The effect of underweight on mid-term outcome following transcatheter aortic valve implantation: an insight from multicenter registry

Background

Obesity has the adverse prognostic impact in the general population, whereas paradoxical effect of obesity has been reported in patients with heart failure. Several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve implantation (TAVI), however, they included limited number of underweight patients.

Purpose

The aim of this study was to clarify the effect of underweight on outcome following TAVI.

Methods

We retrospectively analyzed consecutive 1,027 patients undergoing TAVI between April 2010 and June 2019. The patients were categorized according to body mass index (BMI) as follows: underweight (<18.5 kg/m2, n=150), normal weight (18.5 to 25 kg/m2, n=657), and overweight (>25 kg/m2, n=220). BMI was defined as body weight (kg) divided by the square of body height (m) measured at the hospital admission. We compared the short- and mid-term outcome after TAVI among three groups, and all clinical events were accordance with Valve Academic Research Consortium-2 criteria.

Results

Underweight patients were more often female, and had a higher prevalence of hypertension, dyslipidemia, peripheral artery disease, anemia, and hypoalbuminemia. They also presented lower ejection fraction, smaller aortic valve area, and higher surgical risk score. In procedural findings, device unsuccess and major vascular complication more occurred in underweight patients, but 30-day mortality was equivalent among three groups. The mid-term survival of the underweight was inferior to the other two groups (figure).In the multivariate analysis, female (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.37–0.73, P=0.0002), atrial fibrillation (HR 2.22, 95% CI 1.56–3.17, P<0.0001), albumin value (HR 0.37 per 1-g/dl increase, 95% CI 0.25–0.55, P<0.0001), Society of Thoracic Surgeons score (HR 1.06 per 1% increase, 95% CI 1.02–1.06, P=0.0039), 30-day combined endpoint (HR 2.12, 95% CI 1.33–3.38, P=0.0017), and underweight (HR 1.59, 95% CI 1.04–2.37, P=0.026) were associated with the survival after TAVI.

Conclusion

The underweight had a worse mid-term prognosis, representing the obesity paradox in the TAVI population.

Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None

FRI0079 CHARACTERISTICS OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background:

Despite remarkable progress in therapy, not a few patients with rheumatoid arthritis (RA) have not achieved treatment target. Various factors can be ascribed to difficult-to-treat RA, however, little is known about their characteristics.

Objectives:

To clarify characteristics of patients with difficult-to-treat RA in real-world.

Methods:

We reviewed all consecutive RA patients in Keio University Hospital between 2016 and 2017 and collected medical information. We defined patients in moderate disease activity and high disease activity according to disease activity score for 28 joints (DAS28) at the last visit despite more than one year treatment for RA as difficult-to-treat RA and analyzed their clinical characteristics.

Results:

A total of 1693 patients with RA were enrolled in the analysis. The mean age at the last visit was 64 years old, female was 83%, and the mean disease duration was 11.9 years. Rheumatoid factor and anti-cyclic citrullinated peptide were positive for 76% and 75% of the patients, respectively. The current treatment were conventional synthetic disease modifying anti-rheumatic drugs in 73%, biologic agents or janus kinase (JAK) inhibitors in 57%, and glucocorticoids in 13%. Disease activity according to DAS28 was remission in 65%, low disease activity in 21%, and moderate/high disease activity in 14%, which was defined as difficult-to-treat RA. Characteristics of difficult-to-treat RA were the mean age of 70 years old, female of 89%, and the mean disease duration of 14.8 years. The current treatments were conventional synthetic disease modifying anti-rheumatic drugs alone in 40.7%, biologic agents or JAK inhibitors in 55.8%, and glucocorticoids in 29.0%. The causes of difficult-to-treat RA were unresponsiveness to several biologic agents and/or JAK inhibitors in 22.9%, comorbidities in 33.8%, and personal reasons in 39.8% (costs in 35.9%, low adherence in 4.3%, concerns about possible adverse reaction of drugs in 54.3% and high patient global assessment in 5.4%). Patient characteristics were significantly different between the causes; age at RA onset (51 vs 61 vs 51 years, p<0.001), current age (65 vs 77 vs 66 years, p<0.001), estimated glomerular filtration rate (75 vs 61 vs 73 mL/min/1.73m2, p<0.001), tender joint count (3.4 vs 1.6 vs 2.1, p=0.005), swollen joint count (3.1 vs 1.6 vs 2.9, p=0.003), evaluator global assessment (21 vs 14 vs 16 mm, p=0.03), health assessment questionnaire-disability index (1.3 vs 1.3 vs 0.9, p=0.005), a history of serious infection (28 vs 41 vs 13%, p<0.001) and rheumatic disease comorbidity index (1.2 vs 2.2 vs 0.9, p<0.001).

Conclusion:

There are still 14% of patients with RA were difficult-to-treat in real world in spite of intensive treatment. Their characteristics are distinct by the cause of difficulty to treat, suggesting the approach to difficult-to-treat RA should be personalized.

References:

[1]Roodenrijs NMT, de Hair MJH, van der Goes MC et al. Characteristics of difficult-to-treat rheumatoid arthritis: results of an international survey. Ann Rheum Dis. 2018;77(12):1705-1709.

[2]de Hair MJH, Jacobs JWG, Schoneveld JLM, van Laar JM. Difficult-to-treat rheumatoid arthritis: an area of unmet clinical need. Rheumatology (Oxford). 2017 Oct 4. doi: 10.1093/rheumatology/kex349.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis Care Res (Hoboken)2015;67(6):865–72.

Disclosure of Interests:

Satoshi Takanashi: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

SAT0093 CDAI AND DAS28 IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS IN CLINICAL PRACTICE

Background:

The primary therapeutic target for rheumatoid arthritis (RA) is remission, assessed using validated composited measures. Currently, index-based remission frequently used in clinical practice are disease activity (CDAI) and disease activity score for 28 joints (DAS28). Generally, CDAI is believed more stringent than DAS28 in assessing clinical remission, however, this confirmation was mainly derived from trial results.

Objectives:

To investigate the real-world performance of CDAI and DAS28 -erythrocyte sedimentation rate (ESR) in RA.

Methods:

We reviewed consecutive RA patients who are receiving any disease modifying anti-rheumatic drug (DMARDs) in Keio University Hospital between 2016 and 2017 and collected medical information. We focused on the patients in CDAI remission and/or DAS28-ESR remission at the time of last visit, and analyzed their clinical characteristics.

Results:

A total of 1585 patients with RA were reviewed. Their characteristics were mean age of 64 years old, female of 84% and mean disease duration of 12.0 years. Current treatments were conventional synthetic (cs) DMARDs alone, TNF inhibitors (TNFi), IL-6 receptor inhibitors (IL-6i), CTLA-4Ig, and JAK inhibitors (JAKi) in 39.2%, 29.0%, 22.8%, 7.1%, and 1.8% patients, respectively. Of them, 62.7% were in CDAI remission and 64% were in DAS28-ESR remission. Among patients in CDAI remission, the proportion of DAS28-ESR non-remission was 19.4% in those treated with csDMARDs, 18.2% treated with TNFi, 4.2% treated with IL-6i, 27.6% treated with CTLA-4Ig, and 33.3% treated with JAKi (Figure). In contrast, among patients in DAS28 remission, the proportion of CDAI non-remission was 11.7% in those treated with csDMARDs, 15.4% treated with TNFi, 29.5% treated with IL-6i, 16.0% treated with CTLA-4Ig, and 14.3% treated with JAKi. Venn diagrams of CDAI remission and DAS28-ESR remission demonstrated that more patients satisfied the CDAI remission criteria without satisfying the DAS28-ESR remission criteria than vice versa, except for those treated with IL-6i (Figure). Patients in CDAI remission and DAS28-ESR non-remission had higher C-reactive protein, ESR and comorbidity rates (0.37 vs 0.07 mg/dL, p<0.001; 45.7 vs 8.0 mm/h, p<0.001; 26.4 vs 18.0%, p=0.07, respectively), and those in CDAI non-remission and DAS28-ESR remission had worse patient-reported outcomes including patient global assessment and health assessment questionnaire-disability index (31.1 vs 9.5 mm, p<0.001; 0.82 vs 0.41, p<0.001, respectively). Patients in both CDAI and DAS28-ESR remission were apparently in better disease activity than those who met either criteria.

Conclusion:

Assessing patients with two composite measures simultaneously is important to evaluate patients’ condition from view points of RA itself and comorbidities and adjust treatment appropriately.

References:

[1] Smolen JS et al. T2T Expert Committee. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69(4):631-7.

Disclosure of Interests:

Satoshi Takanashi: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

P1363 Risk factors of severe tricuspid regurgitation after left-sided valve surgery

Background

Tricuspid regurgitation (TR) sometimes deteriorate late after left-sided valve surgery. The recent guidelines recommend tricuspid valve repair at the same time as the left-sided valve surgery. However, little is known about the pathophysiology that leads to severe TR after left-sided valve surgery.

Purpose

To clarify the risk factors of the patients with severe TR after left-sided valve surgery.

Methods

We retrospectively investigated consecutive 526 patients diagnosed as severe TR from January 2004 to December 2018 at our hospital. Clinical background, echocardiographic parameters were evaluated. Demographic information and clinical data (including age, electrocardiograms, type of left-sided valve surgery, underlying valve diseases and history of pacemaker or ICD implantation) were obtained by chart review.

Results

Of the 526 patients with severe TR, 107 patients were after a left-sided valve surgery. Patients developed severe TR at a mean of 14.8 ± 8 years after surgery.The surgical indications were as follows: mitral valve stenosis (74 patients, 69%), mitral valve regurgitation (43 patients, 40%), aortic valve stenosis (37 patients, 35%) and aortic regurgitation (28 patients, 26%), respectively. The mean age at diagnosis of severe TR was 74 ± 10 years and 75 were female (70%). Among those patients, 32 patients (30%) had a tricuspid annuloplasty (TAP) with the first left-sided valve surgery. Ninety-five patients (88%) had atrial fibrillation (AF), 75 patients (70%) were diagnosed as rheumatic heart disease, 64 patients (60%) had pulmonary artery hypertension (PH) and 28 patients (26%) had a permanent pacemaker or ICD implantation.

There were only 12 patients who had severe TR without AF. Eight of 12 patients without AF had PH, and permanent pacemakers were implanted in remaining 4 patients.

Conclusions

Almost all patients with severe TR after left-sided valve surgery present with AF and prevalence of rheumatic heart disease were about 70 percent. These two factors may be one of the important risk factors for severe TR after left-sided valve surgery.

Evaluation of immunochromatography tests for detection of novel GII.17 norovirus in stool samples

A novel GII.17 norovirus has emerged as a major cause of epidemic and endemic acute gastroenteritis in several countries in Asia. We used a small panel of stool samples in which GII.17 virus had been quantified by real-time RT-PCR to evaluate four commercially available norovirus immunochromatography (IC) kits. At least 10(8) copies/mL of GII.17 virus were required by each IC kit for a positive result, which is 1,000-fold more than that reported for these assays for GII.4 viruses.

Biocompatibility of cardiopulmonary bypass circuit with new polymer Senko E-Ternal CoatingTM

Objective:

The aim of this study was to compare the biocompatibility of a new Senko E-Ternal coating (SEC) for cardiopulmonary bypass (CPB) circuits with the well-established poly-2-methoxyethyl acrylate (PMEA) coating.

Methods:

Forty patients undergoing aortic valve replacement were randomly assigned to either an SEC-coated group (n = 20) or a PMEA-coated group (n = 20). Clinical data and the following markers were analyzed: platelet count, platelet factor (PF) 4, fibrinogen, fibrinogen degradation products (FDPs), antithrombin III (AT III), thrombin-antithrombin complex (TAT), plasminogen, complement hemolytic activity (CH50), complement 3 (C3) and interleukin-6 (IL-6). Blood samples were obtained at five time points in both groups.

Results:

CPB time, aortic cross-clamp time and blood loss and transfusion were similar in both groups. There were no significant differences between the groups in terms of platelet count, PF4 and all coagulation and fibrinolytic parameters (FDP, AT III, TAT, and plasminogen) at any time points. Inflammatory markers (CH50, C3 and IL-6) were also similar in both groups at all time points.

Conclusions:

The SEC-coated circuit demonstrated equivalent biocompatibility to the PMEA-coated circuit. SEC-coated circuits are, therefore, favorably comparable to PMEA-coated circuits for clinical use in CPB.

[Early and mid-term outcome of off-pump coronary artery bypass grafting in patients with acute myocardial infarction]

Coronary artery bypass grafting (CABG) is one of the options for treating acute myocardial infarction (AMI). However, the mortality of conventional CABG is reported to be high. Therefore, we assessed the outcomes of off-pump coronary artery bypass grafting (OPCAB) in patients with AMI. Between September 2004 and October 2007, 50 patients with AMI, mean age 71.7 years, were operated on. Anterior, inferior and lateral infarctions were observed in 30, 16 and 4 patients, respectively. The time from AMI to operation was <24 hours in 13 patients, <3 days in 5, <7 days in 9, <14 days in 10 and >14 days in 13. Intra-aortic balloon pumping was used in 44% of the patients. Mean number of anastomoses per patient was 4.0. There was no in-hospital mortality. Low output syndrome was observed in 1 patient, and stroke in 2. Ejection fraction of the left ventricle significantly improved after the operation (p<0.01). The graft patency rate was 97.3%. Actuarial survival was 95.9% at 3.5 years. We concluded that OPCAB is a safe and effective procedure with favorable early and midterm survival outcomes in patients with AMI.

Analyses of the factors influencing bone graft infection after delayed cranioplasty

BACKGROUND

Several factors influencing bone graft infection after delayed cranioplasty are analyzed in order to reduce the occurrence of infection.

METHODS

For about 10 years, from March 1995 to February 2005, delayed cranioplasty was performed for 206 cases. The cases comprised 124 males and 82 females. Age distribution of the patients ranged from 6 months to 79 years old. The mean postoperative follow-up period was 1834 days. Autogenous bone, which was preserved in 100% ethanol at -20 degrees C and autoclaved before operation, was used in 54 patients. Polymethylmethacrylate (PMMA) was used in 55 patients. Custom-made PMMA was used in 3 patients. Custom-made titanium mesh was used in 77 patients. Custom-made ceramics (Alumina-ceramics 10 cases and hydroxyapatite 7 cases) was used in 17 patients.

FINDINGS

Autoclaved and autogenous bone graft and PMMA have a significantly high rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection. Alumina-ceramic has a merit that it has sufficient strength, however the number of cases using custom-made ceramics including alumina-ceramic was relatively small, and thus we cannot find significant differences in infection rate compared with that of other materials. There was no statistically significant difference in the bone graft infection rate among four categories of preceding diseases; cerebrovascular diseases, head trauma, infectious diseases, and brain tumour.

CONCLUSION

Autoclaved and autogenous bone grafts and PMMA have a significantly higher rate of graft infection. Titanium mesh has the significantly lowest rate of graft infection.

[Surgical treatment of two cases with Marfan syndrome]

We report 2 cases of aortic disease with Marfan syndrome underwent surgery. Case 1 was 38-years-old man and case 2 was 36-years-old woman. They were brothers and they had 8 times operation for 13 years. Surgical procedure included aortic root reconstruction, descending aortic aneurysm repair and abdominal aortic aneurysm repair. Patients with Marfan syndrome sometimes require repeated surgical repair of aortic disease.

Eosinophil activation in the tissue: synthetic steroid, budesonide, effectively inhibits the survival of eosinophils isolated from peripheral blood but not nasal polyp tissues

We investigated the effect of a potent synthetic steroid, budesonide (BUD), on the survival of nasal polyp (NP) derived eosinophils (EOS). BUD, at the highest dose used, 10(-6) M, decreased this survival but only by approximately one third. We speculated that the relatively small inhibitory effect of budesonide on the survival of NP-EOS could be the result of these EOS being exposed to substantial amounts of GM-CSF, IL-5 or IL-3. In this regard, we detected 148 pg of GM-CSF per 150 mg of tissue, which approximately contained 106 of eosinophils, in the supernatant of NP explants for 24 h without any stimulation. Contents of both IL-5 and IL-3 were much less. We further studied survival of PB-EOS exposed to rhGM-CSF and found that 10(-6) M of BUD could only inhibit by less than one third the survival of PB-EOS exposed to an amount of rhGM-CSF, similar to that detected in the supernatant of NP explants. In addition, we exposed PB-EOS to 200 pg/ml of rhGM-CSF for a relatively long period of time (4 days) in order to mimic chronic exposure in the tissue and found that the survival of these cells was prolonged to the extent similar to that observed in NP-EOS. Our data suggests that the prolonged spontaneous survival of NP-EOS ex vivo is likely the result of sustained in vivo exposure to GM-CSF and budesonide has a smaller inhibitory effect in the survival of these eosinophils as compared to those from peripheral blood.

Interleukin-1beta stimulates galectin-9 expression in human astrocytes

Galectin-9 is an eosinophil chemoattractant produced by activated T lymphocytes. We have addressed expression of galectin-9 in normal human astrocytes in culture. Expression of galectin-9 mRNA and protein were examined by reverse transcription-polymerase chain reaction (RT-PCR), Western blotting, and immunofluorescent staining. Interleukin-1beta (IL-1beta) was found to enhance the galectin-9 expression in time- and concentration-dependent manners. Galectin-9 protein was detected in the membrane fraction, 105 000 x g precipitate, and immunofluorescent staining revealed diffuse cellular and perinuclear distributions. Dexamethasone pretreatment almost completely suppressed the production. We conclude that astrocytes produce galectin-9 in response to the stimulation with IL-1beta, and this may contribute to inflammatory reactions in the CNS.

Interferon-gamma stimulates fractalkine expression in human bronchial epithelial cells and regulates mononuclear cell adherence

Bronchial epithelial cells may contribute to airway inflammation by releasing chemokines and expressing surface membrane molecules involved in the adhesion of leukocytes. We found that interferon (IFN)-gamma stimulates expression of fractalkine, a potent chemoattractant for monocytes and T lymphocytes, in a time- and concentration-dependent manner by normal human bronchial epithelial cells in culture. Enhanced expression of fractalkine messenger RNA was confirmed by both reverse transcription/polymerase chain reaction and Northern blotting. IFN-gamma also stimulated fractalkine protein production and most of the protein was found in cell lysates. The adherence of blood mononuclear cells to the monolayers of bronchial epithelial cells stimulated with IFN-gamma was partly inhibited by an antifractalkine antibody. An antibody against intercellular adhesion molecule-1 was similarly effective in inhibiting the adhesion. Fractalkine protein levels in bronchoalveolar lavage fluids from patients with inflammatory diseases correlated positively with mononuclear cell counts in the fluids. The bronchial epithelium in a biopsy specimen of lung cancer was stained positively by immunofluorescent staining for fractalkine. We conclude that IFN-gamma stimulates fractalkine expression by bronchial epithelial cells, which may play an important role in inflammatory responses by recruiting mononuclear leukocytes to the bronchial epithelium.

Transforming growth factor-beta1 level correlates with angiogenesis, tumor progression, and prognosis in patients with nonsmall cell lung carcinoma

BACKGROUND

Transforming growth factor-beta1 (TGF- beta1) is a multifunctional factor and is known to affect tumor growth in malignant tumors. The effects of TGF-beta1 on angiogenesis, stromal formation, and immune function suggest its possible involvement in tumor progression. The authors examined whether TGF-beta1 levels may be correlated with angiogenesis, clinicopathologic factors, and survival in patients with surgically resected lung carcinoma.

METHODS

TGF-beta1 protein was extracted from 53 nonsmall cell lung carcinoma tissue samples (19 squamous cell carcinomas, 33 adenocarcinomas, and 1 adenosquamous cell carcinoma), and its level was measured by enzyme-linked immunosorbent assay. To assess tumor angiogenesis, microvessel density (MVD) was determined by CD31 immunostaining.

RESULTS

The protein level of TGF-beta1 was 289 picograms per milligram of protein (pg/mg protein), ranging from 94 pg/mg protein to 584 pg/mg protein. The TGF-beta1 protein level was significantly higher in patients with lymph node metastasis compared with patients who were without lymph node metastasis (P = 0.02), and the TGF-beta1 protein level was significantly higher in patients with Stage III disease (TNM classification) compared with patients who had Stage I and II disease (P = 0.03). There was no significant correlation between the TGF-beta1 protein level and any of the other clinicopathologic factors that were considered. A significant positive correlation between TGF-beta1 protein level and MVD was noted (P < 0.01). Furthermore, in patients with adenocarcinoma, a significant correlation between TGF-beta1 protein level and prognosis was detected by multivariate analysis (P = 0.028).

CONCLUSIONS

TGF-beta1 seems to affect tumor angiogenesis and to play an important role in tumor progression in patients with nonsmall cell lung carcinoma. Furthermore, the TGF-beta1 protein level may be an independent predictor of survival in patients with adenocarcinoma of the lung.

Transforming growth factor-beta1 level correlates with angiogenesis, tumor progression, and prognosis in patients with nonsmall cell lung carcinoma

BACKGROUND

Transforming growth factor-beta1 (TGF- beta1) is a multifunctional factor and is known to affect tumor growth in malignant tumors. The effects of TGF-beta1 on angiogenesis, stromal formation, and immune function suggest its possible involvement in tumor progression. The authors examined whether TGF-beta1 levels may be correlated with angiogenesis, clinicopathologic factors, and survival in patients with surgically resected lung carcinoma.

METHODS

TGF-beta1 protein was extracted from 53 nonsmall cell lung carcinoma tissue samples (19 squamous cell carcinomas, 33 adenocarcinomas, and 1 adenosquamous cell carcinoma), and its level was measured by enzyme-linked immunosorbent assay. To assess tumor angiogenesis, microvessel density (MVD) was determined by CD31 immunostaining.

RESULTS

The protein level of TGF-beta1 was 289 picograms per milligram of protein (pg/mg protein), ranging from 94 pg/mg protein to 584 pg/mg protein. The TGF-beta1 protein level was significantly higher in patients with lymph node metastasis compared with patients who were without lymph node metastasis (P = 0.02), and the TGF-beta1 protein level was significantly higher in patients with Stage III disease (TNM classification) compared with patients who had Stage I and II disease (P = 0.03). There was no significant correlation between the TGF-beta1 protein level and any of the other clinicopathologic factors that were considered. A significant positive correlation between TGF-beta1 protein level and MVD was noted (P < 0.01). Furthermore, in patients with adenocarcinoma, a significant correlation between TGF-beta1 protein level and prognosis was detected by multivariate analysis (P = 0.028).

CONCLUSIONS

TGF-beta1 seems to affect tumor angiogenesis and to play an important role in tumor progression in patients with nonsmall cell lung carcinoma. Furthermore, the TGF-beta1 protein level may be an independent predictor of survival in patients with adenocarcinoma of the lung.

Acute pulmonary thromboembolism with a floating right-heart thrombus. 4 surgical cases

OBJECTIVE

We determined the efficacy of surgery for acute pulmonary thromboembolism with a floating right-heart thrombus.

METHODS AND RESULTS

Thrombi were diagnosed by transthoracic echocardiography and electron beam computed tomography in 4 patients with acute pulmonary thromboembolism with a floating right-heart thrombus, and thromboembolectomy was done in all patients. Surgical procedure included intermittent deep hypothermic circulatory arrest. One patient died of endobronchial hemorrhage and 3 survived.

CONCLUSION

Because acute pulmonary thromboembolism with a right-heart thrombus is life-threatening, immediate thromboembolectomy is required to decrease mortality.

[A case of left ventricular rupture and left ventricular-right atrial communication after mitral valve re-replacement]

We report a case of left ventricular rupture and left ventricular-right atrial communication after mitral valve re-replacement. A 53-year-old man was admitted to our hospital for a primary tissue failure of mitral xenograft. On June 4, 1997, he underwent mitral valve re-replacement. At 12 post operative day, he was suffered from unexpected dyspnea. The transesophageal echocardiography showed floated mitral valve and left ventricular-right atrial communication. The emergent operation was done. At the operation, posterior mitral annulus was disrupted and the disruption reached to a membranous septum. A communication was directly closed, mitral annulus was repaired with perigard and one size smaller mitral valve was implanted. The patient was discharged and returned to social life.

Interleukin-10 level in sputum is reduced in bronchial asthma, COPD and in smokers

Interleukin (IL)-10 is a potent regulatory cytokine that decreases inflammatory responses. This study investigated whether IL-10 levels in the airway are decreased in chronic airway inflammation associated with asthma or chronic obstructive pulmonary disease (COPD). Sputum was obtained from 12 healthy nonsmokers, 10 healthy smokers, 16 asthmatic patients and seven patients with COPD by means of the sputum-induction method. The IL-10 level was measured via enzyme-linked immunosorbent assay and immunocytochemical analysis. The IL-10 level in sputum was significantly lower in asthma and COPD patients and healthy smokers compared with that in healthy nonsmokers (nonsmokers, 68.0+/-11.3; smokers, 45.3+/-7.8; asthma, 26.7+/-4.0; COPD, 18.0+/-2.3 pg x mL(-1); p<0.05 for nonsmokers versus the other groups). The percentage of IL-10-positive cells in the sputum was also significantly lower in asthma and COPD and in smokers (nonsmokers, 13.2+/-1.7; smokers, 6.4+/-1.8; asthma, 5.4+/-3.5; COPD, 3.5+/-1.6%; p<0.05 for nonsmokers versus the other groups). The IL-10-positive cell appeared morphologically to be the macrophage. These data suggest that the reduced level of interleukin-10 within the airways plays a role in the pathogenesis of chronic airway inflammation in asthma and chronic obstructive pulmonary disease.

[A case of primary malignant melanoma of the esophagus]

A case of primary and malignant melanoma of the esophagus was reported. A 64-year-old male complaining of discomfort of anterior chest pain was admitted to our hospital for operation. Findings of upper G-1 X-ray and endoscopic examination revealed suspiciously malignant melanoma. Subtotal thoracic esophagectomy with R III dissection was performed. Operative findings included A0 N2 Pl0 M0 Stage III. Macroscopically it showed black-grayish colored polypoid tumors, 7 cm in size. The typical finding of junctional activity adjacent to the tumor mass and melanocytes were microscopically found. The patient received postoperative systemic chemotherapy, but was died of multiple liver and bone metastases 125 days after surgery. Malignant melanoma of the esophagus has extremely poor prognosis and none of effective therapies has been reported.

[A case of right ventricular myxoma]

A 43-year-old male presented with a history of occasional syncopal episodes and general fatigue for 4 months. On admission, a grade 4/6 systolic murmur was noted, and the electrocardiogram demonstrated frequent premature supraventricular beats. An echocardiogram revealed the presence of a multi-lobular mass in the right ventricle which prolapsed into the pulmonary artery during systole. Ultrafast computed tomography demonstrated a pedunculated mass arising from the right ventricular free well. At operation, the soft mass was excised through the tricuspid valve under cardiac arrest. Histopathologically, the tumor was diagnosed as a myxoma. Myxoma of the right ventricle occurs very rare. We review the literature relevant to cardiac myxoma.

[A surgical case report of ossified left atrial myxoma]

A 68-year-old female has developed dyspnea on effort for 5 years. On admission, a grade 2/6 apical systolic regurgitant murmur was noted. Chest X-ray examination showed moderate cardiac enlargement. Echocardiogram showed a highly echoic mass with acoustic shadow in the left atrium which was attached to the interatrial septum. A partial herniation of the tumor through the mitral annulus in diastolic phase and moderate mitral regurgitation was noted. Ultra fast computed tomography of the chest revealed a left atrial mass with high density area. At operation the mass was excised with atrial septum through the right atriotomy. Microscopic findings showed the myxoma with bone and bone marrow formation.

[The changes of blood gas analysis values and platelet aggregability on acute phase in the experimental model of pulmonary embolism prepared by sephadex G-75 (SG-75) injection]

To study pathophysiologic phenomena in acute pulmonary embolism, we injected sephadex G-75 (SG-75) into rabbit auricular veins and measured the changes in blood gases and in platelet aggregability. Severe hypoxemia developed within 10 minutes of SG-75 injection. Microscopic examination of samples taken 120 minutes after SG-75 injection pulmonary artery had been embolized by the SG-75 particles, and that thrombin had formed around the particles. The lowest platelet counts were measured 10 minutes after SG-75 injection. The rates of platelet aggregation induced by adenosine diphosphate and by platelet-activating factor were abnormally low until 40 minutes after SG-75 injection. These results suggest that platelets were activated by anoxia and that the activated platelets moved around the emboli after obstruction of the pulmonary artery. We conclude that decreases in PaO2 and changes in platelet aggregability exacerbate the pathophysiologic processes in acute pulmonary embolism.

[Pneumonitis in a patient who inhaled a fibrinolysin-deoxyribonuclease mixture]

A 56-year-old man was transferred to our department from the department of oral surgery, with a high fever and a cough. He had inhaled a fibrinolysin-deoxyribonuclease mixture (Elase) to treat inflammation in the oral cavity after resection of an oral tumor. A chest X-ray film showed diffuse patchy shadows in both lung fields. Bronchoalveolar lavage fluid had an abnormally high number of lymphocytes and transbronchial lung biopsy revealed interstitial infiltration by lymphocytes and histiocytes, with granulomatous lesions. The patient was treated with steroids, and his clinical condition improved markedly. He accidentally inhaled the drug again, and the coughing and fever began again. The drug lymphocyte stimulation test was positive only for the fibrinolysin-deoxyribonuclease mixture. Based on these findings, we diagnosed pneumonitis induced by this fibrinolysin-deoxyribonuclease mixture. To our knowledge, this is the first reported case of pneumonitis caused by this fibrinolysin-doxyribonuclease mixture.

[Clinical experience and early results of aortic valve replacements with Medtronic Hall 20 A]

We experienced aortic valve replacement for 18 patients (4 male and 14 female, ranging from 40 to 81 years old, mean 64 years old) with small aortic annulus with new small prosthesis. Medtronic Hall 20 A (MH 20 A). The average body surface area was 1.47 m2 (range 1.28 to 1.81 m2). One patient was died of lung cancer at 3 months postoperatively. One nonstructural dysfunction and one low cardiac output syndrome was noted during operation. Sixteen survivors with MH 20 A, showed satisfactory clinical results, except for minor thromboembolism, in 2 patients. The MH 20 A had the same function as that of MH 21 A, already reported. We concluded that aortic valve replacement by Medtronic Hall 20 A prosthesis was usefull for the patient with small aortic annulus.

[A case of coronary artery bypass grafting without cardiopulmonary bypass in a patient of both coronary ostial stenosis due to Takayasu's arteritis]

A 61-year-old female admitted with the diagnosis of both coronary ostial stenosis & the severe calcified aorta due to Takayasu's arteritis. She underwent coronary artery bypass grafting successfully, using the right internal thoracic artery to RCA & the left internal thoracic artery to LAD, without cardiopulmonary bypass. Coronary artery bypass grafting without cardiopulmonary bypass is one of the useful surgical technique for the patient with the severe calcified aorta due to Takayasu's arteritis.

[A case of Bacillus cereus prosthetic valve endocarditis]

A rare case of prosthetic valve endocarditis by Bacillus cereus was reported. The patient was 43-year-old Japanese man, who had mitral valve replacement 5 months prior to this admission. Remitral valve replacement was immediately done successfully. His postoperative course was uneventful for 8 months.

[A case report of thymolipoma with high titer of serum anti-acetylcholine receptor antibodies--thymolipoma, a review of 49 reports in Japan]

A 22-year-old man was diagnosed as thymolipoma by chest CT scan & MRI. In spite of high titer of serum anti-acetylcholine receptor antibodies, he showed no symptom of myasthenia gravis. An extended thymectomy was done successfully. Tumor was 21 x 15 cm in size and 620 g in weight. Histopathologically the tumor was diagnosed as thymolipoma. The titer of serum anti-acetylcholine receptor antibodies was decreased within normal limit and postoperative course was uneventful. To our knowledge, the 49 case reports in Japan were reviewed.

Subcutaneous administration of recombinant human erythropoietin before cardiac surgery: a double-blind, multicenter trial in Japan

BACKGROUND

Dose and injection times have not previously been determined for subcutaneously administered recombinant human erythropoietin that would allow sufficient deposition of blood for autologous use in cardiac surgery.

STUDY DESIGN AND METHODS

A double-blind, multicenter trial of placebo (Group 1) and recombinant human erythropoietin at 12,000 IU (Group 2) and at 24,000 IU (Group 3) was performed on 114 patients at 26 institutions to determine the dosage that would permit an 800-g preoperative deposit of blood for autologous use. The test drug was administered subcutaneously on Days 21, 14, and 7 prior to operation, and oral iron preparations at 200 mg per day were given for 21 days. There were 28 patients in Group 1, 28 in Group 2, and 30 in Group 3, with 28 excluded for a violation of the protocol.

RESULTS

Blood was safely drawn 14 and 7 days before operation from 22 patients in Group 1 (78.6%), from 26 in Group 2 (92.9%), and from all patients in Group 3 (p = 0.018). The hemoglobin level on the day before operation decreased by 1.1 +/- 1.1 g per dL (11 +/- 11 g/L) in Group 1 and by 0.9 +/- 0.9 g per dL (9 +/- 9 g/L) in Group 2 and rose by 0.1 +/- 0.8 g per dL (1 +/- 8 g/L) in Group 3, compared to initial levels. Allogeneic blood transfusion could be avoided in 62, 89, and 90 percent of Group 1, 2, and 3 patients, respectively (p = 0.013).

CONCLUSION

The present study shows that subcutaneously administered recombinant human erythropoietin at a dose of 24,000 IU per week for 3 weeks is effective and sufficient to allow the safe deposition of 800 g of blood for autologous use in cardiac surgery.

[Characteristics of plasma levels of myosin light chain I in patients under aorta-coronary bypass grafts]

After cardiac operation plasma level of ventricular myosin light chain I (LCI), determined with monoclonal antibodies to myosin fragment, were studied in 30 patients under bypass surgery to assess its possible role as a marker for perioperative myocardial injury. LCI rapidly increased and reached peak levels (15.8 +/- 9.0 gn/ml; T-peak) at 88 +/- 28 minutes after aortic declamp (T-Time). Then LCI rapidly decreased with fast half-time disappearance (1.1 +/- 0.7 hours). In 7 out of 30 patients LCI improved to normal range and MB reached maximum levels (28.8 +/- 11.9 U/L) at 6.3 +/- 2.3 hours after declamp. No abnormal change was noted in ECG and no new defects were noted in T1-201 myocardial images. In the remaining 23 patients LCI decreased to minimum levels (4.1 +/- 2.1 ng/ml; min-LCI) at 9.2 +/- 5 hours (min-Time) and then gradually increased to peak levels (8.4 +/- 5.8 ng/ml; M-peak, M-value) on day 3.3 +/- 1.0 (M-Time). MB reached maximum level (77.6 +/- 82.4 U/L, p < 0.1) at 3.4 +/- 1.4 hours (p < 0.001). Good correlation was noted among min-LCI, min-Time, M-value and summation of daily value of LCI (omega(LCI)) x min-LCI = 5.7-0.17 min-Time (r = -0.42) and M-value = 2.1 min-LCT(r=0.74) and omega(LCI) = -9.6 + 6.1 M-value (r = -0.96). From the rapid appearance of LCI peak levels after aortic declamp it was concluded that LCI, accumulated during aortic clamp, was washed out by aortic declamp.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical localization of cytokeratins in normal eccrine glands, with monoclonal antibodies in routinely processed, formalin-fixed, paraffin-embedded sections

BACKGROUND

Immunohistochemical detection in paraffin sections would be of value in the retrospective analysis of formalin-fixed, paraffin-embedded tissues.

OBJECTIVE AND METHODS

In this study with several monoclonal antibodies directed against fixation-resistant keratin antigens, we performed immunohistochemical staining on routine paraffin-embedded sections to localize specific keratins in the eccrine sweat glands and to determine the tissue distribution of various keratins.

RESULTS

We clarified the localization of specific keratins in different segments of normal eccrine glands. Immunohistochemical localization of individual cytokeratins showed different patterns in secretory and ductal portions, although cytokeratins were expressed in all segments of normal sweat glands. Different immunoreactivities were noted in the luminal and basal cells of eccrine ducts. There were also some differences in immunophenotype between the acrosyringium and the dermal ducts.

CONCLUSION

These data provide information for the determination of the histogenesis and differentiation of skin tumors with eccrine differentiation.