Comparison of dobutamine stress echocardiography with and without real-time perfusion imaging for detection of coronary artery disease

In a pilot study of 27 patients, those who presented with chest pain underwent 2 dobutamine stress echocardiographic studies, 1 with high mechanical index harmonic imaging to analyze wall motion without contrast and 1 with real-time low mechanical index perfusion imaging with intravenous Optison to assess myocardial perfusion and wall motion. All patients then underwent quantitative coronary angiography. Two independent reviewers demonstrated an improvement in sensitivity when analyzing myocardial perfusion. In the 21 patients who had significant coronary stenoses, 14 had abnormal myocardial perfusion detected at peak stress and 7 had abnormal wall motion detected by standard dobutamine stress echocardiography. There was decreased specificity with perfusion imaging by 1 reviewer. The addition of real-time perfusion imaging after intravenous contrast during dobutamine stress echocardiography has the potential to improve detection of coronary artery disease.     

比较有和无实时灌注成像的多巴酚丁胺负荷超声心动图在检测冠状动脉疾病中的作用

在一项初步研究中，27例胸痛患者进行了两种多巴酚丁胺负荷超声心动图检查：一种采用无造影剂的高机械指数谐波成像分析室壁运动，另一种采用静脉内注射造影剂Optison实时低机械指数灌注成像评价心肌灌注及室壁运动。而后，所有患者接受定量冠状动脉造影。两位独立的检查者都证明心肌灌注分析可提高检测的灵敏性。在21例冠状动脉明显狭窄的患者中，14例在峰值负荷时检测到心肌灌注异常，7例在标准多巴酚丁胺负荷超声心动图检出室壁运动异常。     

The problem of seeing hospital staff without G.P. referral--the otolaryngological experience

Over a three month period, a record was kept of the number of hospital staff who approached the E.N.T. team requesting help for a medical problem. Staff members included doctors, nurses, clerical staff, paramedical staff and porters. The total number of employees in the hospital was recorded. The average General practitioner public patient list (General medical Service cardholders) for South Dublin was recorded (our hospital is in south west Dublin). The total number of hospital staff seen by E.N.T. in 3 months was seventy seven. The total number of hospital staff seen by other surgical specialties was approximately one hundred and sixty seven. Extrapolation of numbers seen by E.N.T. service in three months to numbers seen over a one year period is 308 patients. The numbers seen by the E.N.T. service in three months corresponds to 11.7% of the average South Dublin General Practitioner Medical card list. It has been estimated that approximately 20% of all problems the average General practitioner sees in a week are E.N.T. related. Those practices with a smaller paediatric population would have approximately 15% of the total practice concearned with E.N.T. problems. Therefore as 15% of 2,400 (total hospital staff) = 360, there is potentially a small General Practice which is 'hidden' within the hospital.     

Incidence of cardiac arrhythmias with therapeutic versus diagnostic ultrasound and intravenous microbubbles.

OBJECTIVE: The purpose of this study was to determine the type of arrhythmias induced with therapeutic versus diagnostic transthoracic low-frequency ultrasound (TLFUS) transducers in the presence of intravenous microbubbles. METHODS: Intravenous perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles were infused or given as a bolus injection while TLFUS was applied in the standard parasternal and apical views with either a 1-MHz therapeutic ultrasound transducer or high-mechanical-index diagnostic ultrasound (1.7 MHz). RESULTS: Significantly more ectopy was produced by the therapeutic transducer, especially at higher-intensity settings in the continuous wave mode after bolus injections of PESDA (P < .001 compared with lower intensities and lower continuous infusion rates). Six patients (15%) had either clinical supraventricular tachycardia or nonsustained ventricular tachycardia after intravenous PESDA with therapeutic TLFUS. In comparison, diagnostic high-mechanical-index ultrasound produced only isolated ventricular ectopy and no sustained ventricular arrhythmias. CONCLUSIONS: Intravenously injected microbubbles and low-frequency therapeutic transducers operating at longer duty cycles and wide beam widths have the capability of eliciting clinically important arrhythmias in patients at high risk for such events.     

Comparison of low-mechanical index pulse sequence schemes for detecting myocardial perfusion abnormalities during vasodilator stress echocardiography

Myocardial contrast echocardiography has the potential to accurately detect functionally significant coronary artery disease during pharmacologic stress testing. Different low-mechanical index modalities, including triggering replenishment imaging (TRI) and real-time imaging (RTI), are currently used to identify myocardial perfusion defects. We compared the ability of TRI with that of RTI for detecting and localizing perfusion abnormalities. Thirty-six patients (62 +/- 14 years old, 15 men) underwent single-photon emission computed tomography (SPECT) with technetium-99m sestamibi and myocardial contrast echocardiography at baseline and after infusion of 0.56 mg/kg of dipyridamole. Sixteen of these patients also underwent quantitative angiography. Contrast-enhanced images were obtained in 4-, 3-, and 2-chamber views after intravenous bolus injections of lipid-encapsulated microbubbles (0.1 ml of Definity). A myocardial perfusion defect was defined by myocardial contrast echocardiography as a delay of >2 seconds in contrast replenishment after high-mechanical index flash impulse. The myocardial segments were divided into 3 major coronary territories. There was agreement in detecting perfusion defects between SPECT and TRI in 26 patients (72%, kappa = 0.46) and between SPECT and RTI in 27 patients (75%, kappa = 0.50). Agreements between myocardial contrast echocardiography and SPECT for localizing coronary territories with perfusion defects were 81% for TRI (kappa = 0.43) and 85% for RTI (kappa = 0.61). Accuracy of RTI for detecting >50% diameter stenoses by quantitative angiography was 79%, that of TRI was 71%, and that of SPECT was 65%. These data indicate that the different low-mechanical index imaging schemes are equivalent to radionuclide SPECT in accurately detecting diseased coronary artery territories during vasodilator stress.     

A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder--description and outcome

OBJECTIVE: To describe and evaluate a full dialectical behavior therapy (DBT) program for people with comorbid eating disorder and borderline personality disorder. The program included a novel skills training module written especially for eating-disordered patients. METHOD: The program was run for 18 months. Days in hospital and major acts of self-harm were counted for the 18 months before and after DBT. RESULTS: There were no dropouts from the program. The patients seemed to benefit. Most patients were neither eating disordered nor self-harming at follow-up. DISCUSSION: Full DBT is an expensive and demanding treatment but deserves consideration for patients with an eating disorder and co-morbid borderline personality disorder and self-harm. There is a need for a more systematic and thorough evaluation.     

Value of dobutamine stress myocardial contrast perfusion echocardiography in patients with advanced liver disease.

Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P = 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of > or = 65 yr (RR = 2.2; 95% confidence interval (CI) = 1.1-4.4; P = 0.03), MELD score of > or = 25 (RR = 3.2; 95% CI = 1.8-5.5; P < 0.0001), and abnormal MPI (RR = 2.4; 95% CI = 1.1-5.2; P = 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P = 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.     

Predictors of therapeutic engagement in prison-based drug treatment

Few studies to date have examined predictors of therapeutic engagement (TE) or other indicators of responsiveness to prison drug treatment. Subjects were 347 inmates participating in a 12-month modified therapeutic community (TC) drug treatment program at a specialized treatment prison for convicted, drug-involved offenders. Data were obtained through correctional databases and the administration of the TCU Drug Screen II, the Resident Evaluation of Self and Treatment (REST), and the Counselor Rating of Client (CRC) form. Three main hypotheses were supported: (1) baseline motivation predicted therapeutic engagement net of other inmate characteristics; (2) critical dimensions of the treatment experience (e.g., peer support, counselor rapport) also predicted therapeutic engagement; and (3) dynamic predictors and programmatic characteristics became more important over time. Implications for research, theory and policy are discussed.