[Clinical value of dual source computerized tomography in primary diagnosis of coronary heart disease]. / Klinische Wertigkeit der Dual-Source-Computertomographie (DSCT) in der Primärdiagnostik der koronaren Herzkrankheit.

UNLABELLED: Dual-source-CT-technology (DSCT) improves temporal resolution of cardiac computed tomography to 83 ms per heart-phase. In this study, the clinical performance of this new method is evaluated. MATERIALS AND METHODS: In fifty patients (33 male, 17 female; age 50 +/- 13 years) with suspected coronary heart disease, CT angiography (slice thickness 0.75 mm, contrast-agent 60-80 ml iomeprol) was performed with a Somatom Definition scanner. Based on the coronary 15-segment-model of the AHA, scores for image quality and lumen reduction were established to enable the observer, to give recommendations for further therapy. RESULTS: Out of 750 possible AHA-segments, 655 were depicted (87.3%). 591 segments (90.2%) were assessed without any limitation of quality, 49 (7.5%) segments showed moderate, and 15 (2.3%) segments severe limitation in image quality. 508 (77.6%) segments were without pathological findings, 92 (14.0%) segments had minimal atherosclerotic lesions, 42 (6.4%) segments suffered from stenoses with lumen reduction less than 70%, and 13 (2.0%) showed significant stenoses of more than 70%. In 31 patients (62%), coronary heart disease was ruled out by CT angiography without any need for further non-invasive or invasive diagnostics. 8 patients (16%) underwent stress-testing for ischemia. In 11 (22%) patients coronary angiography was recommended, and DSCT findings were confirmed in 10 cases. Only one LCx stenosis was overestimated in DSCT. CONCLUSION: Contrast-enhanced DSCT is a powerful tool in diagnosis of coronary heart disease. 98% of coronary segments could be assessed in diagnostic quality, and at least 90% of haemodynamically significant coronary stenoses were detected.

The expression of dentin sialophosphoprotein gene in bone.

Dentin sialoprotein (DSP) and dentin phosphoprotein (DPP) are expressed as a single mRNA transcript coding for a large precursor protein termed dentin sialophosphoprotein (DSPP). DSP, DPP, and DSPP have been considered to be tooth-specific. To test for the expression of the dspp gene in bone, we performed Western immunoblots and reverse-transcription polymerase chain-reaction (RT-PCR). With Western immunoblots, we detected DSP in the Gdm/EDTA extracts of rat long bone, at a level of about 1/400 of that in dentin. Using RT-PCR, we detected DSPP mRNA in mouse calvaria. Similar to Western immunoblots, the results of RT-PCR indicated that the dspp gene is expressed at a lower level in bone than in dentin and odontoblasts. Analysis of the data shows that DSPP is not a tooth-specific protein, and that dramatically different regulatory mechanisms governing DSPP expression are involved in the bone and dentin.

Osteopontin posttranslational modifications, possibly phosphorylation, are required for in vitro bone resorption but not osteoclast adhesion.

Osteopontin (OPN), a phosphorylated bone matrix glycoprotein, is an Arg-Gly-Asp (RGD)-containing protein that interacts with integrins and promotes in vitro attachment of a number of cell types, including osteoclasts. Gene knockout experiments support the idea that OPN is important in osteoclastic activity. We hypothesize that posttranslational modifications (PTMs) of OPN can influence its physiological function. Previous studies have suggested that phosphorylation of OPN and bone sialoprotein (BSP) is necessary for promoting osteoclast adhesion. However, no reports have explored the importance of phosphoserines and other PTMs in OPN-promoted bone resorption. To study this question, we determined the activities of different forms of OPN and BSP in three in vitro assays: attachment of osteoclasts; formation of actin rings; and bone resorption. For each assay, cells were incubated for 4-24 h, in the presence or absence of RGDS or RGES peptides, to test the involvement of integrin binding. In addition to OPN, activities of milk OPN (fully phosphorylated) and recombinant OPN (rOPN, no phosphate) were compared. We purified two forms of OPN (OPN-2 and OPN-5), which differ in the level of phosphorylation, and compared their activities. For comparison, the activities of BSP and recombinant BSP (rBSP) were determined. All forms of OPN, including rOPN, significantly increased attachment of tartrate-resistant acid phosphatase (TRAP)-positive osteoclasts. BSP and rBSP also promoted cell attachment. After 4 h of incubation, the proportion of cells with actin rings was increased with OPN, milk OPN, and BSP. In the presence of RGDS peptide, osteoclast retraction and the disruption of actin rings were observed, whereas no effect was seen with RGES. In the resorption assay, the number of pits and the total resorbed area per slice were increased in the presence of OPN, milk OPN, and BSP. As in other assays, the OPN enhancement of resorption was inhibited by RGDS, but not RGES, peptides. Significantly, rOPN and rBSP did not promote bone resorption. OPN-5 promoted resorption to a greater extent than OPN-2, and milk OPN significantly stimulated resorption to a greater extent than OPN. Our data suggest that: (1) the RGD sequence of OPN is essential in OPN-mediated cell attachment, actin ring formation, and bone resorption; and (2) some form of PTM, possibly phosphorylation, is necessary for in vitro osteoclastic bone resorption, but not for cell attachment and actin ring formation.

COPD may increase the incidence of refractory supraventricular arrhythmias following pulmonary resection for non-small cell lung cancer.

PURPOSE: This study investigated the association of COPD and postoperative cardiac arrhythmias, specifically supraventricular tachycardia (SVT), as well as mortality in patients undergoing pulmonary resection for non-small cell lung cancer (NSCLC). METHODS: A retrospective chart review of 244 patients who had undergone lung resection for NSCLC at Indiana University Hospital between 1992 and 1997 was undertaken. COPD, which was defined as an FEV(1) of < or = 70% predicted and an FEV(1)/FVC ratio of < or = 70% based on the results of a preoperative pulmonary function test (PFT), was diagnosed in 78 of the 244 patients (COPD group). In the remaining 166 patients, the results of preoperative PFTs did not meet these criteria (non-COPD group). Both groups were otherwise well-matched with respect to multiple variables, including age, comorbid conditions, extent of pulmonary resection, and final pathologic stage. The incidence of cardiac arrhythmias and operative mortality were compared between the two groups using univariate and multivariate analysis. RESULTS: Seventy-six patients (31.9%) experienced new onsets of postoperative SVT, with 58 of these patients (76.3%) demonstrating atrial fibrillation. The COPD group had a 58.7% incidence of SVT (n = 44) compared to a 27.0% incidence (n = 44) in the non-COPD group (p < 0.0 0 1). Moreover, following initial digoxin therapy, the COPD group required more second-line antiarrhythmic therapy than did the non-COPD group (66.7% vs 37.8%, respectively; p = 0.0 03). Overall, there were 16 operative deaths (6.6%), and the mortality rate was significantly higher in the COPD group (14.1%) than in the non-COPD group (3.0%; p = 0.0 04). Patients who developed SVT had a significantly longer hospital course than did patients who did not (p < 0.0001). Thirteen of the 16 patients who died experienced SVT; however, SVT was not an independent risk factor for death. Finally, of the 19 variables evaluated, major resection (ie, pneumonectomy and bilobectomy) and COPD were identified as independent risk factors for the development of cardiac arrhythmias (p = 0.0 033 and p = 0.0 009, respectively). CONCLUSION: Patients with COPD, as defined by the results of preoperative PFTs, are at significantly higher risk for SVT, and in particular SVT refractory to digoxin, following pulmonary resection for NSCLC. Although SVT was not an independent risk factor for death, a significantly longer hospitalization was observed.

Defibrillation efficacy comparing a subcutaneous array electrode versus an "active can" implantable cardioverter defibrillator and a subcutaneous array electrode in addition to an "active can" implantable cardioverter defibrillator: results from active can versus array trials I and II.

INTRODUCTION: Placement of implantable cardioverter defibrillators (ICDs) has been simplified by using the shell of a pectorally implanted ICD as a defibrillation electrode in combination with an endocardial right ventricular defibrillation lead. However, a sufficiently low defibrillation threshold (DFT) cannot be obtained in a few patients. Therefore, alternative approaches were systematically tested in the Active Can versus Array Trial (ACAT). METHODS AND RESULTS: In the first of two prospective randomized studies, the DFT of a subcutaneous left dorsolateral array anode introduced from a pectoral incision was compared to that of a standard active can anode in 68 patients. Intraoperatively, the DFT was determined twice in each patient using either the active can or, in patients with a subcutaneous array lead, once with all three fingers and once omitting the middle finger of the array. The second prospective randomized study included 40 patients. DFT also was determined twice in each patient using an active can in a left pectoral position as anode alone and combined with a left dorsolateral array electrode with two fingers. In ACAT I, stored energy at DFT decreased from 13.1+/-7.7 J (active can) to 9.6+/-6.1 J (three-finger array lead) (P = 0.04), impedance decreased from 53+/-8 ohms to 40+/-6 ohms (P < 0.0001). Omitting the middle finger of the array lead, stored energy at DFT increased by 0.9 J (P = 0.47) and impedance by 2 ohm (P < 0.0001). In ACAT II, DFT and impedance using an active can device were significantly lower when a two-finger array lead was added that decreased stored energy at DFT from 10.1+/-5.2 J to 6.9+/-3.9 J (P = 0.001) and impedance from 56+/-5 1 to 42+/-5 l (P < 0.0001). CONCLUSION: In combination with a right ventricular defibrillation electrode, a left pectoral subcutaneous array lead improves defibrillation efficacy if used instead of, or in addition to, a left pectoral active can ICD device. Implantation of the array lead can be simplified by using two instead of three fingers, without a significant loss of defibrillation efficacy.

A comparative study of sialic acid-rich proteins in rat bone and dentin.

Four sialic acid-rich (SA-rich) proteins found in bone and dentin, osteopontin (OPN), bone sialoprotein (BSP), bone acidic glycoprotein-75 (BAG-75), and dentin matrix protein 1 (DMP1), share some common features. We used SDS-PAGE and Western immunoblots to analyze and compare SA-rich proteins in bone and dentin extracts from rats with a single chromatographic procedure. OPN was detected in dentin extracts, with a relative level less than one-seventieth of that in bone. Both bone and dentin BSP demonstrated an extremely broad distribution pattern, probably due to a high degree of heterogeneity in post-translational modifications. BAG-75 in both bone and dentin was detected as an 83 kDa band, dramatically distinct from that of DMPI. Using a polyclonal antibody raised against a purified bone 57 kDa protein (a portion of DMPI), we detected 150 kDa protein bands in bone fraction; the same bands were recognized by antirecombinant rat DMPI antibody. Bands from dentin migrating at about 150 kDa in earlier fractions and progressing to 200 kDa in later fractions showed a clear immunoreactivity to the anti-57 kDa antibody. We conclude that the majority of DMPI in rat bone is processed into fragments, whereas that in dentin remains intact.

[Multi-slice spiral CT of the coronary arteries: clear vascular imaging using standard software]. / Mehrzeilen-Spiral-CT der Koronararterien: Ubersichtliche Gefässdarstellung unter Verwendung einer Standard-Software.

OBJECTIVE: To visualize the coronary arteries with a clear view and over a long distance by using data sets from contrast-enhanced computed tomography of the heart. MATERIAL AND METHODS: Image data of 151 patients suffering from coronary artery disease were calculated by means of retrospective triggering at four different diastolic delay times in contrast-enhanced CT. The large coronary segments were subsequently reconstructed in two planes with multiplanar volume reconstruction (MPVR)--a non-dedicated postprocessing software. RESULTS: On the pre-condition that data sets were acquired at sinus rhythm and at a heart beat rate lower than 65/min coronary arteries could be depicted over a long distance in single or double angulated reconstruction planes with the help of multiplanar volume reconstruction (MPVR). Time consumption for image reconstruction was reasonable. Additionally to the anatomy of the coronary arteries in two different planes, typical CT findings in occluding coronary artery disease are presented. CONCLUSION: Multiplanar volume reconstruction (MPVR) implemented on most workstations is a powerful and ideal postprocessing tool in reconstructing coronary arteries from contrast-enhanced CT data sets.

Clusters of ventricular tachycardias signify impaired survival in patients with idiopathic dilated cardiomyopathy and implantable cardioverter defibrillators.

OBJECTIVES: This retrospective study was undertaken to provide data on occurrence, significance and therapy of ventricular tachyarrhythmia (VT) clusters (VTCs) in patients with dilated cardiomyopathy (DCM) and implantable cardioverter defibrillators (ICDs). BACKGROUND: Data on the clinical significance of VTCs are lacking in patients with DCM and ICDs. METHODS: Baseline characteristics of 106 consecutive patients with DCM and ICDs were prospectively collected, and chart reviews and episode data retrospectively analyzed. A VTC was defined as > or =3 sustained VTs/24 h. RESULTS: During a mean follow-up of 33+/-23 months, 73 patients (68.9%) had recurrent VT or ventricular fibrillation (VF), 43 patients (40.6%) suffered only single VTs and 30 patients (28.3%) experienced 52 clusters of VTs. Actuarial survival free of VT or VF was 44.6%, 33.0% and 26.5%, and survival free of VTC was 77.3%, 72.2% and 67.1% after one, two and three years, respectively. Independent predictors of VT clusters were heart failure before ICD implantation (p = 0.033), presenting monomorphic VT (p = 0.044), EF <0.40 (p = 0.014) and inducible mVT, especially with right bundle branch block and superior axis configuration (p<0.001). Survival free of recurrent VTCs was 50.8%, 38.1% and 19.0% after one, two and three years, respectively. Once a VTC had occurred, only 56.7%, 46.4%, 30.9% and 15.5% of patients survived and were not transplanted after one, two, three and four years, respectively. Survival was even more reduced if a VTC was associated with cardiac decompensation: 65.6% and 21.9% after one and two years, respectively. CONCLUSIONS: Despite antiarrhythmic intervention, clusters of VTs occur and recur frequently in patients with DCM. They signify impaired survival, especially if they are associated with cardiac decompensation, and may be a harbinger of progressive myocardial deterioration rather than a primarily arrhythmic problem. The benefit of ICD therapy may therefore be low in these patients.

Thoracoscopic sympathectomy for hyperhidrosis palmaris: a periareolar approach.

Severe hyperhidrosis palmaris represents a disabling problem for many patients. Thoracoscopic techniques that involve dissection and removal of the upper thoracic sympathetic chain are believed to result in the lowest incidence of recurrent symptoms. However, aside from an axillary incision, an additional upper anterior chest wall approach is usually required. Over the past 2 years, we have used a periareolar incision in eight patients to improve postoperative cosmesis for this benign condition.

Is there a need for routine testing of ICD defibrillation capacity? Results from more than 1000 studies.

AIMS: Benefits and complications of postoperative implantable cardioverter-defibrillator tests are controversial matters. This study sought to assess the necessity of defibrillation function tests after implantation. METHODS AND RESULTS: We retrospectively analysed 1007 implantable cardioverter-defibrillator tests in 587 systems and 556 patients. Nine hundred and thirty implantable cardioverter-defibrillator tests (89.4%) were routinely performed. Seventy-one tests (7%) were performed after a change in the antiarrhythmic drug regimen and six tests (0.60%) because of a suspected dysfunction of the implantable cardioverter-defibrillator. During routine tests, four systems (0.4%) failed to defibrillate the patient. However, in all but one test, abnormalities of the system had been observed before the test. After the addition of antiarrhythmic drugs, two of 71 implantable cardioverter-defibrillator systems (2.8%) failed to defibrillate the patient. One of six systems tested due to a suspected dysfunction failed to defibrillate the patient. During 16 tests (1.6%), complications occurred. CONCLUSIONS: Our experience demonstrates that postoperative tests of the defibrillation function of implantable cardioverter-defibrillators rarely reveal dysfunctions. As testing is unpleasant for the patient and not free of complications, tests might be restricted to those patients in whom a dysfunction is suspected and to those patients in whom class I or class III antiarrhythmic drugs have been added to the antiarrhythmic drug regimen.

Validation of a life quality (LQ) test for asthma.

BACKGROUND: The American College of Allergy, Asthma, and Immunology (ACAAI) developed a questionnaire, the Life Quality (LQ) Test, for use in its Nationwide Asthma Screening Program. The test is intended as a tool to help individuals with breathing problems determine if they have asthma or, for those already diagnosed with asthma, if their asthma is under control. We attempted to assess whether the LQ Test was a valid tool for use in the screening program. OBJECTIVE: The objective of this study was to validate the LQ Test by determining whether a high score on the LQ Test is a positive predictor of a clinical diagnosis of asthma. METHODS: The 20-question LQ Test was prospectively distributed and self-administered to new patients on their first visit to an asthma and allergy clinic. Total LQ scores were recorded for each patient as the sum of all positive 'yes' responses to the test. All patients were subsequently diagnosed by an allergist as having asthma or not having asthma. The LQ Test also was administered to a group of individual patients who were seen in a dental office. This group of patients, who had no known breathing problems, served as a control. RESULTS: The clinic patients who were subsequently diagnosed with asthma had the highest average LQ score (9.31), 3.9 times higher than the average score for clinic patients diagnosed as not having asthma (2.39), and 8 times higher than the average score for the control group (1.15). CONCLUSION: Higher LQ scores correlate with a higher probability of a positive diagnosis, initially making the LQ Test questionnaire a valid tool to help predict which individuals are more likely to be diagnosed with asthma.

Risk factors associated with postoperative pulmonary complications following total abdominal hysterectomy.

The purpose of this descriptive correlational study was to describe the relationships between risk factors and the development of postoperative pulmonary complications (PPCs) following total abdominal hysterectomy (TAH). As part of a large, prospective study, data were analyzed on a subset of women who had undergone TAH. Data collection included a preoperative interview and chest exam followed by a daily postoperative interview, chest exam, and review of the medical chart. A multicriteria definition of PPC was used for atelectasis/pneumonia. This study describes the incidence of PPCs in a TAH surgical population and provides foundational work to begin identifying important risk factors to guide pulmonary care.

Esophageal cancer: an overview.

Esophageal cancer is the second most common solid intrathoracic malignancy behind lung cancer. Treatment of esophageal cancer is dependent upon the stage of presentation and the options include chemotherapy, radiation therapy, surgery, multimodality therapy, or palliative care. Early detection of this disease is the primary method to decrease its high morbidity and mortality.

Efficacy and safety of the initial use of stability and onset criteria in implantable cardioverter defibrillators.

INTRODUCTION: Inappropriate therapies are the most frequent adverse event in patients with implantable cardioverter defibrillators (ICDs). Most ICDs offer a stability criterion to discriminate ventricular tachycardia (VT) from atrial fibrillation and an onset criterion to discriminate VT from sinus tachycardia. The efficacy and safety of these criteria, if used immediately after implantation, is unknown. METHODS AND RESULTS: In a case control study, 87 patients in whom stability and onset criteria had been activated immediately after ICD implantation were matched to 87 patients in whom these criteria had not been activated. The groups were matched for known predictors of inappropriate therapies. With stability and onset criteria off, 24 patients (28%) received inappropriate therapies due to atrial fibrillation (n = 14) or sinus tachycardia (n = 11); with stability and onset on, only 11 patients (13%) were treated by the ICD due to atrial fibrillation (n = 5) or sinus tachycardia (n = 7) (log rank: P = 0.029). Five patients suffered inappropriate therapies despite the fact that onset (n = 4) or stability (n = 1) criteria were not fulfilled once tachycardias continued for a prespecified duration. Only one patient experienced a failure to detect VT due to the onset criterion; none because of stability. CONCLUSION: The immediate use of stability and onset criteria after ICD implantation reduces inappropriate therapies due to atrial fibrillation and sinus tachycardia. Because of the potential for underdetection of VT, this approach should be limited to tachycardia rates hemodynamically tolerated by the patient.

Potential benefit from implantable cardioverter-defibrillator therapy in patients with and without heart failure.

BACKGROUND: Whether patients with heart failure derive a benefit from therapy with implantable cardioverter-defibrillators (ICDs) has been questioned. The purpose of this study was to investigate whether New York Heart Association (NYHA) functional class had an impact on the potential benefit from ICD therapy as assessed from data stored in the memory of ICDs. METHODS AND RESULTS: Between 1989 and 1996, 603 patients (77% men; 59% with coronary artery disease and 16% with dilated cardiomyopathy; age, 57+/-13 years; ejection fraction, 44+/-18%) were treated with an ICD with extended memory function (storage of electrograms and/or RR intervals from treated episodes) in combination with endocardial lead systems. The stages of heart failure (NYHA functional class I through III) at implantation were correlated with overall mortality and the recurrence of fast ventricular tachyarrhythmias (>240 bpm) during follow-up. The potential benefit of the device was estimated as the difference between overall mortality and the hypothetical death rate had the device not been implanted. The latter was based on the recurrence of fast and, without termination by the devices, presumably fatal ventricular tachyarrhythmias. In the overall group, a significant difference between hypothetical death rate and overall mortality was observed (13.9%, 23.5%, and 26.6% at 1, 3, and 5 years, respectively) that suggested a benefit from ICD implantation. In patients in NYHA class I, the estimated benefit, which increased over time, was 15.2%, 29.2%, and 35.6% after 1, 3, and 5 years, respectively. In patients in NYHA class II or III, the estimated benefit increased until the third year (21.8% and 21.9%, respectively) and then remained constant until the fifth year (22.9% and 23.8%, respectively). Even those patients in NYHA class III with a history of decompensated heart failure benefited from ICD implantation. CONCLUSIONS: Analysis of stored ECG data suggests that in patients with a history of ventricular tachycardia or ventricular fibrillation, ICD therapy may lead to a prolongation of life in NYHA classes I through III. The initial benefit is greatest in patients in NYHA class II and class III, but the estimated benefit might persist longest for patients in NYHA class I.

How and when to reference.

References are not after thoughts, they are critical parts of a quality manuscript. The reference section is often one of the first sections of a manuscript the editor looks at to see if the author has used the journal's guidelines and format. It tells the editor and the reviewer if the author knows the field of research, how her or his idea fits, and pays attention to details. This experienced reviewer, who has identified some trends in manuscript referencing problems, gives advice on how to avoid these problems.

Validation of a predictive model for postoperative pulmonary complications.

OBJECTIVE: To test or validate a previously reported model for predicting postoperative pulmonary complications (PPCs) after elective abdominal surgical procedures. DESIGN: Prospective, descriptive. SETTING: Four midwestern hospitals serving a diverse population of patients. PATIENTS: Two hundred seventy-six adult patients who had undergone abdominal surgery (51% men, 49% women; mean age 54.1 +/- 5.3 years). OUTCOME MEASURES: PPC developed in 26.4%. DATA COLLECTION: Data were collected preoperatively during a brief interview and a pulmonary physical examination and on the first 6 postoperative days. RESULTS: A six risk-factor model was tested in this sample of subjects. The model validated relatively well in the sample of 276 subjects with use of the basic criteria of correct classification, sensitivity, and specificity. However, when a new model was developed from this sample, differing risk factors emerged as significant independent predictors. CONCLUSIONS: Further research is needed to assess the stability of the risk factors and test the models in differing settings and populations of patients.

Syncope in patients with an implantable cardioverter-defibrillator: incidence, prediction and implications for driving restrictions.

OBJECTIVES: This retrospective study was undertaken to provide information on occurrence, risk prediction and prevention of syncope in patients with an implantable cardioverter-defibrillator (ICD). BACKGROUND: ICDs effectively terminate ventricular tachycardia and fibrillation (VT/VF). Incapacitating symptoms, such as syncope, may still occur. METHODS: We performed a retrospective analysis of data from 421 patients (clinical history, outpatient chart reviews and episode data) with mean (+/-SD) follow-up of 26 +/- 18 months. RESULTS: Of 421 patients, 229 (54.4%) had recurrent VT/VF, and 62 (14.7%) had syncope. The actuarial survival rate free of VT/VF was 58%, 45% and 37% and that for survival free of syncope was 90%, 85% and 81% at 12, 24 and 36 months after implantation, respectively. Once VT/VF had occurred, 76%, 68% and 62% of patients remained free of syncope during the following 12, 24 and 36 months, and 68%, 64% and 56% remained free of second syncope 12, 24 and 36 months after first syncope, respectively. In cases of syncope, the mean cycle length (CL) of VT was 251 +/- 56 ms. A low baseline left ventricular ejection fraction (LVEF), induction of fast VT (CL <300 ms) during programmed ventricular stimulation and chronic atrial fibrillation (AF) were associated with an increased risk of syncope. If the LVEF was >40%, fast VT had not been induced, and patients had no chronic AF; 96%, 92% and 92% of patients remained free of syncope after 12, 24 and 36 months, respectively. Once patients had a VT recurrence, syncope during the first VT and a high VT rate were the strongest risk predictors of future syncope. CONCLUSIONS: Identification of patients with an ICD with a low and high risk of syncope seems to be feasible and might help as a guide to driving restrictions in such patients.