671 research outputs found
Validation of first pass magnetic resonance myocardial perfusion imaging using fractional flow reserve
Get PDFBackground - Magnetic Resonance Myocardial Perfusion Imaging (MRMPI) has been used for the detection of reversible myocardial ischaemia in humans since the early 1990’s. This non-invasive method of diagnosing reversible myocardial ischaemia has a number of advantages over the other more commonly used non-invasive tests such as ETT, stress echocardiography and radionuclide single photon emission computerised tomography (SPECT). There is no need to perform physical exercise, no image orientation constraints, excellent spatial and temporal resolution, no photon scatter or attenuation artefacts and no exposure to ionising radiation. The use of MRMPI for the detection of reversible myocardial ischaemia has been extensively investigated in the past using other non-invasive tests as the gold standard namely PET and SPECT. Invasive comparisons have been made with visual coronary angiography and quantitative coronary angiography (QCA). This previous work has been summarised in a meta-analysis which estimated the sensitivity and specificity to be 84% and 85% respectively. The majority of previous studies have used QCA or visual estimation of stenosis severity to determine the diameter of stenosis (DS). This however has been shown to correlate poorly with the functional significance of disease within a coronary artery. Prior to the commencement of this study no comparison had been made with the invasive gold standard of FFR. This is measured using a coronary pressure wire at the time of coronary angiography and is regarded by many cardiologists to be the current invasive gold standard for determining if coronary artery disease (CAD) is physiologically significant. We therefore undertook the present study to determine the true accuracy of MRMPI for the diagnosis of physiologically significant CAD. We also assessed the ability of MRMPI to detect isolated microcirculatory disease as determined by thermodilution derived CFR. Our other aims included an analysis of troponin release following PCI and its relation to QCA, pressure wire data and the occurrence of new late gadolinium enhancement (LGE). New LGE post CABG was also quantified and compared with that encountered post-PCI.
Methods - One hundred and three patients with chest pain were referred for coronary angiography and underwent MRMPI in the week prior to the angiogram. This was performed on a Siemens Sonata 1.5Tesla scanner (Erlangen, Germany). Scanning commenced with localisers and cine long and short axis scans (TrueFISP sequence) to provide left ventricular mass, volume and ejection fraction data. This was followed by perfusion imaging of 3 short axis slices using a turboFLASH sequence (TI 90ms, TE 0.99ms, TR 173ms, Flip Angle 8 degrees, Matrix 80 x 128). Thereafter long and short axis slices were acquired for the detection of LGE (turboFLASH). Maximal hyperaemia was achieved using intravenous adenosine (140µg/kg/min). The first pass bolus contained 0.1mmol/kg of gadolinium (Omniscan, Amersham Health, Oslo, Norway) power injected at 5ml/sec (Medrad, Pittsburgh, PA) followed by a 20ml saline bolus. Twenty minutes after the initial bolus of gadolinium a further bolus was administered to obtain rest perfusion images. During coronary angiography the FFR was recorded in all patent major epicardial coronary arteries using a coronary pressure wire (RADI Medical Systems Ltd, Uppsala, Sweden) with hyperaemia induced using intravenous adenosine as above. An FFR value of <0.75 was taken as the cut off for the diagnosis of significant CAD. CFR measurements were obtained at rest and during maximal hyperaemia by means of thermodilution using 3ml boluses of saline. Following coronary angiography those patients who underwent PCI returned for a repeat MRMPI scan at 24 hours and 4 weeks and CABG patients returned for a 4 week scan. PCI patients had a troponin I measurement performed at approximately 24 hours, just prior to their repeat MRMPI. Qualitative MRMPI analysis, left ventricular mass, volume and ejection fraction analysis and QCA were all performed by two blinded independent experienced observers.
Results - Of the 103 enrolled patients, two were excluded from the final analysis. Seventy-six (74%) were male with a mean age of 60 years (SD = 9). 25 (24.8%) of 101 scans were normal, 40 (39.6%) had single-vessel disease, 26 (25.7%) had two-vessel disease and 10 (9.9%) had triple-vessel disease. 121 perfusion defects were reported in 300 coronary territories (3 patients had complete data for only 2 coronary territories) of which 110 had an FFR0.8 and a CFR<2.0 indicative of isolated microcirculatory disease with no physiologically significant epicardial disease. No coronary territories were found to have a perfusion defect on MRMPI suggesting that by visual analysis MRMPI is unable to detect isolated microvascular disease. The median post PCI troponin level was 0.57µg/L (SD=2, Range undetected - 13.1). The only parameters found to correlate with troponin I levels post-PCI were increasing lesion length (r=0.6, p<0.0001) and increasing total stent length (r=0.37, p=0.02). We compared the increase in mass of LGE between the post-PCI scans and the pre-PCI scan and compared this with the troponin measurement. No significant correlation was found to exist between these parameters at 24 hours (r=0.25, p=0.07) or at 4 weeks (r=-0.19, p=0.2). The change in mass of LGE was calculated for the PCI and CABG patients. The mean difference in the PCI group was -0.12g (Median=0, SD=0.8, Interquartile Range 0 – 0) and for the CABG group was 1.08g (Median=0.11, SD=2.3, Interquartile Range -0.11 – 1.38). There is a trend towards the development of more LGE following CABG than PCI however the difference between groups did not reach statistical significance (p=0.07).
Conclusion - MRMPI can accurately detect significant CHD with excellent results using FFR as the gold standard. Interobserver agreement is also very good even when examining individual coronary artery territories. Qualitative analysis of MRMPI is unable to detect isolated microcirculatory disease as defined by an FFR>0.8 and a CFR<2.0. Small troponin releases are common post-PCI and are related to the length of the lesion being treated and the length of stent deployed to treat the lesion. These small troponin releases do not accurately correlate with the occurrence of new LGE. CABG did result in a trend towards more new LGE compared to PCI
Janice Holt Giles: A Writer\u27s Life
Get PDFIn 1946, at the age of 41, Janice Holt Giles wrote her first novel. Although it took her only three months to complete the first draft, working at night so as not to conflict with her secretarial job, it was another four years before The Enduring Hills was published. Three years later, when her sixth novel appeared, Janice Holt Giles\u27s works had accumulated sales of nearly two million copies. Between 1950 and 1975 she wrote twenty-four books, most of which were bestsellers, regularly reviewed in the New York Times, and selected for inclusion in popular book clubs. Her picture held pride of place in her literary agent\u27s New York office, alongside those of Willa Cather, H.G. Wells, and Edith Wharton, yet until now there has been no biography of this immensely popular American writer.
Humbly professing to be just a good storyteller, Giles was a keen observer of life with great sensitivity, an ear for language, and a superb imagination. Her artistic achievements become even more remarkable when placed in the context of her often difficult personal struggles. Dianne Watkins Stuart, for years the acknowledged expert on Giles\u27s work, has traced the path of her unique life. Stuart walked around the small house where Giles\u27s brother was born and The Kinta Years (1973) had its origin, wandered through the yard where The Plum Thicket (1954) grew, and made countless trips to Adair County, Kentucky, to trace the trails of the Piney Ridge trilogy (The Enduring Hills, Miss Willie, Tara\u27s Healing) and seek out the day-to-day life of her later years. Stuart\u27s long-anticipated biography provides both a narrative of Giles\u27s life and an in-depth description of the art and commerce of American publishing in the middle years of the century.
Dianne Watkins Stuart is former education curator of the Kentucky Museum and editor of Hello, Janice: The Wartime Letters of Henry Giles.
Recounts the story of writer Janice Holt Giles who, at age forty-one while working a day job as a secretary, published her first novel about a couple living in Appalachia. —American Literature
It is interesting and inspiring to learn of the hardship Giles endured to become a writer, and that writing was as important as breathing to her —Booklist
Stuart\u27s Janice Holt Giles, thoroughly researched and beautifully written, is the definitive literary biography of one of Kentucky\u27s and America\u27s finest writers of historical fiction. To paraphrase the brilliant and multitalented subject of this book, Stuart\u27s biography is enduring as Kentucky\u27s hills and a great deal better than plumb. —Bowling Green Daily News
When the last word of the biography is read, the reader feels very close to Janice Holt Giles. —Columbia Magazine
An engrossing, engaging and illuminating biography. —Filson Club History Quarterly
Stuart’s knowledge of Giles’s work, both the stories themselves and the effort and anguish Giles exerted in completing them, is impressive. —Journal of Appalachian Studies
Stuart has written a biography about a truly remarkable woman who overcame numerous obstacles to become one of the state\u27s most beloved authors. —Kentucky Monthly
Now, readers can gain new insight into one of the state\u27s best-selling authors, thanks to the sure-handed study, Janice Holt Giles. —Lexington Herald-Leader
In this admiring biography, Stuart draws from Giles\u27s personal papers to trace her progression from observer to chronicler. —Library Journal
Stuart has covered every aspect of Giles\u27 life — the good times and the bad times. —The Voice-Tribune
The biography Giles justly deserves. —Tulsa World
The fascinating and inspiring story of one of Kentucky\u27s most successful writers—one that was popular during her lifetime and continues to be one of our most read authors. Watkins has recreated her life, one filled with great drama, remarkable successes, and devastating failures. Above all, this is a book about a fully-lived life. —Wade Hallhttps://uknowledge.uky.edu/upk_english_language_and_literature_north_america/1014/thumbnail.jp
Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments
Get PDFCoronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines
“That I should always listen to my body and love it”: Finding the Mind-Body Connection in Nineteenth- and Twentieth-Century Slave Texts
Get PDFThis thesis explores the presence of the movement theories of Irmgard Bartenieff, Peggy Hackney, and Rudolf Von Laban in the following texts: Narrative of the Life of Frederick Douglass, An American Slave. Written by Himself (1845), The History of Mary Prince: A West Indian Slave (1831), Incidents in the Life of a Slave Girl, Written by Herself, Linda Brent (1861), Sherley Anne Williams’s Dessa Rose (1986) and Toni Morrison’s Beloved (1987). The terms and phrases of movement theory will be introduced to the contemporary critical discussion already surrounding the texts, both furthering and challenging existing arguments
Safety of guidewire-based measurement of fractional flow reserve and the index of microvascular resistance using intravenous adenosine in patients with acute or recent myocardial infarction
Get PDFAims:
Coronary guidewire-based diagnostic assessments with hyperemia may cause iatrogenic complications. We assessed the safety of guidewire-based measurement of coronary physiology, using intravenous adenosine, in patients with an acute coronary syndrome.
Methods:
We prospectively enrolled invasively managed STEMI and NSTEMI patients in two simultaneously conducted studies in 6 centers (NCT01764334; NCT02072850). All of the participants underwent a diagnostic coronary guidewire study using intravenous adenosine (140 μg/kg/min) infusion for 1–2 min. The patients were prospectively assessed for the occurrence of serious adverse events (SAEs) and symptoms and invasively measured hemodynamics were also recorded.
Results:
648 patients (n = 298 STEMI patients in 1 hospital; mean time to reperfusion 253 min; n = 350 NSTEMI in 6 hospitals; median time to angiography from index chest pain episode 3 (2, 5) days) were included between March 2011 and May 2013. Two NSTEMI patients (0.03% overall) experienced a coronary dissection related to the guidewire. No guidewire dissections occurred in the STEMI patients. Chest symptoms were reported in the majority (86%) of patient's symptoms during the adenosine infusion. No serious adverse events occurred during infusion of adenosine and all of the symptoms resolved after the infusion ceased.
Conclusions:
In this multicenter analysis, guidewire-based measurement of FFR and IMR using intravenous adenosine was safe in patients following STEMI or NSTEMI. Self-limiting symptoms were common but not associated with serious adverse events. Finally, coronary dissection in STEMI and NSTEMI patients was noted to be a rare phenomenon
Telangiectasia macularis eruptiva perstans: More Than Skin Deep
Get PDFSystemic mastocytosis is a rare disease involving the infiltration and accumulation of active mast cells within any organ system. By far, the most common organ affected is the skin. Cutaneous manifestations of mastocytosis, including Urticaria Pigmentosa (UP), cutaneous mastocytoma or telangiectasia macularis eruptive perstans (TMEP), may indicate a more serious and potentially life-threatening underlying disease. The presence of either UP or TMEP in a patient with anaphylactic symptoms should suggest the likelihood of systemic mastocytosis, with the caveat that systemic complications are more likely to occur in patients with UP. TMEP can usually be identified by the typical morphology, but a skin biopsy is confirmative. In patients with elevated tryptase levels or those with frequent systemic manifestations, a bone marrow biopsy is essential in order to demonstrate mast cell infiltration. Further genetic testing for mutations of c-kit gene or the FIP1L1 gene may help with disease classification and/or therapeutic approaches. Rarely, TMEP has been described with malignancy, radiation therapy, and myeloproliferative disorders. A few familial cases have also been described. In this review, we discuss the clinical features, diagnosis and management of patients with TMEP. We also discuss the possible molecular pathogenesis and the role of genetics in disease classification and treatment
Myocardial hemorrhage after acute reperfused ST-segment-elevation myocardial infarction:Relation to microvascular obstruction and prognostic significance
Get PDFBackground—The success of coronary reperfusion therapy in ST-segment–elevation myocardial infarction (MI) is commonly limited by failure to restore microvascular perfusion.
Methods and Results—We performed a prospective cohort study in patients with reperfused ST-segment–elevation MI who underwent cardiac magnetic resonance 2 days (n=286) and 6 months (n=228) post MI. A serial imaging time-course study was also performed (n=30 participants; 4 cardiac magnetic resonance scans): 4 to 12 hours, 2 days, 10 days, and 7 months post reperfusion. Myocardial hemorrhage was taken to represent a hypointense infarct core with a T2* value of <20 ms. Microvascular obstruction was assessed with late gadolinium enhancement. Adverse remodeling was defined as an increase in left ventricular end-diastolic volume ≥20% at 6 months. Cardiovascular death or heart failure events post discharge were assessed during follow-up. Two hundred forty-five patients had evaluable T2* data (mean±age, 58 [11] years; 76% men). Myocardial hemorrhage 2 days post MI was associated with clinical characteristics indicative of MI severity and inflammation. Myocardial hemorrhage was a multivariable associate of adverse remodeling (odds ratio [95% confidence interval]: 2.64 [1.07–6.49]; P=0.035). Ten (4%) patients had a cardiovascular cause of death or experienced a heart failure event post discharge, and myocardial hemorrhage, but not microvascular obstruction, was associated with this composite adverse outcome (hazard ratio, 5.89; 95% confidence interval, 1.25–27.74; P=0.025), including after adjustment for baseline left ventricular end-diastolic volume. In the serial imaging time-course study, myocardial hemorrhage occurred in 7 (23%), 13 (43%), 11 (33%), and 4 (13%) patients 4 to 12 hours, 2 days, 10 days, and 7 months post reperfusion. The amount of hemorrhage (median [interquartile range], 7.0 [4.9–7.5]; % left ventricular mass) peaked on day 2 (P<0.001), whereas microvascular obstruction decreased with time post reperfusion.
Conclusions—Myocardial hemorrhage and microvascular obstruction follow distinct time courses post ST-segment–elevation MI. Myocardial hemorrhage was more closely associated with adverse outcomes than microvascular obstruction
Annular pancreas: endoscopic and pancreatographic findings from a tertiary referral ERCP center
Get PDFBackground and Aims
Annular pancreas is a congenital anomaly whereby pancreatic tissue encircles the duodenum. Current knowledge of endoscopic findings of annular pancreas is limited to small case series. The aim of this study was to describe the endoscopic and pancreatographic findings of patients with annular pancreas at a large tertiary care ERCP center.
Methods
This is a retrospective observational study. Our Institutional Review Board–approved, prospectively collected ERCP database was queried for cases of annular pancreas. The electronic medical records were searched for patient and procedure-related data.
Results
From January 1, 1994, to December 31, 2016, 46 patients with annular pancreas underwent ERCP at our institution. Index ERCP was technically successful in 42 patients (91.3%), and technical success was achieved in all 46 patients (100%) after 2 attempts, when required. A duodenal narrowing or ring was found in most patients (n = 39, 84.8%), yet only 2 (4.3%) had retained gastric contents. Pancreas divisum was found in 21 patients (45.7%), 18 of which were complete divisum. Pancreatobiliary neoplasia was the indication for ERCP in 7 patients (15.2%). Pancreatographic findings consistent with chronic pancreatitis were noted in 15 patients (32.6%) at the index ERCP.
Conclusion
This is the largest series describing the endoscopic and pancreatographic findings of patients with annular pancreas. We found that 45.7% of patients had concurrent pancreas divisum. Endoscopic therapy was successful in most patients at our institution after 1 ERCP, and in all patients after a second ERCP. Nearly one-third of patients had findings consistent with chronic pancreatitis at the time of index ERCP. It is unclear whether this may be a feature of the natural history of annular pancreas
A randomized trial of deferred stenting versus immediate stenting to prevent no- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI)
Get PDFObjectives:
The aim of this study was to assess whether deferred stenting might reduce no-reflow and salvage myocardium in primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).
Background:
No-reflow is associated with adverse outcomes in STEMI.
Methods:
This was a prospective, single-center, randomized, controlled, proof-of-concept trial in reperfused STEMI patients with ≥1 risk factors for no-reflow. Randomization was to deferred stenting with an intention-to-stent 4 to 16 h later or conventional treatment with immediate stenting. The primary outcome was the incidence of no-/slow-reflow (Thrombolysis In Myocardial Infarction ≤2). Cardiac magnetic resonance imaging was performed 2 days and 6 months after myocardial infarction. Myocardial salvage was the final infarct size indexed to the initial area at risk.
Results:
Of 411 STEMI patients (March 11, 2012 to November 21, 2012), 101 patients (mean age, 60 years; 69% male) were randomized (52 to the deferred stenting group, 49 to the immediate stenting). The median (interquartile range [IQR]) time to the second procedure in the deferred stenting group was 9 h (IQR: 6 to 12 h). Fewer patients in the deferred stenting group had no-/slow-reflow (14 [29%] vs. 3 [6%]; p = 0.006), no reflow (7 [14%] vs. 1 [2%]; p = 0.052) and intraprocedural thrombotic events (16 [33%] vs. 5 [10%]; p = 0.010). Thrombolysis In Myocardial Infarction coronary flow grades at the end of PCI were higher in the deferred stenting group (p = 0.018). Recurrent STEMI occurred in 2 patients in the deferred stenting group before the second procedure. Myocardial salvage index at 6 months was greater in the deferred stenting group (68 [IQR: 54% to 82%] vs. 56 [IQR: 31% to 72%]; p = 0.031].
Conclusions:
In high-risk STEMI patients, deferred stenting in primary PCI reduced no-reflow and increased myocardial salvage
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