Mir S. Siadaty

Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease

OBJECTIVES We hypothesized that combining functional assessment to perfusion enhances the ability of electrocardiographic gating Tc-99m sestamibi single photon emission computed tomography (gated SPECT) myocardial perfusion imaging (MPI) to detect defects in multiple vascular territories in patients with severe three-vessel coronary artery disease (3VD). BACKGROUND In patients with 3VD, perfusion defects in multiple vascular territories may not always be evident due to globally reduced perfusion. METHODS Gated SPECT MPIs were interpreted sequentially with perfusion first, followed by combined perfusion/function, in 143 patients with angiographic 3VD and a control group of 112 non-3VD patients. All patients underwent coronary arteriography within one month of MPI. RESULTS In 3VD patients, combined perfusion/function analysis yielded significantly greater numbers of abnormal segments/patient (6.2 +/- 4.7 vs. 4.1 +/- 2.8, p < 0.001) and more defects in multiple vascular territories (60% vs. 46%, p < 0.05) than perfusion alone. In the control group, there were no differences between the combined perfusion/function and perfusion alone interpretations. Multivariate analysis of 15 different clinical, stress, and scintigraphic variables in all patients revealed age (p < 0.0001) and number of abnormal vascular territories by combined perfusion/function (p < 0.0001) to be the most powerful predictors of 3VD. Addition of functional data to clinical, stress, and perfusion yielded a significant increase in the predictive value of 3VD (global chi-square: 131.7 vs. 89.8, p < 0.00001). Specificity of combined perfusion/function analysis was not lower than perfusion alone (72% vs. 69%, p = NS). CONCLUSIONS; Adjunctive assessment of function with perfusion by gated SPECT MPI enhances the detection of defects in multiple vascular territories in patients with severe 3VD, without adversely affecting its specificity.

Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis

Objective. Pacifier use has been reported to be associated with a reduced risk of sudden infant death syndrome (SIDS), but most countries around the world, including the United States, have been reluctant to recommend the use of pacifiers because of concerns about possible adverse effects. This meta-analysis was undertaken to quantify and evaluate the protective effect of pacifiers against SIDS and to make a recommendation on the use of pacifiers to prevent SIDS. Methods. We searched the Medline database (January 1966 to May 2004) to collect data on pacifier use and its association with SIDS, morbidity, or other adverse effects. The search strategy included published articles in English with the Medical Subject Headings terms “sudden infant death syndrome” and “pacifier” and the keywords “dummy” and “soother.” Combining searches resulted in 384 abstracts, which were all read and evaluated for inclusion. For the meta-analysis, articles with data on the relationship between pacifier use and SIDS risk were limited to published original case-control studies, because no prospective observational reports were found; 9 articles met these criteria. Two independent reviewers evaluated each study on the basis of the 6 criteria developed by the American Academy of Pediatrics Task Force on Infant Positioning and SIDS; in cases of disagreement, a third reviewer evaluated the study, and a consensus opinion was reached. We developed a script to calculate the summary odds ratio (SOR) by using the reported ORs and respective confidence intervals (CI) to weight the ORs. We then pooled them together to compute the SOR. We performed the Breslow-Day test for homogeneity of ORs, Cochran-Mantel-Haenszel test for the null hypothesis of no effect (OR = 1), and the Mantel-Haenszel common OR estimate. The consistency of findings was evaluated and the overall potential benefits of pacifier use were weighed against the potential risks. Our recommendation is based on the taxonomy of the 5-point (A–E) scale adopted by the US Preventive Services Task Force. Results. Seven studies were included in the meta-analysis. The SOR calculated for usual pacifier use (with univariate ORs) is 0.90 (95% confidence interval [CI]: 0.79–1.03) and 0.71 (95% CI: 0.59–0.85) with multivariate ORs. For pacifier use during last sleep, the SORs calculated using univariate and multivariate ORs are 0.47 (95% CI: 0.40–0.55) and 0.39 (95% CI: 0.31–0.50), respectively. Conclusions. Published case-control studies demonstrate a significant reduced risk of SIDS with pacifier use, particularly when placed for sleep. Encouraging pacifier use is likely to be beneficial on a population-wide basis: 1 SIDS death could be prevented for every 2733 (95% CI: 2416–3334) infants who use a pacifier when placed for sleep (number needed to treat), based on the US SIDS rate and the last-sleep multivariate SOR resulting from this analysis. Therefore, we recommend that pacifiers be offered to infants as a potential method to reduce the risk of SIDS. The pacifier should be offered to the infant when being placed for all sleep episodes, including daytime naps and nighttime sleeps. This is a US Preventive Services Task Force level B strength of recommendation based on the consistency of findings and the likelihood that the beneficial effects will outweigh any potential negative effects. In consideration of potential adverse effects, we recommend pacifier use for infants up to 1 year of age, which includes the peak ages for SIDS risk and the period in which the infants need for sucking is highest. For breastfed infants, pacifiers should be introduced after breastfeeding has been well established.

Uptake Rates for Breast Cancer Genetic Testing: A Systematic Review

Purpose: Individuals and families dealing with the possibility of hereditary cancer risk face numerous decisions, including whether to obtain genetic testing. The purpose of this article is to determine what is known about the rate at which people obtain cancer genetic testing. Methods: Using MEDLINE, CINAHL, and PSYCHINFO plus reviewing reference lists of relevant articles, we identified 40 studies in May 2002 that addressed breast cancer–related decisions, enrolled adult participants, were published in 1990 or more recently, were peer-reviewed primary clinical studies, addressed genetic testing either alone or in combination with genetic counseling, and reported rates at which participants showed interest in and/or underwent cancer genetic testing. Information regarding study design, participants, and genetic testing uptake rates was recorded. Each article was reviewed for methodologic quality using a flexible quality review system applicable to all study types. Results: Of the 40 studies, 25 provided information about hypothetical genetic testing decisions, 14 about real decisions, and 1 about both. Mean hypothetical uptake was 66% (range, 20-96%) and real uptake was 59% (range, 25-96%). Multivariate logistic regression analyses found that decision type (real/hypothetical), personal and family history of breast cancer, and variability in sampling strategy, recruitment setting, and criteria for real and hypothetical uptake were independently associated with uptake. Our systematic review identified additional explanations for uptake variability (investigator influences, small sample sizes, variability in target populations, lack of clearly described sampling strategies, sampling methods open to bias, and variability in reporting associated risk factors). Conclusion: In addition to clinical characteristics, research methodologic issues are likely to be major determinants of variability in published breast cancer genetic testing uptake rates. An understanding of these issues will clarify to clinicians why their clinical experience may not be congruent with published rates and help guide future research. (Cancer Epidemiol Biomarkers Prev 2006;15(5):840–55)

The Effect of Physician Feedback and an Action Checklist on Diabetes Care Measures

The objective was to evaluate whether physician feed-back accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [Alc, urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, Alc, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or Alc levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

The Pacifier Debate: In Reply

In Reply .— We thank the authors for their interest in our article and their thoughtful comments. We appreciate the updated US Preventive Services Task Force (USPSTF) grading scale and matrix provided by Drs Calonge and Petitti.1 We had not been aware of the newer scale when we conducted our meta-analysis, and thus our use of the 1996 methodology was an unintentional oversight. However, after carefully reviewing the methodology used currently by the USPSTF, we believe that our pacifier recommendation2 as a potential preventive strategy against sudden infant death syndrome (SIDS) would retain the B grading: fair to good strength of evidence of moderate net benefit. As stated in our article, we used the USPSTF taxonomy to classify our recommendation; the task force was in no way involved in the study or its conclusions. We feel that our review of the evidence was “comprehensive, objective, and attentive to quality.”1 We conducted a comprehensive literature search beginning at 1966 and used an analytic framework for evaluating the quality of each study; we excluded from the meta-analysis any studies that were of lower quality. We included studies that measured the associations between pacifier use (the preventive service) and the health outcome of interest (ie, occurrence of SIDS) rather than intermediate outcomes. Because the best studies available used case-control designs, these would be classified under the hierarchy of research design as level II-2. Using the criteria for grading internal validity of individual studies would qualify them as having “good” internal validity. Next, we examined the quality of the full body of evidence. Here, we found that the evidence for pacifier use at last sleep is highly consistent and internally and externally valid (generalizable). We also believe that the evidence is coherent, that is, makes sense on the basis of hypothesized mechanisms …