Human papillomavirus type 5 is commonly present in immunosuppressed and immunocompetent individuals

DNA of a wide spectrum of epidermodysplasia verruciformis-associated human papillomavirus (HPV) types (EV-HPV) has been detected in skin lesions and plucked hairs from both immunosuppressed and a considerable proportion of non-immunosuppressed persons. Recently, the skin of psoriatic patients was claimed to be an important reservoir for a particular EV-HPV type, HPV 5, which is considered as a high-risk HPV type for skin carcinomas. In the present study, we analysed plucked hairs from immunosuppressed renal transplant patients and immunocompetent individuals, utilizing an HPV 5-specific nested polymerase chain reaction. HPV 5 was detected in hairs derived from 14 of 31 (45%) immunosuppressed patients and 21 of 135 (16%) immunocompetent individuals. Both the immunosuppressed and the immunocompetent groups consisted of individuals with and without non-melanoma skin cancer. HPV 5 DNA was detected in similar proportions of hair samples plucked from individuals with and without skin cancer in either group. Our results indicate that HPV 5 is commonly present in the population. The role of HPV 5 in the pathogenesis of skin carcinomas and psoriasis remains to be established.

Sphincter-sparing treatment for distal rectal adenocarcinoma

BACKGROUND

Studies suggest that the anal sphincter can be preserved in some patients with distal rectal adenocarcinoma (DRA), but this has not been validated in any prospective multi-institutional trial.

METHODS

To test the hypothesis that the anal sphincter can be preserved in some patients with DRA, the Cancer and Leukemia Group B and collaborators reviewed 177 patients who had T1/T2 adenocarcinomas < or = 4 cm in diameter, which encompassed < or = 40% of bowel wall circumference, and were < or = 10 cm from the dentate line. Of the 177 patients, 59 patients who were eligible for the study had T1 adenocarcinomas and received no further treatment; 51 eligible T2 patients received external beam irradiation (5400 cGY/30 fractions 5 days/week) and 5-fluorouracil (500 mg/m2 IV d1-3, d29-31) after local excision.

RESULTS

At 48 months median follow-up, 6-year survival and failure-free survival rates of the eligible patients are 85% and 78% respectively. Three patients died of unrelated disease. Two patients were treated for second primary colorectal tumors; both remain disease free (NED). Another eight patients died of disease, four with distant recurrence only. One T1 patient is alive with distant disease. Two T1 and seven T2 patients experienced isolated local recurrences; all underwent salvage abdominoperineal resection (APR). After APR, one T1 and four of seven T2 patients were NED at the time of last visit (2-7 years). One T1 patient died of local and distant disease. Three of seven T2 patients died with distant disease.

CONCLUSIONS

We conclude that sphincter preservation can be achieved with excellent cancer control without initial sacrifice of anal function in most patients. After local recurrence, salvage resection appears effective, but longer follow-up time of local and distant disease-free survival is advised before extrapolation to patients with T3 primaries.

Cyclin D1 and D3 associate with the SCF complex and are coordinately elevated in breast cancer

D-type cyclins are important cell cycle regulators that promote cellular proliferation in response to growth factors by inactivation of the retinoblastoma protein (Rb). Cyclin D1 has been shown to be overexpressed in several cancer types and to act as an oncogene in breast cancers. As D-type cyclins are rate limiting for progression into S phase, the level at which they accumulate must be carefully regulated. Several mechanisms leading to overexpression of cyclin D1 have been reported including amplification, translocation and stabilization of the mRNA. Here, we present data showing elevated cyclin D1 protein in breast cancer samples in the absence of elevated mRNA level. Further, we found that in these cases, cyclin D3 protein also accumulates and that the coordinate increase in cyclin D1 and D3 occurs in 15% (7/47) of breast cancers. In addition we show that blocking the activity of the 26S proteosome results in the accumulation of cyclin D1 and D3, that both D-type cyclins are ubiquitinated and associate with Cul-1, a component of the SCF ubiquitin ligase complex. Finally, we show that the coordinated elevation of cyclin D1 and D3 is also observed in the breast cell line MCF-7 and demonstrate that the degradation of cyclin D1 and D3 is deficient in this cell line. These results indicate that cyclin D1 and cyclin D3 share a common mechanism of degradation and we propose that the coordinate increase of D-type cyclins observed in primary breast cancers reflects a defect in their proteolysis.

IL-6, IFN-gamma and TNF-alpha production by liver-associated T cells and acute liver injury in rats administered concanavalin A

The relationship between the development of acute hepatitis and the production of TNF-alpha IFN-gamma and IL-6 by liver-associated T lymphocytes following intravenous injection of concanavalin A (Con A) was studied in rats. Following a single injection of Con A, there was a dose and time-dependent correlation in the serum levels of serum alanine aminotransferase (ALT), IL-6, IFN-gamma and TNF-alpha. These increases correlated with an increase in the numbers of CD4+, CD8+ and CD25+ T cells in blood and CD4+ and CD25+ T cells in the liver perfusate, but not with CD8+ T cells in liver perfusate. Increased levels of IL-6, IFN-gamma and TNF-alpha were constitutively produced by liver-associated CD4+ T cells when cultured. In Con A-stimulated cultures, liver-associated CD4+ T cells secreted increasing levels of TNF-alpha in a time-dependent manner following Con A injection, but TNF-alpha production by peripheral blood lymphocytes was transient with peak levels detected at 1 h which then declined over 24 h. Histological examination of the liver revealed fatty change, hepatocyte degeneration and necrosis, with an associated cell infiltrate of neutrophils and CD4+ T cells both in the portal areas and around the central veins. These results support the hypothesis that Con A-induced liver damage is mediated by CD4+ T cells acting within the liver, at least in part through the secretion of TNF-alpha, IFN-gamma and IL-6.

Prevalence of voice problems in teachers

Teachers are frequently cited as experiencing a high rate of vocal dysfunction (1-7). Despite considerable research in the area of voice problems in teachers, the prevalence of voice disorders in this group is unknown. This study investigated the prevalence of self-reported voice problems in teachers using a mail survey of a simple random sample of 1168 state school teachers (preschool-Grade 12) in South Australia. As part of the survey, teachers were asked to report voice problems for the day of the survey, during the current teaching year, and during their careers. The response rate was 75%, with 16% of teachers reporting voice problems on the day of the survey, 20% reporting problems during the current teaching year, and 19% reporting problems at some time during their career. Females were twice as likely as males to report voice problems. These findings clearly indicate a need for further investigation of the causes of vocal dysfunction in teachers and for the development of educational programs aimed at preventing voice problems in this group of professional voice users.

Learning voice analysis using an interactive multi-media package: development and preliminary evaluation

An important outcome of education for speech-language pathology practice is the ability to analyze voices perceptually, a complex task that is often difficult for novices. This article describes an interactive multi-media package, "A Sound Judgement," that is designed to help students develop skills in perceptual voice analysis and to link their perceptions to laryngeal physiology. The package presents a range of clients with vocal impairments at increasing levels of complexity. Each case has a videoed interview, endoscopic views and animations of the larynx, and case history information. Students make perceptual ratings of clients' voices on a format designed specifically for this package and feedback is provided using ratings made by expert speech-language pathologists. High levels of consensus for the perceptual judgments were achieved among the expert raters. Preliminary evaluations by students have demonstrated that "A Sound Judgement" is likely to be a valuable educational tool.

CDP840: a novel inhibitor of PDE-4

We present the in vitro characterization of a novel phosphodiesterase type 4 inhibitor, CDP840 (R-[+]-4-[2-¿3-cyclopentyloxy-4-methoxyphenyl¿-2-phenylethyl]pyridine), which has shown efficacy in a phase II allergen challenge study in asthmatics without adverse effects. CDP840 potently inhibits PDE-4 isoenzymes (IC50 2-30 nM) without any effect on PDE-1, 2, 3, 5, and 7 (IC50 > 100 microM). It exhibited no significant selectivity in inhibiting human recombinant isoenzymes PDE-4A, B, C or D and was equally active against the isoenzymes lacking UCR1 (PDE-4B2 and PDE-4D2). In contrast to rolipram, CDP840 acted as a simple competitive inhibitor of all PDE-4 isoenzymes. Studies with rolipram indicated a heterogeneity within all the preparations of PDE-4 isoenzymes, indicative of rolipram inhibiting the catalytic activity of PDE-4 with both a low or high affinity. These observations were confirmed by the use of a PDE-4A variant, PDE-4A330-886, which rolipram inhibited with low affinity (IC50 = 1022 nM). CDP840 in contrast inhibited this PDE-4A variant with similar potency (IC50 = 3.9 nM), which was in good agreement with the Kd of 4.8 nM obtained from [3H]-CDP840 binding studies. Both CDP840 and rolipram inhibited the high-affinity binding of [3H]-rolipram binding to PDE-4A, B, C, and D with similar Kd app (7-19 nM and 3-5 nM, respectively). Thus, the activity of CDP840 at the [3H]-rolipram binding site was in agreement with the inhibitor's activity at the catalytic site. However, rolipram was approximately 100-fold more potent than CDP840 at inhibiting the binding of [3H]-rolipram to mouse brain in vivo. These data clearly demonstrate that CDP840 is a potent selective inhibitor of all PDE-4 isoenzymes. In contrast to rolipram, CDP840 was well-tolerated in humans. This difference, however, cannot at present be attributed to either isoenzyme selectivity or lack of activity in vitro at the high-affinity rolipram binding site (Sr).

Have women's voices lowered across time? A cross sectional study of Australian women's voices

Various aspects of our communication are well known to have changed over time (1-3). This article describes a cross-sectional study that examined the acoustic characteristics of two groups of Australian women aged 18-25 years from recordings made in 1945 and 1993 and investigated the possible changes in the voice across generations. Archival recordings from 1945 which had been used in a longitudinal study (4) were compared to recordings made in 1993. The results of this study show that women in 1993 have significantly deeper voices than women of the same age recorded in 1945. The possible factors influencing this change are discussed.

Decreased tumor necrosis factor-alpha and interleukin-1alpha production from intrahepatic mononuclear cells in chronic ethanol consumption and upregulation by endotoxin

The relationship between the changes in liver pathology and the production of interleukin (IL)-1alpha, IL-6, and tumor necrosis factor-alpha (TNF-alpha) by intrahepatic mononuclear cells was studied in rats fed alcohol and subsequently exposed to lipopolysaccharide (LPS). Rats were fed 40% ethanol in drinking water, whereas control rats were provided with a chow diet with isocaloric or 2% sucrose drinking solutions for up to 20 weeks. Decreased IL-1alpha and TNF-alpha production in 24-hr culture supernatants of mononuclear cells isolated from liver perfusate was detected while IL-6 remained unchanged over 20 weeks. When animals were injected with LPS (1.0 microg/kg body weight), there was a 5-fold rise in ALT levels in the ethanol-fed group, but not in control groups. Increased IL-6 and TNF-alpha levels in the serum and supernatant of cultured intrahepatic mononuclear cells stimulated with or without LPS or concanavalin A was observed. There was a correlation between levels of ALT and TNF-alpha, but not IL-6. T cells and Kupffer cells were the major source of TNF-alpha in culture supernatants of hepatic perfusate mononuclear cells from ethanol-consuming rats injected LPS. In addition, pathological liver injury was evident, which suggests a pathogenic role for TNF-alpha in alcohol-induced liver disease.

Which characteristics of schizophrenia predate psychosis?

Neuropsychological and brain structural abnormalities are present in first onset schizophrenia; the balance of evidence is that in the majority of cases these are developmental in origin. A proportion of first degree relatives also show lateral ventricular enlargement, cortical volume decrease and possibly loss of the normal cerebral asymmetry; these findings suggest that certain families transmit a genetic defect in the control of neurodevelopment. On the contrary, decrement in left hippocampal volume appears to be secondary to perinatal hypoxia. High risk, follow-back and cohort studies all demonstrate that preschizophrenics as a group show deviant development; delayed milestones, lower IQ, solitary play, excessive anxiety, and minor neurological problems are all common. It seems likely, but not proven, that these are a manifestation of underlying neurodevelopmental disorder.

Risk factors for gout: a hospital-based study in urban black South Africans

The clinical features of 90 Black South African patients with gout seen at a large urban hospital were reviewed. The mean age of the patients was 54.3 and 55.3 years for men and women, respectively. The male:female ratio was 3.3:1. All except one of the women were postmenopausal. Seventy-nine percent of patients were from the lower income groups of "blue collar" workers, old-age pensioners or the unemployed. Polyarticular gout was observed in 44.4% of the patients. Tophi were noted in 51.1% of patients but none had a history of renal calculi. Risk factors were assessed by comparing the gouty patients to an equal number of age- and sex-matched hospital controls. Case-control analysis showed a "white collar" occupation (odds ratio = 7.4), obesity (odds ratio = 5.3), alcohol intake (odds ratio = 3.5) and hypertension (odds ratio = 3.3) to be significant risk factors for gout in the overall group of both men and women. In the subgroup of men only, obesity (odds ratio = 7.8), a "white collar" occupation (odds ratio = 6.4), hypertension (odds ratio = 4.9) and alcohol intake (odds ratio = 3.5) were similarly associated with gout. In women, a history of alcohol intake was the only significant risk factor associated with gout (odds ratio = 5.0). These findings suggest that in a population where gout was previously rare, changing dietary habits and lifestyle, together with improving socioeconomic conditions are contributing significantly to the increasing prevalence of the disease.

Acute neutropenia decreases inflammation associated with murine vaginal candidiasis but has no effect on the course of infection

We have used a mouse model of vaginal candidiasis to determine the effect of neutrophil depletion on (a) the clearance of Candida albicans and (b) the degree of inflammation associated with infection. No differences in recoverable yeast number or rate of clearance were observed between normal and neutrophil-depleted mice; however, vaginal inflammation was significantly decreased in neutrophil-depleted animals.

Neurologic injuries associated with all-terrain vehicles and recommendations for protective measures for the pediatric population

OBJECTIVE

To present data and case studies illustrating the danger, especially in the pediatric population, of all-terrain vehicle (ATV) use, and to provide recommendations for pediatricians on how to educate parents concerning ATVs.

DESIGN

Retrospective review of 33 patients with neurologic injuries sustained in ATV accidents presenting to one institution over a 40-month period.

SETTING

Emergency department and neurosurgery service at Arkansas Children's Hospital and two other hospitals that make up the University of Arkansas for Medical Sciences.

PATIENTS

All patients (n = 33) who presented between January 1993 and April 1996 at the emergency departments with neurologic injuries sustained in accidents involving either a three- or four-wheel ATV requiring hospitalization.

INTERVENTIONS

Depending on the nature of the injury, various treatments, as described herein.

MAIN OUTCOME MEASURES

Demographic measures, the mechanisms of injury, the types of injuries; the current data available regarding the number of injuries nationwide; and the precautionary measures parents should be advised to take.

RESULTS

Ages ranged from four to 68 years (mean, 18; median, 14), 21 of the patients were < 16 years old. The predominant age range was 12 to 15 years; most common mechanisms of injury were being thrown to the ground, striking a tree, and flipping backward. Most injuries were cranial (21) or spinal (11). Nationwide, the proportionate number of injuries are decreasing, but the consequences remain severe. Using a helmet and restricting the use of these vehicles will reduce the number and magnitude of injuries.

CONCLUSIONS

Although perceived as recreational toys, ATVs can be extremely unsafe, especially for children and adolescents; pediatricians should educate parents and patients on the dangers of riding these vehicles.

Molecular cloning and expression of a human phosphodiesterase 4C

A cDNA coding for a human phosphodiesterase 4C (PDE4C2) was isolated from the mRNA prepared from the glioblastoma cell line, U87. The cDNA contained an ORF of 1818 bp corresponding to a 605 amino acid polypeptide. The sequence differed at the 5' end from the human PDE4C previously reported (Engels, P. et al, 1995 FEBs Letters 358, 305-310) indicating that it represents a novel splice variant of the human PDE4C gene. Evidence was also obtained for a third 5' splice variant. The PDE4C2 cDNA was transfected into both COS 1 cells and yeast cells, and shown to direct the expression of an 80 kD polypeptide by Western blotting using a PDE4C specific antiserum. The activity of cell lysates was typical of PDE4 being specific for cAMP and inhibitable by the selective inhibitor, rolipram. However, the Km for cAMP of the enzyme produced in COS cells was 0.6 microM compared to 2.6 microM for the yeast 4C activity. In addition the COS cell PDE4 activity was much more sensitive to R rolipram than the yeast PDE4 enzyme (IC50 of 23 nM compared to 1648 nM). This difference in rolipram sensitivity was associated with the detection of a high affinity [3H] R rolipram binding site on the COS cell 4C enzyme but not on the yeast expressed enzyme. The results indicate that the enzyme can adopt more than one active conformation, which are distinguished by their interaction with rolipram.

Molecular cloning and transient expression in COS7 cells of a novel human PDE4B cAMP-specific phosphodiesterase, HSPDE4B3

5'-Rapid amplification of cDNA ends, done on poly(A)+ RNA from human U87 cells, was used to identify 420 bp of novel 5' sequence of a PDE4B cAMP-specific phosphodiesterase (PDE). This identified an open reading frame encoding a putative 721-residue 'long-form' PDE4B splice variant, which we term HSPDE4B3. HSPDE4B3 differs from the two known PDE4B forms by virtue of its unique 79-residue N-terminal region, compared with the unique N-terminal regions of 94 and 39 residues found in HSPDE4B1 and HSPDE4B2 respectively. In transfected COS7 cells the two long forms, HSPDE4B1 and HSPDE4B3, had molecular masses of approx. 104 and approx. 103 kDa respectively. Expressed in COS-7 cells, the three HSPDE4B isoforms were found in the high-speed supernatant (cytosol) fraction as well as both the high-speed pellet (P2) and low-speed pellet (P1) fractions. All isoforms showed similar Km values for cAMP hydrolysis (1.5-2.6 microM). The maximal activities of the soluble cytosolic activity of the two long forms were very similar, whereas that of the short form, HSPDE4B2, was approx. 4-fold higher. Particulate-associated HSPDE4B1 and HSPDE4B2 were less active (approx. 40%) than their cytosol forms, whereas particulate HSPDE4B3 was similar in activity to its cytosolic form. Particulate and cytosolic forms of HSPDE4B1 and HSPDE4B3 were similarly inhibited by rolipram {4-[3-(cyclopentoxyl)-4-methoxyphenyl]-2-pyrrolidone}, the selective inhibitor of PDE4 (IC50 0.05-0.1 microM), whereas particulate-associated HSPDE4B2 was profoundly (approx. 10-fold) more sensitive (IC50 0.02 microM) to rolipram inhibition than its cytosolic form (IC50 0.2 microM). The various particulate-associated HSPDE4B isoforms showed very different susceptibilities to solubilization with the detergent Triton X-100 and high NaCl concentration. A novel cDNA, called pRPDE74, was obtained by screening a rat olfactory lobe cDNA library. This contained an open reading frame encoding a 721-residue protein that showed approx. 96% amino acid identity with HSPDE4B3 and is proposed to reflect the rat homologue of this human enzyme and is thus called RNPDE4B3. Alternative splicing of mRNA generated from both the human and rat PDE4B genes produces long and short splice variants that have unique N-terminal splice regions. It is suggested that these alternatively spliced regions determine changes in the maximal catalytic activity of the isoforms, their susceptibility to inhibition by rolipram and mode of interaction with particulate fractions.

Cannabis use in a general psychiatric population

It is known that there is an association between cannabis use and psychosis. Clinically we had thought that there were increasing numbers of patients admitted to hospital who were using cannabis and that this was affecting their illness. A study was therefore undertaken to determine the extent of cannabis use and its relationships over a one month period. The findings and their implications for junior doctors on-call are also discussed.

The Dundee out-of-hours cooperative: preliminary outcomes for the first year of operation

The Dundee out-of-hours cooperative (DDOC) was the first of its kind to be developed in a city in Scotland. In its first year of operation, the key features of the cooperative were that (a) two doctors could deal with the large majority of out-of-hours calls for a population of just under 100,000 patients, (b) only one third of calls required a home visit, (c) most calls were handled within a period of time acceptable to patients, (d) seven out of 10 patients rated the service equal to or better than previous services, and (e) there were extended opportunities for general practitioners (GPs) involved in the scheme to meet with other colleagues during out-of-hours work.

Human phosphodiesterase 4A: characterization of full-length and truncated enzymes expressed in COS cells

The type 4 phosphodiesterase (PDE) family comprises four enzymes (4A, 4B, 4C and 4D) that are characterized by their specificity for cAMP and selective inhibition by the anti-depressant drug rolipram (4-[3-(cyclopentoxyl)-4-methoxyphenyl]2-pyrrolidone). In common with other PDEs, they consist of a central conserved domain associated with catalytic activity in addition to two N-terminal upstream conserved regions (UCR1 and UCR2) that are unique to the type 4 enzymes. We have isolated a 2 kb cDNA encoding a full-length type 4A PDE{HSPDE4A4B[Bolger, Michaeli, Martins, St.John, Steiner, Rodgers, Riggs, Wigler and Ferguson (1993) Mol. Cell. Biol. 13, 6558-6571]} from a human frontal cortex cDNA library. Northern blot analysis showed that the major PDE4A mRNA of 4.5 kb was widely distributed in different human tissues. The recombinant PDE4A expressed in COS cells had a molecular mass of approx. 117 kDa as revealed by SDS/PAGE/Western blotting with a PDE4A-specific antibody and was specific for cAMP with a Km of 4.8 microM. The enzyme activity was potently inhibited by R-rolipram (IC50 204 nM) and showed a 2.7-fold stereoselectivity over the S enantiomer. Analysis of the kinetics of inhibition indicated that R-rolipram did not behave as a simple competitive inhibitor. Dixon replots suggested that there was more than one mode of interaction consistent with the detection in the enzyme of a high-affinity binding site for R-rolipram with a Kd of 2.3 nM. Truncation of the PDE4A enzyme by deletion mutagenesis showed that neither of the UCRs was required for catalytic activity and identified an approx. 71 kDa core enzyme with a K(m) for cAMP of 3.3 microM. In contrast with the full-length PDE4A, R-rolipram behaved as a simple competitive inhibitor of this form of the enzyme with decreased potency (IC50 1022 nM) and no stereoselectivity. In addition, no high-affinity rolipram-binding site was detected in the truncated enzyme, indicating that this interaction involves sequences upstream of the catalytic domain of the enzyme.

Sun exposure, sunscreen and their effects on epidermal Langerhans cells

This study examined the effects of chronic and current sun exposure on the number of Langerhans cells in epidermal sheets of UV-exposed and unexposed skin of the arms and assessed the effect of sunscreens. Participants were enrolled in a skin cancer prevention trial and had been using sunscreen daily for the previous 3 years. There were significantly fewer Langerhans cells on the exposed (463 cells/mm2) than on the unexposed forearm (528 cells/mm2) (P = 0.0001). High sun exposure in the previous 2 weeks and a history of predominantly outdoor occupations were both associated with a reduced number of Langerhans cells, although age and other biological indicators of chronic exposure were not associated. Sunscreen use was protective against the effects of current but not chronic sun exposure, with a suggestion of a greater effect at higher levels of exposure. Unexpectedly, people with a past history of nonmelanoma skin cancer had more Langerhans cells in both the exposed and the unexposed skin. These results emphasize the need for continued public health education to protect the immune system from the damaging effects of UV radiation.

How nurses can support people with epilepsy

This article looks at the nurse's role in caring for people with epilepsy in different age groups and at new developments in the treatment of this condition. A previous article (Nursing Times, May 21) looked at the diagnosis of epilepsy and the management of seizures.

Epilepsy: the most common serious neurological condition

This article looks at the diagnosis and management of epilepsy. The seizures associated with this condition are described and the classification is highlighted. Finally, the treatment is explained. A second article which looks at the nurse's role in caring for people with epilepsy and a patient's experience will be published July 2.

Clinical comparison of circular versus noncircular acquisition using technetium-99m myocardial perfusion SPECT imaging

The optimal orbit for myocardial SPECT imaging has not yet been determined. In order to evaluate differences in image quality and reader interpretation between orbiting methods, 50 patients scheduled for routine stress/rest 99mTc-sestamibi imaging had both a circular and a noncircular study using an ADAC Vertex dual-head imaging system.

METHODS

Each study was acquired using a 64 x 64 matrix, 64 stops at 25 sec per stop. Images were processed using a Butterworth filter with a frequency cutoff of 0.6 and an order of 5.0. Studies were interpreted by three experienced readers without knowledge of patient name or orbiting technique for normal and abnormal segments and overall image quality.

RESULTS

There was no significant difference in the semi-quantitative assessment of either defect extent or reversibility or in the quantitative assessment of defect size between the two types of orbits. However, while all 50 noncircular studies were read as good or fair quality, 23 circular studies were read as fair or poor (p = < 0.0002).

CONCLUSION

Qualitative and quantitative analysis revealed similar size and extent of perfusion defects using either circular or noncircular orbit, but images with the noncircular orbit were of significantly better image quality and may be preferable to a circular orbit with 99mTc-sestamibi.