Practical applicability of landiolol, an ultra-short-acting β1-selective blocker, for rapid atrial and ventricular tachyarrhythmias with left ventricular dysfunction

Background

Landiolol effectively controls rapid heart rate in atrial fibrillation or flutter (AF/AFL) patients with left ventricular (LV) dysfunction. However, predicting landiolol Responders and Non-Responders and patients who will experience adverse effects remains a challenge. The aim of this study was to clarify the potential applicability of landiolol for rapid AF/AFL and refractory ventricular tachyarrhythmias (VTs) in patients with heart failure.

Methods

A total of 39 patients with AF/AFL with ventricular response ≥120 bpm and 12 VTs were retrospectively enrolled. Landiolol Responders for rapid AF/AFL were defined as patients whose ventricular response was suppressed to less than 110 bpm or decreased by ≥20% from the initial heart rate after administration of landiolol. Responders for VTs were defined as patients with no recurrent VTs during the 24 h after the initiation of landiolol.

Results

For AF/AFL, 29 patients (74%) were Responders. In nine patients (31%), AF was spontaneously terminated after starting landiolol. Eight Non-Responders (80%) needed to have AF terminated by cardioversion. Left ventricular ejection fraction (LVEF) at baseline was significantly associated with landiolol efficacy. For VTs, seven patients (58%) were Responders, and smaller LV diastolic and systolic diameters were associated with landiolol efficacy. Hypotension after landiolol treatment occurred in 5 of 51 patients, and lower LV systolic function was associated with the development of adverse events.

Conclusions

Landiolol is effective in patients with heart failure not only due to rapid AF/AFL but also due to VTs. However, preserved LVEF is important for efficacy and safety in landiolol treatment.

Defibrillation lead placement using a transthoracic transatrial approach in a case without transvenous access due to lack of the right superior vena cava

A 65-year-old woman with a history of syncope was diagnosed with hypertrophic cardiomyopathy. She had previously undergone mastectomy of the left breast owing to breast cancer. Holter electrocardiogram (ECG) and monitor ECG revealed sick sinus syndrome (Type II) and non-sustained ventricular tachycardia. Sustained ventricular tachycardia and ventricular fibrillation were induced in an electrophysiological study. Although the patient was eligible for treatment with a dual chamber implantable cardioverter defibrillator (ICD), venography revealed lack of the right superior vena cava (R-SVC). Lead placement from the left subclavian vein would have increased the risk of lymphedema owing to the patient׳s mastectomy history. Consequently, the defibrillation lead was placed in the right ventricle by direct puncture of the right auricle through the tricuspid valve. The atrial lead was sutured to the atrial wall, and the postoperative course was unremarkable. Defibrillation lead placement using a transthoracic transatrial approach can be an alternative method in cases where a transvenous approach for lead placement is not feasible.

Impact of renal function deterioration on adverse events during anticoagulation therapy using non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

Renal function is crucial for patients with non-valvular atrial fibrillation (NVAF) using non-vitamin K antagonist oral anticoagulants (NOAC). The incidence of renal function deterioration during anticoagulation therapy and its impact of adverse events are unknown. In 807 consecutive NVAF patients treated with NOAC and with estimated creatinine clearance (eCCr) ≥ 50 ml/min (mean age 68 ± 11 years, mean CHADS2 score = 1.8 ± 1.4, CHA2DS2-VASc score = 2.8 ± 1.8, HAS-BLED score = 1.7 ± 1.1), we analyzed the time course of renal function and clinical outcomes, and compared these with the data of general Japanese inhabitants from the Suita Study (n = 2140). Of the 807 patients, 751 (93 %) maintained eCCr ≥ 50 ml/min (group A) whereas the remaining 56 (7 %) fell into the eCCr < 50 ml/min (group B) during the 382 ± 288 days of follow-up. Multivariate logistic regression analysis revealed that advanced age, lower body weight, and congestive heart failure were independent predictors for renal function deterioration in patients with eCCr ≥ 50 ml/min at baseline. Major and/or minor bleedings were more commonly observed in group B than in group A (21 vs. 8 %; P = 0.0004). The CHADS2, CHA2DS2-VASc, and HAS-BLED scores were also significant predictors of renal function deterioration (P < 0.0001). The incidences of renal function deterioration were 1.4, 3.4, 10.5 and 11.7 % in patients with CHADS2 score of 0, 1, 2 and ≥3, respectively. As to CHA2DS2-VASc score, renal function deterioration occurred in 0, 1.7, 9.8 and 15.0 % with a score of 0, 1-2, 3-4 and ≥5, respectively. In the Suita Study of the general population, on the other hand, 122 of 2140 participants with eCCr ≥ 50 ml/min at baseline (5.7 %) fell into the eCCr < 50 ml/min during about 2 years. The incidence of renal function deterioration increased with the CHADS2 score in the general population as well as in our patients. Renal function deterioration was not uncommon and was associated with more frequent adverse events including major bleeding in NVAF patients with anticoagulation therapy. CHADS2, CHA2DS2-VASc, and HAS-BLED scores may be useful as an index of predicting renal function deterioration.

Significance of electrocardiogram recording in high intercostal spaces in patients with early repolarization syndrome

AIMS

Published reports regarding inferolateral early repolarization (ER) syndrome (ERS) before 2013 possibly included patients with Brugada-pattern electrocardiogram (BrP-ECG) recorded only in the high intercostal spaces (HICS). We investigated the significance of HICS ECG recording in ERS patients.

METHODS AND RESULTS

Fifty-six patients showing inferolateral ER in the standard ECG and spontaneous ventricular fibrillation (VF) not linked to structural heart disease underwent drug provocation tests by sodium channel blockade with right precordial ECG (V1-V3) recording in the 2nd-4th intercostal spaces. The prevalence and long-term outcome of ERS patients with and without BrP-ECG in HICS were investigated. After 18 patients showing type 1 BrP-ECG in the standard ECG were excluded, 38 patients (34 males, mean age; 40.4 ± 13.6 years) were classified into four groups [group A (n = 6;16%):patients with ER and type 1 BrP-ECG only in HICS, group B (n = 5;13%):ERS with non-type 1 BrP-ECG only in HICS, group C (n = 8;21%):ERS with non-type 1 BrP-ECG in the standard ECG, and group D (n = 19;50%):ERS only, spontaneously or after drug provocation test]. During follow-up of 110.0 ± 55.4 months, the rate of VF recurrence including electrical storm was significantly higher in groups A (4/6:67%), B (4/5:80%), and C (4/8:50%) compared with D (2/19:11%) (A, B, and C vs. D, P < 0.05).

CONCLUSIONS

Approximately 30% of the patients with ERS who had been diagnosed with the previous criteria showed BrP-ECG only in HICS. Ventricular fibrillation mostly recurred in patients showing BrP-ECG in any precordial lead including HICS; these comprised 50% of the ERS cohort.

Evaluation of the Necessity for Cardioverter-Defibrillator Implantation in Elderly Patients With Brugada Syndrome

Background—

The clinical characteristics and prognosis of elderly patients with Brugada syndrome (BrS) are largely unknown. The purpose of this study was to evaluate the risks and benefits of implantable cardioverter defibrillator (ICD) in elderly patients with BrS based on a long follow-up.

Methods and Results—

A total of 120 BrS patients with ICD (90 for aborted sudden cardiac arrest or syncope, mean age, 46.6±12.2 years; 50 with age ≥60 years at the last follow-up) were included in this study. During 102±68 months of follow-up, 31 patients (26%) experienced appropriate shocks. Age at the first attack of ventricular fibrillation (VF) was <70 years in all patients (mean, 45.0±12.1 years), the incidence of VF decreased with age, and VF did not recur after 70 years of age except in 2 patients with ischemic heart disease. Eleven of 28 patients with supraventricular tachycardia experienced inappropriate shocks. These inappropriate shocks increased with age and reached a peak in patients who were in their sixties. Lead failures occurred in later stages after implantation in 10 of 120 patients (8%).

Conclusions—

Long-term follow-up of high-risk BrS patients with ICD showed a low incidence of VF in those aged >70 years. Considering the increasing risk of inappropriate shocks because of the relatively late onset of supraventricular tachycardia and lead failures, avoidance of ICD implantation, or replacement may be considered in elderly BrS patients who remain free from VF until 70 years of age.

Clinical and Pathological Impact of Tissue Fibrosis on Lethal Arrhythmic Events in Hypertrophic Cardiomyopathy Patients With Impaired Systolic Function

BACKGROUND

The natural history of hypertrophic cardiomyopathy (HCM) varies from an asymptomatic benign course to a poor prognosis. Myocardial fibrosis may play a critical role in ventricular tachyarrhythmias (VT/VF); however, the clinical significance of tissue fibrosis by right ventricular (RV) biopsy in the long-term prognosis of HCM patients remains unclear.

METHODS AND RESULTS

We enrolled 185 HCM patients (mean age, 57±14 years). The amount of fibrosis (%area) was quantified using a digital microscope. Hemodynamic, echocardiographic, and electrophysiologic parameters were also evaluated. Patients with severe fibrosis had longer QRS duration and positive late potential (LP) on signal-averaged ECG, resulting in a higher incidence of VT/VF. At the 5±4 year follow-up, VT/VF occurred in 31 (17%) patients. Multivariate Cox regression analysis revealed that tissue fibrosis (hazard ratio (HR): 1.65; P=0.003 per 10% increase), lower left ventricular ejection fraction (HR: 0.64; P=0.001 per 10% increase), and positive SAECG (HR: 3.14; P=0.04) led to a greater risk of VT/VF. The combination of tissue fibrosis severity and lower left ventricular ejection fraction could be used to stratify the risk of lethal arrhythmic events in HCM patients.

CONCLUSIONS

Myocardial fibrosis in RV biopsy samples may contribute to abnormal conduction delay and spontaneous VT/VF, leading to a poor prognosis in HCM patients.

Local massive venous invasion in colorectal cancer: CT-pathological correlation and its clinical implication

OBJECTIVE

To identify CT findings of massive venous invasion (MVI) in colorectal cancer, compare them to pathological findings and evaluate its clinical implications.

METHODS

Among 423 patients who received surgical resection of colorectal cancer, pre-operative CT of 26 patients (15 males, 11 females; mean age, 63.0 ± 12.1 years) with histopathologially proven MVI and 26 patients (14 males, 12 females; mean age, 71.1 ± 9.6 years) with histopathologically proven lymph node (LN) metastases were reviewed and compared with histopathological findings. We evaluated CT detectability of MVI and the morphologic differences between MVI and LN metastasis. All cases were followed up for at least 6 months after surgery.

RESULTS

Pre-operative CT correctly diagnosed only one case as tumour thrombus. 9 lesions were not detected on CT, and others were misdiagnosed pre-operatively as regional LN metastasis (14 cases) and juxtatumoural abscess (2 cases). After reviewing these cases, MVIs were identifiable in 20 of 26 cases. MVI was depicted on CT as nodules (oval, lobulated), abscess-like or intravenous tumour thrombus. MVI was significantly larger than LN metastasis (p < 0.05), while contrast enhancement was significantly lower (p < 0.05), and MVI often had an enhanced rim. Ten patients had synchronous metastases, and six patients had metachronous distant metastases within 5 years.

CONCLUSION

Many cases of MVI were distinguishable from LN metastases on pre-operative CT of colorectal cancer, but their appearances were varied, reflecting their histopathological behaviours. The distant metastatic rate was much higher in cases with MVI.

ADVANCES IN KNOWLEDGE

Radiologists should be aware of CT findings of MVI in colorectal cancer as a sentinel sign of distant metastasis.

Negative impact of underlying non-insulin-dependent diabetes mellitus nephropathy on long-term allograft survival in kidney transplantation: a 10-year analysis from a single center

INTRODUCTION

We analyzed the relationship between underlying nephropathy and long-term outcomes in kidney transplant recipients.

METHODS

We retrospectively analyzed data from 678 patients who underwent kidney transplantation (KTx) between 1998 and 2011. Recipients with 13 major nephropathies were evaluated for graft and patient survival, and causes of graft loss.

RESULTS

The best 10-year graft survival rates (100%) were in the patients with autosomal-dominant polycystic kidney disease, preeclampsia, Alport syndrome, and purpura nephritis. The worst rate (50.8%) was in patients with non-insulin-dependent diabetes mellitus nephropathy (NIDDMN; P = .039). Causes of graft-loss in the NIDDM patients included chronic rejection (6 cases), acute rejection (3 cases), infection (2 cases), and cardiovascular event (2 cases). Significant risk factors for graft loss were donor age (P < .01) and NIDDMN (P < .01).

CONCLUSION

Underlying NIDDMN before KTx was a significant risk factor for long-term graft function. Immunologic factors and nonimmunologic factors influenced the long-term outcomes in patients with underlying NIDDMN.

Efficacy and safety of febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase for the treatment of hyperuricemia in kidney transplant recipients

BACKGROUND

Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase, is a potential alternative to allopurinol for patients with hyperuricemia. In this study, we evaluated the efficacy and safety of febuxostat for the management of hyperuricemia in renal transplant recipients.

PATIENTS AND METHODS

Between June 2012 and January 2013, a total of 22 renal transplant recipients (56 ± 10 years old) with hyperuricemia were enrolled in this study. All patients underwent de novo kidney transplantation, except for 1 patient, who received a second kidney transplant. Ten patients receiving allopurinol and 3 patients receiving benzbromarone were converted to febuxostat at doses of 10-20 mg/d. In the remaining 9 patients, who did not have a history of other urate-lowering medications, febuxostat was initiated at a dose of 10 mg/d.

RESULTS

Uric acid levels after initiation of febuxostat were significantly lower than before treatment (5.7 ± 0.7 mg/mL vs 8.0 ± 0.8 mg/mL; P < .001). At last follow-up visit, 16 of the 22 patients (73%) achieved uric acid levels of ≤ 6.0 mg/dL, despite the low dosage of febuxostat. All patients were maintained on febuxostat without serious adverse events, except for 1 patient, who discontinued febuxostat because of numbness in the arms.

CONCLUSIONS

Low-dose febuxostat is a promising alternative to allopurinol or benzbromarone for the treatment of hyperuricemia in kidney transplant recipients. The long-term urate-lowering efficacy and safety of febuxostat with regard to renal function in kidney transplant recipients with hyperuricemia requires further investigation.

Impact of left ventricular diastolic dysfunction on outcome of catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy

BACKGROUND

The relationship between outcome of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) and the severity of left ventricular (LV) diastolic dysfunction in patients with hypertrophic cardiomyopathy (HCM) remains unknown.

METHODS AND RESULTS

Twenty-two HCM patients (12 female, aged 65 ± 11 years) with paroxysmal (n=5; 23%) or persistent (n=17; 77%) AF were enrolled. LV diastolic function was evaluated according to the ratio of the mitral inflow early filling velocity to the velocity of the early medial mitral annular ascent (E/e') measured on pulsed wave and tissue Doppler assessments in all patients. Pulmonary vein isolation was performed in all patients. A second procedure was performed in 3 patients. During a follow-up of 21 ± 12 months, sinus rhythm was maintained in 13 of 22 patients (59%). E/e' was significantly higher in the patients with AF recurrence than in those without (18 ± 7 vs. 11 ± 3; P<0.01). On Kaplan-Meier analysis the prevalence of AF recurrence was significantly higher in patients with E/e' ≥ 15 (n=6) than in those with E/e' <15 (n=16; P<0.01). On multivariate Cox regression analysis the only significant and independent predictor for AF recurrence was E/e' (hazard ratio, 1.16; 95% confidence interval: 1.01-1.37, P=0.03).

CONCLUSIONS

LV diastolic dysfunction evaluated using E/e' was associated with difficulty of rhythm control after RFCA in patients with HCM and AF.

Risk stratification in patients with Brugada syndrome without previous cardiac arrest – prognostic value of combined risk factors

BACKGROUND

Risk stratification in patients with Brugada syndrome for primary prevention of sudden cardiac death is still an unsettled issue. A recent consensus statement suggested the indication of implantable cardioverter defibrillator (ICD) depending on the clinical risk factors present (spontaneous type 1 Brugada electrocardiogram (ECG) [Sp1], history of syncope [syncope], and ventricular fibrillation during programmed electrical stimulation [PES+]). The indication of ICD for the majority of patients, however, remains unclear.

METHODS AND RESULTS

A total of 218 consecutive patients (211 male; aged 46 ± 13 years) with a type 1 Brugada ECG without a history of cardiac arrest who underwent evaluation for ICD including electrophysiological testing were examined retrospectively. During a mean follow-up period of 78 months, 26 patients (12%) developed arrhythmic events. On Kaplan-Meier analysis patients with each of Sp1, syncope, or PES+ suffered arrhythmic events more frequently (P=0.018, P<0.001, and P=0.003, respectively). On multivariate analysis Sp1 and syncope were independent predictors of arrhythmic events. When dividing patients according to the number of these 3 risk factors present, patients with 2 or 3 risk factors experienced arrhythmic events more frequently than those with 0 or 1 risk factor (23/93 vs. 3/125; P<0.001).

CONCLUSIONS

Syncope, Sp1, and PES+ are important risk factors and the combination of these risks well stratify the risk of later arrhythmic events.

Renal transplantation between siblings with unrecognized Fabry disease

Fabry disease is an X-linked lysosomal storage disease caused by deficiency of the lysosomal hydrolase, α-galactosidase A (α-Gal A). We report a case of a renal transplant recipient with unrecognized Fabry disease who received the allograft from a sibling donor with unrecognized Fabry disease. The recipient began to show a gradual increase of the serum creatinine with mild proteinuria at 3 years after transplantation. Histopathologic examination revealed finely vacuolated podocytes, demonstrated by ultrastructural examination to contain osmophilic myelin bodies. Furthermore, the recipient showed reduced circulating levels of α-Gal A and elevated urinary levels of globotriaosylceramide. These findings indicated that both the recipient and the donor suffered from Fabry disease of the renal variant phenotype. Enzyme replacement therapy (ERT) was initiated in the recipient, which resulted in a slight decrease of serum creatinine. Although mild proteinuria persisted, initiation of ERT in the recipient led to improvement of the renal function.

Profiling of differentially expressed microRNA and the bioinformatic target gene analyses in bovine fast- and slow-type muscles by massively parallel sequencing

MicroRNA (miRNA) are highly conserved, noncoding small RNA involved in post-transcriptional gene regulation in a variety of biological processes. To elucidate roles of miRNA in bovine muscle type specification and maintenance, we sought to determine differentially expressed miRNA between semitendinosus (STD) and masseter (MS) muscles from 3 Japanese black cattle by massively parallel sequencing. Differential gene expression of myosin heavy chain (MyHC) isoforms confirmed that STD and MS were MyHC-2x- and MyHC-1-abundant muscles, respectively. In total, 192 known miRNA and 20 potential new bovine miRNA were obtained from the sequencing. The differentially expressed miRNA with more than 2-fold difference in each muscle were identified. In particular, miR-196a and miR-885 were exclusively expressed in STD muscle, which was validated by quantitative reverse transcription-PCR (P=0.045 and P<0.001, respectively), whereas a slow type-directing miR-208b was highly expressed in MS compared with STD (false discovery rate<0.05). In addition, 16 potential novel miRNA were mapped and confirmed for their precursor structures by computational analyses. The results of functional annotation combined with in silico target analysis showed that the predicted target genes of miR-196a/b and miR-885 enriched gene ontology (GO) terms related to skeletal system development and regulation of transcription, respectively. Moreover, GO terms enriched from predicted targets miRNA suggested that STD-abundant- and MS-abundant-miRNA were associated with embryonic body planning and organ/tissue pattern formation, respectively. The present results revealed that the differentially expressed miRNA between the STD and MS muscles may play key roles to determine muscle type-specific tissue formation and maintenance in cattle thorough attenuating putative target genes involved in different developmental events.

Long-term impact of hypertension on renal allografts

OBJECTIVE

We assessed the impact of hypertension on renal transplant function and survival in the past decade after introduction of mycophenolate mofetil and rituximab.

METHODS

We examined the 184 patients who underwent renal transplantation from March 1982 to September 1999 and presented at our outpatient clinic from 2001 to 2011. They were divided into group 1 with mean systolic blood pressure (mSBP) >130 mm Hg and Group 2 with mSBP <130 mm Hg. We compared mean serum creatinine (sCr) levels for 9 years and 12-year actuarial graft survival rates. Risk factors for graft survival were assessed by Cox regression analysis.

RESULTS

There were 75 group 1 and 109 group 2 recipients. The mean sCr level of group 1 was 1.59 ± 0.12 mg/dL and that of group 2 1.54 ± 0.10 mg/dL (P < .0001). Of note was that mean sCr levels of group 1 started to increase about 3 years after transplantation. Although 5-year graft survival rates of both groups were 100%, 9- and 12-year rates among group 1 were 97.3% and 90.5%, respectively, whereas among group 2 they were 99.1% and 98.1%, respectively (P = .0195). Cox univariate and multivariate analyses showed mean SBP to be the only significant risk factor for graft survival (P < .05).

CONCLUSIONS

We concluded that the hypertensive group showed deteriorating renal function from around 3 years after transplantation that lowered graft survival afterward, resulting in a clear distinction from the nonhypertensive group at around 10 years after transplantation. Mean SBP was a significant risk factor for graft survival. Hypertension may be a surrogate for a poor renal graft prognosis in the long run.

Changes in gene expression in a porcine preadipocyte cell line during differentiation

Adipocyte differentiation plays an important role in the formation of fat tissues in pigs and affects meat quality and productivity. Clarification of the nature of the pig genes that participate in adipocyte differentiation will provide a clue to the regulation of fat content and thickness in pig carcases by dietary control; it will also help to find target genes for exploring potentially useful polymorphisms for molecular breeding aimed at fat traits. We constructed a DNA oligomer microarray based on pig transcripts, and we used the array to investigate time-dependent changes in gene expression in the PSPA porcine preadipocyte cell line during differentiation into adipocytes. We selected genes with markedly altered expression (at least fivefold difference in comparison with expression in undifferentiated cells) and classified them into five groups according to gene expression pattern. In the early stage after stimulation of adipocyte differentiation, we observed up-regulation of many genes encoding proteins involved in regulating cell proliferation and transcription. Among the probes corresponding to transcripts that showed marked changes in expression, 27 were located within previously reported QTL regions for traits related to adipose tissues. These results will be valuable resources for finding the genes responsible for fat-related traits that have been identified in previous studies using various pig resource families.

Incessant monomorphic ventricular tachycardia induced by the proarrhythmic effect of amiodarone

This case report describes incessant monomorphic ventricular tachycardia (VT), not torsade de pointes, induced by intravenous amiodarone in a 48-year-old woman with dilated cardiomyopathy. VT was reproducibly triggered by short coupled premature ventricular complex (PVC) with different morphology from VT. After amiodarone infusion, the coupling interval of initiating PVC was prolonged, and moreover, the morphology of initiating PVC became the same as that of VT. Though amiodarone has become the first line drug to treat ventricular tachyarrhythmias in patients with cardiac dysfunction, it is important to be aware of its proarrhythmic effect, which may lead to an electrical storm of monomorphic VT.

Persistent glomerular hematuria in living kidney donors confers a risk of progressive kidney disease in donors after heminephrectomy

Although glomerular hematuria is likely a sign of chronic kidney disease that will develop into overt nephropathy after donation, it remains unclear whether prospective donors with hematuria should be excluded. We reviewed the medical records of 242 donors who donated at our institution from 2001 to 2007 and surveyed the prevalence of hematuria pre- and postdonation. We then investigated the association of hematuria with proteinuria postdonation and trends in glomerular filtration rate. Before donation, 8.3% of 242 donors presented with persistent hematuria, a finding that was significantly associated with dysmorphic hematuria before donation. Most cases of predonation persistent hematuria persisted after donation, and the overall prevalence increased to 15.3%. During a median follow-up period of 2.3 years after donation, 8.3% developed persistent proteinuria, with incidence being significantly higher in donors having persistent hematuria with dysmorphic red blood cells (d-RBC) both before and after donation. Postdonation persistent hematuria with d-RBC was also associated with a progressive decline in renal function. These results indicate that persistent glomerular hematuria is strongly associated with a higher incidence of postdonation progressive kidney disease. Potential donors with persistent glomerular hematuria should be excluded, while those with isolated hematuria need to be evaluated with heightened caution.

How do living kidney donors develop end-stage renal disease?

The clinical course and risk factors for developing end-stage renal disease (ESRD) after heminephrectomy in living kidney donors have scarcely been investigated. We reviewed medical records and identified eight case donors who developed chronic kidney disease (CKD) stage 5 or ESRD, and subsequently investigated the association between postoperative clinical courses and changes in renal function. To conduct a case-control study, we also selected a control group comprising 24 donors who had maintained stable renal function and were matched for age, sex and follow-up time since donation. Except for one donor who developed ESRD caused by a traffic accident, none of the donors developed progressive renal dysfunction immediately after donation. Their renal functions remained stable for a long period of time, but started to decline after developing new comorbidities, especially risk factors known as progression factors (proteinuria or hypertension) or accelerating factors (cardiovascular [CV] event or infection) of CKD. As compared with the control donors, incidence of postoperative persistent proteinuria, acute CV event, severe infection and hospitalization due to accelerating factors of CKD were significantly higher in the case donors. These results suggest the importance of long-term (more than 10 years) follow-up of donors with special attention on the risk factors of CKD.

Hand-assisted laparoscopic splenectomy in ABO-incompatible kidney transplant recipients

OBJECTIVE

We perform living-related ABO-incompatible kidney transplantations to alleviate the organ shortage in our country. Splenectomy has been performed routinely in these recipients, although its clinical significance remains controversial. In this study, we have reported our experience with a hand-assisted laparoscopic splenectomy (HALS) technique.

METHODS

Between April 2000 and December 2006, 50 patients (23 males) underwent ABO-incompatible kidney transplantation with HALS. The mean age and weight of the recipients were 44 +/- 13 years and 56 +/- 12 kg, respectively. All patients underwent preoperative plasmapheresis to reduce isoagglutinin (A and/or B antibody). In 6/50 patients, a hand-assisted device was placed through a peritoneal window in the right lower abdominal skin incision for kidney engraftment. In the remaining 44 patients, a 6-cm upper midline or periumbilical midline incision was made for the hand-assisted device in the lateral position.

RESULTS

An ABO-incompatible procedure was completed successfully in all cases. The average HALS time was 118 +/- 42 minutes, with an average pneumoperitoneum time of 79 +/- 40 minutes and average blood loss of 48 +/- 81 g. There were two conversions to open splenectomy because of intraoperative bleeding and suspected pneumothorax. Two other cases required relaparotomy because of hematoma and perforation of the ileum. Successfully operations were achieved through the previous periumbilical incision.

CONCLUSIONS

Although meticulous, rigorous surgical technique is essential, HALS is safe and feasible for recipients of ABO-incompatible grafts with tissue weakness and a bleeding tendency because of renal failure and preoperative plasmapheresis.

Relationship between patient characteristics, mandibular head morphology and thickness of the roof of the glenoid fossa in symptomatic temporomandibular joints

OBJECTIVE

The purpose of this clinical study was to investigate the minimum thickness of the roof of the glenoid fossa (RGF) of grossly normal temporomandibular joints (TMJ) and to correlate this with patient gender, age and the morphological classification of the mandibular head.

METHODS

The study was performed on 191 TMJs from 109 patients (25 male and 84 female, age range 3-79 years, mean age 28.1 years) who visited Nihon University Dental Hospital, Japan with suspected TMJ disorders. The patients underwent cone beam computed tomography (3DX CT) to enable observation of the morphological features of the mandibular head. The minimum thickness of the RGF was measured using frontal section images acquired by CT. The morphology of the mandibular heads was classified according to the method of Yale and colleagues. Mean linear measurements were used for statistical analyses of patient gender, age and mandibular head morphology.

RESULTS

The average minimum thickness of the RGF was 0.79 mm. No significant difference in thickness was found between male and female patients. In addition, no differences were recorded as a result of variation in age or mandibular head morphology.

CONCLUSIONS

These results indicate that RGF thickness is not significantly correlated with gender, age, or mandibular head morphology, at least in this cohort of patients.

Reproducibility and accuracy of measuring unerupted teeth using limited cone beam X-ray CT

OBJECTIVE

The purpose of this investigation was to determine the reproducibility among observers and accuracy of the measurement of the tooth crown width of unerupted teeth using limited area cone beam X-ray CT.

METHODS

3DX multi-image micro-CT (3DX, Morita Co., Kyoto, Japan) images of impacted supernumerary teeth in the median maxillary region taken prior to extraction were used for the samples. The width of the tooth on the 3DX image was measured five times by five individual observers. Significant differences in values among the observers in the measurement were determined by one-way analysis of variance for examining reproducibility. The measurement results of the ten samples on 3DX images were compared with the laboratory measurements using a three-dimensional co-ordinate measuring apparatus, using the Wilcoxon signed-rank sum test.

RESULTS

There was no significant difference among the observers in the measurement (P>0.05). The measurement results shown on 3DX images were significantly larger than those of the laboratory measurements (P<0.05). The mean difference was +0.088 mm.

CONCLUSIONS

3DX has high reproducibility for measuring the tooth crown width of unerupted teeth. While 3DX measurement values were larger than the laboratory measurements, the difference is clinically insignificant.

Improved outcomes of renal transplantation from cardiac death donors: a 30-year single center experience

Outcomes of renal transplantation from donation after cardiac death (DCD) donors over 30 years were analyzed. Between 1975 and 2004, 256 renal transplantations from DCD donors were performed. The recipients were divided into four groups according to a time period as follows: 1975-1979 (Group 1; n = 18), 1980-1989 (Group 2; n = 81), 1990-1999 (Group 3; n = 84) and 2000-2004 (Group 4; n = 73). Of the 256 transplanted kidneys from DCD donors, 38 (15%) functioned immediately after transplantation. The incidence of delayed graft function (DGF) was 72%. Warm ischemic time and total ischemic time were 7.4 +/- 9.4 min and 11.9 +/- 5.6 h, respectively. The overall graft survival rates at 1, 5 and 10 years were 80%, 72% and 53%, respectively. Graft survival rates in each group have continually improved over time (5-year graft survival; 23% vs. 64% vs. 74% vs. 91%, respectively). However, there was no significant difference in graft survival rates between the groups of patients who survived with a functioning graft for more than 1 year. A multivariate Cox regression analysis showed acute rejection and donor age to be independently associated with graft outcome. DCD donors are a valuable source of kidneys for transplantation with promising long-term outcomes.

Cytokine profile in synovial fluid from patients with internal derangement of the temporomandibular joint: a preliminary study

OBJECTIVES

Temporomandibular joint disorders (TMD) comprise a group of chronic painful conditions of mastication in the temporomandibular joint (TMJ). Although the association between TMD and internal derangement of the TMJ is well documented, the functional relevance is still unclear. Increased concentrations of inflammatory mediators have been identified in the synovial fluid of affected patients with TMD, suggesting an underlying degenerative or inflammatory process. The aim of this study was to generate a comprehensive cytokine expression profile in TMD.

METHODS

15 samples from patients with internal derangement of TMJ were analysed using a novel cytokine array that enables the analysis of 79 different cytokines simultaneously.

RESULTS

Cytokine levels were correlated with the presence of joint effusion (JE) determined by MRI. In the majority of synovial fluid samples, angiogenin (Ang), fibroblast growth factor (FGF)-9, insulin-like growth factor-binding protein (IGFBP)-3, interleukin (IL)-1alpha, IL-1beta, IL-8, inducible protein (IP)-10, macrophage inflammatory protein (MIP)-1beta, osteoprotegerin (OPG), transforming growth factor (TGF)-beta2, tissue inhibitor of metalloproteinase (TIMP)-1, TIMP-2, tumour necrosis factor (TNF)-beta and vascular endothelial growth factor (VEGF) were detectable. Furthermore, the expression levels of Ang, brain-derived neurotrophic factor (BDNF), FGF-4, FGF-9, IGFBP-2, IL-8, MIP-1beta, OPG, pulmonary and activation-regulated protein (PARC), TGF-beta2, TIMP-2 and VEGF were significantly associated with the presence of JE; among these, nine cytokines (Ang, BDNF, FGF-4, FGF-9, IGFBP-2, MIP-1beta, PARC, TGF-beta2 and TIMP-2) were hitherto not described in TMD.

CONCLUSIONS

This study confirmed previous reports of elevated cytokine levels in TMD. Additionally, we identified previously undescribed cytokines that were upregulated and correlated significantly with the presence of JE. We were able to identify novel cytokines that have hitherto not been described in TMD. Strategies targeting the identified cytokines may represent a novel therapy option in TMD.