Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography

OBJECTIVES: This study assessed the incremental prognostic implications of normal and equivocal exercise technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) and sought to determine its incremental prognostic value, impact on patient management and cost implications. BACKGROUND: The prognostic implications of Tc-99m sestamibi SPECT are not well defined, and risk stratification using this test has not been explored. METHODS: We studied 1,702 patients referred for exercise Tc-99m sestamibi SPECT who were followed up for a mean (+/- SD) of 20 +/- 5 months. Patients with previous percutaneous transluminal coronary angioplasty or coronary artery bypass surgery were excluded. The SPECT studies were assessed using semiquantitative visual analysis. Cardiac death and myocardial infarction were considered "hard" events, and coronary angioplasty and bypass surgery > 60 days after testing were considered "soft" events. RESULTS: Of the 1,702 patients studied, 1,131 had normal or equivocal scan results. A total of 10 events occurred in this group (1 cardiac death and 1 myocardial infarction [0.2% hard events]; 4 coronary angioplasty and 4 bypass surgery procedures [0.7% soft events]). The rates of hard events and referral to catheterization after SPECT were similarly low in patients with a low (< 0.15), intermediate (0.15 to 0.85) and high (> 0.85) post-exercise treadmill test (ETT) likelihood of coronary artery disease. With respect to scan type, patients with normal, probably normal or equivocal scan results had similarly low hard event rates. In the 571 patients with abnormal scan results, there were 43 hard events (7.5%) and 42 soft events (7.4%) (p < 0.001 vs. 1,131 patients with normal scan results for both). When the complete spectrum of scan responses was considered, SPECT provided incremental prognostic value in all patient subgroups analyzed. However, the nuclear scan was cost-effective only in patients with interpretable exercise ECG responses and an intermediate to high post-ETT likelihood of coronary artery disease and in those with uninterpretable exercise ECG responses and an intermediate to high pre-ETT likelihood of coronary artery disease. CONCLUSIONS: Normal or equivocal exercise Tc-99m sestamibi study results are associated with a benign prognosis, even in patients with a high likelihood of coronary artery disease. Although incremental prognostic value is added by nuclear testing in all patient subgroups, a testing strategy incorporating nuclear testing proved to be cost-effective only in the groups with an intermediate to high likelihood of coronary artery disease before scanning.     

A bacteriophage reagent for Salmonella: molecular studies on Felix 01

Felix 01 (F01) is a bacteriophage originally isolated by Felix and Callow which lyses almost all Salmonella strains and has been widely used as a diagnostic test for this genus. Molecular information about this phage is entirely lacking. In the present study, the DNA of the phage was found to be a double-stranded linear molecule of about 80 kb. 11.5 kb has been sequenced and in this region A + T content is 60%. There are relatively few restriction endonuclease cleavage sites in the native genome and clones show this is due to their absence rather than modification. A restriction map of the genome has been constructed. The ends of the molecule cannot be ligated although they contain 5' phosphates. At least 60% of the genome must encode proteins. In the sequenced portion, many open reading frames exist and these are tightly packed together. These have been examined for homology to published proteins but only 1 to 17 shows similarity to known proteins. F01 is therefore the prototype of a new phage family. On the basis of restriction sites, codon usage and the distribution of nonsense codons in the unused reading frames, a strong case can be made for natural selection that reacts to mRNA structure and function.     

On constructing an optimal consensus clustering from multiple clusterings

Computing a suitable measure of consensus among several clusterings on the same data is an important problem that arises in several areas such as computational biology and data mining. In this paper, we formalize a set-theoretic model for computing such a similarity measure. Roughly speaking, in this model we have k>1 partitions (clusters) of the same data set each containing the same number of sets and the goal is to align the sets in each partition to minimize a similarity measure. For k=2, a polynomial-time solution was proposed by Gusfield (Information Processing Letters 82 (2002) 159-164). In this paper, we show that the problem is MAX-SNP-hard for k=3 even if each partition in each cluster contains no more than 2 elements and provide a -approximation algorithm for the problem for any k.     

Nucleic acid crystallography: a view from the nucleic acid database

What are the future directions of the field of nucleic acid crystallography? Although there have been many duplex structures determined, the sample is still relatively small. This is especially true if one wants to derive enough information about the relationships between sequence and structure. Indeed, there are data for all the possible 10 dimer steps, but for some steps it is very limited. If the structural code resides in trimers or tetrad steps then there is simply not enough data to do meaningful statistical analyses. So the first direction that needs to be explored is the determination of more structures with more varied sequences. The other noticeable thing about the data is the shortness of the strands. While it is probably true that attempts to crystallize very long sequences will not meet with success, the idea of crystallizing sequences engineered to fit together via sticky ends such as has been done for the CAP-DNA complex (Schultz et al., 1990) should give data about the behavior of much longer stretches of DNA. The question of the effects of environment on the structure of DNA continues to be a very important one to address since DNA is rarely alone. The preliminary data we have analysed from the current sample shows that the conformation of some steps are very sensitive to packing type. Numerous studies of the hydration around DNA shows that there is a real synergy between the hydration structure and the base conformation. More data will allow further quantitation of these observations. RNA structure is the next very exciting frontier. The emerging structures of duplexes with internal loops, the two hammerhead ribozyme structures and the group I intron ribozyme have given us a glimpse of the complexity and elegance of this class of molecules. With the technology now in place to allow the determination of the structures of these molecules, the expectation is that now we will see a large increase in the number of these structures in the NDB.     

Meta-bromobiphenol epoxy resins: Applications in electronic packaging and printed circuit board

Novel 2,2′,6,6′-tetrabromo-3,3′,5,5′-tetramethyl-4,4′-biphenol (TBTMBP), and its epoxy derivatives, were synthesized to incorporate the stable meta-brominated phenol moiety into epoxy resin systems. In electronic encapsulation and laminate applications, epoxy systems derived from TBTMBP have exhibited superior hydrolytic and thermal stability as compared with the conventional ortho-brominated epoxy resins. These properties have resulted in an extended device life for semiconductors and a high T_g with excellent blister resistance for the printed circuit board, while meeting flame retardancy requirements as well.     

Polyarteritis nodosa presenting as temporal arteritis in a 9-year-old child

In a household survey in Guinea-Bissau, 319 episodes of diarrhea in children were followed by interviews every second day with the aim of investigating perceived morbidity and subsequent actions taken. The majority of the mothers had good knowledge of oral rehydration salts (ORS). However, only 58% of the episodes were treated with ORS and the amount given was insufficient. Mothers with no knowledge of ORS did not use it during the observed attack of diarrhea regardless of contact with a health center, which suggests that maternal knowledge is an important determinant of whether health personnel provide ORS. Children with diarrhea considered to be caused by teething were less likely to receive ORS in the acute phase (risk ratio = 0.6, 95% confidence interval [CI] = 0.5-0.9). Univariate analyses showed that the use of ORS was related to number of reported symptoms, the mother being the care taker, consultations, previous use of ORS, good knowledge of ORS, and having ORS sachets at home. Multivariate Cox regression analyses showed that the presence of ORS sachets at home at the onset of diarrhea was the strongest predictor of use (hazard ratio = 3.3, 95% CI = 1.9-3.6). Improved health education should focus more on the quantity of ORS needed, early signs of dehydration, treatment of teething diarrhea, and breast feeding, and address mothers who have no prior knowledge of ORS. Management of diarrhea may be improved by a more liberal distribution of ORS sachets.     

Effects of clorazepate, diazepam, and oxazepam on a laboratory measurement of aggression in men

The liver S9 head space vial equilibration technique is an in vitro alternative that holds promises for a satisfactory in vivo extrapolation of liver metabolism of volatile organic chemicals. The aim of this study was to investigate the suitability of this methodology for the extrapolation of in vitro metabolic data from rodent to man by allometry with the two highly metabolized organic solvents toluene and n-hexane as model substances. The calculated hepatic clearance of toluene in man from rodent liver S9 in this study was equal to the reported total body clearance of toluene in man, suggesting insignificant extrahepatic clearance of toluene in humans. The calculated hepatic clearance of n-hexane was less than the reported values of total body clearance of n-hexane in man, indicating an about 80% extrahepatic clearance of n-hexane in humans. Both results are in line with our present knowledge of the metabolism of the two organic solvents in man. Allometric scaling from rodent liver S9 head space incubations to in vivo metabolism of toluene and n-hexane in man thus seems promising and could be a method of choice for scaling of organic solvent metabolism in general.     

Optimization models for selection of programs, considering cost andreliability

The authors present two optimization models for decision support tools for selecting available programs in the market. Information on reliability and cost of the available programs are considered as basic criteria for the selection. These models apply to software packages that consist of several programs where each, upon execution, performs a different function as required by the user. The objective is to maximize the average reliability of the software package, considering the tradeoff between reliability and cost of the programs. In model one, redundancy of the programs is not considered; thus, the authors select one program for each function. In model two, redundancy is considered: thus, the authors identify the optimal set of programs for each function. They begin with a discussion of the underlying concepts that rationalize the composition of the models