Percutaneous coronary intervention in unprotected left main disease: a status report

Percutaneous coronary intervention (PCI) of the unprotected left main (LM) artery is currently not recommended as a routine procedure based on the history of inferior outcomes of LM percutaneous transluminal coronary angioplasty and bare metal stenting. Instead, surgical revascularization (coronary artery bypass grafting, CABG) is considered to be the gold standard. There is renewed interest in LM-PCI because of improved outcomes of PCI utilizing drug eluting stents (DES) in multiple randomized trials. Several single-center non-randomized registries have evaluated the role of DES for LM-PCI. Data suggest a low mortality and target vessel failure of ostial LM or mid-shaft lesions in contrast to bifurcation lesions, which frequently require complex dual stenting techniques. The complex PCI in the bifurcation is associated with the increased occurrence of target vessel failure ranging from 2% and 38%. The rate of target vessel failure in bifurcation lesions is less in patients in whom the circumflex ostium is not involved so that single cross over stent is suitable. Current recommendations call for a follow-up angiography at 4-6 months to detect LM restenosis prior to a potentially fatal clinical event. The question of the duration of dual antiplatelet therapy in patients who underwent LM-PCI is unanswered. More registry data and randomized trials are needed before unprotected LM-PCI can be routinely offered to patients as an alternative to CABG.

A novel triple purge strategy for eliminating chronic myelogenous leukemia (CML) cells from autografts

Imatinib-refractory chronic myelogenous leukemia (CML) patients can experience long-term disease-free survival with myeloablative therapy and allogeneic hematopoietic cell transplantation; however, associated complications carry a significant risk of mortality. Transplantation of autologous hematopoietic cells has a reduced risk of complications, but residual tumor cells in the autograft may contribute to relapse. Development of methods for purging tumor cells that do not compromise the engraftment potential of the normal hematopoietic cells in the autograft has been a long-standing goal. Since primitive CML cells differentiate more rapidly in vitro than their normal counterparts and are also preferentially killed by mafosfamide and imatinib, we examined the purging effectiveness on CD34(+) CML cells using a strategy that combines a brief exposure to imatinib (0.5-1.0 microM for 72 h) and then mafosfamide (30-90 microg/ml for 30 min) followed by 2 weeks in culture with cytokines (100 ng/ml each of stem cell factor, granulocyte colony-stimulating factor and thrombopoietin). Treatment with 1.0 microM imatinib, 60 microg/ml mafosfamide and 14 days of culture with cytokines eliminated BCR-ABL(+) cells from chronic phase CML patient aphereses, while preserving normal progenitors. This novel purging strategy may offer a new approach to improving the effectiveness of autologous transplantation in imatinib-refractory CML patients.

Diagnostic yield of advanced colorectal neoplasia at colonoscopy, according to indications: an investigation from the Korean Association for the Study of Intestinal Diseases (KASID)

BACKGROUND AND STUDY AIMS

The factors that more accurately predict the detection of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm (CRN), including colorectal cancer, in a group of patients undergoing colonoscopy.

PATIENTS AND METHODS

The 17 468 patients were enrolled in this study between July 2003 and March 2004, from 11 tertiary medical centers in Korea. They were recruited according to 11 itemized colonoscopic indications. The term "advanced adenoma" refers here to tubular adenomas of diameter of 11 mm or more, or to tubulovillous, villous, or severely dysplastic adenomas, irrespective of their size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced CRN was defined as advanced adenoma or invasive cancer.

RESULTS

Advanced CRN was found in 1227/17 307 patients (1176 advanced adenomas plus 51 carcinomas, 7.1 %). According to univariate and multivariate analysis, the factors associated with advanced CRN included age >60 years (odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.8 - 2.4, P < 0.0001), male gender (OR 2.1, 95 %CI 1.7 - 2.7, P < 0.0001), referral for colonoscopy from primary care physician (OR 3.1, 95 %CI 2.5 - 3.7, P < 0.0001), and several other indications (OR 1.8, 95 %CI 1.5 - 2.3, P < 0.001). The yield of colonoscopy for advanced CRN was lower (2.2 %) than expected in patients with iron-deficiency anemia (OR 0.5, 95 %CI 0.2 - 0.9, P = 0.03).

CONCLUSIONS

Age, gender, and referral for colonoscopy from primary care physician constituted important independent predictors of advanced CRN in patients undergoing colonoscopy.

Linezolid-associated toxic optic neuropathy

The oxazolidinone antimicrobial linezolid is effective against gram-positive bacteria. Although maximal recommended therapy is 28 days, treatment durations greater than this are common. Linezolid may cause reversible optic neuropathy and irreversible peripheral neuropathy after months of treatment. Three cases of linezolid-induced optic and peripheral neuropathy are described, and previously reported cases of linezolid-induced optic neuropathy are reviewed. The mechanism of neural toxicity may be impairment of mitochondrial protein synthesis.

Corticospinal disinhibition in paroxysmal kinesigenic dyskinesia

OBJECTIVE

To investigate the underlying mechanism responsible for paroxysmal kinesigenic dyskinesia (PKD).

METHODS

We performed a transcranial magnetic stimulation (TMS) study in 12 drug-naïve patients with PKD and 10 healthy volunteers. TMS parameters included resting motor threshold, recruitment curve of motor evoked potential amplitudes, short intracortical inhibition and facilitation, long intracortical inhibition (LICI), and silent period. We also measured compound muscle action potential.

RESULTS

LICI, representing GABA-mediated inhibition, was significantly reduced in the patients (P = 0.033), while results for all other TMS parameters tested were comparable between the two groups.

CONCLUSIONS AND SIGNIFICANCE

These results suggest that a specific type of corticospinal inhibitory mechanism is impaired in patients with PKD.

Two-incision total hip replacement: Intra-operative fluoroscopy versus imageless navigation for cup placement

The purpose of this study was to describe the surgical technique and to investigate results of a modified two-incision total hip replacement using either intraoperative fluoroscopy or imageless navigation. Twenty-nine patients (30 hips) with a minimum follow-up of one year were enrolled in this study. The patients were evaluated at 3, 6, 12 weeks, 6 months, and 1-year. The functional recovery as represented by the Harris hip score and WOMAC scale were better in the fluoroscopy group of patients at the early postoperative stage (3 wks). Thereafter, both groups showed rapid recovery with no difference in scores. Injury to the lateral femoral cutaneous nerve was the most commonly seen complication and it occurred in 6 hips (fluoroscopy 2; imageless 4). The symptoms were transient and resolved in 6 months in all 6 cases. This study demonstrated that the role of intraoperative fluoroscopy could safely be replaced by an imageless navigation system for the MIS-2 THA.

Effects of Qi therapy (external Qigong) on symptoms of advanced cancer: a single case study

The aim of this study was to examine the effectiveness of Qi therapy (external Qigong) in the management of symptoms of advanced cancer in a man. We used a single case study design to evaluate the effectiveness of Qi therapy (external Qigong) in a 35-year-old man with advanced cancer (Stage IV) involving metastases in the stomach, lung and bone (Karnofsky performance scale: KPS, 40: requires special care and assistance, disabled). Treatment involved six days of pre-assessment, eight treatment sessions on alternate days over 16 days, and a two-week follow-up phase. A visual analogue scale (VAS) was used to assess the patient's self-reported symptoms of cancer over the intervention and follow-up periods. Following treatment, VAS scores' analysis revealed beneficial effects on pain, vomiting, dyspnoea, fatigue, anorexia, insomnia, daily activity and psychological calmness. These improvements were maintained over the two-week follow-up phase. After the first Qi therapy session, the patient discontinued medication and could sit by himself; after the fourth session, the patient was able to walk and use the toilet without assistance (improvement in KPS: 70: care for self, unable to perform normal activity or to do active work). Although limited by the single case study approach, our results support previous studies on this topic and provide reasons to conduct controlled clinical trials.

A more persistent tolerance to islet allografts through bone marrow transplantation in minimal nonmyeloablative conditioning therapy

INTRODUCTION

Islet transplantation is a therapeutic approach to prevent diabetes complications. However, the side effects of the required lifelong immunosuppressive regimens to prevent graft rejection restrict the impact of type 1 diabetes. One strategy to overcome these limitations is tolerance induction and graft acceptance through hematopoietic chimerism. In this study we investigated whether tolerance to major histocompatibility complex (MHC) and minor-disparate islet allografts could be induced by minimal nonmyeloablative conditioning and whether more persistent donor-specific islet allografts were accepted if the grafts were implanted with simultaneous bone marrow cells.

METHODS

The donor and recipient mice were BALB/c(H-2(b)) and C57BL/6(H-2(d)), respectively. In group 1 streptozotocin-induced diabetic C57BL/6(H-2(d)) mice received only 500 islets of BALB/c(H-2(b)). Group 2 recipients conditioned with antilymphocyte serum, 100 cGy total body irradiation and cyclophosphamide were given islet cells of BALB/c(H-2(b)), but group 3 were simultaneously given 30 x 10(6) BALB/c(H-2(b)) mice BMCs and islet cells similar to group 2.

RESULTS

We obtained 5% to 6% allogeneic donor chimerism and 60% graft survival at 80 days after islet transplantation in group 3. We observed lymphocyte infiltration around the islet without destruction of endocrine cells and the presence of strong insulin/glucagon-stained cells in group 3.

CONCLUSION

This minimal nonmyeloablative conditioning therapy induced donor chimerism and immune tolerance between MHC- and minor-disparate (BALB/c-->C57BL/6) mice and long-term islet graft survival was obtained through cotransplantation of bone marrow cells.

Ifosfamide-induced encephalopathy with or without using methylene blue

Ifosfamide is one of the most widely used alkylating chemotherapeutic agents. Before mesna was introduced, its dose-limiting toxicity was hemorrhagic cystitis, but at present, neurotoxicity is one of its most worrisome side effects. A total of 10%-15% of patients treated with ifosfamide develop an encephalopathy. The exact pathophysiologic mechanisms responsible for the development of ifosfamide-induced encephalopathy (IIE) are not known. However, accumulation of chloracetaldehyde, toxic metabolite of ifosfamide, in the central nervous system is theorized to be the cause of the neurotoxicity. No standard treatment has been available for IIE. Recently, many reports suggested that methylene blue (MB) may be an effective treatment of this lethal complication. We report two cases of IIE and their treatment outcomes. The first patient recovered completely with MB. The other patient showed slow and incomplete improvement without using MB. We suggest that MB can be used as an initial treatment for the encephalopathy related to ifosfamide infusion. Thus, we present these two cases with brief review of related literature.

Treatment of deep infection of the hip associated with massive bone loss: two-stage revision with an antibiotic-loaded interim cement prosthesis followed by reconstruction with allograft

We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D'Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection.

In vitro inhibition ofHelicobacter pyloribyEnterococcus faeciumGM-1

A strain of Enterococcus faecium that exhibits antibacterial activity against Helicobacter pylori was isolated from the feces of newborn babies. This strain was selected for its ability to inhibit the growth of H. pylori and to withstand harsh environmental conditions, such as acidic pH and high bile concentration. Biochemical tests and 16S rRNA sequencing specific for Enterococcus faecium GM-1 were used to identify the isolated bacterial strain. In vitro studies were used to investigate the inhibitory effects of E. faecium GM-1 on H. pylori. These results showed that the culture supernatant of E. faecium GM-1 significantly decreased the viability and urease activity of H. pylori. This inhibitory activity remained after adjustment of pH of culture supernatant to neutral. However, treatment with proteolytic enzymes reduced the anti-H. pylori activity of GM-1. Therefore, some substance(s) of E. faecium GM-1 other than pH and lactic acid might be associated with this inhibitory activity. Analysis by electron microscopy also demonstrated that the addition of GM-1 destroyed the cell structure of H. pylori. Additional studies suggested that the binding of H. pylori to human colonial cells decreased in the presence of GM-1.Key words: Enterococcus faecium, Helicobacter pylori, inhibition, human fecal strain, proteinaceous substance(s).

Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment

BACKGROUND AND STUDY AIMS

We evaluated the therapeutic effects of percutaneous transhepatic photodynamic therapy (PDT) in patients with advanced bile duct cancer. The utility of intraductal ultrasonography (IDUS) for the assessment of responses and for regular follow up after PDT was also examined.

METHODS

Percutaneous transhepatic biliary drainage (PTBD) was initiated before PDT. Following dilation and maturation of the PTBD tract, percutaneous PDT was performed. Intraluminal photoactivation was carried out using percutaneous cholangioscopy 2 days after intravenous application of a hematoporphyrin derivative. All patients were additionally provided with percutaneous bile duct drainage catheters after PDT. IDUS was conducted monthly to measure the thickness of the tumor mass before and after PDT.

RESULTS

24 patients with advanced cholangiocarcinomas (Bismuth IIIa, n = 4; IIIb, n = 10; IV, n = 10) were treated with PDT. At 3 months after PDT, the mean thickness of the tumor mass had decreased from 8.7 +/- 3.7 mm to 5.8 +/- 2.0 mm (P < 0.01). At 4 months after PDT, the thickness of the mass had increased to 7.0 +/- 3.7 mm. Quality of life indices improved dramatically and remained stable 1 month after PDT; the Karnofsky index increased from 39.1 +/- 11.36 to 58.2 +/- 22.72 points (P = 0.003). The 30-day mortality rate was 0 %, and the median survival time was 558 +/- 178.8 days (current range 62 - 810 days).

CONCLUSIONS

PDT using percutaneous cholangioscopy is safe and effective for advanced hilar cholangiocarcinoma, and seems to prolong survival. IDUS is useful for evaluating changes in the thickness of the tumor mass after PDT.

Characterization of a bacteriocin produced by Enterococcus faecium GM-1 isolated from an infant

AIM

To partially characterize the bacteriocin produced by the GM-1 strain of Enterococcus faecium, isolated from the faeces of a newborn human infant.

METHODS AND RESULTS

The bacteriocin produced by E. faecium GM-1 showed a broad spectrum of activity against indicator strains of Escherichia coli, Staphylococcus aureus, Vibrio spp., Salmonella typhimurium, Listeria monocytogenes, Lactobacillus acidophilus, and Streptococcus thermophilus. Treatment of the GM-1 bacteriocin with proteolytic enzymes reduced its inhibitory activities. The bacteriocin was stable at 100 degrees C for 20 min and displayed inhibitory activity at neutral pH. The optimal production of bacteriocin from E. faecium GM-1 was obtained when the culture conditions were pH 6.0-6.5 and 35-40 degrees C. The inhibitory activity of the bacteriocin was not substantially changed by the use of different carbon sources in the media, except when galactose was substituted for glucose. The use of a sole nitrogen source caused a decrease in inhibitory activity. A bacteriocin gene similar to enterocin P was identified from the total DNA of E. faecium GM-1 by PCR and direct sequencing methods.

CONCLUSION

E. faecium GM-1, which was isolated from the faeces of a newborn baby, produces an enterocin P-like bacteriocin with inhibitory activity against Gram-positive and Gram-negative bacteria, including food-borne pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

E. faecium GM-1, isolated from infant faeces, produces a new bacteriocin that is similar to enterocin P. This bacteriocin is heat stable and has a broad antibacterial spectrum that includes both Gram-positive and Gram-negative bacteria.

Management of malignant stricture of the esophagogastric junction with a newly designed self-expanding metal stent with an antireflux mechanism

BACKGROUND AND STUDY AIMS

When stents are placed across the esophagogastric junction for palliative treatment of malignant strictures, they may lead to esophagogastric reflux. The aim of this study was to compare the effectiveness of a newly designed antireflux stent with that of a standard open stent and a currently available antireflux stent (Dostent) in preventing gastroesophageal reflux symptoms in patients with inoperable cancer at the esophagogastric junction.

PATIENTS AND METHODS

Thirty-six consecutive patients with cancer at the esophagogastric junction were randomly assigned to undergo placement of a newly designed antireflux stent (n = 12), a Dostent (n = 12), or a standard open stent (n = 12). Technical and clinical success, dysphagia score, reflux symptoms, complications and ambulatory 24-h esophageal pH monitoring were assessed.

RESULTS

The technical success rates were 100 %. After 1 week, dysphagia had improved in all patient groups ( P < 0.05), but the degree of improvement did not differ between the three groups. The DeMeester score was significantly lower in the group with the newly designed antireflux stent than in the other groups. The fraction of the total recording time during which esophageal pH was below 4 was 3.14 +/- 5.78 % using the newly designed antireflux stent, in comparison with 29.25 +/- 15.41 % in the Dostent group and 15.01 +/- 11.72 % in the standard open stent group ( P < 0.001). Fewer reflux episodes occurred with the newly designed antireflux stent than with the Dostent or standard open stent. There were no complications with any of the three stents.

CONCLUSIONS

The newly designed antireflux stent is effective in relieving dysphagia caused by malignant cancer at the esophagogastric junction. The newly designed antireflux stent is significantly more effective in preventing gastroesophageal reflux than currently available antireflux stents.

Inhibition of nitric oxide can ameliorate apoptosis and modulate matrix protein gene expression in bacteria infected chondrocytes in vitro

Bacterial infection stimulates nitric oxide (NO) production in chondrocytes. However, the role of NO in chondrocyte apoptosis after infection remains unclear. The purpose of the study was to test if inhibition of NO could ameliorate apoptosis and modulate matrix protein gene expression in bacteria-infected chondrocytes. It was shown that pre-treating chondrocytes with L-NAME (1 mM) significantly decreased the release of NO (from 72 to 14 microM) and the extent of apoptosis (from 52.9% to 18.9%). Pre-treatment with L-NAME also counteracted the bacteria-induced downregulation of Type II collagen (from 26% to 79%) and aggrecan (from 63% to 105%) mRNA levels. Inhibition of NO after the induction of infection could not decrease the extent of apoptosis and modulate matrix protein gene expression. The results of this study support the hypothesis that NO has an important role in bacteria-induced chondrocyte apoptosis. Pre-treatment but not post-treatment could ameliorate the extent of apoptosis and reestablish the cartilage matrix protein gene expression. This study suggests that in addition to NO, other mechanisms may be responsible for the sustained destruction of articular cartilage in the post-infectious arthropathy.

Fluphenazine and Its Toxic Maculopathy

Ten years ago a 45-year-old female presented with bilateral maculopathy with visual acuity of 6/18 on the right and 6/24 on the left. She had been on fluphenazine for the past 10 years for schizophrenia. Investigation including fluorescein angiogram, colour vision assessment and electrophysiological testing confirmed the nature of the retinal damages. Her maculopathy deteriorated further despite discontinuation of the medication. A previous publication has reported maculopathy with fluphenazine in association with the welding arc injury, but that particular patient had not been exposed to welding flash or other extreme photochemical sources. We believe this is the first reported incidence that fluphenazine has directly caused a maculopathy secondary to its accumulation at the retinal pigment epithelium and its toxic effect.

Management of malignant strictures of the cervical esophagus with a newly-designed self-expanding metal stent

Recently, the use of self-expanding metal stents has become a well-established method of palliative treatment for stenotic malignant diseases in the middle and distal esophagus. However, published results on the use of self-expanding metal stents in cervical esophageal cancer are somewhat limited by a paucity of clinical details and experience. A new self-expanding esophageal metal stent with a short upper flange 0.7 cm in length was studied prospectively in order to assess its efficacy for palliative treatment. This report presents experience in three patients in whom this new stent was used in the treatment of cervical esophageal cancers. Stent placement was successful in all three patients, with no serious complications such as esophageal perforation, hemorrhage, or foreign-body sensation. All of the patients experienced rapid improvement in dysphagia and clinical symptoms. The newly designed self-expanding stent can be of value in the treatment of stenotic cervical esophageal cancer.

Through-the-scope double colonic stenting in the management of inoperable proximal malignant colonic obstruction: a pilot study

BACKGROUND AND STUDY AIMS

Particularly in cases of proximal colonic obstruction, the long distance and tortuosity of the bowel make it difficult for gastroenterologists and radiologists to advance the stent to the point of the obstruction. The purpose of this study was to evaluate the clinical usefulness and efficacy in preventing stent migration and tumor ingrowth of a new self-expanding through-the-scope (TTS) double colonic stent in the palliative management of patients with inoperable proximal malignant colonic obstruction.

PATIENTS AND METHODS

A total of seven patients (four men, three women; mean age 62 years, range 57 - 68) underwent placement of a newly developed through-the-scope self-expanding double colonic stent. The etiologies of the obstructions at the time of stent insertion were colonic adenocarcinoma (no previous surgical resection) in five cases and metastatic adenocarcinoma from gastric carcinoma in two. The locations of the obstructions were the ascending colon in three cases, the hepatic flexure in two, and the transverse colon in two. To prevent tumor ingrowth and stent migration, an uncovered Niti-S stent (Taewoong Medical Co., Ltd., Seoul, South Korea) was inserted into the stenotic area; a partly membrane-covered Niti-S stent was then again inserted into the stenotic area inside the uncovered Niti-S stent.

RESULTS

The self-expanding TTS double colonic stents were placed in the colon in seven patients with acute malignant colonic obstruction. Double stenting was successful in traversing the lesion in six of the seven cases. In one patient, the stent was not successfully placed across the lesion due to a very acute angle at the hepatic flexure. There were no significant complications relating to the insertion, with no clinical or radiographic evidence of perforation or bleeding during or after the procedures, and there were no cases of stent migration or tumor ingrowth during the mean follow-up period of 13 months.

CONCLUSIONS

Placement of these new self-expanding through-the-scope double colonic stents for the management of inoperable proximal malignant colonic obstruction is a feasible, effective, and safe form of palliative treatment for the prevention of stent migration and tumor ingrowth.

Ophiopogon root (Radix Ophiopogonis) prevents ultra-structural damage by SO2 in an epithelial injury model for studies of mucociliary transport

We studied the action of the herb, Ophiopogon root (OR) in a epithelial injury model, hypothesizing that it may have beneficial effects on mucociliary transport following injury to the palate induced by sodium metabisulphite (MB) which releases SO(2) on contact with water. OR (extract from 1g of root/ml)-incubated palates and non-incubated palates were compared to assess the effect of MB on mucociliary clearance on the bull frog palate. MB 10(-1) M, acutely increased mucociliary clearance time (MCT) by 254.5 +/- 57.3% in untreated and 243.3 +/- 98.5% in OR-incubated palates, (over all significance assessed by one-way ANOVA, F = 12.82, p < 0.001, df = 8,54 for MB and F = 10.56, p < 0.001, df = 8,54 for OR). MCT returned to normal during recovery in OR-treated palates following MB. In untreated palates, MCT did not return to control values during a similar recovery period. ANOVA comparing MCTs in the recovery period in untreated vs OR-treated palates was significantly different (F = 2.92, p < 0.03, df = 5,36). SEM images of epithelial tissue, analyzed by morphometry, showed a 25 +/- 12% loss of ciliated cells in untreated palates and little or no damage to cilia in OR-treated palates. Intact groups of ciliated cells were found in SEM micrographs of mucus from MB-treated palates. We conclude that the loss of cilia or ciliated cells prevented full recovery of MCT after MB in untreated palates. In OR-incubated palates, mucociliary transport was completely restored within 20 min after topical application of MB, possibly through a protective action on the extra-cellular matrix.