Prognosis of anemic patients with atrial fibrillation undergoing percutaneous coronary intervention

BACKGROUND

There are limited data regarding whether anemia is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI).

METHODS

Patients with AF undergoing PCI at 15 institutions between January 2015 and March 2021 were included in this analysis. Based on the baseline hemoglobin levels, moderate to severe anemia was defined as hemoglobin levels <11 g/dL, and mild anemia was defined as hemoglobin levels 11-12.9 g/dL for men and 11-11.9 g/dL for women. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, stent thrombosis, and stroke) and major bleeding events (BARC 3 or 5), were compared among patients with moderate/severe anemia, mild anemia, and no anemia.

RESULTS

In a total of 746 enrolled patients, 119 (16.0%) and 168 (22.5%) patients presented with moderate/severe and mild anemia. The incidence of MACE (22.5%, 11.0%, and 9.1%, log-rank p < 0.001), all-cause death (20.0%, 7.2%, and 4.8%, log-rank p < 0.001), and major bleeding events (10.7%, 6.5%, and 2.7%, log-rank p < 0.001) were the highest in the moderate/severe anemia group compared with the mild and no anemia groups. Multivariable Cox regression analyses determined moderate/severe anemia as an independent predictor for MACE (p = 0.008), all-cause death (p = 0.005), and major bleeding events (p = 0.031) at 1 year after PCI.

CONCLUSION

Moderate/severe anemia was significantly associated with the higher incidence of MACE and all-cause death as well as major bleeding events compared with mild and no anemia in AF patients undergoing PCI.

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Clinical characteristics and outcomes in patients with acute type A aortic intramural hematoma

BACKGROUND

Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD.

METHODS

This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality.

RESULTS

Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery.

CONCLUSIONS

The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.

Dual Antithrombotic Therapy with Oral Anticoagulant and P2Y12 inhibitors in Patients with Atrial Fibrillation After Percutaneous Coronary Intervention

BACKGROUND

The efficacy and safety of dual antithrombotic therapy (DAT) with oral anticoagulant and P2Y12 inhibitors (P2Y12i) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been well investigated. The purpose of this study was first to evaluate clinical outcomes of DAT with P2Y12i compared with triple antithrombotic therapy (TAT), and then to compare DAT with low-dose prasugrel and DAT with clopidogrel, in patients with AF undergoing PCI.

METHODS

This study was a multicenter, non-interventional, prospective and retrospective registry. A total of 710 patients with AF undergoing PCI between January 2015 and March 2021 at 15 institutions were analyzed. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE) and major bleeding events (BARC 3 or 5) were compared between patients receiving DAT (n = 239) and TAT (n = 471), and then, compared among prasugrel-DAT (n = 82), clopidogrel-DAT (n = 157), and TAT.

RESULTS

The DAT group showed significantly lower incidence of MACE and major bleeding events compared with the TAT group (log-rank p = 0.013 and 0.047). In the multivariable Cox regression analyses, DAT (p = 0.028), acute coronary syndrome (p = 0.025), and anemia (p = 0.015) were independently associated with MACE. In addition, anemia (p = 0.022) was independently associated with, and DAT (p = 0.056) and thrombocytopenia (p = 0.051) tended to be associated with, major bleeding events. When analyzed among the prasugrel-DAT, clopidogrel-DAT, and TAT groups, there were no significant differences in clinical outcomes between the prasugrel-DAT and clopidogrel-DAT groups, and similar trends were observed for both 2 groups in comparison with the TAT group.

CONCLUSIONS

In AF patients undergoing PCI, DAT was associated with lower incidence of MACE and major bleeding events compared with TAT. In comparison of P2Y12i, there might be no significant difference in the incidence of MACE and bleeding events between prasugrel-based DAT and clopidogrel-based DAT.

Prognostic Impact of Branch Vessel Involvement on Computed Tomography versus Clinical Presentation of Malperfusion in Patients With Type a Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a life-threatening disease. The use of contrast-enhanced computed tomography (CT) for diagnosing AAD has increased, and CT can provide pathophysiologic information on dissection such as intramural hematoma (IMH), longitudinal extent of dissection, and branch vessel involvement. However, the prognostic impact of these CT findings is poorly investigated. This multicenter registry included 703 patients with type A AAD. The longitudinal extent of dissection and IMH was determined on CT. Branch vessel involvement was defined as dissection extended into coronary, cerebral, and visceral arteries on CT. The evidence of malperfusion was defined based on clinical presentations. The primary endpoint was in-hospital death. Of 703 patients, 126 (18%) died during hospitalization. Based on contrast-enhanced CT findings, longitudinal extent of dissection was not associated with in-hospital death, while patients with IMH had lower in-hospital mortality than those without (13% vs 22%, p = 0.004). Coronary, cerebral, and visceral artery involvement on CT was found in 6%, 55%, and 32%. In patients with coronary artery involvement, 90% had clinical coronary malperfusion, while only 25% and 21% of patients with cerebral and visceral artery involvement had clinical evidence of corresponding organ malperfusion. Multivariable analysis showed evidence of malperfusion as a significant factor associated with in-hospital mortality. In conclusions, branch vessel involvement on CT was not always associated with end-organ malperfusion in patients with type A AAD, especially in cerebral and visceral arteries. Clinical evidence of malperfusion was significantly associated with in-hospital mortality beyond branch vessel involvement on CT.

Antithrombotic drugs do not increase the risk of laparotomy for gastrointestinal cancer

Background

Some patients with gastrointestinal cancer requiring laparotomy take antithrombotic drugs (AT). However, safety of continuing or withdrawing AT before surgery is controversial.

Purpose

To investigate whether the use of AT increases intraoperative blood loss, perioperative thromboembolic event and mortality in patients undergoing laparotomy for gastrointestinal cancer.

Methods

In this retrospective study carried out from January 2016 to July 2019, we took a survey of laparotomy for gastrointestinal cancer in our hospital. AT was defined as aspirin, Adenosine-diphosphate receptor antagonists (ADPi), direct oral anticoagulants (DOAC) and vitamin K antagonists (VKA). Patients were stratified into three groups; non-AT (group N), continuing AT (group C) and withdrawing AT before surgery (group W). We investigated differences in risks of events, including intraoperative blood loss, thromboembolic events within 60 days including acute coronary syndrome, cerebral infarction and venous thromboembolism, and long-term mortality. We also compared between continuing and withdrawing AT after propensity score matching.

Results

A total of 335 patients (123 females, mean age 72.5±9.5 years) were enrolled and stratified into group C (n=24), W (n=45) and N (n=266). Mean follow-up period was 684±400 days. Aspirin was taken in twenty of group C and twenty-six of group W. ADPi was taken in ten and nine of each group respectively. DOAC was taken in three and six of each group respectively. And VKA was taken in one and eleven of each group respectively. Patients of group C had more coronary artery disease (75.0% of group C, 33.3% of group W and 2.3% of group N, p&lt;0.001) and prior coronary stent implantation (54.2%, 20.0% and 0% of each group respectively, p&lt;0.001). There was no significant difference in cancer site and cancer stage. There was no significant difference in intraoperative blood loss (median [interquartile] (mL): 102 [8, 154] in group C, 140 [50, 310] in group W, and 150 [53, 324] in group N (p=0.095). Thromboembolic event had occurred in 4.4% of group W and 1.9% of group N (p=NS). Long term mortality was 33.3% of group C, 20% of group W and 22.9% of group N (p=NS). Kaplan-Meier analysis showed there was also no significant difference of long-term mortality (Log-rank p=NS). In patients with AT, after propensity score matching, there was no significant difference in intraoperative blood loss (102 [8,154] vs. 88 [18,217], p=NS), thromboembolic event (none in both group) and long-term mortality (33.3% vs. 12.5%, p=0.168) between continuing AT and withdrawing AT. Kaplan-Meier analysis revealed there was a tendency of higher mortality in group C but not significant difference (Log-rank p=0.0643).

Conclusion

This study suggests that patients taking AT do not have significant higher risk of intraoperative blood loss, thromboembolic event and mortality in laparotomy of gastrointestinal cancer.

Funding Acknowledgement

Type of funding source: None

Cardiac amyloidosis in patients undergoing aortic valve replacement for aortic stenosis

Background

Transthyretin cardiac amyloidosis (ATTR) has been increasingly recognized in patients with degenerative aortic stenosis (AS). In some reports, the uptake of Tc-99m labeled bone radiotracers in cardiac amyloidosis has been documented. Tc-99m pyrophosphate (PYP) scintigraphy in the absence of evidence of a monoclonal gammopathy was diagnostic for transthyretin cardiac amyloidosis, providing a cost-effective and non-invasive technique with a specificity and positive predictive value of nearly 100%. We sought to determine the prevalence of ATTR as detected by the bone scan tracer among the patients with severe AS requiring surgical valve replacement.

Methods

We retrospectively analyzed clinical and echocardiographical data for 44 patients with severe AS requiring surgical valve replacement between Jan. 2009 and Dec. 2016. All eligible patients were offered Tc-99m PYP scintigraphy. Retention of Tc-99m PYP in the heart was assessed using both a semiquantitative visual score (range, 0 [no uptake] to 3 [uptake greater than bone]). Positive uptake was defined score 2 and 3.

Results

Myocardial deposition of Tc-99m PYP (Score 2–3) was identified in 4 of 44 patients (9%), all &gt;70 years and 75% male. Patients with myocardial deposition of the tracer were older (78±8 years vs. 70±12 years), and had more mean interventricular septum thickness (18±3 mm vs. 14±5 mm). Both groups had at least ejection fraction and abnormal global longitudinal strain with no significant difference between groups. Pre-operative serum median NT-pro BNP level was similar between two groups, but post-operative improvement of NT-pro BNP was larger in non-deposition of the tracer group. During the post operative follow-up, survival was significantly worse if patients had amyloid deposition compared with no deposition subjects (25% vs. 7.5%).

Conclusion

Incidental transthyretin cardiac amyroidosis had a prevelance of 9% among patients undergoing surgical aortic valve replacement and was associated with a poor outcome.

Funding Acknowledgement

Type of funding source: None

Positive Myocardial Uptake of Bone Scintigraphic Agents Associated with Cardiac Amyloidosis: Frequency of Positive Uptake Data Based on Daily Clinical Practice

Objective: The bone scan plays an important role for detecting number of conditions relating to bones, including: bone cancer or bone metastasis, bone inflammation. Extraosseous uptake, in particular, myocardial uptake, was observed in some patients examined with the bone scans. Positive uptake of ^99mTc-labeled bone radiotracers is associated with cardiac amyloidosis. However, the frequency and cause of positive cardiac ^99mTc-MDP uptake have not been fully studied. In this regard, the aim of this study was to assess the frequency and characteristics of patients with high myocardi-al uptake of bone scintigraphy in daily clinical practice setting. Methods: We retrospectively analyzed 4180 bone scintigraphies performed in daily clinical practice during 7-years period. The intensity of the myocardial uptake was graded based on a visual scale ranging from 0 to 3 points. Score 0 indicates the absence of uptake. Score 1 defined uptake less than that of bone (referred to as the adjacent rib). Uptake similar to that of bone was classified score 2. Score 3 was defined as uptake greater than that of reference bone. Positive myocardial uptake included a visual score 2 or 3. Result: Positive ^99mTc-MDP myocardial uptake occurred in 12 patients among 4180 patients (0.3%). 7 of 12 positive scan patients were consistent with amyloidosis confirmed by biopsy. In these patients, the mean age was 75.6 ± 5.2 years old. Ten cases showed biventricular uptake and 2 showed LV uptake only. Conclusion: Positive cardiac uptake of bone scintigraphic agents was present in 0.3% of bone scintigraphies in a clinical practice setting. This may be a sign of cardiac amyloidosis involvement which may give the presence of extraosseous bone tracer uptake its own importance and a new role.

P2725Transthyretin cardiac amyloidosis in heart failure with preserved ejection fraction: Imaging by Tc-99m bone scan

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome with multiple underlying causes. Transthyretin amyloidosis (ATTR) is an underdiagnosed cause of HFpEF. Extraosseous uptake, in particular, myocardial uptake, was observed in a number of ATTR patients examined with the bone scan tracers.

Objectives

We sought to determine the prevalence of ATTR as detected by the bone scan among the patients admitted due to HFpEF.

Methods

We screened all consecutive patients ≥60 years old admitted due to HFpEF (left ventricular ejection fraction ≥50%). All eligible patients were offered an echocardiogram and a bone scan (a 99mTc-DPD/MDP/HMDP scintigraphy). Echocardiographic and clinical variables were gathered in all the subjects. The intensity of the myocardial uptake was graded according to a visual scale ranging from 0 to 3 points, in which the absence of uptake was assigned a score of 0 points; uptake less than that of bone (referred to as the adjacent rib), 1 point; uptake similar to that of bone, 2 points; and uptake greater than that of bone, 3 points. The distribution of the uptake in myocardium was defined as focal uptake, diffuse uptake, uptake in a ventricular wall segment, diffuse ventricular uptake, or diffuse biventricular uptake.

Results

The study included 62 HFpEF patients (52% women, 73±9 years). The bone scintigraphic analysis revealed relatively intense myocardial uptake in 7 of 62 patients (11.2%). 7 patients had intense Tc-99m uptake (score of 2–3) in the cardiac region, showing deposition in both right and left ventricles in every case. Patients with amyloid deposition were older (78±6 vs. 70±12 years, p<0.05), had a lower systolic blood pressure (118±23 vs. 148±28 mmHg, p<0.05), and left ventricular ejection fraction (52±11 vs. 58±6%, p<0.05). Both groups had at least moderate left ventricular hypertrophy and abnormal global longitudinal strain with no significant difference between groups. In 6 all the cases, the final diagnosis of amyloidosis was based on the results of abdominal fat aspiration biopsy.

Conclusion

ATTR is an underdiagnosed disease that accounts for a significant number (11.2%) of HFpEF cases. These findings create an opportunity for further investigation in the targeted therapy of patients with HFpEF.

Long Absence from Work Due to Sickness among Psychiatric Outpatients in Japan, with Reference to a Recent Trend for Perfectionism

BACKGROUND

Sick leave from work due to psychiatric disorders is a major public health problem, not only in Japan but also worldwide. As males and females in Japan tend to differ in their approach to work, a gender difference in perfectionism might be expected. We investigated the background factors leading to long-term absence from work due to sickness among psychiatric outpatients in Japan.

METHODS

We surveyed 73 psychiatric outpatients who were absent from work for a long time (POAWs) and 228 employees without long-term sickness absence as controls. GHQ-30, NEO-FFI, MPS, RSS and questionnaires inquiring about background factors, including relationships with others, was used, and the data were compared between males and females.

RESULTS

Male POAWs had a significantly higher tendency for depression and perfectionism than the controls, but in females this difference was not significant. With regard to personal relationships of POAWs, males had worse relationships with superiors and colleagues, whereas females had worse relationships with superiors, colleagues, and family.

CONCLUSIONS

The data suggested that male workers exhibiting perfectionism tend to undertake too much work and become exhausted when trying to cope with complex human relationships in the workplace. Female workers having the double burden of family commitment and perfectionism tend to be isolated in terms of personal relationships, leading to exhaustion both in and outside the workplace.

Contrast media injection into right coronary artery caused thrombus extraction to aorta that may have resulted in left main trunk thrombosis

A 59-year-old man with inferior acute myocardial infarction underwent an urgent coronary angiography and as a result a total occlusion of the ostial right coronary artery (RCA) was observed. Interestingly, the thrombus in the RCA clearly shortened within 2.3 s during the contrast media injection. While we prepared for percutaneous coronary intervention (PCI) of the RCA, ventricular fibrillation occurred and pulseless electrical activity continued in spite of repeated cardioversion. Despite no stenosis in the left main trunk (LMT) in the initial coronary angiography, the LMT was totally occluded. Following aspiration therapy on the LMT with percutaneous cardiopulmonary support, PCI of the RCA was performed. A coronary angiography should be carefully performed if a lot of thrombi exist in the coronary ostium because LMT embolism may have been caused by thrombus extraction from the RCA by contrast media injection.

Hyperuricemia as a risk factor for progressive renal insufficiency after coronary intervention in patients with chronic kidney disease

The development of renal insufficiency after percutaneous coronary intervention (PCI) is associated with increases in morbidity and mortality. Recent studies have reported that hyperuricemia (HU) results in hypertension, intrarenal vascular disease, and renal injury. We postulated that HU contributes to progressive renal disease after PCI. We studied 139 patients with chronic kidney disease (CKD) undergoing elective PCI including 59 HU patients. We assessed the relationship between HU and the development of renal insufficiency after PCI by estimating traditional contrast-induced nephropathy (CIN) and persistent postprocedural nephropathy (PPN) defined as an increase in creatinine ≥0.2 mg/dl of the baseline value 2 weeks after procedure. CIN and PPN were seen in 6.5 and 28.8% respectively. The incidence of PPN was higher in HU patients than in non-HU patients (p < 0.001) although the incidence of CIN was not significantly different between the two groups. PPN was more frequently observed in hyperuricemic patients irrespective of association with hypertension (with and without hypertension, p < 0.001 and p = 0.034, respectively). By univariate analysis, HU and hypertension are associated with PPN although there was no significant predictor of CIN in this study. Multivariate analysis showed HU and hypertension were independent predictors of PPN. HU is a predictor of slow and mild development of renal insufficiency after PCI in patients with CKD.

Hereditary spastic paraplegia with frontal lobe dysfunction: a clinicopathologic study

The authors report an unusual family with hereditary spastic paraplegia (HSP) with frontal lobe dysfunction having the onset in the sixth decade. All the patients showed hypoperfusion in the frontal lobes and thalami on SPECT. Neuropathologic findings revealed thin corpus callosum and degeneration in the thalamic dorsomedial nuclei as well as degeneration of the corticospinal tracts. This family was likely affected by a novel form of HSP characterized by frontal lobe dysfunction caused by thalamic degeneration.

Thrombolysis Increases the Risk of Free Wall Rupture in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

In spite of the progress made in acute angiographic evaluation and obtaining durable reperfusion of acute myocardial infarction (AMI) in the past two decades, cardiac free wall rupture (FWR) is still one of the causes of mortality following AMI. In this study, we evaluated the role of thrombolysis in the risk of FWR in AMI patients treated with acute percutaneous coronary intervention (PCI). Among 3,786 consecutive AMI patients seen between 1985 and 2003, 3,066 patients were treated by primary PCI or rescue PCI, with or without additional thrombolysis. FWR occurred in 24 of 3,066 patients (0.8%) treated by PCI; female gender (1.4% vs 0.6%, P=0.001), age >75 years, (1.4% vs 0.6%, P=0.001) left main coronary artery (LMCA)-related infarction, (4.5% vs all other arteries, P=0.015), and thrombolytic use (3.1% vs 0.4%, P<0.001) were all associated with higher rates of FWR by univariate analysis. In patients treated with PCI and thrombolysis, FWR occurred in 2.7% with optimal PCI results but in only 4.9% if PCI was unsuccessful (P=NS). The incidence of FWR in patients with optimal PCI without thrombolysis was 0.4% (P<0.001). Multivariable analysis identified thrombolytic use (odds ratio [OR]: 8.49, 95% confidence interval [CI]: 3.66-19.7, P<0.001), LMCA-related infarction (OR: 7.06, 95% CI: 1.89-26.4, P=0.004), and female gender (OR: 3.02, 95% CI: 1.27-7.21, P=0.013) as independent predictors of FWR. Thrombolysis is one of the contributing causes of FWR in AMI patients undergoing PCI, even when PCI is successful.

Association of a polymorphism of the transforming growth factor-beta1 gene with cerebral amyloid angiopathy

BACKGROUND

A recent study showed that transforming growth factor-beta1 (TGF-beta1) induces amyloid-beta deposition in cerebral blood vessels and meninges of a transgenic mouse model of Alzheimer's disease (AD), and that TGF-beta1 mRNA levels are correlated with cerebral amyloid angiopathy (CAA) in human AD brains. A T/C polymorphism at codon 10 in exon 1 of the TGF-beta1 gene has been reported to be associated with the serum TGF-beta1 concentration. We investigated whether the TGF-beta1 polymorphism is associated with the risk of CAA.

METHODS

The association between the severity of CAA and the T/C polymorphism at codon 10 in exon 1 of the TGF-beta1 was investigated in 167 elderly Japanese autopsy cases, including 73 patients with AD. The apolipoprotein E (APOE) genotype was also determined.

RESULTS

The genotypes (TT/ TC/ CC) were associated with the severity of CAA significantly in all patients (p = 0.0026), in non-AD patients (p = 0.011), and APOE non-epsilon4 carriers (p = 0.0099), but not in AD patients or APOE epsilon4 carriers. The number of the T alleles positively correlated with the severity of CAA in all patients (p = 0.0011), non-AD patients (p = 0.0026), and APOE non-epsilon4 carriers (p = 0.0028), but not in AD patients or APOE epsilon4 carriers. The polymorphism was not significantly associated with AD.

CONCLUSIONS

Our results suggest that the polymorphism in TGF-beta1 is associated with the severity of CAA, especially in non-AD patients and APOE non-epsilon4 carriers.

Involvement of the peripheral nervous system in human prion diseases including dural graft associated Creutzfeldt-Jakob disease

OBJECTIVE

To investigate abnormal prion protein (PrP) deposition in the peripheral nervous system (PNS) in human prion diseases.

METHODS

Eight patients with prion diseases were examined: three with sporadic Creutzfeldt-Jakob disease (sCJD), two with dural graft associated CJD (dCJD), one with Gerstmann-Straussler-Scheinker disease (GSS) with a PrP P102L mutation (GSS102), and two with a P105L mutation (GSS105). An atypical case of sCJD with PrP plaques in the brain presented clinically with peripheral neuropathy, and showed demyelination in 12% of the teased fibres of the sural nerve. The PNS was investigated by immunohistochemical and western blotting analyses of PrP.

RESULTS

In immunohistochemical studies, granular PrP deposits were detected in some neurones of dorsal root ganglia and a few fibres of peripheral nerves and spinal posterior roots in one sCJD and two dCJD patients, but not in GSS102 or GSS105 patients. The atypical case of sCJD with peripheral neuropathy showed no obvious PrP deposition in the nerves. Western blotting analysis of the PNS from the dCJD patients revealed a small amount of protease K resistant PrP in the dorsal root ganglia and peripheral nerves.

CONCLUSIONS

Abnormal PrP deposition occurs in the dorsal root ganglia and peripheral nerves in sCJD and dCJD. The PrP deposits in the PNS are not correlated with clinical manifestation of peripheral neuropathy in CJD.

Coronary angioplasty reduces free wall rupture and improves mortality and morbidity of acute myocardial infarction

BACKGROUND

Free wall rupture (FWR) is one of the major causes of mortality in acute myocardial infarction (AMI). To what extent coronary angioplasty for AMI would modify the predictors of FWR is not clear.

METHODS

In prospective database of consecutive 3,138 AMI patients seen between May 1985 to May 2002, 3,096 patients (98.7%) who underwent emergent coronary angiography were analyzed retrospectively. The incidence of FWR was determined by univariate and multivariate analyses.

RESULTS

FWR after admission occurred in 40 (1.3%) patients. A higher rate of FWR was associated with: 1) not having coronary angioplasty (3.2% vs. 0.9%, p< 0.0001); 2) thrombolytic agents usage (2.4% vs. 1.0%, p = 0.004); 3) female gender (2.5% vs. 1.1%, p = 0.0004); 4) failed reperfusion (5.4% vs. 0.9%, p< 0.0001); and 5) LMT-related infarct (4.7% vs. 1.2%, p = 0.02) in univariate analysis. Five conditions were identified as significant protective or predictive factors of FWR in multivariate logistic regression analysis: having coronary angioplasty (odds ratio [OR]: 0.45, 95% confidence interval [95% CI] 0.22-0.94, p = 0.03), failed reperfusion (OR: 4.57, 95% CI: 2.31-9.05, p< 0.0001), LMT-related infarct (OR: 4.96, 95% CI: 1.42-17.34, p = 0.01), female gender (OR: 2.17, 95% CI: 1.11-4.25, p = 0.02) and age (OR: 1.04, 95% CI: 1.00-1.07, p = 0.03). Coronary angioplasty alone resulted in a lower incidence of FWR (0.5%) than thrombolysis alone (1.6%, p = 0.02), coronary angioplasty with thrombolysis (3.3%, p< 0.0001) and without either treatment (6.3%, p< 0.0001).

CONCLUSIONS

Angiographic reperfusion success was the most significant protective factor from FWR. Coronary angioplasty reduced FWR complicating AMI and its concomitant fatality.

Sporadic Creutzfeldt-Jakob disease with MM1-type prion protein and plaques

The authors report a 75-year-old woman with atypical sporadic Creutzfeldt-Jakob disease (CJD) characterized by MM1-type prion protein (PrP) (methionine homozygosity at codon 129 in the PrP gene and type-1 protease-resistant PrP) and PrP plaques. This patient is the first case of sporadic CJD with plaque-forming MM1-type PrP, suggesting either a shared prion strain with the plaque-forming subset of dural graft-associated CJD or shared host genetic factors that are unrelated to the PrP genotype.

Homozygosity and linkage disequilibrium mapping of autosomal recessive distal myopathy (Nonaka distal myopathy)

Autosomal recessive distal myopathy or Nonaka distal myopathy (NM) is characterized by its unique distribution of muscular weakness and wasting. The patients present with spared quadriceps muscles even in a late stage of the disease. The hamstring and tibialis anterior muscles are affected severely in early adulthood. We have localized the NM gene to the region between markers D9S319 and D9S276 on chromosome 9 by linkage analysis. To further refine the localization of the NM gene, we conducted homozygosity and linkage disequilibrium analysis for 14 patients from 11 NM families using 18 polymorphic markers. All of the patients from consanguineous NM families were found to be homozygous for six markers located within the region between markers D9S2178 and D9S1859. We also provided evidence for significant allelic associations between the NM region and five marker loci. Examination of the haplotype analysis identified a predominant ancestral haplotype comprising the associated alleles 199-160-154-109 (marker order: D9S2179-D9S2180-D9S2181-D9S1804), present in 60% of NM chromosomes and in 0% of parent chromosomes. On the basis of the data obtained in this study, the majority of NM chromosomes were derived from a single ancestral founder, and the NM gene is probably located within the 1.5-Mb region between markers D9S2178 and D9S1791.

Ethyl(methyl)dioxirane as an efficient reagent for the oxidation of nucleoside phosphites into phosphates under nonbasic anhydrous conditions

A convenient method for the oxidation of nucleoside phosphites into phosphates under nonbasic and nonaqueous conditions using commercially available ethyl(methyl)dioxirane has been developed. This oxidation is effective with both N-protected and N-unprotected strategies.

[Autosomal dominant adult-onset spinal muscular atrophy with vocal cord paralysis: a case report]

This report concerns a 41-year-old female case of spinal muscular atrophy (SMA) associated with vocal cord paralysis. Her parents were not consanguineous. Her maternal grandmother and younger brother were suspected of having SMA. At age 37, she first experienced gait disturbance and began to have slowly progressive dysarthria and weakness of the extremities. Neurological examination revealed that she had inspiratory stridor, dysarthria and proximal muscular weakness of the extremities. Achilles tendon reflexes were absent, while there were no pathological reflexes or sensory disturbances. She showed a waddling gait and Gowers' sign. The laboratory data indicated mild elevation of serum CK. The nerve conduction study was normal, while the electromyographic study and muscle biopsy revealed neurogenic changes. We diagnosed the case as adult onset SMA of the autosomal dominant type. Laryngoscopy revealed that the patient had vocal cord paralysis, which was predominant in abductor muscles and of the posterior paralysis type according to the categories established by Isozaki. Genetic analysis showed no mutations in the genes of the neuronal apoptosis inhibitory protein and of the survival motor neuron.

Physiological and pathophysiological regulation of cytochrome P450

This article is a report on a symposium sponsored by the American Society for Pharmacology and Experimental Therapeutics and held at the April 1998 Experimental Biology '98 meeting in San Francisco. The presentations focused on the mechanisms of regulation of cytochrome P450 gene expression by developmental factors and by hormones and cytokines, as well as on the interplay between physiological and chemical regulation. Approaches and systems used to address these questions included conditional gene knockouts in mice, primary hepatocyte cultures, immunofluorescence imaging of cells, and cell lines stably expressing reporter gene constructs.

Mediastinal lymphadenitis associated with Chlamydia pneumoniae infection

A young woman presented with mediastinal lymphadenitis and measles-like eruption. All clinical manifestations promptly responded to macrolide therapy. Serologically, current infection of Chlamydia pneumoniae was highly suspected. Evaluation of Chlamydia pneumoniae infection should be included in the diagnostic approach to mediastinal lymphadenitis.

Severe chest pain due to gastric anisakiasis

We treated two cases of gastric anisakiasis presenting with severe chest pain. In both cases, there was a history of prior ingestion of raw saltwater fish. After endoscopic removal of larvae, the chest pain disappeared and never recurred. Other diseases causing chest pain were ruled out by symptoms, signs, blood tests, electrocardiography, chest radiograph, and ultrasonic examination of the heart and abdomen. Thus the chest pain was considered to be caused by gastric anisakiasis. Gastric anisakiasis should be included in the differential diagnosis of acute chest pain.

Familial benign myoclonus epilepsy of adult onset: a previously unrecognized myoclonic disorder

Three families with a common clinical feature of adult onset myoclonus epilepsy were studied. Onset of the myoclonus, continuously presented and intensified by movement and emotional stress, was between the 3rd and 5th decades. Generalized seizures, following worsening of the myoclonus, occurred only a few times in life. This condition was considered to be an autosomal dominant trait with a high rate of penetrance. Although the symptoms gradually worsened with age in some cases, they were not associated with dementia or cerebellar disorder, distinguishing this condition from progressive myoclonus epilepsies (PMEs). Electrophysiologically, polyspikes on the electroencephalogram (EEG), giant wave in somatosensory evoked potentials, enhanced long-loop C reflexes and a preceding wave on jerk-locked back averaging of EEG were demonstrated, suggesting that the myoclonus originated in the cerebral cortices. This is a distinct hereditary disease different from PMEs, juvenile myoclonic epilepsy or other myoclonic disorders seen in adults.

The quadrilateral space syndrome

We describe a 21-year-old woman with left shoulder pain increased by desk work. Left subclavian angiography disclosed occlusion of the posterior circumflex humeral artery on abduction and external rotation of the arm, compatible with the previous reports of the quadrilateral space syndrome. This syndrome should be considered in patients with shoulder pain of unknown aetiology.

[A case of Wernicke-Korsakoff syndrome caused by gastrojejunostomy--specific findings of MRI and SPECT]

A 63-year-old woman with Wernicke-Korsakoff syndrome, despite the absence of alcoholism and malnutrition, is reported. She had undergone gastrojejunostomy for ileus 30 years ago, and this operation was thought to be an important risk factor for her vitamin B1 deficiency. Brain MRI showed symmetrical high intensity areas on T2-weighted images in the periaqueductal region and bilateral dorsomedial nuclei of the thalamus. On single photon emission computed tomography (SPECT) using 99mTc-hexamethylpropyleneamine oxime, bilateral frontal perfusion was reduced, which was attributed to thalamo-cortical diaschisis due to injury to the dorsomedial nuclei of the thalamus. Presumably this phenomenon explains the Korsakoff psychosis. A history of gastrojejunostomy, even if normal intake is possible, is a risk factor for vitamin B1 deficiency, and should be considered in the differential diagnosis of Wernicke-Korsakoff syndrome.

Characterization of a second gene product related to rabbit cytochrome P-450 1

A cDNA, p1-88, was cloned from a library constructed using rabbit liver mRNA. Sequence analysis indicates that p1-88 is highly similar (congruent to 95%) to the cDNA, p1-8, that encodes rabbit liver cytochrome P-450 1 and that had been isolated from the same library. The predicted amino acid sequence of the protein encoded by p1-88, P-450 IIC4, differs at 25 of 487 amino acids from that encoded by p1-8. P-450 IIC4 was synthesized in vitro using rabbit reticulocyte lysate primed with RNA transcribed from the coding sequence of p1-88 using a bacteriophage T7 RNA polymerase/promoter system. P-450 IIC4 reacts with two monoclonal antibodies that recognize P-450 1 and exhibits the same relative electrophoretic mobility as P-450 1. In contrast, the reactivity of a third monoclonal antibody recognizing P-450 1, 1F11, toward P-450 IIC4 synthesized in vitro is greatly diminished. The latter antibody extensively inhibits hepatic progesterone 21-hydroxylase activity and recognizes phenotypic differences among rabbits in the microsomal concentration of P-450 1. This difference in the immunoreactivity of P-450 IIC4 and P-450 1 with the 1F11 antibody suggests that P-450 IIC4 does not contribute significantly to hepatic progesterone 21-hydroxylase activity. S1 nuclease mapping demonstrates that the expression of mRNAs corresponding to p1-88 are expressed to equivalent extents in rabbits exhibiting high and low expression of mRNAs corresponding to p1-8. Thus, P-450 1 differs from the protein encoded by p1-88, in its regulation, immunoreactivity, and by inference its catalytic properties although the amino acid sequences of P-450 1 and P-450 IIC4 are highly similar (congruent to 95%).

Multiple gene-like sequences related to the rabbit hepatic progesterone 21-hydroxylase cytochrome P-450 1

Rabbits exhibit phenotypic differences, 21H and 21L, in the rate of hepatic progesterone 21-hydroxylation that reflect 10-fold higher microsomal concentrations of cytochrome P-450 1 in 21H rabbits. A cDNA library in pBR322 was prepared from liver mRNA isolated from a 21H rabbit. A clone, p1-8, producing a hybrid protein resulting from the insertion of the cDNA into the beta-lactamase gene of the plasmid expressed 5 distinct epitopes that were recognized by a panel of monoclonal antibodies developed toward P-450 1. RNAs selected from total hepatic mRNA by filter hybridization with p1-8 yield at least two electrophoretically distinct proteins when translated in vitro and immunoprecipitated with the 3C3 monoclonal antibody. Only one of the two proteins is recognized by the 1F11 monoclonal antibody, which is highly specific for P-450 1, and the immunoprecipitated protein exhibits the electrophoretic mobility of P-450 1. The other protein remains unidentified. Northern blot analysis indicates that the 3' noncoding portion of p1-8 hybridizes to higher steady state concentrations of polyadenylated RNA in the 21H as compared to 21L rabbits. This correspondence in expression with that of P-450 1 in the 21H and 21L phenotypes further suggests that p1-8 encodes P-450 1 or a closely related protein. The cDNA is 1871 base pairs in length and encodes a protein of 487 amino acids. Southern blot analysis indicates that several independent, gene-like sequences hybridize with the 3' noncoding region of p1-8 under conditions of high stringency. These results indicate that P-450 1 is a member of an extensive multigene family.