Dobutamine stress echocardiography for the detection of significant coronary artery disease in renal transplant candidates. Coronary angiography is the best predictor of events in renal transplant candidates compared with noninvasive testing. Usefulness of dobutamine stress echocardiography in detecting coronary artery disease in end-stage renal disease. Preoperative dobutamine stress echocardiography versus cardiac arteriography for risk assessment prior to renal transplantation. Ischaemia imaging in type 2 diabetic kidney transplant candidates--is coronary angiography essential? A preoperative echocardiographic predictive model for assessment of cardiovascular outcome after renal transplantation. Utility of carotid intimal medial thickness as a screening tool for evaluation of coronary artery disease in pre-transplant end stage renal disease. Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure. Stress echocardiography: abnormal response of tissue Doppler-derived indices to dobutamine in the absence of obstructive coronary artery disease in patients with chronic renal failure. The diagnostic and prognostic value of tissue Doppler imaging during dobutamine stress echocardiography in end-stage renal disease. Coronary artery calcification measured with electron-beam computerized tomography correlates poorly with coronary artery angiography in dialysis patients. Evaluation using dobutamine stress echocardiography in patients with insulin-dependent diabetes mellitus before kidney and/or pancreas transplantation. Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Usefulness of tachycardic-stress perfusion imaging to predict coronary artery disease in high-risk patients with chronic renal failure. Thoracic epidural anesthesia for cardiac surgery: a randomized trial. Prevention of bone loss in cardiac transplant recipients. A comparison of biphosphonates and vitamin D. Effects of different steroid treatment on reperfusion-associated production of reactive oxygen species and arrhythmias during coronary surgery. Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease. Neurocognitive function and progression in patients with brain metastases treated with whole-brain radiation and motexafin gadolinium: results of a randomized phase III trial.
Prophylactic coronary revascularization may reduce the risk for cardiac events in diabetic renal transplant candidates. No published data exist on the accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of angiographically defined coronary artery disease (CAD) in renal transplant candidates. The purpose of this study is to examine the accuracy of DSE for the detection of CAD in high-risk renal transplant candidates compared with coronary angiography. Fifty renal transplant candidates with diabetic nephropathy (39 patients) or end-stage renal disease (ESRD) from other causes (11 patients) underwent prospectively performed DSE, followed by quantitative coronary angiography (QCA) and qualitative visual assessment of CAD severity. Twenty of 50 DSE tests were positive for inducible ischemia. Twenty-seven patients (54%) had a stenosis of 50% or greater by QCA, 12 patients (24%) had a stenosis of greater than 70% by QCA, and 16 patients (32%) had a stenosis greater than 75% by visual estimation. The sensitivity and specificity of DSE for CAD diagnosis were respectively 52% and 74% compared with QCA stenosis of 50% or greater, 75% and 71% compared with QCA stenosis greater than 70%, and 75% and 76% for stenosis greater than 75% by visual estimate. On long-term follow-up (22.5 +/- 10.1 months), 6 of 30 patients (20%) with negative DSE results and 11 of 20 patients (55%) with positive DSE results had a cardiac death, myocardial infarction (MI), or coronary revascularization. Six of 27 patients (22%) with a QCA stenosis of 50% or greater had a cardiac death or MI compared with none of the 23 patients (0%) with QCA stenosis less than 50% (P = 0.025). We conclude that DSE is a useful but imperfect screening test for angiographically defined CAD in renal transplant candidates. Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (>or=70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (>or=50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were <75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (P=0.007) and CA (P=0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with <70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with >or=70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (P=0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised. The cardiovascular evaluation of patients with end-stage renal disease (ESRD) has been hampered by the suboptimal sensitivity and specificity of currently employed diagnostic tests. Dobutamine stress echocardiography (DSE) is a recently developed technique which is accurate for the diagnosis of coronary artery disease (CAD) in general populations. The purpose of this study was to assess its diagnostic accuracy and prognostic implications in patients with ESRD. Patients with ESRD (n = 97) underwent DSE as part of a preoperative evaluation before being listed for renal transplantation. Patients were followed for 12 +/- 6 months (range 1 to 24) after the study. Rest and dobutamine stress echocardiograms were analyzed for regional and global function. Coronary angiography was performed in 30 patients, and 25 underwent renal transplantation in the follow-up period. DSE had a sensitivity of 95% (92% for 1-vessel, 100% for > or = 2-vessel disease), specificity of 86%, and accuracy of 90% for the detection of CAD. During the follow-up period, 6 patients died; DSE revealed inducible ischemia in 4, and catheterization before death revealed multivessel CAD in 2. Conversely, a normal DSE identified a very low risk population, with a 97% probability of being free of cardiac complications or death during the follow-up period. We conclude that DSE accurately identifies CAD in patients with ESRD and identifies a cohort of patients at low risk for cardiac complications. Because coronary artery disease is the leading cause of death in patients with end-stage renal disease, we prospectively studied the prognostic value of dobutamine stress echocardiography (DSE) compared to coronary angiography (CA) as an evaluative tool. Thirty-three patients at high risk for coronary artery disease were selected from a cohort of 133 renal transplant candidates and underwent both DSE and CA. In this study, the value of DSE was found to exist in its strong negative predictive value (92%). A negative DSE coupled with a negative clinical cardiac evaluation was found to practicably exclude the necessity for CA. DSE can thus serve as a non-invasive, low cost screening test. Coronary artery disease (CAD) remains the leading cause of death in type 2 diabetes mellitus (DM) patients undergoing renal transplantation. There is a high prevalence of silent CAD in these patients. Controversy exists regarding the role of dobutamine stress echocardiography (DSE) in detection of CAD. Our purpose was to compare DSE with coronary angiography (CA) for the detection of CAD in type 2 diabetic patients undergoing evaluation for renal transplantation.
                Forty (36 male, four female) type 2 diabetic patients with end-stage renal disease (ESRD) were subjected to DSE followed by CA as a part of their pre-renal transplant evaluation. The ability of DSE to predict 70% stenosis in one or more coronary arteries as determined by CA was evaluated. Mean age of the patients was 49.2 +/- 5 years (range 39-60 years).
                DSE was positive in 10 (25%) patients, while 19 patients (48%) had a more than 70% lesion in at least one epicardial vessel on CA (six patients had single vessel, three had double vessel and 10 had triple vessel disease). The sensitivity and specificity in identifying CAD was 47.3 and 95.2%, respectively, while positive predictive value and negative predictive value was 90% and 66%. Accuracy of DSE was 72.5%. All four patients with diffuse diabetic coronary artery disease had negative DSE.
                DSE is a poor predictor of coronary artery disease in type 2 DM patients being evaluated for renal transplantation. CA should be included in evaluation of type 2 diabetic patients who are renal transplant candidates. Major adverse cardiac events (MACE) frequently determine the outcome of renal transplantation (RT). Stress testing is advocated for preoperative risk assessment, but limited information is available on the prognostic value of these tests. We aimed to retrospectively assess the value of preoperative dobutamine stress echocardiography (DSE) in predicting MACE in patients undergoing RT.
                A total of 185 patients (age 56 +/- 11 years, 64% were men, creatinine level of 7.3 +/- 2.9 mg/d, 27% were smokers, 86% had hypertension, 54% had diabetes, 57% were dyslipidemic) with end-stage renal disease (ESRD) underwent DSE before RT. A standard DSE protocol was used with the administration of 5-50 mug/kg/min incremental doses in 3-minute intervals and up to 1 mg of atropine if needed to reach prespecified end points.
                Regional left ventricular wall motion abnormality (WMA) at rest (fixed), with stress (inducible), or both were present in 54, 35, and 18 patients, respectively. In 38 patients who underwent coronary angiography, the sensitivity, specificity, and positive and negative predictive values of inducible WMA for predicting angiographic coronary artery disease (> or = 70% luminal diameter reduction) were 88%, 62%, 65%, and 87%, respectively. Cox regression analysis identified the presence of combined fixed and inducible WMA (ie, resting WMA that did not change during DSE, accompanied by new WMA evident during DSE; hazard ratio [HR] 5.6, P = .012), left atrial enlargement (HR 4.2, P = .002), and aortic valve sclerosis (HR 3.9, P = .013) as independent predictors of 48-month MACE (cardiac death, nonfatal acute myocardial infarction, and coronary revascularization after RT). Patients with all 3 predictors had a 48-month MACE of 60% compared with 5% in those with none (P = .007). Compared with those without WMA, patients with both fixed and inducible WMA had a higher rate of MACE at 48 months (7% vs 33%, P = .004).
                In RT candidates, DSE can effectively identify those at low and high risk of MACE.
                2010 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved. Coronary artery disease (CAD) is associated with a higher incidence of allograft failure and mortality in patients with end-stage renal disease (ESRD) following renal transplant.
                To evaluate the efficacy of using carotid intimal medial thickness (CIMT) to predict the presence of CAD in patients with ESRD, using coronary angiography (CAG) as the gold standard.
                This prospective study enrolled consecutive patients with ESRD who underwent CAG as a part of pretransplant evaluation to rule out the presence of atherosclerotic CAD. An operator who was blinded with respect to the results of the CAG, measured carotid IMT in all patients prior to CAG and recorded it on videotape. Two independent observers blinded to the results of CAG measured carotid IMT offline to validate its predictive accuracy as a noninvasive test in predicting the presence or absence of CAD. Measurement of carotid IMT was done on USG B mode 7.5 MHZ probe [HP 5500 andover, Massachusetts]. Student's t-test was used for inter-group comparisons. Pearson correlation coefficient test was used to assess the relation between CAD and various risk factors and carotid IMT. Linear regression analysis was applied to identify independent factors determining presence of CAD. A P value < 0.05 was considered statistically significant.
                Mean CIMT was significantly higher in those with CAD as compared to those without [0.80+/- 0.06 vs.0.70+/-0.06 mm, P< 0.0001). Patients with CIMT> 0.75 mm were older and had more incidence of diabetes(78% vs. 47%; P=0.001). Only 4/53 (7%) of patients with CIMT< 0.75 mm had CAD, vs. 38/52 (73%) in those with CIMT >0.75 mm. The sensitivity and specificity of using CIMT > 0.75 as a predictor of CAD was 90.47%and 73% and its positive and negative predictive values were 0.73 and 0.92. On multivariate analysis, only CIMT was a significant predictor of CAD.
                Carotid IMT can be used to predict CAD in patients with ESRD. In the absence of other risk factors,patients with IMT< 0.75 mm may not need a pretransplant CAG. The efficacy of dipyridamole single photon emission computed tomography (SPECT) thallium as a screening test for coronary artery disease (CAD), was studied in 45 patients with end-stage renal failure undergoing evaluation for renal transplantation. Coronary arteriography, dipyridamole SPECT thallium imaging and clinical follow-up were performed in all patients. Nineteen patients (42%) had an obstruction of 50% or more in at least one coronary artery. Fourteen patients had a positive thallium scan, but 7 of these were false-positives (sensitivity 37%, specificity 73%). The sensitivity was considerably lower than that quoted for non-ESRF patients in the literature, and significantly lower than a control group of 19 patients without ESRF having comparable severity and distribution of CAD. Five of the 6 patients who died of cardiac causes over a mean follow-up period of 25 months had normal thallium imaging, but all had significant coronary artery disease at cardiac catheterization. Dipyridamole SPECT thallium imaging has not proved a useful screening test for angiographically significant CAD, and does not predict cardiac prognosis in this population. Abnormal tissue Doppler (TD)-derived indices during dobutamine stress echocardiography (DSE) can predict the presence of coronary artery disease (CAD) in patients with normal renal function. These indices include a reduction in annular systolic velocity (S'), a decrease in early diastolic annular velocity (E'), and prolongation of the time to E'. However, the ability of these indices to detect or exclude CAD in patients with chronic renal failure (CRF) is unclear.
                To examine the ability of TD-derived indices to detect or exclude the presence of CAD in patients with CRF.
                We evaluated a total of 30 patients (13 males, mean age 57 +/- 15 years) using both DSE and coronary angiography. This cohort consisted of 12 control patients with normal renal function (mean creatinine 0.5 mg/dL) and 18 patient with CRF (mean creatinine 2.5 mg/dL). At each stage of the DSE, left ventricular (LV) diastolic function was assessed using conventional (peak early (E) and late (A) transmitral, E/A ratio, E-wave deceleration time (DT), and isovolumic relaxation time (IVRT)) and TD-derived indices (lateral annular systolic (S'), early diastolic (E'), and late atrial velocities (A'), time to E' and E/E').
                All 30 patients had a normal DSE based on systolic regional function and a normal coronary angiogram. There was no difference in E, A, E/A, DT or IVRT between the two groups at each stage. Despite normal coronaries, patients with CRF demonstrated lower S' and E' velocities at peak stress compared to the control patients (8.0 +/- 2.2 cm/sec vs 15.1 +/- 2.6, P < 0.05 and 6.7 +/- 1.6 cm/sec vs 13.3 +/- 3.1, P < 0.05, respectively). During DSE, the time to E' at peak stress in CRF patients was also prolonged compared to control (400 +/- 44 ms vs 329 +/- 51, P < 0.05). Patients with CRF also had increased filling pressures (as estimated by E/E') as compared to controls at peak stress (14.7 +/- 5.2 vs 7.4 +/- 1.5, P < 0.05, respectively).
                In patients with CRF, a reduction in TD derived indices does not predict the presence of obstructive CAD. To determine whether a quantitative measurement of peak systolic velocity (PSV) during dobutamine stress echocardiography (DSE) detects severe coronary artery disease (CAD) and predicts mortality in patients with end-stage renal disease.
                One hundred and forty renal transplant candidates had DSE and coronary angiography. DSE analysis was performed using conventional visual wall motion assessment, longitudinal PSV, and combining the two modalities. Failure of PSV to rise by more than 50% predicted an ischemic response. Significant CAD was defined as luminal stenosis greater than 70%.
                The number of positive DSE studies according to conventional, PSV, and combined criteria was 41 (30%), 42 (31%), and 46 (34%) respectively. Forty patients (29%) had significant CAD at angiography. The sensitivity, specificity, positive and negative predictive values for conventional DSE analysis were 84, 91, 86, and 90% respectively. The same values for PSV analysis were 86, 92, 86, and 91%, respectively. The same values for the combination of visual and PSV analysis were 88, 94, 87, and 92% respectively. The differences between the three methods were not statistically significant. Sensitivity for single-vessel CAD (P=0.05) and circumflex artery disease (P=0.05) diagnosis was higher with PSV compared with conventional DSE analysis. Failure of PSV to rise by more than 50% during DSE was associated with significantly increased mortality (P=0.001).
                A quantitative interpretation of DSE, based on the percentage rise of PSV during stress, accurately detects CAD and predicts prognosis in end-stage renal disease. Coronary artery calcification measured by electron-beam computerized tomography (EBCT) correlates with plaque burden and vessel stenosis and is predictive of future cardiac events in the general population. Uremic vascular calcification is common and widespread, tends to be medial as well as intimal, and may not relate solely to atherosclerotic lesions. Despite this difference and in the absence of any direct evidence in uremic patients, it is generally implied that coronary artery calcification equates to occlusive atherosclerosis.
                We set out to compare the predictive value of coronary artery calcification assessed by EBCT with contemporaneous coronary angiography. We studied 18 patients with end-stage renal disease undergoing maintenance dialysis. Seventy-two coronary vessels were analyzed for angiographic evidence of stenotic disease and correlated with individual vessel calcification score.
                There was no significant correlation between degree of vessel stenosis and calcification score for individual vessels in patients with a positive calcium scan. Specificity was 48% and the positive predictive value was 53%. However, a calcification score <20 strongly correlated with the absence of significant luminal narrowing, and a 0 calcification score had a negative predictive value of 87.5%.
                Coronary artery calcification measured by EBCT is not an accurate marker of the degree of vessel stenosis in coronary artery disease in uremic patients and should not be used as a single screening test for atherosclerotic coronary disease. The purpose of this study was to examine the ability of dobutamine stress echocardiography to stratify patients with juvenile onset, insulin-dependent diabetes mellitus who are being considered for kidney and/or pancreas transplantation, into high-or low-risk groups for future cardiac events. Fifty-three such patients underwent dobutamine stress echocardiography before kidney and/or pancreas transplantation. Cardiac events, including cardiac death, nonfatal myocardial infarction, unstable angina, pulmonary edema, and need for coronary revascularization, occurring between the time of the dobutamine stress echocardiogram and the last patient follow-up contact were retrospectively identified. Twenty patients 938%) had an abnormal dobutamine stress echocardiogram. Eleven patients had 15 cardiac events over a mean (+/- SD) follow-up period of 418 +/- 269 days. Event rates were 45% among those with an abnormal, versus 6% among those with a normal dobutamine stress echocardiogram (p = 0.002). The result of the dobutamine stress test independently predicted prognosis in a multivariate analysis (p = 0.003, odds ratio = 12.7). We conclude that dobutamine stress echocardiography accurately stratifies patients with juvenile onset, insulin-dependent diabetes being considered for kidney and/or pancreas transplantation for risk of future cardiac events. Mental practice (MP) of a particular motor skill has repeatedly been shown to activate the same musculature and neural areas as physical practice of the skill. Pilot study results suggest that a rehabilitation program incorporating MP of valued motor skills in chronic stroke patients provides sufficient repetitive practice to increase affected arm use and function. This Phase 2 study compared efficacy of a rehabilitation program incorporating MP of specific arm movements to a placebo condition using randomized controlled methods and an appropriate sample size. Method- Thirty-two chronic stroke patients (mean=3.6 years) with moderate motor deficits received 30-minute therapy sessions occurring 2 days/week for 6 weeks, and emphasizing activities of daily living. Subjects randomly assigned to the experimental condition also received 30-minute MP sessions provided directly after therapy requiring daily MP of the activities of daily living; subjects assigned to the control group received the same amount of therapist interaction as the experimental group, and a sham intervention directly after therapy, consisting of relaxation. Outcomes were evaluated by a blinded rater using the Action Research Arm test and the upper extremity section of the Fugl-Meyer Assessment.
                No pre-existing group differences were found on any demographic variable or movement scale. Subjects receiving MP showed significant reductions in affected arm impairment and significant increases in daily arm function (both at the P<0.0001 level). Only patients in the group receiving MP exhibited new ability to perform valued activities.
                The results support the efficacy of programs incorporating mental practice for rehabilitating affected arm motor function in patients with chronic stroke. These changes are clinically significant. Uncertainty remains as to the most appropriate preoperative screening investigation to evaluate patient cardiac risk in prospective renal transplant recipients. We prospectively compared tachycardic-stress (exercise/pacing) scintigraphy with coronary angiography for the detection of significant coronary artery disease in this group. With a negative predictive value of 92%, tachycardic-stress scintigraphy may reduce the need for unnecessary coronary angiography in these patients. The addition of thoracic epidural anesthesia (TEA) to general anesthesia (GA) during cardiac surgery may have a beneficial effect on clinical outcomes. TEA in cardiac surgery, however, is controversial because the insertion of an epidural catheter in patients requiring full heparinization for cardiopulmonary bypass may lead to an epidural hematoma. The clinical effects of fast-track GA plus TEA were compared with those of with fast-track GA alone.
                A randomized controlled trial was conducted in 654 elective cardiac surgical patients who were randomly assigned to combined GA and TEA versus GA alone. Follow-up was at 30 days and 1 yr after surgery. The primary endpoint was 30-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke.
                Thirty-day survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 85.2% in the TEA group and 89.7% in the GA group (P = 0.23). At 1 yr follow-up, survival free from myocardial infarction, pulmonary complications, renal failure, and stroke was 84.6% in the TEA group and 87.2% in the GA group (P = 0.42). Postoperative pain scores were low in both groups.
                This study was unable to demonstrate a clinically relevant benefit of TEA on the frequency of major complications after elective cardiac surgery, compared with fast-track cardiac anesthesia without epidural anesthesia. Given the potentially devastating complications of an epidural hematoma after insertion of an epidural catheter, it is questionable whether this procedure should be applied routinely in cardiac surgical patients who require full heparinization. Bone mineral density is already abnormally reduced at the moment of cardiac transplantation and bone loss occurs at an impressive rate in the first postoperative year. The aim of the study was to compare two prophylactic medical regimens as to their efficacy in mitigating bone loss after transplantation. Forty-eight consecutive recipients were randomized to receive either alternating calcium carbonate and disodium etidronate (group A) or a daily supplement of calcium carbonate and alphacalcidol (group B). Bone mineral density measurements were performed immediately before hospital discharge and 6, 12, and 24 months after surgery using dual energy X-ray absorptiometry. Clinical events were recorded and roentgenograms of the spine were performed postoperatively and 1 and 2 years later. In both treatment groups bone loss remained significant at the level of the lumbar spine in the first postoperative year (P<0.005) and at the level of the femoral neck in the first (P<0.005) and the second (P<0.06) year after transplantation. Six months after transplantation, however, patients receiving alphacalcidol had a significant reduction in bone loss at the level of the lumbar spine (P=0.047) and at the level of the femoral neck (P=0.043). At the level of the femoral neck this decrease in bone loss was even more pronounced in the second postoperative year (P<0.001). In the group of patients treated with disodium etidronate, 4 recipients needed additional hospitalizations for treatment of symptomatic fractures at the level of the lumbar spine or the femoral neck. No such events happened in recipients receiving vitamin D supplements. Prophylactic administration of calcium carbonate and alphacalcidol after cardiac transplantation reduces bone loss and seems to decrease osteoporotic complications. During conventional cardiac surgery ischemia and reperfusion may cause excessive production of reactive oxygen species leading to tissue damage including early arrhythmias. We therefore assessed the kinetics of markers of radical stress including oxidized and reduced glutathione (GSSG/GSH), oxidized proteins (PCG) and malondialdehyde (MDA), and tested the hypothesis that different steroid treatments inhibit these markers and early reperfusion-associated supraventricular and ventricular extrasystolic beats.
                In a randomized, controlled, blinded, prospective trial 36 patients received a preoperative infusion of methylprednisolone (MP, 15 mg kg-1, n = 12), tirilazad mesylate (TM, 10 mg kg-1, n = 12) or placebo (PL, NaCl, n = 12). Coronary sinus and arterial blood was drawn at baseline and 2, 5, 15, 30, 60 and 240 min after aortic declamping. Holter-ECG analysis was used to identify arrhythmias.
                Cardiac GSSG release occurred very early (< 15 min) and was not significantly attenuated by either drug treatment. Cardiac PCG production showed biphasic increases, lasted > 4 h and was significantly reduced only by TM. Cardiac MDA release was short (< 30 min) and significantly reduced by MP and TM. Neither treatment had a significant influence on the early occurrence of ventricular or supraventricular arrhythmias. The number of patients needing cardioversions or defibrillations also were not different.
                The results indicate that cardiac production of reactive oxygen species occurs after reperfusion in humans and is not inhibited by steroid treatment. Steroid treatment effectively reduces lipid peroxidation during cardiac surgery but has no influence on arrhythmias. A prospective, randomized, controlled clinical trial in patients with coronary artery disease (CAD) and a concurrent physical disability evaluated the effects of a home exercise training program on cardiovascular function and blood lipids. Eighty-eight men between the ages of 42 and 72 years (mean 62) with documented CAD and a physical disability with functional use of > or = 2 extremities including 1 arm were randomized to either a 6-month home exercise training program using wheelchair ergometry or to a control group that received usual and customary care. Both groups received dietary instructions and were requested to follow a fat-controlled diet. Exercise test variables with echocardiography and blood lipids were measured at baseline and at 6 months. The home exercise training group significantly improved both peak exercise left ventricular ejection fraction (p = 0.007) and fractional shortening (p = 0.01) between baseline to 6 months, whereas the control group showed no significant changes. Exercise training effects of decreased resting heart rate (p = 0.03) and decreased peak rate pressure product (p = 0.03) were also found in the treatment group. No exercise-related cardiac complications occurred. Both groups significantly (p < or = 0.01) increased high-density lipoprotein cholesterol levels. These results indicate that physically disabled men with CAD can safely participate in a home exercise training program which may result in intrinsic cardiac benefits. The metabolic cost of activities of daily living imposed on this disabled population may also have a positive effect on high-density lipoprotein cholesterol levels. To report the neurocognitive findings in a phase III randomized trial evaluating survival and neurologic and neurocognitive function in patients with brain metastases from solid tumors receiving whole-brain radiation therapy (WBRT) with or without motexafin gadolinium (MGd).
                Patients were randomly assigned to receive WBRT 30 Gy in 10 fractions with or without MGd 5 mg/kg/d. Monthly neurocognitive testing for memory, executive function, and fine motor skill was performed.
                Four hundred one patients were enrolled (251 with non-small-cell lung cancer, 75 with breast cancer, and 75 with other cancers); 90.5% patients had impairment of one or more neurocognitive tests at baseline. Neurocognitive test scores of memory, fine motor speed, executive function, and global neurocognitive impairment at baseline were correlated with brain tumor volume and predictive of survival. There was no statistically significant difference between treatment arms in time to neurocognitive progression. Patients with lung cancer (but not other types of cancer) who were treated with MGd tended to have improved memory and executive function (P =.062) and improved neurologic function as assessed by a blinded events review committee (P =.048).
                Neurocognitive tests are a relatively sensitive measure of brain functioning; a combination of tumor prognostic variables and brain function assessments seems to predict survival better than tumor variables alone. Although the addition of MGd to WBRT did not produce a significant overall improvement between treatment arms, MGd may improve memory and executive function and prolong time to neurocognitive and neurologic progression in patients with brain metastases from lung cancer.
DSE may perform better than MPS but additional studies directly comparing these cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.