Simultaneous assessment of coronary flow reserve and left ventricular function during vasodilator stress evaluated by 13N-ammonia hybrid PET/MRI.

AIM: To explore changes in left ventricular (LV) function and the relationship of these changes with myocardial blood flow (MBF) evaluated by 13N-ammonia hybrid positron-emission tomography (PET)/magnetic resonance imaging (MRI) during vasodilator stress in patients with suspected coronary artery disease (CAD). MATERIALS AND METHODS: Fifty-two consecutive patients with suspected CAD, who underwent 13N-ammonia PET/MRI, were enrolled. Vasodilator stress was induced by intravenous injection of adenosine. MBF and coronary flow reserve (CFR) were calculated from dynamic acquisition of 13N-ammonia PET. LV function was evaluated by MRI both at rest and during vasodilator stress. An abnormal perfusion on myocardial images was defined as a summed difference score of ≥4. RESULTS: MRI showed that the LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction (LVEF) remained unchanged during vasodilator stress in all patients (n=52) as well as in the patients with CFR of <2 (n=27), stress MBF of <1.3 ml/g/min (n=28), abnormal myocardial perfusion (n=30), and more than one diseased vessel (n=46). In only four patients, the LVEF measured by MRI decreased by >5% during vasodilator stress. In these four patients, CFR was lower (1.57 ± 0.12 versus 2.18 ± 0.86, p<0.01) and the number of diseased vessels was higher (2.75 ± 0.50 versus 1.48 ± 0.92, p<0.01) than in patients without post-stress LV dysfunction. CONCLUSION: The LV volume and systolic function evaluated by cardiac MRI remained unchanged during vasodilator stress; however, LV dysfunction during vasodilator stress may occur in patients with severe CAD.

Geospatial patterns of access to self-care resources for obesity among endometrial cancer survivors in a high poverty urban community.

OBJECTIVE: To examine endometrial cancer survivors' access to recommended obesity-related self-care resources. METHODS: Participants included women treated 2010-2015 for endometrial cancer at an academic medical center who lived in the surrounding 16 ZIP code area on Chicago's South Side. Demographic and health data were abstracted from medical records. A socioeconomic status (SES) score (SES-1 = low, SES-5 = high) was generated for each patient using census block group-level data. Self-care resources for exercise, healthy weight, and diet were obtained from a community resource census. Geospatial techniques assessed "walkable access" (~½-mile radius around a patient's home) to obesity-related resources. Multivariable logistic regression investigated associations between access to obesity-related resources and patient characteristics. RESULTS: Of 195 endometrial cancer survivors, 81% identified as Black/African American and 34% lived in an SES-1 census block. Two thirds (68%) had Stage I or II endometrial cancer. Nearly two thirds (62%) were obese (BMI ≥ 30 kg/m2). Obesity was inversely associated with SES (p = 0.05). Two thirds of survivors had access to at least one of all three recommended resource types. Access was lower in low SES regions and among Black/African American women. Lower SES was associated with lower odds of walkable access to recommended resources (AOR for access to two of each resource type 0.75, 95%CI 0.59, 0.97; AOR for access to three or more of each 0.44, 95%CI 0.32, 0.61). CONCLUSIONS: Obesity rates were higher and access to recommended resources was lower for Black/African American endometrial cancer survivors living in high poverty areas in Chicago.

Risk assessment of recent Egyptian H5N1 influenza viruses.

Highly pathogenic avian influenza (HPAI) viruses of the H5N1 subtype are enzootic in poultry populations in different parts of the world, and have caused numerous human infections in recent years, particularly in Egypt. However, no sustained human-to-human transmission of these viruses has yet been reported. We tested nine naturally occurring Egyptian H5N1 viruses (isolated in 2014-2015) in ferrets and found that three of them transmitted via respiratory droplets, causing a fatal infection in one of the exposed animals. All isolates were sensitive to neuraminidase inhibitors. However, these viruses were not transmitted via respiratory droplets in three additional transmission experiments in ferrets. Currently, we do not know if the efficiency of transmission is very low or if subtle differences in experimental parameters contributed to these inconsistent results. Nonetheless, our findings heighten concern regarding the pandemic potential of recent Egyptian H5N1 influenza viruses.

Clinicians' prescribing practices for bariatric surgery patients: is there an issue?

WHAT IS KNOWN AND OBJECTIVES: Patients undergoing Roux-en-Y gastric bariatric (RYGB) surgery present a reduced absorption site, and special attention should therefore be taken when prescribing oral-dosage forms. This study was carried out to investigate the extent to which non-bariatric clinicians are aware of this issue when prescribing medicines for this population, and what type of information is available to aid them in their decision-making. METHODS: Two questionnaires were created, one for non-bariatric clinicians and another for their patients who had undergone RYGB surgery, to gather information about the prescription practices for this population. Additionally, a literature search of pharmacokinetic studies on bariatric patients and recommended prescription practices was carried out. RESULTS AND DISCUSSION: Of the 62 non-bariatric clinicians surveyed, 50% believed RYGB surgery interferes with drug absorption; however, 68% still prescribed tablets as the first choice form of dosage. Young clinicians (35%) were less likely to believe that RYGB surgery could affect drug absorption than experienced clinicians (43%). The main reasons for changing dosage forms were patient complaints about efficacy or difficulty in swallowing tablets. Of the 73 patients, 43 were taking drugs in tablet form after the surgery, 24 of whom had health issues unrelated to the surgery. None of the journals read by the clinicians contained pharmacokinetics (PK) studies involving bariatric surgery patients or presented recommendations for the prescription of oral-dosage forms for this population. The literature search revealed a total of 22 drugs that had undergone PK studies in RYGB patients. Fifteen of them were reported to have decreased effects, 12 of which were administered as tablets. WHAT IS NEW AND CONCLUSION: There is still a relative lack of clinical evidence to guide clinicians when prescribing medicines for bariatric patients. It is therefore recommended that pharmacists should have greater participation in the prescription process to advise non-bariatric clinicians and educate RYGB surgery patients to help avoid therapeutic failure.

Design of ridge filters for spread-out Bragg peaks with Monte Carlo simulation in carbon ion therapy.

Spread-out Bragg peaks made by ridge filters or wheel range modulators are used in charged particle therapy with passive methods to achieve uniform biological responses in irradiated tumors. Following the biological responses needed to design the ridge filters, which were developed at the National Institute of Radiological Sciences in Japan, new ridge filters were designed using recent developments in heavy-ion reactions and dosimetry. The Monte Carlo code of Geant4 was used to calculate the qualities of carbon ion beams in a water phantom. The results obtained from the simulation were corrected so that they agreed with the measurements of depth dose distributions. The calculations of biological responses to fragments other than carbon ions were assumed to be for helium ions. The measured dose distributions with the designed ridge filters were compared to the calculated distributions. A beam modifying system using this adaptable method was successively applied to carbon ion therapy at Gunma University.

Assessing gynecologic and breast cancer survivors' sexual health care needs.

BACKGROUND: The objective of this study was to identify patterns of interest in receiving care for sexual concerns among women who were survivors of gynecologic and breast cancers. METHODS: Survey and medical records data were collected from June 2008 to March 2009 from 261 gynecologic and breast cancer patients. Logistic regression was used to estimate the effect of age and months since treatment on interest in receiving sexual healthcare. RESULTS: The mean participant age was 55 years (range, 21-88 years). Only 7% of women had recently sought medical help for sexual issues, yet 41.6% were interested in receiving care. Greater than 30% responded that they would be likely to see a physician to address sexual matters, and 35% of all women were willing to be contacted if a formal program was offered. Compared with older women (aged >65 years), younger women (ages 18-47 years) were significantly more likely to report interest in receiving care to address sexual issues (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.14-7.54) and to see a physician to address sexual matters (OR, 4.51; 95% CI, 1.51-13.43), and they were more willing to be contacted for a formal program (adjusted OR [AOR], 5.00; 95% CI, 1.63-15.28). Compared with women who were currently in treatment, women who last received treatment >12 months previously were significantly more interested in receiving care (AOR, 2.02; 95% CI, 1.02-4.01) and were more willing to be contacted (AOR, 2.49; 95% CI, 1.18-5.26). CONCLUSIONS: Greater than 40% of survivors expressed interest in receiving sexual healthcare, but few had ever sought such care. The current results indicated that there is an unmet need for attention to sexual concerns among women with gynecologic and breast cancers.

Novel quantitative assessment of myocardial perfusion by harmonic power Doppler imaging during myocardial contrast echocardiography.

OBJECTIVE: To test the hypothesis that the power of the received signal of harmonic power Doppler imaging (HPDI) is proportional to the bubble concentration under conditions of constant applied acoustic pressure, and to determine whether a new quantitative method can overcome the acoustic field inhomogeneity during myocardial contrast echocardiography (MCE) and identify perfusion abnormalities caused by myocardial infarction. METHODS: The relation between Levovist concentration and contrast signal intensity (CI) of HPDI was investigated in vitro under conditions of constant acoustic pressure. MCE was performed during continuous infusion of Levovist with intermittent HPDI every sixth cardiac cycle in 11 healthy subjects and 25 patients with previous myocardial infarction. In the apical views myocardial CI (CI(myo)) was quantified in five myocardial segments. The CI from the left ventricular blood pool adjacent to the segment was also measured in dB and subtracted from the CI(myo) (relative CI (RelCI)). RESULTS: CI had a logarithmic correlation and the calculated signal power a strong linear correlation with Levovist concentration in vitro. Thus, a difference in CI of X dB indicates a microbubble concentration ratio of 10(X/10). In normal control subjects, CI(myo) differed between the five segments (p < 0.0001), with a lower CI(myo) in deeper segments. However, RelCI did not differ significantly between segments (p = 0.083). RelCI was lower (p < 0.0001) in the 39 infarct segments (mean (SD) -18.6 (2.8) dB) than in the 55 normal segments (mean (SD) -15.1 (1.6) dB). RelCI differed more than CI(myo) between groups. CONCLUSIONS: The new quantitative method described can overcome the acoustic field inhomogeneity in evaluation of myocardial perfusion during MCE. RelCI represents the ratio of myocardium to blood microbubble concentrations and may correctly reflect myocardial blood volume fraction.

Alcohol consumption, homeostasis model assessment indices and blood pressure in middle-aged healthy men.

A total of 1595 middle-aged healthy men consuming alcohol up to 120 ml per day and 538 without alcohol consumption were recruited from an occupational population, and their insulin resistance (IR) and beta-cell function (BC) were measured using the homeostasis model assessment (HOMA-IR and HOMA-BC), and the associations with alcohol consumption, blood pressure (BP), and serum gamma-glutamyltransferase (GGT) levels were analysed cross-sectionally. Both HOMA-IR and HOMA-BC were decreased with increasing alcohol consumption, but HOMA-BC corresponding to a level of HOMA-IR was 4-10 and 8-20% lower in drinkers consuming less than 60 ml of alcohol per day and those consuming more, respectively, than in nondrinkers, suggesting an altered fasting serum insulin-glucose relationship in alcohol consumers. Although BP was higher and HOMA-IR was lower in alcohol consumers than in nonconsumers, BP was higher at higher HOMA-IR irrespective of alcohol consumption. Elevations of serum GGT were positively associated with BP and HOMA-IR in both alcohol consumers and nonconsumers. Multiple regression analyses in the subjects showed that elevated serum GGT was an independent contributor to HOMA-IR elevations, and both serum GGT and HOMA-IR were significantly related to BP elevations after adjusting for alcohol consumption, age, body mass index, cigarette consumption, and physical activity at leisure. Although cross-sectional observations do not provide evidence of causal association, the results suggest that elevated serum GGT in alcohol consumers relates to elevations of IR and that the elevated insulin resistance relates, at least partly, to BP elevations in alcohol consumers.

On the biopsychosocial model: the example of political economic causes of diabetes in the Marshall Islands.

Biomedical reductionism, the unwritten theory underlying the practice of medicine, is being supplanted by the biopsychosocial model. The explanatory power of the biopsychosocial model, however, is hampered by an inadequate mechanism to account for the social production of disease. We examine diabetes in the Marshall Islands to explore a conceptual approach that incorporates ecology, history, and political economy into the biopsychosocial model. The use of the Marshall Islands by the United States as testing grounds for nuclear war has led to ecological destruction, population displacement, and economic dependency. The consequence at the biological level has been an epidemic of weight gain, altered metabolism, and diabetes. A political economic perspective reveals that such outcomes are the result of decisions made by those who do not live with these decisions. Such a perspective points the way for social engagement and political work toward justice and health.

Cultural competence: a proposal for physicians reaching out to Native Hawaiian patients.

Many physicians of Native Hawaiian ancestry, as well as others, have noted a cultural gap between themselves and their Native Hawaiian patients. This cultural gap could potentially lead to discordance in the physician-patient relationship, and in turn, result in less than adequate therapeutic outcomes. Native Hawaiian physicians and those who treat Native Hawaiian patients are seeking ways to improve therapeutic relationships. Developing cultural competency in Native Hawaiian physicians and those who treat Native Hawaiian patients may be expected to improve therapeutic relationships. Principles of cultural competency, including increasing awareness of self and others, enhancing one's cultural knowledge base, and developing skills to communicate effectively, could be applied to physician-patient encounters with Native Hawaiian patients. The principles and skills of cultural competency could be learned during the formal and continuing medical education process. Developing an educational system that promotes cultural competency in physicians is necessary to address the health needs of Native Hawaiians and other diverse populations in Hawai'i.

Usefulness of early diastolic flow propagation velocity measured by color M-mode Doppler technique for the assessment of left ventricular diastolic function in patients with hypertrophic cardiomyopathy.

Flow propagation velocity (FPV) of left ventricular (LV) filling flow has been shown to be a useful index for the evaluation of LV diastolic function, which is relatively independent of preload in myocardial infarction and dilated cardiomyopathy, but the usefulness of FPV for hypertrophic cardiomyopathy (HCM) has not yet been determined. In 23 HCM patients and 26 control subjects, peak transmitral flow velocities in early diastole (E) and during atrial contraction (A), E/A ratio, deceleration time of E velocity, and isovolumic relaxation time were measured with the conventional Doppler technique, and FPV was measured from color M-mode Doppler images of LV filling flow. The time constant of LV isovolumic pressure decay (tau) was measured by a micro-manometer-tipped catheter in all HCM patients and 13 control subjects. Flow propagation velocity was significantly lower and deceleration time was significantly greater in HCM patients than in the control subjects, though no significant differences were observed in the other noninvasive indexes. Tau was significantly prolonged in HCM patients compared with that of control subjects (54+/-12 cm/s and 32 +/-7 cm/s, respectively; P<.0001). While the conventional indexes did not correlate with tau among the 36 patients in whom invasive studies were performed, FPV correlated well with tau (r = -0.76, P<.0001). Flow propagation velocity is a useful noninvasive index for the assessment of LV diastolic function in patients with HCM.

[Intraoperative assessment by laser-Doppler skin blood flowmetry of the efficacy of endoscopic thoracic sympathectomy].

We have investigated whether laser-Doppler (L-D) skin blood flowmetry on the finger could be useful for an intraoperative assessment of the efficacy of endoscopic thoracic sympathectomy (ETS) under general anesthesia. Subjects were 5 young adults receiving ETS for palmar hyperhidrosis. ETS was performed with the patients in the semi-sitting position under one lung ventilation. A pair of LDF probes were placed on the palmar side of the both second fingers. Palmar hyperhidrosis disappeared after ETS in all cases, but compensatory hyperhidrosis developed in the back of the body and the thigh. After completion of ETS on one side, the L-D skin blood flow increased to 267.6 +/- 211.1% on the side of ETS, and it increased in 2 other cases and decreased on the contrary in 3 cases on the other side. After ETS on both sides the L-D skin blood flow increased to 265.0 +/- 185.9% on the side of initial ETS and to 211.4 +/- 172.8% on the side of subsequent ETS. The initial EST induced reflex vasoconstriction on the finger of both sides and also on the toe. Spontaneous fluctuation and reflex vasoconstriction of the skin blood flow were still observed, although the periodicity of spontaneous fluctuation between the right and the left finger was lost in some of the cases. An increase in L-D skin blood flow on the side of ongoing ETS is useful for intraoperative assessment of ETS.

Assessment of myometrial invasion at the invasion site of an endometrial carcinoma by ultrasonography along with an intrauterine catheter.

OBJECTIVES: To evaluate by transvaginal ultrasonography (TVU) the thickness of the intact myometrium at the presumed tumor-origin site and to establish criteria for a half myometrial invasion. METHODS: A total of 19 successive patients with endometrial cancer who were treated between January 1, 1997, and January 31, 1998, participated in this study. TVU mode B with and without the use of an intrauterine silicon catheter was performed. RESULTS: Using a catheter, the origin site was correctly detected in 15 cases (79%). The best criterion for half myometrial invasion was a 6-mm thickness of the intact myometrium at the origin site. The sensitivity/specificity/accuracy of TVU with the use of a catheter in cases with the correct estimated origin site, were 1.00/0.67/0.86 for myometrial invasion < 1/2, and 0.67/1.00/0.86 for myometrial invasion > or = 1/2. CONCLUSION: It is of value to use 6-mm as the criterion for the thickness of the intact myometrium at the estimated tumor-origin site in connection with TVU with the use of a catheter for preoperatively assessing half myometrial invasion.

[Cost effectiveness analysis of FDG-PET in the differential diagnosis and staging of lung cancer in Japan].

UNLABELLED: Several studies have shown that FDG-PET is more accurate than CT for the differential diagnosis and for the staging of lung cancer. We have analyzed potential effect of FDG-PET on the medical cost for the management of patients suspected of lung cancer. In the differential diagnosis, chest CT plus FDG-PET protocol reduced the number of bronchofiberscope (BFS) and biopsy by one fourth of that in the conventional protocol using CT alone. PET protocol reduced unnecessary examinations for the patients of benign disease, however, it increased the total cost of examinations by 25% due to the higher cost of PET than that of BFS and biopsy in Japan. In the staging of lung cancer, PET protocol improved accuracy of staging, reduced unnecessary surgery by 67%, and showed a saving of the cost of examination by 5%, and the total medical cost by 2.5% compared to that in the conventional protocol using CT, brain MRI, and bone scan. CONCLUSION: Use of FDG-PET for the staging may contribute to the improvement of patient management of lung cancer patients also to the saving of the medical cost.

Assessment of cancer recurrence in residual tumors after fractionated radiotherapy: a comparison of fluorodeoxyglucose, L-methionine and thymidine.

UNLABELLED: This study evaluates the midterm follow-up of tumor and normal tissue uptake of deoxyglucose, thymidine and methionine after fractionated radiotherapy to assess cancer recurrence in residual tumors. METHODS: AH109A tumor-burdened rats were treated with one to eight doses of 5Gy 60Co radiation. Tissue distribution study with 18F-FDG, 3H-thymidine and 14C-methionine, double-tracer autoradiography with 18F-FDG and 14C-methionine, and single-tracer autoradiography with 14C-labeled deoxyglucose, thymidine and methionine were performed 6 days after the end of therapy. RESULTS: Dose response study shows a significant decrease of tumor uptake of all tracers after two and more doses, even in the case of later recurrence. Whereas 3H-Thd and 14C-Met tumor uptake was similar to that of normal muscle, 18F-FDG tumor uptake remains higher than that of muscle, even in the case of complete tumor cure. The irradiated muscle shows a higher 18F-FDG uptake than the nonirradiated muscle. Autoradiography after eight doses (100% tumor cure) reveals elevated 14C-DG tumor uptake to be ascribable to nonmalignant cellular elements, in particular to a macrophage layer at the rim of necrotic areas. Autoradiography after four and six doses (33% and 57% tumor cure) shows the highest methionine and thymidine uptake in viable cancer cells, whereas deoxyglucose uptake did not differ between viable cancer cells and macrophages. CONCLUSION: To detect and differentiate viable cancer cells in a residual tumor mass after radiotherapy, PET using 11C-methionine or 11C-thymidine may have some advantages over 18F-FDG, especially if the residual tumor includes larger areas of necrosis.

Comparison of serum 7S fragment of type IV collagen and serum central triple-helix of type IV collagen for assessment of liver fibrosis in patients with chronic viral liver disease.

BACKGROUND/AIMS: A competitive radioimmunoassay for serum 7S fragment of type IV collagen (7S collagen) using a polyclonal antibody against 7S collagen and a sandwich enzyme immunoassay for serum central triple-helix of type IV collagen (IV collagen) using two monoclonal antibodies against the pepsin-solubilized type IV collagen may be used as diagnostic aids for liver fibrosis in clinical medicine. We compared the clinical usefulness for assessing liver fibrosis of serum 7S collagen and IV collagen tests in chronic viral liver diseases, and also examined the elution pattern of 7S collagen- and IV collagen-related antigens in serum by gel filtration analysis. METHODS: Serum 7S collagen and IV collagen levels were assayed in 151 patients with chronic viral liver disease and 30 healthy control subjects. RESULTS: Gel filtration on the Sephacryl S400HR column revealed that the 7S collagen antigenicity in serum was heterogeneous, whereas the IV collagen antigen in serum was uniform in size. Serum levels of 7S collagen and IV collagen showed increases closely correlated with the severity of liver disease. The abnormal percentage of 7S collagen in three patient groups was similar to that of IV collagen in the corresponding groups. Serum 7S collagen and IV collagen levels were strongly correlated with the histological degree of liver fibrosis; the correlation coefficients were r = +0.675 for 7S collagen and r = +0.665 for IV collagen. When we assessed the ability of each test to detect cirrhosis with a receiver operating curve, the serum 7S collagen test was a slightly better marker than the serum IV collagen test. For the detection of cirrhosis, serum 7S collagen was 83% sensitive and 88% specific at a cutoff value of 9 ng/ml, and serum IV collagen was 80% sensitive and 81% specific at a cutoff value of 160 ng/ml. CONCLUSIONS: These findings suggested that serum 7S collagen and IV collagen tests are similarly useful for assessing liver fibrosis in patients with chronic viral liver disease, although the former is slightly better for diagnosing cirrhosis than the latter.

Clinical assessment of oxygen delivery and consumption during hypotensive anaesthesia--a clinical application of The Deep Picture.

Usual evaluation of the relationship between oxygen delivery (DO2) and oxygen uptake (VO2) is based on the arterial oxygen tension (pO2), oxygen saturation (sO2), haemoglobin concentration (ctHb), the same indicators in mixed venous blood and cardiac output, sometimes supplemented by the expiratory carbon dioxide concentration. And, so far, the relationship among DO2, VO2 and the new parameters for an evaluation of oxygen status (oxygen extraction tension: px, concentration of extractable oxygen: cx, oxygen compensation factor: Qx) (1) has not been discussed enough. Therefore, this study was designed to evaluate whether the new parameters give the clinically significant information to analyse the relationship between DO2 and VO2 during the acute haemodynamic change with intentionally induced hypotension in anaesthetized adult patients.

An international analysis of smoking control levels in relation to health, social and economic indicators.

The relationship was examined between government smoking control levels and eight health, social and economic indicators in 93 countries. Governmental smoking control levels were quantified by assigning a point to each control measure. The controls were as follows: health warning on cigarette package; tar, nicotine or carbon monoxide level indications on cigarette package; ban on advertising on TV or radio; and prohibiting sales to minors. The eight indicators were annual rate of population increase, infant mortality rate, population per hospital bed, number of TV sets per 1000 people, protein supply per capita per day, military expenditure as % of GNP, gross national product (GNP) and % of primary school enrollment. We analyzed predictors of the smoking control level using multiple linear regression analysis with these eight indicators. This regression model indicates that the higher the GNP is, the stronger the smoking control level is, and GNP alone accounts for 42% of the variance in smoking control levels. The set of eight indicators explained 49% of it. GNP had the largest partial regression coefficient in the standardized model. Therefore, a low GNP might be an important factor behind the difficulty in strengthening government controls on smoking.

[Educational courses for the teaching staffs of exercises for health promotion].

The new Industrial Safety and Health Law in Japan, published in 1988, not only has improved the protection of workers against hazards or other risk factors at work, but also has implemented the health promotion of workers. In order to improve their health, factors on workers' daily-lifestyle, including smoking, alcohol consumption, nutrition and exercise, have to be modified to increase well-being. As exercise is one of the most important factors in health promotion, a fundamental knowledge of exercise physiology and exercise prescription is essential for the occupational physician. As various staffs for evaluation and consultation of the workers' exercise ability are necessary, different Ministries and associations have made efforts to educate several kinds of staff members, including doctors for sports medicine, and exercise and/or fitness-instructors. The state of educational courses for the teaching staffs of exercise for health promotion is discussed.