Open Access Case Study

Case Report: Surgical Scar Endometriosis Following Caesarean Section

Tayfur Cift

Journal of Advances in Medicine and Medical Research, Page 3393-3397
DOI: 10.9734/BJMMR/2014/8202

Endometriosis is the presence of functioning endometrium outside the uterus. Endometriosis rarely occurs in the surgical scar of abdominal wall and is difficult to diagnose without pathological assessment. The symptoms are non-specific, typically involving cyclic abdominal wall pain around the incision site at the time for menstruation. It commonly occurs following obstetrical or gynaecological surgical procedures. We report a case of scar endometriosis following caesarean section.

Open Access Case Study

Endoscopic Treatment of Middle Ear Myoclonus with Stapedius and Tensor Tympani Section: A New Minimally-Invasive Approach

Natasha Pollak, Roya Azadarmaki, Sidrah Ahmad

Journal of Advances in Medicine and Medical Research, Page 3398-3405
DOI: 10.9734/BJMMR/2014/9181

Aims: We describe a new, entirely endoscopic surgical technique for treatment of middle ear myoclonus.
Case Presentation: In our patient, the stapedius and tensor tympani tendons were sectioned to control chronic middle ear myoclonus. The procedure was performed using endoscopic ear surgery techniques, with the aid of rigid Hopkins rod endoscopes. Control of the pulsatile tinnitus was achieved after endoscopic tenotomy of the stapedius and tensor tympani, without any complications.
Discussion and Conclusion: Endoscopic tensor tympani and stapedius tendon section is a new, minimally invasive treatment option for middle ear myoclonus that should be considered as a first line surgical approach in patients who fail medical therapy. The use of an endoscopic approach allows for easier access and vastly superior visualization of the relevant anatomy, which in turn allows the surgeon to minimize dissection of healthy tissue for exposure. The entire operation, including raising the tympanomeatal flap and tendon section can be safely completed under visualization with a rigid endoscope with good control of the pulsatile tinnitus.

Open Access Short Communication

Pilot Study of Ambulatory Inguinal Hernia Repair under Ultrasound-guided Transversus Abdominis Plane Block Anesthesia Plus Conscious Sedation

Dimitrios K. Manatakis, Nikolaos Stamos, Ioannis D. Dontas, Christos Agalianos, Michael Gkiaourakis, Michail Athanasios Karvelis, Ioannis D. Kyriazanos, Demetrios Davides

Journal of Advances in Medicine and Medical Research, Page 3269-3275
DOI: 10.9734/BJMMR/2014/8976

Aim: Transversus abdominis plane (TAP) block is mainly used as part of multimodal postoperative analgesia regimens in a wide variety of abdominal operations. Our purpose was to evaluate feasibility and safety of TAP block as anesthesia method for inguinal hernia repair.
Methodology: Twenty patients scheduled to undergo ambulatory inguinal hernia repair were selected and consented to ultrasound-guided TAP block anesthesia plus conscious sedation. Twenty to 25 ml of ropivacaine 0.5% were administered into the TAP and sensory blockade of T11-L1 dermatomes was examined 30 minutes later. Data on intraoperative tolerance, postoperative pain levels, rescue analgesia requirements, ambulation and complications were recorded.
Results: Nineteen blocks (95%) were successful. One patient (5%) required conversion to general anesthesia. One patient (5%) needed further local anesthetic infiltration before mesh fixation. Postoperative pain levels were excellent, with only one patient (5%) requiring rescue analgesia at home. No complications were observed and all patients were discharged on the evening of surgery.
Conclusion: Inguinal hernias can be safely repaired under ultrasound-guided TAP block anesthesia. Preliminary data are encouraging, in terms of intraoperative anesthesia adequacy, postoperative pain levels and rescue analgesia requirements. The role of TAP block as anesthetic modality for abdominal wall operations should be further investigated.

Open Access Original Research Article

Upregulation of PP1 Expression in Hippocampus Impairs Long-term Spatial Memory in Rats

Yi-Gang Chen

Journal of Advances in Medicine and Medical Research, Page 3220-3230
DOI: 10.9734/BJMMR/2014/6591

Aims: Either down-regulation of protein kinases or up-regulation of protein phosphatases weakens the level of neuronal protein phosphorylation and affects the function of neuron. Low-function and/or low-content of protein phosphatases in the hippocampus neurons is proposed to be a possible causative factor to the impairment of spatial memory ability. We show here that upregulation of PP1(protein phosphatase1) expression in hippocampus correlates with the decline of the spatial-memory retention ability in rat brain.
Study Design: In the present study, 30 adult Wistar rats were tested in a one trial step-down test to assess normal and impaired memory retention, examining protein phosphatases expression in their hippocampi and analysing both relationship.
Place and Duration of Study: Department of Pathophysiology, Medical College in Wuhan University of Science and Technology (WUST), between June 2010 and July 2011.
Methodology: To examine which rats have lower ability of learning and memory, thirty Wistar rats, male, 5-7 months old (360~450g), were trained and tested in step-down inhibitory avoidance task. R129d, R126d, R123d, Cdk5 (8) & CREB antibodies were respectively used to detect the content of PP1, PP2B, PP2A, Cdk5 & CREB. Densitometric analysis was used to quantitate the blots.Equal variance T test was used to analyze the escape latency and error from the two group rats, and the immunoblotting data from two groups of rat hippocampus proteins.
Results: 72h after the fourth trail, MMI (mild memory impairmemt) rats showed performance markedly worse than that of the NC (normal control) rats ( latency shorter, <150sec; error more, ≥1 vs latency, 300sec; error, 0times; Both P<<0.01). From the learning and retention curves of the both groups of rats in Fig. 1, author found that in the first step-down train, the error times in MMI rats were also more than those in NC rats (P< 0.05), indicating that the ability of learning new material in MMI rats is worse than that in NC rats. The results showed that the contents of PP1 and PP-2B in MMI rats have increased or decreased ~50% (P<0.01) or ~40% (P<0.01) respectively compared with NC rats; Whereas the expression of PP2A in both groups of rats showed no obvious difference, implying that PP1 and/or PP2B might participate in the regulation of learning and memory in the rat brain. In addition, we all found that the middle degree of adverse correlation between the expression of PP1 and the latency of MMI & NC rats (-0.618, P<0.001, two tails), and the low degree of positive correlation between the expression of PP-2B and the latency of MMI & NC rats (0.381, P<0.05, two tails), indicating that the increase of PP1 content in itself might impress in part the memory ability of rats.
Conclusion: It is concluded that upregulation of PP1 content may mediate worsened memory retention in rat brain.

Open Access Original Research Article

Prevalence of Hospital-Based Malaria among Children in Jos, North Central Nigeria

Caroline Okoli, Mariam Solomon

Journal of Advances in Medicine and Medical Research, Page 3231-3237
DOI: 10.9734/BJMMR/2014/8068

Background: In Nigeria, malaria is one of the main causes of morbidity and mortality in children. Nigeria government has put in efforts on malaria control and prevention. This is in consonance with Roll back malaria initiative’s objectives. Thus, with the expiration of RBM 2010 target deadline for malaria, there is a need to assess the prevalence of malaria among the risk group in this malaria endemic area, to ascertain how far we have gone in achieving the initiatives objectives.
Objective: The aim of this study was to determine the prevalence of malaria among children.
Method: This is a hospital based cross- sectional study of 600 children with or without malaria attending various health care centers in the urban area of Jos, North central Nigeria. Giemsa stained thick and thin blood films were examined for malaria parasite using x 100 (oil immersion) objective.
Result: Six hundred children with or without malaria were recruited for the study, in which 287 (47.8%) were boys. Based on microscopical diagnosis of malaria, 306 (51.00%) of the children had malaria parasitaemia. 48.06% prevalence rate was obtained among febrile under-5 children. One hundred and twenty-one (20.17%, 121/600) of the children had fever out of which 103 (85.12%, 103/121) had fever and the remaining had no fever. The geometric mean of the parasites was 385.85 parasites/ul and 20 (6.53%) of the children with malaria parasitaemia had parasite density> 500 parasites/μl. Malaria parasitaemia was relatively higher in children aged 5-9 years.
Conclusion: There is still a high prevalence of hospital-based malaria among children aged 1-day to18 years in the urban areas of Jos, north central Nigeria. Consequently, there is a need to intensify effort on malaria treatment, control and prevention in these areas.

Open Access Original Research Article

Health Maintenance Organization-Federally Qualified Health Center (HMO-FQHC) Collaboration to Provide After-Hours Pediatric Primary Care: A Feasibility Study

Leah S. Fischer, Charles E. Begley, Shabnam Azadeh, Xuan G. Tran, Angelo P. Giardino

Journal of Advances in Medicine and Medical Research, Page 3238-3247
DOI: 10.9734/BJMMR/2014/8370

Aims: Examine feasibility, implementation and impact of a Health Maintenance Organization (HMO)-Federally Qualified Health Center (FQHC) collaboration in providing after-hours care as an Emergency Department (ED) diversion strategy.
Study Design: Prospective study using pre-post comparison design.
Methodology: Service enhancement program with the addition of after-hours clinic services coupled with a Texas Children’s Health Plan outreach campaign were conducted in Houston, Texas to promote the increased availability of clinic services during a six month period from September 2006 to February 2007 to enrolled Medicaid and State Children’s Health Insurance Program (SCHIP) enrollees. Claims data were used to identify after-hours clinic utilization and a pre-post analysis compared ED use rates of after-hours clinic users, non-users within the service area, and other enrollees in the health plan. Start-up costs provided by community funders amounted to 46,000 dollars (onetime payment) and marketing outreach campaign was supported with 52,000 dollars from TCHP.
Results: During the intervention time frame, September 1, 2006 thru February 28, 2007, at least 194 enrollees visited the after-hours clinic. An impact on ED utilization was not found and the six-month post intervention ED utilization for both the intervention and comparison groups increased when compared to the six-month baseline measurement period.
Conclusion: Establishing and promoting the after-hours clinic during this project targeting HMO enrollees was determined to be feasible with at least 194 enrollees who resided in the targeted area visiting the after-hours clinic at the FQHC.A six-month study period was long enough to examine the feasibility of providing after-hours pediatric health services, but probably not long enough to assess the full impact of after-hours health services on ED use. Further study, over an entire year allowing for the incorporation of both high and low seasonal trends will be essential to definitively assess if and HMO-FQHC collaboration on an after-hours clinic is an effective strategy to reduce ED visits in a traditionally underserved population of children covered under the Medicaid and SCHIP.

Open Access Original Research Article

A Controlled Trial of Oral Rifampin in Chronic Plaque Psoriasis

Luvdeep Dogra, V. N. Saxena, Jaideep Dogra, Nimisha Kishoria

Journal of Advances in Medicine and Medical Research, Page 3248-3254
DOI: 10.9734/BJMMR/2014/9331

Group A Streptococcal infection in the throat is responsible for causing initial and recurrent attacks of acute guttate psoriasis (AGP). Up to 70% of these AGP patients go on to develop chronic plaque psoriasis (CPP). We hypothesized that chronic sub-clinical, on-going streptococcal infection might solely be responsible for CPP in a genetically predisposed individual.
Rifampin, a useful drug for several types of bacterial infections including Group A Streptococci (GAS) because of its broad spectrum, excellent tissue penetration, low side-effect profile and its salivary concentrations after oral administration greatly exceeds the minimum inhibitory concentration for most GAS, thus helpful in eradicating pharyngeal carriage of GAS, was considered for long term use in CPP.
Fifty patients with moderate to severe CPP were enrolled. Of these 25 were randomly selected to receive rifampin for 36 weeks as a single oral morning dose of 10 mg/kg body weight (approx. patient weighing <50 kg received 450mg per day and patients >50 kg received 600mg per day). Remaining 25 patients received placebo. Rifampin group was further followed-up to one more year.
Significant improvement in PASI score was noted from 12 weeks in majority of patients in Rifampin group. Relevant investigations and clinical assessment was done at regular intervals to observe any side effects and check progress of the disease. Data were analyzed statistically using the t-test.
As psoriasis is a chronic disorder that waxes and wanes over time, withdrawal of treatments usually is accompanied by relapse of skin manifestations so a follow-up with one year drug-free period was added to verify treatment consistency. Patients tolerated the therapy well.

Open Access Original Research Article

An Outpatient-based Survey about the Recognition of Locomotive Syndrome and the Results of the Loco-check at a University Hospital in Tokyo

Taketo Okubo, Yoshiyuki Suehara, Takayuki Kawasaki, Keisuke Akaike, Midori Toda, Naoko Okubo, Daisuke Kubota, Kenta Mukaihara, Yongji Kim, Takafumi Kaketa, Yasuhiro Homma, Norio Shimanouchi, Tsuyoshi Saito, Tatsuya Takagi, Kazuo Kaneko

Journal of Advances in Medicine and Medical Research, Page 3255-3268
DOI: 10.9734/BJMMR/2014/7506

Background: To prevent locomotor dysfunction, the Japanese Orthopaedic Association (JOA) proposed the concept of locomotive syndrome (LS) in 2007, and has carried out many campaigns to increase the awareness of LS. Recently, the JOA reported that 26.6% of people recognized LS in internet based surveys. However, a survey of the recognition of LS using outpatient (hospital-based) cohorts has never been performed. Therefore, we surveyed the recognition of LS, the prevalence of LS and any correlations between LS and the clinical data in the outpatient cohort.
Methods: To investigate the recognition of LS and prevalence of LS, we conducted a questionnaire survey including the “loco-check” in 1010 (429 male and 581 female) orthopaedic outpatients at Juntendo University Hospital (Tokyo, Japan) from April to June 2013.
Results: Only 24.6% of the patients knew about the concept of LS. In terms of the media sources from which the patients had received information about LS, 49.5% received LS information from TV. With regard to the prevalence of LS, 43.8% was classified into the LS group. The prevalence of LS was 32.9% in males and 51.8% in females. When the relationship between LS and orthopaedic disease was examined, 50 of 55 (90.9%) knee osteoarthritis (OA) patients, 21 of 26 (80.8%) hip OA patients and 98 of 151 (64.9%) lumbar spondylosis patients had statistically significant correlations with LS (p<0.0001).
Conclusion: This study confirmed the rate of recognition of LS indicated by the JOA survey. Our studies also revealed that LS score was related to orthopaedic disorders. Our outpatient-based surveys may help provide a better understanding of the effects and trends of the campaigns to promote the recognition of LS.

Open Access Original Research Article

Nasopharyngeal Carcinoma: An Awareness and Screening Initiative in Boston’s Chinatown

Jeremiah Tracy, Mazin Merdad, Miriam O’Leary, Richard O. Wein

Journal of Advances in Medicine and Medical Research, Page 3276-3282
DOI: 10.9734/BJMMR/2014/5895

Aims: Our objective is to describe our institutional experience with nasopharyngeal carcinoma (NPC), and the initiation of a community education and screening program.
Study Design: Retrospective case series; academic medical center.
Methodology: All cases of NPC treated at our institution between 1995 and 2009 were included; in total, 63 consecutive cases. Initially a retrospective review of patient characteristics was performed (Phase 1). Information reviewed included stage at presentation, completion of primary treatment and follow-up greater than 1 year. Findings of Phase 1were interpreted as demonstrating an issue in communication between the medical center and the community of patients at large. As such, a community education and screening program was instituted as part of an attempted community outreach program (Phase 2). The primary goals were to increase awareness about this disease, symptoms requiring evaluation and to educate patients about the resources available to them.
Results: At the time of diagnosis, 67% of patients with NPC presented with advanced-stage (III,IV) disease. Of the patients treated with curative intent, only 76% fully completed their plan of treatment. Also of note, only 60% of patients were seen in follow-up at 1-year post-treatment. A community education and screening program was initiated in order to address a presumed gap in provider-patient communication. To date a total of 176 patients have been screened; with approximately 10% warranting further diagnostic evaluations.
Conclusions: Although NPC is an unusual diagnosis in the United States, it is a common entity in the immigrant Cantonese population that live in Boston’s Chinatown. A review of the characteristics of our patient population with NPC led to a community awareness and screening initiative, which has sought to achieve earlier diagnosis and improved continuity of care for patients.

Open Access Original Research Article

Placental Leucine Aminopeptidase/Oxytocinase Expression in Miscarriage

Taghreed H. AL Sadoon, Ferah Gh. Al-Salihi, Adnan I. Al-Badran

Journal of Advances in Medicine and Medical Research, Page 3283-3292
DOI: 10.9734/BJMMR/2014/6185

Objectives: To evaluate the role of placental leucine aminopeptidase (P-LAP) in miscarriage and searching to select the gene of this enzyme in miscarriage to exclude direct or indirect effects of abortion.
Methods: Total RNA is purified from the fresh placental tissue sample according to the protocol of the QIAamp®RNA Tissues Mini Kit (Qiagen). The sample is visualized by 0.7% agrose gel containing. Total RNA is reverse-transcribed RT-PCR carried out on the previously extracted RNA samples using (QIAGEN One Step RT –PCR Kit). Aliquots (1ml) of RT reaction samples are amplified by PCR, the PCR products (10µl) per lane are resolved by using electrophoresis on 2.0% agrose gel .Later the product is detected and examined under UV transiluminator.
Results: The obtained results indicate that there is an expression of P-LAP mRNAs in placentas of normal pregnancy women (28±SE0.45) and there is a decrease in miscarriage. Furthermore, there is a difference between single miscarriage and those with recurrent miscarriage, the mean values in single miscarriage (1st and 2nd) are (16.1%±SE0.84) and (13%±SE0.24) respectively while the mean values in recurrent miscarriage (1st and 2nd) are (12%±SE0.19) and (9%±SE0.52) respectively. The expression of P-LAP is significantly lower (p=0.05) in miscarriage and highly significant decrease in recurrent than in single miscarriage women.
Conclusion: The decrease of P-LAP mRNA levels in miscarriage placentas could be a sign that p-LAP function is an important step in pregnancy regulation.

Open Access Original Research Article

WHOQOL-BREF among Singaporean Patients with Type II Diabetes Mellitus: What Does It Measure?

Tan Luor Shyuan Maudrene, Bautista Dianne Carrol Tan, Khoo Eric Yin Hao, Griva Konstadina, New Michelle, Amir Mohammad, Lee Yung Seng, Lee Jeannette, Tai E Shyong, Wee Hwee Lin

Journal of Advances in Medicine and Medical Research, Page 3293-3316q
DOI: 10.9734/BJMMR/2014/9054

Aims: Health-related quality of life (HRQoL) of Type 2 diabetes mellitus (T2DM) is a growing concern globally given the increase in T2DM prevalence. Generic HRQoL instruments are important to allow cross-cultural, cross-population and cross-study comparisons. The short version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire is a widely used generic questionnaire. Hence, we aimed to evaluate the psychometric properties of the WHOQOL-BREF among patients with T2DM in Singapore.
Study Design: Patients at a diabetes outpatient specialist clinic in Singapore were recruited via convenience sampling. Classical Test Theory methods were used to evaluate data quality, scaling assumptions, targeting, internal consistency reliability and construct validity (structural, convergent and discriminant) and criterion validity using HbA1c control (good versus poor). Principal Component Analyses (PCA) and Confirmatory Factory Analyses (CFA) were performed to assess unidimensionality (domain-level) as well as conformity with the original four-factor structure. Exploratory Factor Analysis (EFA) was done if CFA indicated lack of fit.
Results: 212 subjects were analyzed of whom 50% were Chinese, 28% Indians, 11% Malays and 10% others. 63% were males with mean (SD) age 45.8 (11.9) years. Data quality was superior, scaling assumptions were met, targeting was satisfactory and internal consistency was achieved. PCAs were compatible with unidimensionality, except in the Physical domain. Domain level CFA indicated that unidimensionality had poor fit and overall CFA did not support the original 4-factor structure. EFA runs showed that the Physical and Environment domains overlapped while the Social and Psychological domains could not be recovered. Therefore construct (structural) validity was not established. Criterion validity was not achieved as all domains could not discriminate between those with good versus poor HbA1c control.
Conclusion: Construct and criterion validity of WHOQOL-BREF posed some concerns. Thus, we recommend that an adequately-powered random sample of T2DM patients in Singapore be studied to confirm the findings of our study.

Open Access Original Research Article

Histological and Immunohistochemical Study on Nitric Oxide Synthase and Effects of Angiotensin Receptor Blockade in Early Phase of Diabetes in Rat Kidney

Menna M. Abdel-Dayem, Manal M. Hatem, Mohamed S. Elgendy

Journal of Advances in Medicine and Medical Research, Page 3317-3338
DOI: 10.9734/BJMMR/2014/7585

Hypothesis: Several studies demonstrated that the patho-physiologic and morphologic changes in early diabetic nephropathy were mediated by either an increase or decrease in the nitric oxide (NO) production and/or activity. There are few reports suggesting a relationship between NO and renin-angiotensin system.
Objectives: The present study was designed to determine the effects of early diabetic state on NO production and also to assess the protective effects of angiotensin receptor blockers (ARB) on these changes.
Material and Methods: Thirty adult male albino rats were included in this study. Twenty were injected with streptozotocin for induction of diabetes. The other ten were injected with the vehicle and served as control. Two days after injection, the diabetic animals were randomly divided into two groups of ten animals each. One group was given Valsartan as an ARB and the other group received no further treatment. Three weeks later, all animals were sacrificed and the kidneys were processed for paraffin sections. The sections were stained with H & E, Masson trichrome and PAS reaction. Also, the sections were stained with immunohistochemical stain against endothelium-derived nitric oxide synthase (eNOS).
Results: Diabetes induced histological changes in the form of glomerular hypertrophy, increased glomerular matrix, focal areas of tubular atrophy, medullary congestion and slight fibrosis. eNOS immunostaining was present in the control kidney in the golumeruli and the collecting tubules of the medulla. Diabetes induced positive reaction in the proximal and distal convoluted tubules and increased eNOS immunoreactivity in the collecting tubules. Treatment with Valsartan induced improvement of the morphology of the kidney and reduction in the intensity of eNOS immunostaining.
Conclusion: NO increases in early diabetic kidney and ARB as Valsartan could be recommended in the prevention of the development of diabetic nephropathy.

Open Access Original Research Article

Circulating Angiogenesis Factors in Patients with Non-Hodgkin’s Lymphoma

Roba M. Talaat, Naser Abdel-Bary, Rawia F. Sadek, Eman A. El-Maadawy, Amal M. Abdel-Aziz

Journal of Advances in Medicine and Medical Research, Page 3366-3383
DOI: 10.9734/BJMMR/2014/8582

Aims: Non-Hodgkin’s lymphoma (NHL) is a heterogeneous group of hematological malignancies. Several angiogenic factors are important in NHL. The objective of this study was to determine plasma levels of various proangiogenic [vascular endothelial growth factor (VEGF), platelet derived growth factor (PDGF), tumor necrosis factor (TNF-α), transforming growth factor (TGF-β), interleukin (IL-6), IL-8] and antiangiogenic [IL-4, IL-12, interferon gamma (IFN-γ)] factors in NHL patients and implication of CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone) therapy on these mediators.
Study Design: This study was conducted on 100NHL patients recruited from the Oncology Hospital, Menofia University, Egypt. Fifty patients had different doses of CHOP chemotherapy and 50 patients were without treatment. Another 119 healthy blood donors were served as healthy controls.
Methodology: Enzyme-linked immunosorbent assay (ELISA) was used to detect the concentrations of these mediators in plasma of NHL patients and normal controls.
Results: Several proangiogenic (VEGF, PDGF, IL-8, and TNF-α) (P<.001, P<.01, P<.01, and P<.001) and antiangiogenic (IL-4,IL-12) (P=.05, P<.01) mediators were decreased in NHL patients. In contrast, IL-6, and IFN-γ) were increased (P<.001). After CHOP treatment, VEGF, and PDGF were significantly increased (P<.001) as compared to NHL without therapy Fig. 1. Reduction in IL-8 (P<.01) and TNF-α (P<.001) in untreated NHL patients was continued after CHOP treatment. IL-6 was the only elevated cytokine in NHL patients with (P<.001) or without (P<.001) treatment compared to healthy individuals. Concerning the antiangiogenic mediators, treatment resulted in reduction in the secretion level of IFN-γ) (P<.001) and IL-12 (P<.001). Although CHOP treatment required more than 8 doses to be able to down regulate proangiogenic (VEGF,PDGF, IL-8,TNF-α and IL-6) and elevate antiangiogenic (IL-4,IL-12,IFN-γ) mediators, changes were statistically insignificant.
Conclusion: Collectively, our study stressed on the importance of having an angiogenic profile of NHL patients under treatment which could be used to monitor the efficacy of cancer therapy particularly in therapy with antiangiogenic drugs. Further studies are required to confirm these results.

Open Access Original Research Article

Temporal Trends in Radiation Exposure and Utilization of Coronary CT Angiography, SPECT, and Invasive Coronary Angiography

Ronald L. Jones, Richard A. Clark, Bernard J. Rubal, Ryan J. McDonough, Kenneth Stone, Edward A. Hulten, Todd C. Villines, Ahmad M. Slim, Kevin E. Steel

Journal of Advances in Medicine and Medical Research, Page 3384-3392
DOI: 10.9734/BJMMR/2014/9394

Background: The use of noninvasive medical imaging has increased over the past decade at a cost of significant lifetime radiation exposure to study subjects. We report the implementation of radiation dose reduction methods and associated reduction in ionizing radiation exposure with Coronary Computed Tomography Angiography (CCTA) over time.
Methods: Radiation doses and total number of studies performed were evaluated constantly from January 2010 to September 2012 for CCTA (N=2613), as well as Single photon emission computed tomography (SPECT, N=8060) part of an ongoing effort to minimize radiation exposure. Analysis of variance was used to evaluate the radiation exposure reduction among modalities. We compared CCTA radiation doses in the era of retrospective protocols coupled with dose modulation (40%-80%phase) using Siemens® 64-slice Dual Source technology, with prospective scanning on the same equipment, as well as radiation doses on the newer Siemens® Flash Equipment and the implementation of nursing/technologist aggressively driven protocol for heart rate control and image acquisition independent of imaging provider presence during acquisition.
Results: The radiation dose reduction with implementation of multiple measures of radiation reduction to include physician independent-technician driven CCTA protocol resulted in a reduction from mean of 9.85±5.96 (median 8.8mSv) to mean of 3.00±2.53(median 2.1mSv) (p<0.0001). CCTA radiation dose has decreased by 69.2% since January of 2010 while SPECT radiation dose remained constant at 14mSv (p<0.0001).
Conclusion: Continued advances in software and hardware technology, combined with “physician independent-technician driven” CCTA protocol have drastically reduced radiation dosing in CCTA to annual background radiation exposure, while maximizing the benefit of the study and without sacrificing patient safety.

Open Access Review Article

A Body Divided: Toward Reunification of the Paradigm

Miranda A. Farage, Kenneth W. Miller, Gabe Tzeghai, Howard I. Maibach

Journal of Advances in Medicine and Medical Research, Page 3339-3365
DOI: 10.9734/BJMMR/2014/9506

Symptoms without obvious physical cause are commonly reported in medical practice; when chronic, they can have a significant influence on patients' well-being. When traditional medicine is unable to provide relief, sufferers of such conditions often turn to alternative therapies. Western medicine has historically viewed the body through a silo model, i.e, a whole consisting of disparate body systems with well-defined boundaries and little relevant interaction. This model ignores the myriad of interactive functions that each system must require and hinders understanding of syndromes for which etiology is not confined to one organ system, particularly those with a strong psychosocial component. In addition, this model is increasingly shown to be antiquated: recent evidence of Pavlovian conditioning of physiological processes (i.e., placebo and nocebo affects, immune system conditioning), physiological distinctions between multiple personalities, and the pervasive effects of psychosocial stress on every body system (down to the level of the genome) demand a new paradigm. As our appreciation expands of the innumerable interactions between body systems as well as those between all body systems and the mind, the human body is revealed to be a complex web of neurological, immunologic and endocrine interactions that in turn modulate a fluid epigenetic base. Firmly planted in the rationalistic viewpoint that is the foundation of Western medicine, but inclusive of the more wholistic (mind and body) view of Eastern medicine, a nexus model which views the body as the series of multi-connected, interacting physiological webs is essential to continued progress in medicine.