A Multicenter Study on the Utility of Selective Enrichment Broth for Detection of Group B Streptococcus in Pregnant Women in Japan

Universal screening for Streptococcus agalactiae, Group B Streptococcus (GBS), in pregnant women is important for the prevention of severe infectious diseases in neonates. The subculture method using selective enrichment broth significantly improves GBS detection rates in the United States; however, this method is not widely utilized in Japan mainly because of the lack of large-scale validation. Therefore, we aimed to validate the utility of the subculture method in collaboration with multiple facilities. A total of 1957 vaginal-rectal swab specimens were obtained from pregnant women at 35-37 gestational weeks from March 1, 2020, to August 30, 2020, at Fukushima Medical University Hospital, Aiiku Hospital, Kitano Hospital, and the University of the Ryukyus Hospital. Conventional direct agar plating, subculture using selective enrichment broth, and direct latex agglutination (LA) testing with incubated broth were performed for GBS detection, and discrepant results were confirmed using real-time PCR. The GBS detection rates for direct agar plating, subculture, and direct LA testing were 18.2% (357/1957), 21.6% (423/1957), and 22.3% (437/1957), respectively. The use of selective enrichment broth showed promise for GBS detection with high sensitivity and is therefore recommended for GBS screening to prevent GBS-related infectious diseases in neonates in Japan.

Utility of short-time electrocardiogram to assess risk for atrial arrhythmia recurrence: Impact of atrial premature beat occurrence 1 day after pulmonary vein isolation for atrial fibrillation

INTRODUCTION

Atrial premature beats (APBs) are the trigger for atrial fibrillation (AF). We sought to investigate the clinical significance of APB occurrence 1 day after pulmonary vein isolation (PVI) for AF using a short-time electrocardiogram.

METHODS

A total of 206 patients undergoing PVI for paroxysmal AF were included. Electrocardiogram recording for 100 consecutive beats was performed 1 day after PVI. The patients were divided into two groups: those with reproducible APBs (≥1 beat) during reassessment (APB group, n = 49) or those without (non-APB group, n = 157). Late recurrence was defined as atrial tachyarrhythmia recurrence 3-12 months after PVI. The impact of APB occurrence on outcomes was investigated.

RESULTS

Late recurrence occurred in 19 patients (9.2%). The presence of low-voltage areas, left atrial volume, and recurrence rate were higher in the APB group than in the non-APB group. In the APB group, the patients with recurrence had lower prematurity index (PI, coupling interval of APB/previous cycle length) compared to those without. Receiver-operating characteristic analysis revealed PI (<59.3) to be a predictive factor of recurrence (area under the curve: 0.733). The study subjects were then reclassified into three groups according to the absence of APB occurrence (n = 157), presence thereof with PI ≥ 59.3 (n = 33), and presence with PI < 59.3 (n = 16). The multivariate Cox models revealed that APB with PI < 59.3 was an independent predictor for recurrence (hazard ratio, 8.735; p < 0.001).

CONCLUSION

A short-time electrocardiogram enables risk assessment for arrhythmia recurrence, and APB with low PI 1 day after PVI is a powerful predictor.

Hepatic Venous Stasis Index Reflects Hepatic Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in patients with heart failure (HF). However, the parameter that quantifies hepatic vein waveforms has not been established. We suggest the hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in patients with HF, we aimed to clarify the associations of HVSI with the parameters of cardiac function and right heart catheterization, as well as that with prognosis, in patients with HF. Methods and Results We performed abdominal ultrasonography, echocardiography, and right heart catheterization in patients with HF (n=513). The patients were divided into 3 groups based on HVSI as follows: HVSI 0 (HVSI=0, n=253), low HVSI (HVSI 0.01-0.20, n=132), and high HVSI (HVSI>0.20, n=128). We examined the associations of HVSI with parameters of cardiac function and right heart catheterization and followed up for cardiac events defined as cardiac death or worsening HF. There was a significant increase in level of B-type natriuretic peptide, inferior vena cava diameter, and mean right atrial pressure with increasing HVSI. During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan-Meier analysis, cardiac event rate increased across increasing HVSI (log-rank, P=0.002). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF and is associated with adverse prognosis in patients with HF.

Prognostic significance of spleen shear wave elastography and dispersion in patients with heart failure: the crucial role of cardio-splenic axis

INTRODUCTION

The interaction between the heart and spleen plays a crucial role among cardiac and multiple organ networks, particularly in heart failure (HF). Ultrasound shear wave imaging is a non-invasive technology capable of quantifying tissue quality, but its significance in the spleen in patients with HF is poorly understood.

METHODS AND RESULTS

This prospective observational study enrolled hospitalized 232 patients with HF undergoing abdominal ultrasonography. We used shear wave elastography (SWE) to assess spleen tissue elasticity and shear wave dispersion (SWD) to assess spleen tissue viscosity. Clinical, echocardiography, right heart catheterization, and outcome data were collected. Spleen SWE was negatively correlated with right ventricular fractional area change (R =  - 0.180, P = 0.039), but not with right-sided pressure or congestion indices. When patients were divided into three groups based on tertile values of splenic parameters, Kaplan-Meier analysis demonstrated that patients with the highest spleen SWE and SWD had lower event-free survival rates from cardiac deaths and decompensated HF over a median 494-days follow-up period (P < 0.0001 and P < 0.0001, respectively). In a multivariable Cox proportional hazard model, both spleen SWE and SWD were independently associated with increased risks of adverse cardiac events (hazard ratio, 4.974 and 1.384; P = 0.003 and P < 0.0001). Mechanistically, we evaluated mRNA expressions of CD36, a monocyte/macrophage-associated molecule, in peripheral leukocytes, and found that enhanced spleen stiffness was associated with the upregulation of CD36 expressions.

CONCLUSION

Share wave imaging of the spleen is useful for stratifying the prognosis of HF patients and may suggest a role of the cardio-splenic axis in HF pathogenies.

Matrix-Assisted Laser Desorption Ionization-Time-of-Flight Mass Spectrometry with Time-of-Flight Peak Analysis for Rapid and Accurate Detection of Group B Streptococcus in Pregnant Women

Severe infections in neonates caused by Streptococcus agalactiae, Group B Streptococcus (GBS), are often associated with GBS transmission from their mothers during labor or birth. Hence, it is necessary to develop a universal method for screening vaginal-rectal GBS colonization in pregnant women worldwide. A subculture of vaginal-rectal swabs using a selective enrichment broth and an agar plate is conventionally recommended for GBS screening. However, infants born to mothers who are GBS negative on subculture sometimes contract GBS infections. Therefore, we developed another method with high sensitivity for GBS screening. A total of 178 vaginal-rectal swabs from pregnant women were inoculated into the enrichment broth, of which 126 were suspected of containing GBS due to the change in the color of the broth. The subculture results were positive for GBS in 34 (27.0%) swabs. Each broth was then analyzed using matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). Analysis of the TOF peaks specific to GBS revealed 45 (35.7%) swabs as GBS positive. Of the 11 GBS positive samples on TOF peak analysis but negative on subculture, S. agalactiae gene targets were detected through PCR in 4 samples. MALDI detection with analysis of peaks of TOF (MDAPT) can detect GBS directly from cultured broth with high sensitivity. MDAPT can be an alternative method for GBS screening in pregnant women and contribute to the prevention of severe GBS infectious diseases in neonates. IMPORTANCE As previously reported, 10%-30% of pregnant women carry Streptococcus agalactiae, Group B Streptococcus (GBS), in their vagina or rectum, and approximately 50% of them vertically transmit GBS to their neonates during labor or birth. Moreover, 1%-2% of the GBS-transmitted neonates develop severe GBS infectious diseases, which have a mortality rate of 19.2% in a preterm infant and 2.1% in a full-term infant. Hence, universal screening for GBS colonization in pregnant women is conducted worldwide using the subculture procedure; however, infants born to GBS negative mothers sometimes contract GBS infections. Therefore, other laboratory techniques are required for detecting GBS more accurately. The proposed method "MALDI detection with analysis of peaks of TOF (MDAPT)" detects GBS directly from cultured broth with high sensitivity. Therefore, it can be an alternative method for GBS screening in pregnant women, thereby contributing to the prevention of severe GBS infectious diseases in neonates.

Increases in Hepatokine Selenoprotein P Levels Are Associated With Hepatic Hypoperfusion and Predict Adverse Prognosis in Patients With Heart Failure

Background

Although multiorgan networks are involved in the pathophysiology of heart failure (HF), interactions of the heart and the liver have not been fully understood. Hepatokines, which are synthesized and secreted from the liver, have regulatory functions in peripheral tissues. Here, we aimed to clarify the clinical impact of the hepatokine selenoprotein P in patients with HF.

Methods and Results

This is a prospective observational study that enrolled 296 participants consisting of 253 hospitalized patients with HF and 43 control subjects. First, we investigated selenoprotein P levels and found that its levels were significantly higher in patients with HF than in the controls. Next, patients with HF were categorized into 4 groups according to the presence of liver congestion using shear wave elastography and liver hypoperfusion by peak systolic velocity of the celiac artery, which were both assessed by abdominal ultrasonography. Selenoprotein P levels were significantly elevated in patients with HF with liver hypoperfusion compared with those without but were not different between the patients with and without liver congestion. Selenoprotein P levels were negatively correlated with peak systolic velocity of the celiac artery, whereas no correlations were observed between selenoprotein P levels and shear wave elastography of the liver. Kaplan‐Meier analysis demonstrated that patients with HF with higher selenoprotein P levels were significantly associated with increased adverse cardiac outcomes including cardiac deaths and worsening HF.

Conclusions

Liver‐derived selenoprotein P correlates with hepatic hypoperfusion and may be a novel target involved in cardiohepatic interactions as well as a useful biomarker for predicting prognosis in patients with HF.

Decreases in hepatokine Fetuin-A levels are associated with hepatic hypoperfusion and predict cardiac outcomes in patients with heart failure

BACKGROUND

Interactions of the heart and the liver remain to be fully understood in the pathophysiology of heart failure (HF). Hepatokines are proteins synthesized and secreted from the liver and regulate systemic metabolisms of peripheral tissues. This study sought to clarify the clinical relevance of hepatokine Fetuin-A in patients with HF.

METHODS AND RESULTS

We enrolled 217 participants including 187 hospitalized patients with HF and 30 control subjects who were sought with a comparable age- and sex profile and who had never had HF or structural cardiac abnormalities. First, we examined the levels of Fetuin-A and found that its levels were significantly lower in patients with HF than in the controls. Next, HF patients were categorized into four groups based on hepatic hemodynamics assessed by abdominal ultrasonography which determines liver hypoperfusion by peak systolic velocity (PSV) of the celiac artery and liver stiffness by shear wave elastography (SWE). Fetuin-A levels were significantly decreased in HF patients with liver hypoperfusion compared to those without, but were not different between HF patients with and without elevated liver stiffness. Correlation analysis revealed that circulating Fetuin-A was positively correlated with PSV of the celiac artery but not with SWE of the liver. Kaplan-Meier analysis demonstrated that HF patients with lower Fetuin-A levels were significantly associated with increased adverse outcomes including cardiac deaths and decompensated HF.

CONCLUSIONS

Liver-derived hepatokine Fetuin-A may be a novel target involved in the cardio-hepatic interactions, as well as a useful biomarker for predicting the prognosis in patients with HF.

Renal Venous Stasis Index Reflects Renal Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Background

It has been recently reported that the renal venous stasis index (RVSI) assessed by renal Doppler ultrasonography provides information to stratify pulmonary hypertension that can lead to right-sided heart failure (HF). However, the clinical significance of RVSI in HF patients has not been sufficiently examined. We aimed to examine the associations of RVSI with parameters of cardiac function and right heart catheterization (RHC), as well as with prognosis, in patients with HF.

Methods

We performed renal Doppler ultrasonography, echocardiography and RHC in hospitalized patients with HF (n = 388). RVSI was calculated as follows: RVSI = (cardiac cycle time-venous flow time)/cardiac cycle time. The patients were classified to three groups based on RVSI: control group (RVSI = 0, n = 260, 67%), low RVSI group (0 &lt; RVSI ≤ 0.21, n = 63, 16%) and high RVSI group (RVSI &gt; 0.21, n = 65, 17%). We examined associations of RVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF.

Results

There were significant correlations of RVSI with mean right atrial pressure (mRAP; R = 0.253, P &lt; 0.001), right atrial area (R = 0.327, P &lt; 0.001) and inferior vena cava diameter (R = 0.327, P &lt; 0.001), but not with cardiac index (R = −0.019, P = 0.769). During the follow-up period (median 412 days), cardiac events occurred in 60 patients. In the Kaplan–Meier analysis, the cumulative cardiac event rate increased with increasing RVSI (log-rank, P = 0.001). In the multivariate Cox proportional hazard analysis, the cardiac event rate was independently associated with RVSI (high RVSI group vs. control group: hazard ratio, 1.908; 95% confidence interval, 1.046–3.479, P = 0.035).

Conclusion

RVSI assessed by renal Doppler ultrasonography reflects right-sided overload and is associated with adverse prognosis in HF patients.

Liver Congestion Assessed by Hepatic Vein Waveforms in Patients With Heart Failure

Background

It has been reported that the pattern of hepatic vein (HV) waveforms determined by abdominal ultrasonography is useful for the diagnosis of hepatic fibrosis in patients with chronic liver disease. We aim to clarify the clinical implications of HV waveform patterns in patients with heart failure (HF).

Methods

We measured HV waveforms in 350 HF patients, who were then classified into 3 categories based on their waveforms: those with a continuous pattern (C group); those whose V wave ran under the baseline (U group), and those with a reversed V wave (R group). We performed right-heart catheterization, and examined the rate of postdischarge cardiac events, such as cardiac death and rehospitalization due to worsening HF.

Results

The number of patients in each of the 3 HV waveform groups was as follows: C group, n = 158; U group, n = 152, and R group, n = 40. The levels of B-type natriuretic peptide (R vs C and U; 245.8 vs 111.7 and 216.6 pg/mL; P < 0.01) and mean right atrial pressure (10.5 vs 6.7 and 7.2 mm Hg; P < 0.01) were highest in the R group compared with the other groups. The Kaplan-Meier analysis found that cardiac event–free rates were lowest in the R group among all groups (log-rank P < 0.001). In the multivariable Cox proportional hazard analysis, the R group was found to be an independent predictor of cardiac events (hazard ratio, 4.90; 95% confidence interval, 2.23-10.74; P < 0.01).

Conclusion

Among HF patients, those with reversed V waves had higher right atrial pressure and were at higher risk of adverse prognosis.

Intrarenal Doppler ultrasonography reflects hemodynamics and predicts prognosis in patients with heart failure

We aimed to clarify clinical implications of intrarenal hemodynamics assessed by intrarenal Doppler ultrasonography (IRD) and their prognostic impacts in heart failure (HF). We performed a prospective observational study, and examined IRD and measured interlobar renal artery velocity time integral (VTI) and intrarenal venous flow (IRVF) patterns (monophasic or non-monophasic pattern) to assess intrarenal hypoperfusion and congestion in HF patients (n = 341). Seven patients were excluded in VTI analysis due to unclear imaging. The patients were divided into groups based on (A) VTI: high VTI (VTI ≥ 14.0 cm, n = 231) or low VTI (VTI < 14.0 cm, n = 103); and (B) IRVF patterns: monophasic (n = 36) or non-monophasic (n = 305). We compared post-discharge cardiac event rate between the groups, and right-heart catheterization was performed in 166 patients. Cardiac index was lower in low VTI than in high VTI (P = 0.04), and right atrial pressure was higher in monophasic than in non-monophasic (P = 0.03). In the Kaplan–Meier analysis, cardiac event rate was higher in low VTI and monophasic groups (P < 0.01, respectively). In the Cox proportional hazard analysis, the combination of low VTI and a monophasic IRVF pattern was a predictor of cardiac events (P < 0.01). IRD imaging might be associated with cardiac output and right atrial pressure, and prognosis.

Validation of MALDI-TOF MS devices in reanalysis of unidentified pathogenic bacteria detected in blood cultures

In hospital microbial laboratories, morphological and biochemical analyses are performed to identify pathogenic microbes;however, these procedures lack rapidity and accuracy. Recently, Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) has been clinically utilized, and is expected to enable rapid and accurate microbial identification. We aimed to validate two MALDI-TOF MS devices available in Japan: the VITEK-MS (BioMérieux) and the Microflex LT (Bruker Daltonics). Clinically isolated bacteria, 100 samples in all, detected in blood cultures but incompletely identified by conventional procedures, were reanalyzed using the two devices. The VITEK-MS and Microflex LT, respectively, identified 49% (49/100) and 80% (80/100) of the tested bacteria at the species level, as well as 96% (96/100) and 95% (95/100) at the genus level. Among those reidentified strains, 26% (26/100) at the species level and 88% (88/100) at the genus level were concordant with each other, though three strains were unmatched. Moreover, four bacterial strains were unable to be identified using the VITEK-MS, versus five using the Microflex LT. MALDI-TOF MS devices can provide more rapid and accurate bacterial identification than ever before;however, the characteristics of each system were slightly different;therefore, it is necessary to understand the difference in performance of MALDI-TOF MS models.

Clinical Implications of Hepatic Hemodynamic Evaluation by Abdominal Ultrasonographic Imaging in Patients With Heart Failure

Background It has been reported that liver stiffness assessed by transient elastography are correlated with right atrial pressure, which is associated with worse outcome in patients with heart failure (HF). We aimed to clarify clinical implications of hepatic hemodynamic evaluation (liver congestion and hypoperfusion) by abdominal ultrasonography in patients with HF. Methods and Results We performed abdominal ultrasonography, right-heart catheterization, and echocardiography, then followed up for cardiac events such as cardiac death or worsening HF in patients with HF. Regarding liver congestion, liver stiffness assessed by shear wave elastography (SWE) of the liver was significantly correlated with right atrial pressure determined by right-heart catheterization (R=0.343; P<0.01), right atrial end-systolic area, and inferior vena cava diameter determined by echocardiography. Regarding liver hypoperfusion, peak systolic velocity (PSV) of the celiac artery was correlated with cardiac index determined by right-heart catheterization (R=0.291; P<0.001) and tricuspid annular plane systolic excursion determined by echocardiography. According to the Kaplan-Meier analysis, HF patients with high SWE and low PSV had the highest cardiac event rate (log-rank P=0.033). In the Cox proportional hazard analysis, high SWE and low PSV were associated with high cardiac event rate (high SWE: hazard ratio [HR], 2.039; 95% CI, 1.131-4.290; low PSV: HR, 2.211; 95% CI, 1.199-4.449), and the combination of high SWE and low PSV was a predictor of cardiac events (HR, 4.811; 95% CI, 1.562-14.818). Conclusions Intrahepatic congestion and hypoperfusion determined by abdominal ultrasonography (liver SWE and celiac PSV) are associated with adverse prognosis in patients with HF.

[How to efficiently conduct a physiological examination of a child--from the viewpoint of a medical technologist]

Children are often frightened, cry, refuse to sit still, and may not cooperate during a physiological examination. Technologists must take considerable care to reduce the child's anxiety. Specifically, we should use creative solutions, start by interacting with the patient, using dolls or toys, and explain the procedure to him/her in a friendly way, communicating more effectively with the patient's family. When performing the actual examinations, technologists need to work skillfully with a complete understanding of the purpose of the examinations, having the ability to identify the changes that occur in various developmental stages and interpret the pathophysiological mechanisms specific to children. Furthermore, we must always have an awareness of safety, taking measures to prevent falls from the bed and/or to keep the room warm if examinations require the child to be naked, so that he/she will not catch a cold. I explain various points of caution and possible solutions regarding electrocardiograms, electroencephalograms, and ultrasonography, from the viewpoint of a medical technologist.

Doppler ultrasound measurements of knee joint synovitis in rheumatoid arthritis patients treated with infliximab

Doppler ultrasound measurements were done for the thickness of synovial effusion and synovial proliferation (pannus), and diameter of the flow signals using digital calipers as well as flow signal grades and vascular resistance in the knee joint synovitis of patients with rheumatoid arthritis (RA) treated with infliximab. Forty knee joints of 20 RA patients were assessed before and after three injections of infliximab. The flow signals in the pannus were classified into the superficial and the deep signals and the joints were classified into the superficial signal pattern and the deep signal pattern. After treatment, the number of joints with superficial signal pattern reduced from 23 to 11, whereas the number of joints with deep signal pattern increased from 17 to 29 (P=0.0066), with a significant reduction of the superficial signal grades (P=0.0003). The mean cortical (posterior) pannus thickness increased significantly in the joints with superficial signal pattern (P=0.022) and in the total joints (superficial plus deep signal pattern) (P=0.031) but not in the joints with deep signal pattern. After 6 weeks of treatment with infliximab, the hyperemia in the superficial layer of the pannus developed into proliferation of the cortical pannus in the knee joints.

Power Doppler and spectral Doppler measurements of knee-joint synovitis in rheumatoid arthritis patients with superficial pattern signals and in those with deep pattern signals

Power Doppler and spectral Doppler ultrasonography were used to scan 127 knee joints of 72 patients with rheumatoid arthritis (RA). Synovial effusion thickness and synovial proliferation (pannus) thickness, as well as the flow signal diameter, were measured on ultrasonogram prints of the power Doppler using digital calipers. In addition, color-flow signal grades on power Doppler and the resistance index (RI) values on spectral Doppler were evaluated. The values of these five variables were compared among 58 joints with superficial pattern flow signals and 69 joints with deep pattern flow signals. Compared with the joints with deep pattern signals, the joints with superficial pattern signals had significantly higher mean values of effusion thickness (P < 0.0001) and flow signal grades (P < 0.0001), and significantly lower mean RI (P < 0.0001). On the other hand, the joints with deep pattern signals had a significantly higher value of signal diameter (P = 0.0125) and had a trend to higher value of pannus thickness (P = 0.079) as well. Significant correlations were observed between effusion thickness and signal grades (P < 0.0001); effusion thickness and RI (P < 0.0001); signal diameter and pannus thickness (P = 0.0102); signal diameter and RI (P < 0.0001); and signal grades and RI (P < 0.0001). The ultrasonographic measurements of synovitis in RA patients provide valuable information on synovial inflammation.

Power Doppler sonography for detection of intraarticular vascularization in knee joints of patients with rheumatoid arthritis

A series of 47 knee joints in 24 patients with rheumatoid arthritis were examined for intraarticular vascularization by power Doppler sonography. The intensity of vascularization was compared with the synovial effusion and proliferation evaluated by gray-scale sonography and the clinical findings in the patients. Vascularization was graded from 0 to 3 by counting the number of color-flow signals: grade 0, no signals; grade one, 1-4 signals; grade two, 5-8 signals; grade three, 9 or more signals. The grade of vascularization correlated with the grade of synovial effusion (P < 0.01), the grade of synovial proliferation (P < 0.05), and the serum levels of C-reactive protein (P < 0.05). It correlated inversely with disease duration (P < 0.01). Consistent with improvement of articular inflammation, a decrease in the number of color-flow signals was observed in two patients. Power Doppler sonography is suitable for evaluating the intensity of synovitis and for monitoring the clinical activity of rheumatoid patients.

Doppler sonographic comparative study on usefulness of synovial vascularity between knee and metacarpophalangeal joints for evaluation of articular inflammation in patients with rheumatoid arthritis treated by infliximab

We used Doppler sonography to evaluate the therapeutic effects of infliximab on the knee and metacarpophalangeal (MCP) joints of 10 patients with rheumatoid arthritis (RA), based on the color flow signals (CFS) and resistance index (RI) of synovial vascularity. After three injections of infliximab, we observed significant improvement in numbers of tender joints (P < 0.01), values of C-reactive protein (CRP) (P < 0.01), erythrocyte sedimentation rate (ESR) (P < 0.001), disease activity scores including tender joints, swollen joints, and ESR (DAS28-E3) (P < 0.0001), and CFS of knee (P < 0.001) and MCP (P < 0.05) joints. There was no significant improvement in RI values of knee or MCP joints after the therapy. We observed significant correlation between CFS of knee joints (knee-CFS) and values of CRP (P < 0.01), ESR (P < 0.01), and DAS28-E3 (P < 0.05), but not between CFS of MCP joints (MCP-CFS) and values of CRP, ESR, and DAS28-E3. However, no significant correlation was observed between 10 difference values (before values-after values) of CFS grades of knee or MCP joints and 10 difference values each of CRP, ESR, or DAS28-E3. The knee joints are more suitable than MCP joints for obtaining CFS in Doppler sonography, and are more useful than MCP joints for evaluation.

Doppler sonographic evaluation of effect of treatment with infliximab (Remicade) for rheumatoid arthritis

Synovial vascularization in the knee joints of six patients with rheumatoid arthritis who were treated with infliximab was evaluated by Doppler sonography. Power Doppler sonography demonstrated a significant reduction of color flow signals (P < 0.05), and spectral Doppler sonography demonstrated a significant increase in vascular resistance (P < 0.05) at week 6 (after three injections) evaluation of the therapy. A significant decrease in the number of tender joints (P < 0.05) and C-reactive protein value (P < 0.05) was also observed in these patients.

Comparison in values of color flow signals and vascular resistance of synovial vascularity demonstrated by Doppler sonography between knee and metacarpophalangeal joints of patients with rheumatoid arthritis

Synovial vascularity of 12 patients with rheumatoid arthritis (RA) was examined by Doppler sonography for color flow signals and vascular resistance on knee joints and metacarpophalangeal (MCP) joints, and the results were compared with each other and with C-reactive protein (CRP) levels of the patients. A significant correlation was observed between knee resistance index (RI) and MCP-RI (P = 0.0140), but not between knee color flow signals and MCP color flow signals (P = 0.1029). A significant correlation was also observed between knee color flow signals and knee RI (P = 0.0107), and knee pulsatility index (PI) (P = 0.0146). On the other hand, no correlation was observed between MCP color flow signals and MCP-RI (P = 0.828), and MCP-PI (P = 0.434). There was no significant correlation between CRP levels and grades of color flow signals, RI, and PI for both knee and MCP joints. Doppler sonographic evaluation of RI, especially knee RI, could be a useful marker for estimating synovial inflammation in RA patients.

Doppler sonographic analysis of synovial vascularization in knee joints of patients with rheumatoid arthritis: increased color flow signals and reduced vascular resistance

Synovial vascularization was analyzed by power Doppler and spectral Doppler sonography in 42 knee joints of 28 patients with rheumatoid arthritis. The synovial vessels with greater intensity of color flow signals demonstrated significantly lower indicators of vascular resistance - resistive index (P < 0.01) and pulsatility index (P < 0.01) - than those with lesser intensity. Consequently, an inverse correlation was observed between intensity of color flow signals and both resistive index (P < 0.01) and pulsatility index (P < 0.01).

Two localization patterns of vascularity demonstrated by power Doppler sonography at the suprapatellar recess in knee joints of patients with rheumatoid arthritis: intracapsular and supracortical

Intraarticular vascularization in 54 knee joints of 27 patients with rheumatoid arthritis was examined by power Doppler sonography. Localization of the vascularity at the suprapatellar recess was classified into two patterns: intracapsular and supra-cortical. The patients with supra-cortical vascularization showed a tendency to higher grades of synovitis and higher levels of inflammatory laboratory indices than those with intracapsular vascularization.

[Immunomodulatory effect of daily low-dose cisplatin treatment]

Immunomodulatory effects of daily low-dose cisplatin treatment were investigated on compromised patients with advanced or recurrent gastrointestinal cancer. One case of esophageal cancer, 7 of gastric cancer, 2 of colorectal cancer, 1 of carcinomatous peritonitis from unknown origin, and 1 of hepatocellular carcinoma, were treated by daily low-dose cisplatin combined with 5-FU or tegafur, and their ECOG Performance Status Score (PS), number of lymphocytes, and CD3 zeta chain expression of peripheral blood lymphocytes were studied to compare with the effects of treatment. Seven patients with esophageal cancer and gastric cancer showed a partial response and their PS was improved, and the number of lymphocytes and CD3 zeta chain expression of lymphocytes was increased. However, in two patients with progressive disease, a decreased number of lymphocytes and less expression of CD3 zeta chain were seen.

Blunt pancreatic trauma with main pancreatic duct disruption managed successfully with total parenteral nutrition: report of a case

Although surgery is the usual treatment of choice for pancreatic trauma with disruption of the main pancreatic duct, we report herein the case of a patient in whom blunt pancreatic trauma with disruption of the proximal main pancreatic duct was successfully managed by conservative treatment. An 18-year-old women presented with abdominal pain 22 days after being involved in a car accident in which her upper abdomen was thrust against the steering wheel. Computed tomography revealed a pancreatic pseudocyst and a prevertebral pancreatic fracture, and endoscopic retrograde pancreatography showed complete disruption of the main pancreatic duct at the neck. Considering that the patient had been clinically stable since the accident, we elected to continue with conservative management and placed her on total parenteral nutrition. Rapid recovery followed and 6 years later, the patient remains well without any exocrine or endocrine insufficiency despite atrophy of the distal pancreas. This experience indicates that selected cases of main pancreatic duct disruption following blunt trauma may be amenable to conservative management.

[Nutritional assessments in the long-term survivors following massive resection of the small intestine]

Nutritional assessments were measured in the sixteen long-term survivors who had undergone a massive resection of more than two-thirds of the small intestine or less than 170 cm of the remaining small intestine. Prealbumin, retinol binding protein and zinc in serum and arm muscle circumference were significantly lower than the normal range. Serum albumin had a tendency to correlate to the length of the remaining small intestine. Nutritional risk index had a correlation with the length of the remaining small intestine. In this study, nutritional assessments in the patients with a massive resection of the small intestine indicated to be in preclinical malnutritional state. This may support that supplementary nutritional therapy is necessary for such patients. In addition, we reported a patient with sensory polyneuropathy caused by vitamin E deficiency due to short bowel syndrome. The level of vitamin E was low in his serum, 294 micrograms/dl (normal: 1004 +/- 65) and in his red blood cells, 136 micrograms/dl (normal: 176 +/- 9). His symptom was markedly decreased within two weeks after the administration of large doses of vitamin E.