A Case of Electrocardiographic Change Caused by Subarachnoid Haemorrhage Mimicking Acute Myocardial Infarction

A 60-year-old woman was admitted to the emergency department due to syncope. The electrocardiogram (ECG) revealed normal sinus rhythm with ST segment elevation in leads I, II, and aVL. There was no stenosis or vasospasm in the coronary arteries. Transient electrocardiographic ST segment elevation which is indistinguishable from that associated with acute myocardial infarction has been reported in patients with subarachnoid hemorrhage (SAH). Until now no case was ever reported with the ECG finding with pattern of posterolateral myocardial infarction in SAH patients. So we describe a patient with SAH mimicking acute myocardial infarction.

An Analysis of Escalator-Related Injuries in an Emergency Department

Background

Escalator-related injuries have been considered uncommon and most likely to occur in children. In this study, we described the epidemiology of these injuries with focus on the aged population in order to determine whether escalators are safe for the aged, and to obtain information to help in preventing escalator-related injuries.

Methods

A prospective survey was taken to identify the number and nature of these injuries from May 2004 to December 2008. We enrolled patients who had sustained escalator-related injuries. A standard list of questions and answers were recorded by the emergency physician. A total of 104 questionnaires were completed during the study period.

Results

The average patient age was 59.2±24.0 years (range 1-94). There were 64 (61.5%) females. Only 11 (10.6%) were younger than 15 years old, and 59 (56.7%) were aged 65 or above; 35 (59.3%) of the aged people were injured while standing on the escalator. However, out of the 45 patients younger than age 65, 22 (48.9%) were injured from walking on a moving escalator. Head injury was the commonest site of injury overall and all were due to fall or slipping down.

Conclusions

Escalator-related injuries are not as rare as previously believed and the aged population 65 years old or above is the highest risk group. In particular, walking on a moving escalator was the main cause of injury in people under age 65. Therefore, primary prevention strategies are needed to prevent users from walking on escalators, especially young people, and educate aged people the safe utilization of escalators to prevent slip and fall injuries.

Haemopericardium and Liver Laceration Associated with Airbag Deployment

Airbags and seat belts are safety devices in automobiles. First invented in the 1950s, they are now commonplace in most automobiles. However, a seat occupant may sustain unexpected injuries even if the airbag deploys in a car collision. We describe a patient who was suspected of simultaneously sustaining haemopericardium and liver laceration during the “punch out” and “membrane force” phases of airbag deployment. The patient's vital signs stabilised after an emergency pericardiocentesis was performed. In a car accident when high-energy injury is suspected despite airbag deployment, computed tomography of the chest and abdomen or echocardiography should be considered because of the possibility of abdominal solid organ and chest injury.

Severe Hypokalaemic Paralysis due to Chronic use of Acanthopanax Senticosus Ingestion: A Case Report

Acanthopanax senticosus is a traditional herb in China, Russia and many other Asian countries. However no comprehensive study has evaluated its side effects in humans. We report a rare case of hypokalaemic paralysis possibly attributed to A. senticosus induced pseudohyperaldosteronism.

A Case of Pulmonary Pneumatocoele with Splenic Laceration Caused by Vehicular Accident

Traumatic pneumatocoele is an uncommon complication, resulting from air trapping in an area of lung laceration, and may appear a few hours or even immediately after injury. Young adults and children are most commonly affected. Its clinical relevance lies in its rarity, which might mislead emergency physicians to perform unnecessary surgical intervention. We report a 10-year-old boy suffering from traumatic pneumatocoele with spleen laceration caused by blunt trauma. It is important for emergency physicians to be aware of this condition and of its benign course so as to avoid unnecessary operative procedures due to incorrect diagnosis.

Deep Venous Thrombosis Caused by a Huge Uterine Myoma

Cases of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) related to the isolated risk factor of uterine myoma are very rare. In a setting of emergency department (ED), it is unlikely that uterine myoma would be suspected as the primary cause of symptoms in a patient with thromboembolism. We presented a 44-year-old woman who visited the ED for DVT presenting with right lower leg swelling with an underlying cause of a huge uterine myoma. Various aetiologies, including obstetric and gynaecological causes (especially uterine myoma), should be considered in female patients visiting the ED with suspected DVT or PTE.

Does the Bed Frame Deflection Occur along with Mattress Deflection during In-Hospital Cardiopulmonary Resuscitation? an Experiment Using Mechanical Devices

Objectives

When we perform chest compression on a patient on a bed, the mattress and bed frame can be depressed together with the patient's chest. This study was conducted to assess whether bed frame deflection occurred during chest compressions.

Methods

We designed a firm bed (“bed like the ground,” BLG) to assess the bed frame deflection in the Stryker Trauma Stretcher (STS) and the ER stretcher cart (ER-SC). The STS included a soft mattress and the ER-SC a hard mattress. We performed 50 continuous chest compressions on the Resusci Anne Skill Reporter with CPRmeter in each experiment. The experiments were done in four settings. Test 1 included the BLG; test 2 included a mattress and backboard on each bed; test 3 included the mattress of each bed and a backboard on the BLG; and test 4 included the mattress of each bed on the BLG. We calculated the mattress and bed frame deflections using the gaps of compression depths between the values measured by Resusci Anne and CPRmeter.

Results

The mattress deflections of the STS and ER-SC mattress were determined to be 11.2 and 0.67 mm, respectively. The bed frame deflection for the STS and ER-SC were 0.95 and 5.17 mm, respectively.

Conclusion

The study confirms that bed frame deflection will occur when we perform chest compressions on the manikin lying on a bed. Additionally, the bed frame deflections differ depending on the type of bed. (Hong Kong j.emerg.med. 2016;23:35-41)

A 67-Year-Old Man with Epistaxis, Melena, Gross Haematuria and Haemarthrosis

Superwarfarins are widely used as rodenticides. They are similar to warfarin, but they are more potent and act longer. In case of poisoning, they cause severe bleeding, usually from multiple sites. Prolonged treatment with high doses of vitamin K and/or fresh frozen plasma (FFP) transfusions may be necessary. Awareness of the problem of superwarfarin intoxication among physicians remains low and cases may go undiagnosed for days or weeks, resulting in increased morbidity and even mortality. We presented a case of delayed diagnosis of superwarfarin ingestion. The patient presented to emergency department with epistaxis, melena, and gross haematuria. He was treated with vitamin K and the International Normalised Ratio (INR) dropped from >7.0 to 1.4. The patient was discharged. However, 3 weeks later, the patient presented with haemarthrosis. Blood investigation revealed INR value >7.0 again. The patient finally received treatment with FFP and vitamin K. This case illustrates the importance to consider superwarfarin ingestion when patients presented with poisoning with coagulopathy. (Hong Kong j.emerg.med. 2015;22:324-327)

Is There Any Difference in Cardiopulmonary Resuscitation Performance According to Different Instructional Models of Cardiopulmonary Resuscitation Education for Junior and Senior High School Students?

Objective

This study aims to determine whether or not cardiopulmonary resuscitation (CPR) skills differ according to different instructional models for CPR education and training for junior and senior high school students.

Methods

This was a prospective and randomised study including 519 junior and senior high school students. After the lecture on CPR, students practiced the skill on the manikin. Group 1 used model 1 and Group 2 used model 2 for practical training and practical skills and CPR performance quality were evaluated.

Results

Data from skill tests were analysed in 229 students in group 1 and 210 students in group 2. The total score of sequence skill tests was 17.8±2.0 points. During 2 cycles, no chest elevation was observed in 33.3% and was significantly lower in group 1. There were no significant differences in the frequency of proper ventilation and in ventilation volume between the 2 groups. Excessive ventilation was more frequently observed in group 1 and insufficient ventilation was observed more frequently in group 2. The percentage of the frequency of a proper chest compression rate was 80.5±31.2% and there were no significant differences in proper and insufficient depths, mean rate and recoil of the chest in chest compression between the 2 groups.

Conclusions

There were differences in CPR skills according to different CPR training manikins. Therefore, certain conditions seem to be considered in selection of instructional models for CPR psychomotor skills. (Hong Kong j.emerg.med. 2011;18:375-382)

Cervical Emphysema and Pneumomediastinum following “Light Strangulation” Injury

Pneumomediastinum is an uncommon radiographic finding resulting from various causes, such as trauma, infection and unknown causes. The pneumomediastinum due to minor trauma is rarely reported and treatment and diagnostic process is not established. We report on a 20-year-old female patient who initially presented with neck pain and dyspnoea following manual strangulation. Her chest X-ray and computed tomography (CT) of neck imaging showed subcutaneous emphysema and extensive pneumomediastinum, but pneumothorax was not shown. She was transferred to the thoracic surgery and admitted to the general ward. The patient's condition improved and she was discharged on the sixth hospital day. In conclusion, patients with pneumomediastinum following a minor strangulation injury can be observed alone without invasive testing or repeated imaging. CT scans are of great value for safe observation in determined patients and for the further evaluation of pneumomediastinum.

Structural basis for the interaction between DJ-1 and Bcl-XL

DJ-1 is a multifunctional protein associated with Parkinson's disease (PD) and tumorigenesis. In response to ultraviolet B (UVB) irradiation, DJ-1 is translocated into the mitochondria, and its interaction with the mitochondrial protein Bcl-X_L protects cells against death. In this study, we characterized the molecular interaction between DJ-1 and Bcl-X_L by NMR spectroscopy. The NMR chemical shift perturbation data demonstrated that the oxidized but not the reduced form of DJ-1 binds to the predominantly hydrophobic groove surrounded by the BH1-BH3 domains in Bcl-X_L. In addition, our results showed that the C-terminal α8-helix peptide (Cpep) of DJ-1 binds to the pro-apoptotic BH3 peptide-binding hydrophobic groove in Bcl-X_L and, thus, acts as a Bcl-X_L-binding motif. In combination with the NMR chemical shift perturbation data, a refined structural model of the Bcl-X_L/DJ-1 Cpep complex revealed that the binding mode is remarkably similar to that of other Bcl-X_L/pro-apoptotic BH3 peptide complexes. Taken together, our results provide a structural basis for the binding mechanism between DJ-1 and Bcl-X_L, which will contribute to molecular understanding of the role of mitochondrial DJ-1 in Bcl-X_L regulation in response to oxidative stress.

Association of angiotensin-II levels with albuminuria in subjects with normal glucose metabolism, prediabetes, and type 2 diabetes mellitus

OBJECTIVES

The relationship between the renin-angiotensin system (RAS) and diabetes has been studied for many years. However, studies that assessed RAS components comprehensively were limited. We hypothesized that serum RAS components, especially the effector peptide angiotensin-II, might be closely associated with glucose metabolism status and diabetic complications.

METHODS

We investigated the association of individual RAS component with albuminuria in 407 subjects with normal glucose metabolism (NGM), prediabetes, or type 2 diabetes mellitus (T2DM). Anthropometric and biochemical parameters, including glucose homeostasis, albuminuria, and RAS-related parameters such as plasma renin activity (PRA), aldosterone, angiotensin-converting enzyme (ACE), and angiotensin-II levels, were measured.

RESULTS

The mean±standard deviation (SD) age and body mass index were 57.1±11.1years and 24.7±3.3kg/m², respectively. There were 54 subjects with NGM, 102 with prediabetes, and 251 with T2DM. The mean±SD angiotensin-II levels in these groups were 9.32±6.89, 12.89±10.39, and 17.00±15.28pg/mL, and the respective urinary albumin-to-creatinine ratios (ACRs) were 8.1±5.3, 13.3±17.3, and 30.7±51.9mg/g, which were significantly different among the groups. The serum angiotensin-II levels were correlated with levels of PRA, insulin resistance, C-reactive protein, and urinary ACR. Among RAS-related parameters, only the angiotensin-II level was significantly associated with urinary ACR after adjusting for relevant risk factors.

CONCLUSIONS

Angiotensin-II may play an important role in the development of albuminuria, particularly in subjects with impaired glucose metabolism.

Hemoglobin Glycation Index Is Associated With Cardiovascular Diseases in People With Impaired Glucose Metabolism

CONTEXT

There is a substantial interindividual variation in the association between glycated hemoglobin (HbA1c) and plasma glucose concentrations. Its impact on cardiovascular disease (CVD) has not been comprehensively evaluated.

OBJECTIVE

We examined associations between interindividual variations in HbA1c, which was estimated as the hemoglobin glycation index (HGI), and CVD.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cross-sectional analysis with 1248 treatment-naïve subjects with prediabetes or diabetes. The HGI was defined as the measured HbA1c minus predicted HbA1c, which was calculated from the linear relationship between HbA1c and fasting plasma glucose levels.

MAIN OUTCOME MEASURES

The prevalence of composite and individual CVDs including coronary artery disease (CAD), stroke, and peripheral artery disease (PAD).

RESULTS

The overall prevalence of composite CVD was 10.3% and individual prevalences of CAD, stroke, and PAD were 5.7%, 5.1%, and 1.3%, respectively. All prevalences significantly increased from the first to third tertile of HGI. In multivariate analysis, the highest HGI tertile was independently associated with composite CVD [odds ratio (95% confidence interval): 2.81 (1.59-4.98)], and individual CAD [2.30 (1.12-4.73)], stroke [3.40 (1.50-7.73)], and PAD [6.37 (1.18-34.33)] after adjustment for other CVD risk factors including HbA1c levels. Two consecutive measurements of HGI obtained on different days showed good correlation (r = 0.651, P < 0.001) and high concordance rate in the tertile classification (69.1%).

CONCLUSIONS

High HGI was independently associated with overall and individual CVDs. This result suggests that discrepancy between HbA1c and fasting glucose levels can reflect vascular health in subjects with impaired glucose metabolism.

Systemic therapy treatment patterns in patients with advanced non-small cell lung cancer (NSCLC): PIvOTAL study

The aim of this multinational retrospective cohort study, conducted at academic and community oncology centres, was to describe real‐world treatment patterns for patients with a confirmed diagnosis of advanced/metastatic (stage IIIB/IV) non‐small cell lung cancer (NSCLC) who initiated first‐line systemic therapy from January 2011 through June 2014. The study included 1265 patients in Italy, Spain, Germany, Australia, Korea, Taiwan and Brazil. The proportion of patients with squamous versus non‐squamous NSCLC was approximately 20% versus 75%, and associated patient demographic characteristics were similar in all countries, excepting race. Patients with squamous NSCLC were predominantly male and current/ex‐smokers. Biomarker tests were performed for the majority of patients with non‐squamous NSCLC, ranging from 54% (Brazil) to 91% in Taiwan, where, of those tested, 68% with non‐squamous NSCLC had positive epidermal growth factor receptor (EGFR)‐mutation status; in other countries the EGFR‐positive percentages ranged from 17% (Spain/Brazil) to 40% (Korea). Platinum‐based regimens were the most common first‐line therapy in all countries except Taiwan, where gefitinib was the most common first‐line agent. Median overall survival ranged from 9.3 months (Brazil) to 25.5 months (Taiwan). The diagnostic and treatment patterns recorded in this study were heterogeneous but largely in line with NSCLC guidelines during the study period.

Outcomes analysis of surgical and medical treatments for patients with primary aldosteronism

Patients with aldosterone-producing adenomas are treated using surgery, and patients with idiopathic hyperaldosteronism receive medical treatment using mineralocorticoid receptor antagonists (MRAs). However, the outcomes of surgical and medical treatment for primary aldosteronism (PA) remain unclear. Therefore, we compared the outcomes of surgical and medical treatment for PA and aimed to identify a specific subgroup that might benefit from medical treatment. We identified 269 patients who were treated for PA (unilateral excess: 221 cases; bilateral excess: 48 cases) during 2000-2015 at the Seoul National University Hospital and two other tertiary centers. The main outcomes were the amelioration of hypertension and hypokalemia. Treatment improved hypertension in the surgical treatment group (78.2%) and the medical treatment group (55.6%) (p = 0.001). At the last follow-up, hypokalemia was normalized in the surgical treatment group (97.1%) and the medical treatment group (93.7%, p = 0.046). Among patients with unilateral aldosterone excess, surgery provided advantages in resolving hypertension without worsening renal function. Among patients who were >60 years old or had impaired renal function, surgical and medical treatment provided similar amelioration of hypokalemia and hypertension. Three patients developed hyperkalemia after surgery, and no patients developed hyperkalemia after initiating medical treatment. The surgical treatment group exhibited a lower postoperative estimated glomerular filtration rate (eGFR) and higher serum potassium levels, compared to the medical treatment group. Surgical treatment provided better hypertension and hypokalemia outcomes among patients with PA, compared to medical treatment. However, MRAs may be appropriate for elderly patients with impaired renal function.

Differential protein stability and clinical responses of EML4-ALK fusion variants to various ALK inhibitors in advanced ALK-rearranged non-small cell lung cancer

Background

Anaplastic lymphoma kinase (ALK) inhibition using crizotinib has become the standard of care in advanced ALK-rearranged non-small cell lung cancer (NSCLC), but the treatment outcomes and duration of response vary widely. Echinoderm microtubule-associated protein-like 4 (EML4)-ALK is the most common translocation, and the fusion variants show different sensitivity to crizotinib in vitro. However, there are only limited data on the specific EML4-ALK variants and clinical responses of patients to various ALK inhibitors.

Patients and methods

By multiplex reverse-transcriptase PCR, which detects 12 variants of known EML4-ALK rearrangements, we retrospectively determined ALK fusion variants in 54 advanced ALK rearrangement-positive NSCLCs. We subdivided the patients into two groups (variants 1/2/others and variants 3a/b) by protein stability and evaluated correlations of the variant status with clinical responses to crizotinib, alectinib, or ceritinib. Moreover, we established the EML4-ALK variant-expressing system and analyzed patterns of sensitivity of the variants to ALK inhibitors.

Results

Of the 54 tumors analyzed, EML4-ALK variants 3a/b (44.4%) was the most common type, followed by variants 1 (33.3%) and 2 (11.1%). The 2-year progression-free survival (PFS) rate was 76.0% [95% confidence interval (CI) 56.8-100] in group EML4-ALK variants 1/2/others versus 26.4% (95% CI 10.5-66.6) in group variants 3a/b (P = 0.034) among crizotinib-treated patients. Meanwhile, the 2-year PFS rate was 69.0% (95% CI 49.9-95.4) in group variants 1/2/others versus 32.7% (95% CI 15.6-68.4) in group variants 3a/b (P = 0.108) among all crizotinib-, alectinib-, and ceritinib-treated patients. Variant 3a- or 5a-harboring cells were resistant to ALK inhibitors with >10-fold higher half maximal inhibitory concentration in vitro.

Conclusion

Our findings show that group EML4-ALK variants 3a/b may be a major source of ALK inhibitor resistance in the clinic. The variant-specific genotype of the EML4-ALK fusion allows for more precise stratification of patients with advanced NSCLC.

Identification of Risk Factors Associated With Clostridium difficile Infection in Liver Transplantation Recipients: A Single-Center Analysis

Clostridium difficile remains the leading cause of health care-associated infectious diarrhea, and its incidence and severity are increasing in liver transplant recipients. Several known risk factors for C difficile infection (CDI) are inherently associated with liver transplantation, such as severe underlying illness, immunosuppression, abdominal surgery, and broad-spectrum antibiotic use. We conducted a single-center retrospective case control study to characterize risk factors for CDI among patients who received a liver transplant from January 2008 to December 2012. We also examined the associations of post-transplantation CDI with transplant outcomes. Cases were defined as having diarrhea with a positive test for C difficile by either toxin A/B enzyme immunoassay (EIA) or glutamate dehydrogenase EIA and polymerase chain reaction within 1 year after transplantation. Sixty-five consecutive patients were evaluated, of which 15 (23%) developed CDI. The median time from transplantation to CDI diagnosis was 65 days (interquartile range [IQR] 13-208) and more than one-half (53%) had severe infection. Risk factors that were associated with CDI among liver transplant recipients included: (1) previous history of CDI (20% vs 0%; P = .001); (2) exposure to proton-pump inhibitor therapy (93% vs 60%; P = .015); (3) antimicrobial therapy before transplantation (47% vs 18%; P = .039); (4) a prolonged length of stay before transplantation (1 day [IQR, 1-19] vs 1 day [IQR, 0-1]; P = .028); and (5) chronic kidney disease (53% vs 20%; P = .011). There was no significant differences in patient survivals at 6 months (93% vs 96%; P = .67) and 12 months (87% vs 94%; P = .35) among CDI case and control subjects, respectively.

Sclerosing mucoepidermoid carcinoma of the sublingual gland

INTRODUCTION

Sclerosing mucoepidermoid carcinoma of the salivary gland is a rare subtype of mucoepidermoid carcinoma. The most common site of sclerosing mucoepidermoid carcinoma of the salivary glands is the parotid gland, followed by the submandibular gland, and the minor salivary glands.

OBSERVATION

Here we report the first case of sclerosing mucoepidermoid carcinoma of the sublingual gland.

DISCUSSION

Clinicians should consider sclerosing mucoepidermoid carcinoma in the differential diagnosis of salivary gland neoplasm. Surgical excision with clear margins seems to be a sufficient initial treatment option for sclerosing mucoepidermoid carcinoma of the salivary gland.

Performance of the simplified acute physiology score III in acute organophosphate poisoning: A retrospective observational study

The performances of acute physiology and chronic health evaluation (APACHE) II and simplified acute physiology score (SAPS) II have previously been evaluated in acute organophosphate poisoning. We aimed to compare the performance of the SAPS III with those of the APACHE II and SAPS II, as well as to identify the best tool for predicting case fatality using the standardized mortality ratios (SMRs) in acute organophosphate poisoning. A retrospective analysis of organophosphate poisoning was conducted. The APACHE II, SAPS II, and SAPS III were calculated within 24 h of admission. Discrimination was evaluated by calculating the area under the receiver operating characteristic curve (AUROC). The SMRs were calculated as 95% confidence intervals (CIs). In total, 100 cases of organophosphate poisoning were included. The in-hospital case fatality was 19%. The median scores of the APACHE II, SAPS II, and SAPS III were 20.0 (10.0–27.0), 41.0 (28.0–54.8), and 53.0 (36.3–68.8), respectively. The AUROCs were not significantly different among the APACHE II (0.815; 95% CI, 0.712–0.919), SAPS II (0.820; 95% CI, 0.719–0.912), and SAPS III (0.850; 95% CI, 0.763–0.936). Based on these scores and in-hospital case fatality, the SMRs for the APACHE II, SAPS II, and SAPS III were 1.01 (95% CI, 0.50–2.72), 1.01 (95% CI, 0.54 -2.78), and 0.98 (95% CI, 0.33–1.99), respectively. The SAPS III provided a good discrimination and satisfactory calibration in acute organophosphate poisoning. It was therefore a useful tool in predicting case fatality in acute organophosphate poisoning, similar to the APACHE II and SAPS II.

Effect of sarpogrelate, a selective 5-HT2A receptor antagonist, on characteristics of coronary artery disease in patients with type 2 diabetes

BACKGROUND AND AIMS

Sarpogrelate, a 5-hydroxytryptamine type 2A antagonist, is a potential antiplatelet agent. We performed a randomized study to evaluate the effect of sarpogrelate on vascular health in Korean patients with diabetes.

METHODS

Forty diabetic patients aged 58.6 ± 6.8 years with 10-75% coronary artery stenosis, as assessed by coronary computed tomography angiography, were randomly assigned to sarpogrelate 300 mg/day plus aspirin 100 mg/day (SPG + ASA group) or aspirin 100 mg/day alone (ASA group) for 6 months. The primary endpoint of this study was the change in coronary artery disease including the calcium score (CACS), maximal stenosis, and plaque volume (calcified vs. noncalcified). The secondary endpoints were changes in biochemical parameters related to glucose and lipid metabolism, and in subclinical atherosclerosis assessed by ankle-brachial index and pulse wave velocity.

RESULTS

After 6-month treatment, there was no significant difference in the changes in CACS, coronary stenosis, ankle-brachial index, and pulse wave velocity, between groups. The total plaque volume decreased from 82.4 ± 14.5 mm³ to 74.6 ± 14.4 mm³ in the SPG + ASA group, but increased from 64.9 ± 16.0 mm³ to 68.6 ± 16.3 mm³ in the ASA group (p < 0.05), mainly driven by changes in the noncalcified component (SPG + ASA group 15.6 ± 4.6 mm³ to 11.2 ± 3.7 mm³vs. ASA group 21.2 ± 6.2 mm³ to 22.8 ± 6.6 mm³, p < 0.01). Serum C-reactive protein levels and homeostasis model assessment of insulin resistance tended to decrease in the SPG + ASA group, but they were not altered in the ASA group.

CONCLUSIONS

The present study demonstrated that sarpogrelate treatment may decrease coronary artery plaque volume, particularly the noncalcified portion, in patients with diabetes.

Comparison of High-Resolution MR Imaging and Digital Subtraction Angiography for the Characterization and Diagnosis of Intracranial Artery Disease

BACKGROUND AND PURPOSE

High-resolution MR imaging has recently been introduced as a promising diagnostic modality in intracranial artery disease. Our aim was to compare high-resolution MR imaging with digital subtraction angiography for the characterization and diagnosis of various intracranial artery diseases.

MATERIALS AND METHODS

Thirty-seven patients who had undergone both high-resolution MR imaging and DSA for intracranial artery disease were enrolled in our study (August 2011 to April 2014). The time interval between the high-resolution MR imaging and DSA was within 1 month. The degree of stenosis and the minimal luminal diameter were independently measured by 2 observers in both DSA and high-resolution MR imaging, and the results were compared. Two observers independently diagnosed intracranial artery diseases on DSA and high-resolution MR imaging. The time interval between the diagnoses on DSA and high-resolution MR imaging was 2 weeks. Interobserver diagnostic agreement for each technique and intermodality diagnostic agreement for each observer were acquired.

RESULTS

High-resolution MR imaging showed moderate-to-excellent agreement (interclass correlation coefficient = 0.892-0.949; κ = 0.548-0.614) and significant correlations (R = 0.766-892) with DSA on the degree of stenosis and minimal luminal diameter. The interobserver diagnostic agreement was good for DSA (κ = 0.643) and excellent for high-resolution MR imaging (κ = 0.818). The intermodality diagnostic agreement was good (κ = 0.704) for observer 1 and moderate (κ = 0.579) for observer 2, respectively.

CONCLUSIONS

High-resolution MR imaging may be an imaging method comparable with DSA for the characterization and diagnosis of various intracranial artery diseases.

Comprehensive assessment of lipoprotein subfraction profiles according to glucose metabolism status, and association with insulin resistance in subjects with early-stage impaired glucose metabolism

BACKGROUND

Early detection of atherogenic dyslipidemia is crucial. We investigated lipoprotein subfraction parameters according to glucose metabolism status.

METHODS

We recruited 1255 lipid-lowering drug-naïve subjects with normal fasting glucose (NFG; n=200, 15.9%), impaired fasting glucose (IFG; n=443, 35.3%), or type 2 diabetes (T2D; n=612, 48.8%). Lipoprotein subfractions (1-7) were determined by polyacrylamide gel electrophoresis, separating low-density lipoprotein (LDL) into large buoyant LDL (lbLDL, LDL1-2) and small dense LDL (sdLDL, LDL3-7). Lipoprotein subfraction parameters including the sdLDL% (LDL3-7/LDL1-7), the sdLDL/lbLDL ratio (LDL3-7/LDL1-2), and weighted LDL subfraction (LDLSF) scores, were compared between groups. Their associations with insulin resistance, estimated using the homeostasis model assessment of insulin resistance, were examined.

RESULTS

The concentrations of sdLDL particles were significantly higher in subjects with T2D and IFG than in those with NFG (15.78±13.47mg/dl and 14.60±14.33mg/dl, respectively, vs. 12.22±12.31mg/dl). Compared with those with NFG, subjects with IFG or T2D had significantly a higher sdLDL% (15.98±15.26% vs. 19.50±16.21% or 21.46±16.81%, respectively), a higher sdLDL/lbLDL ratio (0.24±0.30 vs. 0.31±0.37 or 0.35±0.39), and a higher LDLSF score (2.08±0.91 vs. 2.30±1.14 or 2.36±1.17). These lipoprotein subfraction parameters had stronger associations with insulin resistance compared to conventional lipid profiles in the IFG and T2D groups.

CONCLUSIONS

Atherogenic dyslipidemia is initiated in an early stage of impaired glucose metabolism, when early intervention might be required.

Attenuation of carotid neointimal formation after direct delivery of a recombinant adenovirus expressing glucagon-like peptide-1 in diabetic rats

AIMS

Enhancement of glucagon-like peptide-1 (GLP-1) reduces glucose levels and preserves pancreatic β-cell function, but its effect against restenosis is unknown.

METHODS AND RESULTS

We investigated the effect of subcutaneous injection of exenatide or local delivery of a recombinant adenovirus expressing GLP-1 (rAd-GLP-1) into carotid artery, in reducing the occurrence of restenosis following balloon injury. As a control, we inserted β-galactosidase cDNA in the same vector (rAd-βGAL). Otsuka Long-Evans Tokushima rats were assigned to three groups (n = 12 each): (1) normal saline plus rAd-βGAL delivery (NS + rAd-βGAL), (2) exenatide plus rAd-βGAL delivery (Exenatide + rAd-βGAL), and (3) normal saline plus rAd-GLP-1 delivery (NS + rAd-GLP-1). Normal saline or exenatide were administered subcutaneously from 1 week before to 2 weeks after carotid injury. After 3 weeks, the NS + rAd-βGAL group showed the highest intima-media ratio (IMR; 3.73 ± 0.90), the exenatide + rAd-βGAL treatment was the next highest (2.80 ± 0.51), and NS + rAd-GLP-1 treatment showed the lowest IMR (1.58 ± 0.48, P < 0.05 vs. others). The proliferation and migration of vascular smooth muscle cells and monocyte adhesion were decreased significantly after rAd-GLP-1 treatment, showing the same overall patterns as the IMR. In injured vessels, the apoptosis was greater and MMP2 expression was less in the NS + rAd-GLP-1 than in the exenatide or rAd-βGAL groups. In vitro expressions of matrix metalloproteinases-2 and monocyte chemoattractant protein-1 and nuclear factor-kappa-B-p65 translocation were decreased more in the NS + rAd-GLP-1 group than in the other two groups (all P < 0.05).

CONCLUSION

Direct GLP-1 overexpression showed better protection against restenosis after balloon injury via suppression of vascular smooth muscle cell migration, increased apoptosis, and decreased inflammatory processes than systemic exenatide treatment. This has potential therapeutic implications for treating macrovascular complications in diabetes.