assess whether these genetic variants have prognostic importance for progression to advanced AMD and related visual loss. Design, Setting, and Participants  Prospective analysis of 1466 white participants in the Age-Related Eye Disease Study (AREDS), a US multicenter clinical trial conducted from 1990 to 2001 with a mean follow-up time of 6.3 years. Age-related macular degeneration status was determined by grading of fundus photographs. Progression (n = 281) was defined as newly diagnosed advanced AMD (geographic atrophy, exudative disease, or AMD causing visual loss) in one or both eyes during the course of the study. Genotypic analysis was conducted in 2006. Main Outcome Measure  Incidence rates of dry and neovascular advanced AMD. Results  The CFH Y402H and LOC387115 A69S polymorphisms were each independently related to progression from early or intermediate stages to advanced stages of AMD, controlling for demographic factors, smoking, body mass index, and AREDS vitamin-mineral treatment assignment, with odds ratios (ORs) of 2.6 (95% confidence interval [CI], 1.7-3.9) for CFH and 4.1 (95% CI, 2.7-6.3) for LOC387715 for the homozygous risk genotypes (P<.001 for trend for each additional risk allele for both genes). The effect of LOC387715 was stronger for progression to neovascular disease (OR, 6.1; 95% CI, 3.3-11.2) compared with geographic atrophy (OR, 3.0; 95% CI, 1.4-6.5) relative to no progression for the homozygous risk state. The presence of all adverse factors (both risk genotypes, smoking, and body mass index 25) increased risk 19-fold. Smoking and high body mass index increased odds of progression within each risk genotype. Genetic plus nongenetic risk scores provided an area under the receiver operating characteristic curve of up to 0.78. Conclusions  Common polymorphisms in the genes CFH and LOC387715 are independently related to AMD progression after adjustment for other known AMD risk factors. Presence of these polymorphisms plus AREDS vitamin-mineral treatment, smoking, and body mass index of 25 or higher identify patients who are highly susceptible to developing advanced stages of this visually disabling disease.      

A fat lot of good: balance and trends in fat intake in children with cystic fibrosis

BackgroundThe fundamental nutritional treatment of a high fat diet for cystic fibrosis (CF) is established and essentially unchanged in the last 25 years. However, recent concerns have emerged regarding the potential risks of such a diet. We investigated the diets of children with CF to determine the source of energy, energy imbalance, and changing trends of fat intake.MethodIn a prospective longitudinal study over 8 years at a single paediatric CF clinic three-day food diaries that included supplementary nutrition (SN) either as enteral feeds or oral nutritional supplements (ONS), were analysed annually. Influence of year on percent energy by type (fat, carbohydrate and protein) and on fat component: saturated (SFA); monounsaturated (MUFA) and polyunsaturated fatty acids (PUFA) was examined.Results136 food diaries were analysed in 27 children (age range 1–18 years). 51 (37%) food diaries included SN (enteral feeds n = 15 and ONS n = 36). Mean energy intake was 1726 Kcals (oral diet alone) and 2245 Kcals (including SN). Percent energy from macronutrients did not change significantly over time (protein p = 0.06; carbohydrate p = 0.44; fat p = 0.07) and remained within recommended levels. Mean caloric contribution from fat was 38.7% from oral diet alone and 37.8% including SN. Percent energy derived from SFA remained statistically unchanged (SFA p = 0.57) but fell from MUFA (p = 0.05) and PUFA (p = 0.004). Mean SFA consistently contributed > 134% (mean 158%) of reference nutrient intake and mean PUFA intake < 100% (92%).ConclusionMacronutrient intakes did not change significantly in our population of CF children, but there was a consistent imbalance of fat-sources with over-dependence on saturated fats which, in the context of increased survival in CF may potentially increase risk of cardiovascular disease. Further studies are needed to confirm our findings, investigate consequences of fat imbalance and guide clearer advice regarding appropriate proportions of sources of fat for CF patients.     

Why do child contacts of multidrug-resistant tuberculosis not come to the assessment clinic?

Background:

Local policy advises that children exposed to multidrug-resistant tuberculosis (MDR-TB) should be assessed in a specialist clinic. Many children, however, are not brought for assessment.

Methods:

Focus group discussion was used to design appropriate questionnaires. From 1 September 2011, the first 50 children referred to the specialist paediatric MDR-TB clinic, Cape Town, South Africa, and who attended their clinic appointment, were recruited. The first 50 children who were referred but who did not attend were concurrently identified, traced and recruited. Differences in group characteristics were compared.

Results:

The median age of the children was 35 months: 48 (48%) were boys, 4 (4%) were human immunodeficiency virus infected and 47 (47%) were of coloured ethnicity. Factors significantly associated with non-attendance at the MDR-TB clinic were: Coloured ethnicity (OR 2.82, 95%CI 1.21–6.59, P = 0.01), the mother being the source case (OR 3.78, 95%CI 1.29–11.1, P = 0.02), having a smoker resident in the house (OR 2.37, 95%CI 1.01–5.57, P = 0.04), the time (P = 0.002) and cost (P = 0.03) required to get to the specialist clinic, and fear of infection whilst waiting to be seen (OR 2.45, 95%CI 1.07–5.60, P = 0.03).

Conclusions:

Reasons for non-attendance at paediatric MDR-TB clinic appointments are complex and are influenced by demographic, social, logistical and cultural factors.     

Decentralised care for the management of child contacts of multidrug-resistant tuberculosis

Setting:

Cape Town, South Africa.

Objective:

To determine the number of multidrug-resistant tuberculosis (MDR-TB) child contacts routinely identified by health services, and whether a model of decentralised care improves access.

Methods:

All MDR-TB source cases registered in Cape Town from April 2010 to March 2011 were included. All child contacts assessed at hospital and outreach clinics were recorded from May 2010 to June 2011. Electronic probabilistic matching was used to match source cases with potential child contacts; the number of children accessing decentralised (Khayelitsha) and hospital-based care was compared.

Results:

Of 1221 MDR-TB source cases identified, 189 (15.5%) were registered in Khayelitsha; 31 (16.4%) had at least one child contact assessed. In contrast, 95 (9.2%) of the 1032 source cases diagnosed in the other Cape Town subdistricts (hospital-based care) had at least one child contact assessed (P = 0.003). Children in Khayelitsha were seen at a median of 71 days (interquartile range [IQR] 37–121 days) after source case diagnosis compared to 90 days (IQR 56–132 days) in other subdistricts (P = 0.15).

Conclusion:

Although decentralised care led to an increased number of child contacts being evaluated, both models led to the assessment of a small number of potential child MDR-TB contacts, with considerable delay in assessment.