The impact of breast cancer knowledge and attitudes on screening and early detection among an immigrant Iranian population in southern California.

Few studies explored factors influencing breast cancer screening and early detection behaviors among immigrant Iranian women residing in the USA. Using a cross-sectional survey, a convenience sample of 319 Iranian American women was selected to investigate the impact of breast cancer knowledge and attitude on screening. A self-administered questionnaire assessed breast cancer screening knowledge, attitude, and mammography use (ever, previous year, and future intention). 79 % of the women in the study reported ever receiving at least one mammogram and 74 % received a mammogram in the past year. Personal attitude had an independent significant effect on: mammography use in the last year, ever use of mammography, and future intention to screen. Knowledge and morality-induced attitude influenced screening behavior but not significantly. Interventions targeting breast cancer screening among immigrant Iranian women in the USA should focus on enhancing personal attitudes in order to influence actual screening behavior.

Cortical excitability and transcallosal inhibition in chronic tinnitus: transcranial magnetic study.

INTRODUCTION: It has been proposed that tinnitus may be caused by maladaptive plasticity of processing in the central auditory pathways, and that this may be due in part to a generalised deficit in NMDA-dependent glutamatergic synapses. STUDY AIM: To test this hypothesis, we used transcranial magnetic stimulation to assess the excitability of a number of well-defined synaptic connections in the motor cortex of patients with tinnitus. PATIENTS AND METHODS: Thirty-seven patients with chronic tinnitus and 12 normal age- and sex-matched volunteers were used as a control group. We measured resting and active motor thresholds (rMT/aMT) and the duration of the contralateral and ipsilateral cortical silent periods (CSP and ISP). Short interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were evaluated using a paired pulse stimulation paradigm in the left (dominant) hemisphere. RESULTS: There was no difference between patients and healthy subjects in rMT or aMT or the onset latency of the ISP. The CSP was shorter in patients (P=0.046) whereas the ISP was longer than in healthy subjects (P=0.048) but there was no difference between the hemispheres nor any relation to tinnitus side in patients with predominantly unilateral symptoms. There was no difference in the time course of SICI/ICF between patients and control groups and no significant correlation between tinnitus handicap inventory (THI) score and any of the measures of cortical excitability. CONCLUSIONS: There are small changes incortical excitability in patients with chronic tinnitus. However, given the number of factors we examined in each individual, such minor changes seem unlikely to be an important factor in development of clinical symptoms.

Lack of post-exercise depression of corticospinal excitability in patients with Parkinson's disease.

There is lack of clarity in the literature over whether patients with Parkinson's disease (PD) show the same post-exercise depression of corticospinal excitability as is usually observed in healthy control. This study set out to resolve the problem. Ten patients with idiopathic PD and 10 age-matched controls were included in this study. Each subject performed a submaximal sustained voluntary contraction of the right first dorsal interosseous muscle (FDI) for 10 min or until force could no longer be sustained. Resting motor threshold, motor-evoked potential (MEP), input-output curve, cortical silent period duration, interference pattern (IP) and M/F ratio were recorded at baseline, immediately after fatigue and after 20 min rest. Immediately after exercise, decreased MEP amplitude and increased cortical SP duration were observed in the control group whilst no such changes were observed in PD patients. The input-output curve was also significantly suppressed only in controls, but not in patients. The amplitude of IP was significantly reduced immediately after exercise in both PD patients and controls. Almost all these changes returned nearly to baseline values after 20 min rest. The amount of exercise was approximately equal in both groups because the effect on M-waves and EMG amplitude was similar. However, the expected decline in corticospinal excitability was absent in PD patients. The absence of this effect in PD patients may reflect reorganization of motor commands in response to basal ganglia deficit.

Long-term results of pulmonary balloon valvulotomy in adult patients.

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the long-term outcome of pulmonary balloon valvulotomy (PBV) in adult patients. METHODS: PBV was performed in 87 patients (46 females, 41 males; mean age 23+/-9 years; range: 15-54 years) with congenital pulmonary valve stenosis (PS). Intermediate follow up catheterization (mean 14.6+/-5.0; range: 6-24 months) was performed after PBV in 53 patients. Clinical and Doppler echocardiography examinations were carried out annually in 82 patients (mean 8.0+/-3.9; range: 2-15 years). RESULTS: There were no immediate or late deaths. The mean catheter peak pulmonary gradient (PG) before and immediately after PBV, and at intermediate follow up was 105+/-39, 34+/-26 (p <0.0001) and 17+/-14 (p <0.0001) mmHg, respectively. The corresponding values for right ventricular (RV) pressure were 125+/-38, 59+/-21 (p <0.0001) and 42+/-12 (p <0.0001) mmHg, respectively. The infundibular gradients immediately after PBV and at intermediate follow up were 31+/-23 and 14+/-9 mmHg (p <0.0001), whilst cardiac index improved from 2.68+/-0.73 to 3.1+/-0.4 l/min/m2 (p <0.05) at intermediate follow up. Doppler PG before PBV and at intermediate and long-term follow up were 91+/-33 (range 36-200) mmHg, 28+/-12 (range 10-60) mmHg (p <0.0001) and 26+/-11 mmHg (p = 0.2), respectively. New pulmonary regurgitation (PR) was noted in 21 patients (25%) after PBV. Five patients (6%) with a suboptimal result (immediate valve gradient > or =30 mmHg) developed restenosis and underwent repeat valvulotomy 6-12 months later using a larger balloon, and with satisfactory outcome. Moderate to severe tricuspid regurgitation (TR) in seven patients regressed after PBV. CONCLUSION: The long-term results of PBV in adults are excellent, with regression of concomitant, severe infundibular stenosis and/or severe TR. Hence, PBV should be considered as the treatment of choice for adult patients with PS.

Underreporting of food intake by dietary recall is not universal: a comparison of data from egyptian and american women.

Underreporting of dietary intake has been observed consistently in food consumption surveys in affluent societies and in clinical studies in a variety of settings. Almost one third of quantitative 24-h recalls provided by adults in U.S. surveys appear to result in estimates that are biologically implausible. Underreporting has been linked to obesity in both the U.S. and Europe, with heavier individuals underreporting to a greater degree than lean persons. A relative dearth of data exists from developing countries and those in transition to address the question whether such underreporting is universal. We present the first data from a large survey of women in a rapidly urbanizing developing country to address this question. More than 4500 adult women in Egypt provided quantitative 24-h recalls of food intake on the previous day in 1993-1994, and weights and heights were measured. We compared the data, in terms of the ratio of reported energy intake to estimated basal metabolic rate, to data from 3010 women in the 1994-1996 U.S. Continuing Survey of Food Intake by Individuals, on whom quantitative 24-h recalls were also conducted. The Egyptian women reported food intakes consistent with FAO/WHO recommendations for energy intakes for women of comparable activity levels, whereas the data for U.S. women showed underreporting consistent with other U.S. surveys. Only 10% of Egyptian women reported energy intakes below accepted criteria for plausibility, compared with one third of American women. We discuss possible reasons for this difference, including cultural and food supply differences, and methodological differences between the two surveys.

Double-chambered right ventricle in 73 patients: spectrum of the disease and surgical results of transatrial repair.

OBJECTIVE: To review the spectrum of double-chambered right ventricle (DCRV) and the outcome of surgical repair in patients diagnosed between February 1988 and March 1999. DESIGN: The charts of patients with DCRV were studied. SETTING: Tertiary care hospital. PATIENTS AND METHODS: A total of 73 patients were identified. Sixty-nine underwent surgical repair, while four are awaiting surgery. The repair was through a transatrial approach in 61 patients, while in eight an additional ventriculotomy was performed. MAIN RESULTS: An associated ventricular septal defect (VSD) was present in 56 of 73 patients (77%). These patients were significantly younger (P<0.05) than the 17 patients without a VSD. Among patients with a VSD, the 31 requiring patch closure were significantly younger than the 25 patients having direct closure. Five older patients among those with intact septum had impaired right ventricular (RV) function as well as higher intraventricular gradients. At surgery the intraventricular obstruction was relieved by myomectomy. There was no hospital or late mortality. Following surgery, at a mean follow-up of 13.6 months, no increase in the intraventricular gradient was detected by Doppler echocardiography. CONCLUSIONS: The development of DCRV is associated with VSD in early life. The probability of the presence of a VSD decreases with age. The disease is progressive, resulting in increased intracavitary gradient within the RV and in RV impairment if it is not treated in a timely fashion. Transatrial repair is safe with excellent midterm results. In the presence of high gradients within the RV, a ventriculotomy may be necessary to obtain acceptable results.

Anaemia among Egyptian adolescents: prevalence and determinants.

We aimed to estimate the nationwide prevalence of anaemia among adolescents in Egypt and to study possible risk factors. A cross-sectional approach was used. Blood samples were collected from 1980 adolescents for haemoglobin estimation. The overall prevalence of anaemia was 46.6%, most of which was mild or moderate, with severe cases in less than 1.0% of the sample. Gender difference was almost nonexistent. A significant inverse relationship was observed between the level of anaemia and age (especially among boys), socioeconomic level and educational level. Anaemia was more prevalent in rural areas and in Upper (southern) Egypt. Anaemia is a major public health problem among Egyptian adolescents and wide-scale public health education is warranted.

Micronutrient deficiency conditions in the Middle East region: an overview.

The Middle East is perhaps the world's best laboratory for learning more about iron and zinc deficiencies, and their widespread prevalence contributes much to constraining the quality of life for a large share of the population. Always, in the context of endemic IDD, countries in the region need to make sure that the programs are in place to consign this still-serious problem to the history books. Research is not required so much in relation to IDD, but clearly applications need to be monitored. Vitamin A deficiency is probably widespread at mild to moderate levels, and should be addressed by a combination of appropriate case management for infectious disease, breastfeeding promotion, and dietary diversification/nutrition education. Iron deficiency is the most prevalent, and so far the most intractable, micronutrient problem. It probably will not yield to less than a multipronged strategy including fortification of the food supply with iron. Several other micronutrient deficiencies require our eventual attention as well, and looking forward to their solution should be part of the research agenda.

Changes of management in a patient with double outlet left ventricle.

Double outlet left ventricle is an extremely rare anomaly. Until recently, the diagnosis was usually established by angiography or at postmortem. There are only a few reports describing the echocardiographic findings in this lesion, and as far as we know, no report showing the anatomy as well as the velocity and pattern of flow by color Doppler echocardiography. The patient reported here underwent surgery at the age of four years, when an aortic homograft was placed between the right ventricle and the pulmonary trunk. This biventricular repair had to be changed into a Fontan-type procedure, 15 years later since the hypoplastic right ventricle did not grow adequately.

[Interventions in congenital heart disease and their sequelae in adults]. / Neue Therapiemöglichkeiten in der interventionellen Kardiologie. Bedeutung für angeborene Herzfehler im Erwachsenenalter.

The advancements of cardiac surgery over the last decades led to larger numbers of patients with operated congenital heart diseases surviving into adulthood. In Germany it is estimated that over 120,000 adults have operated congenital heart diseases. Five to 7% of them will need yearly hospital admissions. Interventional procedures are additional tools used to treat these patients with various sequelae or residua (Table 1). In the following review we concentrate on 2 different interventional procedures: dilatation and stent implantations for treatment of stenosis and the different devices used for the closure of shunt lesions. For congenital valvular pulmonary stenosis, balloon dilatation is the therapy of choice regardless the age of the patient. Stent implantation for the treatment of peripheral pulmonary stenosis (e.g., after previous systemic pulmonary shunts) can decrease the need for redo surgery, which is accompanied with increased risk. Stent implantations proved also to be useful to treat stenoses after Mustard patch in patients with transposition of the great arteries, after Fontan procedures or dealing with the rare pulmonary venous stenosis. In contrast, dilatation of bioprosthesis and conduit stenosis are not promising. Balloon dilatation of valvular aortic stenosis is an accepted therapy in childhood up to adolescents. Table 2 compares a surgical series including many infants with critical aortic stenosis with a series of balloon dilatation in children and another one in adults regarding lethality, complications, and results. Table 3 illustrates the immediate and late results of balloon dilatation of aortic coarctation in 3 different studies. The high recurrence rate in infants made clinicians refrain from taking this age group for balloon dilatation. In children and adult patients, good results are reported (75% reduction of gradients). The complication rate is low (2.3 to 3.3%) and aneurysm formation rate seldom (1 to 7%). Stenosed aorto-pulmonary collaterals will rarely need balloon dilatation. Surgical closure of atrial septal defect is a low risk procedure with a very low rate of residual shunts (2%). Of the 5 available devices for transcatheter closure of atrial septal defect Type II, only 2 occluders are in use in Germany, the Clamshell and the Amplatzer device. The largest clinical studies of the different systems, their efficacy, complications and residual shunt rate are presented in Table 4. For the deployment of these occluders a TEE is always needed. There are many more systems in clinical use to close the patent arterial duct (PDA) (Table 5). The Ivalon plug as well as the Rashkind device have probably only historical value. Different types of coils (Gianturco, Cook detachable, PFM) are now in use worldwide. The reason for their widespread use, besides their easy application, is the fact that most coils are relatively cheap and need only small sheaths for deployment. Their further evaluation identified a residual shunt rate of 5% as well as a number of complications (embolization, hemolysis, stenosis of the left pulmonary artery) in 0 to 6%. For the large PDA the Amplatzer device has recently been introduced. An additional indication for the use of the different occluding devices are aorto-pulmonary collaterals, venovenous fistulae, pulmonary or coronary artery fistulae. Aorto-pulmonary collaterals are often associated with complex cardiac lesions and occasionally appear after palliative procedures. An excellent cooperation between adult and pediatric cardiologists is needed in order to offer the group of adults with congenital heart diseases an adequate and comprehensive management.

Long-term effects of balloon angioplasty on systemic hypertension in adolescent and adult patients with coarctation of the aorta.

AIMS: To define the long-term effect of balloon angioplasty of aortic coarctation on hypertension, in adolescent and adult patients. METHODS: Balloon angioplasty of discrete, native aortic coarctation was performed on 50 patients (34 male) aged 23+/-8 (mean+/-standard deviation) years. In 42 of these patients cardiac catheterization and angiography were repeated 1 year later, and on the basis of sphygmomanometric blood pressure determination at that time, they were divided into 31 patients (group A) with normalized blood pressure and 11 patients (group B) who still needed antihypertensive medication. Both groups were followed annually thereafter for 12-123 (66+/-37) months. RESULTS: Coarctation gradient values before, immediately after and 1 year after angioplasty were 69+/-24 mmHg, 12+/-8 mmHg (P<0.001) and 7+/-6 mmHg. The corresponding systolic blood pressure values were 165+/-17 mmHg, 128+/-12 mmHg (P<0.001) and 115+/-10 mmHg (P<0.001) in group A; 182+/-21 mmHg, 141+/-24 mmHg (P<0.001) and 134+/-18 mmHg (P<0.001) in group B. Echocardiographic left ventricular mass index before angioplasty and at follow-up was 130+/-31 g x m-2 and 105+/-23 g x m-2 in group A; 157+/-38 g x m-2 and 132+/-35 g x m-2 in group B (P<0.001 for both comparisons). CONCLUSION: Normalization of blood pressure without medication occurred in 74% of patients after angioplasty for aortic coarctation, with subsequent long-term regression of left ventricular hypertrophy. In comparison to reported surgical results, balloon angioplasty should be considered as first line treatment for native, discrete aortic coarctation in adolescent and adult patients.

Phentolamine improves clinical outcome after balloon valvoplasty in neonates with severe pulmonary stenosis.

Two neonates with severe pulmonary stenosis deteriorated immediately after successful balloon valvoplasty as a result of increased infundibular obstruction. They were treated with beta-adrenoceptor blockers and intravascular expansion with limited success. Phentolamine was then given, resulting in dramatic improvement. The children could be weaned from the ventilator within hours of starting this new therapeutic modality.

The role of selenium deficiency in dilated cardiomyopathy in Saudi Arabia.

BACKGROUND: Selenium deficiency is implicated in the etiology of endemic juvenile dilated cardiomyopathy in China, and in sporadic cases in other countries. The aim of this study was to evaluate the role of selenium deficiency in the pathophysiology of dilated cardiomyopathy in the Saudi Arabian population. PATIENTS AND METHODS: Plasma and urine selenium concentrations from 72 Saudi patients with confirmed dilated cardiomyopathy were compared with corresponding values from 70 control subjects of the same national origin who had normal ventricular function. RESULTS: Plasma and urine selenium concentrations (mean+/-SD) were 1.347plusmn;0.45 and 0.49+/-0.37 micromol/L, respectively, for the patient group, and 1.32+/-0.41 and 0.60+/-0.41 micromol/L, respectively, for the control group. The differences in the values between the two groups were statistically insignificant. CONCLUSION: In the Saudi population, dilated cardiomyopathy is not caused by selenium deficiency.

Reconstruction of supravalvar aortic stenosis with autologous pulmonary artery.

Use of autologous tissue in corrective cardiac operations offers many advantages including the potential for growth. We report a surgical technique using autologous pulmonary artery in the repair of supravalvar aortic stenosis in a 6-year-old child. At 30 months' follow-up, the pulmonary arterial tissue shows no evidence of calcification or dilatation and appears to be growing with the aorta.

Results of three to 10 year follow up of balloon dilatation of the pulmonary valve.

BACKGROUND: The results of immediate and short term follow up of balloon dilatation of the pulmonary valve have been well documented, but there is limited information on long term follow up. OBJECTIVE: To evaluate the results of three to 10 year follow up of balloon dilatation of the pulmonary valve in children and adolescents. SETTING: Tertiary care centre/university hospital. DESIGN: Retrospective study. METHODS AND RESULTS: 85 patients (aged between 1 day and 20 years, mean (SD) 7.0 (6.4) years) underwent balloon dilatation of the pulmonary valve during an 11 year period ending August 1994. There was a resultant reduction in the peak to peak gradient from 87 (38) to 26 (22) mm Hg. Immediate surgical intervention was not required. Residual gradients of 29 (17) mm Hg were measured by catheterisation (n = 47) and echo Doppler (n = 82) at intermediate term follow up (two years). When individual results were scrutinised, nine of 82 patients had restenosis, defined as a peak gradient of 50 mm Hg or more. Seven of these patients underwent repeat balloon dilatation of the pulmonary valve: peak gradients were reduced from 89 (40) to 38 (20) mm Hg. Clinical evaluation and echo Doppler data of 80 patients showed that residual peak instantaneous Doppler gradients were 17 (15) mm Hg at long term follow up (three to 10 years, median seven), with evidence for late restenosis in one patient (1.3%). Surgical intervention was necessary to relieve fixed infundibular stenosis in three patients and supravalvar pulmonary stenosis in one. Repeat balloon dilatation was performed to relieve restenosis in two patients. Actuarial reintervention free rates at one, two, five, and 10 years were 94%, 89%, 88%, and 84%, respectively. Pulmonary valve regurgitation was noted in 70 of 80 patients at late follow up, but neither right ventricular dilatation nor paradoxical interventricular septal motion developed. CONCLUSIONS: The results of late follow up of balloon dilatation of the pulmonary valve are excellent. Repeat balloon dilatation was performed in 11% of patients and surgical intervention for subvalvlar or supravalvar stenosis in 5%. Most patients had mild residual pulmonary regurgitation but right ventricular volume overload was not required. Balloon dilatation is the treatment of choice in the management of moderate to severe stenosis of the pulmonary valve. Further follow up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.

One- to ten-year follow-up results of balloon angioplasty of native coarctation of the aorta in adolescents and adults.

OBJECTIVES: We attempted to evaluate the role of balloon angioplasty in the treatment of discrete coarctation of the aorta in adolescents and adults, with special emphasis on long-term results. BACKGROUND: Controversy persists over the use of balloon dilation for the treatment of native coarctation of the aorta. METHODS: Between July 1986 and January 1997, 43 consecutive adolescent and adult patients with discrete coarctation of the aorta underwent balloon angioplasty. One- to 10-year follow-up data of 37 patients, including results of cardiac catheterization and magnetic resonance imaging (MRI), form the basis of this study. RESULTS: No early or late deaths occurred. Balloon angioplasty produced a reduction in the peak to peak coarctation gradient from a mean +/- SD of 69 +/- 24 mm Hg (95% confidence interval [CI] 61 to 76) to 12 +/- 8 mm Hg (95% CI 10 to 14.8) (p < 0.001). Follow-up catheterization 12 months later (37 patients) revealed a residual gradient of 6.7 +/- 6 mm Hg (95% CI 4.6 to 8.9); 3 (7%) of 43 patients had suboptimal results with development of recoarctation, defined as peak gradient >20 mm Hg, with successful repeat angioplasty. A small aneurysm developed at the site of dilation in 3 (7%) of the 43 patients. MRI follow-up data 1 to 10.8 years (mean 5.2 +/- 2.7) after angioplasty (37 patients) revealed no new aneurysm or appreciable change in the size of the preexisting aneurysm in the three patients. The blood pressure had normalized without medication in 27 (73%) of 37 patients at follow-up examination. CONCLUSIONS: Balloon angioplasty is safe and effective and should be considered a viable alternative to operation for treatment of discrete coarctation of the aorta in adolescents and adults.

Pulmonary artery augmentation with autologous aortic tissue.

OBJECTIVE: To assess durability and viability of autologous aortic tissue used to augment severe branch pulmonary artery stenosis with a novice surgical technique. PATIENTS AND METHODS: Seven patients underwent corrective surgery for complex cyanotic congenital heart disease. Their age ranged from 3-6 years, and their weight 11-17.4 kg. All had concomitant branch pulmonary artery stenosis repaired utilizing an autologous patch, harvested from the patient's own aorta by excising a ring and opening it to form the patch. The aorta is reconstructed directly by end to end anastomosis. RESULTS: One patient died in hospital. Another patient died at 18 months at home. The surviving five patients have remained well in the follow up period of mean 31 months (range 10-52). All patients were restudied by follow up echocardiography and remain with no evidence of the aortic autograft tissue calcification or stenosis. The reconstructed aorta showed no stenosis at the site of anastomosis. CONCLUSION: The intermediate term results of this novice surgical technique appear encouraging and justify the technique. However, longer follow up will be required to confirm the continued growth of this patch material.