Inpatient teledermatology improves diagnostic accuracy and management of erythroderma in hospitalized patients.

With the onset of the COVID-19 pandemic, healthcare providers have made increasing use of inpatient teledermatology; however, few studies have analysed the impact of teledermatology on patient outcomes. In this study, we investigated the diagnostic concordance between the primary team and teledermatologist, and we analysed the impact of this technology on the diagnosis and management of erythroderma, a condition with high morbidity and mortality. Overall, out of 2987 inpatient teledermatology encounters reviewed, we found 33 cases of erythroderma, and, of these, 78.8% had a change in diagnosis after teledermatology consult, 81.8% were recommended biopsy and all patients had a change in topical/systemic therapy. We hope to promote further study of the efficacy of teledermatology as it may begin to address large gaps in dermatological access to care particularly in regional and community hospitals.

Electrochemical and Structural Property of TiSiNb TFSOC on Affordable Interconnects in Proton Exchange Membrane Fuel Cell Applications.

High cost and low electrochemical stability of the interconnection in Proton Exchange Membrane Fuel Cell (PEMFC) in the presence of H2SO4 are one of the main issues hindering the commercialization of these devices. This manuscript presents the utilization of cost-effective steel in an attempt to minimize the PEMFC interconnection costs with a thin-film solid oxide coating (TFSOC) providing sufficient corrosion resistance for efficient long-term operation. Novel Ti0.50-y/2Si0.50-y/2Nby1,2O2 as TFSOC was deposited on the C45E steel as a metal interconnect utilizing a sol-gel process at various annealing temperatures. The analysis of the phase and surface morphology demonstrates that lower annealing temperatures developed nanometric crystallite size of 68 nm, more uniform structure and higher corrosion resistance. Under standard test conditions, the TFSOC demonstrated high polarization resistance (1.3 kΩ cm2) even after 720 hours (h). Electrical conductivity of the TFSOC as low as 1.4 × 10-2 (Ω m)-1 and activation energy of 0.20 eV were achieved, which helps to maintain the PEMFC output power.

Ixazomib-induced cutaneous necrotizing vasculitis.

Ixazomib is a second-generation proteasome inhibitor that has been approved in the combination treatment of multiple myeloma and is currently under clinical investigation for the management of Waldenstrom's macroglobulinemia. While cutaneous adverse events secondary to proteasome inhibitors have been reported, the side effect profile of ixazomib remains to be documented. We report two patients, one with multiple myeloma and one with Waldenstrom's macroglobulinemia, who developed cutaneous necrotizing vasculitis after the initiation of ixazomib. Both patients exhibited no signs of systemic vasculitis and completed their anti-cancer regimens with resolution of their respective eruptions following dose reductions in ixazomib and initiation of low-dose prednisone. A collaborative effort towards the characterization of such cutaneous toxicities facilitates early intervention, maintenance of life-preserving anti-cancer therapy, and allows clinicians opportunity to better understand the pathophysiology of vasculitis. Moreover, appropriate identification and characterization of cutaneous toxicities from novel therapies allows providers to accurately identify safety concerns, treat toxicity, and improve patient quality of life.

The effect of vitamin D supplementation in combination with low-calorie diet on anthropometric indices and androgen hormones in women with polycystic ovary syndrome: a double-blind, randomized, placebo-controlled trial.

PURPOSE: Polycystic ovary syndrome (PCOS) is known as the most common endocrine disorder in reproductive age women. The aim of this studywas to evaluate the effects of vitamin D supplementation in combination with low-calorie diet on anthropometric indices, reproductive hormones and menstrual regularity in overweight and obese PCOS women. METHODS: In this randomized controlled clinical trial, 60 PCOS women with vitamin D insufficiency were randomly assigned to 12 weeks of either (1) weight-loss intervention + 50,000 IU/week oral vitamin D3 or (2) weight-loss intervention + placebo. At the beginning and end of the study, the anthropometric indices, body composition, 25-hydroxyvitamin D, total testosterone, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG) and free androgen index (FAI) were measured and regularity of menses was compared among the two groups. RESULT: After 12-week intervention, median of serum 25-hydroxyvitamin D3 significantly increased from 18.5 (10.75-20) ng/ml to 42.69 (34-53.25) ng/ml in vitamin D group compared to placebo group (p < 001). Moreover, there was a significant improvement in frequency regular menstrual cycle (p = 0.01). Mean of weight, body mass index, fat mass, waist and hip circumference and waist-to-hip ratio significantly decreased in both groups, but was not different between two groups. Mean of total testosterone insignificantly decreased from 0.7 to 0.5 ng/ml in vitamin D group (p = 0.18). In addition, we did not observe significant differences regarding DHEAS, FAI and SHBG between two groups. CONCLUSIONS: In women with PCOS, androgen profile did not change with vitamin D supplementation when combined with low-calorie diet, but menstrual frequency significantly improved. CLINICAL TRIAL REGISTRATION NUMBER: IRCT2016062710826N19.

Effect of Gold Nanoparticles on Prostate Dose Distribution under Ir-192 Internal and 18 MV External Radiotherapy Procedures Using Gel Dosimetry and Monte Carlo Method.

BACKGROUND: Gel polymers are considered as new dosimeters for determining radiotherapy dose distribution in three dimensions. OBJECTIVE: The ability of a new formulation of MAGIC-f polymer gel was assessed by experimental measurement and Monte Carlo (MC) method for studying the effect of gold nanoparticles (GNPs) in prostate dose distributions under the internal Ir-192 and external 18MV radiotherapy practices. METHOD: A Plexiglas phantom was made representing human pelvis. The GNP shaving 15 nm in diameter and 0.1 mM concentration were synthesized using chemical reduction method. Then, a new formulation of MAGIC-f gel was synthesized. The fabricated gel was poured in the tubes located at the prostate (with and without the GNPs) and bladder locations of the phantom. The phantom was irradiated to an Ir-192 source and 18 MV beam of a Varian linac separately based on common radiotherapy procedures used for prostate cancer. After 24 hours, the irradiated gels were read using a Siemens 1.5 Tesla MRI scanner. The absolute doses at the reference points and isodose curves resulted from the experimental measurement of the gels and MC simulations following the internal and external radiotherapy practices were compared. RESULTS: The mean absorbed doses measured with the gel in the presence of the GNPs in prostate were 15% and 8 % higher than the corresponding values without the GNPs under the internal and external radiation therapies, respectively. MC simulations also indicated a dose increase of 14 % and 7 % due to presence of the GNPs, for the same experimental internal and external radiotherapy practices, respectively. CONCLUSION: There was a good agreement between the dose enhancement factors (DEFs) estimated with MC simulations and experiment gel measurements due to the GNPs. The results indicated that the polymer gel dosimetry method as developed and used in this study, can be recommended as a reliable method for investigating the DEF of GNPs in internal and external radiotherapy practices.

A study to establish international diagnostic reference levels for paediatric computed tomography.

The article reports results from the largest international dose survey in paediatric computed tomography (CT) in 32 countries and proposes international diagnostic reference levels (DRLs) in terms of computed tomography dose index (CTDI vol) and dose length product (DLP). It also assesses whether mean or median values of individual facilities should be used. A total of 6115 individual patient data were recorded among four age groups: <1 y, >1-5 y, >5-10 y and >10-15 y. CTDIw, CTDI vol and DLP from the CT console were recorded in dedicated forms together with patient data and technical parameters. Statistical analysis was performed, and international DRLs were established at rounded 75th percentile values of distribution of median values from all CT facilities. The study presents evidence in favour of using median rather than mean of patient dose indices as the representative of typical local dose in a facility, and for establishing DRLs as third quartile of median values. International DRLs were established for paediatric CT examinations for routine head, chest and abdomen in the four age groups. DRLs for CTDI vol are similar to the reference values from other published reports, with some differences for chest and abdomen CT. Higher variations were observed between DLP values, based on a survey of whole multi-phase exams. It may be noted that other studies in literature were based on single phase only. DRLs reported in this article can be used in countries without sufficient medical physics support to identify non-optimised practice. Recommendations to improve the accuracy and importance of future surveys are provided.

Nail dystrophy, edema, and eosinophilia: harbingers of severe chronic GVHD of the skin in children.

The prognostic value of adnexal findings in chronic GVHD (cGVHD) has not been investigated in children. Dermatologic examinations were performed in a severe cohort of 11 children with skin cGVHD seen over a 2-year period. Findings were compared with 25 additional patients with skin cGVHD and 97 control patients. In 36 patients with skin cGVHD, nail dystrophy was present in 45% of patients, and was significantly associated with sclerotic disease and lung cGVHD. Pterygium inversum unguis (PIU) was associated with severe lung disease, with significantly lower % predicted FVC and FEV1 in those with PIU than those without. Forty-four percent of GVHD patients had preceding peripheral edema and 56% had preceding peripheral eosinophilia. Peripheral edema and eosinophilia were significantly associated with sclerotic cGVHD and persisted until the diagnosis of cGVHD in all patients. Comparison of data with control patients showed that incidence of nail dystrophy, incidence of peripheral edema and mean peak peripheral eosinophil count of patients with skin cGVHD was significantly higher than those without cGVHD. This study suggests that nail dystrophy, persistent peripheral edema and persistent peripheral eosinophilia are harbingers of severe cGVHD of the skin in children. The presence of PIU may be a harbinger of severe lung involvement.

3D calculation of absorbed dose for 131I-targeted radiotherapy: a Monte Carlo study.

Various methods, such as those developed by the Medical Internal Radiation Dosimetry (MIRD) Committee of the Society of Nuclear Medicine or employing dose point kernels, have been applied to the radiation dosimetry of (131)I radionuclide therapy. However, studies have not shown a strong relationship between tumour absorbed dose and its overall therapeutic response, probably due in part to inaccuracies in activity and dose estimation. In the current study, the GATE Monte Carlo computer code was used to facilitate voxel-level radiation dosimetry for organ activities measured in an (131)I-treated thyroid cancer patient. This approach allows incorporation of the size, shape and composition of organs (in the current study, in the Zubal anthropomorphic phantom) and intra-organ and intra-tumour inhomogeneities in the activity distributions. The total activities of the tumours and their heterogeneous distributions were measured from the SPECT images to calculate the dose maps. For investigating the effect of activity distribution on dose distribution, a hypothetical homogeneous distribution of the same total activity was considered in the tumours. It was observed that the tumour mean absorbed dose rates per unit cumulated activity were 0.65E-5 and 0.61E-5 mGY MBq(-1) s(-1) for the uniform and non-uniform distributions in the tumour, respectively, which do not differ considerably. However, the dose-volume histograms (DVH) show that the tumour non-uniform activity distribution decreases the absorbed dose to portions of the tumour volume. In such a case, it can be misleading to quote the mean or maximum absorbed dose, because overall response is likely limited by the tumour volume that receives low (i.e. non-cytocidal) doses. Three-dimensional radiation dosimetry, and calculation of tumour DVHs, may lead to the derivation of clinically reliable dose-response relationships and therefore may ultimately improve treatment planning as well as response assessment for radionuclide therapy.

Effects of a single post-partum injection of a high dose of vitamin D on glucose tolerance and insulin resistance in mothers with first-time gestational diabetes mellitus.

AIM: This study was performed to determine the effect of a single, large, intramuscular injection of vitamin D post-partum on glucose tolerance and insulin resistance in women with gestational diabetes. METHODS: Forty-five participants in a randomized controlled trial on gestational diabetes mellitus were divided into an intervention group and a control group. Only subjects in the intervention group received one intramuscular injection of 300,000 IU of vitamin D3. HbA(1c), serum 25-hydroxyvitamin D3, fasting insulin and blood glucose, C-peptide, homeostasis model assessment insulin resistance index (HOMA-IR), ß-cell function, insulin sensitivity and the Quantitative Insulin Sensitivity Check Index (QUICKI) were measured at baseline and after 3 months of intervention. RESULTS: Approximately 80% of the mothers had a degree of vitamin D deficiency. Post-intervention, this was found in 4.2 and 71.4% in the intervention and control groups, respectively. The medians of HOMA-IR indices before and after intervention were 0.6 and 0.5 (P = 0.7), respectively, in subjects in the intervention group, and 0.5 and 0.9 (P = 0.01) in subjects in the control group. The mean of the QUICKI fell only in the control group (P = 0.008). In the control group, ß-cell function increased by ~8% (P = 0.01) and insulin sensitivity decreased after 3 months (P = 0.002). Post-intervention, the median C-peptide decreased in the intervention group and increased in the control group, but the change was significant only in the control group (P = 0.03). CONCLUSIONS: A single injection of 300,000 IU of vitamin D3 achieves a 3-month serum 25-hydroxyvitamin D range of 50-80 nmol/l and is an efficient, effective and safe procedure for improving the vitamin status and indices of insulin resistance in mothers with gestational diabetes after delivery.

Poster - Thur Eve - 68: Evaluation and analytical comparison of different 2D and 3D treatment planning systems using dosimetry in anthropomorphic phantom.

PURPOSE: The aim of this study was to evaluate and analytically compare different calculation algorithms applied in our country radiotherapy centers base on the methodology developed by IAEA for treatment planning systems (TPS) commissioning (IAEA TEC-DOC 1583). MATERIAL & METHODS: Thorax anthropomorphic phantom (002LFC CIRS inc.), was used to measure 7 tests that simulate the whole chain of external beam TPS. The dose were measured with ion chambers and the deviation between measured and TPS calculated dose was reported. This methodology, which employs the same phantom and the same setup test cases, was tested in 4 different hospitals which were using 5 different algorithms/ inhomogeneity correction methods implemented in different TPS. The algorithms in this study were divided into two groups including correction based and model based algorithms. RESULTS: A total of 84 clinical test case datasets for different energies and calculation algorithms were produced, which amounts of differences in inhomogeneity points with low density (lung) and high density (bone) was decreased meaningfully with advanced algorithms. The number of deviations outside agreement criteria was increased with the beam energy and decreased with advancement of the TPS calculation algorithm. CONCLUSION: Large deviations were seen in some correction based algorithms, so sophisticated algorithms, would be preferred in clinical practices, especially for calculation in inhomogeneous media. Use of model based algorithms with lateral transport calculation, is recommended. Some systematic errors which were revealed during this study, is showing necessity of performing periodic audits on TPS in radiotherapy centers.

Evaluation of patient dose in some mammography centres in Iran.

High diagnostic sensitivity and specificity while maintaining the least dose to the patient is the ideal mammography. The objective of this work was to evaluate patient dose and image quality of mammograms to propose corrective actions. The image quality for 1242 patient in 7 mammography facilities in Tehran city was evaluated based on selected image quality criteria using a three-point scale. Clinical image quality, the entrance surface air kerma, the average glandular dose and optical density of films for standard PMMA phantom of 4.5 cm thickness were evaluated. The results showed that up to 72 % of mammograms were in good condition to be diagnosed, and only about 3.4 % of the images were unacceptable or with suboptimal quality. The entrance surface air kerma values were in the range of 3.8-10.5 mGy, average glandular dose 0.5-1.8 mGy and optical density of films 0.74-2.03. The image quality evaluation after correction actions, periodic image quality evaluation and using the correct equipment certainly will improve patient dose.

Doses to the scanned individual and to the operator from an X-ray body scanner system.

The X-ray body scanner (BS) is going to find common use as a body-checking equipment at the entrance borders of countries, to find illicit drugs or forbidden items which have been hidden inside the body cavities, or attached to the body parts of the passengers. Considering the tissue weighting factors of the sensitive organs, the total effective dose due to the scanning by the system was estimated to be 3.8 µSv per scan. The ambient dose equivalent rates within the distance range of 300-40 cm from the X-ray generator were measured to be 4.5 up to 50 µSv h(-1). It is concluded that, in general, BS systems could be a safe device for the operators and people who are being scanned. But using such systems should be justified for everybody and special care should be taken for children and pregnant ladies.

Criteria for patient release according to external dose rate and residual activity in patients treated with 131I-sodium iodide in Iran.

External dose rate (ED) and residual activity (RA) of patients treated with (131)I sodium iodide are two main factors, to consider before release of patients. In this study, six nuclear medicine centres out of total seven centres in Iran were selected and measurements have been done on 330 patients. ED of patients was measured by physicists of the centres for 6 months (May-November 2009) at a 1 m distance from the thyroid of each patient on the first, second and third days after administration by a calibrated survey meter. The maximum and minimum values of ED were 21 (SD = 18) and 11 (SD = 4) µSv h(-1), respectively. Furthermore, the maximum and minimum values of RA during release of patient were 720 and 250 MBq, respectively. According to the study, we recommend a release activity limit of 500 MBq (14 mCi) or a dose rate level of 20 µSv h(-1) at 1 m from the patient to be set instead of a release activity limit of 1100 MBq (30 mCi) as it is now for the country.

An investigation on the response of PADC detectors to neutrons.

The response of PADC was calculated by Monte Carlo simulation using MCNPX code. H, C and O recoils as well as nuclear reactions have been taken into account. The calculated results show important contribution to detection efficiency of PADC due to H, C and O recoils. The irradiated detectors with (241)Am-Be source and (241)Am-Be softened with a spherical polyethylene moderator were electrochemically etched. The paper presents the results of the experimental and Monte Carlo simulations, which are in a good agreement.

Combination of bolus dose vitamin D with routine vaccination in infants: a randomised trial.

INTRODUCTION: The present study was designed to compare two methods of vitamin D supplementation in infants: every two months as a routine vaccination versus a daily dose. METHODS: A randomised clinical trial was performed on 120 healthy breastfed infants between January and September 2007 in Yazd, Iran. The infants were randomly divided into three groups with different doses of vitamin D3 supplementation: 200 IU daily, 400 IU daily and a bolus of 50,000 IU every two months. A blood sample was taken and evaluated for 25-hydroxy vitamin D and calcium levels when the infants were six months old. The data was reported as the mean and standard deviation. RESULTS: No significant differences were observed between the serum level of 25-hydroxy vitamin D in the groups administered with 200 IU and 400 IU vitamin D daily. However, the serum level of 25-hydroxy vitamin D reached significance in the third group (p is less than 0.001). All the blood calcium measured was below 11 mg/dl in the bolus group. A few complications such as diarrhoea and agitation, all of which were self-limited, were seen in the bolus group. No other significant side effects were reported in the other groups. CONCLUSION: This study demonstrates that a bolus of 50,000 IU of vitamin D every two months with a routine child vaccination program provides the ideal serum level of vitamin D. This method produces no serious side effects and offers a highly convenient way to supply vitamin D, especially among non-compliant parents.

Effect of a magnetic field on high-harmonic generation by carbon nanotubes.

We consider a metallic single-walled carbon nanotube under the influence of the combination of laser and static magnetic fields. We study the nonlinear motion of pi electrons in metallic carbon nanotubes driven by external fields, and the induced current spectrum has been analyzed. High-harmonic generation in the presence of a transverse magnetic field is studied theoretically. Numerical calculations show that the plateau is extended to higher harmonics owing to the presence of magnetic field.

The relationship between BMI and iron status in iron-deficient adolescent Iranian girls.

OBJECTIVE: Many Iranian adolescent girls are Fe-deficient, but it is unclear whether Fe deficiency is associated with other nutritional risk indicators. The present study aimed to investigate the association between Fe deficiency and weight status (measured as BMI) among a representative sample of adolescent girls. DESIGN: A cross-sectional study. Fe-deficient high-school girls (with or without anaemia) were selected by systematic random sampling among all students in grades 1 to 4 from high schools for girls. Blood samples were collected and analysed for Hb, haematocrit, serum ferritin, Fe and total Fe binding capacity. Weight and height were measured. BMI was calculated and compared with age- and gender-specific BMI reference values. SETTING: South Iran. SUBJECTS: A total of 431 adolescent girls aged 13-20 years. RESULTS: Some 15.3 % of the participants were at risk for overweight and 9.5 % of them were overweight. An inverse association was found between serum ferritin and BMI (r = -0.38, beta = -0.21, P < 0.001). Anaemia was more prevalent among overweight Fe-deficient adolescents than among those Fe-deficient and at risk for overweight or normal weight (34.1 % v. 28.8 % v. 27.8 %, respectively; P < 0.001). CONCLUSIONS: An inverse association was found between BMI and serum ferritin. Overweight adolescents demonstrated an increased prevalence of Fe-deficiency anaemia. It seems that both abnormalities of weight and Fe status should simultaneously be targeted in overweight female adolescents.

The effects of sour tea (Hibiscus sabdariffa) on hypertension in patients with type II diabetes.

To compare the antihypertensive effectiveness of sour tea (ST; Hibiscus sabdariffa) with black tea (BT) infusion in diabetic patients, this double-blind randomized controlled trial was carried out. Sixty diabetic patients with mild hypertension, without taking antihypertensive or antihyperlipidaemic medicines, were recruited in the study. The patients were randomly allocated to the ST and BT groups and instructed to drink ST and BT infusions two times a day for 1 month. Their blood pressure (BP) was measured on days 0, 15 and 30 of the study. The mean of systolic BP (SBP) in the ST group decreased from 134.4+/-11.8 mm Hg at the beginning of the study to 112.7+/-5.7 mm Hg after 1 month (P-value <0.001), whereas this measure changed from 118.6+/-14.9 to 127.3+/-8.7 mm Hg (P-value=0.002) in the BT group during the same period. The intervention had no statistically significant effect on the mean of diastolic BP (DBP) in either the ST or BT group. The mean pulse pressure (PP) of the patients in the ST group decreased from 52.2+/-12.2 to 34.5+/-9.3 mm Hg (P-value <0.001) during the study, whereas in the BT group, it increased from 41.9+/-11.7 to 47.3+/-9.6 mm Hg (P-value=0.01). In conclusion, consuming ST infusion had positive effects on BP in type II diabetic patients with mild hypertension. This study supports the results of similar studies in which antihypertensive effects have been shown for ST.

Body mass index and thyroid function in adolescent girls.

The present research was conduted to examine the relationship between thyroid function and body mass index. A cross-sectional study was carried out in Lar province and its' vicinity in south of Iran. By stepwise random sampling from all public girls' high schools, 227 high school participants (aged 12-21) were selected. Serum samples were collected and assayed for Triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone (TSH), reverse triiodothyronine (rT3), free thyroxine (FT4), free triiodothyronine (FT3). Weight and height were measured and body mass index (BMI) were calculated (weight (kg)/height2 (m)). Subgroup analysis was done according to body mass index. TSH, T4 and rT3 were correlated with BMI (r = 0.66, p = 0.001 and r = 0.12, p = 0.05 and r = 0.65, p = 0.001, respectively). Adolescent girls with BMI > or = 25 kg m(-2) showed higher serum TSH, T4 and rT 3 than subjects with BMI < 25 kg m(-2) (p = 0.001, p = 0.05 and p = 0.001, respectively). Present results showed that, although thyroid function was normal in the studied participants TSH and rT3 were positively correlated to BMI. TSH and rT3 could present a marker of altered energy balance in overweight and obese adolescent girls.

The role of infection in atherosclerosis and coronary artery disease: a new therapeutic target.

There is growing evidence that inflammatory processes may be involved in the development of atherosclerosis and its complications. Viral and bacterial pathogens have been implicated as possible causative factors in the pathogenesis of coronary artery disease (CAD) and restenosis after angioplasty. Antibiotic trials are now in progress to examine whether treatment of infection can prevent the complications of CAD. Atherosclerosis, the primary pathologic process in coronary artery disease (CAD), carotid artery disease, abdominal aortic aneurysm, and peripheral vascular disease, is no longer considered to be an obscure, slowly progressive, degenerative disease. Indeed, recent molecular studies on the atherosclerotic plaque have shown that the initiation, progression, and acute sequelae of atherosclerosis can be explained in part by a low-grade inflammatory process. Studies show that mediators of inflammation can be found at all stages of the life cycle of the atherosclerotic plaque. These include activated macrophages and lymphocytes, cytokines, growth factors, matrix degenerating proteinases, and tissue factor. It is hypothesized that risk factors such as hypertension, smoking, or elevated levels of low-density lipoprotein (LDL) cholesterol result in injury to the endothelial cell of the artery, and this injury initiates the inflammatory process. However, many patients with vascular disease do not have these established risk factors, and this observation has galvanized efforts to find new risk factors. Because inflammation is now considered to be an operative paradigm for atherosclerosis, it is not a major leap to the hypothesis that infectious agents, such as viral or bacterial, may play a role. Certainly this is not a new concept, and with the recent discovery that peptic ulcer disease, heretofore considered a disease of excess acid and reduced mucosal resistance, is caused by the ubiquitous bacterium Helicobacter pylori, interest in finding an infectious etiology for atherosclerosis has increased. Accordingly, the purpose of this discussion is to review in a historical manner the evidence that infectious agents-including herpes simplex virus (HSV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), Enterovirus (adenovirus, Coxsackie virus), Chlamydia pneumoniae, and H. pylori-may play a role in atherosclerosis and its manifestations, especially as they relate to CAD.