Nonselective left internal mammary artery angiography during right transradial coronary angiography: a simple, rapid, and safe technique

Internal mammary artery angiography is increasingly required, but the technique for left internal mammary artery (LIMA) angiography during right transradial coronary angiography is not well established. The authors investigated the feasibility and safety of a new, simple, and rapid nonselective technique. Following right transradial coronary angiography, LIMA angiography was performed using a 5 French (Fr) Judkins JL-3.5 catheter in 110 patients. The catheter, placed in the ascending aorta with its natural curve, was withdrawn slowly while being rotated clockwise to engage its tip in the proximal left subclavian artery. Contrast material was injected while sphygmomanometer cuff inflation was applied to the left upper arm. In the last 50 patients, the angiography was performed twice randomly with and without the cuff inflation. In 108 patients (98%), the catheter was successfully engaged in the subclavian artery in a mean of 11 +/- 8 seconds (range, 3-136) from the time when it was withdrawn from the ascending aorta, and nonselective LIMA angiography was successfully performed. The image quality of the angiograms was satisfactory in 103 (95%) of the 108 patients. In the last 50 patients, the image quality of the angiograms was determined satisfactory in 48 (96%) and 45 (90%) patients, with and without the cuff inflation, respectively. The difference was statistically not significant. There were no complications, including arterial dissection and thromboembolism. In conclusion, nonselective LIMA angiography can be readily and safely performed during right transradial coronary angiography using a 5 Fr Judkins JL-3.5 catheter.

Ventricular shape visualization using selective volume rendering of cardiac datasets

In this paper, we present a novel technique of improving volume rendering quality and speed by integrating original volume data and global model information attained by segmentation. The segmentation information prevents object occlusions that may appear when volume rendering is based on local image features only. Thus the presented visualization technique provides meaningful visual results that enable a clear understanding of complex anatomical structures. In the first part, we describe a segmentation technique for extracting the region of interest based on an active contour model. In the second part, we propose a volume rendering method for visualizing the selected portions of fuzzy surfaces extracted by local image processing methods. We show the results of selective volume rendering of left and right ventricle based on cardiac datasets from clinical routines. Our method offers an accelerated technique to accurately visualize the surfaces of segmented objects.

Is negative ulnar variance a risk factor for Kienböck's disease? A meta-analysis

Current treatment for Kienbock's disease using joint-leveling procedures is based on the hypothesis that the disease is caused by negative ulnar variance. The authors conducted a meta-analysis to evaluate this hypothesis, and assessed the quality of available published studies. They searched MEDLINE to collect literature that evaluated this association. Only 3 of 18 collected studies had sufficient data or study design to meet their inclusion criteria. A summary odds ratio (OR) calculated using a conservative random-effect method showed that the odds of Kienböck's disease was 3.10 times more likely for those with negative ulnar variance than those with positive or neutral ulnar variance, but this was not significant (95% confidence interval, 0.95-10.05; p = 0.06). The combined OR was unstable because of marked heterogeneity across the studies. This meta-analysis reveals that there is insufficient data to support a significant (p < 0.05) association between negative ulnar variance and Kienbock's disease.

Approach and issues relating to shield material design to protect astronauts from space radiation

One major obstacle to human space exploration is the possible limitations imposed by the adverse effects of long-term exposure to the space environment. Even before human spaceflight began, the potentially brief exposure of astronauts to the very intense random solar energetic particle (SEP) events was of great concern. A new challenge appears in deep space exploration from exposure to the low-intensity heavy-ion flux of the galactic cosmic rays (GCR) since the missions are of long duration and the accumulated exposures can be high. Since aluminum (traditionally used in spacecraft to avoid potential radiation risks) leads to prohibitively expensive mission launch costs, alternative materials need to be explored. An overview of the materials related issues and their impact on human space exploration will be given.

Clinical significance of molecular genetic changes in sporadic invasive pituitary adenomas

Several molecular and genetic changes have been found in pituitary adenomas. We looked for correlations between these changes and the degree of invasiveness of the tumors. The invasiveness of 11 pituitary adenomas was graded by Hardy classification. We examined the retinoblastoma gene (RB1.20 on chromosome 13q) and the region around the MEN1 locus (chromosome 11q13.1-5) for loss of heterozygosity. Also examined are p53 mutations using single strain conformation polymorphism, p53 protein overexpression using immuno cytochemistry, homozygous deletions of p15 and p16 by polymerase chain reaction, and cellular proliferative activity using MIB-1 antibody. Six tumors (54.5%) had an LOH at either RB1.20 or the MEN1 locus. LOHs were found more frequently in Grade 4 and stage E tumors (72% and 67%) than in Grade 3 and stage D tumors (25% and 40%). However, no mutation or overexpression of p53 was found. No homozygous deletions of p15 or p16 were identified. The cell proliferative index ranged from 0 to 3%. LOH at 11q13 and 13q may be valuable in predicting the invasiveness of pituitary adenomas.

Efficacy of single-dose SA 14-14-2 vaccine against Japanese encephalitis: a case control study

BACKGROUND

In China, since 1989, an estimated 120 million children have been immunised with the SA 14-14-2 live-attenuated Japanese encephalitis (JE) vaccine at ages 1, 2, and 6 years. A case-control study of licensed vaccine found two doses to be 98% effective. Subsequently, researchers found that single-dose vaccine efficacy was high; we aimed to confirm this result.

METHODS

During July 11-24, 1999, 160000 doses of JE vaccine were given to children aged 1-15 years, resident in three districts of Nepal. Several cases of JE were admitted to hospital from early August. We obtained names and addresses of cases with serological evidence of a recent infection from Bheri Zonal Hospital, Nepalgunj. We did a matched case-control study and calculated the odds ratio of vaccination among JE cases and age-sex matched village controls.

FINDINGS

20 children, aged 1-15 years, were identified whose illness conformed with the JE case definition and were resident in villages receiving the vaccine. None of 20 JE cases had received JE vaccine compared with 326 of 557 age-sex matched village controls. The efficacy of a single dose of JE vaccine was 99.3% (CI 94.9-100%).

INTERPRETATION

A single dose of JE vaccine is highly efficacious in preventing Japanese encephalitis when administered only days or weeks before exposure to infection.

Incomplete pancreas divisum: is it merely a normal anatomic variant without clinical implications?

BACKGROUND AND STUDY AIMS

Incomplete pancreas divisum (PD) has been generally regarded as merely a normal anatomic variant, without clinical implications. This study compares the prevalence, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment in patients with incomplete PD and those with complete PD.

PATIENTS AND METHODS

The study population consisted of 56 patients (27 with complete PD and 29 with incomplete PD), identified from 4473 newly performed endoscopic retrograde cholangiopancreatography examinations. Endoscopic treatment (minor papilla sphincterotomy with stents or nasopancreatic drainage tube insertion) was attempted in 25 symptomatic patients with PD, which was suspected to be causing the associated pancreatic diseases: acute recurrent pancreatitis (ARP) (n = 13; five patients with complete PD and eight with incomplete PD); chronic pancreatitis (CP) (n = 10: five patients with complete PD and five with incomplete PD); and pancreatic-type pain (PP) (n = 2; one patient with complete PD and one with incomplete PD). The mean follow-up period was 17 months (range 9 - 49 months).

RESULTS

In 12 of the 27 patients with complete PD--six with ARP, five with CP, and one with PP--it was suspected that PD was the cause of pancreatic disease. Ten of the 11 symptomatic patients with complete PD underwent successful endoscopic treatment (five with endoscopic minor papilla sphincterotomy and stenting, and five with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and seven of these ten patients benefited from the endoscopic treatment. In 14 of the 29 patients with incomplete PD--eight with ARP, five with CP, and one with PP--it was suspected that pancreas divisum was the cause of pancreatic disease. Thirteen of the 14 symptomatic patients with incomplete PD underwent successful endoscopic treatments (six with endoscopic minor papilla sphincterotomy and stenting, and seven with endoscopic minor papilla sphincterotomy and endoscopic nasopancreatic drainage), and eight of these 13 patients experienced clinical improvement.

CONCLUSIONS

The prevalence rate, symptom occurrence rate, clinical presentation, and outcomes of endoscopic treatment were similar in patients with complete PD and incomplete PD. Incomplete PD may therefore have similar clinical implications to those of complete PD.

Bilateral selective internal mammary artery angiography via right radial approach: clinical experience with newly designed Yumiko catheter

The radial artery has been increasingly used as a primary access site for coronary angiography and intervention. But the technique for internal mammary artery (IMA) visualization via the right radial artery has not been well described. Therefore, the study was conducted to investigate the feasibility, safety, and adequacy of selective bilateral IMA angiography via the right radial artery using the recently developed Yumiko catheter. From November 1999 to October 2000, both IMA angiographies were undertaken immediately following the diagnostic coronary angiogram taken from right transradial approach in 114 patients. IMA angiography was successfully obtained in 99% (113/114) patients. For left IMA angiography, 73 (64%), 28 (25%), and 12 (11%) imagings were obtained in a selective, a semiselective, and a nonselective way, respectively. After initial periods of 33 left-IMA-only imaging, right IMA angiography was obtained in 81 patients (phase 2). Selective right IMA imaging was done in 73 (90%), semiselective in 6, and nonselective in 2 patients. The reasons for failure of selective or semiselective visualization were severe vascular tortuosity, far distal anatomical origin of left IMA and ulcerative plaque, or acutely angled left subclavian artery. The feasibility and safety of selective and semiselective bilateral IMA angiography were demonstrated using a 5 Fr Yumiko catheter from the right radial approach. Cathet Cardiovasc Intervent 2001;54:19-24.

Colonoscopic findings in intestinal Behçet's disease

The aims of this study were to investigate the clinical and colonoscopic characteristics of patients with intestinal Behçet's disease and to compare the findings of typical and atypical intestinal Behçet's disease. Ninety-four patients diagnosed as having intestinal Behçet's disease were included. Of these, we considered 42 patients as having complete or incomplete type; these fulfilled the international criteria as "typical," and the other 52 patients were classified as having "atypical" intestinal Behçet's disease. Abdominal pain was the most common symptom (92%), followed by diarrhea and gastrointestinal bleeding. All of the 22 patients with a history of surgery had ulcers at the anastomotic site. Most of the patients, who had never been operated on, had lesions in the ileocecal area (96%). Sixty-three patients (67%) had a single ulcer. Many (76%) of the ulcers were larger than 1 cm, and the mean size of the ulcers was 2.9 cm. Most (99%) of the ulcers were round/oval or geographic in shape. Usually ulcers were deep (62%), and their margins discrete (80%). There was no difference in the endoscopic findings of typical and atypical intestinal Behçet's disease. Typical colonoscopic findings in intestinal Behçet's disease were single or a few deep ulcers with discrete margins in the ileocecal area or anastomotic site. Endoscopic characteristics of patients with intestinal involvement in the case of "suspect" or "possible" type of Behçet's disease that lack the systemic manifestations of Behçet's disease were in accord with those in "complete" or "incomplete" types of Behçet's disease, who fulfill the International Study Group for Behçet's Disease criteria.

Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy

BACKGROUND

Endoscopic biliary sphincterotomy (EST) is a well-established procedure for bile duct stone extraction. Bile duct stones can be classified as primary or secondary. However, few data are available on the recurrence of primary and secondary bile duct stones after EST. Therefore risk factors for the recurrence of primary bile duct stones after EST were prospectively studied.

METHODS

Between 1991 and 1997, 61 patients underwent EST for primary bile duct stones. All met the following criteria: (1) previous cholecystectomy without bile duct exploration, (2) detection of bile duct stones at least 2 years after initial cholecystectomy. Mean follow-up was 2.2 years. Fourteen patients were lost to follow-up. The recurrence of primary bile duct stones was defined as the detection of bile duct stones no sooner than 6 months after complete clearance of primary bile duct stones.

RESULTS

The overall recurrence rate of primary bile duct stones was 21% (10 of 47). Two significant risk factors for recurrence were identified by multivariate analysis: (1) patients with a bile duct diameter of 13 mm or greater after stone removal had recurrences more frequently than those with a duct diameter of 13 mm or less, and (2) patients whose papilla was located on the inner rim or deep within a diverticulum, so that the papillary orifice was not visible endoscopically, had more frequent recurrences than patients with a papilla outside the diverticulum, or no peripapillary diverticulum.

CONCLUSION

The independent risk factors for recurrence of primary bile duct stones were sustained dilation of the bile duct even after complete removal of stones and location of the papilla on the inner rim or deep within a diverticulum.

Combined right transradial coronary angiography and selective carotid angiography: safety and feasibility in unselected patients

We evaluated the safety and feasibility of ad hoc carotid angiography following the right transradial coronary angiography. Selective carotid angiography was performed subsequent to coronary angiography in 213 consecutive patients. A 5 Fr Simmons catheter was reformed in descending or ascending aorta, then, withdrawn and rotated to cannulate the left and right carotid artery. Both carotid angiography was performed selectively in 211 (99%) patients. In two patients with severely tortuous subclavian artery, selective cannulation of the left carotid artery failed. There was no thromboembolism or arterial dissection. After the learning phase of 50 patients, the time to reform the catheter in aorta and to cannulate the left and right carotid artery was 50 +/- 77, 66 +/- 68, and 58 +/- 57 sec, respectively. Total procedural time was 195 +/- 145 sec. In conclusion, ad hoc carotid angiography can be performed reliably and safely following the right transradial coronary angiography. It might be useful for evaluation of an isolated or associated carotid artery stenosis. Cathet Cardiovasc Intervent 2001;53:380-385.

Effects of conventional and new peritoneal dialysis solutions on human peritoneal mesothelial cell viability and proliferation

OBJECTIVE

To investigate the biocompatibility of "new" peritoneal dialysis (PD) solutions with bicarbonate/lactate buffer, non glucose osmotic agents (icodextrin or amino acids), neutral pH, and low levels of glucose degradation products (GDPs).

DESIGN

Using M199 culture medium as a control, we compared conventional and new PD solutions with respect to their effects on the viability of human peritoneal mesothelial cells (HPMCs) [using lactate dehydrogenase (LDH) release], on DNA damage in HPMCs [using single-cell gel electrophoresis (Comet assay)], and on HPMC proliferation (using [3H]-thymidine incorporation). The experiments were performed after cell growth was synchronized by incubation with serum-free media for 24 hours. The PD solutions tested included commercial 1.5% glucose and 4.25% glucose solutions with 40 mmol/L lactate (D 1.5 and D 4.25, respectively), 7.5% icodextrin (E), 1.1% amino acid (N), 1.5% glucose solution in a triple-chambered bag (Bio 1.5), 1.5% glucose solution in a dual-chambered bag with neutral pH (Bal 1.5), and 1.5% glucose and 4.25% glucose solution containing 25 mmol/L bicarbonate and 15 mmol/L lactate (P 1.5 and P 4.25, respectively).

RESULTS

When HPMCs were continuously exposed to undiluted PD solutions, D 1.5, D 4.25, P 4.25, and E increased LDH release by more than 60% at 24 hours. All PD solutions tested increased LDH release by more than 75% at 96 hours. With 2-fold diluted PD solutions, only D 4.25 significantly increased LDH release at 96 hours, though not at 24 hours. When cells were exposed to undiluted PD solutions for 60 min and allowed to recover in M199 for up to 96 hours, LDH release was significantly higher at 24-96 hours in E (55%-69%) and D 1.5 (48%-72%) as compared with control [M199 (18%)]. Release of LDH was significantly lower with PD solutions containing lower levels of GDPs than those in D 1.5, suggesting that GDPs may have a role in cell viability. The D solutions (D 1.5 and D 4.25) and E solution also induced significant DNA damage. Both LDH release and DNA damage by D and E were significantly attenuated by adjusting the solution pH to 7.4, suggesting that low pH may be implicated in PD solution-induced DNA damage and cell death. When diluted 2-fold, D 1.5, D 4.25, and P 4.25 decreased [3H]-thymidine incorporation to 43%, 34%, and 41% of control, respectively, at 24 hours and to 45%, 26%, and 35% of control, respectively, at 96 hours. When cells were exposed to undiluted PD solutions for 5 minutes and allowed to recover in M199 for up to 96 hours, D1.5 and P 4.25--but not D 4.25--significantly inhibited cell proliferation at 24 hours. This effect was sustained up to 96 hours.

CONCLUSIONS

The present in vitro data demonstrate that PD solutions with low pH, or high levels of GDPs, or both, promote HPMC death and DNA damage, and that PD solutions with high osmolality inhibit cell proliferation. Solutions with neutral pH, amino acids, and "low GDPs" appear to be more biocompatible than conventional PD solutions. These results require confirmation in in vivo animal and clinical studies.

Acute funisitis of preterm but not term placentas is associated with severe fetal inflammatory response

Acute funisitis, whose basic pathologic feature is umbilical vasculitis, constitutes a type of fetal inflammatory response to intrauterine infection. In the present study, a comparative analysis was performed between the clinicopathologic profiles of acute funisitis in term and preterm placentas along with measurement of fetal plasma interleukin 6 (IL-6) levels by specific immunoassay to assess the different biologic implications for the fetus. Acute funisitis in preterm placentas showed a significantly higher incidence of umbilical arteritis (P <.000001), higher fetal plasma IL-6 level (P <.0001), and higher prevalence of major perinatal morbidities (P <.0001). To assess the possible variation in fetal cell response to infectious agents according to gestational age, amnion cells and placental villous tissues obtained at different gestational ages were treated with bacterial lipopolysaccharides, and the IL-6 level of the culture media was assayed. Amnion cells and placental villous tissues from preterm placenta showed a more pronounced cytokine response than those from term placenta. The findings of this study indicate that the clinicopathologic significance of acute funisitis in term placentas is different from that of preterm placentas. Furthermore, they indicate that the robust inflammatory response of the fetus associated with elevated fetal plasma IL-6 level may reflect the biologic needs of the premature fetus to escape from the hostile intrauterine environment.

uPA and uPAR contribute to NK cell invasion through the extracellular matrix

BACKGROUND

The urokinase plasminogen activator (uPA) system has been implicated in cellular invasiveness of tumor cells and immune cells. Herein we provide evidence for the production by natural killer (NK) cells of both uPA and its receptor (uPAR).

MATERIALS AND METHODS

Western blot analysis, RTPCR, casein/plasminogen zymography, and fluorescence microscopy were employed to detect uPA and uPAR on NK cells. NK cell invasiveness was examined using Matrigel invasion assays.

RESULTS

NK cell uPA appeared at its characteristic molecular weights, is enzymatically active in casein/plasminogen zymography, and is recognized by monoclonal antibodies. uPAR was detected by RTPCR and fluorescence microscopy. Matrigel invasion assays demonstrated an active role of uPA in NK cell invasion.

CONCLUSION

The uPA system contributes to extracellular matrix (ECM) degradation by NK cells, which may be essential for NK cell accumulation into metastases, and may be prerequisite for their killing of tumor cells following NK cell adoptive transfer.

Prevalence of central venous occlusion in patients with chronic defibrillator leads

BACKGROUND

Many patients with previously implanted ventricular defibrillators are candidates for an upgrade to a device capable of atrial-ventricular sequential or multisite pacing. The prevalence of venous occlusion after placement of transvenous defibrillator leads is unknown. The purpose of this study was to determine the prevalence of central venous occlusion in asymptomatic patients with chronic transvenous defibrillator leads.

METHODS

Thirty consecutive patients with a transvenous defibrillator lead underwent bilateral contrast venography of the cephalic, axillary, subclavian, and brachiocephalic veins as well as the superior vena cava before an elective defibrillator battery replacement. The mean time between transvenous defibrillator lead implantation and venography was 45 +/- 21 months. Sixteen patients had more than 1 lead in the same subclavian vein. No patient had clinical signs of venous occlusion.

RESULTS

One (3%) patient had a complete occlusion of the subclavian vein, 1 (3%) patient had a 90% subclavian vein stenosis, 2 (7%) patients had a 75% to 89% subclavian stenosis, 11 (37%) patients had a 50% to 74% subclavian stenosis, and 15 (50%) patients had no subclavian stenosis.

CONCLUSIONS

The low prevalence of subclavian vein occlusion or severe stenosis among defibrillator recipients found in this study suggests that the placement of additional transvenous leads in a patient who already has a ventricular defibrillator is feasible in a high percentage of patients (93%).

Prurigo pigmentosa from contact allergy to chrome in detergent

Prurigo pigmentosa is a recurrent inflammatory dermatosis characterized by pruritic erythematous papules and reticulate hyperpigmentation that occurs most frequently in spring and summer. The etiology of prurigo pigmentosa remains unknown. Numerous authors have suggested that various contact allergens may be pathogenic or triggering factors, but nearly all attempts to identify an allergen have been unsuccessful. We report a case of prurigo pigmentosa induced by contact allergy to chrome in detergent, supporting the conclusion that contact allergens such as chrome may play a rôle in inducing prurigo pigmentosa.

The application of comparative genomic hybridization as an additional tool in the chromosome analysis of acute myeloid leukemia and myelodysplastic syndromes

In acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) there are frequently complex karyotypes with multiple structurally altered chromosomes, many of which are marker chromosomes of unknown origin. The aim of this study was to apply comparative genomic hybridization (CGH) to cases of AML or MDS in transformation submitted for routine cytogenetic analysis to investigate whether this approach would yield any further information and, if possible, to predict which cases would benefit from CGH analysis. Nineteen cases with AML or MDS in transformation were analyzed. CGH revealed nine cases with gains or losses of chromosomal material. In six of these cases the chromosomal location of this material was not apparent from cytogenetic analysis especially when multiple markers were present. By using fluorescence in situ hybridization (FISH) with specific libraries for the chromosome regions that showed discordance between CGH and conventional cytogenetics, we were able to identify the chromosome location of material within the karyotype. In this group of six patients, four cases of an unbalanced translocation involving regions of chromosomes 5 and 17 were characterized. Three of these cases had additional abnormalities, including two cases with regions of amplification in which oncogenes are located (MYC, MLL) and one case with a dic(7;21)(p10;p10). In all six cases it was possible to characterize complex chromosomal aberrations such as derivative chromosomes, marker chromosomes, and ring chromosomes. This study demonstrates that CGH can detect true gain and loss of critical chromosome regions more accurately than conventional karyotyping in cases with very complex karyotypes, and can thus prove useful in predicting prognosis and pinpointing areas of the genome that require further study. Also, CGH can be a useful technique to identify the origin of marker chromosomes, and it can assist in choice of probes for confirmatory FISH, when there is no clue provided from the analysis of G-banded chromosomes.

Effect of postoperative atrial fibrillation on length of stay after cardiac surgery (The Postoperative Atrial Fibrillation in Cardiac Surgery study [PACS(2)]

Atrial fibrillation (AF) after cardiac surgery is thought to increase length of stay (LOS). A clinical pathway focused on the management of postoperative AF, including prophylaxis with beta blockers, was implemented to assess the effect of AF on LOS after cardiac surgery. Data were obtained on consecutive cardiac surgery patients in preoperative normal sinus rhythm, no prior history of AF, and no chronic antiarrhythmic therapy from January to May 1995 (control) and November 1996 to June 1997 (pathway). Statistical analysis was performed to assess the effect of postoperative AF on the LOS, clinical outcomes, and cost after cardiac surgery. Despite the clinical pathway, the LOS (7 days for both periods; p = 0.12) and incidence of AF (28.9% vs 28.4%; p = 0.92) remained unchanged. Unadjusted direct costs were 15% higher in the pathway period (p <0.001). Increased rates of beta-blocker therapy had a marginal effect on the incidence of postoperative AF, except in the group who only underwent primary coronary artery bypass graft surgery (31.2% vs 25.3%; p = 0.31). Multivariate analysis revealed that AF contributed only 1 to 1.5 days to the LOS. Thus, this investigation represents the most recent analysis of the effects of postoperative AF on LOS, clinical outcomes, and cost after cardiac surgery. Unlike prior studies, the impact of postoperative AF is less prominent in the current era of cardiac surgical care regardless of the presence of a clinical pathway addressing AF.

Cardiac risk assessment in noncardiac thoracic surgery

Preoperative cardiac risk assessment for noncardiac thoracic surgery is limited by the lack of data specific to this type of surgery, especially prospective, controlled data. However, the value of clinical predictors in determining accurate postoperative cardiac outcomes is a reliable tool. Thus, the approach is similar to traditional cardiac risk assessment for noncardiac surgery. The essential elements of cardiovascular evaluation as it pertains to noncardiac thoracic surgery are reviewed with a specific focus on coronary artery disease, perioperative arrhythmias, and selected topics relevant to noncardiac thoracic surgery. The core recommendations of the clinical guidelines by the American College of Cardiology and American Heart Association are discussed in the context of noncardiac thoracic surgery.

Electrogram polarity and cavotricuspid isthmus block during ablation of typical atrial flutter

INTRODUCTION

The atrial activation sequence around the tricuspid annulus has been used to assess whether complete block has been achieved across the cavotricuspid isthmus during radiofrequency ablation of typical atrial flutter. However, sometimes the atrial activation sequence does not clearly establish the presence or absence of complete block. The purpose of this study was to determine whether a change in the polarity of atrial electrograms recorded near the ablation line is an accurate indicator of complete isthmus block.

METHODS AND RESULTS

Radiofrequency ablation was performed in 34 men and 10 women (age 60 +/- 13 years [mean +/- SD]) with isthmus-dependent, counterclockwise atrial flutter. Electrograms were recorded around the tricuspid annulus using a duodecapolar halo catheter. Electrograms recorded from two distal electrode pairs (E1 and E2) positioned just anterior to the ablation line were analyzed during atrial flutter and during coronary sinus pacing, before and after ablation. Complete isthmus block was verified by the presence of widely split double electrograms along the entire ablation line. Complete bidirectional isthmus block was achieved in 39 (89%) of 44 patients. Before ablation, the initial polarity of E1 and E2 was predominantly negative during atrial flutter and predominantly positive during coronary sinus pacing. During incomplete isthmus block, the electrogram polarity became reversed either only at E2, or at neither E1 nor E2. In every patient, the polarity of E1 and E2 became negative during coronary sinus pacing only after complete isthmus block was achieved. In 4 patients (10%), the atrial activation sequence recorded with the halo catheter was consistent with complete isthmus block, but the presence of incomplete block was accurately detected by inspection of the polarity of E1 and E2.

CONCLUSION

Reversal of polarity in bipolar electrograms recorded just anterior to the line of isthmus block during coronary sinus pacing after ablation of atrial flutter is a simple, quick, and accurate indicator of complete isthmus block.

Retrieval of dislodged and disfigured transradially delivered coronary stent: report on a case using forcep and antegrade brachial sheath insertion

We report a case of dislodged and damaged stent during transradial coronary procedure using 6 Fr device, which was successfully retrieved by using a forcep and 8 Fr antegrade brachial sheath. The disfigured and bulky stent can be removed, after their retrieval from the coronary circulation, using a forcep inserted through an 8 Fr brachial artery sheath if the radial artery is deemed too small to accommodate larger sheath.

Characterization of four isolates of Bombyx mori nucleopolyhedrovirus

Bombyx mori nucleopolyhedroviruses (BmNPVs), isolated from a sericultural Korean farm, were purified and characterized by their DNA restriction pattern, virus replication, polyhedra production and gene structures. The EcoR I and Sal I fragments showed similar overall patterns with minor difference but distinguishable patterns in each isolate. There was no significant difference in the virus replication pattern, yield of total polyhedra production and polyhedra morphology, but the yield of released polyhedra by BmNPV-K1 in Bm5 cells was 2 to 5 times higher than that of other isolates. In comparative studies of p10 gene, BmNPV-K1 and K3 had same structure and they encoded a protein consisting of 94 amino acids. Although BmNPV-K2 encoded the same length of amino acids with BmNPV-K1 and K3, it had different structure, and BmNPV-K4 had the p10 gene encoding 70 amino acids.

Plasma levels of interleukin-6 and interleukin-10 are affected by ketorolac as an adjunct to patient-controlled morphine after abdominal hysterectomy

OBJECTIVE

Because morphine affects various immune functions, patient-controlled analgesia with morphine may further deteriorate the immune mechanisms after surgery. Therefore, the purpose of this study was to determine differences between morphine patient-controlled analgesia and a combination of morphine and ketorolac in interleukin-6 and interleukin-10 responses, and in analgesia and morphine-related side effects.

DESIGN

Prospective study.

PATIENTS

Twenty-two patients who underwent abdominal hysterectomy were classified randomly into two groups: (1) patient-controlled analgesia with morphine; and (2) patient-controlled analgesia with a combination of morphine and ketorolac. Blood samples to measure cytokines were collected at preoperatively, immediately postoperatively, and 2 hours, 4 hours, and 24 hours postoperatively.

OUTCOME MEASURES

Plasma was separated and frozen until the analysis of cytokines using enzyme-linked immunosorbent assays. Postoperative pain was assessed using a visual analog score. Sedation was checked based on a protocol developed at the Samsung Medical Center.

RESULTS

In the two groups, interleukin-6 increased immediately postoperatively, and it remained consistent for 24 hours. Interleukin-10 concentrations peaked at 2 hours postoperatively and progressively decreased. Cytokine concentrations between the two groups were significantly different for interleukin-6 24 hours postoperatively (p = 0.026) and for interleukin-10 4 hours postoperatively (p = 0.045). Total analgesic use was not different, but morphine consumption was significantly different (p = 0.037 at 4 hours postoperatively, p = 0.015 at 24 hours postoperatively). Pain scores, sedation, and side effects were unaffected by the patient-controlled analgesia regimen.

CONCLUSIONS

The authors conclude that supplementation using ketorolac plus administration of morphine modifies cytokine responses and may contribute to immune augmentations during postoperative periods.

Characterization of primary pure cholesterol hepatolithiasis: cholangioscopic and selective cholangiographic findings

BACKGROUND

Primary pure cholesterol hepatolithiasis has been described recently. The aim of this study was to analyze its clinical and radiologic features, focusing on the cholangioscopic and selective cholangiographic findings.

METHODS

Primary pure cholesterol hepatolithiasis was identified in 3% (6 of 172) of patients who were treated with cholangioscopic stone removal for primary hepatolithiasis during the study period from 1995 to 1999. These 6 consecutive patients (M/F 5:1, mean age 40 years) were enrolled in the study. They underwent abdominal US, CT, endoscopic retrograde cholangiography (ERC), and percutaneous transhepatic cholangioscopy (PTCS). After confirming that the stones were of the cholesterol type, cholangioscopic stone removal via the percutaneous transhepatic route was performed. For the prevention of recurrence, ursodeoxycholic acid (10 mg/kg/day) was prescribed during follow-up.

RESULTS

US demonstrated high echogenicity with strong shadowing in dilated peripheral ducts, whereas CT failed to demonstrate any intraductal abnormal density or calcification except localized duct dilatation. PTCS demonstrated multiple, white to yellowish stones that were morphologically readily distinguishable from brown pigment intrahepatic stones. In all patients, selective cholangiography disclosed the ductal abnormalities, which could not be delineated by ERC in 4 patients. Complete stone removal by PTCS was achieved in 5 of 6 patients. During follow-up (12 to 49 months, mean 22 months), they were asymptomatic and stone recurrence was not detected by US.

CONCLUSIONS

Primary pure cholesterol hepatolithiasis is distinguishable from the more common brown pigment hepatolithiasis by its cholangioscopic and selective cholangiographic characteristics.

Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence

BACKGROUND

Percutaneous transhepatic cholangioscopy (PTCS) has a major role in the treatment of hepatolithiasis. The aims of this study were to evaluate immediate and long-term results of PTCS treatment and to elucidate the risk factors for recurrence of stones or cholangitis.

METHODS

A retrospective study was conducted of patients with hepatolithiasis who underwent PTCS treatment. A total of 92 patients underwent PTCS treatment and 68 were followed for 24 to 60 months (median 42 months).

RESULTS

Complete clearance of stones was achieved in 74 (80%) patients. The rate of complete clearance was significantly lower in patients with severe intrahepatic strictures compared with that for those with no strictures (14 of 24, 58% vs. 16 of 16, 100%, p < 0.01) and those with mild to moderate strictures (14 of 24, 58% vs. 44 of 52, 85%, p < 0.05). Patients with severe intrahepatic strictures had a higher recurrence rate than those with no or mild strictures (100% vs. 28%, p < 0.01). In addition the recurrence rate in patients with advanced biliary cirrhosis (Child's class B or C) was higher than in those with no or mild (Child's class A) cirrhosis (89% vs. 29%, p < 0.01). In patients with type I and II hepatolithiasis (Tsunoda classification), stones recurred in 2 (12%) patients at 28 and 32 months after successful stone removal, without further recurrence afterwards. The recurrence rate in patients with type III and IV hepatolithiasis increased gradually up to 50% at 60 months of follow-up.

CONCLUSIONS

Severe intrahepatic stricture was the only factor that affected the immediate success rate of PTCS in the treatment of hepatolithiasis. Several risk factors including severe biliary stricture, advanced biliary cirrhosis and Tsunoda type III and IV affected the long-term results.

Complete atrioventricular block after valvular heart surgery and the timing of pacemaker implantation

The natural history of patients who developed complete atrioventricular block after valvular heart surgery was investigated to determine the optimal timing for pacemaker implantation. Patients who developed complete atrioventricular block within 24 hours after operation, which then persisted for > 48 hours, were unlikely to recover; such patients could potentially undergo earlier pacemaker implantation if otherwise ready for discharge.

Diastolic dysfunction in the presence of left ventricular systolic dysfunction: implications of beta-adrenergic blocking therapy

The contribution of left ventricular diastolic dysfunction to the impairment in overall left ventricular performance in patients with systolic dysfunction is underappreciated. This article summarizes the available data on diastolic dysfunction in patients with congestive heart failure in which the predominant abnormality was thought to be left ventricular systolic dysfunction. The prevalence and identification of diastolic abnormalities and their clinical relevance are addressed, particularly the role of beta-adrenergic blocking therapy. The potential benefits of beta-adrenergic blocking therapy to diastolic performance are discussed from both a hemodynamic and clinical standpoint, with the implication that diastolic performance and its modulation should be considered in future investigations. (c)2001 by CHF, Inc.

Isolation of novel cDNA encompassing the ADU balanced translocation break point in the DiGeorge critical region

DiGeorge syndrome (DGS) is a developmental field defect of the third and fourth pharyngeal pouches that are associated with congenital heart defects, hypoparathyroidism, cell-mediated immunodeficiency, velopharyngeal insufficiency, and craniofacial anomalities. Approximately 90% of patients exhibit monosomy in the 22q11 region. In order to isolate the critical gene responsible for DGS, the cDNA libraries were screened with a probe containing the ADU balanced translocation break point, that is a locus reported in one patient (ADU) caused by a balanced translocation between chromosomes 22 and 2. Out of 10(6) clones, three independent overlapping clones were isolated, which were assumed to have originated from a single transcript, DGCR7. This transcript contained a 175-aa long open reading frame (ORF), encoding an acidic (pI = 5.81) and a proline-rich peptide, which are often found in the activation domain of several transcription factors. Also, it was predicted to be a nuclear protein. Northern hybridization detected an approx 1.9 kb transcript in all fetal and adult tissues tested, with strong expression in the fetal liver and kidney. In the case of adult tissues, strong expression was also detected in areas such as the heart, skeletal muscle, liver, and kidney.

Electroacupuncture may relax the sphincter of Oddi in humans

BACKGROUND

This study was designed to evaluate the effects of electroacupuncture on sphincter of Oddi (SO) motility in humans and to associate the manometric findings with cholecystokinin (CCK) plasma levels.

METHODS

Eleven patients (M:F = 5:6) with various kinds of biliary disorders were enrolled. SO motility was monitored with conventional low-compliance, continuous perfusion technique at ERCP (n = 9) or via percutaneous transhepatic cholangioscopy (n = 2). After baseline monitoring for phasic wave contractions of SO, electroacupuncture was applied at a specific acupoint GB 34. A nonspecific acupoint 5 cm away from GB 34 was selected as a control. Manometric parameters of the SO were also measured in 6 subjects during stimulation of the control acupoint. CCK plasma levels were measured during electroacupuncture stimulation.

RESULTS

All manometric parameters including basal pressure, amplitude, frequency, and duration of phasic wave contractions of the SO were significantly decreased (p < 0.05) during electroacupuncture stimulation. The inhibition of SO contractility was accompanied by increased CCK plasma levels. After discontinuation of electroacupuncture stimulation, restoration of amplitude and duration to basal conditions was noted. A tendency toward return of SO basal pressure and contractile frequency to baseline was also observed. Stimulation of the control acupoint did not affect SO contractility.

CONCLUSION

Electroacupuncture stimulation of acupoint GB 34 resulted in reversible inhibition of SO contraction in humans. The response of SO to electroacupuncture stimulation may be mediated by some neurohormonal mechanisms including CCK release.

Expression of neutrophil collagenase (MMP-8) in Jurkat T leukemia cells and its role in invasion

BACKGROUND

Previous studies have shown that MMP-8, the neutrophil collagenase, was expressed in neutrophils, chondrocytes and rheumatoid synovial fibroblasts.

MATERIALS AND METHODS

We used semi-quantitative RT-PCR analysis, Western blotting, and immunofluorescence assays to determine the expression of MMP-8 in Jurkat T cells.

RESULTS

We have determined the expression of MMP-8 from Jurkat cells and the down-regulation of its expression by genistein, a principal soy isoflavone. Genistein inhibited the invasion of Jurkat cells through a model basement membrane by about 75%, similar to the inhibition by BB-94, a synthetic MMP inhibitor. Genistein also down-regulated the expression of MMP-13, but slightly up-regulated the expression of TIMP-1 and TIMP-2.

CONCLUSIONS

Our findings documented for the first time the expression of the neutrophil collagenase by a T-cell line. We also determined the inhibition of Jurkat cell invasion by genistein, which was in part mediated through the regulation of the expression of MMPs and TIMPs.

The effect of tissue plasminogen activator on premacular hemorrhage

BACKGROUND AND OBJECTIVE

Early vitrectomy is recommended for eyes with premacular hemorrhage, which causes fibrovascular proliferation and macular traction. The purpose of this study was to investigate the therapeutic effects of tissue plasminogen activator (tPA) on premacular hemorrhage, and the clearing of hemorrhage from the macula.

PATIENTS AND METHODS

The authors injected tPA (25-37.5 microg) into the vitreous cavity of 13 eyes with premacular hemorrhage. The causes of premacular hemorrhage were diabetic retinopathy in 11 eyes and traumatic injuries in 2 eyes. Prior to tPA injection, 4 eyes had complete posterior vitreous detachment (PVD) and 9 eyes had no PVD.

RESULTS

After tPA injection, the hemorrhages in 10 eyes were completely absorbed. They were absorbed partially in 2 eyes and were not absorbed at all in 1 eye. Absorption of hemorrhage in the 4 eyes with complete PVD took an average of 5.5 days, and in the 6 eyes with no PVD, it took an average of 12.7 days (P=0.002). After tPA injection, visual acuity improved in 9 eyes, remained stable in 3 eyes, and worsened in 1 eye. In 5 eyes, pars plana vitrectomy (PPV) was required after tPA injection because of recurrent vitreous hemorrhage, macular traction or nonabsorbed premacular hemorrhage.

CONCLUSION

TPA seems to be a good alternative method of treatment for premacular hemorrhage, especially in eyes with complete PVD. It appears to improve vision and defer the need for PPV.

Diagnostic pitfalls in the cholangiographic diagnosis of choledochoceles: cholangiographic quality and its effect on visualization

BACKGROUND

We wanted to establish reasonable cholangiographic diagnostic criteria by determining the sensitivity of cholangiography in detecting choledochoceles and those factors that could compromise visualization of choledochoceles.

METHODS

Over 4 years, 21 patients (seven male, 14 female; mean age = 67 years) were confirmed as having choledochoceles on endoscopic retrograde cholangiopancreatography (ERCP). Cholangiographic diagnosis was made by following three criteria: a radiolucent halo around the distal common bile duct (CBD), bulbous dilatation of the distal CBD, and the presence of sequential morphologic changes on serial cholangiography. Any two or more combinations of these three criteria were considered enough to diagnose a choledochocele on cholangiography. We compared cholangiographic imaging findings with the ERCP results.

RESULTS

Of 21 patients with choledochoceles, nine (43%) were correctly diagnosed on cholangiography. A radiolucent halo was present in six (28%) patients; four of these cases showed optimal duodenal filling, one showed faint duodenal filling, and one showed poor duodenal filling. The shapes of the distal CBD were bulbous, conelike, and blunt. Morphologic changes such as collapsing and bulging of the choledochocele could be seen in 12 (57%) patients on serial cholangiography. Waists were seen in 11 (52%), pseudowebs in four (19%), and wrinkling of the distal CBD in seven (33%).

CONCLUSION

Cholangiography should be obtained with optimal timing and adequate conditions to diagnose choledochocele correctly.

Intrathecal midazolam increases the analgesic effects of spinal blockade with bupivacaine in patients undergoing haemorrhoidectomy

In the present double-blind study we aimed to evaluate the postoperative analgesic effects of intrathecal midazolam with bupivacaine following haemorrhoidectomy. Forty-five patients were randomly allocated to one of three groups: the control group received 1 ml of 0.5% heavy bupivacaine plus 0.2 ml of 0.9% saline intrathecally, group BM1 received 1 ml of 0.5% bupivacaine plus 0.2 ml of 0.5% preservative-free midazolam and group BM2 received 1 ml of 0.5% bupivacaine plus 0.4 ml of 0.5% midazolam. Time to first analgesia was significantly greater in the midazolam groups than in the placebo and significantly less in the BM1 group than in the BM2 group.

Y chromosome microdeletions in idiopathic azoospermia and non-mosaic type of Klinefelter syndrome

The objective of this study was to elucidate the cause of the spermatogenic defect in idiopathic azoospermia and non-mosaic type of Klinefelter syndrome. Genomic DNAs from 9 cases of Korean idiopathic azoospermia and 6 of Korean non-mosaic type of Klinefelter syndrome were used for the detection of Y chromosome microdeletions by polymerase chain reaction using 60 primers. Microdeletions of the Y chromosome were found in 1 of 9 (11.1%) patients with idiopathic azoospermia, whereas none was deleted in non-mosaic type of Klinefelter syndrome. This result suggests that Y chromosome microdeletions could be one of the etiologic factors in idiopathic azoospermia.

A small-scale survey on the status of intestinal parasite infections in rural villages in Nepal

The status of intestinal parasite infections was investigated in two rural villages (Chitrasar, Jerona) in Chitwan District, Nepal in 1999. Stool examination was performed with a total of 300 specimens from schoolchildren by formalin-ether sedimentation technique. The prevalence rate of intestinal parasite infections in the surveyed areas was 44.0%. The prevalence rate in Jerona was slightly higher than that in Chitrasar. The prevalence rate of intestinal parasite infections in female was slightly higher than that in male without statistically significant difference. Entamoeba coli was the most commonly found protozoan parasite (21.0%) followed by Giardia lamblia (13.7%) and others (5.3%). Hookworm was the most prevalent intestinal helminth (13.0%) followed by Trichuris trichiura (3.0%) and others (5.0%). Forty-three specimens (14.3%) showed mixed infections. It is necessary to implement large-scale treatment with anthelminthics, health education and sanitary improvement for intestinal parasite control in the surveyed areas.

Protein kinase C inhibitors attenuate protective effect of high glucose against hypoxic injury in H9c2 cardiac cells

In this study, we demonstrated that PKC inhibitors significantly attenuated the cardioprotective effect produced by high-glucose (22 mM) treatment for 48 h against hypoxic injury in H9c2 cardiac cells. PKC activators mimicked the cardioprotective effect of high glucose. These results suggest a possible role of PKC activation in high-glucose--induced protection.

Effects of digoxin on acute, atrial fibrillation-induced changes in atrial refractoriness

BACKGROUND

Atrial fibrillation (AF) shortens the atrial effective refractory period (ERP) and predisposes to further episodes of AF. The acute changes in atrial refractoriness may be related to tachycardia-induced intracellular calcium overload. The purpose of this study was to determine whether digoxin, which increases intracellular calcium, potentiates the acute effects of AF on atrial refractoriness in humans.

METHODS AND RESULTS

In 38 healthy adults, atrial ERP was measured at basic drive cycle lengths (BDCLs) of 350 and 500 ms after autonomic blockade. Nineteen patients had been treated with digoxin for 2 weeks. After a several-minute episode of AF, atrial ERP was measured serially at alternating BDCLs. Compared with pre-AF ERPs, the first post-AF ERPs were significantly shorter in both the digoxin and the control groups (P:<0.001). The post-AF ERP at a BDCL of 350 ms shortened to a greater degree in the digoxin group (37+/-16 ms) than in the control group (20+/-13 ms, P:<0.001); similar changes occurred at a BDCL of 500 ms. During post-AF determinations of the atrial ERP, secondary AF episodes occurred significantly more often in the digoxin group (32% versus 16%; P:<0. 04).

CONCLUSIONS

After a brief episode of AF, digoxin augments the shortening that occurs in atrial refractoriness and predisposes to the reinduction of AF. These effects occur in the setting of autonomic blockade and therefore are more likely to be due to the effects of digoxin on intracellular calcium than to its vagotonic effects.

Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture

BACKGROUND

An irregularly dilated and tortuous vessel, the so-called tumor vessel, is considered to be one of the cholangioscopic features that suggest biliary malignancy. This is a prospective analysis of the presence of a tumor vessel as a finding that discriminates between benign and malignant biliary strictures.

METHODS

From August 1997 to August 1998, a total of 63 patients with biliary strictures diagnosed with endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography obtained during percutaneous transhepatic biliary drainage tube placement were included in this study. Strictures were characterized as benign or malignant based on the observation of tumor vessels. The results were compared with those of percutaneous transhepatic cholangiography-guided biopsy and final diagnosis.

RESULTS

Forty-one patients were confirmed to have malignant strictures and 22 had benign biliary strictures. Cancer was confirmed by histopathologic evaluation of biopsies in 33 of 41 patients with malignancy (80.4%). Tumor vessel was seen in 25 of 41 patients with malignancy (61%). No patients with benign stricture had tumor vessels. Of the 8 patients with negative percutaneous transhepatic cholangioscopy-guided biopsies but with a final diagnosis of malignancy, 6 had tumor vessels. Combining the observation of tumor vessel and percutaneous transhepatic cholangiography-guided biopsy resulted in a diagnosis of malignancy in 39 of 41 patients (96%) and significantly increased the rate of preoperative diagnosis when compared with percutaneous transhepatic cholangiography-guided biopsy or presence of tumor vessel alone (p<0.05).

CONCLUSION

The presence of tumor vessel may be a valuable cholangioscopic finding that indicates the presence of a malignant biliary stricture. The combination of tumor vessel observation and percutaneous transhepatic cholangiography-guided biopsy may improve the preoperative diagnosis of malignancy.