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.     

Limited influence of the mesothelium on the influx of monocytes into the peritoneal cavity

Exposure of Farage, a human B-cell line, to interleukin 4 (IL4) reduced the amount of CD38 antigen on the surface of the cells and in cell lysates. No evidence was obtained for accelerated breakdown, shedding, or internalization of CD38 molecules following IL4 treatment, nor the accumulation of CD38 molecules in the cell interior. The inhibition of protein synthesis with cycloheximide (CXM) diminished the down-regulation of CD38 induced by IL4. CXM decreased the expression of CD38 in Farage cells with arrested mitosis, and IL4 failed to further reduce CD38 expression. Staurosporine, an inhibitor of serine/threonine protein kinases, and H7 (1-(5-isoquinolinylsulfonyl)-2-methylpiperazine), a preferential inhibitor of protein kinase C (PKC), abrogated the effect of IL4 on CD38, while inhibitors of other serine protein kinases W7 (N-(aminohexyl)-5-chloro-1-naphthalenesulfoamide) and H8 (N-(2-[methylamino]ethyl)-5-isoquinolinesulfonamide) failed to interfere with the effect of IL4. Phorbol 12-myristate 13-acetate (PMA), an activator of PKC, resembled IL4 in decreasing the expression of CD38, and either staurosporine or H7 abolished this effect. Genistein, an inhibitor of tyrosine kinases, increased the expression of CD38, but failed to abrogate the inhibitory effect of IL4 on CD38. It is concluded that serine/threonine protein kinases mediated the IL4-induced down-regulation of the expression of CD38 molecules in B cells.     

Service differentiation in a single-period inventory model with numerous customer classes

We study critical-level inventory-management policies as means to provide differentiated (\(\alpha \) and \(\beta \)) service levels to more than two classes of customers. First, we derive closed-form expressions for the service levels of a single-period critical-level policy with an arbitrary number of customer classes (with Poisson demand). Based on the service-level expressions, we derive additional structural insights and provide an efficient algorithm with which to compute the essential system parameters, that is, the minimum required starting inventory and the associated critical levels. Based on these results, we conduct numerical experiments and develop structural insights into the system’s behavior.     

Lentil lectin enriched microsomes from the plasma membrane of the human B-lymphocyte cell line H2LCL carry a heavy load of type-1 porin

Using an established biochemical approach, five subcellular fractions of human B lymphocytes were prepared by differential centrifugation. Crude membranes were passed over a lentil lectin column to enrich carbohydrate-coated cell surface microsomes. The lectin-bound fraction contained a high amount of plasma membrane-derived microsomes as indicated by cell surface markers. All subcellular fractions in Western blots proved to contain distinct but variable amounts of porin. There was a strong increase in porin content from crude membranes to plasma membrane-derived vesicles. The porin content of this fraction appeared to be higher than that of mitochondria. In the final step the plasma membrane-derived microsome fraction proved to be devoid of contamination by outer mitochondrial membranes, as revealed by antibodies against the established markers MAO B and Tom20 applied in Western blots. These data prove the extramitochondrial expression of human type-1 porin/ type-1 VDAC.     

Risk factors for a medically inappropriate admission to a Department of Internal Medicine

OBJECTIVE: To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine. METHODS: Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends. RESULTS: Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization. CONCLUSIONS: Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.     

Correlation of fecundability and serum estradiol after danazol treatment in patients with advanced endometriosis

OBJECTIVE: To examine the relationship between pregnancy incidence and the level of serum E2 during danazol therapy. DESIGN: Danazol was given by 200 mg four times daily for 3 months. Serum E2 level was checked after completing the therapy, but before stopping medication. Patients then were advised to conceive at the appropriate time over a 6-month period. SETTING: Reproductive and Endocrine Laboratory of the Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan. PATIENTS: Infertile women with invasive endometriosis receiving conservative surgery and danazol treatment. INTERVENTIONS: Serum E2 is checked before medication and at the end of danazol therapy, but before stopping medication. MAIN OUTCOME MEASURES: Whether pregnancy is related to the change of serum E2 caused by danazol therapy. RESULTS: There were 24 pregnancies in 38 patients with invasive endometriosis after treatment. Pregnant patients had significantly lower serum E2 levels as compared with the nonpregnant patients. CONCLUSIONS: After conservative surgery for invasive endometriosis associated with infertility, the therapeutic period of danazol treatment could be shortened to 3 months. Because there is significant correlation of fecundability and serum E2 after danazol medication, serum E2 could be a guideline for predicting pregnancy or for prolonging or changing of treatment after danazol therapy.     

Automatic verification of Java programs with dynamic frames

Framing in the presence of data abstraction is a challenging and important problem in the verification of object-oriented programs Leavens et al. (Formal Aspects Comput (FACS) 19:159–189, 2007). The dynamic frames approach is a promising solution to this problem. However, the approach is formalized in the context of an idealized logical framework. In particular, it is not clear the solution is suitable for use within a program verifier for a Java-like language based on verification condition generation and automated, first-order theorem proving. In this paper, we demonstrate that the dynamic frames approach can be integrated into an automatic verifier based on verification condition generation and automated theorem proving. The approach has been proven sound and has been implemented in a verifier prototype. The prototype has been used to prove correctness of several programming patterns considered challenging in related work.     

A novel and simple approach for assessing the freshness of hazelnuts

Visual inspection and sensory analysis are the only suitable ways to assess the quality of hazelnuts under routine conditions. To obtain a more objective parameter for the freshness, a fast and easy-to-use method was developed. It is based on the well-known test for the germination capacity of seeds where their vitality is determined by use of 2,3,5-triphenyltetrazolium chloride (TTC) which is reduced by flavo enzymes to 1,3,5-triphenylformazane, which appears red. For the determination, 100 hazelnut halves were embedded in TTC containing methyl cellulose gel on a glass plate and kept at 35 °C in the dark. After 6 h, the cut planes of viable nuts were stained red, the cut planes of rotten nuts were yellow or brown, and the colour of dead or mould-infected nuts remained unchanged. The colour pattern was examined either visually by counting the coloured halves or with computer support using image editing software. The ratio of the sum of coloured areas to the total area of the hazelnut cut planes gave a measure of the average degree of viability ("vitality index"). The analysis of several samples of hazelnuts of well-defined age and storage conditions confirmed the efficiency of the method.     

Easily made and handled carbon nanocones for scanning tunneling microscopy and electroanalysis

Well-formed carbon nanocones at the ends of micrometer-diameter carbon fibers (CFs) were fashioned into functional tips for scanning tunneling microscopy (STM) and miniaturized voltammetric sensors. Sharpening of single graphite filaments was achieved by simple DC electrochemical etching in 0.1 N NaOH. Operated as STM tips, pointed CFs resolved in air the contour and surface morphology of a nanoscopic Au line pattern and imaged in vacuum a Si (1 1 1) surface with clear atomic resolution. Subjecting already etched CFs to tip-sparing insulation with electrodeposited paint produced conical carbon ultramicroelectrodes (UMEs) with effective radii down to about 900 nm. Comparative cyclic voltammetry trials in alkaline, neutral and acidic solutions showed that the conical carbon UME’s had a wider practical potential window for electroanalytic applications than, for instance, Pt disk UMEs. The CF-based conical sensors described here are exceptionally easy to make with simple laboratory equipment and perform well in STM topography imaging and voltammetry. The inherent simplicity of sensor production widens the field of potential users, and offers clear advantages over existing types of UMEs, in particular those based on carbon nanotubes, which are especially hard to handle in an optical microscope setting.