Metabolomics and its application in the mechanism analysis on diabetic bone metabolic abnormality

OBJECTIVE

This study is aimed at analysing the endogenous metabolites profiling of patients with diabetic osteoporosis, so as to provide the reference for pathogenesis research of diabetic osteoporosis.

PATIENTS AND METHODS

The 1H-NMR metabolomics technology, combined with pattern recognition analysis and SIMCA-P 12.0 statistical analysis, were employed to identify the metabolites differences between diabetic patients with disordered bone metabolism (research group) and healthy volunteers (normal group) in this study.

RESULTS

Compared with normal group, the results show that in research group, the levels of O-acetyl glycoprotein, proline, 1-methyl histidine, tricarboxylic acid cycle (TCA cycle) product (citric acid and α-ketoglutaric acid) decline, while the levels of branched chain amino acids (leucine, isoleucine, valine), glucose, choline, creatine, inositol, glutamine, aspartic acid, alanine, glycine, and citrulline increase.

CONCLUSIONS

There are disordered metabolic pathways and imbalanced bone synthetic materials and regulatory substances in diabetic patients with bone metabolic abnormality. These metabolic abnormalities could be the specific indicators in early diagnosis of diabetic osteoporosis.

Effect of different blood glucose intervention plans on elderly people with type 2 diabetes mellitus combined with dementia

OBJECTIVE

We analyzed the effects of intensive and mitigatory blood glucose control strategy on elderly people with type 2 diabetes mellitus (T2DM) combined with Alzheimer disease (AD).

PATIENTS AND METHODS

We enrolled 90 elderly patients with T2DM combined with AD to participate in this study. They were randomly divided into 3 groups: the control group, the strength group and the mitigation group with 30 cases in each group. In the control group, patients were only treated with diet and exercise while in the strength group patients were treated with oral hypoglycemic medications, subcutaneous insulin infusion or continuous infusion by micropump. Blood glucose level in the strength group patients was stabilized within 1 month (pre-meal ≤ 7.0 mmol/L, 2 hours post-meal glucose ≤ 12.0 mmol/L and glycosylated hemoglobin or HbA1c ≤ 7.0%). Personalized treatment programs were adopted for the mitigation group and the objective was to control the pre-meal blood glucose at ≤ 10.0 mmol/L (within 3 to 6 months) and also to control 2 hours post-meal blood glucose at ≤ 20.0 mmol/L (within 3 to 6 months). We compared the occurrence rate of diabetic complications, occurrence rate of new-onset dementia and progressive rate of dementia.

RESULTS

Our results showed that target glucose rate in the mitigation group was significantly higher than that in the strength group. The occurrence rate of diabetic complications in the mitigation group was significantly lower than that observed in the other two groups. Occurrence rate of diabetic hyperosmolar coma was significantly higher in the control group, the occurrence rate of hypoglycemia was meaningfully lower in the strength group and the occurrence rate of new-onset target-organ injury was considerably higher in the mitigation group. The occurrence rate of new-onset dementia and progressive rate of dementia in mitigation group was significantly lower than those in other two groups. Comparison between the control group and the strength group did not reveal any statistical significance (p > 0.05). In the meantime, the survival time in mitigation group was significantly longer.

CONCLUSIONS

Elderly patients with T2DM combined with AD may benefit more from the moderate control of blood glucose and a proper increase of the target value.

Component spectra extraction from terahertz measurements of unknown mixtures

The aim of this work is to extract component spectra from unknown mixtures in the terahertz region. To that end, a method, hard modeling factor analysis (HMFA), was applied to resolve terahertz spectral matrices collected from the unknown mixtures. This method does not require any expertise of the user and allows the consideration of nonlinear effects such as peak variations or peak shifts. It describes the spectra using a peak-based nonlinear mathematic model and builds the component spectra automatically by recombination of the resolved peaks through correlation analysis. Meanwhile, modifications on the method were made to take the features of terahertz spectra into account and to deal with the artificial baseline problem that troubles the extraction process of some terahertz spectra. In order to validate the proposed method, simulated wideband terahertz spectra of binary and ternary systems and experimental terahertz absorption spectra of amino acids mixtures were tested. In each test, not only the number of pure components could be correctly predicted but also the identified pure spectra had a good similarity with the true spectra. Moreover, the proposed method associated the molecular motions with the component extraction, making the identification process more physically meaningful and interpretable compared to other methods. The results indicate that the HMFA method with the modifications can be a practical tool for identifying component terahertz spectra in completely unknown mixtures. This work reports the solution to this kind of problem in the terahertz region for the first time, to the best of the authors' knowledge, and represents a significant advance toward exploring physical or chemical mechanisms of unknown complex systems by terahertz spectroscopy.

Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years

Minimally invasive total knee replacement (MIS-TKR) has been reported to have better early recovery than conventional TKR. Quadriceps-sparing (QS) TKR is the least invasive MIS procedure, but it is technically demanding with higher reported rates of complications and outliers. This study was designed to compare the early clinical and radiological outcomes of TKR performed by an experienced surgeon using the QS approach with or without navigational assistance (NA), or using a mini-medial parapatellar (MP) approach. In all, 100 patients completed a minimum two-year follow-up: 30 in the NA-QS group, 35 in the QS group, and 35 in the MP group. There were no significant differences in clinical outcome in terms of ability to perform a straight-leg raise at 24 hours (p = 0.700), knee score (p = 0.952), functional score (p = 0.229) and range of movement (p = 0.732) among the groups. The number of outliers for all three radiological parameters of mechanical axis, frontal femoral component alignment and frontal tibial component alignment was significantly lower in the NA-QS group than in the QS group (p = 0.008), but no outlier was found in the MP group. In conclusion, even after the surgeon completed a substantial number of cases before the commencement of this study, the supplementary intra-operative use of computer-assisted navigation with QS-TKR still gave inferior radiological results and longer operating time, with a similar outcome at two years when compared with a MP approach.

Optical characterization of a Cd(0.85)Mg(0.15)Se mixed crystal

We present an optical characterization of a Bridgman-grown wurtzite-type Cd(0.85)Mg(0.15)Se mixed crystal in the near-band-edge interband transitions using temperature-dependent contactless electroreflectance (CER) and photoreflectance (PR) in the temperature range 15-400 K. The interband excitonic transitions A and C originating from the band edge and spin-orbital splitting critical points of the sample, respectively, have been observed in the CER/PR spectra. The transition energies and broadening function of the excitonic features are determined via a lineshape fit to the CER/PR spectra. The parameters that describe the temperature dependence of the transition energies of excitons A and C, and the broadening function of exciton A, are evaluated and discussed.

Efficacy and safety of imidapril in patients with essential hypertension: a double-blind comparison with captopril

In this 12-week, double-blind, parallel-group, comparative trial, 57 adult patients with mild-to-moderate hypertension were randomly allocated to receive imidapril or captopril, initially at a dose of 5 mg once a day and 25 mg twice daily, respectively. After 4 weeks of therapy, the dose of each drug was increased twice if diastolic blood pressure (DBP) remained > or =90 mm Hg. Both treatments effectively lowered DBP in a comparable manner. Mean changes from baseline in DBP at 12 weeks were -9.9 mm Hg for imidapril and -8.8 mm Hg for captopril (p = 0.488). Responder rates in patients receiving active treatment for at least 6 weeks were 53.9% for imidapril and 48% for captopril (p = 0.676). Both treatments were well tolerated. Adverse drug reactions were observed in 20.7% (6/29) of the imidapril group and 46.4% (13/28) of the captopril group (p < 0.05). A cough was the most frequent side effect, reported in 13.8% of the imidapril group and 35.7% of the captopril group. The results indicate that imidapril is as effective as captopril in the treatment of hypertension. Imidapril produces less adverse effects compared with captopril.

Spontaneous femoral neck fracture complicating a healed subtrochanteric fracture--a case report

A rare case of spontaneous femoral neck fracture complicating a healed subtrochanteric fracture was encountered in an 85-year-old female. The subtrochanteric fracture was caused by a minor trauma with no other combined injury. Patient received close reduction and internal fixation two days later and the fracture healed in three months. Six months after operation, spontaneous ispilateral femoral neck fracture occurred without trauma. Although there were some reports about subcapital fracture or femur neck fracture complication after operation, this is the first case of spontaneous femoral neck fracture after healed subtrochanteric fracture which was treated with a 95 degrees dynamic condylar screw (DCS) and side plate previously without technical error.

Inhomogeneity of myocardial perfusion in heart transplant recipients: evaluation with dobutamine thallium-201 SPECT

Progressive heterogeneity of thallium-201 single photon emission computed tomography (Tl-201 SPECT) in heart transplant recipients has been documented in Caucasians. However, in Chinese heart transplant recipients, a lower incidence of transplant coronary artery disease (CAD) has been noted than in Western transplant recipients. In this study, we examine whether heterogeneity of Tl-201 SPECT exists in Chinese transplant recipients. Dobutamine Tl-201 SPECT was performed in 40 heart transplant recipients and the inhomogeneity scores were calculated. The difference between the scores of transplant recipients surviving less than 12 months and those of control subjects were not statistically significant. One year after transplantation, the inhomogeneity score increased progressively. The scores of transplant patients in the second and third years after transplant were similar to those of single-vessel CAD patients. Three years after transplant the scores were greatly increased. Thus, our data suggest that the progressive nature of graft vasculopathy also exists in Chinese heart transplant recipients. The progressive Tl-201 abnormalities may be one of the early signs of graft vasculopathy.

Surgical treatment for Haglund's deformity

Haglund's deformity, or "pump bump" is a common cause of posterior heel pain, characterized clinically by a painful soft tissue swelling at the level of the Achilles tendon insertion. We reviewed 30 heels in 19 patients with failure of conservative treatment. Surgical management consisted of excision of the posterior calcaneal tuberosity and bursectomy through a medial longitudinal incision. The average follow-up period was 6 years (range, 3-10 years). Only 3 heels (10%) in 2 patients had persistent pain. Twenty-seven heels (90%) were cured after operation. However, 25 heels (83%) had residual pain for a half to two years after operation and became free of symptoms thereafter. We conclude surgical treatment of Haglund's deformity produces a predictably good result (90%) but requires a long time about a half to two years for full recovery.

Isolated talonavicular arthrodesis for talonavicular arthritis

We have reviewed a single surgeon's experience with isolated talonavicular fusion in 16 patients with talonavicular arthritis. Fixation was either by staples or screws. Fifteen solid unions were achieved in the 16 patients who were followed (mean: 51 months). The average Ankle-Hindfoot Scale improved from 77.2 preoperatively to 92.9 postoperatively (p < 0.001). Subjectively, 15 patients were satisfied and one patient dissatisfied with the results. Further osteoarthritis in the adjacent joints was noted in five patients. We concluded that isolated talonavicular fusion is an effective method of treatment of talonavicular arthritis regarding pain relief and functional improvement. Though osteoarthritis was found in some adjacent joints postoperatively, the results were still satisfactory.

Accuracy of biphasic response, sustained improvement and worsening during dobutamine echocardiography in predicting recovery of resting myocardial dysfunction after revascularization: comparison with thallium-201 SPECT

To evaluate the accuracy of various types of wall motion response during dobutamine echocardiography (DE) in predicting functional recovery after revascularization, we studied 30 patients with stable coronary disease and left ventricular dysfunction by simultaneous DE and (201)Tl reinjection SPECT. Among 480 segments (16 segments/patient), 199 had abnormal wall motion at baseline and 167 were revascularized. The predictive value for recovery of function was 72% for a biphasic response, 61% for sustained improvement, 77% for worsening, and 27% for no change (p < 0.01 vs. each). Biphasic response had a sensitivity of 40% and specificity of 85%. Combining biphasic, sustained improvement and worsening responses, the sensitivity, specificity and accuracy were 76%, 65% and 71%, respectively. For (201)Tl SPECT, they were 90%, 65% and 78%, respectively. Thus, a biphasic response alone is of low sensitivity. Combination of biphasic, sustained improvement and worsening responses gives an accuracy rate comparable to that of (201)Tl reinjection SPECT in assessing functional recovery.

Low tibial osteotomy for moderate ankle arthritis

Low tibial osteotomy is one of the significant advances of ankle reconstruction techniques that has been made recently in an effort to halt arthritis in its early stages and leave fusion as the last, not the only, alternative treatment of ankle arthritis. From 1989 to 1995, we performed 18 low tibial osteotomies which included 6 cases of post-traumatic arthritis and 12 cases of degenerative arthritis. The ages of the 7 male and 11 female patients ranged from 18 to 78 years with an average of 41.9 years. The follow-up period lasted a mean of 47.7 months, ranging from 25 to 82 months. The average functional score changed from 49.6 pre-operatively to 88.5 at the last follow up, and showed yearly improvement. Complications included one case of late infection and two cases of implant failure, none of which led to nonunion. The indication for low tibial osteotomy is the intermediate stage of moderate ankle arthritis with a medial joint lesion and intact lateral facet. Using pressure redistribution on the joint surface, this procedure is an alternative treatment for ankle arthritis which may save an arthritic ankle from the fate of fusion or at least postpone fusion surgery.

Comparison of ischemic patterns in myocardial bridge and syndrome X: evaluation by dobutamine stress echocardiography and stress thallium-201 SPECT

BACKGROUND AND PURPOSE

Ischemic patterns in patients with syndrome X are thought to differ from those in patients with myocardial bridge, because the mechanisms of coronary flow reduction in these two diseases are different. The aim of this study was to compare the ischemic patterns in patients with syndrome X and those with myocardial bridge through the use of dobutamine stress echocardiography (DSE) and stress thallium-201 single-photon emission computed tomography (SPECT).

METHODS

Twenty-six patients with typical angina and stress-induced ST-segment depression were enrolled. All patients underwent coronary angiography, DSE, and stress thallium-201 SPECT within 7 days after enrollment.

RESULTS

Of the 26 patients enrolled, 10 had myocardial bridge of the left anterior descending artery and 16 had syndrome X. Among patients with myocardial bridge, myocardial dyssynergy was found by DSE in five patients and reversible or fixed thallium-201 perfusion defects were found in four. Seven patients with myocardial bridge had reverse redistribution patterns on thallium-201 scintigraphy. In the 16 patients with syndrome X, myocardial dyssynergy was found by DSE in only one patient (p = 0.018 vs myocardial bridge group) and reversible or fixed thallium-201 perfusion defects were found in nine (p > 0.05 vs myocardial bridge group). Four patients with syndrome X had reverse redistribution patterns on thallium-201 scintigraphy. The resting left ventricular end-diastolic pressure was higher in patients with myocardial bridge than in those with syndrome X (17 +/- 4 vs 12 +/- 5 mm Hg, p = 0.02).

CONCLUSIONS

The most common ischemic patterns in patients with syndrome X were chest pain and stress-induced ST-segment depression, followed by myocardial perfusion defects. Dobutamine-induced dyssynergy was rare. Left ventricular end-diastolic pressure elevation and dobutamine-induced wall motion abnormalities were more common in patients with myocardial bridge than in those with syndrome X.

Assessment of the myocardial changes in heart transplant recipients without evident acute myocardial rejection by integrated backscatter: comparison with simultaneous dobutamine stress echocardiography and (201)thallium spect

Cardiomyocyte hypertrophy and interstitial fibrin deposition develop in cardiac allografts and contribute to the functional changes of transplanted hearts. We hypothesized that integrated backscatter (IBS) can detect these myocardial changes. A total of 32 heart transplant recipients with either no or mild acute rejection (International Society of Heart and Lung Transplantation grade IA) were enrolled in this study. IBS data of myocardium were collected immediately before simultaneous dobutamine stress echocardiography (DSE) and (201)thallium imaging. Coronary angiography and endomyocardial biopsy were also performed. Coronary angiography showed diffuse narrowing in 1 patient who also had abnormal results of IBS, DSE, and thallium results. In the other 31 patients with patent coronary arteries, there were 3 patients (10%) with abnormal DSE results, 19 patients (61%) with abnormal IBS patterns, and 16 patients (52%) with reversible thallium perfusion defects. Of the patients, 44% had cardiomyocyte hypertrophy and 56% interstitial fibrin deposition. There were significant differences in the prevalence of (201)thallium perfusion defects and serum cyclosporine levels between patients with and without abnormal IBS patterns. Pathologic changes were also associated with abnormal IBS patterns (p = 0.01). However, there was no association between abnormal IBS and DSE results. By multiple logistic regression analysis, the abnormal IBS patterns were associated inversely with serum cyclosporine level (p = 0.028). In conclusion, abnormal IBS patterns are associated significantly with perfusion heterogeneity and pathologic changes in heart transplant recipients without evident acute myocardial rejection. There is no association between abnormal IBS patterns and dobutamine-induced dyssynergy in these patients. IBS provides a noninvasive approach for detection of myocardial changes in transplanted hearts without evident acute rejection.

Integrated backscatter for quantification and risk stratification of blood stagnation in left atrial appendages of patients with rheumatic mitral stenosis

This study was designed to quantify the blood stagnation in left atrial appendages (LAA) of patients with rheumatic mitral stenosis, and to stratify the risk of spontaneous echo contrast (SEC) for thrombus formation. A total of 45 patients were enrolled in this study. Thirty of the 45 patients had rheumatic mitral stenosis. All the above patients were evaluated for LAA contractility by transesophageal echocardiography. Acoustic density of the stagnant blood was assessed using the integrated backscatter (IBS) mode. Multivariate linear regression analysis showed that the significant independent variables determining relative IBS in LAA were the mitral valve area (p = 0.02) and the atrial fibrillation rhythm (p = 0.0003). In patients with mitral stenosis, the IBS in LAA correlated well with the presence of thrombus (p = 0.004) and SEC (p = 0.002). Using the relative IBS in LAA with 6.8 dB as the cutoff value, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy of SEC formation in LAA was 83, 86, 95, 60 and 83%, respectively. Using the relative IBS in LAA with 10.0 dB as the cutoff value, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy of SEC with thrombus formation in LAA was 80, 80, 67, 89 and 80%, respectively. In conclusion, the blood stasis in LAA can be objectively quantified using IBS. Utilizing different cutoff values, the acoustic densitometry in LAA enables identification of stagnant blood which represents a risk for the development of either SEC only or SEC with thrombus formation.

Comparison of simultaneous dobutamine echocardiography and thallium-201 stress-reinjection single-photon emission computed tomography in predicting improvement of chronic myocardial dysfunction after revascularization

Previous studies have shown that ultrasonic integrated backscatter is valuable in characterizing stunned myocardium. Recent investigations have demonstrated that resting cardiac cycle-dependent variation of integrated backscatter closely paralleled the contractile reserve in patients with chronic left ventricular ischemic dysfunction. The purpose of this study was to validate whether ultrasonic tissue characterization (UTC) compared with dobutamine stress echocardiography (DSE) and thallium-201 stress-reinjection single-photon emission computed tomography (Tl-SPECT) could predict reversible myocardial dyssynergy in patients with chronic coronary artery disease. Forty-eight patients with stable coronary artery disease underwent UTC, DSE, and Tl-SPECT simultaneously before successful coronary revascularization and were followed up with echocardiograms at rest >3 months later. Among the 58 investigated segments, the weighted amplitude, a composite parameter derived from the integrated backscatter power curve, was larger for those groups with greater functional recovery (p <0.001). For the persistent akinetic segments, the weighted amplitudes were small with large deviations of the nadir ratios that represented the asynchrony between the intramural contractile events and the global systole. Using the cut-off value 2.0 of the weighted amplitude, the sensitivity and specificity for predicting functional improvement after revascularization were both 82.8% (kappa = 0.66) and comparable to the sensitivity and specificity of DSE and Tl-SPECT. UTC, delineating the myocardial physical state and intramural contraction, can be a novel approach in predicting functional improvement of chronic dyssynergy after revascularization.

High glucose-induced apoptosis in human endothelial cells is mediated by sequential activations of c-Jun NH(2)-terminal kinase and caspase-3

BACKGROUND

Diabetes mellitus causes multiple cardiovascular complications. High glucose can induce reactive oxygen species and apoptosis in endothelial cells. Little is known about the molecular mechanisms in high glucose-induced endothelial cell apoptosis.

METHODS AND RESULTS

We elucidated the signaling pathway of high glucose-induced apoptosis in human umbilical vein endothelial cells (HUVECs). HUVECs were treated with media containing 5.5, 19, or 33 mmol/L of glucose in the presence or absence of an antioxidant, ascorbic acid. The level of intracellular H(2)O(2) was measured by flow cytometry. For detection of apoptosis, the cell death detection ELISA assay and the morphological Hoechst staining were used. High glucose was capable of inducing the activity of c-Jun NH(2)-terminal kinase (JNK) but not extracellular signal-regulated kinase 1/2 or p38 mitogen-activated protein kinase during the treatment periods, as evidenced by immunocomplex kinase assay. Moreover, we found that the interleukin 1beta-converting enzyme (ICE)/CED-3 family protease (caspase-3) became activated in high glucose-induced apoptosis. Caspase-3/CPP32-specific inhibitor, Ac-DEVD-CHO, could inhibit high glucose-induced apoptosis. Furthermore, we found that JNK1 specific antisense oligonucleotide could suppress caspase-3 activity but not affect H(2)O(2) generation and could block apoptosis induced by high glucose. Also, H(2)O(2) generation, JNK activity, caspase-3 activity, and the subsequent apoptosis induced by high glucose could be suppressed by ascorbic acid.

CONCLUSIONS

The present study indicates that reactive oxygen species induced by high glucose may be involved in JNK activation, which in turn triggers the caspase-3 that facilitates the apoptosis in HUVECs.

Ultrasonic tissue characterization evaluates myocardial viability and ischemia in patients with coronary artery disease

To evaluate whether or not ultrasonic tissue characterization (UTC) can detect jeopardized or salvageable myocardium in patients having chronic coronary artery disease, we studied 103 patients with sequential UTC, dobutamine stress echocardiography (DSE) and (201)thallium stress-reinjection single-photon emission computed tomography (T1-SPECT). This revealed that the weighted amplitude of the cyclic modulation of integrated backscatter was larger for the myocardium with less ischemia burden or greater viability (p<0.001). The segments with larger ischemia burden or the nonviable myocardium demonstrated the contrary result. Using the receiver-operating characteristic curve analyses to determine the cutoff value of weighted amplitude for various predictions, UTC can detect ischemia in normokinetic myocardium (kappa = 0.34 compared to DSE or T1-SPECT) and viability in dyssynergic myocardium (kappa = 0.57 compared to DSE and 0.45, to T1-SPECT). These observations show that UTC may prove useful in the identification and pathophysiological understanding of myocardial ischemia and viability.

Open total talar dislocation--report of two cases

Total dislocation of talus from all its surrounding joints (tibiotalar, subtalar and talonavicular) is an extremely rare injury. Because of its rarity, only few case reports can be found in the literature. In the review of the literature, infection and AVN are the most commonly encountered complications that affect the outcome of these severe injuries. Herein we report two cases of open total talar dislocation. Immediate debridement, reduction of the talus, and primary skin closure was done followed by cast immobilization. After more than 2 years follow up, neither infection nor AVN was found. We conclude that reimplantation of the talus is preferable if the wound is relatively clean. Talectomy, or combined with tibiocalcaneal fusion should be reserved for later salvage procedure.

Postero-medio-anterior approach of the ankle for the pilon fracture

A good view of the operative field is important for better reduction and fixation in surgical treatment of fractures. The exposure of the ankle joint for the pilon fracture is commonly through the anterior approach, or combined with the medical approach. But sometimes it is still difficult to have complete viewing of the articular surface and to apply internal fixation by that approach. In recent years, we developed a "postero-medio-anterior" approach of the ankle joint by one incision. This approach provides an excellent exposure of the anterior, medial and posterior aspects of the ankle joint with a clear view of the articular surface. In our 45 cases of pilon fracture during 1991 to 1995, there was no incisional injury to the neurovascular bundle. Superficial wound edge necrosis was noted in two cases which healed later without further procedure. Therefore, we recommend this approach as a simple and reliable incision for open reduction of pilon fractures.

The surgical treatment for degenerative disease of the ankle

Although a variety of surgical techniques are available for the surgical treatment of early degenerative disease of the ankle, arthrodesis remains the preferred treatment for severe cases. We studied 126 ankles with an average follow up of 39 months of whom 25 with early disease underwent debridement and cheilectomy, 18 with intermediate disease underwent lower tibial osteotomy and 83 with severe disease underwent either arthrodesis (78) or total ankle replacement (5). In 96% of cases there was a satisfactory functional outcome.

Persistent myocardial ischemia after termination of dipyridamole-induced ventricular tachycardia by intravenous aminophylline: scintigraphic demonstration

Ventricular tachycardia is a rare complication of dipyridamole stress testing. We present a case in which dipyridamole induced symptomatic ventricular tachycardia. The patient, a 41-year-old man with a history of chest discomfort on exertion for 1 year, underwent dipyridamole thallium imaging. Sustained ventricular tachycardia occurred 1 minute and 40 seconds after completion of the dipyridamole infusion. Intravenous aminophylline (125 mg) was given immediately and the tachycardia was terminated. Two minutes later, thallium-201 was injected and subsequent myocardial imaging showed reversible perfusion defects in the inferior wall, septum, and apex. Coronary angiography revealed three-vessel disease. This case discloses that reversible perfusion defects can still be demonstrated on thallium scan in spite of injection of aminophylline, an antagonist of dipyridamole, before thallium administration.

Gait analysis after ankle arthrodesis

The purpose of this study was to employ a computerized motion analysis system to identify the effect of ankle arthrodesis on the three-dimensional kinematic behavior of the rear and fore foot during level walking. A three-segment rigid body model was used to describe the motion of the foot and ankle. The results demonstrated that sagittal plane motion of the hindfoot was significantly decreased in the foot of patients having had ankle arthrodesis compared to normal subjects. The kinematic data indicated a generalized stiffness of the hindfoot on the involved foot in the sagittal plane. Sagittal plane movement in the forefoot and transverse plane movements in the hindfoot and forefoot increased in patients compared to controls.

Nitric oxide prevents apoptosis of human endothelial cells from high glucose exposure during early stage

Hyperglycemia is a major cause of diabetic vascular disease. High glucose can induce reactive oxygen species (ROS) and nitric oxide (NO) generation, which can subsequently induce endothelial dysfunction. High glucose is also capable of triggering endothelial cell apoptosis. Little is known about the molecular mechanisms and the role of ROS and NO in high glucose-induced endothelial cell apoptosis. This study was designed to determine the involvement of ROS and NO in high glucose-induced endothelial cell apoptosis. Expression of endothelial nitric oxide synthase (eNOS) protein and apoptosis were studied in cultured human umbilical vein endothelial cells (HUVECs) exposed to control-level (5.5 mM) and high-level (33 mM) glucose at various periods (e.g., 2, 12, 24, 48 h). We also examined the effect of high glucose on H(2)O(2) production using flow cytometry. The results showed that eNOS protein expression was up-regulated by high glucose exposure for 2-6 h and gradually reduced after longer exposure in HUVECs. H(2)O(2) production and apoptosis, which can be reversed by vitamin C and NO donor (sodium nitroprusside), but enhanced by NOS inhibitor (N(G)-nitro-L-arginine methyl ether), were collated to a different time course (24-48 h) to HUVECs. These results provide the molecular basis for understanding that NO plays a protective role from apoptosis of HUVECs during the early stage (<24 h) of high glucose exposure, but in the late stage (>24 h), high glucose exposure leads to the imbalance of NO and ROS, resulting to the observed apoptosis. This may explain, at least in part, the impaired endothelial function and vascular complication of diabetic mellitus that would occur at late stages.

Effect of acupuncture at nei-kuan on left ventricular function in patients with coronary artery disease

Effect of acupuncture at Nei-Kuan (EH-6) on left ventricular ejection fraction (LVEF) was examined in 22 patients with angiographically proved coronary artery disease (CAD) and 22 normal subjects. Serial equilibrium radionuclide angiography was done to measure LVEF at 4 different times (at baseline, at 1 to 15 minutes, and 16 to 30 minutes during acupuncture, and immediately after acupuncture). One week later, each patient had an identical imaging protocol with acupuncture performed at a dummy point. Our results showed that in normal subjects, the mean values of LVEF did not change significantly during or after acupuncture. In contrast, in patients with CAD, the mean values of LVEF in the initial 15 minutes of acupuncture significantly increased from baseline (42.5 +/- 15.6% vs. 40.6 +/- 15.4%, p < 0.05). The increase persisted through the next 15 minutes of acupuncture and 15 minutes after acupuncture, but became insignificant at one week. Thus, acupuncture at Nei-Kuan can temporarily improve LV function in patients with CAD.

Ankle arthrodesis: internal non-compression arthrodesis versus internal compression arthrodesis

Ankle arthrodesis is still considered to be the standard treatment for most disabling types of ankle arthritis, but fusion methods are varied. We report our experience of ankle arthrodesis and compare a group of 34 cases treated by Blair's non-compression arthrodesis to another group of 32 cases treated by internal compression arthrodesis using two crossed screws. The same surgeon performed all the operations. The Blair's non-compression arthrodesis group included 21 males and 13 females with an average age of 42 y/o (range 18-70 y/o) and an average follow up period of 38.6 months (range 26-62 months). The union rate was 91.2% and the average union time was 5.6 months (range 2-10 months). There were three cases of non-union. The cross-screw compression arthrodesis group included 20 males and 12 females with an average age of 45 y/o (range 20-86 y/o) and an average follow up period of 38.3 months (range 15-81 months). The union rate was 96.9% and the average union time was 2.7 months (range 1.5-4.4 months). There was one case of non-union. We conclude that our cross-screws compression arthrodesis with its shorter fusion time was found to be superior to the Blair's non-compression arthrodesis.

Significance of dobutamine-induced ST-segment evaluation and T-wave pseudonormalization in patients with Q-wave myocardial infarction: simultaneous evaluation by dobutamine stress echocardiography and thallium-201 SPECT

The clinical significance of stress-induced ST-segment elevation and T-wave pseudonormalization in infarct-related leads is still controversial. Therefore, we conducted the present study to assess this issue using simultaneous dobutamine stress echocardiography (DSE) and thallium-201 single-photon emission computed tomography. A total of 119 patients with Q-wave myocardial infarction were enrolled in this study. There were 58 patients with (group I) and 61 patients without (group II) dobutamine-induced ST-T changes. Left ventricular ejection fraction was 43 +/- 13% in group I and 49 +/- 14% in group II (p <0.05). The baseline, low-, and peak-dose global wall motion scores were similar between these 2 groups (26.2 +/- 6.1 vs 26.2 +/- 6.3 [p = NS]; 24.1 +/- 5.3 vs 23.5 +/- 5.7 [p = NS]; 26.4 +/- 5.7 vs 26.7 +/- 6.1 [p = NS]). The sensitivity, specificity, and accuracy of these ST-T changes for detecting residual myocardial viability and ischemia documented by DSE in all patients were 50%, 53%, and 51% (for viability), and 47%, 48%, and 47% (for ischemia), respectively. The sensitivity, specificity, and accuracy of these ST-T changes for detecting a reversible perfusion defect documented by thallium-201 single-photon emission computed tomography were 51%, 54%, and 52%, respectively. In conclusion, dobutamine-induced ST elevation and/or T-wave pseudonormalization is associated with poor resting left ventricular function. These ST-T changes are not associated with residual myocardial ischemia and viability in the infarct area. Therefore, these electrocardiographic changes alone cannot be reliably considered as distinctive markers in formulating the therapeutic strategy of coronary intervention.

Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy

Primary subtalar arthritis is not common. In most cases, it is the late sequela of intra-articular calcaneal fracture. Subtalar arthrodesis is mostly used for the treatment of traumatic subtalar arthritis in our clinics. We have compared our early cases of in-situ subtalar fusion with our recent cases of fusion with sliding corrective osteotomy in this clinical report. From 1989 to 1992, 15 feet of 13 patients were treated with subtalar arthrodeses for subtalar arthritis caused by malunion of calcaneal fractures. Fusion in situ was done by Ollier's approach, and resection of bony protrusion was done if there was lateral entrapment syndrome. From 1992 to 1995, 13 feet of 12 patients also received subtalar arthrodeses to salvage their calcaneal fractures, but the subtalar fusion was done by wide lateral approach, calcaneal sliding corrective osteotomy, and sometimes (11 of 13 feet) with Achilles tendon lengthening to restore the calcaneal height and width. Patients of both groups experienced obvious clinical improvement in subtalar pain relief, but there was no difference with walking distance, running, or jumping. The group undergoing fusion with sliding corrective osteotomy was more satisfied with regard to cosmetic results and shoe wear. The overall satisfactory rate in the group who underwent fusion with sliding corrective osteotomy (92%) was superior to the group who underwent fusion in situ (77%). Though our method of sliding corrective osteotomy does not provide much improvement to the talus declination angle, it is suitable for those patients with a "banana"-shaped calcaneus malunion. If the patient has prominent anterior ankle pain caused by tibiotalar impingement, we believe that a distraction subtalar arthrodesis would be more appropriate.

Modified Mitchell osteotomy for hallux valgus

From 1988 to 1995, 96 patients (161 feet) underwent a modified Mitchell distal metatarsal osteotomy performed for mild-to-moderate hallux valgus. On AP x-rays of the standing foot, the average intermetatarsal angle was corrected from 15 degrees to 9 degrees, and the first metatarsophalangeal angles were corrected from an average of 41 degrees to 15 degrees. Criteria for evaluation of clinical results included relief of pain, appearance of foot, and shoe wear. After an average follow-up of 38 months, the overall satisfaction rate was 92.5%. Complications included 13 pin tract infections, two delayed unions, and two correction losses. The most common late sequela was transfer metatarsalgia of the lesser toes, which occurred in 20 feet (12.4%), leading to some dissatisfaction. The Mitchell osteotomy can be used on cases with less than 20 degrees of intermetatarsal angle, offering a stable construct with easy postoperative care.

A retrospective hospital-based study of coronary risk factors in Taiwan. Analysis of patients with established diagnoses

In Taiwan over the past decades there has been enormous economic growth and rapid westernization of people's life style, as well as a concomitant rise in coronary heart disease (CHD) mortality and morbidity. Studying the effects of such a degree of socioeconomic development on the coronary risk factors of the Chinese population, an ethnic group long regarded as having a low incidence of CHD, may provide some insight into the etiology of coronary atherosclerosis. Coronary risk factors among 1,449 patients (759 with CHD) were retrospectively studied. Diagnosis was established by angiography or a definite history of myocardial infarction in approximately 60% of the patients, and for the remainder, at least by noninvasive testing. The frequencies of dyslipidemia and nonlipid risk factors in patients with and without CHD were determined and compared. The lipid levels of subjects with or without CHD were close to or approaching those reported from the United States. Socioeconomic development and changes in dietary patterns seem influential in this regard. Among risk factors, high-density lipoprotein cholesterol (HDL-C), smoking, diabetes mellitus, hypertension and family history in males and, in females, total cholesterol, HDL-C, diabetes mellitus and hypertension, were significantly and independently correlated with CHD. These risk factors are similar to those found in the West; however, there is an important association of serum HDL-C concentrations with CHD, irrespective of gender. This issue requires further study in Chinese populations in other Asian countries.

Modified Blair method for ankle arthrodesis

In this study, the ordinary Blair's ankle arthrodesis was modified by longitudinal oblique cutting to get the sliding bone graft, up side down grafting, and additional screw fixation at talar site with or without staples fixation of tibia-talar junction. The method of ankle arthrodesis was used on 34 cases from 1987 to 1990 with a 91.2% fusion rate and an average 5.6 months fusion time. The oblique cut bone graft provided larger contact surface to enhance bony fusion and the upside-down bone graft provided stronger tibia-talar bone bridge with thicker cortex for distal screw fixation and the distal screw fixation of bone graft to talus had the advantage of securing union and maintaining position. With such modifications, solid ankle arthrodesis could be obtained even without interarticular compression.

Assessment of coronary artery disease in women by dobutamine stress echocardiography: comparison with stress thallium-201 single-photon emission computed tomography and exercise electrocardiography

BACKGROUND

Dobutamine stress echocardiography (DSE) is sensitive and specific in detecting myocardial ischemia of male patients. However, there have been few reports about the use of DSE for the detection of coronary artery disease (CAD) in women.

METHODS

DSE was evaluated in 51 consecutive women who underwent concomitant quantitative coronary angiography. Forty-four of the 51 patients received stress thallium-201 single-photon emission computed tomography (SPECT), and 30 of the 51 patients had interpretable results (exercise level > or = 85% of age-predicted maximal heart rate) of treadmill exercise. Twenty-nine patients had angiographically documented CAD defined as > or = 50% diameter stenosis.

RESULTS

The overall sensitivity of DSE and stress 201Tl SPECT in detecting CAD was 93% and 79% (p = nonsignificant), and the specificity was 82% and 75% (p = nonsignificant), respectively. A combination of both tests increased the sensitivity (96%) at the expense of some decrease in specificity (60%). The agreement of DSE and 201Tl SPECT was 68% (30 of 44; kappa statistic = 0.35; p < 0.0001). The overall sensitivity, specificity, and accuracy in detecting CAD by treadmill exercise test and DSE were 71% vs 93% (p = nonsignificant), 44% vs 82% (p = 0.036), and 57% vs 88% (p = 0.003). In patients with abnormal results of treadmill exercise testing, the false-positive rate in detecting CAD was 2 (18%) of 11 in patients with abnormal results of DSE and 7 (88%) of 8 in those with normal results of DSE (p = 0.005). In patients with normal results of treadmill exercise testing, the false-negative rate in detecting CAD was 4 (100%) of 4 in patients with abnormal results of DSE and 0 (0%) of 7 in those with normal results of DSE (p = 0.003).

CONCLUSION

The diagnostic accuracy of DSE was similar to that of stress 201Tl SPECT in women. DSE was able to stratify female patients with either abnormal or normal results of treadmill exercise testing and to avoid unnecessary cardiac catheterization.

Comparison of S-T segment/heart rate slope with exercise thallium imaging and conventional S-T segment criteria in detecting coronary artery disease: effect of exercise level on accuracy

The S-T segment/heart rate (ST/HR) slope has been proposed as a more accurate electrocardiographic criterion for the diagnosis of coronary artery disease, but studies comparing the diagnostic value of the ST/HR slope with exercise thallium imaging are scant. The aims of this study were to assess the diagnostic accuracy of the ST/HR slope, conventional S-T segment criteria and exercise thallium imaging in detecting coronary artery disease and to evaluate the effect of exercise level on the sensitivity and specificity of these three techniques. Ninety consecutive patients underwent treadmill testing and exercise thallium single-photon emission computed tomography (SPECT) simultaneously. All 90 patients also underwent coronary angiography within 1 month of the exercise test. We found that exercise thallium SPECT had a significantly higher diagnostic accuracy than either the ST/HT slope or conventional S-T segment criteria (thallium imaging 82%, ST/HR slope 67%, conventional S-T segment criteria 63%). The overall accuracy of the ST/HR slope was slightly but insignificantly greater than conventional S-T segment criteria (ST/HR slope 67%, conventional S-T segment criteria 63%; p = 0.639). In 50 patients with a lower exercise level, defined as not achieving 85% of their maximal predicted heart rate, the accuracy of the ST/HR slope was insignificantly greater (ST/HR slope 72%, conventional S-T segment criteria 66%; p = 0.517). In 40 patients with adequate exercise, the accuracy rate was the same (60%) for both the ST/HR slope and conventional S-T segment criteria. We conclude that exercise thallium imaging is more accurate than the ST/HR slope in diagnosing coronary artery disease and that the accuracy of the ST/HR slope is marginally better than conventional S-T segment criteria only in patients with a lower exercise level, and not in those with adequate exercise.

Ankle arthrography and chronic lateral ankle instability

Sixty-five ankle arthrograms of the patients who underwent surgical reconstruction for their chronic ankle instability from 1987 to 1995 were studied retrospectively by comparing their operative findings. There were 15 cases (23.1%) with definite positive arthrographic findings. In the remaining 50 cases (76.9%), the arthrograms showed a "tear-drop" extravasation of dye beneath the fibular tip which we called "suspectable positive". Of these all but one, which had normal ligament, proved to correspond to the operative finding. As there was only one false positive finding among our surgical cases with both the "definite" and "suspectable" positive arthrograms, we concluded that ankle arthrography is relatively reliable and may be worth doing even in chronic cases if only for reference. Even when other diagnostic methods are negative, arthrography might help surgeons make surgical decisions in clinical symptomatic cases.

Surgical treatment for pilon fracture of the ankle-open reduction and internal fixation

From 1991 to 1994, 39 ankles of 38 patients underwent surgical open reduction and internal fixation for pilon fractures. These patients included 29 males and 9 females with an average age of 38.6 y/o (range 28 y/o-58 y/o). The follow up and evaluation period averaged 31.7 months (range 22Ms-44Ms), during which time a standing x-ray for arthrosis grading and functional scale was used for clinical evaluation. Complications included 1 case of infection, 1 case of loss reduction, 2 cases of partial skin necrosis and 2 cases of delayed union. Post-traumatic arthritis occurred in 23 ankles (59%) but only 4 ankles of grade 4 arthrosis resulted in poor functional scale and the overall satisfactory rate was 82%. It was found that anatomic reduction, rigid fixation and early motion exercise are important to successful treatment of ankle fractures. Regarding pilon fracture, specifically the severity of fracture pattern and delay of reduction are important problems to overcome to ensure successful results. Therefore, adequate surgical approach for entire view of ankle joint, reduction and fixation of fibula, sufficient bone graft for articular support, intraoperative x-ray check and postoperative immobilization are essential for the achievement of better clinical results.

Do beta-blockers affect the diagnostic sensitivity of dobutamine stress thallium-201 single photon emission computed tomographic imaging?

BACKGROUND

The effects of beta-blockers on dobutamine stress 201Tl tomographic imaging are not known. This study was undertaken to examine whether beta-blockers affect the sensitivity of dobutamine stress 201Tl imaging.

METHODS AND RESULTS

One hundred ten patients without previous myocardial infarction underwent dobutamine stress 201Tl single photon emission computed tomography (SPECT) and coronary arteriography, both studies within a 1-week period. Dobutamine was infused at rates of 5, 10, 20, 30, and 40 microg/kg/min in 3-minute stages. Atropine (as much as 1 mg) was injected intravenously when the patient's heart rate was <100 beats/min. Patients in group 1 (n = 72) were receiving beta-blockers and patients in group 2 (n = 38) were not. The SPECT images in group 1 showed perfusion abnormalities in 62%, 87%, and 94% of patients with one-, two-, and three-vessel coronary artery disease (> or = 50% diameter stenosis), respectively, compared with 75%, 71% and 100% in group 2 (p not significant). The overall sensitivities were 82% (37 of 45) in group 1 and 80% (16 of 20) in group 2 (p not significant). The specificities were 81% (22 of 27) in group 1 and 83% (15 of 18) in group 2 (p not significant). The overall accuracies were the same for both groups (82%). Atropine was added more often in group 1 than in group 2 (37/72 vs 5/38, p < 0.001).

CONCLUSIONS

Our results suggest that beta-blockers do not affect the sensitivity, specificity, and accuracy of dobutamine stress 201Tl SPECT imaging for detecting coronary artery disease if atropine is given when the chronotropic response is inadequate. In patients receiving beta-blockers, however, the addition of atropine to dobutamine stress is more frequently required.

Subtalar arthrodesis for subtalar arthritis

Primary subtalar arthritis is not common except in cases of generalized arthritis such as rheumatoid arthritis. The majority of subtalar arthritis results from intraarticular calcaneal fractures. Arthrodesis seems to be the only way to solve this problem. Thirteen patients (15 feet) were treated with subtalar arthrodesis at KMCH. Preoperative diagnosis included 13 feet with traumatic arthritis secondary to a calcaneal fracture, one foot with rheumatoid arthritis and one foot with primary osteoarthritis. The mean follow up period was 24.9 months. Lateral approach without fibular osteotomy was done with decompression if there was entrapment syndrome and the arthrodesis were accomplished with use of staples for internal fixation. Eleven (85%) of the patients were satisfied with the results. Objectively, the results were excellent after 11 arthrodesis (73%), good or fair after three (20%), and poor after one (7%). There was no nonunion. Complications occurred in 1 patient who developed superficial wound infection, and in 1 patient with staple loosening. Though there was no case of nonunion, the fusion time was rather long. This might have been due to the fixation method because staples can not provide compression force which accelerates union. We believe subtalar arthrodesis is appropriate for isolated subtalar arthritis unless there are associated talonavicular or calcaneocuboid arthritis in which case triple arthrodesis will be more appropriate.

Simultaneous dobutamine stress echocardiography and thallium-201 perfusion imaging for the detection of coronary artery disease

To compare the diagnostic value of dobutamine stress echocardiography with dobutamine thallium-201 single-photon-emission computed tomography (SPECT) in detecting coronary artery disease, we performed both tests simultaneously on 93 patients who also underwent coronary arteriography. Dobutamine was infused at rates of 5, 10, 20, 30 and 40 microns/kg/min in 3-min stages. The left ventricle was divided into anteroseptal, posterolateral and inferior regions. Within each region, wall motion or perfusion abnormalities were classified as normal, ischemia or fixed defect. The response to stress was concordantly classified by both tests in 67 patients (72%, kappa = 0.48). Regional agreement for abnormalities was observed in 79% (kappa = 0.56) of the 279 regions analyzed. Dobutamine echocardiography detected 62 (93%) and thallium SPECT 60 (90%, p = NS) of the 67 patients with significant coronary artery disease (> or = 50% diameter stenosis). The specificity was 77 (20 of 26) and 81% (21 of 26), respectively. The accuracy was 88 and 87%, respectively. Combined the two tests gave a sensitivity of 97%, a specificity of 65% and an accuracy of 88%. The accuracy for detecting individual coronary stenosis with echocardiography was 83% for the left anterior descending artery, 84% for the right coronary artery and 73% for the left circumflex artery. With SPECT, it was 83, 87 and and 76%, respectively. In conclusion, dobutamine stress echocardiography and thallium SPECT provide a comparable accuracy for detection and localization of coronary artery disease, and for identification of regional myocardial abnormalities. Performing the two tests simultaneous is feasible but it adds limited value in detecting coronary artery disease.

Salvage operation for neglected ankle fractures

From 1986 to 1993, 49 cases of untreated or poorly treated ankle fractures who received salvage surgery were followed up for an average of 36.4 months. The patients included 31 males & 18 females with an average age of 41.6y/o and the time interval from initial injury to reconstructive surgery average due 17.6 months. They were classified and treated according to their grade of reduction and degree of arthrosis. The surgical methods included arthrotomy & joint debridement, revised open reduction, lower tibial osteotomy and ankle arthrodesis, depending on different individual conditions. After surgery, all cases had symptomatic relief and functional improvement with an average score increased from 26.3 preoperatively to 86.8 at follow up. The goals of ankle fractures is as articular fractures, they are treated by surgical anatomic reduction with rigid fixation as early as possible in order to provide good functional results. Nevertheless they are varied in neglected ankle fractures according to their individual conditions: open reductions were performed on cases with no or little arthritic change even though arthrosis might occur later because, if necessary, future conversion to osteotomy or arthrodesis would be easier. As for late cases with advanced arthritis, ankle arthrodesis were done by compressive arthrodesis with necessary bone graft to secure fusion in an optimal position.

Streptococcus adjacens endocarditis in a patient with nephrotic syndrome

Streptococcus adjacens has never previously been reported as an etiologic organism of infective endocarditis in Taiwan. We describe a case of severe native valve endocarditis caused by S. adjacens, involving the mitral valve, the aortic valve, and the left atrium, in a 29-year-old woman with nephrotic syndrome on steroid therapy. Blood cultures yielded gram-positive cocci that grew poorly on blood agar but strongly on chocolate agar. Despite aggressive antibiotic treatment, the patients continued to have high fever and progressive congestive heart failure, which necessitated surgical intervention. Symptoms were alleviated after surgery; teicoplanin was continued for 4 weeks and the patient remained symptom-free at the 6 month follow up. To our knowledge, this is the first reported case of bacterial endocarditis involving the left atrium without preexisting myxoma.

Dobutamine stress echocardiography compared with exercise thallium-201 single-photon emission computed tomography in detecting coronary artery disease-effect of exercise level on accuracy

Dobutamine stress echocardiography (DSE) and exercise thallium-201 single-photon emission computed tomography (SPECT) were compared for the accuracy in detecting coronary artery disease (CAD) in 51 consecutive patients. Twenty-six (group 1) of the 51 patients achieved adequate exercise end points, and 25 (group 2) did not. There were 38 patients with angiographically documented CAD. The overall sensitivity of DSE and thallium-201 SPECT in detecting CAD was 92 and 76% (p = NS), and the specificity was 77 and 77% (p = NS), respectively. The sensitivity of DSE is the same as that of SPECT in group 1 (90 vs. 90%; p = NS) and higher than that of SPECT in group 2 (94 vs. 61%; p < 0.05). In patients with CAD without a history of acute myocardial infarction or pathological Q wave on resting electrocardiogram, the sensitivity of DSE is the same as that of SPECT in group 1 (82 vs. 82%; p = NS) and also higher than that of SPECT in group 2 (90 vs. 40%; p = 0.03). The sensitivity in detecting individual coronary artery lesions with DSE and thallium-201 SPECT was not affected by the exercise level. The agreement between DSE and thallium SPECT in detecting patients with CAD was 88% in group 1 (kappa = 0.69; p < 0.001) and 76% in group 2 (kappa = 0.45; p = 0.01). The agreement in detecting vascular territories with ischemia was 68% in group 1 (kappa = 0.30; p < 0.01) and 75% in group 2 (kappa = 0.33; p < 0.001). The agreement in detecting vascular territories with a scar was 87% in group 1 (kappa = 0.55; p < 0.001) and 85% in group 2 (kappa = 0.44; p < 0.001). In conclusion, the sensitivity and specificity of DSE in detecting CAD are similar to that of thallium-201 SPECT with an exercise level > or =85% of the maximal predicted heart rate. However, in patients who cannot exercise adequately, DSE is more accurate than thallium SPECT. The agreement between DSE and thallium SPECT in detecting patients with CAD and identifying ischemia of individual vascular territories is also affected by the exercise level.

Localizing individual coronary artery obstructions with the dobutamine stress echocardiography

The diagnostic accuracy of detecting individual coronary artery lesions using dobutamine stress echocardiography was evaluated in 206 patients with clinical manifestations of agnina pectoris. The sensitivity, specificity, and accuracy in detecting individual coronary artery lesions was described. The sensitivity was higher in the single-vessel group than in the double- or triple-vessel group. Furthermore, the sensitivity of dobutamine stress echocardiography in localizing vascular territories was greater for proximal segment lesions than for distal segment lesions. The increment of total score and score index at peak dose did not reach statistical significance between the left main lesion and the double-vessel lesions of left anterior descending artery and left circumflex artery (4.88 +/- 1.44 vs. 3.79 +/- 0.39, nonsignificant; 0.83 +/- 0.25 vs. 0.54 +/- 0.06, nonsignificant). In conclusion, although dobutamine stress echocardiography is sensitive for diagnosing coronary artery disease, localizing individual coronary artery lesions is less sensitive for triple-vessel disease and distal lesions.

Low-serum, high-density lipoprotein cholesterol concentration is an important coronary risk factor in Chinese patients with low serum levels of total cholesterol and triglyceride

The significance of low-serum high-density lipoprotein concentrations (<35 mg/dl) with respect to coronary atherogenesis in Chinese patients with low levels of total serum cholesterol (<200 mg/dl) and triglycerides (<250 mg/dl) was assessed. Persons with such a lipid profile pattern were still at high risk, and high-density lipoprotein. like smoking, appeared to be the most predictive independent coronary risk factor.

Correlation between quantitative severity of stress thallium-201 myocardial perfusion defect and severity of coronary stenosis

The correlation between the quantitative myocardial perfusion defect severity of stress 201Tl single-photon emission computed tomography and the severity of coronary stenosis was investigated in 28 patients with angina pectoris. Among the 28 patients, four had normal or nearly normal coronary angiograms, seven had one-vessel disease, six had two-vessel disease and 11 had three-vessel disease. Seven patients had prior myocardial infarctions and two had collateral flows to the diseased vessels. The quantitative 201Tl defect severity score was obtained by summing the standard deviations of each pixel in which the counts fell > 2.5 SD below the mean normal counts. The severity of coronary stenosis was expressed as the Gensini score. The quantitative 201Tl defect severity score correlated significantly with the Gensini score. In patients without prior myocardial infarction or collateral flow, a more significant correlation between the quantitative 201Tl defect severity score and the Gensini score was found. Quantitative analysis of stress 201Tl defect severity provides a useful, noninvasive assessment of the functional severity of coronary stenosis compared with coronary angiography.

Recurrent vertebral osteomyelitis and psoas abscess caused by Streptococcus constellatus and Fusobacterium nucleatum in a patient with atrial septal defect and an occult dental infection

We describe a case in which recurrent vertebral osteomyelitis and psoas abscess due to Streptococcus constellatus and Fusobacterium nucleatum developed in a patient with a previously unrecognized atrial septal defect with bidirectional shunts. Disease recurrence was ascribed to the presence of dental disease, which served as the source of infection. To the best of our knowledge, this is the first case in which vertebral osteomyelitis and psoas abscess have been associated with atrial septal defect.

Dobutamine stress echocardiography compared with dipyridamole thallium-201 single-photon emission computed tomography in detecting coronary artery disease

To compare the diagnostic value of dobutamine stress echocardiography with dipyridamole thallium-201 single-photon emission computed tomography (SPECT) in detecting coronary artery disease (CAD), we performed both tests on 54 patients who also underwent coronary arteriography. Dobutamine was infused at an incremental regimen of 5, 10, 20, 30 and 40 micrograms.kg-1.min-1. Dipyridamole was infused at a rate of 0.14 mg.kg-1.min-1 over 4 min. Dobutamine stress echocardiography detected 40 (93%) and SPECT 42 (98%, P = ns) of the 43 patients with significant CAD, defined as > or = 50% diameter stenosis. The specificity was 73% (8 of 11) for both tests. The sensitivity for detecting individual coronary artery stenosis with dobutamine stress echocardiography was 81% (30 of 37) for the left anterior descending artery, 75% (24 of 32) for the right coronary artery, and 61% (17 of 28) for the left circumflex artery. For SPECT it was 89%, 97% (P < 0.05 vs dobutamine stress echocardiography) and 75%, respectively. Among the 97 stenotic coronary arteries, 17 had mild to moderate stenosis (50%-69% diameter stenosis) and 80 had severe stenosis (> or = 70% diameter stenosis). With dobutamine stress echocardiography, 53% of the arteries with mild to moderate stenosis were identified vs 78% of those with severe stenosis (P < 0.05). With SPECT, the sensitivity was 82% (14 of 17) in mild to moderate stenosis and 89% (71 of 80) in severe stenosis (P = ns). No major side effects occurred during either test. Thus, both dobutamine stress and SPECT are highly sensitive for detection and localization of CAD.(ABSTRACT TRUNCATED AT 250 WORDS)