Impact of weight loss on cardiac function: improvement in left ventricular global longitudinal strain following metabolic surgery

Introduction

Obesity leads to an increased risk of cardiovascular disease (CVD) morbidity and mortality and is associated with the metabolic risk factors such as hypertension, diabetes mellitus, hyperlipidemia [1]. Metabolic surgery has been proven to be the most effective long term weight management tool and has known benefits in CVD prevention [2]. Global longitudinal strain (GLS) is an effective quantitative measurement of left ventricular (LV) function that is also a powerful predictor of future CVD events and mortality [3]. The impact of metabolic surgery on LV structure and function is unknown.

Purpose

This study investigated the changes in cardiac structure and function after metabolic surgery, including GLS. To our knowledge there has not been a study investigating this relationship previously reported.

Methods

Consecutive patients undergoing metabolic surgery at our center between March 2005 and February 2019 were recruited. Patients with transthoracic echocardiographic imaging (TTE) pre and post metabolic surgery (May 2005 to January 2019) were included. Electronic medical records were searched to obtain demographic, surgical and clinical data. GLS was calculated with Velocity Vector Imaging (VVI, Siemens, v2.0, Pennsylvania, USA). Averaged GLS values were derived from 4 chamber, 2 chamber and 3 chamber calculations.

Results

398 patients with pre- and post-operative cardiac imaging were included. Please see Table 1 for the baseline demographics of our study population. The mean age was 60.0 years with 70% being female. There were significant rates of CVD risk factors such as: hypertension (76.4%), diabetes mellitus (58.8%) and hyperlipidemia (76.4%).

The clinical and echocardiographic changes noted post metabolic surgery are detailed in Table 2. Along with decreases in weight post operatively, there were significant improvements in the markers of CVD risk factors such as mean blood pressure (134/75 to 129/72 mmHg, p value <0.001), mean gylcated hemoglobin levels (7.0 to 6.1%, p value <0.001) and mean low density lipoprotein (LDL) levels (97.7 to 88.2 mg/dl, p value <0.001).

There were a number of statistically significant positive changes in the left ventricular structure and function. The mean LV ejection fraction increased from 56.3% to 57.4% (p=0.008); left ventricular mass decreased from 238.2 g to 179.3 g (p value <0.001), and both septal and posterior wall thicknesses decreased significantly (p value <0.001). The LV mass indexed to body surface area (BSA) also decreased from 93.5 g/m2 to 83.1 g/m2.

The average global LV GLS was −15.7% pre-operatively, improving significantly to −17.9% post-operatively (p<0.001).

Conclusion

Our study has shown for the first time the impact of metabolic surgery on ventricular structure and function, with reduction in LV mass and improvement in LV GLS. These novel findings lends further support to the cardiovascular benefits of metabolic surgery.

Funding Acknowledgement

Type of funding sources: None.

Post-systolic shortening index by echocardiography evaluation of dyssynchrony in the non-dilated and hypertrophied left ventricle

Background

Post-systolic shortening index (PSI) is defined as myocardial shortening that occurs after aortic valve closure, and is an emerging measure of regional LV contractile dysfunction. PSI measurement variability amongst software vendor and its relationship with mechanical dyssynchrony and mechanical dispersion index (MDI) remains unknown. We evaluated PSI by speckle-tracking echocardiography from several vendors in patients with increased left ventricular wall thickness, and associations with MDI.

Methods

This is a prospective cross-sectional study of 70 patients (36 hypertrophic cardiomyopathy [HCM], 18 cardiac amyloidosis and 16 healthy controls) undergoing clinically indicated echocardiography. PSI was measured using QLAB/aCMQ (Philips), QLAB/LV auto-trace (Philips), EchoPAC (GE), Velocity Vector Imaging (Siemens), and EchoInsight (EPSILON) software packages, and calculated as 100% × (post systolic strain − end-systole strain)/post systolic strain.

Results

There was a significant difference in mean PSI among controls 2.1±0.6%, HCM 6.1±2.6% and cardiac amyloidosis 6.8±2.7% (p<0.001). Variations between software vendors were significant in patients with pathologic increases in LV wall thickness (for HCM p=0.03, for amyloidosis p=0.008), but not in controls (p=0.11), as seen in Figure 1. Furthermore, there were moderate correlations between PSI and both MDI (r=0.77) and left ventricular global longitudinal strain (r=0.69), as seen in Figure 2.

Conclusion

PSI was greater in HCM and cardiac amyloidosis patients than controls, and a valuable tool for dyssynchrony evaluation, with moderate correlations to MDI and strain. However, there were significant variations in PSI measurements by software vendor especially in patients with pathological increase in LV wall thickness, suggesting that separate vendor-specific thresholds for abnormal PSI are required.

Funding Acknowledgement

Type of funding sources: None.

A preliminary study of the safety and effectiveness of isoproterenol loading transesophageal echocardiography in atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with sludge or severe spontaneous echo contrast (SEC) in the left atrial appendage (LAA), isoproterenol loading transesophageal echocardiography (ISP-TEE) has been reported to check the presence of thrombus in the LAA, as the sludge or severe SEC disappears (Figure 1).

Purpose

The aim of this study was to assess the safety of ISP-TEE for the identification of LAA thrombus and the hemodynamic changes in the LAA caused by ISP loading.

Methods

We prospectively enrolled 25 patients with atrial fibrillation (AF) and sludge or SEC in the LAA who underwent ISP-TEE from April 2020 to July 2021. ISP was administered intravenously to achieve the target heart rate (HR) defined as follows: Max HR [beats per minutes: bpm] = 220 – age (years), Target HR [bpm] = Max HR × 0.8. Patients with tachycardia exceeding Max HR before ISP administration, hemodynamic instability, and other contraindications to ISP were excluded from the study. To assess the safety of ISP-TEE, we evaluated patients’ condition, changes in systolic blood pressure (sBP) and HR before and after ISP loading. We also assessed the presence or absence of worsening heart failure, new arrhythmias other than atrial fibrillation, and cerebral infarction or transient ischemic attack during the examination, and after 24 hours. Hemodynamic evaluation was performed using LAA blood flow velocity, LAA tissue Doppler imaging (TDI) velocity, and LAA volume fraction (LAAVF) defined as follows: LAAVF (%) = (Max LAA volume – Min LAA volume) / Max LAA volume × 100. Quantification of LAA volume was performed using the stacked-contour method of a 3-dimensional TEE full-volume acquisition.

Results

Among 25 patients, 13 patients had sludge or grade3 SEC, 7 patients had grade2 SEC, 5 patients had grade1 SEC. HR after ISP loading was significantly higher than before loading, but sBP did not change significantly before and after ISP loading. No complications due to ISP loading were observed during examination and after 24 hours. After ISP loading, there were 18 patients with grade 1 SEC or no SEC (classified as Group1), 7 patients had residual sludge or grade 2 to 3 SEC (classified as Group2). The differences in LAA blood flow velocity between before and after ISP loading was faster in Group1 than in Group2: 13.0 ± 10.5 vs 2.6 ± 4.2. p = 0.019. The differences in TDI velocity was also faster in Group1 than in Group2: 1.46 ± 1.14 vs 0.19 ± 0.50, p = 0.010. The differences in LAAVF was higher in Group1 than in Group2: 13.7 ± 10.3 vs 2.2 ± 2.0, p = 0.009.

Conclusions

In our study, no complications were observed in ISP-TEE for the identification of LAA thrombus. Patients with grade 1 SEC or no SEC, the LAA function was increased by ISP loading. These results may provide insights into the mechanisms of ISP loading on SEC in the LAA. Abstract Figure.

Left atrial strain evaluation and prognostic value in constrictive pericarditis patients undergoing pericardiectomy

Background

Left Atrial (LA) phasic volumes analyses is flawed with geometrical assumption requiring high endocardial border definition. LA strain analysis is an emergent technique that overcome some of these technical limitations. Prior studies of LA mechanics in pericardiectomy patients found improvement in LA strain at follow-up and manifested as symptomatic improvement, however their relationships with survival have not been investigated.

Purpose

We assessed LA strain before and after pericardiectomy and its association with all- cause mortality.

Methods

Consecutive patients with constrictive pericarditis who underwent pericardiectomy from 2000–2017 were retrospectively analyzed, analyzing pre-operative and post-operative (at 12 months) echocardiography. Exclusion criteria included atrial fibrillation, previous left sided valve surgery, concomitant valvular surgery at the index pericardiectomy, more than mild left sided valvulopathy and poor echocardiographic windows. Strain analyses was performed with Vector velocity imaging independent software. Univariate and multivariable analyses were utilized to identify factors associated with reduced survival.

Results

Amongst 190 patients included in the analyses, mean age was 58.5±12.7 years and 37 (19.5%) were female. The etiology of constriction was deemed idiopathic in 61.6% of the cases, median time interval surgery-postoperative echo was 67 days (IQR 6, 312 days). During median follow up of 3.3 years (IQR 0.73, 5.9 years) there were 37 deaths. After surgery, there was a significant decrease in LA reservoir, conduit and regional wall strains. (Table 1). Multivariable analysis demonstrated that postoperative 4C AL strain reservoir was independently associated with all-cause mortality (Table 2).

Conclusions

In pericardiectomy patients, postoperative 4C LA strain reservoir is independently associated with all-cause mortality. Perhaps, compensatory changes of septal and antero-posterior walls during constriction explain why after surgery these walls become less dynamic, negatively impacting the overall function. Overall, LA quantification and strains may become a useful clinical tool for risk stratification in pericardiectomy patients

Funding Acknowledgement

Type of funding sources: None. Table 1. Left atrial variables.Table 2. All-cause mortality predictors

Diastolic stress test echocardiography in patients with hypertrophy cardiomyopathy: association with exercise capacity

Background

Diastolic dysfunction (DD) is a frequent occurrence in hypertrophic cardiomyopathy (HCM) patients. Symptoms of DD are often unmasked only during exercise, as left ventricular (LV) filling pressure is normal at rest.

Purpose

We sought to establish if abnormal DST parameters are associated with reduced exercise capacity in HCM patients.

Methods

We examined 590 asymptomatic/minimally symptomatic HCM patients (54±14 years, 57% men, body mass index 30±6 kg/m2, 84% on beta-blockers) with HCM by echocardiography at rest & maximal exercise. Septal and lateral [e'] mitral annular velocity, peak early [E] and late [A] mitral inflow velocity, Mitral E/e' and left atrial volume index (LAVI) was recorded. Exercise functional capacity was stablished as age-gender predicted metabolic equivalents (AGP-METs).

Results

Echocardiography at rest had LVEF of 62±6, wall thickness of 16.7±0.5 mm, LVMI of 111±43 g m–2, LVOT gradient of 26±33 mmHg, LAVI 34.5±17 mm, E/A ratio of 1.2±0.6, and average E/e' ratio 12.7±0.6. Following maximal exercise had a mean LVOT gradient of 61±59 mmHg, E/A ratio of 1.2±1.0 and average E/e' ratio 12.7±1.0. Only 42% had >85% of age-sex predicted METs. Logistic regression analysis testing the association between various predictors and 85% AGP-METs are shown in table 1.

Conclusion

There is a significant association between abnormal diastolic response to exercise and reduced exercise capacity in patients with HCM.

Funding Acknowledgement

Type of funding source: None

Exercise capacity is associated with rest and peak-exercise left ventricular global longitudinal strain in patients with hypertrophic cardiomyopathy

Background

Patients with hypertrophic cardiomyopathy (HCM) frequently have reduced exercise capacity, which can be associated with subclinical cardiac dysfunction. Left ventricle global myocardial strain (LV-GLS) is a sensitive index to detect subclinical myocardial dysfunction. However, the clinical utility of LV-GLS during exercise test remains uncertain.

Purpose

We assessed the association of functional capacity with LV-GLS at rest and at the peak of stress in HCM patients.

Methods

We examined 566 asymptomatic/minimally symptomatic HCM patients (54±14 years, 57% men, body mass index 30±6 kg/m2, 84% on beta-blockers) by echo at rest and following maximal exercise. We recorded clinical, echo variables (LV ejection fraction [LVEF], LV thickness, left ventricle mass index [LVMI], left ventricle outflow tract [LVOT] gradient, LV-GLS at rest and at peak stress), and exercise variables (percent of age-gender predicted metabolic equivalents [AGP-METs]).

Results

Echo parameters were as follows: LVEF at rest of 62±6%, wall thickness of 16.9±0.4 mm, LVMI of 117±47 g/m2, LVOT gradient at rest of 27±33 mmHg, LV-GLS at rest of −15.9±3.6%, LV-GLS at peak of stress of −17.4±4.3%, and change in LV strain from rest to stress of −1.9±2.3%. Only 41% of patients achieved >85% of AGP-METs. Logistic regression demonstrating an association between AGP-METs less than 85% and various predictors are shown in Table 1.

Conclusion

Impaired deformation at peak of stress assessed by LV-GLS was associated with reduced exercise capacity measured as AGP-METs less than 85%. These findings suggest that early systolic cardiac deterioration should be considered as a cause of exercise impairment in patients with HCM.

Funding Acknowledgement

Type of funding source: None

Umbilical cord extracts improve diabetic abnormalities in bone marrow-derived mesenchymal stem cells and increase their therapeutic effects on diabetic nephropathy

Bone marrow-derived mesenchymal stem cells (BM-MSC) has been applied as the most valuable source of autologous cell transplantation for various diseases including diabetic complications. However, hyperglycemia may cause abnormalities in intrinsic BM-MSC which might lose sufficient therapeutic effects in diabetic patients. We demonstrated the functional abnormalities in BM-MSC derived from both type 1 and type 2 diabetes models in vitro, which resulted in loss of therapeutic effects in vivo in diabetic nephropathy (DN). Then, we developed a novel method to improve abnormalities in BM-MSC using human umbilical cord extracts, namely Wharton’s jelly extract supernatant (WJs). WJs is a cocktail of growth factors, extracellular matrixes and exosomes, which ameliorates proliferative capacity, motility, mitochondrial degeneration, endoplasmic reticular functions and exosome secretions in both type 1 and type 2 diabetes-derived BM-MSC (DM-MSC). Exosomes contained in WJs were a key factor for this activation, which exerted similar effects to complete WJs. DM-MSC activated by WJs ameliorated renal injury in both type 1 and type 2 DN. In this study, we developed a novel activating method using WJs to significantly increase the therapeutic effect of BM-MSC, which may allow effective autologous cell transplantation.

Superlinear and sublinear urban scaling in geographical networks modeling cities

Using a geographical scale-free network to describe relations between people in a city, we explain both superlinear and sublinear allometric scaling of urban indicators that quantify activities or performances of the city. The urban indicator Y(N) of a city with the population size N is analytically calculated by summing up all individual activities produced by person-to-person relationships. Our results show that the urban indicator scales superlinearly with the population, namely, Y(N)∝N(β) with β>1, if Y(N) represents a creative productivity and the indicator scales sublinearly (β<1) if Y(N) is related to the degree of infrastructure development. These results coincide with allometric scaling observed in real-world urban indicators. We also show how the scaling exponent β depends on the strength of the geographical constraint in the network formation.

Phosphorus flame retardants in indoor dust and their relation to asthma and allergies of inhabitants

Organophosphate esters are used as additives in flame retardants and plasticizers, and they are ubiquitous in the indoor environment. Phosphorus flame retardants (PFRs) are present in residential dust, but few epidemiological studies have assessed their impact on human health. We measured the levels of 11 PFRs in indoor floor dust and multi-surface dust in 182 single-family dwellings in Japan. We evaluated their correlations with asthma and allergies of the inhabitants. Tris(2-butoxyethyl) phosphate was detected in all samples (median value: 580 μg/g in floor dust, 111 μg/g in multi-surface dust). Tris(2-chloro-iso-propyl) phosphate (TCIPP) was detected at 8.69 μg/g in floor dust and 25.8 μg/g in multi-surface dust. After adjustment for potential confounders, significant associations were found between the prevalence of atopic dermatitis and the presence of TCIPP and tris(1,3-dichloro-2-propyl) phosphate in floor dust [per log10 -unit, odds ratio (OR): 2.43 and 1.84, respectively]. Tributyl phosphate was significantly associated with the prevalence of asthma (OR: 2.85 in floor dust, 5.34 in multi-surface dust) and allergic rhinitis (OR: 2.55 in multi-surface dust). PFR levels in Japan were high compared with values reported previously for Europe, Asia-Pacific, and the USA. Higher levels of PFRs in house dust were related to the inhabitants' health status.

Relationship between cytokine single nucleotide polymorphisms and sarcoidosis among Japanese subjects

Several susceptibility genes for sarcoidosis have been identified, but their relationship to the clinical state and prognosis remains to be elucidated. The aim of this study was to elucidate the relationship between sarcoidosis and five single nucleotide polymorphisms (SNPs) of three cytokines expected to play an important role in the inflammatory response. A case-control study was performed with 208 unrelated patients who met the diagnostic criteria for sarcoidosis used in Japan since 2006, and 328 control subjects. Five SNPs were analyzed: interleukin (IL)-10-819T/C (rs1800871), IL-10-592A/C(rs1800872), IL-6-634C/G (rs1800796), tumor necrosis factor-alpha (TNF-alpha)-857C/T (rs1799724), and TNF-alpha -1031T/C (rs1799964). No significant differences in SNPs were observed between the total sarcoidosis and control groups. However, the prevalence of rs1800871 and rs1800872 polymorphisms differed significantly in the sarcoidosis with eye involvement group compared with the control group [rs1800871 TT (vs. TC + CC): OR = 1.67, P = 0.034; rs1800872 AA (vs. AC + CC): OR = 1.66, P = 0.036]. Analyzing the cardiac involvement group, the prevalence of the rs1799724 polymorphism was significantly different from that of the control group [rs1799724 TT (vs. CC + CT): OR = 6.01. P = 0.006]. We concluded that the rs1799724 C/T polymorphism may affect susceptibility to cardiac sarcoidosis, while the rs1800871 T/C and rs1800872A/C polymorphisms may affect susceptibility to sarcoidosis with eye involvement.

Expansion of human autologous cytotoxic T lymphocytes on fixed target tumor cells

Human tumor specific cytotoxic T lymphocytes (CTL) were expanded on formalin-fixed autologous target tumor cells derived from glioblastoma multiforme. Growth response of the CTL restimulated with the fixed target cells was larger than those with live target cells. The results suggest that formalin-fixed tumor cells will be stable sources of tumor antigen for efficient autologous CTL expansion and be useful for adoptive immunotherapy of tumors.

Updated overall survival results from a randomized phase III trial comparing gefitinib with carboplatin-paclitaxel for chemo-naïve non-small cell lung cancer with sensitive EGFR gene mutations (NEJ002)

BACKGROUND

NEJ002 study, comparing gefitinib with carboplatin (CBDCA) and paclitaxel (PTX; Taxol) as the first-line treatment for advanced non-small cell lung cancer (NSCLC) harboring an epidermal growth factor receptor (EGFR) mutation, previously reported superiority of gefitinib over CBDCA/PTX on progression-free survival (PFS). Subsequent analysis was carried out mainly regarding overall survival (OS).

MATERIALS AND METHODS

For all 228 patients in NEJ002, survival data were updated in December, 2010. Detailed information regarding subsequent chemotherapy after the protocol treatment was also assessed retrospectively and the impact of some key drugs on OS was evaluated.

RESULTS

The median survival time (MST) was 27.7 months for the gefitinib group, and was 26.6 months for the CBDCA/PTX group (HR, 0.887; P=0.483). The OS of patients who received platinum throughout their treatment (n=186) was not statistically different from that of patients who never received platinum (n=40). The MST of patients treated with gefitinib, platinum, and pemetrexed (PEM) or docetaxel (DOC, Taxotere; n=76) was around 3 years.

CONCLUSIONS

No significant difference in OS was observed between gefitinib and CBDCA/PTX in the NEJ002 study, probably due to a high crossover use of gefitinib in the CBDCA/PTX group. Considering the many benefits and the risk of missing an opportunity to use the most effective agent for EGFR-mutated NSCLC, the first-line gefitinib is strongly recommended.

Relationships between mite allergen levels, mold concentrations, and sick building syndrome symptoms in newly built dwellings in Japan

This study investigated the possible relationships between exposures to mite allergen and airborne fungi with sick building syndrome (SBS) symptoms for residents living in newly built dwellings. We randomly sampled 5709 newly built dwellings in six prefectures from northern to southern Japan. A total of 1479 residents in 425 households participated in the study by completing questionnaire surveys and agreeing to environmental monitoring for mite allergen (Der 1), airborne fungi, aldehydes, and volatile organic compounds. Stepwise logistic regression analyses adjusted for confounders were used to obtain odds ratios (OR) of mite allergen and fungi for SBS symptoms. Der 1 had a significantly high OR for nose symptoms. Rhodotorula had a significantly high OR for any symptoms, and Aspergillus had significantly high OR for eye symptoms. However, the total colony-forming units had a significantly low OR for throat and respiratory symptoms. Eurotium had a significantly low OR for skin symptoms. In conclusion, dust-mite allergen levels and indoor airborne Rhodotorula and Aspergillus concentrations may result in SBS symptoms in newly built dwellings.

PRACTICAL IMPLICATIONS

Various factors can cause sick building syndrome symptoms. This study focused on biologic factors such as dust-mite allergen and airborne fungi in newly built dwellings in Japan. Dust-mite allergen levels were significantly associated with higher rates of nose symptoms, airborne Rhodotorula concentrations were significantly associated with higher rates of any symptoms, and Aspergillus concentrations were significantly associated with higher rates of eye symptoms. Measures should be taken to reduce mite allergen levels and fungal concentrations in these dwellings.

Association between indoor exposure to semi-volatile organic compounds and building-related symptoms among the occupants of residential dwellings

The aim of this study was to evaluate the levels of semi-volatile compounds (SVOCs) in residential detached houses in Sapporo, Japan, and whether exposure to these SVOCs was associated with the development of building-related symptoms named 'sick house syndrome' (SHS). The definition of SHS is fundamentally the same as that of the sick building syndrome (SBS). The presence of symptoms of SHS was evaluated using a validated self-administered questionnaire. Surveys and samplings of air and house dust in 41 dwellings were performed from October 2006 to January 2007, and 134 occupants responded to questionnaires. Samples were analyzed to quantify the concentrations of eight plasticizers, eleven phosphate triester flame retardants, two alkyl phenols used as anti-oxidants, and one organochlorine synergist called s-421, by gas chromatography-mass spectrometry and gas chromatography-flame photometry. The compounds frequently detected were di-n-butylphthalate, di(2-ethylhexyl)phthalate (DEHP), and dibutylhydroxytoluene in air, and DEHP and tris(2-butoxyethyl)phosphate (TBEP) in dust. Tributylphosphate was strongly and directly associated with mucosal symptoms of SHS; s-421 was also directly associated with mucosal symptoms of SHS. On the contrary, some chemicals such as diethylphthalate and TBEP were inversely associated with SHS. In future studies, we plan to assess these associations in a larger population.

PRACTICAL IMPLICATIONS

This study suggests that it may be possible to reduce building-related symptoms by altering exposure to certain SVOCs, such as tributylphosphate commonly found in ceiling and wall coverings and s-421 used as a synergist for pyrethroids. The association between SHS and s-421 suggested that use of pyrethroid insecticides could elicit symptoms of SHS. However, further studies are necessary to test the associations observed in the present study and to examine whether the SVOCs associated with symptoms are causative agents or simply surrogates for some other factor that is causing the symptoms.

Randomized phase II trial of weekly paclitaxel combined with carboplatin versus standard paclitaxel combined with carboplatin for elderly patients with advanced non-small-cell lung cancer

BACKGROUND

The optimal platinum doublet regimen in elderly patients with non-small-cell lung cancer (NSCLC) is still uncertain. We conducted a randomized phase II study to compare the efficacy and safety of weekly paclitaxel combined with carboplatin with those of the standard schedule.

PATIENTS AND METHODS

Elderly patients (age > or =70 years) with advanced NSCLC were randomly assigned to either the weekly arm {70 mg/m(2) paclitaxel on days 1, 8, and 15 and carboplatin [area under the curve (AUC) = 6] on day 1} or the standard arm [200 mg/m(2) paclitaxel and carboplatin (AUC = 6) on day 1]. The primary end point was the overall response rate (ORR).

RESULTS

Eighty-two patients were enrolled. The ORR and median progression-free survival were 55% and 6.0 months for the weekly arm and 53% and 5.6 months for the standard arm. Grade 3/4 neutropenia and peripheral neuropathy were observed in 41% and 0% of the patients in the weekly arm and in 88% and 25% in the standard arm, respectively.

CONCLUSIONS

This is the first randomized study that compares the platinum doublet designed specifically for the elderly. Regarding the safety, the weekly regimen was less toxic than the standard regimen and seems to be preferable for elderly patients with advanced NSCLC.

Regional differences in residential environments and the association of dwellings and residential factors with the sick house syndrome: a nationwide cross-sectional questionnaire study in Japan

This study was conducted to clarify regional differences in residential factors and the association of those factors with dwellings having sick house syndrome (SHS) problems. The survey was conducted in six areas of northern and southern Japan. In terms of regional differences, dampness was not as severe in the dwellings in Sapporo as compared with that in areas in the south. SHS was defined using five categories of nasal, throat and respiratory, skin and general symptoms, which appeared frequently or not frequently and improved upon leaving the home. The dampness index was estimated by the sum of the presence of several indicators: condensation on the window panes and/or wall, visible mold growth, moldy odor, slow-drying wet towels in the bathroom, and water leakage. The dwellings where inhabitants showed any symptoms of SHS comprised 3.7% of all surveyed dwellings. We found significant associations between SHS and dampness index, odors, and stuffiness of the air. For dampness, the adjusted odds ratio (OR) increased with increased dampness index, adjusting for the age of the house, pets indoors, stuffiness of the air, and odors. These results showed an increased risk when several dampness indicators appeared simultaneously.

PRACTICAL IMPLICATIONS

To evaluate the associations of residential environments and Sick House Syndrome (SHS), this cross-sectional questionnaire study was conducted on 2297 dwellings in six areas in Japan from 2003 to 2004. The dwellings where inhabitants showed any of nasal, throat and respiratory, skin and general symptoms comprised 3.7% of all surveyed dwellings, and an increased risk for SHS was found when several dampness indicators, 'condensation', 'visible mold growth', 'moldy odor', 'slow drying wet towels in the bathroom' and 'water leakage', appeared simultaneously.

Feasibility and efficacy of gemcitabine and carboplatin neoadjuvant chemotherapy in muscle-invasive bladder cancer

e16100

Background: The neoadjuvant M-VAC followed by radical cystectomy for muscle-invasive bladder cancer has improved survival compared to radical cystectomy alone. Nevertheless, M-VAC has been associated with severe toxicity. The objective of this retrospective study was to evaluate the objective response rate, the impact on overall survival, disease-free survival, disease-free survival and toxicity adverse events of gemcitabine and carboplatin (GC) neoadjuvant chemotherapy in patients with locally advanced bladder cancer. Methods: We reviewed the clinical and pathological data of 140 patients who underwent radical cystectomy and bilateral pelvic lymphadenectomy for T2N0M0 to T4aN0M0 bladder cancer at our institution between January 2001 and August 2008. Seventy patients were treated with neoadjuvant GC followed by cystectomy between March 2005 and August 2008 (GC group), and 70 patients were treated with cystectomy alone between January 2001 and May 2007 (cystectomy alone group). In the GC group, the patients received 2 courses of GC therapy consisted of 800mg/m2 gemcitabine on days 1, 8, and 15 and carboplatin (AUC 4) on day 2. The primary endpoint was the objective response rate, and the secondary endpoints were overall survival, cancer-specific survival, disease free survival, and toxicity. Results: Fifteen patients (23.8%) had a complete response and 26 patients (41.3%) had a partial response in the GC group. At a mean follow-up period of 26.7 months, the overall survival was 85.0% in the GC group and 47.8% in the cystectomy alone group (p = 0.003). The cancer-specific survival was 78.4% in the GC group and 44.6% in the cystectomy alone group (p = 0.0018). The disease-free survival was 82.9% in the GC group and 35.7% in the cystectomy alone group (p = 0.0001). Hematologic toxicities were the main adverse events. Grade 3/4 neutropenia occurred in 26 patients (37.1%) and thrombocytopenia in 15 (21.4%). There was no grade 3/4 gastrointestinal toxicity and no renal function abnormalities. Conclusions: Although this is not a randomized study, the GC neoadjuvant therapy followed by radical cystectomy is feasible and may be associated with improved survival among patients with muscle-invasive bladder cancer. A randomized trial is warranted.

No significant financial relationships to disclose.

First-line gefitinib versus first-line chemotherapy by carboplatin (CBDCA) plus paclitaxel (TXL) in non-small cell lung cancer (NSCLC) patients (pts) with EGFR mutations: A phase III study (002) by North East Japan Gefitinib Study Group

8016

Background: Based on our promising results of phase II studies estimating gefitinib in NSCLC pts with sensitive EGFR mutations (JCO 2006, BJC 2006), this multicenter phase III trial compared progression free survival (PFS) of first line gefitinib versus first line chemotherapy in EGFR mutation positive pts with stage IIIB/IV NSCLC. Per protocol, an analysis for safety except response, PFS and overall survival were estimated. Methods: PNA-LNA PCR clamp test, which had been developed and validated by us (Cancer Res 2005, Cancer Sci 2007), was employed to detect EGFR mutations using cytological samples or histological samples. Pts having sensitive EGFR mutations, measurable site(s), ECOG PS 0–1, age of 20–75 years, and no prior chemotherapy were randomized (1:1 ratio; balanced for institution, sex, and stage) to receive Arm A: gefitinb (250 mg/ day) orally, or Arms B: CBDCA AUC 6 and TXL 200mg/m2 in 21-day cycles until disease progression. The primary endpoint was PFS, and the sample size was calculated to be 320 in total (alpha=5%, power=80%) to confirm the superiority of Arm A (hazard ratio = 0.69). Results: From April 2006 to July 2008, 155 pts were enrolled (Arm A=80; Arm B=75). Their characteristics were well balanced between arms: median age=65 years; 64% female; 77% Stage IV; 93% adenocarcinoma, 61% non-smoker. There were several differences in toxicities between Arm A and Arm B (grade 4 neutropenia: 1% vs. 29%, grade 3–4 liver dysfunction: 24% vs. 1%, grade 3 neuropathy: 0% vs. 5%, respectively, p<0.01). But these were tolerable in both arms. Furthermore, there were no interstitial lung disease and no toxic deaths in both arms. Analyzing both arms together, preliminary response rate and PFS of the 155 pts were 53.7% and 6.5 mos, respectively. Conclusions: This is the first prospective study to compare first line gefitinib with first line chemotherapy for advanced NSCLC pts harboring EGFR mutations. Due to acceptable toxicities, the independent safety committee decided to continue this study further. At the end of 2008, 200 pts have been entered to this study, and, per protocol, an interim analysis to investigate PFS will be performed in May 2009.

No significant financial relationships to disclose.

Sensorless control for a sophisticated artificial myocardial contraction by using shape memory alloy fibre

The authors have been developing an artificial myocardium, which is capable of supporting natural contractile function from the outside of the ventricle. The system was originally designed by using sophisticated covalent shape memory alloy fibres, and the surface did not implicate blood compatibility. The purpose of our study on the development of artificial myocardium was to achieve the assistance of myocardial functional reproduction by the integrative small mechanical elements without sensors, so that the effective circulatory support could be accomplished. In this study, the authors fabricated the prototype artificial myocardial assist unit composed of the sophisticated shape memory alloy fibre (Biometal), the diameter of which was 100 microns, and examined the mechanical response by using pulse width modulation (PWM) control method in each unit. Prior to the evaluation of dynamic characteristics, the relationship between strain and electric resistance and also the initial response of each unit were obtained. The component for the PWM control was designed in order to regulate the myocardial contractile function, which consisted of an originally-designed RISC microcomputer with the input of displacement, and its output signal was controlled by pulse wave modulation method. As a result, the optimal PWM parameters were confirmed and the fibrous displacement was successfully regulated under the different heat transfer conditions simulating internal body temperature as well as bias tensile loading. Then it was indicated that this control theory might be applied for more sophisticated ventricular passive or active restraint by the artificial myocardium on physiological demand.

Assessment of synchronization measures for effective ventricular support by using the shape memory alloy fibred artificial myocardium in goats

Thromboembolic and haemorrhagic complications are the primary causes of mortality and morbidity in patients with artificial hearts, which are known to be induced by the interactions between blood flow and artificial material surfaces. The authors have been developing a new mechanical artificial myocardial assist device by using a sophisticated shape memory alloy fibre in order to achieve the mechanical cardiac support from outside of the heart without a direct blood contacting surface. The original material employed as the actuator of artificial myocardial assist devices was 100um fibred-shaped, which was composed of covalent and metallic bonding structure and designed to generate 4-7 % shortening by Joule heating induced by the electric current input. In this study, we focused on the synchronization of the actuator with native cardiac function, and the phase delay parameter was examined in animal experiments using Saanen goats. Total weight of the device including the actuator was around 150g, and the electric power was supplied transcutaneously. The device could be successfully installed into thoracic cavity, which was able to be girdling the left ventricle. The contraction of the device could be controlled by the originally designed microcomputer. The mechanical contraction signal input had been transmitted with the phase delay of 50-200 msec after the R-wave of ECG, and hemodynamic changes were investigated. Cardiac output and systolic left ventricular pressure were elevated with 20% delay of cardiac cycle by 27% and 7%, respectively, although there was smaller difference under the condition of the delay of over 30%. Therefore, it was suggested that the synchronization measures should be examined in order to achieve sophisticated ventricular passive/active support on physiological demand.

Fractal dimension of 40 MHz intravascular ultrasound radio frequency signals

OBJECTIVE

Fully automatic tissue characterization in intravascular ultrasound systems is still a challenge for the researchers. The present work aims to evaluate the feasibility of using the Higuchi fractal dimension of intravascular ultrasound radio frequency signals as a feature for tissue characterization.

METHODS

Fractal dimension images are generated based on the radio frequency signals obtained using mechanically rotating 40 MHz intravascular ultrasound catheter (Atlantis SR Plus, Boston Scientific, USA) and compared with the corresponding correlation images.

CONCLUSION

An inverse relation between the fractal dimension images and the correlation images was revealed indicating that the hard or slow moving tissues in the correlation image usually have low fractal dimension and vice-versa. Thus, the present study suggests that fractal dimension images may be used as a feature for intravascular ultrasound tissue characterization and present better resolution then the correlation images.

Detection and quantification of calcifications in intravascular ultrasound images by automatic thresholding

An innovative application of automatic thresholding is used for the detection of calcification regions in intravascular ultrasound images. A priori knowledge of the acoustic shadow that usually accompanies calcification regions is used to discriminate these from other bright regions in the image. A method for the calculation of the angle of calcification has also been developed. The proposed algorithms are applied to in-vivo images obtained from left anterior descending coronary arteries during percutaneous transluminal coronary angioplasty (n = 14). The resulting specificity is 72% and the sensitivity 84%. The receiver operating characteristic curve, the area under the curve being equal to 0.91, is plotted to evaluate the algorithm performance.

Targeted delivery of NK4 to multiple lung tumors by bone marrow-derived mesenchymal stem cells

Most advanced solid tumors metastasize to different organs. However, no gene therapy effective for multiple tumors has yet been developed. Since a unique characteristic of bone marrow-derived mesenchymal stem cells (MSCs) is that they migrate to tumor tissues, we wanted to determine whether MSCs could serve as a vehicle of gene therapy for targeting multiple tumors. First, we confirmed that mouse MSCs preferentially migrate to multiple tumors of the lung in the Colon-26 (C-26) lung metastasis model. Next, MSCs were efficiently transduced with NK4, an antagonist of hepatocyte growth factor (HGF), by an adenoviral vector with an RGD motif. MSCs expressing NK4 (NK4-MSCs) strongly inhibited development of lung metastases in the C-26 lung metastasis model after systemic administration via a tail vein. Treatment with NK4-MSCs significantly prolonged survival of the C-26-tumor-bearing mice by inhibiting tumor-associated angiogenesis and lymphangiogenesis and inducing apoptosis of the tumor cells. MSC-based gene therapy did not induce the severe adverse effects induced by conventional adenoviral vectors. These results indicate that MSCs can serve as a vehicle of gene therapy for targeting multiple lung metastatic tumors.

Development of an Artificial Myocardium using a Covalent Shape-memory Alloy Fiber and its Cardiovascular Diagnostic Response

The authors have been developing a newly-designed totally-implantable artificial myocardium using a covalent shape-memory alloy fibre (Biometal&#174;, Toki Corporation), which is attached onto the ventricular wall and is also capable of supporting the natural ventricular contraction. This mechanical system consists of a contraction assistive device, which is made of Ti-Ni alloy. And the phenomenon of the martensitic transformation of the alloy was employed to achieve the physiologic motion of the device. The diameter of the alloy wire could be selected from 45 to 250&#956;m. In this study, the basic characteristics of the fiber of 150&#956;m was examined to design the sophisticated mechano-electric myocardium. The stress generated by the fiber was 400gf under the pulsatile driving condition (0.4W, 1Hz). Therefore it was indicated that the effective assistance might be achieved by using the Biometal shape-memory alloy fiber.