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1.  Enhanced morphological diagnosis in infective endocarditis by transoesophageal echocardiography. 
British Heart Journal  1990;63(2):109-113.
Thirty three consecutive patients with clinically suspected endocarditis were studied by both precordial cross sectional echocardiography and transoesophageal echocardiography. The diagnostic value of both techniques was assessed. The data were compared with findings at operation in 25 patients. In 21 patients with native valve endocarditis precordial echocardiography showed evidence of vegetations in six patients and suggested their presence in nine. Transoesophageal echocardiography identified vegetations in 18 patients. Complications were seen in four patients at precordial echocardiography and in nine patients at transoesophageal echocardiography. Precordial echocardiography did not show vegetations in any of the 12 patients with prosthetic valve endocarditis whereas transoesophageal echocardiography showed vegetations in four. Complications were seen in four patients at precordial echocardiography and in 10 at transoesophageal echocardiography. Echocardiographic findings were confirmed at operation in all 25 operated patients. In two patients both echocardiographic techniques had missed the perforation of the cusps of the aortic valve that was seen at operation, but this had no effect on patient management. Transoesophageal echocardiography is the best diagnostic approach when infective endocarditis is suspected in patients with either native or prosthetic valves.
PMCID: PMC1024336  PMID: 2317403
2.  Assessing Patient Attitudes to Computerized Screening in Primary Care: Psychometric Properties of the Computerized Lifestyle Assessment Scale 
Computer-based health-risk assessments are electronic surveys which can be completed by patients privately, for example during their waiting time in a clinic, generating a risk report for the clinician and a recommendation sheet for the patient at the point of care. Despite increasing popularity of such computer-based health-risk assessments, patient attitudes toward such tools are rarely evaluated by reliable and valid scales. The lack of psychometric appraisal of appropriate scales is an obstacle to advancing the field.
This study evaluated the psychometric properties of a 14-item Computerized Lifestyle Assessment Scale (CLAS).
Out of 212 female patients receiving the study information at a family practice clinic, 202 completed a paper questionnaire, for a response rate of 97.6%. After 2 weeks, 52 patients completed the scale a second time.
Principal component analysis revealed that CLAS is a multidimensional scale consisting of four subscales (factors): (1) Benefits: patient-perceived benefits toward the quality of medical consultation and means of achieving them, (2) Privacy-Barrier: concerns about information privacy, (3) Interaction-Barrier: concerns about potential interference in their interaction with the physician, and (4) Interest: patient interest in computer-assisted health assessments. Each subscale had good internal consistency reliability ranging from .50 (2-item scale) to .85 (6-item scale). The study also provided evidence of scale stability over time with intraclass correlation coefficients of .91, .82, .86, and .67 for the four subscales, respectively. Construct validity was supported by concurrent hypotheses testing.
The CLAS is a promising approach for evaluating patients’ attitudes toward computer-based health-risk assessments.
PMCID: PMC2483923  PMID: 18440918
Computers; scale; psychometric; screening; risk assessment; family practice
3.  ‘Honeycomb appearance’ on three-dimensional transthoracic echocardiography as the landmark of left ventricular non-compaction: two case reports 
Left ventricular non-compaction is a rare congenital heart disease, and is most commonly diagnosed via two-dimensional echocardiography according to echocardiographic criteria. Recently, transthoracic three-dimensional echocardiography has become available in the clinical setting.
Case presentation
We present two isolated cases of left ventricular non-compaction from Japan (in an 84-year-old woman and 47-year-old man) that were confirmed by two-dimensional echocardiography, contrast-enhanced two-dimensional echocardiography, three-dimensional echocardiography and cardiac magnetic resonance imaging. In both cases, three-dimensional echocardiography successfully demonstrated the trabecular meshwork of the left ventricle, referred to as a ‘honeycomb appearance’.
Three-dimensional echocardiography has the advantage of visualizing an en-face view of the trabecular meshwork, which is not possible with two-dimensional echocardiography. We further emphasize the clinical utility of three-dimensional echocardiography, which is not limited to just the observation of the trabeculations and inter-trabecular recesses, but can also visualize the trabecular meshwork with a ‘honeycomb appearance’.
PMCID: PMC3673848  PMID: 23718567
Left ventricular non-compaction; Magnetic resonance imaging; Three-dimensional echocardiography
4.  History of echocardiography in the Netherlands: 30 years of education and clinical applications 
Netherlands Heart Journal  2008;16(1):16-20.
The development of ultrasound has created great opportunities for diagnostic cardiac imaging. For more than 30 years, echocardiography has been the most important and cost-effective diagnostic imaging modality in clinical cardiology. Many developments originated in the Netherlands, including the very first practical real-time crosssectional imaging of the moving heart with a linear array. Milestones include the first portable echo apparatus, early versions of echo catheters and transoesophageal echocardiography probes as well as many clinical ‘firsts’ with reference to the more than 100 Dutch dissertations related to echocardiography. The future of echocardiography promises to be as productive and exciting as it has been in the previous three decades, including threedimensional echocardiography, myocardial perfusion echocardiography, tissue Doppler imaging and speckle tracking. New potential therapeutic applications are upcoming. In this article, the advances of echocardiography in the Netherlands are described, in the past and during 30 years of education, as was recently presented by three Dutch pioneers during the ‘Echomiddagen 2006-2007’ organised by the CVOI. (Neth Heart J 2008;16:16-20.18317539)
PMCID: PMC2246311  PMID: 18317539
history; cardiac ultrasound; echocardiography; Doppler; Buys Ballot
5.  A framework for assessing Health Economic Evaluation (HEE) quality appraisal instruments 
Health economic evaluations support the health care decision-making process by providing information on costs and consequences of health interventions. The quality of such studies is assessed by health economic evaluation (HEE) quality appraisal instruments. At present, there is no instrument for measuring and improving the quality of such HEE quality appraisal instruments. Therefore, the objectives of this study are to establish a framework for assessing the quality of HEE quality appraisal instruments to support and improve their quality, and to apply this framework to those HEE quality appraisal instruments which have been subject to more scrutiny than others, in order to test the framework and to demonstrate the shortcomings of existing HEE quality appraisal instruments.
To develop the quality assessment framework for HEE quality appraisal instruments, the experiences of using appraisal tools for clinical guidelines are used. Based on a deductive iterative process, clinical guideline appraisal instruments identified through literature search are reviewed, consolidated, and adapted to produce the final quality assessment framework for HEE quality appraisal instruments.
The final quality assessment framework for HEE quality appraisal instruments consists of 36 items organized within 7 dimensions, each of which captures a specific domain of quality. Applying the quality assessment framework to four existing HEE quality appraisal instruments, it is found that these four quality appraisal instruments are of variable quality.
The framework described in this study should be regarded as a starting point for appraising the quality of HEE quality appraisal instruments. This framework can be used by HEE quality appraisal instrument producers to support and improve the quality and acceptance of existing and future HEE quality appraisal instruments. By applying this framework, users of HEE quality appraisal instruments can become aware of methodological deficiencies inherent in existing HEE quality appraisal instruments. These shortcomings of existing HEE quality appraisal instruments are illustrated by the pilot test.
PMCID: PMC3507835  PMID: 22894708
6.  Role of Echocardiography in Atrial Fibrillation 
Atrial fibrillation (AF) is most common arrhythmia and its prevalence appears to be increasing as the population ages. Echocardiography can play a key role in risk stratification and management of patients with AF. Transthoracic echocardiography allows rapid and comprehensive assessment of cardiac anatomical structure and function. Pulmonary vein flow monitoring using echocardiography has the potential to an increasing role in the evaluation of cardiac function and AF ablation procedures. Transesophageal echocardiography also provides accurate information about the presence of a thrombus in the atria and thromboembolic risk. The novel technique of intracardiac echocardiography has emerged as a popular and useful tool in the everyday practice of interventional electrophysiology. Other imaging modalities, such as computed tomography and magnetic resonance imaging have complementary roles in risk stratification and assessment of patients with AF. Echocardiography continues to be the foundation of clinical evaluation and management of AF.
PMCID: PMC3150696  PMID: 21860717
Atrial fibrillation; Transthoracic echocardiography; Transesophageal echocardiography
7.  Critical appraisal in clinical practice: sometimes irrelevant, occasionally invalid 
A core activity of evidence-based practice is the search for and appraisal of evidence on specific clinical issues. Clinicians vary in their competence in this process; we therefore developed a 16-item checklist for quality of content (relevance and validity) and presentation (useability, attribution, currency and contact details). This was applied to a set of 55 consecutive appraisals conducted by clinicians and posted at a web-based medical journal club site.
Questions were well formulated in 51/55 (92%) of the appraisals. However, 22% of appraisals missed the most relevant articles to answer the clinical question. Validity of articles was well appraised, with methodological information and data accurately extracted in 84% and accurate conversion to clinically meaningful summary statistics in 87%. The appraisals were presented in a useable way with appropriate and clear bottom-lines stated in 95%.
The weakest link in production of good-quality critical appraisals was identification of relevant articles. This should be a focus for evidence-based medicine and critical appraisal skills.
PMCID: PMC1282242  PMID: 11691894
8.  Assessment of intracardiac masses by transesophageal echocardiography. 
Texas Heart Institute Journal  1995;22(2):134-137.
Transesophageal echocardiography and 2-dimensional transthoracic echocardiography have proved to be extremely valuable in the diagnosis of cardiac masses. In this report, we review the echocardiographic findings, clinical history, and histopathologic findings in 21 patients with intracardiac masses who underwent transthoracic echocardiography, transesophageal echocardiography, or both, at our institution. Of these patients, 14 had benign masses and 7 had malignant tumors. The potential role of transesophageal echocardiography in the diagnosis and treatment of patients with intracardiac masses is discussed. We believe that transesophageal echocardiography offers the cardiologist and cardiovascular surgeon the capability of more accurate preoperative and intraoperative assessment of cardiac masses.
PMCID: PMC325232  PMID: 7647596
9.  Motion of mitral apparatus in hypertrophic cardiomyopathy with obstruction. 
British Heart Journal  1976;38(7):732-737.
Motion of the mitral apparatus in hypertrophic cardiomyopathy with obstruction was investigated by conventional single dimensional and multidimensional echocardiography. In systole, anterosuperior displacement of the posterior papillary muscle, failure of mitral valve closure, and anterior motion of both mitral leaflets were shown. The anterior leaflet was seen to impinge on the posterior papillary muscle but not on the interventricular septum in systole. The abnormality of the single dimensional mitral echogram, previously ascribed to systolic anterior motion of the mitral anterior leaflet, was found to be a complex of echoes from the chordae tendineae, the papillary muscle, and, furthest from the septum, the mitral anterior leaflet. It is concluded that systolic anterior motion of the mitral anterior leaflet is of smaller amplitude than others have suggested, and that obstruction to left ventricular outflow in hypertrophic cardiomyopathy is produced by systolic contact between the mitral anterior cusp and the posterior papillary muscle. The theory is put forward that displacement of the posterior papillary muscle above and in front of the mitral leaflets produces chordal slackening, and that it is displacement of the chordae tendineae by the blood flowing to the aortic root during left ventricular ejection, which is responsible for systolic anterior motion of the mitral leaflets.
PMCID: PMC483077  PMID: 987790
10.  Knowledge gains from a computer-based health risk appraisal. 
During 1990, 83 patients seen for a general physical examination at a family practice clinic completed a computer-based health risk appraisal in one of two formats, batch or interactive. They also completed a written questionnaire on their health risks and knowledge before taking the appraisal, and 65 of them completed another health risk appraisal and questionnaire three months later. No difference in user evaluation of the appraisal regarding its helpfulness, their intent to change behavior based on the appraisal, or amount learned from the appraisal was found between batch and interactive formats. About half (48%) of the individuals correctly estimated their overall health risks before taking the health risk appraisal. Among those who initially misjudged their health risks, few women adjusted their health risk rating at followup. Men showed a tendency to adjust their rating to more closely agree with the health risk appraisal estimates although the differences are not statistically significant. Eighty percent of the men and 55% of the women accurately rated their overall risk at followup. Knowledge of specific causes of death did not improve at followup.
PMCID: PMC2247518  PMID: 1807581
11.  Current concepts in the management of hepatopulmonary syndrome 
Vascular Health and Risk Management  2008;4(5):1035-1041.
The hepatopulmonary syndrome is characterized as the triad of liver disease, pulmonary gas exchange abnormalities leading to arterial deoxygenation and evidence of intrapulmonary vascular dilatations. This review summarizes the pathological mechanisms leading to pulmonary vascular changes in hepatopulmonary syndrome. The role of the three currently used diagnostic imaging modalities of contrast-enhanced echocardiography, perfusion lung scanning and pulmonary arteriography that identify the presence of intrapulmonary vascular abnormalities are reviewed. Liver transplantation is considered to be the definitive treatment of hepatopulmonary syndrome with often successful reversal of hypoxemia, however other treatments have been trialed. This review further appraises the evidence for the use of pharmacological agents and the role of radiological interventions in hepatopulmonary syndrome.
PMCID: PMC2605324  PMID: 19183751
hepatopulmonary syndrome; liver cirrhosis; lung diseases
12.  Study of Body Image in Fertile and Infertile Men 
Body Image as a multidimensional entity is related to both physical and psychological aspects of the image one has of his or her own body. Lack/absence of an acceptable body image is one of the reasons of mental distress in infertile individuals.
In this study, an equal number (No=120) of fertile and infertile men attending Avicenna Infertility Clinic (AIC) were enrolled. The participants were compared in regard to body image variables based on the "Multidimensional Body-Self Relations Questionnaire (MBSRQ)" consisting of 10 subscales. Data was analyzed by SPSS, version 11.5, using Chi square and independent t-tests.
Fertile men had a more positive body image as compared to infertile individuals. Significant statistical differences were observed when body image subscales were compared in both groups; in other words appearance evaluation, appearance orientation, Novy, health evaluation, health orientation, illness orientation, body satisfaction, overweight preoccupation and self-classified weight showed differences, while no significant difference was observed in regard to fitness orientation.
It seems that the ability and efficiency of body image is affected by infertility leading to dissatisfaction of one's body image.
PMCID: PMC3719313  PMID: 23926517
Body image; Infertility; Multidimensional Body-Self Relations Questionnaire; Self perception
13.  Comparison of contrast enhanced three dimensional echocardiography with MIBI gated SPECT for the evaluation of left ventricular function 
In clinical practice and in clinical trials, echocardiography and scintigraphy are used the most for the evaluation of global left ejection fraction (LVEF) and left ventricular (LV) volumes. Actually, poor quality imaging and geometrical assumptions are the main limitations of LVEF measured by echocardiography. Contrast agents and 3D echocardiography are new methods that may alleviate these potential limitations.
Therefore we sought to examine the accuracy of contrast 3D echocardiography for the evaluation of LV volumes and LVEF relative to MIBI gated SPECT as an independent reference. In 43 patients addressed for chest pain, contrast 3D echocardiography (RT3DE) and MIBI gated SPECT were prospectively performed on the same day. The accuracy and the variability of LV volumes and LVEF measurements were evaluated.
Due to good endocardial delineation, LV volumes and LVEF measurements by contrast RT3DE were feasible in 99% of the patients. The mean LV end-diastolic volume (LVEDV) of the group by scintigraphy was 143 ± 65 mL and was underestimated by triplane contrast RT3DE (128 ± 60 mL; p < 0.001) and less by full-volume contrast RT3DE (132 ± 62 mL; p < 0.001). Limits of agreement with scintigraphy were similar for triplane andfull-volume, modalities with the best results for full-volume. Results were similar for calculation of LV end-systolic volume (LVESV). The mean LVEF was 44 ± 16% with scintigraphy and was not significantly different with both triplane contrast RT3DE (45 ± 15%) and full-volume contrast RT3DE (45 ± 15%). There was an excellent correlation between two different observers for LVEDV, LVESV and LVEF measurements and inter observer agreement was also good for both contrast RT3DE techniques.
Contrast RT3DE allows an accurate assessment of LVEF compared to the LVEF measured by SPECT, and shows low variability between observers. Although RT3DE triplane provides accurate evaluation of left ventricular function, RT3DE full-volume is superior to triplane modality in patients with suspected coronary artery disease.
PMCID: PMC2702292  PMID: 19531259
14.  Limitations of transoesophageal echocardiography in patients with focal cerebral ischaemic events. 
British Heart Journal  1992;67(4):297-303.
OBJECTIVE--To investigate the detection rate of cardiac sources of embolism by transoesophageal echocardiography in patients with focal cerebral ischaemic events and to relate the echocardiographic findings to other clinical findings. DESIGN--Prospective study with blinded analysis of the echocardiographic data and subsequent comparison with the other clinical findings. SETTING--Regional cardiothoracic unit based in a teaching hospital. PATIENTS--131 consecutive patients with focal ischaemic cerebral events (49 with a transient ischaemic attack, 77 with a cerebrovascular accident, and five with a retinal arterial embolus) referred for echocardiography. INTERVENTIONS--Full M mode, cross sectional, Doppler, and contrast echocardiography by both the precordial and transoesophageal techniques. RESULTS--Precordial echocardiography detected a cardiac abnormality in 72 patients. Transoesophageal echocardiography confirmed all the precordial findings (except left ventricular hypertrophy, which at present cannot be defined with this technique) and detected other abnormalities in a further 20 patients (18 with potential right-to-left shunts and two with valve vegetations). It also showed spontaneous contrast echoes in 27 of 28 patients with a large left atrium and showed atrial thrombus in three. Cardiac abnormalities were clinically detected in 53 patients, all of which were confirmed or documented by echocardiography. In the 78 patients with no clinically detectable cardiac abnormality six had mitral valve prolapse and one had a regional wall motion defect (identified by precordial echocardiography) and 17 had potential right-to-left shunts (11 of which were identified only by transoesophageal echocardiography). CONCLUSIONS--Transoesophageal echocardiography is more sensitive than precordial echocardiography in detecting potential sources of embolism in these patients. However, except for the detection of a potential right-to-left shunt, the yield in patients with no cardiac abnormality is low. Moreover, the abnormalities detected in those with previously detected cardiac disease merely confirm the clinical diagnosis. Patients with left atrial spontaneous contrast echoes may benefit from anticoagulation but this requires further study. Until more data are available on this feature and on the role of potential right-to-left shunts in this population, the contribution of echocardiography, precordial or transoesophageal, remains limited.
PMCID: PMC1024836  PMID: 1389703
15.  Comparison of echocardiography and radiology in the diagnosis of aortic root dilatation in Marfan's syndrome and in syphilis. 
Thorax  1980;35(6):467-471.
Aortic root dilatation was sought by echocardiography and radiology in 500 consecutive patients referred to an echocardiography laboratory from cardiac or medical clinics and wards. Forty-four of these patients (8.8%) had false echocardiographic evidence of aortic root dissection, but no clinical evidence of the disease. These false findings were attributed to the changing of the transducer angulation, post-stenotic dilatation, calcific aortic stenosis, generalised arteriosclerosis, and thin reverberations behind the posterior wall echo. In one patient with Marfan's syndrome, the chest radiograph was normal and a diagnosis was established by echocardiography. In another patient with syphilis, the dilatation was seen in the chest radiograph while echocardiography revealed a normal proximal aorta. In syphilis the dilatation begins distally and because of the intervening lung tissue echocardiography is unhelpful. Echocardiograms easily detect the aortic valve ring while radiographs show the more distal ascending aorta. These observations may be of added value in the diagnosis of aortic root disease.
PMCID: PMC471312  PMID: 7434304
16.  Clinical implications of the morphological features of central pulmonary artery thromboemboli shown by transoesophageal echocardiography. 
British Heart Journal  1994;72(1):58-62.
OBJECTIVES--To illustrate the use of transoesophageal echocardiography in the detection of the morphological features of central pulmonary artery thromboemboli and their clinical implications. DESIGN--Review of five cases of central pulmonary artery thromboemboli detected by transoesophageal echocardiography. SETTING--University teaching hospital. PATIENTS--Five patients (three men and two women) admitted under general medical units. RESULTS--Central pulmonary artery thromboemboli were detected by the use of transoesophageal echocardiography in all the patients presented. Presentations were acute, subacute, or chronic. The morphological features of the thromboemboli on transoesophageal echocardiography were used to correlate with the time course of the illness, and to guide treatment. Two patients received thrombolytic treatment, one patient was treated with anticoagulation alone, and two patients had inferior vena caval filters implanted. CONCLUSIONS--Transoesophageal echocardiography is an alternative diagnostic tool in the detection of central pulmonary artery thromboemboli. Morphological features of central pulmonary thromboemboli on echocardiography can provide useful information that may help to guide treatment.
PMCID: PMC1025426  PMID: 8068471
17.  Echocardiography or auscultation? How to evaluate systolic murmurs. 
Canadian Family Physician  2003;49:163-167.
OBJECTIVE: To compare cardiac physical examination with echocardiography for evaluating systolic murmurs. QUALITY OF EVIDENCE: Three databases were searched for studies comparing echocardiography and auscultation as to sensitivity and diagnostic accuracy: MEDLINE (Ovid Online), EMBASE, and Current Contexts. The quality of reported data is lowered by subjective interpretation of results of both cardiac physical examination and echocardiography, especially Doppler colour flow imaging. MAIN MESSAGE: In adults, functional systolic murmurs can usually be distinguished from organic murmurs. Pathologic murmurs frequently have one or more associated clinical abnormalities. If a clinician determines a murmur is benign, results of echocardiography are very likely to be normal, especially in young and middle-aged adults. According to current guidelines, echocardiography should not be ordered for "innocent" systolic murmurs in patients who are asymptomatic and have otherwise normal findings on examination. If patients with functional systolic murmurs could be identified and not routinely referred for echocardiography, great cost savings could be realized. CONCLUSION: Echocardiography is not required for all patients with systolic murmurs and should not replace cardiac physical examination.
PMCID: PMC2214179  PMID: 12619738
18.  Valvular heart disease and 3-dimensional echocardiography: ready for prime-time? 
Significant advances in 3-dimensional echocardiography (3DE) technology have ushered its use into clinical practice. The recent advent of real-time 3DE using matrix array transthoracic and transesophageal transducers has resulted in improved image spatial resolution, and therefore, enhanced visualization of the patho-morphological features of the cardiac valves. Three-dimensional echocardiography provides unique perspectives of valvular structures by presenting “en face” views of valvular structures, allowing for a better understanding of the topographical aspects of pathology, and a refined definition of the spatial relationships of intracardiac structures. Three-dimensional echocardiography makes available indices not described by 2D echocardiography and has been demonstrated to be superior to 2D echocardiography in a variety of valvular disease scenarios. In this review, we discuss the incremental role of 3DE in evaluating valvular anatomic features, volumetric quantification, pre-surgical planning, intra-procedural guidance, and post-procedural assessment of valvular heart disease.
PMCID: PMC3499936  PMID: 23173101
Aortic valve; mitral valve; three-dimensional echocardiography; valvular heart disease
19.  How long has NICE taken to produce Technology Appraisal guidance? A retrospective study to estimate predictors of time to guidance 
BMJ Open  2013;3(1):e001870.
To assess how long the UK's National Institute for Health and Clinical Excellence's (NICE) Technology Appraisal Programme has taken to produce guidance and to determine independent predictors of time to guidance.
Retrospective time to event (survival) analysis.
Technology Appraisal guidance produced by NICE.
All appraisals referred to NICE by February 2010 were included, except those referred prior to 2001 and a number that were suspended.
Outcome measure
Duration from the start of an appraisal (when the scope document was released) until publication of guidance.
Single Technology Appraisals (STAs) were published significantly faster than Multiple Technology Appraisals (MTAs) with median durations of 48.0 (IQR; 44.3–75.4) and 74.0 (IQR; 60.9–114.0) weeks, respectively (p <0.0001). Median time to publication exceeded published process timelines, even after adjusting for appeals. Results from the modelling suggest that STAs published guidance significantly faster than MTAs after adjusting for other covariates (by 36.2 weeks (95% CI −46.05 to −26.42 weeks)) and that appeals against provisional guidance significantly increased the time to publication (by 42.83 weeks (95% CI 35.50 to 50.17 weeks)). There was no evidence that STAs of cancer-related technologies took longer to complete compared with STAs of other technologies after adjusting for potentially confounding variables and only weak evidence suggesting that the time to produce guidance is increasing each year (by 1.40 weeks (95% CI −0.35 to 2.94 weeks)).
The results from this study suggest that the STA process has resulted in significantly faster guidance compared with the MTA process irrespective of the topic, but that these gains are lost if appeals are made against provisional guidance. While NICE processes continue to evolve over time, a trade-off might be that decisions take longer but at present there is no evidence of a significant increase in duration.
PMCID: PMC3549260  PMID: 23315516
Health Economics; Public Health; Statistics & Research Methods
20.  An investigation of trauma-associated appraisals and posttraumatic stress disorder in British and Asian trauma survivors: the development of the Public and Communal Self Appraisals Measure (PCSAM) 
SpringerPlus  2014;3:44.
Two studies examined the role of culture on cognitive appraisals of trauma and associated implications for posttraumatic psychological adjustment. Study 2 also investigated the reliability and validity of a new measure assessing public and communal aspects of trauma-associated appraisals (Public and Communal Self Appraisals Measure; PCSAM). Study 1′s non-clinical sample (N = 75) and Study 2′s sample of British and Asian trauma survivors with and without PTSD (N = 95) provided an everyday and trauma memory, completed an Appraisal Inventory, the Posttraumatic Cognitions Inventory and measures of PTSD. Study 2 participants also completed the PCSAM. Conjoined, there were cultural differences in appraisals of everyday and trauma experiences. Nonetheless, there appeared to be cultural similarities in the dysfunctional appraisals of those with PTSD. The PSCAM had good internal consistency, test-retest reliability, convergent validity, and discriminative validity. Findings are discussed in terms of combining cultural models of self with current PTSD models.
PMCID: PMC3913797  PMID: 24516784
Appraisals; PTSD; Culture; Posttraumatic Cognition; PTCI; Trauma
21.  Understanding how appraisal of doctors produces its effects: a realist review protocol 
BMJ Open  2014;4(6):e005466.
UK doctors are now required to participate in revalidation to maintain their licence to practise. Appraisal is a fundamental component of revalidation. However, objective evidence of appraisal changing doctors’ behaviour and directly resulting in improved patient care is limited. In particular, it is not clear how the process of appraisal is supposed to change doctors’ behaviour and improve clinical performance. The aim of this research is to understand how and why appraisal of doctors is supposed to produce its effect.
Methods and analysis
Realist review is a theory-driven interpretive approach to evidence synthesis. It applies realist logic of inquiry to produce an explanatory analysis of an intervention that is, what works, for whom, in what circumstances, in what respects. Using a realist review approach, an initial programme theory of appraisal will be developed by consulting with key stakeholders in doctors’ appraisal in expert panels (ethical approval is not required), and by searching the literature to identify relevant existing theories. The search strategy will have a number of phases including a combination of: (1) electronic database searching, for example, EMBASE, MEDLINE, the Cochrane Library, ASSIA, (2) ‘cited by’ articles search, (3) citation searching, (4) contacting authors and (5) grey literature searching. The search for evidence will be iteratively extended and refocused as the review progresses. Studies will be included based on their ability to provide data that enable testing of the programme theory. Data extraction will be conducted, for example, by note taking and annotation at different review stages as is consistent with the realist approach. The evidence will be synthesised using realist logic to interrogate the final programme theory of the impact of appraisal on doctors’ performance. The synthesis results will be written up according to RAMESES guidelines and disseminated through peer-reviewed publication and presentations.
Trial registration number
The protocol is registered with PROSPERO 2014:CRD42014007092.
PMCID: PMC4067866  PMID: 24958211
22.  Race and Gender Matter: A Multidimensional Approach to Conceptualizing and Measuring Stress in African American Women 
Based on prior research and theory, the authors constructed a multidimensional model of stress in African American women comprised of race-related, gender-related, and generic stress. Exposure to and appraisal of these three types of stress were combined into a higher-order global stress factor. Using structural equation modeling, the fit of this stress factor and its ability to predict distress symptoms were examined in 189 socioeconomically diverse African American women aged 21 to 78. Results support the multidimensional conceptualization and operationalization of stress. Race-related, gender-related, and generic stress contributed equally to the global stress factor, and global stress predicted a significant amount of variance in distress symptoms and intensity. This model exhibited better fit than a model without a global stress factor, in which each stress component predicted distress directly. Furthermore, race-related, gender-related, and generic stress did not contribute to distress beyond their representation in the global stress factor. These findings illustrate that stress related to central elements of identity, namely race and gender, cohere with generic stress to define the stress experience of African American women.
PMCID: PMC2553624  PMID: 18624581
stress; women; African American; gender; racism
23.  Radiographic disk height increase after a trial of multimodal spine rehabilitation and vibration traction: a retrospective case series 
Journal of Chiropractic Medicine  2008;7(4):140-145.
Although spinal decompression therapy has been touted as an effective treatment of disk pathologies, there is little existing research that specifically uses disk parameters as an outcome measure after a course of spinal decompression therapy. Our study presents multidimensional outcomes after a structured protocol of multimodal chiropractic rehabilitation and uses a radiographic parameter of disk disease as an indication of the effects of a vibration traction decompression-type table.
Clinical Features
Patients selected for this retrospective cohort reported a medical history of lumbar herniated or bulging disk verified by previous magnetic resonance imaging/computed tomography, history of paresthesia in one or both lower extremities, pain level reported as a minimum of 8/10, and/or history of sciatica or other radicular pain finding.
Intervention and Outcome
A total of 6 patients' outcomes are reported in this study. All patients received a multimodal spinal rehabilitation treatment with vibration traction therapy. Positive and statistically significant outcomes were obtained in radiographic disk height, functional rating index, numeric pain rating, spirometry, and patient height. All patients achieved improved outcomes after treatment.
The multidimensional outcomes reported here were achieved after a structured protocol of multimodal chiropractic rehabilitation. It is unknown which, if any, of these procedures were responsible for the observed improvements.
PMCID: PMC2697595  PMID: 19646376
Chiropractic; Decompression; Intervertebral disk; Rehabilitation; Low back
24.  Nanotechnology 
Executive Summary
Due to continuing advances in the development of structures, devices, and systems with a length of about 1 to 100 nanometres (nm) (1 nm is one billionth of a metre), the Medical Advisory Secretariat conducted a horizon scanning appraisal of nanotechnologies as new and emerging technologies, including an assessment of the possibly disruptive impact of future nanotechnologies.
The National Cancer Institute (NCI) in the United States proclaimed a 2015 challenge goal of eliminating suffering and death from cancer. To help meet this goal, the NCI is engaged in a concerted effort to introduce nanotechnology “to radically change the way we diagnose, treat and prevent cancer.” It is the NCI’s position that “melding nanotechnology and cancer research and development efforts will have a profound, disruptive effect on how we diagnose, treat, and prevent cancer.”
Thus, this appraisal sought to determine the systemic effects of nanotechnologies that target, image and deliver drugs, for example, with respect to health human resources, training, and new specialties; and to assess the current status of these nanotechnologies and their projected timeline to clinical utilization.
Clinical Need: Target Population and Condition
Cancer is a heterogeneous set of many malignant diseases. In each sex, 3 sites account for over one-half of all cancers. In women, these are the breast (28%), colorectum (13%) and lungs (12%). In men, these are the prostate (28%), lungs (15%), and the colorectum (13%).
It is estimated that 246,000 people in Ontario (2% of the population) have been diagnosed with cancer within the past 10 years and are still alive. Most were diagnosed with cancer of the breast (21%), prostate (20%), or colon or rectum (13%).
The number of new cancer cases diagnosed each year in Ontario is expected to increase from about 53,000 in 2001 to 80,000 in 2015. This represents more than a 50% increase in new cases over this period. An aging population, population growth, and rising cancer risk are thought to be the main factors that will contribute to the projected increase in the number of new cases.
The Technology Being Reviewed - Medical Advisory Secretariat Definition of Nanotechnology
First-Generation Nanotechnologies
Early application of nanotechnology-enabled products involved drug reformulation to deliver some otherwise toxic drugs (e.g., antifungal and anticancer agents) in a safer and more effective manner.
Examples of first-generation nanodevices include the following:
albumin bound nanoparticles;
gadolinium chelate for magnetic resonance imaging (MRI);
iron oxide particles for MRI;
silver nanoparticles (antibacterial wound dressing); and
nanoparticulate dental restoratives.
First-generation nanodevices have been in use for several years; therefore, they are not the focus of this report.
Second-Generation Nanotechnologies
Second-generation nanotechnologies are more sophisticated than first- generation nanotechnologies, due to novel molecular engineering that enables the devices to target, image, deliver a therapeutic agent, and monitor therapeutic efficacy in real time. Details and examples of second-generation nanodevices are discussed in the following sections of this report.
Review Strategy
The questions asked were as follows:
What is the status of these multifunctional nanotechnologies? That is, what is the projected timeline to clinical utilization?
What are the systemic effects of multifunctional nanodevices with integrated applications that target, image, and deliver drugs? That is, what are the implications of the emergence of nanotechnology on health human resources training, new specialties, etc.?
The Medical Advisory Secretariat used its usual search techniques to conduct the literature review by searching relevant databases. Outcomes of interest were improved imaging, improved sensitivity or specificity, improved response rates to therapeutic agents, and decreased toxicity.
The search yielded 1 health technology assessment on nanotechnology by The Centre for Technology Assessment TA-Swiss and, in the grey literature, a technology review by RAND. These, in addition to data from the National Cancer Institute (United States) formed the basis for the conclusions of the review.
With respect to the question as to how soon until nanotechnology is used in patient care, overall, the use of second-generation nanodevices, (e.g., quantum dots [QDs]), nanoshells, dendrimers) that can potentially target, image, and deliver drugs; and image cell response to therapy in real time are still in the preclinical benchwork stage.
Table 1 summarizes the projected timelines to clinical utilization.
Summary of Timelines to Clinical Use*
NCI refers to National Cancer Institute; QD, quantum dot.
Medical Advisory Secretariat Estimated Timeline for Ontario
Upon synthesizing the estimated timelines from the NCI, the Swiss technology assessment and the RAND reports (Figure 1), it appears that:
the clinical use of separate imaging and therapeutic nanodevices is estimated to start occurring around 2010;
the clinical use of combined imaging and therapeutic nanodevices is estimated to start occurring around 2020;
changes in the way disease is diagnosed, treated and monitored are anticipated; and
the full (and realistic) extent of these changes within the next 10 to 20 years is uncertain.
Medical Advisory Secretariat Estimated Timeline for the Clinical Use of Second-Generation Nanodevices in Ontario
With respect to the question on potential systemic effects of second-generation nanodevices (i.e., the implications of the emergence of these nanodevices on health human resources training, new specialties etc.), Table 2 summarizes the findings from the review.
Potential Systemic Effects Caused by Second Generation Nanodevices*
MRI indicates magnetic resonance imaging; PSA, prostate-specific antigen; QD, quantum dot.
Uncertainties Not Addressed in the Literature
The United States National Nanotechnology Initiative (NNI) funds a variety of research in the economic, ethical, legal, and cultural implications of the use of nanotechnology, as well as the implications for science, education and quality of life.
There are many uncertainties that are sparsely or not addressed at all in the literature regarding second generation nanodevices. These include the following:
long-term stability and toxicology of nanodevices;
cost-effectiveness of nanodevices;
refinement of specific targeting;
effects on hospitals, physician/nurse training, creation/removal of specialties; and
that pertaining to the question, where does disease begin if therapy is applied before the symptoms have appeared?
PMCID: PMC3379172  PMID: 23074489
25.  Assessment of myocardial perfusion and contractile function by inotropic stress Tc-99m sestamibi SPECT imaging and echocardiography for optimal detection of multivessel coronary artery disease 
Heart  1998;79(3):274-280.
Objective—To assess whether inotropic stress myocardial perfusion imaging, echocardiography, or a combination of the two could enhance the detection of multivessel disease, over and above clinical and exercise electrocardiographic data.
Design—100 consecutive patients investigated by exercise electrocardiography and diagnostic coronary arteriography underwent simultaneous inotropic stress Tc-99m sestamibi SPECT (MIBI) imaging and echocardiography. MIBI imaging and echocardiographic data were analysed using a 12 segment left ventricular model, and each segment was ascribed to a particular coronary artery territory. The presence of perfusion defects with MIBI imaging or of wall thickening abnormality with echocardiography in at least two coronary artery territories at peak stress was taken as diagnostic of multivessel disease. Arteriographic evidence of ⩾ 50% stenosis was considered significant.
Results—56 patients had multivessel disease. The sensitivity of the combination of MIBI imaging and echocardiography for detecting this was greater than either MIBI imaging or echocardiography alone (82%, 68%, and 68%, respectively; p = 0.005). Clinical and exercise electrocardiographic variables gave an R2 value of 18.2% for predicting multivessel disease. The addition of either MIBI imaging (R2 = 29.2%; p = 0.002) or echocardiography (R2 = 28.8%; p < 0.001) enhanced the detection of multivessel disease, and the inclusion of both had further incremental value (R2 = 34.8%; p = 0.003). Age (p = 0.03), MIBI imaging (p = 0.007), and echocardiography (p = 0.001) were independent predictors of multivessel disease.
Conclusions—The assessment of both myocardial perfusion and contractile function by simultaneous inotropic stress MIBI imaging and echocardiography optimises the non-invasive detection of multivessel disease.

 Keywords: multivessel disease;  inotropic stress;  SPECT imaging;  echocardiography
PMCID: PMC1728627  PMID: 9602662

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