Differential diagnosis of cardiac masses using contrast echocardiographic perfusion imaging

OBJECTIVES: We investigated the usefulness of echocardiographic contrast perfusion imaging in differentiating cardiac masses. BACKGROUND: Two-dimensional echocardiography is the primary diagnostic modality for cardiac masses. However, differentiation between the different types of cardiac masses may be difficult at times. We hypothesized that echocardiographic contrast perfusion imaging would differentiate the neo-vascularization of malignancies from the avascularity of thrombi and the sparse vascularity of stromal tumors. METHODS: Sixteen patients with cardiac masses underwent power-modulation imaging after echocardiographic intravenous contrast administration. Pixel intensities in the mass and an adjacent section of myocardium were analyzed visually and by dedicated software. All masses had a pathologic diagnosis or resolved after anticoagulation. In a subset of patients, video-intensity curves of contrast replenishment in the mass and myocardium over time were generated. The post-impulse steady-state pixel intensity (A) and initial rate of contrast replenishment after impulse (beta) were compared with an index of blood vessel area on pathology. RESULTS: In seven of 16 patients, contrast enhancement resulted in greater pixel intensity in the mass than in the adjacent myocardium. All of these masses were classified pathologically as malignant (n = 6) or benign and vascular (n = 1). Nine masses demonstrated decreased pixel intensity, compared with the myocardium, and were diagnosed pathologically as myxomas (n = 2) or thrombi (n = 5), or they resolved with anticoagulation (n = 2). For the subset of patients, beta correlated with the vessel area index (r = 0.60). CONCLUSIONS: Echocardiographic contrast perfusion imaging aids in the differentiation of cardiac masses. Compared with the adjacent myocardium, malignant and vascular tumors hyper-enhanced, whereas stromal tumors and thrombi hypo-enhanced.     

Suicidality among nonadherent patients living with HIV in Buenos Aires,Argentina: prevalence and correlates

Of those in the general population hospitalized for suicidal ideation and suicide attempts in Argentina, many reattempt suicide and are readmitted. However, few studies in Argentina have examined suicidal ideation and suicide-related behaviors among people living with HIV (PLHIV) and none have examined these factors among nonadherent PLHIV, though the prevalence of suicidal ideation in this group may be higher than in the general population and also than in other groups of PLHIV. This study of PLHIV in Buenos Aires, Argentina, examined the correlates of suicidal ideation in nonadherent PLHIV. Nonadherent patients with HIV (N?=?118) were recruited from two clinics providing outpatient healthcare services to PLHIV in Buenos Aires, Argentina. Participants completed assessments on demographic characteristics, depression and suicidality, stigma, and self-efficacy. Participants were HIV-infected men (51%) and women (49%) with a median age of 40 years (IQR?=?11). About half had completed high school or more, two-thirds were employed, and had a mean monthly income of 4196.79 (SD?=?3179.64) Argentine pesos (USD$221). Thirty-three (28% [95% CI 20.3, 37.3]) participants reported suicidal ideation in the past two weeks, and one-third (35.6% [27.1, 44.9]) reported lifetime suicidal ideation. In bivariate analyses, attending a public clinic, being female, younger, unemployed, and experiencing greater stigma and depression were associated with suicidal ideation. In multivariable logistic regression, stigma interacted with the number of years since HIV diagnosis to predict suicidal ideation. The impact of stigma on suicidal ideation decreased with time since HIV diagnosis, suggesting that suicidal ideation may arise following HIV diagnosis due to perception of HIV-related stigma. Interventions to reduce perceived stigma during the period following HIV diagnosis may reduce suicidal ideation in this population. Organizational initiatives that explore HIV stigma microagressions in the healthcare setting may be needed to optimize health outcomes.     

Biplane stress echocardiography using a prototype matrix-array transducer.

BACKGROUND: Rapid image acquisition after cessation of exercise is essential for accurate stress echocardiography. Recently, a prototype matrix-array transducer has been developed that allows simultaneous acquisition of 2 imaging planes (biplane [BP] imaging). METHODS: In all, 19 healthy volunteers underwent 2 separate stress echocardiographic studies. Images were acquired in traditional 2-dimensional or BP format pre-exercise and postexercise. RESULTS: Total image acquisition time for 2-dimensional stress echocardiography was 38 +/- 8 seconds versus 29 +/- 8 seconds for BP imaging (P <.05). Heart rates were acquired closer to age-predicted maximum with BP imaging in the apical 3- and 2-chamber and parasternal long- and short-axis views (82%, 75%, 70%, 70% for BP vs 76%, 72%, 68%, 66% for 2-dimensional, respectively). CONCLUSION: BP imaging using a recently developed matrix-array probe allows more rapid imaging postexercise, resulting in acquisition of poststress images at higher heart rates without compromising image quality.     

Value of placental microbial evaluation in diagnosing intra-amniotic infection

OBJECTIVE: To evaluate the ability of microbiologic and pathologic examination of the placenta to accurately diagnose intraamniotic infection and inflammation. METHODS: One hundred eighty-three women with a clinically indicated amniocentesis were enrolled prospectively. We applied our analysis to 56 women with evidence of preterm labor or preterm premature rupture of membranes who delivered within 48 hours of amniotic fluid testing results. Twenty-three patients, assessed for fetal lung maturity in the third trimester, served as controls. Amniotic fluid was cultured for aerobic, anaerobic, Ureaplasma, and Mycoplasma species. We used mass spectrometry to assess the degree of intraamniotic inflammation (Mass Restricted scoring). After delivery, microbiologic and histologic studies of the placenta were performed. These results were interpreted in comparison with the direct microbiologic and inflammatory analysis of the amniotic fluid. A sample size of 45 patients was required to show a test accuracy of 80% or more. RESULTS: Ninety-two percent of women with positive amniotic fluid cultures tested with at least one positive placenta culture. Eighty percent of women who had negative amniotic fluid cultures also tested with a positive placenta culture. The accuracy of placental cultures in predicting amniotic fluid infection varied from 44% to 57%. Placental pathology showed an accuracy of only 58% in diagnosing intraamniotic inflammation. CONCLUSION: Placental microbiologic and histologic studies poorly reflect the infectious and inflammatory status of the amniotic fluid. Results of such studies should be interpreted with caution in the management and future counseling of women with preterm labor or preterm premature rupture of membranes. LEVEL OF EVIDENCE: II.     

Minimally disruptive decompression and transforaminal lumbar interbody fusion.

BACKGROUND: Posterior spinal procedures through tubular exposures have been described. However, tubes restrain visibility and require co-axial instrument manipulation, increasing difficulty and potentially compromising surgical results. An independent-blade retractor system overcomes the obstacles of working through a tube and has been used to perform minimally-disruptive decompression and instrumented tranforaminal lumbar interbody fusion (TLIF). PURPOSE: To evaluate the advantages to patient recovery and surgical efficacy of this technique. METHODS/RESULTS: Retrospective review of technique employing a minimally-disruptive approach to decompression and transforaminal lumber interbody fusion (TLIF). CONCLUSIONS: Minimally-disruptive decompression and instrumented TLIF can be performed in a safe and effective manner using an independent-blade retractor system. Relative to traditional-open techniques, surgical goals can be accomplished, but with the benefits of minimally-disruptive surgery.     

A meta-analytic review of psychosocial interventions for substance use disorders

OBJECTIVE: Despite significant advances in psychosocial treatments for substance use disorders, the relative success of these approaches has not been well documented. In this meta-analysis, the authors provide effect sizes for various types of psychosocial treatments, as well as abstinence and treatment-retention rates for cannabis, cocaine, opiate, and polysubstance abuse and dependence treatment trials. METHOD: With a comprehensive series of literature searches, the authors identified a total of 34 well-controlled treatment conditions-five for cannabis, nine for cocaine, seven for opiate, and 13 for polysubstance users-representing the treatment of 2,340 patients. Psychosocial treatments evaluated included contingency management, relapse prevention, general cognitive behavior therapy, and treatments combining cognitive behavior therapy and contingency management. RESULTS: Overall, controlled trial data suggest that psychosocial treatments provide benefits reflecting a moderate effect size according to Cohen's standards. These interventions were most efficacious for cannabis use and least efficacious for polysubstance use. The strongest effect was found for contingency management interventions. Approximately one-third of participants across all psychosocial treatments dropped out before treatment completion compared to 44.6% for the control conditions. CONCLUSIONS: Effect sizes for psychosocial treatments for illicit drugs ranged from the low-moderate to high-moderate range, depending on the substance disorder and treatment under study. Given the long-term social, emotional, and cognitive impairments associated with substance use disorders, these effect sizes are noteworthy and comparable to those for other efficacious treatments in psychiatry.     

Quantification of in vivo anaerobic metabolism in the normal cat retina through intraretinal pH measurements

We examined intraretinal [H+] in the intact retina of anesthetized cats using H+-sensitive microelectrodes to obtain spatial profiles of extracellular [H+]. One H+ is produced when an anaerobically generated ATP is utilized. We theorized that H+ production directly reflects anaerobic glucose consumption. From the choroid (pH approximately 7.40), [H+]o steadily increased to a maximum concentration in the proximal portion of the outer nuclear layer (pH approximately 7.20). The shape of the profile was always concave down, indicating that a net production of H+ occurred across the avascular outer retina. A three-layer diffusion model of the outer retina was developed and fitted to the data to quantify photoreceptor H+ extrusion into the extracellular space (Q(OR-H+)). It was determined that the outer segment (OS) layer had negligible H+ extrusion. The data were then refitted to a special three-layer model in which the OS layer Q(H+) was set equal to zero, but in which the inner segments and outer nuclear layer produced H+. The resulting Q(OR-H+) was several orders of magnitude lower than previous measurements of Q(OR-lactate), which were based on choroidal mass balances of lactate. Stoichiometrically, one H+ is produced for each lactate produced, so we concluded that Q(OR-H+) is a measure of net rather than total H+ production. Because retinal acid production is so high, the retina must contain efficient H+ clearance and/or neutralization mechanisms that prevent severe acidosis. The effect of light on retinal extracellular [H+] and Q(OR-H+) was also examined. As expected, light adaptation caused a retinal alkalinization that resulted from a 52% reduction in Q(OR-H+). This is in agreement with previous studies that have shown that both oxidative (e.g. Haugh et al., 1990) and glycolytic metabolism (Wang et al., 1997a,c) in the photoreceptor are decreased by a factor of 2 during light adaptation. Although we could not obtain absolute values for outer retinal glycolysis, changes in Q(OR-H+) appear to directly reflect changes in glycolytic metabolism.     

Effects of ox bile on the growth and organogenesis ofHymenolepis microstoma in vitro

Hymenolepis microstoma has been cultured in vitro from 4 to 11 days of age using Eagle's medium (BME) supplemented with horse serum, lamb's liver extract and ox gall (dehydrated bile) in five different concentrations (0.025%, 0.1%, 0.2%, 0.5% and 1% all in BME) including a control without the added ox gall. The results of these experiments demonstrated that growth is related inversely to the concentration of ox gall in the media. However, the number of proglottids containing fertilized ova in the lateral sacs becomes higher in worms grown in the medium containing 0.025% ox bile than in those grown in the control medium. This number increases with the bile concentration up to 0.2%. It is concluded that bile stimulates oogenesis and in higher concentrations retards the growth of worms.