Approach to optimal care at end of life.

At no other time in any patient's life is the team approach to care more important than at the end of life. The demands and challenges of end-of-life care (ELC) tax all physicians at some point. There is no other profession that is charged with this ultimate responsibility. No discipline in medicine is immune to the issues of end-of-life care except perhaps, ironically, pathology. This presentation addresses the issues, options, and challenges of providing optimal care at the end of life. It looks at the principles of ELC, barriers to good ELC, and what patients and families expect from ELC. Barriers to ELC include financial restrictions, inadequate care-givers, community support, legal issues, legislative issues, training needs, coordination of care, hospice care, and transitions for the patients and families. The legal aspects of physician-assisted suicide is presented as well as the approach of the American Osteopathic Association to ensure better education for physicians in the principles of ELC.

Evaluation of osteoporosis.

Osteoporosis is a silent epidemic that is preventable and treatable. Few people are currently having osteoporosis diagnosed early enough to receive the benefit of prevention. Therefore, most present with a fracture as the first clinical manifestation of the disease. The physician taking a history must have a high index of suspicion for osteoporosis. All women should be counseled about risk factors for osteoporosis. The diagnosis of this disease includes an evaluation of bone mineral density by radiologic technique. The osteopathic physician is uniquely well trained to recognize and diagnose osteoporosis.

Family perceptions of future programming needs in a sample of individuals with mental retardation.

The present study examined parents' perceived programming needs of their children with mental retardation. Parents (44 mothers, 8 fathers) of individuals attending programming in an agency for mental retardation responded to a telephone survey. Analysis showed parents were most concerned about future housing needs. A significant difference was found between older and younger parents in their perception of future needs.

Left ventricular function and perfusion from gated SPECT perfusion images: an integrated method.

UNLABELLED: A new technique for computing left ventricular function, including left ventricular volumes, mass and ejection fraction, has been developed. This method is a logical extension of the results of a standard perfusion quantification technique; thus, it allows integration of perfusion and functional information. METHODS: Anatomically based models of the endocardial and epicardial surfaces are generated using the myocardial samples for which perfusion values are quantified, for all frames in the cardiac cycle. With these surface points, left ventricular chamber volume and myocardial volume can be computed. A computer simulation was used to determine the sensitivity of the approach to the assumptions of the model. Validation of volume, mass and ejection fraction was performed with correlative MR studies, and ejection fraction and left ventricular volumes were further investigated using correlative first-pass studies. RESULTS: Automated processing was successful in 96% of the cases analyzed. End diastolic volume, end systolic volume, left ventricular mass and left ventricular ejection fraction correlated with MRI with r = 0.97, 0.99, 0.87, and 0.85, respectively. Ejection fraction from tomography correlated with first-pass values with r = 0.82, and end diastolic and end systolic volumes from tomography correlated with first-pass values with r = 0.85 and r = 0.91, respectively. CONCLUSION: The new integrated approach is accurate and robust for computing both perfusion and function from perfusion tomograms.

Fast stress and rest acquisitions for technetium-99m-sestamibi separate-day SPECT.

UNLABELLED: Abbreviated acquisition protocols were designed for stress and rest to decrease stress and rest SPECT image acquisition times but maintain the high count density of 99mTc-sestamibi separate-day cardiac images. METHODS: Scan findings were compared visually and quantitatively with standard SPECT for 12 rest and 32 stress patient studies. RESULTS: Of 29 stress defects detected by standard SPECT, 27 were present with the fast technique; of 8 resting SPECT defects, all were detected with fast SPECT. Two stress and no resting false-positive defects occurred with fast SPECT. Linear correlations (r) between standard and fast quantitative defect extent and severity were 0.76 and 0.86, respectively for stress SPECT, and 0.88 and 0.96 for rest SPECT. Stress fast defects were slightly less severe (p = 0.02) than those observed using standard acquisition. CONCLUSION: We conclude that these fast protocols for separate-day 99mTc-MIBI SPECT accurately detect and characterize perfusion defects and provide a means to improve patient tolerance and increase laboratory throughput.

Simultaneous biplane first-pass radionuclide angiocardiography using a scintillation camera with two perpendicular detectors.

UNLABELLED: Generally performed in a single anterior or right anterior oblique (RAO) view, first-pass radionuclide angiocardiography (RNA) is limited due to its inability to evaluate septal and posterior wall motion. METHODS: Thirty-five patients undergoing stress/rest sestamibi SPECT (22 mCi/22 mCi 2-day protocol) underwent biplane RNA at the time of resting injection. The stress SPECT images (acquired with the patient at rest) were ECG-gated to evaluate resting regional myocardial wall thickening. By this means wall motion assessed by RNA was compared to the presence of a resting SPECT perfusion defect accompanied by a localized decrease in wall thickening. RESULTS: In 16 patients in whom both resting perfusion and wall thickening were normal one demonstrated apical hypokinesis by RNA in the RAO view. In the other 29 patients, a total of 58 resting segmental perfusion defects with abnormal wall thickening were present (12 anterior, 13 inferior, 14 apical, 11 septal and 8 posterolateral). Wall motion abnormalities were detected in all these patients and in 57/58 segments (98%) by biplane RNA. Septal and posterolateral wall motion abnormalities were detected in only the LAO RNA study. In three patients, wall motion abnormalities were detected by LAO imaging only. Of the remaining 87 normally perfused segments in these 29 patients, RNA wall motion was normal in 85. Two posterolateral segments demonstrated apparent hypokinesis, probably due to left atrial overlap in the LAO projection. CONCLUSION: Simultaneous biplane RNA accurately detects wall motion abnormalities frequently missed by single-plane RAO imaging.

Atypical measles: a diagnostic conundrum.

Atypical measles syndrome has been reported extensively in the pediatric medical literature. However, the clinical picture in the adult is similar to that of many other diseases, making the diagnosis elusive. The case reported here was unusually morbid. The patient, a young man, had been in excellent health until the onset of a perplexing syndrome. When seen by the author, he had been ill for 1 week with chills, pharyngitis, and vomiting; later, a nonpruritic, maculopapular rash developed. Symptoms progressed to pneumonitis and hepatitis. A rubeola titer was obtained and was found to be considerably elevated. Because of the high titer and the fact that the patient had been immunized against measles in early childhood, the diagnosis was atypical measles syndrome. Two theories are offered to explain the pathogenesis of this disease.

Accuracy and reproducibility of left ventricular ejection fraction measurements using an ambulatory radionuclide left ventricular function monitor.

The accuracy and reproducibility of a new ambulatory radionuclide detector system (the VEST) for ejection fraction measurement has not been fully validated. Thirty-six subjects, (19 volunteers and 17 patients) underwent repetitive bicycle exercise using sequences of both VEST monitoring and gamma camera imaging. A high intraclass correlation was noted for both absolute ejection fraction [0.84 (0.56, 0.95)] and delta ejection fraction [0.87 (0.63, 0.96)] during repeat VEST monitoring. The intraclass correlation for ejection fraction was comparable for data averaged over 30 sec versus 2 min. These correlations compared favorably to those obtained for assessment of absolute and delta ejection fraction as derived by gamma camera determination by the same computer operator (intraobserver variability), two different computer operators (interobserver variability), and during repeat exercise using gamma camera imaging. In concordance, correlations between VEST and gamma camera measurements were relatively high for both absolute ejection fraction (0.78 [0.61, 0.88]) and delta ejection fraction (0.63 [0.39, 0.79]). Thus, the VEST represents a reproducible means of measuring ejection fraction change during dynamic physical activity. Its accuracy in ejection fraction measurements is similar to gamma camera imaging during exercise testing.