Potential of carotid ultrasonography in the diagnosis of coronary artery disease: a comparison with exercise test and variance ECG

BACKGROUND AND PURPOSE

Carotid artery atherosclerosis has been shown to correlate with coronary artery disease (CAD). This study evaluates the capacity of duplex ultrasonography of the carotid arteries as a tool in the diagnosis of CAD in comparison with exercise stress test and variance ECG.

METHODS

Carotid ultrasonography, exercise stress test, and variance ECG were performed in 184 symptomatic patients evaluated with coronary angiography. The diagnostic capacity of the studied noninvasive methods was assessed by use of receiver operating characteristic (ROC) curves constructed by successive consideration of several cut points, such as (1) the presence of unilateral/bilateral plaques and (2) cross-sectional common carotid artery (CCA) intima-media (IM) area from 10 to 30 mm2 for ultrasonography; (1) ST depression > or =0.1 mV and > or =0.2 mV with and (2) without chest pain for exercise test; and electrical variability index from 50 to 100 for variance ECG.

RESULTS

Coronary angiography revealed the presence of CAD (> or =50% luminal stenosis in 1 or more major epicardial arteries) in 147 patients (80%). Identification of carotid plaques on one or both sides and calculation of the left-sided (but not right-sided) CCA IM area provided a significant discrimination (P<.001 and P<.01, respectively) of patients with CAD. The discriminating capacity of the ultrasound procedures was equal to that of variance ECG and exercise test with ST depression criterion only but somewhat lower than that of exercise test with the combined chest pain and ST depression criterion (P<.05). However, at the chosen cut points, carotid plaque identification offered higher sensitivity than exercise test with either criterion (P<.01 and P<.001, respectively).

CONCLUSIONS

Carotid ultrasonography is a useful diagnostic method that is comparable to exercise test and variance ECG for detection of CAD in a high-prevalence population.

[Total gastrectomy using Longmire's and Roux method. Evaluation of the invagination technique for esophageal-jejunal anastomosis]

582 patients were gastrectomized between 1976 and 1996 in the Department for Gastrointestinal Surgery in Katowice/Poland for gastric cancer. Before 1985 esophago-jejunal anastomosis have been accomplished using a simple end-to-end or special end-to-side (Schreiber-Eichfuss) method with jejunoplication. Thereafter we used an end-to-end invagination method with 4-5 cm deep intussusception of the first raw of sutures into jejunum. Comparison of the occurrence of short and long term complications at the site of esophago-jejunal anastomosis showed that invagination technique is safer that the previous one. It is associated with the lower rate of short and long term complications (dehiscence, stenosis, oesophagitis). Details of the surgical procedure facilitating the accomplishment of the tight and safe anastomosis are presented.

Flow cytometric analysis of tumour-infiltrating lymphocytes in patients with renal cell carcinoma

OBJECTIVE

To determine the immunophenotype of tumour-infiltrating lymphocytes (TIL) and peripheral blood lymphocytes (PBL) isolated from patients with renal cell carcinoma (RCC) and to analyse the correlations between the quantity of analysed cell subsets and the progression of the disease.

PATIENTS AND METHODS

PBL and TIL samples were obtained from 23 patients with RCC at different stages of disease. The immunophenotype of PBL and TIL was measured, and the TNM stage, tumour size, cellular type, histological grade, lymphocytic infiltration and performance status assessed.

RESULTS

The predominant mononuclear cells infiltrating the tumour, in all patients, were T lymphocytes (CD3+ median 66.9%, CD8+ median 34.6%, CD4+ median 26.7%). The cells possessing gamma/delta type T cell receptor accounted for a small fraction of the T cells in PBL and TIL (median 5.6% and 3.7%). Tumour-infiltrating T lymphocytes had a significantly higher percentage of cells expressing human leucocyte antigen (HLA) DR (median 30.9%) and CD25 (median 6.2%) antigens than the equivalent populations in peripheral blood from the same patient group (P < 0.001). The degree of T cell activation appeared to negatively correlate with the tumour stage (K = -0.3, P = 0.04). The percentage of natural killer (NK) cells among TIL (median 15.4%) did not reflect the value in PBL. The percentage of B cells in TIL was slightly lower than in PBL and accounted for 5.0% of cells. There was no relationship between the degree of lymphocytic infiltration and either tumour stage or grade but there appeared to be a positive correlation between the intensity of lymphocytic infiltration and the percentage of CD4+ cells in TIL (K = 0.5, P = 0.001). Moreover, the composition of TIL depended on tumour grade, which positively correlated with the percentage of CD8+ cells (K = 0.4, P = 0.005) and negatively with the percentage of NK cells (K = -0.5, P = 0.005). There was an inverse correlation with the percentage of gamma/delta T cells in PBL and the TIL concentration (K = -0.3, P < 0.05).

CONCLUSIONS

The TIL immunophenotype is different from PBL and is influenced by the histological grade of the tumour. The activation of TIL and its relationship with tumour progression suggests that they might be sensitized and activated by tumour cells.

Hepatitis B and C virus infection in Polish children with malignancies

Infections by hepatotropic viruses belong to the most common complications of chemotherapy in children suffering from neoplastic diseases. The rate of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and the effectiveness of passive immunization against HBV were studied in 285 children; 148/285 with lymphoproliferative diseases and 137/285 with solid tumours. HBV infection was observed in 10.2% children receiving hepatitis B immune globulin as compared to 36.8% without passive immunization against HBV. Anti-HCV antibodies were similar in both groups amounting 38.7% and 32.6% respectively.

CONCLUSION

The results show that hepatitis B immune globulin administration is effective and that HCV might become the main cause of hepatitis among immunosuppressed patients in the future.

Inoculum density, temperature, and genotype effects on in vitro growth promotion and epiphytic and endophytic colonization of tomato (Lycopersicon esculentum L.) seedlings inoculated with a pseudomonad bacterium

The effects of inoculum density (0, 4.6 × 107, 4.2 × 108, and 8.8 × 108 cfu∙mL−1), temperature (10, 20, and 30 °C), and plant genotype (cultivars Celebrity, Blazer, Scotia, and Mountain Delight) on bacterial colonization and plant growth promotion were investigated in a gnotobiotic system. An in vitro dual culture of tomato (Lycopersicon esculentum L.) plantlets and a Pseudomonas sp., strain PsJN, were used. Epiphytic (external) and endophytic (internal) bacterial populations were determined to evaluate plantlet colonization. Shoot and root biomass of bacterized plantlets was significantly higher (p ≤ 0.05) than that of nonbacterized controls. Growth promotion was best with inoculum densities of 3 × 108 – 7 × 108 cfu∙mL−1 at 20 °C, particularly in the early maturing cultivars Blazer and Scotia. Lower inoculum densities were required to maximize root growth (approximately 1 × 108 cfu∙mL−1) than shoot growth (approximately 3 × 108 cfu∙mL−1). Shoot surface populations did not vary with inoculum density or temperature, but the bacterium colonized the shoot exterior of cultivars Celebrity, Mountain Delight, and Scotia better than cultivar Blazer. The root surface populations increased linearly with increasing inoculum density (within a range of 107–108 cfu∙mL−1), decreased with increasing temperatures (from 10 to 30 °C), and were higher for the main season cultivar Celebrity than for cultivars Blazer, Scotia, and Mountain Delight. Populations of shoot endophytes did not vary with initial inoculum density or genotype but were affected by temperature; the highest colonization was at 10 °C. The number of root endophytes was also highest at 10 °C at the inoculum density of approximately 4 × 108 cfu∙mL−1 and did not vary with genotypes. The experiments clearly indicate that there was no relationship between root surface colonization and plant growth promotion. However, the range of inoculum levels (3 × 108 – 7 × 108 cfu∙mL−1) that promoted colonization of the inner root tissues (endophytic) also best promoted plant growth. A possible biostimulation threshold within the tissues of the inoculated plants under conditions favourable to the growth of tomato is proposed.Key words: Pseudomonas sp., tomato, colonization, growth promotion.

[Echocardiographic evaluation of cardiac structures in patients with rheumatoid arthritis]

Since heart lesions were found at autopsy in 55-60% of rheumatoid arthritis patients, we decided to assess echocardiographically their clinical significance. The study comprised 100 consecutive patients with rheumatoid arthritis (77 females and 23 males) of the mean age 55.7 +/- 12.5 yrs (range 18-83 yrs) and the disease duration of 8.3 +/- 8.0 yrs (range 1-35 yrs). The control group consisted of 100 consecutive age and sex matched patients admitted to university hospital. All the patients underwent echocardiographic examinations in apical and parasternal projections. The activity of the rheumatoid process, the severity of articular lesions, the presence of extraarticular sings as well as HLA DR and DQ antigens were determined clinically and with laboratory tests. Twenty six patients with rheumatoid arthritis had pericardial effusion, 10 revealed the sings of chronic pericarditis, in the control group 4 and 0 respectively (p = 0.001 and p = 0.025). No difference was shown in the wall contractions disturbances, size of the cardiac cavity, or thicknesses of the interventricular septum or posterior wall. In 3 rheumatoid arthritis patients, a valvular heart disease was diagnosed, this number was not significantly different from that in the control group (2 patients). There was no correlation between the lesions observed in the heart and the rheumatoid process activity estimated with clinical and laboratory indices.

[Class II HLA antigens in patients with multiple sclerosis from Warsaw and Gdansk regions]

An investigation of class II histocompatibility antigens was carried out in patients with definite diagnosis of multiple sclerosis (MS) according to Poser's criteria. There were 42 patients from Warsaw and 98 patients from Gdańsk. Histocompatibility antigens were assayed with microlymphocytotoxicity test. 6 antigens on locus DR and 1 antigen on locus DQ were evaluated. The antigen frequencies were compared in the two groups using the chi-square test. The antigen HLA-DQw1 occurred significantly more frequently in MS patients compared to healthy control group. Antigens HLA-DR2 and DR3 occurred more frequently in patients from Gdańsk than Warsaw region.

Activated gamma/delta T lymphocytes infiltrating renal cell carcinoma

Gamma/delta (gamma delta) T lymphocytes have been postulated to play a role in a surveillance mechanism that eliminates transformed or otherwise damaged cells. In this study, we examined by flow cytometry the frequency and phenotype of gamma delta T cells in the tumour infiltrating lymphocytes (TIL) and peripheral blood (PBL) from renal cell carcinoma patients. The TCR gamma delta + cells comprised an average of 3.8% of the CD3+ TIL and 5.2% of circulating T cells. Analysis of surface immunophenotype revealed that activation markers of T lymphocytes: CD25 and HLA DR were highly expressed on the tumour infiltrating gamma delta + T lymphocytes (median 27.6% for CD25 and 52.0% for HLA DR). More importantly, percentage of activated gamma delta T cells was found to be much higher than compared to all activated CD3+ cells. Furthermore, an unusually high proportion of gamma delta positive TILs express CD4 or CD8 molecules (17.2 and 36.8%, respectively), indicating that they might recognise antigen presented within MHC II or I context. These results suggest that gamma delta T lymphocytes may play a certain role in immune response against tumour cells.

[Congenital heart defects in adolescence and adulthood: fatalities and morbidity in primary and reoperation]

Adolescents and adults with congenital heart disease have become a new, continuously growing group of patients, because currently improved diagnostics and therapy allow the majority of newborns with congenital heart disease to survive to adulthood. The objective of this retrospective study was to investigate lethality and morbidity after surgery for congenital heart disease in adolescents and adults. Between 1989 and 1994, we operated 137 patients (age between 15 and 75 years; mean 33.8 +/- 15.1) because of congenital heart disease. This was equivalent to 2.7% of all patients, who were operated during this period of time. 101 cases were primary operations, in 36 cases (26.3%) a reoperation was performed. The most frequent diagnoses were ostium-secundum-defect (37.9%), anomalies of the aortic valve including sub- and supravalvular stenoses (9.5%), anomalies of the mitral valve (8%), ventricular septal defect (7.3%) and aortic coarctation (7.3%). Overall lethality was 5.8%, including emergency cases and all late deaths, which have been reported so far. Evaluation of morbidity showed an intraoperative cardiac low-output-syndrome in 3.7%, pulmonary failure in 5.8%, postoperative renal failure in 4.4% and postoperative bleeding complications in 7.3% of cases. Mean duration of postoperative ventilation and intensive care treatment were 2.3 +/- 5.3 and 3.6 +/- 7.3 d, respectively. In comparison to their preoperative status, 71% of patients had improved by one or two NYHA classes. We found that the higher perioperative risk related to reoperation had no impact on the operation's functional result, as evaluation of postoperative functional class showed no difference between primary and re-do cases. The general term congenital heart disease describes a very inhomogeneous group of patients with a broad spectrum of different diagnoses. The variable morphology and pathophysiology of the different congenital heart defects require an individual surgical strategy for each patient, in rare cases even the decision for a heart- or heart-lung-transplantation. Furthermore, adequate follow-up and competent ambulatory treatment of these patients require the cooperation of pediatric and adult cardiologists and cardiac surgeons in interdisciplinary outpatient clinics.

Thromboxane metabolite excretion in patients with hand-arm vibration syndrome

As chronic exposure to hand-held vibrating tools may cause endothelial injury, a subsequent sustained platelet activation with the increased release of vasoconstricting thromboxane A2 (TxA2) could be of pathophysiological importance in vibration-induced Raynaud's phenomenon. Therefore, the aim of this study was to elucidate whether or not hand-arm vibration syndrome is accompanied by increased endogenous TxA2 biosynthesis. The study involved 64 men, aged 23-61 years, stratified according to the exposure to vibrating tools, the presence of Raynaud's phenomenon, and smoking habit. Forty of them were car mechanics and 24 were age-matched healthy volunteers who served as controls. The assessment of platelet TxA2 formation in vivo was performed by quantification of the urinary excretion of its major metabolite, 2,3-dinorthromboxane B2 (2,3-dinor-TxB2), employing gas chromatography-mass spectrometry. The average urinary excretion rate of 2,3-dinor-TxB2 in patients with Raynaud's phenomenon was 296 +/- 42 pg/mg creatinine and did not differ significantly from the corresponding values in controls (328 +/- 62 pg/mg creatinine) or individuals exposed to vibrating tools, but without any signs of vasospastic disease (232 +/- 29 pg/mg creatinine). The only statistically significant difference was found between smokers and non-smokers (P < 0.001), a finding confirming the existence of chronic platelet dysfunction in cigarette smokers. The present data indicate that chronic exposure to vibrating tools, with or without Raynaud's phenomenon, is not associated with an enhanced platelet function as monitored by the urinary excretion of 2,3-dinor-TxB2. Hence, a possible vibration-induced vascular injury does not seem to provide a stimulus sufficient to induce a persistent platelet activation.

Beat-to-beat QRS amplitude variability after acute myocardial infarction and coronary artery bypass grafting

Ischemic myocardial injury has been demonstrated to be associated with increased beat-to-beat electrical variability of the depolarization phase. This can be quantified by electrocardiographic (ECG) signal variance analysis, a technique that has proven its diagnostic value in the detection of coronary artery disease (CAD). This study evaluates QRS amplitude variability during a 6-month follow-up period in 73 patients with acute myocardial infarction (AMI) and in 56 patients subjected to coronary artery bypass grafting (CABG). The beat-to-beat QRS amplitude variability was quantified with variance electrocardiography. The equipment allows computerized time domain analysis of high-fidelity ECG signals from 24 leads, and the detected electrical heterogeneity is then expressed as a nondimensional index ranging from 0 to 150, with values >90 being indicative of ischemic myocardial involvement. One week after AMI 55% of the patients presented with an abnormal QRS variability index >90. A significant (p <0.01) increase in the index values occurred during the follow-up period, but only in the patients with an initial index <70. In the CABG group 44% of the patients had a preoperative QRS variability index >90. The values increased (p <0.05) in all patients after surgery; the increase was transient in patients with an initial index <70 (p <0.01). The results demonstrate that the myocardial injury in patients with CAD is often associated with increased electrical variability of myocardial depolarization. The QRS amplitude variability index can be used as a marker of such an injury, and analysis of its changes in the course of ischemic cardiac events may provide new insights into the dynamics of ischemic heart disease and the myocardial healing process.

Effect of nicotine infusion in humans on platelet aggregation and urinary excretion of a major thromboxane metabolite

The objective of this study was to evaluate further a possible role of nicotine as a stimulator of platelet aggregability and platelet arachidonic acid metabolism in vivo. In six healthy, non-smoking males, platelet aggregability was assessed by filtragometry and impedance aggregometry before, during and after an intravenous infusion of nicotine at two different doses (0.25 and 0.5 microgram kg-1 min-1) for 30 min. The aggregatory response was also measured after the addition of nicotine at final concentrations ranging from 10(-11) mol L-1 directly to the aggregating blood. The synthesis of thromboxane A2 (TxA2) in platelets was estimated by quantitating the urinary excretion of 2.3-dinor-thromboxane B2 (Tx-M). Despite the plasma concentrations of nicotine, cotinine and catecholamines in the range of those occurring during acute cigarette exposure, the excretion of Tx-M (204 +/- 36 pg mg-1 creatinine) remained unaltered during nicotine infusion. Similarly, platelet aggregatory response to collagen was not influenced by nicotine when infused or added in vitro. However, an enhanced aggregability was detected by filtragometry during the infusion of nicotine at the higher dose employed. The results indicate that nicotine, infused at moderate doses, produces a weak platelet stimulation that is not accompanied by significant release of thromboxane A2, as monitored by urinary excretion of Tx-M. Although a direct action of nicotine on platelets cannot be excluded, it appears more likely that the enhancement of platelet function is mediated by other, secondary mechanisms.

Chaos-related deterministic regulation of heart rate variability in time- and frequency domains: effects of autonomic blockade and exercise

OBJECTIVES

To study non-linear complexity or chaotic behaviour of heart rate in short time series and its dependence on autonomic tone.

METHODS

Ten healthy individuals (5 men, mean age 44 years) were investigated at rest, after intravenous injections of propranolol (0.15 mg/kg), followed by atropine (0.03 mg/kg). On another occasion, investigation was made during exercise on a bicycle ergometer at 40% and at 70% of maximal working capacity. Heart rate variability was assessed by: local sensitive dependence on initial conditions as quantitated by the dominant Lyapunov exponent, coefficient of variation of heart rate, power spectral analysis of high- and low-frequency bands and the 1/f-slope of the very-low-frequency band and time domain analysis.

RESULTS

The approximate dominant Lyapunov exponent was positive at rest and remained positive during autonomic blockade and during exercise. The exponent decreased significantly with propranolol+atropine and even more so during exercise but did not attain zero. At baseline approximate predictability was lost after about 30 s whereas after autonomic blockade or exercise it was lost after about 60 s. The 1/f-slope remained unaltered around -1. As expected, power in high- and low-frequency bands as well as time domain index decreased significantly with autonomic blockade. The low-frequency band and time domain index were affected by exercise.

CONCLUSIONS

Heart rate variability of sinus rhythm in healthy individuals has characteristics suggestive of low-dimensional chaos-like determinism which is modulated but not eliminated by inhibition of autonomic tone or by exercise. The dominant Lyapunov exponent characterises heart rate variability independent or the other investigated measures.

Beat-to-beat QRS amplitude variability during dobutamine infusion in patients with coronary artery disease

The aim of this study was to investigate if provoked myocardial ischemia induces increased beat-to-beat QRS amplitude variability in patients with angiographically verified coronary artery disease. 15 patients (median age 62 years, range 46-73 years) and 10 healthy controls (median age 25 years, range 22-42 years) were studied. Dobutamine was infused intravenously at a low and at a high dose. The mean low dose of the drug was 10.0 micrograms/kg/min for both patients and controls, whereas the mean maximum dose was 31 +/- 2 for patients and 38 +/- 1 microgram/kg/min for controls. The total QRS amplitude beat-to-beat variance from 12 leads as well as individual variance scores in each single lead were evaluated. Before infusion, the total QRS variance did not differ between patients and controls, nor did the individual variance in 9 of the 12 ECG leads. Dobutamine elicited an increase (p < 0.01) in the total QRS variance, with significantly higher (p < 0.001) total variance in patients than in controls. At the high dose of the drug, the patients displayed significantly higher individual variance values in each ECG lead as well. During dobutamine infusion, 7 of 15 patients developed ST depressions (> or = 0.1 mV in > or = 2 leads) in 12-lead ECG readings. Eleven of 15 patients developed chest pain (grade > or = 3 at the Borg's CR-10 scale). In conclusion, in patients with ischemic heart disease, dobutamine-provoked stress gives rise to increased QRS amplitude beat-to-beat variability, as a sign of electrical instability of the myocardium.

[The effect of administering Omega-3 acids on lipids in serum, functional state of erythrocyte membrane and function of the kidneys in patients with primary glomerulonephritis]

There are reports concerning profitable influence of unsaturated acids administration on blood pressure, inflammation and proteinuria. The aim of presented study was to estimate the effect of Omega-3 on plasma lipids and renal function in patients with primary glomerulopathies. The tested group consisted of 13 patients (7F and 6M) aged from 22 to 60 years, with primary glomerulopathies and normal renal function. They received Omega-3 (Fishproduct, iceland) 3 x 2 caps for three months. Before, after 2 and 3 months of treatment and 3 months after its discontinuation following parameters were estimated: total cholesterol, HDL and LDL cholesterol (HDL, LDL), triglycerides and an order parameter of erythrocyte lipid bilayer (S). Simultaneously N-acetylglutamate (NAG), creatinine clearance and 24-hours proteinuria were measured. For calculation t-Student test was used. In our study we found statistically significant increase of HDL after 2 and 3 months and decrease of LDL after 3 months of Omega-3 administration (p < 0.05). During the 2 and 3 months of treatment statistically significant decrease of NAG was noticed but a month after its discontinuation significant increase of NAG excretion was observed (p < 0.05). The S parameter in tested group of patients was higher than in healthy population but during Omega-3 administration the value of an order parameter of erythrocyte bilayer increased significantly (p < 0.01). On the base of given results we could conclude that unsaturated acids may have profitable influence on plasma lipids, functional status of erythrocyte membrane and probably proximal tubule function in patients with primary glomerulopathies.

Aluminum sensitivity of loblolly pine and slash pine seedlings grown in solution culture

To probe variation in Al sensitivity of two co-occurring pine species, seedlings from six full-sib families of loblolly pine (Pinus taeda L.) and slash pine (Pinus elliottii Engelm.) were grown in solution culture containing 4.4 mM (high-Al) or 0.01 mM (low-Al) AlCl(3) at pH 4 for 58 days. On average, both pine species had 41% less total dry weight in the high-Al treatment than in the low-Al treatment. Stem volume growth of slash pine was more sensitive to the high-Al treatment than that of loblolly pine. In both species, the high-Al treatment inhibited root dry weight more than shoot dry weight. Within-species variation in Al sensitivity among families was greater in loblolly pine (24 to 52% inhibition of seedling dry weight) than in slash pine (35 to 47% inhibition of seedling dry weight). Foliar Al concentration was positively correlated with Al sensitivity in slash pine but not in loblolly pine; however, in both species, the concentration of Al in roots was 20-fold greater than in foliage.