Factors associated with romantic relationship formation difficulties in women with breast cancer.

OBJECTIVE: Many un-partnered women report difficulty in forming romantic relationships after breast cancer, characterized by high dating-related anxiety and low perceived interpersonal competence. This study examined the relationship between poor body image (appearance investment and body dissatisfaction) and self-compassion, and women's ability to form romantic relationships post-breast cancer. METHODS: Women (N = 152) diagnosed with breast cancer, who were either un-partnered and expressed interest in romantic dating, or who had commenced a relationship post-diagnosis, completed an online survey. Assessments included the Interpersonal Competence Questionnaire, Dating Anxiety Scale, Self-compassion Scale, Appearance Schemas Inventory-Revised, Body Image Scale, and Experiences in Close Relationships Scale. Multiple regression analyses assessed the relationships between these variables. RESULTS: Partnered and un-partnered women differed in levels of dating anxiety, interpersonal competence, anxious attachment, and the self-evaluative salience facet of appearance investment. Analyses revealed a significant model for dating anxiety, with high self-evaluative salience, body image dissatisfaction, and attachment avoidance independently associated with this outcome. The model for interpersonal competence was also significant, with low attachment avoidance and high self-compassion independently associated with this outcome. CONCLUSIONS: Un-partnered women who place high importance on appearance for their self-worth and who report poor body image and low self-compassion are at risk of experiencing difficulties in forming new romantic relationships after breast cancer. Future interventions should target these variables to facilitate romantic dating during cancer survivorship.

Coronary revascularization in lung transplant recipients with concomitant coronary artery disease.

Coronary artery disease (CAD) is not uncommon among lung transplant candidates. Several small, single-center series have suggested that short-term outcomes are acceptable in selected patients who undergo coronary revascularization prior to, or concomitant with, lung transplantation. Our objective was to evaluate perioperative and intermediate-term outcomes in this patient population at our institution. We performed a retrospective, observational cohort analysis of 898 lung transplant recipients between 1997 and 2010. Pediatric, multivisceral, lobar or repeat transplantations were excluded, resulting in 791 patients for comparative analysis, of which 49 (median age 62, 79.6% bilateral transplant) underwent concurrent coronary artery bypass and 38 (median age 64, 63.2% bilateral transplant) received preoperative percutaneous coronary intervention (PCI). Perioperative mortality, overall unadjusted survival and adjusted hazard ratio for cumulative risk of death were similar among both revascularization groups as well as controls. The rate of postoperative major adverse cardiac events was also similar among groups; however, concurrent coronary artery bypass was associated with longer postoperative length of stay, more time in the intensive care unit and more postoperative days requiring ventilator support. These results suggest that patients with CAD need not be excluded from lung transplantation. Preferential consideration should be given to preoperative PCI when feasible.

Efficiency comparison between 99m Tc-tetrofosmin and 99m Tc-sestamibi myocardial perfusion studies.

The purpose of this investigation was to compare the efficiency of two different imaging protocols using two different clinically available 99mTc labelled myocardial perfusion tracers. One thousand one hundred and thirty-four imaging studies were performed prospectively, using either 99mTc-tetrofosmin or 99mTc-sestamibi, alternating the use of each tracer for a total period of 8 months. 99mTc-tetrofosmin rest studies were performed with injections of 259MBq-370MBq and imaging 30 min later. Exercise studies were performed with injections of 777MBq-1.11GBq and imaging 20 min later. 99mTc-sestamibi studies used doses similar to those in the 99mTc-tetrofosmin studies. Imaging followed a standard procedure, at 60 min after rest injection, and 30 min after exercise. For patients undergoing pharmacological stress testing99mTc-sestamibi was imaged 45 min after injection and 99mTc-tetrofosmin was imaged 30 min after injection. Variables analysed were (1) injection-to-imaging time for the procedure, and (2) the number of repeated scans because of extra cardiac activity. The completion time for the rest study was significantly shorter for 99mTc-tetrofosmin compared to 99mTc-sestamibi (47.7+/-21.7 min vs 74.3+/-25.8 min P<0.0001). Likewise, the total study time was shorter for 99mTc-tetrofosmin compared to 99mTc-sestamibi (90+/-32.7 min vs 124+/-37 min, P<0.0001). More importantly, the number of repeated scans was higher with 99mTc-sestamibi compared to 99mTc-tetrofosmin, 21.4% vs 10%, P=0.001 for rest studies and 16.4% vs 7.9% P=0.001 [corrected] for rest and stress. It was concluded that, using a same day rest/stress protocol, 99mTc-tetrofosmin provided higher patient throughput with fewer repeat scans. These factors may be considered for efficiency improvement in nuclear cardiology laboratories using 99mTc perfusion tracers.

Incremental prognostic value of RNA ejection fraction measurements during pharmacologic stress testing: a comparison with clinical and perfusion variables.

UNLABELLED: This investigation examined the prognostic power of first-pass radionuclide angiocardiography (RNA) ejection fraction compared with clinical information and myocardial perfusion imaging in patients undergoing pharmacologic stress testing. The value of RNA and myocardial perfusion imaging in predicting death or nonfatal myocardial infarction (MI) is well established. However, limited information exists on the usefulness of combined myocardial perfusion imaging and RNA to predict prognosis, especially in patients undergoing pharmacologic stress testing. METHODS: We identified 240 patients who underwent pharmacologic stress testing with myocardial perfusion imaging and combined RNA. The patients were followed for a mean of 1.4 y. Cox proportional hazards models were used to assess the value in predicting death and MI. Multivariable models were generated to assess the independent incremental predictive value of clinical and nuclear imaging variables. Kaplan-Meier survival and event-free survival estimates were examined in patients with low (< or = 45%) versus high (>45%) ejection fractions. RESULTS: Clinical information, myocardial perfusion imaging, and RNA ejection fraction were significant predictors of the death/MI composite outcome (chi(2) = 7.4, 14.0, and 21.8, respectively). The addition of myocardial perfusion imaging to the clinical information provided incremental prognostic information (chi(2) = 15.2). The addition of RNA ejection fraction provided further predictive information (chi(2) = 22.5). However, when RNA ejection fraction was first added to the clinical information, myocardial perfusion imaging had no incremental prognostic value. CONCLUSION: For hard cardiac events, RNA ejection fraction provides prognostic information besides that provided by clinical and myocardial perfusion imaging. In patients who cannot exercise and are undergoing noninvasive evaluation with pharmacologic stress testing and myocardial perfusion imaging, ejection fraction should be measured simultaneously for risk assessment optimization.

Poststress measurements of left ventricular function with gated perfusion SPECT: comparison with resting measurements by using a same-day perfusion-function protocol.

PURPOSE: To investigate the relationship between the development of ischemia during stress testing and the changes in left ventricular ejection fraction (LVEF) measurements obtained after stress and at rest with a same-day perfusion-function imaging protocol. MATERIALS AND METHODS: One hundred twenty-six patients underwent a same-day rest-stress (61%) or stress-rest (39%) protocol and gated single photon emission computed tomography (SPECT). Perfusion analysis was performed with a 12-segment model. Defects were scored (0 = no defect, 1 = mild defect, 2 = moderate defect, and 3 = severe defect); differences between the summed stress and resting scores of greater than three indicated substantial ischemia. RESULTS: Resting and poststress LVEFs correlated significantly (r = 0.97, P <.001); however, patients with and patients without ischemia had significant differences in poststress versus resting LVEFs (-4.0 vs 1.0, respectively; P <.01). In patients with ischemia versus patients without ischemia, subgroup analysis stress-rest (-2.5 vs 1.0, P =.047) and rest-stress (-4.0 vs 1.0, P =.006) protocols yielded similar results. CONCLUSION: In patients with clinically important stress-induced perfusion abnormalities, the LVEF after stress was significantly lower than the LVEF at rest with same-day rest-stress and stress-rest imaging protocols. In the clinical setting, poststress LVEFs may be lower than true resting measurements, particularly in patients with moderate to severe stress-induced ischemia.

Specificity of electrocardiographic myocardial infarction screening criteria in patients with nonischemic cardiomyopathies.

BACKGROUND: The 32-point, 54-criteria Selvester QRS scoring system has been successfully used to estimate the size of nonacute myocardial infarction (MI). Three criteria of the system have been shown to be sensitive for the identification of nonacute MI and specific in normal control subjects. The validity of the system has not been tested in patients with cardiomyopathy of nonischemic origin. The purpose of this study was to examine the electrocardiographs (ECGs) of patients with abnormal left ventricular function but no presence of coronary disease to determine the diagnostic specificity of the MI screening criteria subset of the Selvester QRS scoring system. METHODS AND RESULTS: Six hundred ninety patients were considered. Exclusion criteria included age <10 years, cardiac transplantation, thrombolytic therapy, any angiographic evidence of coronary disease, left ventricular ejection fraction (LVEF) >60%, or history of myocardial revascularization. ECG exclusion criteria included left ventricular hypertrophy, right ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular pacing, left anterior fascicular block, left posterior fascicular block, ventricular preexcitation, and low voltage, because these confounding factors could mimic an infarct on the ECG. The 261 remaining patients were then examined for the presence of the MI screening criteria subset: (1) inferior location: Q > or =30 msec in aVF, (2) anterior location: either any Q or R< or =0.1 mV and < or =10 msec in V2, and (3) posterior location: R> or =40 msec in V1. Thirty-two of the 261 patients falsely met at least 1 of the 3 MI screening criteria, resulting in an overall specificity of 88% (vs 95% in normal control subjects, P=.0006). A specificity of 98% (n = 256) was achieved for the inferior MI screening criterion alone, whereas the anterior and posterior MI screening criteria alone achieved significantly lower specificities: 94% (n = 245) and 95% (n = 249), respectively. When the patient population was divided into LVEF <30% and LVEF > or =30%, no significant association was found between MI screening criteria and LVEF with specificities of 87% and 88%, respectively, for the 2 groups (P= .34). CONCLUSIONS: The MI screening criteria subset is relatively specific in patients with nonischemic cardiomyopathy, falsely identifying only 12% with nonacute MI. However, this specificity is lower than the 95% achieved in normal subjects. Regional accumulation of scarring caused by cardiomyopathy could result in false-positive indication of MI in the present population. Another possibility could be that some patients could have hypertrophy of the myocardium insufficient to produce positive ECG criteria for left ventricular hypertrophy or right ventricular hypertrophy but sufficient to mimic infarction.

Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy.

OBJECTIVES: We sought to characterize the clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. BACKGROUND: Patients with ischemic cardiomyopathy may have a worse prognosis than patients with nonischemic cardiomyopathy. Few studies have assessed the effect of ischemic versus nonischemic etiology on outcomes. METHODS: We analyzed prospectively collected data on 3,787 patients with a left ventricular ejection fraction < or = 40% who underwent coronary angiography. Patients were considered to have ischemic cardiomyopathy (n = 3,112) if they had a history of myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery or at least one major epicardial coronary artery with > or = 75% stenosis; all others were considered to have nonischemic cardiomyopathy (n = 675). RESULTS: The median age, ejection fraction and proportion of patients with New York Heart Association functional class III or IV symptoms for the nonischemic and ischemic groups were 55 years versus 63 years, 27% versus 32% and 57% versus 25%, respectively. After adjustment for baseline clinical risk factors and presenting characteristics, ischemic etiology remained an important independent predictor of 5-year mortality (p < 0.0001). The extent of coronary artery disease was a better predictor of survival than ischemic or nonischemic etiology (log likelihood chi-square 700 vs. 675, respectively). CONCLUSIONS: Ischemic etiology is a significant independent predictor of mortality in patients with cardiomyopathy. However, the extent of coronary artery disease contributes more prognostic information than the clinical diagnosis of ischemic or nonischemic cardiomyopathy. Further research is needed to refine the clinical definition of ischemic cardiomyopathy so that physicians can appropriately prescribe treatment and accurately predict outcome.

Racial variation in the use of coronary-revascularization procedures. Are the differences real? Do they matter?

BACKGROUND: Studies have reported that blacks undergo fewer coronary-revascularization procedures than whites, but it is not clear whether the clinical characteristics of the patients account for these differences or whether they indicate underuse of the procedures in blacks or overuse in whites. METHODS: In a study at Duke University of 12,402 patients (10.3 percent of whom were black) with coronary disease, we calculated unadjusted and adjusted rates of angioplasty and bypass surgery in blacks and whites after cardiac catheterization. We also examined patterns of treatment after stratifying the patients according to the severity of disease, angina status, and estimated survival benefit due to revascularization. Finally, we compared five-year survival rates in blacks and whites. RESULTS: After adjustment for the severity of disease and other characteristics, blacks were 13 percent less likely than whites to undergo angioplasty and 32 percent less likely to undergo bypass surgery. The adjusted black:white odds ratios for receiving these procedures were 0.87 (95 percent confidence interval, 0.73 to 1.03) and 0.68 (95 percent confidence interval, 0.56 to 0.82), respectively. The racial differences in rates of bypass surgery persisted among those with severe anginal symptoms (31 percent of blacks underwent surgery, vs. 45 percent of whites, P<0.001) and among those predicted to have the greatest survival benefit from revascularization (42 percent vs. 61 percent, P<0.001). Finally, unadjusted and adjusted rates of survival for five years were significantly lower in blacks than in whites. CONCLUSIONS: Blacks with coronary disease were significantly less likely than whites to undergo coronary revascularization, particularly bypass surgery - a difference that could not be explained by the clinical features of their disease. The differences in treatment were most pronounced among those predicted to benefit the most from revascularization. Since these differences also correlated with a lower survival rate in blacks, we conclude that coronary revascularization appears to be underused in blacks.

The mortality of Ontario undertakers and a review of formaldehyde-related mortality studies.

In a study of the mortality of Ontario undertakers, a cohort of 1,477 men first licensed during 1928 through 1957 was followed up until the end of 1977. Numbers of observed and expected deaths were determined for the period 1950 through 1977, using mortality rates of Ontario men as the standard. In all, 319 persons had died, compared with 322 expected. Ontario undertakers were not at increased risk of death from cancers at sites of contact with formaldehyde. Cirrhosis of the liver (standardized mortality ratio, 238) and chronic rheumatic heart disease (standardized mortality ratio, 199) were the only causes of death found to be significantly in excess. The data are discussed in the context of current epidemiologic information on the mortality experience of persons exposed to formaldehyde.