High-Resolution Free-Breathing Automated Quantitative Myocardial Perfusion by Cardiovascular Magnetic Resonance for the Detection of Functionally Significant Coronary Artery Disease

AIMS

Current assessment of myocardial ischaemia from stress perfusion cardiovascular magnetic resonance (SP-CMR) largely relies on visual interpretation. This study investigated the use of high-resolution free-breathing SP-CMR with automated quantitative mapping in the diagnosis of coronary artery disease (CAD). Diagnostic performance was evaluated against invasive coronary angiography (ICA) with fractional flow reserve (FFR) measurement.

METHODS & RESULTS

Seven-hundred and three patients were recruited for SP-CMR using the research sequence at 3 Tesla. Of those receiving ICA within 6 months, 80 patients either had FFR measurement, or identification of a chronic total occlusion (CTO) with inducible perfusion defects seen on SP-CMR. Myocardial blood flow (MBF) maps were automatically generated in-line on the scanner following image acquisition at hyperaemic stress and rest, allowing myocardial perfusion reserve (MPR) calculation. 75 coronary vessels assessed by FFR, and 28 vessels with CTO were evaluated at both segmental and coronary territory level. Coronary territory stress MBF and MPR were reduced in FFR-positive (≤ 0.80) regions (median stress MBF: 1.74 [0.90-2.17] ml/min/g; MPR: 1.67 [1.10-1.89]) compared with FFR-negative regions (stress MBF: 2.50 [2.15-2.95] ml/min/g; MPR 2.35 [2.06-2.54] p < 0.001 for both). Stress MBF ≤ 1.94 ml/min/g and MPR ≤ 1.97 accurately detected FFR-positive CAD on a per-vessel basis (area under the curve: 0.85 and 0.96 respectively; p < 0.001 for both).

CONCLUSIONS

A novel scanner-integrated high-resolution free-breathing SP-CMR sequence with automated in-line perfusion mapping is presented which accurately detects functionally significant CAD.

Continuing bonds following stillbirth: protective and risk factors associated with parental bereavement adaptation

OBJECTIVE

To investigate any association between expressions of parents' continuing bond with their stillborn baby and bereavement adaptation.

BACKGROUND

Continuing bonds theory suggests that bereaved parents adapt to the loss of their child by sharing and transforming mental representations of the child, allowing them to be integrated into parents' everyday lives. Little is known about the mental health benefits of expressing continuing bonds following stillbirth. This study examined any association between aspects of parents' relationship with their stillborn baby, social support for the relationship, and bereavement adaptation.

METHODS

Cross-sectional questionnaire study. Parents of stillborn babies (N=170) completed an online questionnaire examining engagement in continuing bonds expressions; characteristics of parents' relationship with their stillborn baby and their experience of sharing it; social support, and meaning-making. Measures of mental health were included to quantify bereavement adaptation.

RESULTS

Regression analyses showed that time since death, meaning-making, engaging with nature, and legacy building are positively linked to bereavement adaptation. Risk factors included inadequate social support for the relationship, a greater desire to share it more freely, an increased sense of integration with baby, and societal pressure to move on.

CONCLUSION

Key aspects of parents' ongoing relationship with their stillborn baby and the social context are related to bereavement adaptation.

What are women stressed about after birth?

BACKGROUND

Having a baby is associated with a variety of stressors, change, and adjustment. This study aimed to identify what women find stressful during the early postpartum period in contemporary Western society.

METHODS

Women (n = 148) 6-12 weeks postpartum wrote anonymously about a situation they found stressful as part of the Health after Birth Trial (HABiT) of expressive writing. Transcripts were analyzed for categories of stressors and cross-cutting themes.

RESULTS

Five categories of stressors were identified. Stressors in pregnancy, labor, and the early postpartum period (49.3%) included physical and emotional difficulties, and insensitive treatment by health professionals. Stressors related to adjusting to life with a baby (35.8%) included difficulties coping with a new baby, parenting, juggling responsibilities, changes to physical health, and loneliness. Stressors related to the baby's health (32.4%) included infant digestive problems, acute health problems, long-term impact, and neonatal intensive care unit experiences. Stressors related to breastfeeding (23.7%) included pressure to breastfeed, feeling like a 'bad mum' for not breastfeeding, or wanting to breastfeed and not being able to. Other stressors related to changing relationships (18.2%): with their partner, children, and other family members. Cross-cutting themes that emerged in different stressor categories were women making negative self-appraisals (eg, a bad mum, failure), feeling guilty, and lack of support from others.

DISCUSSION

Our findings emphasize the importance of exploring stressors and psychological well-being with women to provide support, help women's adjustment postpartum, and ensure interventions are offered when appropriate.

Evaluation of expressive writing for postpartum health: a randomised controlled trial

Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect the health of women. There is some evidence that expressive writing can have positive effects on psychological and physical health, particularly during stressful periods. The current study aimed to evaluate whether expressive writing would improve women's postpartum health. A randomized controlled trial was conducted with three conditions: expressive writing (n = 188), a control writing task (n = 213), or normal care (n = 163). Measures of psychological health, physical health and quality of life were measured at baseline (6-12 weeks postpartum), 1 and 6 months later. Ratings of stress were taken before and after the expressive writing task. Intent-to-treat analyses showed no significant differences between women in the expressive writing, control writing and normal care groups on measures of physical health, anxiety, depression, mood or quality of life at 1 and 6 months. Uptake and adherence to the writing tasks was low. However, women in the expressive writing group rated their stress as significantly reduced after completing the task. Cost analysis suggest women who did expressive writing had the lowest costs in terms of healthcare service use and lowest cost per unit of improvement in quality of life. Results suggest expressive writing is not effective as a universal intervention for all women 6-12 weeks postpartum. Future research should examine expressive writing as a targeted intervention for women in high-risk groups, such as those with mild or moderate depression, and further examine cost-effectiveness.Clinical trial registration number ISRCTN58399513 www.isrctn.com.

Feasibility and acceptability of expressive writing with postpartum women: a randomised controlled trial

Background

Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect women’s mental and physical health. Expressive writing, where people write about a stressful event for at least 15 min on three consecutive days, has been associated with improved health in some groups but it is not clear whether it is feasible and acceptable for use with postpartum women. This study therefore examined the feasibility and acceptability of expressive writing for postpartum women as part of a randomised controlled trial (RCT).

Methods

The Health After Birth Trial (HABiT) was an RCT evaluating expressive writing for postpartum women which included measures of feasibility and acceptability. At 6 to 12 weeks after birth 854 women were randomised to expressive writing, a control writing task or normal care, and outcome measures of health were measured at baseline, one month later and six months later. Feasibility was measured by recruitment, attrition, and adherence to the intervention. Quantitative and qualitative measures of acceptability of the materials and the task were completed six months after the intervention.

Results

Recruitment was low (10.7% of those invited to participate) and the recruited sample was from a restricted sociodemographic range. Attrition was high, increased as the study progressed (35.8% at baseline, 57.5% at one month, and 68.1% at six months) and was higher in the writing groups than in the normal care group. Women complied with instructions to write expressively or not, but adherence to the instruction to write for 15 min per day for three days was low (Expressive writing: 29.3%; Control writing: 23.5%). Acceptability measures showed that women who wrote expressively rated the materials/task both more positively and more negatively than those in the control writing group, and qualitative comments revealed that women enjoyed the writing and/or found it helpful even when it was upsetting.

Conclusions

The feasibility of offering expressive writing as a universal self-help intervention to all postpartum women 6 to 12 weeks after birth in the HABiT trial was low, but the expressive writing intervention was acceptable to the majority of women who completed it.

Trial registration

ISRCTN58399513, 10/09/2013.

Supporting parents through stillbirth: A qualitative study exploring the views of health professionals and health care staff in three hospitals in England

OBJECTIVE

To investigate the views of a range of hospital based health professionals and health care staff involved in the management of stillbirth.

STUDY DESIGN

A qualitative pilot study informed by grounded theory conducted in three hospital trusts in the North East of England. In total, 21 consultant obstetricians, 3 trainees (including 1 senior trainee), 29 midwives, 3 midwife sonographers and 4 chaplains took part in six focus groups and two semi-structured interviews.

RESULTS

Two different approaches in stillbirth management could be detected in our study. One approach emphasised the existing evidence-base and patient directed choice whilst the other emphasised tradition and profession-directed care. These differences were particularly apparent in choices over mode of delivery, and the location of women as well as the time interval between diagnosis of an IUD and delivery. The existence of these two approaches was underscored by a lack of high quality evidence.

CONCLUSION

Robust, high quality evidence is needed regarding the longer term psychological and emotional sequelae of different modes of delivery and varying time intervals and locations of women between diagnosis and delivery in stillbirth. If the competing discourses demonstrated here are found elsewhere then such need to be considered in any future policy development, evidence implementation and training programmes.

Stillbirth and stigma: the spoiling and repair of multiple social identities

This study investigated mothers' experiences surrounding stillbirth in the United Kingdom, their memory making and sharing opportunities, and the effect these opportunities had on them. Qualitative data were generated from free text responses to open-ended questions. Thematic content analysis revealed that "stigma" was experienced by most women and Goffman's (1963) work on stigma was subsequently used as an analytical framework. Results suggest that stillbirth can spoil the identities of "patient," "mother," and "full citizen." Stigma was reported as arising from interactions with professionals, family, friends, work colleagues, and even casual acquaintances. Stillbirth produces common learning experiences often requiring "identity work" (Murphy, 2012). Memory making and sharing may be important in this work and further research is needed. Stigma can reduce the memory sharing opportunities for women after stillbirth and this may explain some of the differential mental health effects of memory making after stillbirth that is documented in the literature.

The Birth Memories and Recall Questionnaire (BirthMARQ): development and evaluation

Background

Childbirth is a challenging and emotive experience that is accompanied by strong positive and/or negative emotions. Memories of birth may be associated with how women cognitively process birth events postpartum and potentially their adaptation to parenthood. Characteristics of memories for birth may also be associated with postnatal psychological wellbeing. This paper reports the development and evaluation of a questionnaire to measure characteristics of memories of childbirth and to examine the relationship between memories for birth and mental health.

Methods

The Birth Memories and Recall Questionnaire (BirthMARQ) was developed by generating items from literature reviews and general measures of memory characteristics to cover dimensions relevant to childbirth. Fifty nine items were administered to 523 women in the first year after childbirth (M = 23.7 weeks) as part of an online study of childbirth. Validity of the final scale was checked by examining differences between women with and without probable depression and PTSD.

Results

Principal components analysis identified 23 items representing six aspects of memory accounting for 64% of the variance. These were: Emotional memory, Centrality of memory to identity, Coherence, Reliving, Involuntary recall, and Sensory memory. Reliability was good (M alpha = .80). Women with probable depression or PTSD reported more emotional memory, centrality of memories and involuntary recall. Women with probable depression also reported more reliving, and those with probable PTSD reported less coherence and sensory memory.

Conclusion

The results suggest the BirthMARQ is a coherent and valid measure of the characteristics of memory for childbirth which may be important in postnatal mood and psychopathology. While further testing of its reliability and validity is needed, it is a measure capable of becoming a valuable tool for examining memory characteristics in the important context of childbirth.

Model for the neuromuscular complications of systemic lupus erythematosus

The purpose of this study is to evaluate nerve and muscle physiology and histopathology in a murine lupus model. Muscle strength, compound muscle action potentials (distal latency and amplitude), proximal limb muscle, sciatic nerve and joint specimens were studied in MRL/lpr (lupus model) and MRL/++ (control) mice. MRL/lpr mice showed decreased muscle strength (P < 10(-6, Wilcoxon rank sum), lower compound muscle action potential mean amplitude and prolonged distal latency (P = 0.005 and 0.042. Mann-Whitney U-test), and muscle and nerve inflammation (P = 0.002 and P = 0.037, Fisher's exact test) compared with MRL/++ mice. The MRL/lpr strain evaluated in this study demonstrated muscle weakness, abnormal motor nerve conduction studies and inflammation of both muscle and nerve. These features make it an excellent model for studying the neuromuscular complications of lupus.

Molecular mimicry, anti-coxsackievirus B3 neutralizing monoclonal antibodies, and myocarditis

Molecular mimicry has been suggested as one mechanism to explain chronic myocarditis in some murine strains in the postinfectious period following induction of acute myocarditis by coxsackievirus B3 (CVB3). To test this hypothesis, neutralizing mAbs were generated against a highly myocarditic CVB3 virus (CVB3m). These mAbs neutralized several myocarditic and amyocarditic CVB3 variants by cytopathic effects inhibition assays. Data from several experiments suggest that these mAbs recognize discontinuous epitopes on CVB3m capsid proteins. Several mAbs were found to induce cardiopathologic alterations subsequent to i.p. inoculation of normal adolescent male CD-1 or C3H/HeJ mice. Immunocytochemical assays demonstrated significant binding of two mAbs to the surface of normal cultured murine cardiac fibroblasts. Also, several mAbs were shown to participate in C-mediated lysis of normal cardiac fibroblasts, but this property did not correlate well with cardiopathogenic potential. The two properties of a mAb that were the best predictors for cardiopathogenic potential were the capacity for stimulation of normal murine fibroblasts to produce a chemoattractant activity for unelicted murine peritoneal macrophages, and the capacity for recognition of an epitopes(s) on murine or human cardiac myosins. These data show that some anti-CVB3m neutralizing mAbs can participate in proinflammatory reactions in vitro and induce cardiopathologic alterations in vivo, suggesting one mechanism by which CVB3-induced chronic inflammation in murine heart tissues can be sustained in the absence of continued virus replication.

Molecular mimicry, anti-coxsackievirus B3 neutralizing monoclonal antibodies, and myocarditis

Molecular mimicry has been suggested as one mechanism to explain chronic myocarditis in some murine strains in the postinfectious period following induction of acute myocarditis by coxsackievirus B3 (CVB3). To test this hypothesis, neutralizing mAbs were generated against a highly myocarditic CVB3 virus (CVB3m). These mAbs neutralized several myocarditic and amyocarditic CVB3 variants by cytopathic effects inhibition assays. Data from several experiments suggest that these mAbs recognize discontinuous epitopes on CVB3m capsid proteins. Several mAbs were found to induce cardiopathologic alterations subsequent to i.p. inoculation of normal adolescent male CD-1 or C3H/HeJ mice. Immunocytochemical assays demonstrated significant binding of two mAbs to the surface of normal cultured murine cardiac fibroblasts. Also, several mAbs were shown to participate in C-mediated lysis of normal cardiac fibroblasts, but this property did not correlate well with cardiopathogenic potential. The two properties of a mAb that were the best predictors for cardiopathogenic potential were the capacity for stimulation of normal murine fibroblasts to produce a chemoattractant activity for unelicted murine peritoneal macrophages, and the capacity for recognition of an epitopes(s) on murine or human cardiac myosins. These data show that some anti-CVB3m neutralizing mAbs can participate in proinflammatory reactions in vitro and induce cardiopathologic alterations in vivo, suggesting one mechanism by which CVB3-induced chronic inflammation in murine heart tissues can be sustained in the absence of continued virus replication.

Variability of a bacterial surface protein and disease expression in a possible mouse model of systemic Lyme borreliosis

During persistent infection of scid mice with Borrelia turicatae, an agent of relapsing fever and neuroborreliosis, there was variation in the surface proteins the bacteria expressed and in disease manifestations over time. Two serotypes, A and B, were isolated from the mice, cloned by limiting dilution, and further characterized. The only discernible difference between the two variants was in the size of the major surface protein they expressed: serotype A had a variable major protein (Vmp) of 23,000, and serotype B had a Vmp of 20,000. When other scid mice were inoculated with clonal populations of A and B, the infections were similar with respect to onset and degree of spirochetemia, involvement of the eye and heart, and occurrence of a peripheral vestibular disorder. However, there were differences between the serotypes in other respects: (a) serotype B but not A caused reddened and significantly enlarged joints, markedly impaired performance on a walking bar, and severe arthritis by histologic examination; (b) serotype A but not B invaded the central nervous system during early infection; and (c) serotype A penetrated monolayers of human umbilical vein endothelial cells more readily than did serotype B. The combination of arthritis, myocarditis, and neurologic disease resembled human Lyme borreliosis. The findings indicate that differences in disease expression are determined by variable surface proteins of the bacterium and that scid mouse infections with B. turicatae provide a model for the study of the pathogenesis of Lyme borreliosis and other persistent spirochetal diseases.

Hepatic response to a very-low-energy diet and refeeding in rats

Hepatic effects of very-low-energy diets (VLEDs) and refeeding were studied in dietary obese rats. Rats weighing 490-530 g (ages 72-119 d) were randomly assigned to control (C) and VLED groups. Control animals consumed a complete diet ad libitum whereas VLED animals consumed 20% of the energy intake of C animals for 7, 14, or 21 d, and some VLED animals were refed the C diet for 7 d. Hepatic weights, lipid, DNA, and total protein decreased in VLED animals. Observed hepatocytic lipid was high in C and progressively decreased in VLED rats. Hepatocytes from VLED rats lost cytoplasmic organelles, contained myelin figures, and became smaller. Decreased protein-DNA ratios and lipids in these same animals is consistent with atrophy. Other biochemical findings included reductions in blood urea nitrogen, albumin, triglycerides, total protein, and glucose, all of which are synthesized or metabolized by the liver. These observations suggest that attenuation of hepatic function is likely.

Anti-Coxsackievirus B3 neutralizing antibodies with pathological potential

Adolescent CD-1 mice inoculated with coxsackievirus B3 (CVB3m) will develop acute myocarditis with focal lesions by 7 days post-inoculation (p.i.). Administration of murine sera containing anti-CVB3m-neutralizing antibodies into CVB3m-inoculated mice at 3 days p.i. will exacerbate myocarditis, suggesting the presence of pathological antibodies. To study potential pro-inflammatory properties of virus-induced antibodies, a panel of anti-CVB3m-neutralizing monoclonal antibodies (mAbs) was generated. Several studies demonstrated shared epitopes between CVB3m particles and cultured murine cardiac or neonatal skin fibroblasts: (1) one or more mAbs bound to cultured cardiac fibroblasts; (2) several mAbs can participate in complement-mediated lysis of neonatal skin fibroblasts; and (3) at least one mAbs stimulated synthesis of a macrophage chemoattractant from cultured neonatal skin fibroblasts. Injection of one mAb in three doses, each of about 5 micrograms, into adolescent male CD-1 mice induced focal myocarditic lesions which were similar to CVB3m-induced lesions. One mAb induced a diffuse interstitial hypercellularity in most mice and two mAbs did not induce detectable cardiopathology. These data suggest that some anti-CVB3m neutralizing idiotypes (antibodies) which initially can provide protection via virus clearance mechanisms can also bind to cross-reacting epitopes on normal tissues. Binding of antibodies to normal heart tissues could stimulate proinflammatory reactions by several mechanisms and sustain myocarditis.

Regulation of physicians' office laboratories. The Idaho experience

Timely availability of reliable test results enhances the office practitioner's ability to provide high-quality care that is personally satisfying to patients. Modern technology allows physicians to have such timely information available through test analyses performed in an office laboratory. Studies of physicians' office laboratories in Idaho found the performance, initially, to be unacceptably variable for many hematology, urinalysis, clinical chemistry, and microbiology tests. State regulation, requiring each office laboratory to comply with quality assurance guidelines and to participate in a proficiency testing program, resulted in a marked improvement in the proficiency level of office laboratory testing in Idaho. With the increasing dispersion of clinical laboratory technology, it is essential that standards of practice for the office laboratory be developed that ensure, within reasonable limits, the reliability of test information used in patient care. If widespread acceptance of such standards cannot be developed with a voluntary approach, states should consider regulation of office laboratories within their jurisdiction. Compliance with standards of practice, voluntarily or as a result of regulation, should promote quality performance in the office laboratory and allow the physician to use confidently the timely test information in dealing with diagnostic and management problems in patient care.