Neighbourhood Social Determinants of Health and Geographical Inequalities in Premature Mortality in Taiwan: A Spatiotemporal Approach.

Geographical inequalities in premature mortality and the role of neighbourhood social determinants of health (SDOH) have been less explored. This study aims to assess the geographical inequalities in premature mortality in Taiwan and how neighbourhood SDOH contribute to them and to examine the place-specific associations between neighbourhood SDOH and premature mortality. We used township-level nationwide data for the years 2015 to 2019, including age-standardized premature mortality rates and three upstream SDOH (ethnicity, education, and income). Space-time scan statistics were used to assess the geographical inequality in premature mortality. A geographical and temporal weighted regression was applied to assess spatial heterogeneity and how neighbourhood SDOH contribute to geographic variation in premature mortality. We found geographical inequality in premature mortality to be clearly clustered around mountainous rural and indigenous areas. The association between neighbourhood SDOH and premature mortality was shown to be area-specific. Ethnicity and education could explain nearly 84% variation in premature mortality. After adjusting for neighbourhood SDOH, only a handful of hotspots for premature mortality remained, mainly consisting of rural and indigenous areas in the central-south region of Taiwan. These findings provide empirical evidence for developing locally tailored public health programs for geographical priority areas.

Increased heterogeneity of brain perfusion predicts the development of cerebrovascular accidents.

ABSTRACT: The heterogeneity of brain perfusion is related to the risk factors of thromboembolic events such as antiphospholipid syndrome. However, the effectiveness of brain perfusion heterogeneity as a marker to predict thromboembolic events has not been confirmed. Our objective was to evaluate the effectiveness of brain perfusion heterogeneity as a marker to predict the development of cerebrovascular accidents. In this retrospective cohort study, patients who underwent Tc-99m ECD brain SPECT from January 1, 2006 through December 31, 2008 were included. Each study was reoriented with the Talairach space provided by the NeuroGam Software package. Heterogeneity of brain perfusion was measured as the coefficient of variation. The study outcome was the risk of cerebral vascular accidents in patients with increased heterogeneity of brain perfusion between January 1, 2006 and December 31, 2015. A multiple Cox proportional hazards model was applied to evaluate the risk of cerebrovascular accidents. A total of 70 patients were included in this study. The median age was 39 years (range, 28 - 59 years). There were 55 (78.6%) women. For increased heterogeneity of brain perfusion, the hazard ratio of cerebrovascular accidents was 2.68 (95% CI, 1.41 - 5.09; P = .003) after adjusting for age, sex, hypertension, diabetes mellitus, and dyslipidemia. Our study suggests that increased heterogeneity of brain perfusion is associated with an increased risk of cerebrovascular accidents.

Improved diagnostic accuracy of thallium-201 myocardial perfusion single-photon emission computed tomography with CT attenuation correction.

BACKGROUND: The benefits of attenuation correction (AC) in technetium-99m myocardial perfusion imaging (MPI) have been well established. However, the value of thallium (Tl-201) AC and routine computed tomography AC (CTAC) were less well established. The aims of this study were to evaluate the diagnostic performance of thallium (Tl-201) MPI with additional CTAC and to determine which participants would benefit most. METHODS AND RESULTS: A total of 108 consecutive patients who underwent Tl-201 MPI and received coronary angiography within 3 months were enrolled. Diagnostic performance was determined by sensitivity, specificity, and receiver operating characteristic curve analysis. Subgroup analyses were performed using gender and obesity. CTAC improved the area under the curve (0.84 vs. 0.77, P = 0.037 at patient level), primarily due to a significant improvement in specificity (0.78 vs. 0.57, P = 0.013) and no significant difference in sensitivity (0.79 vs. 0.82, P = 0.75). In subgroup analysis, CTAC was most helpful in obese subjects, men, and especially right coronary artery lesions. CONCLUSIONS: CTAC significantly improved diagnostic performance primarily by increasing the specificity, and the improvements were significantly greater in obese patients and male patients. These findings suggest that CTAC should be applied to Tl-201 MPI as routine clinical practice.

Increased heterogeneity of brain perfusion is an early marker of central nervous system involvement in antiphospholipid antibody carriers.

OBJECTIVE: The non-criteria neuropsychiatric manifestations of antiphospholipid syndrome include headache, dizziness, vertigo, seizure, depression and psychosis. There were still no objective methods qualified to detect the early central nervous system involvement in non-criteria antiphospholipid syndrome. We evaluated the effectiveness of Tc-99m ECD SPECT in assessing circulatory insufficiency in the brains of patients with antiphospholipid antibodies and neuropsychiatric symptoms but without thromboembolism. MATERIALS AND METHODS: Patients with a history of positive antiphospholipid antibodies and neuropsychiatric symptoms composed the case group; patients without antiphospholipid antibody served as the control group. Subjects with a history of thromboembolism or autoantibodies to extractable nuclear antigens were excluded. All patients received Tc-99m ECD SPECT studies and were classified by the number of positive antiphospholipid antibodies they carried. The heterogeneity of brain perfusion was defined as the coefficient of variation of the SPECT signals. Analysis of variance (ANOVA) was applied to evaluate the differences between the groups. RESULTS: Total 60 adult patients were included in this study. There were 54 patients in the case group and 6 patients in the control group. The mean age was 38.3 ± 11.5 years. There were 52 women and 8 men. There was no significant difference in the mean brain perfusion between groups (P = 0.69). However, Tc-99m ECD SPECT demonstrated significant heterogeneity of brain perfusion in relation to the number of antiphospholipid antibodies (P = 0.01). CONCLUSIONS: This is the first study demonstrating that Tc-99m ECD SPECT can early detect the increased heterogeneity of brain circulation in non-criteria antiphospholipid antibody carriers.

Diagnostic and Prognostic Implications of Exercise Treadmill and Rest First-Pass Radionuclide Angiography in Patients With Pulmonary Hypertension.

PURPOSE: Pulmonary hypertension (PH) is characterized by abnormally increased pulmonary vascular pressure, leading to deteriorated right ventricular function and premature death. Pulmonary mean transit time (PMTT) and biventricular function response to exercise in first-pass radionuclide angiography (FP-RNA) may provide early detection and timely disease monitoring of PH. This study aimed to investigate the diagnostic and prognostic values of this imaging modality in PH patients. METHODS: Left and right ventricular ejection fraction (LVEF/RVEF) and PMTT at rest and immediately after exercise treadmill test were measured by FP-RNA in 77 consecutive patients with clinical presentations suggestive of PH (aged 46 ± 15 years, 33 men), mostly with symptoms of unexplained progressive dyspnea. These parameters, along with other clinical variables, were correlated with right-sided heart catheterization data and clinical outcomes. RESULTS: Fifty patients (64.9%) were diagnosed as having definite PH. Besides higher N-terminal pro-B-type natriuretic peptide levels, right atrial pressure, and pulmonary vascular resistance, PH patients had significantly longer PMTT, lower LVEF after exercise and rest, and lower poststress RVEF (all P < 0.05), compared with non-PH subjects. Moreover, PH patients exhibited stress-induced right ventricular dysfunction and stationary poststress PMTT. Poststress PMTT and echocardiography had comparable diagnostic utility (area under the curve, 0.80 vs 0.84, respectively). Eighteen patients died during a median follow-up period of 380 days. Failure of exercise treadmill test, lower peak heart rate response, and stress/rest LVEF ratio of less than 90% using exercise treadmill FP-RNA were independent predictors of mortality in PH patients. CONCLUSIONS: Exercise treadmill and rest FP-RNA provided diagnostic value and had prognostic implications in patients with PH.

The Incremental Diagnostic Performance of Coronary Computed Tomography Angiography Added to Myocardial Perfusion Imaging in Patients with Intermediate-to-High Cardiovascular Risk.

PURPOSE: Several studies have suggested that a combined approach of stress myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) can provide diagnostic results with excellent accuracy. We aimed to explore whether the addition of CCTA to stress MPI provides incremental diagnostic value in intermediate-to-high cardiovascular risk patients. METHODS: A total of 106 consecutive patients (93 male, 65 ± 10.4 years) underwent coronary artery calcium scoring (CACS), CCTA and (201)Thallium stress MPI before coronary angiography was reviewed. Thirty-seven patients (34.9%) had a history of proven coronary artery disease (CAD) or revascularization procedures, and four had documented non-significant CAD (3.8%). The remaining patients consisted of 17 (16.0%) classified as intermediate, and 48 (45.3%) as the high-risk groups. RESULTS: Obstructive CAD was diagnosed by invasive coronary angiography in 88 patients with 161 vessels. The sensitivity and specificity in a patient-based analysis for obstructive CAD were 99% and 17% for CCTA, 80% and 50% for MPI and 91% and 67% for the combined method, respectively. The per-vessel diagnostic sensitivity and specificity were 95% and 54% for CCTA, 59% and 75% for MPI and 84% and 76% for the combined method. There were significant differences (p < 0.05) when comparing the combined method with MPI or CCTA by areas under the curve in a patient- or vessel-based analysis. However, CACS of 400 or more could not further stratify the patients with obstructive CAD. CONCLUSIONS: CCTA, not CACS, provided additional diagnostic values to stress MPI in patients with intermediate-to-high cardiovascular risk. KEY WORDS: Coronary artery disease (CAD) • Coronary computed tomography angiography (CCTA) • Myocardial perfusion imaging (MPI) • Single-photon emission computed tomography (SPECT).

Comparison of biventricular ejection fractions using cadmium-zinc-telluride SPECT and planar equilibrium radionuclide angiography.

BACKGROUND: We compared biventricular ejection fractions (EFs) from gated blood-pool single-photon emission computed tomography (SPECT) using a cadmium-zinc-telluride camera (CZT-SPECT) with planar equilibrium radionuclide angiography (ERNA) using a NaI gamma camera (NaI-planar). We also evaluated whether imaging time can be reduced without compromising image quality using the CZT camera. METHODS: Forty-eight patients underwent NaI-planar and CZT-SPECT on the same day. CZT-SPECT datasets were re-projected at an LAO orientation similar to ERNA acquisition, forming CZT-repro planar datasets. The resulting biventricular volumetric measurements and EFs were compared. RESULTS: LVEF calculated from CZT-SPECT and CZT-repro correlated better with NaI-planar (r = 0.93 and 0.99, respectively) than RVEF (r = 0.76 and 0.82, respectively). Excellent intra-class correlation and low bias in intra-observer comparisons were observed for the biventricular EFs derived from three datasets. A wider limit of agreement in CZT-SPECT-derived LVEFs, lower correlation and significant bias for NaI-planar, and CZT-repro-derived RVEFs was found in the inter-observer analyses. Nonetheless, the imaging time can be reduced to 4 minutes without increasing variability in EFs using the CZT camera (P = NS). CONCLUSIONS: LVEFs calculated from CZT-SPECT and CZT-repro correlated well with NaI-planar. CZT camera may reduce imaging time while preserving image quality in the assessment of biventricular EFs.

Evaluation of circulating adipokines and abdominal obesity as predictors of significant myocardial ischemia using gated single-photon emission computed tomography.

OBJECTIVE: Coronary artery disease (CAD) is associated with abdominal obesity and metabolic syndrome. Adipocytes secrete adipokines, including the newly discovered adipocyte fatty acid binding protein (A-FABP) and chemerin. Adipokines contribute to the pathogenesis of CAD. In patients with CAD, the presence of significant ischemia predicts adverse outcomes. It is unknown whether adipokines can be better predictors of the presence of significant myocardial ischemia than conventional risk factors. This study aimed to compare adipokines with clinical risk factors and abdominal obesity as predictive factors for significant myocardial ischemia. METHODS: One hundred and ninety-six adults with suspected, but unproven, CAD were consecutively enrolled. The main measures were clinical and biochemical parameters and stress myocardial perfusion imaging with gated myocardial perfusion single-photon emission computed tomography (SPECT), with computed tomography (CT) attenuation correction. The abdominal visceral fat area was examined using a hybrid SPECT/CT scanner. Serum levels of high-sensitivity C-reactive protein (hs-CRP) and adipokines (adiponectin, A-FABP, and chemerin) were evaluated. RESULTS: A-FABP levels correlated significantly with adiponectin, hs-CRP, body mass index, waist circumference, and visceral fat area. A-FABP was significantly associated with metabolic syndrome (OR 3.2, 95% CI 1.6-6.4, p = 0.001), significant myocardial ischemia (OR 1.9, 95% CI 1.0-3.4, p = 0.05), and stress lung-to-heart ratio (ß = 0.03, p = 0.03) on SPECT. Chemerin was significantly associated with serum triglyceride levels but not with metabolic syndrome, significant ischemia, or stress lung-to-heart ratio on SPECT. A-FABP was better at detecting significant inducible ischemia than other biomarkers, although this was a modest improvement (area under ROC curve 0.579, 95% CI 0.46-0.69). CONCLUSIONS: Serum A-FABP concentrations correlate significantly with visceral fat area, metabolic syndrome, and predicted significant myocardial ischemia on SPECT. This may help to more accurately assess CAD risk, especially in patients with metabolic syndrome.

Association between serum adipocyte fatty-acid binding protein concentrations, left ventricular function and myocardial perfusion abnormalities in patients with coronary artery disease.

BACKGROUND: Adipokines, including adipocyte fatty acid-binding protein (A-FABP), have been demonstrated to be involved in the pathogenesis of atherosclerosis. In the present study, we investigated the association of circulating A-FABP level with severity of myocardial perfusion abnormalities analyzed by Tl-201 dipyridamole single-photon emission computed tomography. METHODS: A total of 170 patients with coronary artery disease (CAD) from cardiovascular clinics were enrolled in the study. Serum A-FABP levels, echocardiography, and stress myocardial perfusion imaging results were analyzed. RESULTS: Compared with the patients with mild CAD (summed stress score [SSS] ≤ 8), those with moderate to severe CAD (SSS > 8) had significantly higher A-FABP concentrations. However, the difference was attenuated in the subgroup of patients with heart failure. In the correlation analyses, A-FABP level was correlated with age, body mass index, waist circumference, levels of creatinine, fasting glucose, high-sensitivity C-reactive protein, N-terminal pro-brain natriuretic peptide, adiponectin, and several echocardiographic parameters, including left ventricular ejection fraction. Multivariate logistic regression analysis demonstrated that the A-FABP level was not only associated with higher SSS (odds ratio, 1.30; 95% confidence interval [CI], 1.01-1.69; P = 0.048), but also an independent risk factor for heart failure (odds ratio 2.71, 95% CI, 1.23-5.94; P = 0.013). CONCLUSIONS: Serum A-FABP levels not only were associated with myocardial perfusion abnormalities and left ventricular function, but also predicted the presence of heart failure in our patients with CAD.

Gallium-67 SPECT/CT for abdominal abscess.

An 80-year-old woman, who had suffered from end-stage renal disease under peritoneal dialysis, was presented with intermittent fever, leukocytosis, and elevated C-reactive protein for 4 months. She did not have symptom of abdominal pain. Culture of ascites showed Klebsiella pneumoniae. Abdominal utrasonography was negative. Whole-body gallium-67 imaging showed a segmental uptake mimicking bowels in right abdomen. SPECT/CT revealed the uptake in a soft tissue density beneath the abdominal wall instead of bowels. Contrast-enhanced CT demonstrated a low-density mass with peripheral enhancement at the aforementioned area. Her clinical condition stabilized gradually after CT-guided percutaneous drainage of pus from the abscess.

F-18 FDG PET images for subcutaneous panniculitis-like T-cell lymphoma.

A 14-year-old girl, who had been suffering from intermittent fevers for 2 months, developed painful erythematous plaques on the lower extremities. Laboratory data revealed elevated C-reactive protein, lactate dehydrogenase, and aspartate aminotransferase/alanine aminotransferase (AST/ALT). Blood and urine cultures were negative. CT showed hepatosplenomegaly. F-18 FDG PET revealed multiple patchy uptakes on the subcutaneous surfaces residing mainly at the lower trunk and extremities. The PET images and clinical manifestations appeared indistinguishable from those due to panniculitis while the pathology from skin biopsy demonstrated panniculitis-like T-cell lymphoma. She received chemotherapy and the follow-up PET showed significant resolution of previous abnormal uptakes from the subcutaneous lesions.