Viability after myocardial infarction: can it be assessed within five minutes by low-dose dynamic iodine-123-iodophenylpentadecanoic acid imaging with a multicrystal gamma camera?

Although positron emission tomography (PET) assesses myocardial viability (V) accurately, a rapid, inexpensive substitute is needed. Therefore, the authors developed a low-dose (1 mCi) Iodine-123-Iodophenylpentadecanoic Acid (IPPA) myocardial viability scan requiring analysis of only the first three minutes of data acquired at rest with a standard multicrystal gamma camera. Twenty-one patients > 2 weeks after myocardial infarction (MI) (24 MIs, 10 anterior, 14 inferoposterior, 21 akinetic or dyskinetic) had cardiac catheterization and resting IPPA imaging. V was determined by either transmural myocardial biopsy during coronary bypass surgery (12 patients, 14 MIs) or reinjection tomographic thallium scan (9 patients, 10 MIs), and 50% of MIs were viable. The IPPA variables analyzed were: time to initial left ventricular (LV) uptake in the region of interest (ROI), the ratio of three-minute uptake in the ROI to three-minute LV uptake, three-minute clearing (counts/pixel) in the ROI (decrease in IPPA after initial uptake), and three-minute accumulation (increase in IPPA after initial uptake) in the ROI. Rules for detecting V were generated and applied to 10 healthy volunteers to determine normalcy. While three-minute uptake in nonviable MIs was only 67% of volunteers (P < 0.0001) and 75% of viable MIs, uptake alone identified only 50% of viable MIs and 75% of nonviable MIs. IPPA clearing, however, was > or = 13.5 counts/pixel in 10/12 (83%) of viable MIs, and IPPA accumulation > or = 6.75 counts/pixel identified one more viable MI, for a sensitivity for V of 11/12 (92%), with a specificity of 11/12 (92%), and a 100% normalcy rate. The authors conclude low-dose IPPA (five-minute acquisition with analysis of the first three minutes of data) has potential for providing rapid, inexpensive V data after MI. Since newer multicrystal cameras are mobile, IPPA scans can be done in emergency rooms or coronary care units generating information that might be useful in decisions regarding thrombolysis, angioplasty, or bypass surgery.     

Induction of proinflammatory cytokine and antioxidant enzyme gene expression following brief myocardial ischaemia

PURPOSE: In a recent study we found an increased resistive index immediately after extracorporeal shock wave lithotripsy (ESWL) in patients older than 60 years, which suggests renovascular disturbance. The present 26-month followup study was undertaken to investigate the relevance of elevated resistive index levels and the incidence of new onset hypertension. MATERIALS AND METHODS: Of the initial 76 patients 57, including 20 of the 23 at risk patients 60 or greater years, group 3), were followed for more than 26 +/- 6 months after ESWL. Followup included 2 resistive index measurements by Doppler ultrasound of the treated and the contralateral kidney, at least 2 blood pressure measurements 1 week apart and excretory urography as well as determination of plasma renin activity in 9 patients. RESULTS: With 1 exception, elevated resistive index levels and hypertension were observed exclusively in patients older than 60 years. In these patients the resistive index ranged between 0.65 and 0.86 (mean plus or minus standard deviation 0.74 +/- 0.05, normal less than 0.7). This increase in resistive index was statistically significant (p < 0.0001). Compared to the levels obtained immediately after ESWL, the resistive index continued to increase in all 9 patients older than 60 years who had hypertension (45%), whereas in the normotensive patients the resistive index was either stable or decreased. There was a strong positive correlation (0.903) between pathological resistive index levels and blood pressure. CONCLUSIONS: Patients older than 60 years are at risk for disturbances of renal perfusion as assessed by the resistive index, and 45% of these patients have new onset hypertension within 26 months of treatment.     

Carcinoid of the gallbladder. A report of a clinical case treated by video laparoscopic cholecystectomy

The authors report a clinical case of the gallbladder carcinoid tumour treated with laparoscopic cholecystectomy. After a short analysis of the classification, the malignant potentiality and the symptoms of gallbladder carcinoids, they conclude that it is possible to treat carcinoids with laparoscopic cholecystectomy, but only in some selected cases, that is to say in the absence of factors indicative of local invasion and that in the other cases it is preferable the classic surgical treatment of laparotomic resection.     

An analysis of fine-needle aspiration biopsy of the thyroid in children and adolescents

Fine-needle aspiration biopsy (FNAB) has proven safe and efficacious in the evaluation nodular thyroid disease in adults. Only one study has evaluated FNAB exclusively in children, for whom the prevalence of thyroid nodules and the probability of malignancy are different. In addition, no study has compared the accuracy of FNAB with that of other diagnostic procedures in the evaluation of thyroid nodules in children. The authors report the results of FNAB in 18 children evaluated for thyroid nodules between 1985 and 1994. The overall accuracy of FNAB was similar to that of other diagnostic procedures, including thyroid scintiscan and ultrasonography, but none of these was sufficiently accurate to be used as the sole predictor of malignancy. There were three false-negative biopsy results; this limited the overall accuracy and suggests that children with negative FNAB results should be monitored cautiously.     

Radiologic findings in gout

Radiological gout manifestations are detectable in the early stage, but also especially in the chronic stage of gout. Whereas in the early stage only soft tissue mutations (bursitis inflammation) and light calcium deposits are usually discernible, chronic gout leads to asymmetrical, diverse forms of osseous destruction, favouring smaller joints, but also affecting larger ones, which are caused by the intra-articular and extra-articular deposit of tophus material, corresponding to the progression and degree of severity of the illness. Radiologically-detectable changes in other organs, such as the kidneys, will be addressed. The high number of, and to some extent very characteristic, osseous mutations are compared with those mutations which are very similar to the diagnoses of other syndromes affecting the joints. Specifically, problems in differentiating diagnosis of rheumatoid arthritis, arthritis psoriatica, chondrocalcinosis, and other diseases of the joints will receive special mention. Reference is also made to the extreme diagnostic difficulties resulting from the rare but nevertheless conceivable influence of gout on the spine or sacroiliac joints. The method of magnetic resonance imaging for gout shows a characteristic signal behaviour of the tophus material. It has been determined that, through magnetic resonance tomography, interosseous tophi can be detected earlier and in a more widespread manner than with the aid of native X-ray images, such that an increase in the use of this method is to be expected.     

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization?

PURPOSE: Arteriography is the diagnostic test of choice before lower extremity revascularization, because it is a means of pinpointing stenotic or occluded arteries and defining optimal sites for the origin and termination of bypass grafts. We evaluated whether a duplex ultrasound scan, used as an alternative to arteriography, could be used as a means of accurately predicting the proximal and distal anastomotic sites in patients requiring peripheral bypass grafts and, therefore, replace standard preoperative arteriography. METHODS: Forty-one patients who required infrainguinal bypass grafts underwent preoperative duplex arterial mapping (DAM). Based on these studies, an observer blinded to the operation performed predicted what operation the patient required and the best site for the proximal and distal anastomoses. These predictions were compared with the actual anastomotic sites chosen by the surgeon. RESULTS: Whether a femoropopliteal or an infrapopliteal bypass graft was required was predicted correctly by means of DAM in 37 patients (90%). In addition, both anastomotic sites in 18 of 20 patients (90%) who had femoropopliteal bypass grafts and 5 of 21 patients (24%) who had infrapopliteal procedures were correctly predicted by means of DAM. CONCLUSION: DAM is a reliable means of predicting whether patients will require femoropopliteal or infrapopliteal bypass grafts, and, when a patient requires a femoropopliteal bypass graft, the actual location of both anastomoses can also be accurately predicted. Therefore, DAM appears able to replace conventional preoperative arteriography in most patients found to require femoropopliteal reconstruction. Patients who are predicted by means of DAM to require crural or pedal bypass grafts should still undergo preoperative contrast studies to confirm these results and to more precisely locate the anastomotic sites.     

Reexamining the delivery system as part of Medicare reform

Medicare is more than a payment system. As the nation's largest public payer of health care, Medicare dictates the way health care is delivered to elderly and disabled persons. Health care and health outcomes cannot make substantial improvements until the delivery system is changed. Medicare reform must support a coordinated health care delivery system (in place of hospital-centered, fragmented care) and proactive chronic disease management (in place of episodic, reactive care). Consumers, government, community-based agencies, employers, health plans, and others need to develop a shared understanding of what outcomes we want to obtain, what delivery system reforms are required, and how financing can support those reforms.     

Double mutant cycle analysis of aspartate 69, 97, and 103 to asparagine mutants in the m2 muscarinic acetylcholine receptor

Double mutant cycles provide a method for analyzing the effects of a mutation at a defined position in the protein structure on the properties of an amino acid at a second site. This approach was used to map potential interactions between aspartates 69, 97, and 103 in the m2 muscarinic acetylcholine receptor transmembrane helices 2 and 3. Receptors containing single and double aspartate to asparagine mutants were expressed in Chinese hamster ovary cells and their effects on ligand binding, signal transduction, and thermal stability determined. Analysis of the double mutant cycles showed that the mutations had approximately additive effects on ligand binding, signal transduction, and thermal stability. Ligand binding and thermal inactivation results support the conclusion that aspartate-103 is the ligand amine counterion. Effector coupling properties of the mutant receptors showed that aspartate-103 was also required for signal transduction activity. The mutation of aspartate-69 to asparagine completely eliminated signal transduction by the agonists acetylcholine, carbachol, and pilocarpine but not oxotremorine M, which caused reduced but significant inhibition of adenylyl cyclase and stimulation of phospholipase C. In contrast, adenylyl cyclase stimulation by the asparagine-69 mutant was elicited only by acetylcholine and carbachol but not by oxotremorine M. The variation in agonist-dependent effector coupling properties provides evidence that the asparagine-69 mutant can exist in activated receptor states that are different from the wild-type m2 muscarinic receptor.