Long-term effects of a multimodal behavioral intervention on myocardial perfusion--a randomized controlled trial.

BACKGROUND: Recent advances in drug therapy question as to the additional impact behavioral interventions may have on the prognosis of patients with clinically stable coronary heart disease (CHD). PURPOSE: The aim of the study was to evaluate the effects of a multimodal, behavioral intervention on myocardial perfusion (MP) and cardiac events, compared to standardized cardiologic care, in patients with stable CHD. METHODS: Seventy-seven CHD patients (age 54.2 +/- 6.9 years, male 87%) were randomly assigned to a behavioral intervention plus standardized cardiologic care (INT, n = 39) or standardized cardiologic care alone (CO, n = 38). MP was assessed by (201)Thallium MP-scintigrams (SPECT) at baseline, after 2, 3, and 7 years, respectively. Subsequent cardiac events (MI, PCI, CABG) were assessed using the cardiologists' charts. RESULTS: Sixty-five patients (84%) completed the study. In all patients, the course of MP was significantly better in INT analysis of variance (ANOVA group x time p = 0.001); this was also true for patients without subsequent PCI/CABG (ANOVA group x time p = 0.002). Incidence of cardiac events was significantly associated with INT (6 vs. 14; log rank test p = .047). CONCLUSION: The study suggests additional long-term benefits of a behavioral intervention on myocardial perfusion and cardiac events in patients with stable CHD compared to standardized cardiologic care only.

Incidence of postradioiodine immunogenic hyperthyroidism/Graves' disease in relation to a temporary increase in thyrotropin receptor antibodies after radioiodine therapy for autonomous thyroid disease.

BACKGROUND: The aim of the study was to analyze retrospectively the incidence of postradioiodine immunogenic hyperthyroidism/Graves' disease in relation to a temporary increase in TSH-receptor antibodies without overt hyperthyroidism after radioiodine therapy for autonomous thyroid disease. PATIENTS AND METHODS: Between May 2000 and May 2003 all patients (n = 1,357) who had undergone radioiodine therapy for autonomous thyroid disease were retrospectively analyzed for development of postradioiodine immunogenic hyperthyroidism. On pretreatment evaluation 565 of 1,357 patients (41.6%) had unifocal autonomous thyroid disease (UFA), 693 of 1,357 patients (51.1%) had multifocal autonomous thyroid disease (MFA), and 99 of 1,357 patients (7.3%) had diffuse thyroid disease (DISS). Free triiodothyronine (FT(3)), free thyroxine (FT(4)), thyrotropin (TSH), and thyroid antibodies were measured. Ultrasound examinations and thyroid scintigraphy were performed before and after radioiodine therapy. A sensitive assay with the human TSH receptor as antigen was chosen for measurement of the TSH receptor antibody and the study was limited to analysis of data obtained since introduction of this assay. RESULTS: Fifteen of 1,357 patients (1.1%) (UFA, 8/565 = 1.4%; MFA, 6/693 = 0.9%; DISS 1/99 = 1.0%) developed postradioiodine hyperthyroidism between 1 and 13 months after radioiodine therapy with clinically overt hyperthyroidism and an elevation of TSH receptor antibodies. Patients with elevated thyroid peroxidase (TPO) antibodies before radioiodine therapy had an almost 10-fold (6/57 patients =10.5%) higher risk of developing postradioiodine immunogenic hyperthyroidism. Thirteen of 999 patients (1.3%) with antibody measurements after radioiodine therapy (UFA, 2/421 = 0.5%; MFA, 9/494 = 1.8%, DISS, 2/84 = 2.4%) had increased levels of TSH receptor antibodies and, to some extent, TPO antibodies without development of clinically overt hyperthyroidism. CONCLUSIONS: There is an estimated 1.1% risk of developing postradioiodine immunogenic hyperthyroidism/Graves' disease in patients undergoing radioiodine therapy for autonomous thyroid disease and this increases approximately 10-fold when TPO antibody levels are elevated before radioiodine therapy. Furthermore, there is an estimated 1.3% risk of a temporary increase of TSH receptor antibodies after radioiodine therapy for autonomous thyroid disease without development of clinically overt hyperthyroidism.

QT dispersion in comparison to Tl-201-SPECT for detection of myocardial ischaemia.

OBJECTIVE: There is controversy whether the measurement of QT dispersion might provide information about the presence and extent of ischaemic myocardium. It was the aim to analyse the diagnostic value of QT dispersion for the detection of myocardial ischaemia in comparison to Tl-201-SPECT. PATIENTS AND METHODS: 100 patients were randomly selected from patients referred for Tl-201-SPECT. QT duration was measured in all 12 leads in the resting ECG and in the ECG either at maximal bicycle exercise or during peak dipyridamole stress. QT dispersion was calculated and correlated with parameters of ischaemia for all patients and for the bicycle exercise and the dipyridamole group separately. RESULTS: 25 patients had to be excluded from the analysis because QT dispersion could not be measured. Regression analysis did not show significant correlation neither for all 75 patients nor for the bicycle exercise nor for the dipyridamole group correlating grade of myocardial ischaemia, number of ischaemic segments and summed ischaemic stress score with QT dispersion in the resting or the stress ECG and QTd and there was no significant difference between groups. CONCLUSION: QT dispersion could not be measured in 25/100 patients (25%). In the remaining patients QT dispersion did not correlate with the extent or grade of myocardial ischaemia.

Symptomatic relief precedes improvement of myocardial blood flow in patients under spinal cord stimulation.

BACKGROUND: Spinal cord electrical stimulation (SCS) has shown to be a treatment option for patients suffering from angina pectoris CCS III-IV although being on optimal medication and not suitable for conventional treatment strategies, e.g. CABG or PTCA. Although many studies demonstrated a clear symptomatic relief under SCS therapy, there are only a few short-term studies that investigated alterations in cardiac ischemia. Therefore doubts remain whether SCS has a direct effect on myocardial perfusion. METHODS: A prospective study to investigate the short- and long-term effect of spinal cord stimulation (SCS) on myocardial ischemia in patients with refractory angina pectoris and coronary multivessel disease was designed. Myocardial ischemia was measured by MIBI-SPECT scintigraphy 3 months and 12 months after the beginning of neurostimulation. To further examine the relation between cardiac perfusion and functional status of the patients we measured exercise capacity (bicycle ergometry and 6-minute walk test), symptoms and quality of life (Seattle Angina Questionnaire [SAQ]), as well. RESULTS: 31 patients (65 +/- 11 SEM years; 25 male, 6 female) were included into the study. The average consumption of short acting nitrates (SAN) decreased rapidly from 12 +/- 1.6 times to 3 +/- 1 times per week. The walking distance and the maximum workload increased from 143 +/- 22 to 225 +/- 24 meters and 68 +/- 7 to 96 +/- 12 watt after 3 months. Quality of life increased (SAQ) significantly after 3 month compared to baseline, as well. No further improvement was observed after one year of treatment. Despite the symptomatic relief and the improvement in maximal workload computer based analysis (Emory Cardiac Toolbox) of the MIBI-SPECT studies after 3 months of treatment did not show significant alterations of myocardial ischemia compared to baseline (16 patients idem, 7 with increase and 6 with decrease of ischemia, 2 patients dropped out during initial test phase). Interestingly, in the long-term follow up after one year 16 patients (of 27 who completed the one year follow up) showed a clear decrease of myocardial ischemia and only one patient still had an increase of ischemia compared to baseline. CONCLUSION: Thus, spinal cord stimulation not only relieves symptoms, but reduces myocardial ischemia as well. However, since improvement in symptoms and exercise capacity starts much earlier, decreased myocardial ischemia might not be a direct effect of neurostimulation but rather be due to a better coronary collateralisation because of an enhanced physical activity of the patients.

F-18-FDG uptake is a reliable predictory of functional recovery of akinetic but viable infarct regions as defined by magnetic resonance imaging before and after revascularization.

Identification of akinetic but viable myocardium is important for the selection of patients for coronary revascularization. In order to assess predictive values of end-diastolic wall thickness and dobutamine induced wall thickening obtained by magnetic resonance imaging (MRI) and [18F]Fluorodeoxyglucose uptake assessed by positron emission tomography (F-18-FDG-PET), these parameters were compared to recovery of left ventricular function after successful revascularization. Forty patients with chronic myocardial infarction and regional a- or dyskinesia by ventriculography underwent rest- and dobutamine-MRI studies (10 microg dobutamine/kg body weight/min) and F-18-FDG-PET. Viability of the infarct region was considered to be present if; 1) end-diastolic wall thickness was > or =5.5 mm; 2) dobutamine induced wall thickening > or =2 mm could be measured; and 3) normalized F-18-FDG-uptake was > or =50% in > or =50% of akinetic segments. Preserved end-diastolic wall thickness was found in 32/40 patients, functional improvement during dobutamine infusion in 26/40 patients and preserved F-18-FDG-uptake in 29/40 patients. After revascularization regional left ventricular function improved in 25/40 patients. Positive and negative predictive values and diagnostic accuracy were 78%, 100%, and 83% for preserved end-diastolic wall thickness, 92%, 93%, and 93% for dobutamine inducible contraction reserve and 86%, 100%, and 90% for preserved F-18-FDG-uptake. Quantitative assessment of dobutamine induced systolic wall thickening by MRI and F-18-FDG-uptake by PET are highly accurate techniques for the identification of viable myocardium and prediction of functional recovery after successful revascularization. Preserved end-diastolic wall thickness results in an overestimation of viable myocardium compared to functional improvement, but wall thickness <5.5 mm excludes recovery of regional function.

Prevalence of thyroid disorders in the working population of Germany: ultrasonography screening in 96,278 unselected employees.

Germany continues to be iodine deficient despite considerable improvement in the past years. To assess the current prevalence of diffuse and/or nodular thyroid disorders, a cross-sectional observational study in a nonrandom sample of the working population was carried out throughout Germany in 2001 and 2002. A total of 96,278 employees 18-65 years of age from 214 companies or other private or public institutions voluntarily underwent ultrasonographic examinations by 230 experienced investigators. To compare the prevalence of different abnormal findings in relation to age and gender, descriptive statistics and the Kruskal-Wallis test were used. Data from volunteers with previous thyroid treatment (13.0% of total sample) were not included in the analysis. Abnormal findings (goiter and/or nodules > 0.5 cm) were observed in 33.1% (men, 32.0%; women, 34.2%) of the examined patient population, an enlarged thyroid without nodules in 9.7% (men, 11.9%; women, 7.6%), nodules only without enlargement of the thyroid in 14.3% (men, 11.5%; women, 17.0%), and nodular goiter in 9.1% (men, 8.6%; women, 9.6%). Nodules (with or without goiter) between 0.5 and up to 1.0 cm were found in 10.0%, and nodules above 1.0 cm in 11.9% of the population. Rates of abnormal findings increased with age in both genders. Goiter was more common in men, nodules in women. In light of these findings, the prevalence of thyroid disorders in Germany continues to be high. Although the study may slightly overestimate the prevalence, about one third of the working population is affected and remains unaware of this condition. These results emphasize the importance of effective sonographic screening to detect early thyroid abnomalities in order to initiate preventive and therapeutic measures to prevent the onset or progression of disease and its sequels.

Depth of olfactory sulcus and olfactory function.

The aim of this study was to identify whether the depth of the olfactory sulcus relates to olfactory function in healthy subjects. Forty-four healthy, male volunteers (age range 22-45 years, mean age 28.3 years) were included in this study. Olfactory function was measured for phenyl ethyl alcohol odor thresholds, odor discrimination, and odor identification. Magnetic resonance imaging of the olfactory sulcus was performed immediately following olfactometry. Based on previous investigations the depth of the olfactory sulcus was measured in the plane of the posterior tangent through the eyeballs. Olfactory function correlated significantly with left-sided depth of the olfactory sulcus (r(44)=0.33, P=0.03); no such correlation was seen for the right side. In addition, olfactory sulcus depth was found to be significantly deeper on the right compared to the left side (t=5.61, P<0.001). The present results suggest that there is small, but significant relation between morphological brain structures and measures of olfactory function. Further, lateralization of olfactory sulcus depth may correlate to functional lateralization in the olfactory system. Thus, it may be carefully speculated that sensory input in the olfactory system results in cortical growth in the area of the olfactory sulcus, at least at some developmental stage.

Intranasal volume and olfactory function.

The aim of this exploratory study was to identify the volume intranasal segments as they relate to parameters of olfactory function. Fifty healthy male volunteers (age range 22-59 years, mean age 28.5 years) were included. Olfactory function was measured by lateralized phenyl ethyl alcohol odor thresholds and odor discrimination, and by bilateral odor identification. Magnetic resonance imaging of the nasal cavity was performed immediately following olfactometry. To correlate the results of olfactometry with intranasal volume, each nasal cavity was divided into 11 segments. Significant correlations were found between the odor thresholds and volumes of the anterior part of the lower and upper meatus of the right nasal cavity. These results reveal that two nasal segments are important for inter-individual differences of odor thresholds in healthy subjects: (i) the segment in the upper meatus below the cribriform plate and (ii) the anterior segment of the inferior meatus. The latter finding is of special interest for nasal surgery, which allows modification of this volume through resection of the inferior turbinate and/or septoplasty.