By Y. Lares. Teachers College.
Patients with primary pulmonary hypertension should be counseled against becoming pregnant Pulmonary Edema and encouraged to seek termination of pregnancy and permanent forms of birth control 120mg sildalis sale. Long-term manage- increased left ventricular afterload order generic sildalis pills, myocardial ment could include epoprostenol (prostacyclin purchase 120mg sildalis overnight delivery, dysfunction, the alterations in colloid oncotic a category B agent) or sildenaﬁl (category B), but pressure discussed earlier, as well as ﬂuid over- the oral endothelin receptor blocker agents such load. Tobacco Peripartum Cardiomyopathy At the end of the 19th century and beginning of the 20th century, cigarette smoking and tobacco use Pregnancy-related cardiomyopathy can deve- were limited primarily to male subjects and were lop in 1 in 1,300 to 1 in 4,000 deliveries, and usually thought to be socially unacceptable for women. The study also stated promoted the use of tobacco by women, includ- that the risk of lung cancer increases with quantity, ing well-known advertisements with the famous duration, and intensity of smoking. Lung cancer and that the risk of lung cancer increases with the incidence rates in women began to level off from increasing number of cigarettes smoked per day, the mid-1990s to early 2000 and are now decreasing; earlier ages of cigarette smoking, longer duration however, death rates in women from lung cancer of smoking, greater tar and nicotine content of continue to increase and are just now reaching the cigarettes, and inhalation of cigarette smoke. It is expected that The study predicted that rates of mortality the death rates from lung cancer in men and women in women from lung cancer may be comparable will approach unity in the next 5 to 10 years. A possible The study also found that the incidence of other increase in the susceptibility of tobacco carcinogens respiratory conditions such as inﬂuenza was 20% in women has been a highly debated topic. Finally, the study concluded that women of tobacco-related lung cancer in women only for smokers had worse pulmonary function than some certain types of lung cancer. For example, it ex-smokers or never-smokers and that the severity appears that smoking women have a greater odds of decrease in pulmonary function was dose related ratio for small cell carcinoma developing than do to the number of cigarettes smoked. These children have more monal replacement may play a role in the variable airway obstruction, increased airway hyperre- susceptibility to tobacco carcinogens, particularly sponsiveness, and alterations in lung maturation with adenocarcinoma. Those children exposed to environmental cancer in women include a family history of lung tobacco smoke in the postnatal period have an cancer; occupational exposures to compounds such increased incidence of cough, wheezes, respira- as asbestos, cadmium, beryllium, silicosis, radon; tory illnesses, and infection. These children tend to have nosis and equal or better survival with treatment an increase in childhood asthma, earlier develop- than do men, regardless of cell type and stage. Patients wishing to conceive include small air airway size, which alters the or who do not want ovulation suppressed should distribution of toxins contained in tobacco, hor- undergo thoracotomy with repair of diaphragmatic monal mechanisms, and variations in cytochrome defects, if present, followed by pleurodesis. Spontaneous pneumothoraces with sirolimus, but the tumor size increased after 718 Women’s Issues in Pulmonary Medicine (Levine) discontinuation of treatment. Report of the Working Group on Asthma American Thoracic Society/Centers for Disease Control and Pregnancy: management of asthma during and Prevention/Infectious Diseases Society of America. American Thoracic Society/Centers for Disease An article suggesting that there is no sex difference in rates of Control and Prevention/Infectious Diseases Society lung cancer with comparable smoking histories. This is the most recent evidence-graded consensus conference Obstet Gynecol Clin North Am 2001; 28:553–569 regarding antithrombotic agents in pregnancy. Lancet 1999; 353:1258–1265 Position statement: the use of newer asthma and allergy This is a thorough review in this area, with a detailed discussion medications during pregnancy. Lung cancer in This article discusses the pathophysiology of asthma and the women: emerging differences in epidemiology, biology, effects of asthma on pregnancy and vice versa, and reviews the and therapy. Chest 2005; 128:370–381 National Asthma Education Program guidelines for the treat- An update on the epidemiology, biology, and therapy of lung ment of asthma in pregnancy. This has been termed work-aggravated realm of adult asthma asthma and, from the point of view of medical man- • Outline mechanisms by which asthma develops from agement, is similar to other forms of occupational exposures in the work setting asthma. This determination usually requires a clear statement in the medical record as to whether the patient’s This chapter expands on the introduction to occupa- asthma is or is not occupational. If nonoccupational, it is safe to allow monary Disease Certiﬁcation “Occupational and the patient to continue in the same job, focusing on Environmental Disease” content category topics of better medical management. Braman’s chapter on “Asthma,” we is employed and who presents with new-onset read that: “Allergens and occupational factors are asthma should thus be questioned about occupa- considered the most important causes of asthma. Two Natural History of Occupational types of asthma have been described: asthma that Asthma follows a latent period of exposure to either a high- or low-molecular-weight sensitizing antigen, and Numerous useful reviews, both brief and com- prehensive, are available. One form of irritant asthma is begin weeks to years after working with a new sub- called reactive airways dysfunction syndrome, a condi- stance that can cause asthma. Symptoms may be tion that usually results from the sudden inhalation minor or intermittent at ﬁrst and gradually increase of a large dose of a highly irritating substance. Most Frequently Reported Speciﬁc Causes or Contributors Pathophysiology, Histopathology, and to Work-Related Asthma in the United States* Physiologic Mechanisms Di-isocyanates Stainless steel welding plume In these respects, occupational asthma does not dif- Formaldehyde fer, or differs only in minor ways, from other types Paint 14,15 of asthma. History: The combination of the following four elements of the patient’s medical history has a 64% In some cases, patients will have had childhood positive predictive value in the diagnosis of oc- asthma that remitted in adolescence, but for others, cupational asthma16: current diagnosis of asthma; this onset of asthma will be the ﬁrst. The cardinal and onset of asthma after entering the workplace; feature is the onset of asthma while working with association between symptoms of asthma and inhalational exposure to a substance that can cause work; and workplace exposure to an agent known asthma, although there is emerging evidence that to give rise to occupational asthma. Allergic rhinitis repeated skin contact with some substances can to the offending substance often precedes the onset result in respiratory sensitization. Pulmonary Function Testing: Comprehensive, evidence-based reviews of diagnostic approaches to occupational asthma17,18 recommend the following Causes of Occupational Asthma tests in addition to a medical history and physical More than 400 substances have been identiﬁed examination: as causes of occupational asthma. Some allergists also have skin-prick asthma for a few causes of occupational asthma, testing reagents for some of the large-molecular- but testing for these is not clinically useful. However, there is no speciﬁc tory of atopy or cigarette smoking is a risk factor for IgE for many of the less common low-molecular- sensitization to high-molecular-weight substances weight substances. A positive test result for a (eg, biologically derived antigens, such as proteins speciﬁc IgE to the suspected antigen increases from laboratory animals or wheat ﬂour) but not for the diagnostic certainty of occupational asthma. Unlike other types of occupational four times per day during days at work and days asthma, severe cases may be associated with epi- away from work may also help to distinguish sodic fever on exposure. Clinical inter- In the case of occupational asthma, a most pretation by visual comparison of the patient’s difﬁcult initial decision may be in determining exposure history has been found to be as accurate whether it is safe to allow the patient to return to as computer-based interpretation. Once a diagnosis of occupational asthma is made, it is often important for the treat- Treatment of Occupational Asthma ing physician to determine whether disability is present and, if so, to what extent. As with all asthma, the treatment goal is to For any pulmonary patient who presents with remove the patient from exposure to triggers and a request for disability evaluation, the physi- to minimize symptoms by controlling asthma with cian must ﬁrst decide whether the lung disease medications that have the least adverse effects for is nonoccupational (in which case federal Social the patient. Once diagnosed, the main difference Security Administration disability criteria apply between treating occupational and nonoccupational if the patient is totally disabled), or whether it is asthma is removing the patient from exposure. This occupational (ie, caused by the job) in which state- treatment begins with notifying the patient and, with speciﬁc worker compensation disability rules may the patient’s permission, the employer, and trying to apply. It is usually much to the patient’s advan- American Medical Association Guides tage to continue working for the same employer, but in circumstances in which the offending agent has Many states require the physician to apply the been removed, the reduction of air levels has been criteria of the Guides to the Evaluation of Permanent achieved or, in some cases, respiratory protection Impairment20 in rating the degree of disability for has been added. For the patient who is unable to work at all because of lung disease, whether occupational or Byssinosis nonoccupational, Social Security Administration disability criteria may apply. Each review takes control of asthma counts as two attacks, and a little different tack but covers essentially the same an evaluation period of at least 12 consecu- material. Although infrequently reported, fatal cases of Can Respir J 1998; 5:289–300 occupational asthma22 have occurred in patients Perhaps the clearest, most clinically useful review addres- for whom the association with the workplace was sing diagnosis. Outcome of Excellent short review with a balanced discussion of the occupational asthma after cessation of exposure: a controversial areas of this disorder. Accessed April 22, 2009 racic Society statement: occupational contribution If you know only the brand names or product names of the to the burden of airway diseases. Eur Respir J 2003; 22:364–373 Both articles discuss the known facts and the proposed Work/Disability Evaluation theories of the pathogenetic mechanisms at work in occupational asthma. Is the This rating system is the one most widely required by clinical history a satisfactory means of diagnosing individual state worker compensation systems. It is recommended that methacholine challenge tests March 29, 2009 and speciﬁc IgE assays or skin-prick tests (when available) be used to improve diagnostic accuracy.
Patients exercising over 3 hours per week is aimed to help People with Disability (PwD) deal with Activity of achieved higher mobility (p=0 purchase 120 mg sildalis otc. Conclusion: The results support the Material and Methods: One cadre is responsible for one PwD 120mg sildalis visa. A preservation of distal limb level and knee joint at surgical stage cheap sildalis online mastercard, book of manual will be provided for each caregiver of a PwD in ac- which is associated with fewer activity restriction, higher mobility cordance with what the PwD needs based on the matrix. The results also promote prosthesis use is made once in every six months by completing Form 2 during the and exercise during rehabilitation for better mobility and general period of 1012 to 2015. After evaluation 4 PwD (66%) 1University of Tsukuba Hospital, Department of Rehabilita- experience some improvements and 2 PwD (34%) shows no differ- tion Medicine, Tsukuba, Japan, 2University of Tsukuba Hospital, ence. The Center for Innovative Medicine and Engineering, Tsukuba, Japan, evaluation shows that 2 persons (66%) experience improvements, 3Kowagishi Laboratory, Department of Prosthesis and Orthosis, but 1 person (34%) indicates no difference. She had been repeatedly prescribed her prosthesis in a special hospital for prosthesis, however without involvement of Introduction/Background: Stroke is the third number of leading rehabilitation team. At the initial visit, her leg of the prosthetic side cause of death in Bangladesh and prevalence is 0. Ten participants people with disability (PwD) perform Activity Daily Living at selected by purposive sampling who have match inclusion criteria. Mate- analyzed using three stages: question analysis, content analysis and rial and Methods: Every Cadre handled one PwD and every PwD analysis of themes. Results: From the content analysis participants caregiver given a guidebook based on the matrix. The evaluation face some challenges: work stress, writing diffculty, working hour, is held every six months by flling form 2 from 2012 until 2015. The data collected until Dec about of extra facilities like: easy job given, fexible work load, support 26 PwD. Matsuba (hereinafter: PwD) with respect to the policies, actions, measur- 1 2 able targets, and the performance of the competent institutions and Yokohama, Japan, Yokohama Brain and Spine Center, Rehabilita- tion department, Yokohama, Japan, 3Tohoku University Graduate providers of vocational rehabilitation in achieving planned objec- tives. The analysis School of Medicine, Department of Physical Medicine and Reha- in 2013 focused on the entire concession period 2010–2013, which bilitation, Yokohama, Japan served as a pilot analysis. In doing so, we collected data on the Introduction/Background: Stroke impairs movement, activities of characteristics of the target groups involved in vocational rehabili- daily living, and quality of life. The determination of factors infuencing and their obstacles compared with other unemployed persons. Results: The average patient age was 65 which found out that cost for not being in employment, training years (range, 16–95 years), and 369 (34. Emotional problems were common and several reported problems with fatigue, memory and executive function. Jokel1 stroke are said to have emotional setbacks such as negativity of 1Rotman Research Institute, Toronto, Canada mood and lack of will due to low self-esteem. This study was neurodegenerative disorder characterized by a gradual loss of abil- conducted to determine the effectiveness of different kinds of mu- ity to communicate. They participated in 10 assigned into four groups; the frst group was listening to jazz type two-hour sessions on a weekly basis. The frst hour was focused on of music, second group was listening to upbeat type of music, third language therapy for the patients and concurrent counselling for group was listening to melodrama type of music while the fourth spouses. Headphones, music players, Prime tion in both structured tasks and conversational speech. The second hour was devoted to education, problem solv- Self-Esteem Scale were given to the patients before and after every ing, and practicing communication strategies in dyads. Three out of the fve patients showed signifcant im- the mood and self-esteem of stroke patients. The effects can be Medicine, Gothenburg, Sweden maintained when a follow-up strategy is built-in into the program. Material 1 2 2 2 and Methods: The study population were persons living in Goth- F. The focus here will be presentation on the LiSat-11 ences, Rehab Medicine, Lahore, Pakistan from the participating clinics. Results and Conclusion: The pre- liminary results indicate that, irrespective of country and clinic, life Introduction/Background: Stroke is the leading cause of neurologi- satisfaction is perceived as dissatisfying post stroke. The presentation will preferably be Sometimes they have to make quick decisions regarding diagnosis in a symposium where presenters from four of the countries (Nor- and management. Questionnaire was constructed using textbooks of medicine and current stroke guide- lines. Having a Family member 1 Hannover Medical School, Rehabilitation Medicine, Hannover, with stroke was associated with higher confdence in diagnoses of 2 Germany, Hannover Medical School, Clinical Immunology and stroke (p<0. Majority of the respondents correctly Rheumatology, Hannover, Germany defned stroke (60. Conclusion: different types of chronic musculoskeletal pains with their clinical This multi-center survey shows that knowledge and confdence lev- parameters, such as pain and mood-related behaviour (e. Therefore, in this study we determined subset regarding initial diagnosis and management of stroke is adequate in of immune cells in chronic pain patients and compared them with most domains. Different types of immune cells were determined tion Hospital, Faculty of Health, 2Sunnaas Rehabilitation Hospi- by using fuorescence-activated cell sorting. QoL may be affected by the individu- depression score in all chronic musculoskeletal pain patients is cor- als’ health, psychological state, level of independence, social rela- related with the percentage of lymphocytes (R: –0. Life satisfaction is considered Subgroup analysis of each group of patients show that depression purely subjective and related to goals. A salute-genic interpretation of the QoL concept may clusion: Taken together, it seems immune cells play a role in patho- combine the global, external, interpersonal and personal resources mechanism of chronic musculoskeletal pain. The microstroke was radiation can promote myoblasts proliferation and inhibit differen- induced by two-photon laser irradiation. Secondly, among 1The Second Affliated Hospital of Chongqing Medical University, the three groups, there were signifcant more neuron death, micro- Rehabilitation Medicine, Chongqing, China glia and astrocyte in T2 (p<0. How- Zhibin3 ever, for all the three Finglimod concentrations, there is no differ- 1University-Town Hospital of Chongqing Medical University, Reha- entiation signifcant difference between neurons and astrocytes. Proliferating myoblasts ir- radiated for 6 consecutive days and differentiating myoblasts for 4 Introduction/Background: Diabetes mellitus affect gait ability due consecutive days. The aim of the study to evaluate the effect of tected by immunofuorescence staining. Diabetes induced by streptozotozin injection (45 mg/kg ip) combined with high fat diet fed ad libitum. Introduction/Background: Since the new constitution of 2011, the management of disability in Morocco has become a constitutional right. Material and Meth- 1 2 1 1 ods: We have consulted the Moroccan action plan on health and T. Chou 1Taipei Veterans General Hospital, Physical Medicine and Reha- disability 2015–2021 and all the offcial documents of the Ministry of Health on disability in Morocco. It was prepared on the basis of a participatory approach common source of anterior knee pain.
Publicly the conflict between Campbell and Deer surfaced only in a small item in the New Statesman at the end of April best sildalis 120mg. In none of these communications did Duncan Campbell present himself as a socialist in conflict with the right wing press buy sildalis toronto. As far as Andrew Neil was concerned generic sildalis 120mg without prescription, the conflict which had been thrust upon him, and which involved a journalist renowned for his acerbic personal confrontations, was tangential to the running of a major newspaper. Deer was called in for talks and interviews, and the Sunday Times solicitors were put to work looking for a hook on which to hang an action against Campbell. The campaign which Campbell waged against Deer continued throughout 1989 and early 1990, and ended only when Deer was sent by the Sunday Times to work in America. The War on Cass Mann and Positively Healthy I will decide the route that I will follow. This was the line of enquiry which Brian Deer was to take up with his April articles in the Sunday Times. There was every sign in the first months of 1989 that Positively Healthy would grow in influence. The campaign which Duncan Campbell was planning against Cass Mann, was, however, soon to destroy all the credibility which Positively Healthy had built up. What made Positively Healthy different from many other organisations in the gay community, was the individual nature of Cass Mann and the other mainstay of the organisation, Stuart Marshall. As with all the other campaigns carried out by Campbell, there were two strands to the assault on Positively Healthy, the overt and the covert. Cass Mann and Stuart Marshall lived in a condition of fear for over a year, during the time of the campaign against them. Those who saw the public presentation of the conflict, saw only the published articles and probably concluded that there was no smoke without fire. Privately, Mann and Marshall endured a secret campaign which etched away at their confidence, their health, their self-esteem, and their social standing. It was then that 28 the real trouble began and we became targets of some unseen force. By April 1989, Duncan Campbell was expert in the techniques of covert journalistic campaigning. By circulating memoranda and letters and by telephone calls and a stream of faxes, Campbell began to get feedback from a variety of people about Cass Mann and Positively Healthy. In April 1989, a Ms Rosson of the Department of Genito-Urinary Medicine at the Withington Hospital in Manchester, sent a selection of material 30 from Positively Healthy to David Pearson. In the letter which Pearson returned to Ms Rosson, he carefully points out his qualifications for judging nutritional information. Internal evidence (sic) gives strong cause for concern that they are the latter rather than a respectable voluntary 32 organisation as you seem to believe. To this day, Cass Mann does not know how Campbell obtained the phone number of his relatives who have a different name from his family name. Right up until his death he was hurt by the allegations which were being made against his son. Throughout 1989, coincidentally with the growing conflict between Campbell and Positively Healthy, both Cass Mann and Stuart Marshall became the subjects of constant harassment from unseen forces. Both Marshall and Mann had the clear impression that their telephones were tapped. The months between April and September, the first four months of the official life of the Campaign. Against Health Fraud, Campbell spent gathering information and then privately distributing critical material against Mann, Marshall and Positively Healthy. There it came under the administrative control of the local Health Authority and was answerable within the hospital to the senior medical consultant. Working on the project in the first quarter of the year, he began inviting speakers. There were to be two sessions about treatment and research, and King had no hesitation in inviting both Cass Mann and Stuart Marshall to participate. Edward King contacted Campbell at the New Statesman offices, to sound him out; he was utterly unprepared for the reaction which his invitation received. Campbell told King that while he did not wish to attend himself, he would be interested to know whether there was to be any discussion of health-fraud at the conference. All of them withheld from Positively Healthy and Cass Mann the fact that they had received the memorandum. The document presents a good ground plan for the strategy which Campbell was to use over the coming year. With other themes, the idea that Cass Mann was about to wreck the Concorde trials which were backed by both the British and French governments, runs like a trickle of hysteria through the document. The question of where the money came from is left begging in order to make it appear vaguely sinister. Campbell also charged Mann with introducing a Concorde trial subject to Brian Deer. In this way, Campbell claimed to link Cass Mann to a number of people who were, in his opinion, charlatans and quacks. Here Campbell is referring to the attack which he was to mount in the New Statesman on Monica Bryant. Cass Mann and Stuart Marshall both spoke, but it was not until the end of the conference that both activists got to see the six-page memorandum. One recipient of the memorandum broke ranks and, taking Cass Mann to his home, showed it to him. But Cass Mann told the Pink Paper that 35 Positively Healthy had never promoted or sold germanium. The disclosure of the Campbell memorandum in the Pink Paper, within five days of the conference, signalled the beginning of internecine strife within the gay community. Edward King came back from holiday following the conference to find that he was the centre of a raging row. He was subjected to continuous phone calls, letters at his home and faxes at work. It was as if Campbell was forced to go public with the story following the disclosure to Cass Mann of the confidential memorandum. Certainly the New Statesman article was assembled quickly because instead of picturing Dr Michael Kirkman, named in the main photograph, the New Statesman pictured his chauffeur. The central claim was that he and others in Positively Healthy were, by unstated acts, planning to bring an end to the Concorde trials. Campbell, however, was deadly serious, as were those whose interests he ultimately, if unknowingly, served; the slightest threat to the Concorde trials was a major threat to Wellcome and its share price. The list of those people Campbell drew upon for his expert advice in the article is instructive: he took a very personal and authoritative quote from Michael Howard, the chief executive of Frontliners, which was to shut down a year later following claims of financial mismanagement. As he had done in his six-page memorandum, Campbell calls up the genies of HealthWatch.
A delayed or fragmented bolus may affect the shape of the pulmonary curve generated discount 120mg sildalis with visa, which should be monoexponential buy discount sildalis 120 mg online, even in the absence of a shunt proven 120 mg sildalis. Shunting separates the pulmonary activity curve into two components, which are proportional to the systemic and shunt flows, respectively, giving an index of the severity of the shunt. Studies showing prolonged tracer transit through the left side of the heart may 172 5. From the pulmonary and left ventricular time–activity curves, the degree of regurgitation may be calculated and quantified. Resting studies performed serially can be helpful in monitoring the severity of the valvular insufficiency and in deciding when valve replacement is necessary. Radiopharmaceuticals The ideal radionuclide as a first pass imaging agent must remain intravas- cular as it moves through the central circulation. It should also be safe for application in large doses in order to generate the necessary high count rates. Technetium-99m pertechnetate can be used when a single assessment of ventricular function is needed. Other technetium based compounds such as sestamibi and tetrofosmin are also suitable. First pass imaging can be performed upon injection of the tracer during peak exercise, thus combining information on regional and global ventricular function as well as myocardial perfusion in one setting. The half-life of 6 h and varying biological clearance times limit the number of acquisitions that can be done in a given period. In order to reduce the patient’s radiation exposure and allow for a greater number of studies to be performed, radionuclides with half-lives in terms of seconds or minutes would be ideal. Tantalum-178 produces suboptimal results when used with standard gamma cameras because of its low energy; more satisfactory results have been reported with a multiwire proportional gamma camera. Gold-195m is ideal for adult patients, and the calculated ejection fraction correlates well with that obtained using 99mTc agents. A bicycle ergometer is an additional requirement for first pass studies during exercise. The use of cameras with low count rate capabilities leads to an inaccurate measurement of ejection fraction and assessment of wall motion. Originally, only multicrystal gamma cameras could record such high counts, although with some loss of spatial resolution. Newer generations of multi- crystal cameras can now acquire the same range of counts with enhanced energy and spatial resolutions. Modern single crystal cameras are also capable of achieving rates of up to 200 000 counts/s, as opposed to older cameras with rates of only up to 60 000 counts/s. The choice of collimator depends on the objective of the study and the dose to be injected. Computer software should allow acquisitions to be performed with 64 ¥ 64 or smaller matrices. Procedure (a) Tracer injection First pass studies require the injection of a small volume of radionuclide bolus. Large proximal veins must be used as injection sites, since smaller, peripheral veins may cause bolus fragmentation. The injection parameters appropriate to the various kinds of study are listed in Table 5. For left ventricular evaluation or shunt studies, it is important that the bolus arrive in the heart as a single front. Rapid injection of the radionuclide and a 10–20 mL saline flush (within 2–3 s) is necessary. In right ventricular studies, since the bolus reaches the right ventricle without significant dispersion, an antecubital vein is preferred since the use of the external jugular vein may result in too rapid transit of the bolus through the chamber. A slower bolus is preferred to increase the number of beats available for analysis; the saline flush may be then infused without interruption for 3–4 min. The upright straight anterior view is best for exercise studies since the chest is stabilized against the detector. The descending aorta and the basal portion of the inferoseptal wall may, however, overlap with the left atrium and basal portion of the left ventricle. Fifty ms/frame is adequate at heart rates lower than 80 beats per minute decreasing to 10–20 ms/ frame for faster heart rates, especially if diastolic function is of interest. Two thousand frames are sufficient to encompass the entire left ventricular phase. Frame rates are not as essential in a shunt study since data analysis uses curves of lower temporal resolution. Although supine bicycle exercise results have been shown to correlate with catheteri- zation, upright bicycles are more often used since they minimize chest motion and are better tolerated by patients. Any graded exercise protocol is acceptable and no time is required to stabilize the heart rate. It permits inspection of the separation of the right and left ventricular phases, allows the estimation of the peak count achieved, and detects the presence of irregular beats. The cycles before and after the beat with the maximum number of counts are selected. Beats whose end-diastolic counts are below 50% of the maximum end-diastolic count should also be omitted if they do not preclude a statistically adequate representative cycle. Only beats around the peak of the time–activity curve (80% or more of maximum activity) are to be used. This leaves one or two beats during the right ventricular phase and four to five beats during the left ventricular phase available for analysis. Averaging of several individual beats can also be done to form a summed representative cycle. The systolic emptying rates and diastolic filling rates are calculated with appropriate software using a Fourier filter applied to the representative cycle and taking the first derivative of the filtered curve. Left ventricular end- diastolic volume may be measured using the geometric or count proportional method. The geometric method measures the area of the left ventricle and the length of the major axis in pixels. In the count proportional method, volume is derived from the total counts and the counts in the hottest pixel in the left ventricle. Interpretation The radionuclide bolus appears sequentially in the superior vena cava, right atrium, right ventricle, pulmonary circulation, left side of the heart and aorta. Any changes in this pattern would suggest the presence of a congenital abnormality. Delayed tracer transit on the left side of the heart would suggest mitral or aortic insufficiency. Regional wall motion is analysed by superimposing the end-diastolic outline against the end-systolic image or by viewing the representative cycle in cine-mode. However, it has to be noted that since the study was acquired in only one projection, regional wall motion abnormalities may be difficult to identify in overlapping segments.
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