Mania occurring during systemic lupus erythematosus relapse and its amelioration on clinical and neuroimaging follow-up

Psychiatric manifestations of systemic lupus erythematosus (SLE) that are commonly preceded by organic syndromes include confusional states, anxiety disorder, cognitive dysfunction, mood disorder and psychosis. A 35-year-old woman was admitted to hospital with a relapse of SLE. Laboratory data were exacerbated, with some physical symptoms, and her primary psychiatric symptom was mania. The symptoms were reduced by treatment with prednisolone, methylprednisolone and aripiprazole. Magnetic resonance imaging and single-photon emission computed tomography (SPECT) using 123I-IMP was then performed and analyzed with three-dimensional stereotactic surface projection. This case emphasizes that SLE can commence with organic syndromes and relapse with predominantly psychiatric symptoms, and that the treatment efficacy may be confirmed using a follow-up of SPECT.

Synthesis of monolayer platinum nanosheets

Platinum (Pt) nanosheets were developed by exfoliating layered platinum oxide. Moreover, we succeeded in synthesizing monolayer Pt nanosheets for the first time by adjusting the conditions for reduction. Monolayer Pt nanosheets were highly active in oxygen reduction reaction.

Association between visual message and health knowledge in a 4-month follow-up study at worksites

OBJECTIVES

This study evaluated a simple workplace intervention that used visual messages to create awareness of two highly specific recommendations for good health.

METHODS

Four worksites were recruited in Iwakuni, Japan. The 4-month intervention used three promotional media-A2-size posters, A4-size flyers and displays on the company intranet. The visual messages were designed with silhouettes, pictograms and slogans. Knowledge acquisition concerning the two recommendations (daily vegetable intake of 350 g and 23 exercises weekly) was evaluated using questionnaires. In addition, recall of media and attitudes toward health behavior were assessed.

RESULTS

Of the 2,322 workers, 827 responded to both the pre- and postintervention surveys. Correct responses at the four worksites increased from initial levels of 36-48% to 38-73% for the vegetable intake questions and from 7-14% to 7-59% for the physical activity questions. Media recall results were 35-73% for posters, 20-43% for flyers and 19% for intranet. The workers who recalled the posters and flyers had more correct answers on knowledge questions than those who did not recall the posters or flyers (p<0.01). In multivariate analyses, seeing the visual messages was associated with a positive change in response to physical activity questions (odds ratio=1.49-2.03), and the number of media recalled was also significant (odds ratio=1.16-1.17).

CONCLUSIONS

Interventions with a combination of media and simple visual messages should be considered for health promotion among general populations at worksites.

Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection

BACKGROUND AND STUDY AIM

Esophageal perforation caused by endoscopic submucosal dissection (ESD) induces serious pneumomediastinum. In the absence of endoscopically detected perforation, postprocedural pneumomediastinum may occur. The aim of this study was to evaluate the association between the clinical factors/courses and pneumomediastinum revealed by chest computed tomography (CT) with special reference to an exposed muscle layer during esophageal ESD.

PATIENTS AND METHODS

A total of 58 patients undergoing ESD for esophageal neoplasms between February 2003 and June 2007 also underwent both chest radiography and chest CT within 1 hour after ESD. We studied the association between findings on CT scan and tumor-related and technical factors of esophageal ESD by uni- and multivariate analyses. We also analyzed the clinical factors/courses experienced by all patients.

RESULTS

Pneumomediastinum was detected in 18 / 58 patients (31 %) by chest CT compared with only 1 / 58 patients (1.7 %) by chest radiography. ESD-induced exposure of the muscular layer (32 patients) was the only significant factor for pneumomediastinum (18 / 32; P < 0.0001). Clinical factors such as fever, white blood cell count, and C-reactive protein were significantly increased in the group positive for both endoscopically exposed muscular layer and pneumomediastinum (+/+, n = 18) compared with the (-/-) group (n = 26) in the early phase (day 1) after ESD. However, these factors did not affect the length of the fasting period or the length of hospital stay.

CONCLUSIONS

In esophageal ESD, pneumomediastinum detected by chest CT only does not cause clinically significant complication. Endoscopic muscle exposure during ESD is a significant risk factor for pneumomediastinum, which causes mild inflammation in the early post-ESD phase.

Long-term prognosis of late spontaneous reperfusion after failed thrombolysis for acute myocardial infarction

BACKGROUND

Early reperfusion improves left ventricular (LV) function and survival after acute myocardial infarction (MI). Thrombolytic therapy achieves early patency of the infarct artery in about two-thirds of patients. In nearly half of the remaining patients, in whom early reperfusion was not achieved with thrombolytic therapy, the infarct artery might reopen by the time of predischarge angiography. However, the impact of such late spontaneous reperfusion after failed thrombolytic therapy on LV function and long-term survival remained unclear.

HYPOTHESIS

This study was undertaken to assess implication of late spontaneous reperfusion after failed thrombolytic therapy on LV function and long-term survival after acute MI.

METHODS

The study consisted of 198 patients with anterior acute MI who underwent thrombolytic therapy and predischarge angiography: 160 patients with infarct artery patent early and late after therapy (persistent patency), 17 patients with infarct artery occluded early after therapy but patent at predischarge angiography (late spontaneous reperfusion), and 21 patients with infarct artery occluded early and late after therapy (persistent occlusion).

RESULTS

Persistent patency was associated with enhanced improvement in LV ejection fraction (7.7 +/- 11.8%) compared with late spontaneous reperfusion (0.0 +/- 9.6%, p = 0.03) and persistent occlusion (-1.4 +/- 9.7%, p = 0.003). Persistent patency was associated with better long-term survival than with late spontaneous reperfusion (p < 0.001) and persistent occlusion (p < 0.001). Multivariate analysis comparing persistent patency and late spontaneous reperfusion showed that early reperfusion was an independent predictor of long-term survival.

CONCLUSION

Late spontaneous reperfusion after failed thrombolytic therapy was associated with poor LV function and long-term survival, emphasizing the importance of early reperfusion.

Visualization of cervical nerve roots and their distal nerve fibers by diffusion-weighted scanning using parallel imaging

PURPOSE

To report a technique developed for visualizing cervical nerve roots and distal nerve fibers using diffusion-weighted magnetic resonance imaging employing parallel imaging.

MATERIAL AND METHODS

We performed maximum intensity projection for a stack of isotropic axial diffusion-weighted images obtained with parallel imaging applying a motion-probing gradient in six directions with a b-value of 500 s/mm2 in a preliminary series of 13 subjects.

RESULTS

This method worked well for visualizing the spinal cord and most of the nerve roots, the dorsal root ganglia, and proximal peripheral nerves.

CONCLUSION

Although the technique remains limited in depicting the brachial plexus and distal nerves, the ability to visualize the proximal peripheral nervous system at the cervical level is promising.

Changes in the axonal membrane potential and Ca2+ concentration associated with peripheral nerve grafting after spinal cord injury

We performed peripheral nerve allografting in rats with spinal cord injury, and measured motor function and axonal membrane potential as well as Ca(2+) concentration of the nerve grafting spinal cord area by using a behavior observation system and a confocal laser-scanning microscope, respectively. In our experiments, we produced a model of peripheral nerve grafting after spinal cord injury by peripheral nerve allografting (sciatic nerve) in rats with spinal cord injury (thoracic cord hemisection). The group with spinal cord injury that underwent peripheral nerve grafting showed improvement in motor function, a significant increase in the axonal action potential, and a slight increase in the Ca(2+) concentration compared with the group that did not undergo nerve grafting.

Occupational health nurses' participation in health committee surveyed in Yamaguchi prefecture, Japan

This survey was conducted to know the present conditions of occupational health nurses (OHNs) activity related to health committees (HCs) in Japan. Questionnaires that included items related to duties of the OH physician (OHP), those of the OHN, and their mutual duties within the HC, were mailed to 41 companies employing OHNs and questionnaires from 18 companies were analyzed. Comparison of the frequency of OHN attendance at Health Committee Meetings (HCMs) revealed that 33.3% of OHNs attended the HCs when their companies employed full-time OHPs and 83.3% attended when their companies employed part-time OHPs. In a question about the OHN's opportunity to deliver a speech, give a report or make a presentation at their HCMs, 16.7% of OHNs in companies with full-time OHPs and 66.7% of OHNs in companies with part-time OHPs reported they had such opportunity. In companies with part-time OHPs, 50.0% of the OHNs reported that they were asked for their opinions at the HCMs, but OHNs at companies employing full-time OHPs were not asked for their opinions. It was considered that in the future, OHNs, particularly those working with a part-time OHP, will have an important role in the HC and developing OH services for their companies.

Binding evaluation of the combination between the superconductor and matrix by ultrasonic spectra

Combination of the superconductor and high conductive normal metal is now indispensable in the practical use of superconducting magnet. And the binding property of both materials is one of the key points whether superconductive characteristics are fully attained or the current fails prematurely in the practical magnet. But this binding evaluation is not so easy, because even in the mechanically well-jointed conductor, it often appears poor in electric and magnetic joint in cryogenic temperature. Since we have examined and reported fundamental AE properties of superconductor from UI-91, UI-93, UI-95, and UI-97, we have found the simple but important discovery for getting new information about the binding evaluation. Here we report a new technique for evaluating these bindings by observing ultrasonic spectra when a normal transition is propagated along the superconductor. We have discovered that a good contacting conductor has an emission of this sound with sharp resonating frequency peak or peaks at around the highest spectrum area; from 0.5 to 1.0 MHz. Our interpretation of the evaluations are so simple that we can say that binding degrees are best, good or bad, according to the resonating Q-value at around the highest spectrum of the ultrasonic sound.

Accumulation of beta-catenin in the cytoplasm and the nuclei during the early hepatic tumorigenesis

Hepatocellular carcinomas (HCCs) are thought to develop as well-differentiated tumors and progress to less-differentiated tumors. However, the genetic changes underlying the development and progression of HCCs are not well understood. Recent studies have shown frequent beta-catenin gene activation in HCCs by somatic alterations involving exon 3, resulting in the activation of the Wnt/Wingless signal transduction pathway. However, the exact process in which activation of Wnt/Wingless signal transduction pathway occurs during hepatic tumorigenesis remains to be elucidated. The aim of the present study was to investigate at what stage of hepatocellular tumorigenesis this pathway was activated. Altered expression of beta-catenin was investigated immunohistochemically with special reference to the grade of histological differentiation in 41 HCCs and eight dysplastic nodules. Mutational analysis of the beta-catenin gene with single-strand conformation polymorphism method and polymerase chain reaction amplification was related with the expression of this protein. beta-Catenin was expressed in the cytoplasm and the nuclei in three cases among eight dysplastic nodules, in four cases among 20 well differentiated HCCs, in five cases among 15 moderately differentiated HCCs, and one case among six poorly differentiated HCCs, respectively. Expression of beta-catenin in the cytoplasm and the nuclei was associated in one case with mutation and two cases without mutation for beta-catenin gene among 11 screened HCCs. It was concluded that beta-catenin was accumulated in the cytoplasm and the nuclei in pre-cancerous lesions of the liver and might contribute, at least in part, to hepatic tumorigenesis.

Familial Del(18p) syndrome

We report on sibs and their mother, all with del(18p). The propositus, an 11-month-old, had developmental delay, round face, hypertelorism, large ears, broad nasal bridge, upturned nostrils, micrognathia, a high palate, redundant skin around the neck, micropenis, and cryptorchidism. The elder sister, a two and 7/12-year-old, had round face, hypertelorism, broad nasal bridge, narrow and high palate, redundant skin around the neck, short fingers, and hypoplastic genitalia. Their mother had microcephaly, hypertelorism, prominent columella, broad nasal bridge, wide mouth, high palate, malaligned teeth, and clinodactyly of the fifth fingers. Serial photographs of the mother showed that the characteristic round face in infancy changed to long face with age. The present report suggests that the mother with del(18p) may be fertile, and proper genetic counseling and long follow-up is necessary for the patient with del(18p) syndrome.

Bartonella infection associated with systemic juvenile rheumatoid arthritis

A 4-year-old girl with systemic juvenile rheumatoid arthritis had Bartonella infection diagnosed serologically. This case suggested that Bartonella (most probably Bartonella henselae) infection may in part be responsible for the development of systemic juvenile rheumatoid arthritis.

The usefulness, indications, and complications of laparoscopy-assisted colectomy in comparison with those of open colectomy for colorectal carcinoma

The technique of laparoscopy-assisted colectomy (LAC) was developed for benign and malignant diseases of the colon and rectum; however, its feasibility and the associated clinical outcome remain unclear. We reviewed 45 patients who underwent LAC (LAC group) and 62 patients who underwent traditional open surgery (Open group) for colorectal carcinoma in our hospital, and compared the clinical data between the two groups in an effort to determine whether LAC is really minimally invasive and if it enhances the quality of life. So that the backgrounds of the patients in both groups were almost the same, we only compared data of patients with colorectal carcinoma of stages 0, I, and II. The duration of surgery in the Open group was significantly shorter for all procedures except sigmoid resection, but the blood loss was not significantly different between any of the procedures except for right colectomy. The time to the first passing of flatus and restarting oral intake, length of hospital stay, and duration of epidural analgesia were significantly shorter in the LAC group. The morbidity and mortality rates in the LAC group were almost the same as those in the Open group at 29.5% and 3.3% versus 22.6% and 1.6%, respectively. However, five major complications of LAC for advanced colorectal carcinomas might be prevented by performing an open procedure. In conclusion, LAC is a safe and minimally invasive surgical technique following which we can expect a faster recovery; however, patients with advanced colorectal carcinomas must be carefully selected for this operation.

Beneficial effect of prodromal angina pectoris is lost in elderly patients with acute myocardial infarction

BACKGROUND

Prodromal angina pectoris occurring shortly before the onset of acute myocardial infarction is associated with a favorable outcome by the mechanism of ischemic preconditioning. Recent experiments have reported that the beneficial effect of ischemic preconditioning are reversed in the aged heart.

METHODS

We studied 990 patients who underwent coronary angiography within 12 hours after the onset of acute myocardial infarction. Patients were divided into 2 groups: those aged <70 years (nonelderly patients, n = 722) and those aged >/=70 years (elderly patients, n = 268). Prodromal angina in the 24 hours before infarction was found in 190 of 722 nonelderly patients and in 66 of 268 elderly patients (26% vs 25%, P =.61).

RESULTS

In nonelderly patients, prodromal angina was associated with lower peak creatine kinase levels (2438 +/- 1939 IU/L vs 2837 +/- 2341 IU/L, P =.04), lower in-hospital mortality rates (3.7% vs 8.8%, P =.02), and better 5-year survival rates (P =. 007). On the contrary, in elderly patients there was no significant difference in peak creatine kinase levels (2427 +/- 2142 IU/L vs 2256 +/- 1551 IU/L, P =.51), in-hospital mortality rate (21.2% vs 17. 4%, P =.49), and 5-year survival rates (P =.47). A multivariate analysis showed that prodromal angina in the 24 hours before infarction was associated with 5-year survival rate in nonelderly patients (odds ratio 0.49, P =.009) but not in elderly patients (odds ratio l.12, P =.65).

CONCLUSIONS

In nonelderly patients, prodromal angina in the 24 hours before infarction was associated with a smaller infarct size and better short- and long-term survival, suggesting a relation to ischemic preconditioning. However, such a beneficial effect was not observed in elderly patients.

Identification of 142 single nucleotide polymorphisms in 41 candidate genes for rheumatoid arthritis in the Japanese population

Single-nucleotide polymorphisms (SNPs) can make an important contribution to our understanding of genetic backgrounds that may influence medical conditions and ethnic diversity. We undertook a systematic survey of genomic DNA for SNPs located not only in coding sequences but also in non-coding regions (e.g., introns and 5' flanking regions) of selected genes. Using DNA samples from 48 Japanese patients with rheumatoid arthritis (RA) as templates, we surveyed 41 genes that represent candidates for RA, screening a total of 104 kb of DNA (30 kb of coding sequences and 74 kb of non-coding DNA). Within this 104 kb of genomic sequences we identified 163 polymorphisms (1 per 638 bases on average), of which 142 were single-nucleotide substitutions and the remainder, insertions or deletions. Of the coding SNPs, 52% were non-synonymous substitutions, and non-conservative amino acid changes were observed in a quarter of those. Sixty-nine polymorphisms showed high frequencies for minor alleles (more than 15%) and 20 revealed low frequencies (<5%). Our results indicated a greater average distance between SNPs than others have reported, but this disparity may reflect the type of genes surveyed and/or the relative ethnic homogeneity of our test population.

Treatment of ulcerative colitis with germinated barley foodstuff feeding: a pilot study

BACKGROUND

Germinated barley foodstuff (GBF) has been shown to attenuate intestinal injury in animal models, largely by increasing luminal short-chain fatty acid production.

AIM

To investigate the safety and efficacy of GBF in the treatment of ulcerative colitis (UC).

METHODS

Ten patients with active UC received 30 g of GBF daily for 4 weeks in an open-label treatment protocol while the baseline anti-inflammatory therapy was continued. The response to treatment was evaluated clinically and endoscopically. Pre- and post-treatment stool concentrations of short-chain fatty acids were measured by gas-liquid chromatography.

RESULTS

Patients showed improvement in their clinical activity index scores, with a significant decrease in the score from 6.9+/-1.4 to 2.8+/-1.5 (mean+/-S.E.M., P < 0.05). The endoscopic index score fell from 6.1+/-2.3 to 3.8+/-2.3 (P < 0.0001). Patients showed an increase in stool butyrate concentrations after GBF treatment (P < 0.05). No side-effects were observed.

CONCLUSIONS

Oral GBF therapy may have a place in management of ulcerative colitis, but controlled studies are needed to demonstrate its efficacy in the treatment of this disorder.

Monoclonal expansion of synoviocytes in rheumatoid arthritis

OBJECTIVE

To examine whether synoviocytes from patients with rheumatoid arthritis (RA) have a stronger growth ability than those from patients with osteoarthritis (OA), and to determine whether these synoviocytes clonally expand in situ.

METHODS

Synovial tissues from 13 RA patients and 4 OA patients were cultured, and their ability to form colonies in soft agarose was examined. RA and OA synoviocytes were also examined in varying concentrations of fetal calf serum (FCS)-containing medium to test the effects of FCS on colony formation. DNA was extracted from clones with colony-forming ability in nonpannus lesions and from synoviocytes in pannus lesions. Restriction fragment length polymorphism (RFLP) analysis was used to examine phosphoglycerate kinase 1 (PGK-1) gene patterns. Production of cytokines by these cells was also assessed.

RESULTS

All 13 RA synoviocytes exhibited colony formation, whereas none of the 4 OA synoviocytes did. This tendency was also seen with all of the concentrations of FCS examined, although growth varied in a dose-dependent manner. In contrast to OA synovial clones, cloned RA synoviocytes obtained from colonies exhibited a partial RFLP PGK-1 gene pattern, suggesting that the clones originated from monoclonal cells. Of note, 3 of 7 noncloned synoviocytes from pannus lesions exhibited a monoclonal pattern. Pannus cells produced high levels of transforming growth factor beta and platelet-derived growth factor.

CONCLUSION

These findings suggest that synoviocytes with a strong growth ability are present in the rheumatoid synovium, and that these cells expand monoclonally, particularly in pannus lesions.

Usefulness of the high-frequency ultrasound probe in pretherapeutic staging of superficial-type colorectal tumors

We evaluated the usefulness of the high-frequency ultrasound probe (HFUP, 20 MHz) to determine the depth of tumor invasion in 45 patients with superficial colorectal tumors. The correct diagnostic rate was 66% (30/45) when the depth of tumor invasion was classified into the following 6 layers: mucosa (m), upper 1/3 (sm1), middle 1/3 (sm2), and lower 1/3 (sm3) areas of the submucosa, muscularis propria (mp), and the subserosa or deeper areas (s). However, when the depth of tumor invasion was evaluated in 3 layers (m-sm1, sm2-sm3, and mp-deeper layer), which is the classification used to select cases for endoscopic mucosal resection, the correct diagnostic rate was 88.9% (40/45). These results suggest that the HFUP is useful to determine the depth of invasion to select treatment for superficial colorectal tumors.

Tumor stage in the proximal colon under conditions of a proximal shift of colorectal cancer with age

BACKGROUND/AIMS

Although the incidence of proximal colon cancer is known to increase with age, the prognosis of proximal colon cancer remains unclear.

METHODOLOGY

One thousand two hundred and five patients with colorectal cancer were analyzed with regard to tumor location, age and Duke's stage.

RESULTS

When Duke's stage was compared with tumor location, an advanced Duke's stage was found more frequently in the proximal colon than in the distal colorectum (p<0.01). In Duke's A colorectal cancer, the incidence of tumors limited to within the submucosal layer decreased from 73.1% in patients under 65 years of age to 60.9% in patients over 65 years of age.

CONCLUSIONS

Since advanced stage cancer was more frequently found in the proximal colon than in the distal colorectum, careful examination for the early detection of proximal colon cancer, particularly in the elderly, is called for.

[Analysis of 18 breast cancer patients with hypercalcemia]

A total of 91 breast cancer patients died of advanced and recurrent breast cancer at the Osaka Teishin Hospital from 1986 to 1996. There were 18 cases (19.8%) among them showing hypercalcemia (serum corrected Ca > or = 11.0 mg/dl). These 18 cases were analyzed to determine the incidence of hypercalcemia and to find a more effective treatment. All these patients had multiple bone metastases during their clinical course, and six patients (33.3%) had pathologic bone fracture just before the occurrence of hypercalcemia. Their common symptoms were general fatigue, gastrointestinal symptoms, renal dysfunction or neurological symptoms. There was no definitive correlation between clinical signs and serum calcium values. Among various therapies, the use of pamidronate disodium (Aredia) in combination with hydration, steroid and calcitonin was found to be the most effective treatment for hypercalcemia. The survival time from the diagnosis of hypercalcemia in the patients undergoing treatment with Aredia was significantly better than without it (p < 0.01). This suggests that Aredia should be effective and useful for advanced breast cancer patients with hypercalcemia.

Ceramic unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee joint

Unicompartmental replacement with a ceramic knee prosthesis was performed in 10 patients with spontaneous osteonecrosis. The follow-up period averaged 42 months, with a range of 24 to 68 months. All of the knees received a Kyocera unicompartmental knee arthroplasty and all patients were evaluated using The Knee Society Clinical Rating System. The mean knee score increased from 50.6 to 90.8 at the last follow-up, showing no deterioration with time. All of the patients showed marked improvement of pain and excellent or good results were obtained in all cases. None of the patients had progressive radiolucency wider than 2 mm at the final follow-up. Ceramic unicompartmental knee arthroplasty is an acceptable treatment for spontaneous osteonecrosis of the knee joint; a satisfactory postoperative range of motion can be achieved, there are few complications, and a high initial success rate.

Clinical implications of cigarette smoking in acute myocardial infarction: acute angiographic findings and long-term prognosis

This study was undertaken to assess whether reperfusion in smokers could be achieved spontaneously or therapeutically and to assess whether favorable outcome in smokers could be sustained for years after infarction. We studied 260 patients with anterior myocardial infarction who underwent coronary angiography and thrombolysis within 24 hours after the onset of chest pain. There were 158 smokers and 102 nonsmokers. Smoking was associated more with men, younger age, and less multivessel disease. On initial angiography, the distribution of Thrombolysis in Myocardial Infarction grade was similar between smokers and nonsmokers. After thrombolysis, Thrombolysis in Myocardial Infarction grade 3 was more frequent in smokers (32% vs 18%; p = 0.004). In-hospital mortality rates were lower (8% vs 18%; p = 0.022) and long-term cardiac survival was better in smokers (5-year survival: 82% vs 70%; p = 0.022). Our data demonstrated that the infarct artery of smokers responded more efficiently to thrombolysis and favorable outcome in smokers was sustained throughout 5 years.

Esophagojejunostomy with manual single layer suturing after a total gastrectomy for gastric cancer

BACKGROUND

We wished to verify the clinical usefulness of manually performed single layer suturing for an esophagojejunostomy after a total gastrectomy versus stapled suturing.

METHODS

We compared retrospectively 24 patients who underwent manual single layer suturing with 38 patients who underwent stapled suturing.

RESULTS

Anastomotic leakage was seen in one patient (4%) with single layer suturing and one patient (3%) with stapled suturing. No anastomotic stenosis was seen in the patients with single layer suturing. There was no difference in the operative time, blood loss, postoperative days for oral intake, or the length of hospital stay between the patients with single layer suturing and those with stapled suturing.

CONCLUSIONS

Manual single layer suturing is considered to be as safe as stapled suturing and is also thought to be clinically useful in reducing anastomotic failure for esophagojejunostomy.

Implications of prodromal angina pectoris in anterior wall acute myocardial infarction: acute angiographic findings and long-term prognosis

OBJECTIVES

This study was undertaken to assess how prodromal angina affects long-term prognosis after acute myocardial infarction.

BACKGROUND

Although it has been reported that prodromal angina occurring shortly before the onset of acute myocardial infarction has protective effects against ischemia, its implication for long-term prognosis remains unclear.

METHODS

We studied consecutive 350 patients with anterior myocardial infarction who underwent coronary angiography within 24 h after the onset of chest pain. Follow-up was achieved for 340 patients (97%).

RESULTS

Eighty-nine patients had one or more episodes of angina within 24 h before infarction. On initial angiography, patients with prodromal angina in the 24 h before infarction had a patent infarct-related artery more frequently than did those without prodromal angina (34% vs. 22%, p = 0.03). Among 213 patients who underwent thrombolytic therapy for an occluded infarct-related artery, reperfusion was more frequently achieved in patients with prodromal angina in the 24 h before infarction (76% vs. 56%, p = 0.01). Prodromal angina in the 24 h before infarction was associated with a lower in-hospital mortality rate (6% vs. 14%, p = 0.02) and better 5-year survival (p = 0.009). There was no significant difference in survival between patients with previous angina at any time (n = 202) and those without. Multivariate analysis showed that prodromal angina in the 24 h before infarction was an independent factor related to 5-year survival after acute myocardial infarction (odds ratio 0.49, p = 0.04).

CONCLUSIONS

Prodromal angina occurring shortly before the onset of infarction, but not previous angina itself, has a beneficial effect on long-term prognosis after infarction, suggesting a relation to ischemic preconditioning.

Directional coronary atherectomy for the treatment of acute myocardial infarction

Directional coronary atherectomy (DCA) was performed after intracoronary thrombolysis in 32 patients with a first acute myocardial infarction. DCA was successful in 31 (97%) of 32 patients. Abrupt closure of the treated segment occurred in one patient but was managed successfully by conventional balloon angioplasty. Repeat angiography was performed in 32 patients before discharge (2.7 +/- 0.7 weeks later) and in 29 patients during the follow-up (4.5 +/- 1.5 months later). No restenosis (stenosis > 50%) occurred before discharge; however restenosis occurred in 12 (41%) of 29 patients during follow-up. The restenosis rate in patients with subintimal resection was significantly higher than in those with intimal resection (78% vs 25%, p < 0.01). These data suggest that DCA in patients with acute myocardial infarction is feasible for persistent early patency of the infarct-related coronary artery, but late restenosis continues to limit success and subintimal resection may increase the restenosis rate during the follow-up.

Effects of various doses of intracoronary verapamil on coronary resistance vessels in humans

To investigate the vasodilatory effect of various doses of intracoronary verapamil on coronary resistance vessels, we studied 13 patients with normal angiograms. A coronary Doppler guide wire was inserted into the left anterior descending coronary artery, and coronary blood flow velocity (CBFV) was measured. Verapamil was injected into the left coronary artery at doses of 0.1 mg, 0.5 mg, 1.0 mg, and 2.0 mg at 10-min intervals. Nitroglycerin was also injected into the same artery to avoid changes in cross-sectional area. As a measure of coronary vascular resistance, coronary vascular resistance index (CVRI) was calculated as the quotient of mean aortic pressure/CBFV. An injection of verapamil produced a dose-dependent increase in CBFV: 79 +/- 38% with 0.1 mg, 131 +/- 56% with 0.5 mg, 143 +/- 46% with 1.0 mg, and 128 +/- 47% with 2.0 mg of verapamil. The percent peak decreases in CVRI were dose dependent: -42 +/- 13% with 0.1 mg, -50 +/- 17% with 0.5 mg, -62 +/- 14% with 1.0 mg, and -60 +/- 9% with 2.0 mg of verapamil. Thus, intracoronary verapamil produces a dose-dependent dilation of coronary resistance vessels, and the optimal effect is produced with an injection of verapamil at a dose of 1.0 mg into the left coronary artery. At this dose, verapamil did not affect atrioventricular conduction.

Usefulness of directional coronary atherectomy in patients with acute anterior myocardial infarction

To assess the usefulness of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI), 139 consecutive patients with anterior wall AMI undergoing successful catheter intervention were studied. The reocclusion rate was significantly lower in the last 70 patients who underwent DCA as aggressively as possible compared with the first 69 patients treated with coronary balloon angioplasty (12.1% vs 3.0%, p <0.05).

Antitumor effect of transcatheter oily chemoembolization for hepatocellular carcinoma assessed by computed tomography: role of iodized oil

The efficacy of transcatheter oily chemoembolization (TOCE) was evaluated in 82 patients with unresectable hepatocellular carcinoma (HCC) by computed tomography more than 6 months after TOCE. A doxorubicin in oil emulsion (DOE) was administered to 42 cases and an epirubicin in oil emulsion (EOE) was administered to 40 cases. No significant differences were found in the patient background characteristics between the DOE-treated group and the EOE-treated group. Tumor regression of more than 50% of the product of two dimensions was observed in 26 DOE-treated cases and in 25 EOE-treated cases at 1 year or more after TOCE. No difference in antitumor effect was observed between DOE and EOE, although a sufficient dose per tumor volume would be required to manifest an antitumor effect on hepatocellular carcinoma.

Appraisal of combination treatment for hepatocellular carcinoma: long-term follow-up and lipiodol-percutaneous ethanol injection therapy

Since 1988, 124 patients with hepatocellular carcinoma were treated in our departments. Among them, 31 cases treated by surgical resection and 30 cases administered a combination therapy (Lipiodol [Laboratoire Guerbet, Villepinte, France]-transcatheter arterial embolization [L-TAE] and lipiodol-percutaneous ethanol injection therapy [L-PEIT]) were analyzed retrospectively. The 1-, 3-, and 5-year survival rates were, respectively, 89.0%, 72.7%, and 63.6% for the surgical resection group and 93.3%, 72.8%, and 42.0% for the combination therapy group. The follow-up results at less than 4 years after the procedures revealed that the survival rate with the combination therapy was slightly better than that with the surgical treatment. However, in the subsequent 4 years, the survival rate of the combination therapy group decreased rapidly. The reasons for this deterioration were local recurrence and/or new primary lesions of hepatocellular carcinoma, mainly due to inappropriate ethanol injection. To achieve adequate and accurate injection of ethanol, a 10% volume of Lipiodol was mixed with the ethanol so that the location of the injected ethanol could be easily confirmed. The effectiveness of L-PEIT was thus confirmed by computed tomography, performed on the following day. Defective Lipiodol accumulation in the tumor and/ or neighboring tissues was able to be corrected by additional ethanol injections. With this L-PEIT technique, the tumor necrosis rate is now improving. Therefore, a better prognosis is expected.

Macrophage cathepsin L, a factor in the erosion of subchondral bone in rheumatoid arthritis

OBJECTIVE

To test the hypothesis that the proteinase cathepsin L is involved in the subchondral bone lesions found in chronic rheumatoid arthritis (RA).

METHODS

The medial tibial plateaus from 4 control cases and 30 patients diagnosed as having end-stage RA were examined immunochemically for cathepsin L.

RESULTS

RA lesions include large groups of mononuclear cells, many of which are rich in cathepsin L. Since these mononuclear cells contained the CD68 glycoprotein and, in the electron microscope, displayed an irregular cell surface, cytoplasmic vacuoles, lysosomes, and phagosomes, they were identified as belonging to the macrophage family. The lesions were classified into 2 main patterns, both displaying these cathepsin L-rich cells, which, in at least 1 of the 2, were closely associated with bone degradation.

CONCLUSION

The cathepsin L-rich macrophages are sufficiently numerous to be considered a major factor in producing the erosion of subchondral bone found in chronic RA lesions.

[Histological findings of specimens obtained by directional coronary atherectomy from patients with acute myocardial infarction]

The histological characteristics of acute myocardial infarction were examined in specimens obtained from infarct-related coronary artery lesions (20 left anterior descending artery, 2 left circumflex artery, 8 right coronary artery) in 30 patients with initial acute myocardial infarction who underwent directional coronary atherectomy following intracoronary thrombolysis within 6 hours after the onset of chest pain. Resected tissues were fixed in 10% buffered formalin and embedded in paraffin, and the 4 microns-thick paraffin sections were stained with hematoxylin-eosin and examined by light microscopy. Thrombus and/ or intramural hemorrhage were present in all samples. There were high incidences of cholesterol cleft in 19 (63%), foam cell in 21 (70%), calcium deposit in 19 (63%) and intimal proliferation in 16 (53%). These data suggest that thrombus and/or intramural hemorrhage are important in the onset of acute myocardial infarction.

Role of cytokines in experimental colitis: relation to intestinal permeability

There is now clear evidence supporting the role of cytokines in the clinical and immunopathological manifestations of human inflammotory bowel disease. The purpose of the present study was to determine the possible role of a cytokine network in a rat model of trinitrobenzene sulfonic acid-induced colitis and to examine its relation to intestinal permeability. After a rapid increase in the intestinal permeability of Evans blue in the colon, tumor necrosis factor-alpha increased transiently, and interleukin-1 and interleukin-6 followed thereafter. The majority of tumor necrosis factor-alpha- and interleukin-1-producing cells observed by immunofluorescent staining was revealed to be macrophages. Repeated injections of interleukin-1 receptor antagonist led to a modest decrease in myeloperoxidase activity and colon weight. These findings suggest that enhanced pro-inflammatory cytokine production from intestinal macrophages accompanied by increased intestinal permeability may contribute to intestinal and systemic features of trinitrobenzene sulfonic acid-induced colitis. Pharmacologic blockade of pro-inflammatory cytokines may help reduce intestinal inflammation.

Time course of impaired coronary flow reserve after reperfusion in patients with acute myocardial infarction

To evaluate the time course of coronary flow reserve after reperfusion, 14 patients with a first anterior wall acute myocardial infarction who underwent successful coronary angioplasty within 6 hours after symptom onset were studied. After angioplasty, coronary flow reserve of the left anterior descending artery was measured with a coronary Doppler guidewire and intravenous dipyridamole (0.56 mg/kg over 4 minutes). Measurements were repeated at predischarge (16 +/- 3 days, n = 12) and at follow-up (6 +/- 3 months, n = 9). Patients with restenosis at the time of repeat catheterization were excluded. An additional 13 patients with normal angiograms served as reference patients. Coronary flow reserve was 1.33 +/- 0.29 after angioplasty. It increased to 1.88 +/- 0.36 at predischarge (p <0.01) and further to 2.34 +/- 0.38 at follow-up (p <0.01 vs after angioplasty and at predischarge, respectively). However, compared with reference patients (3.15 +/- 0.48), coronary flow reserve was significantly reduced in the infarct patients even at follow-up (p <0.01). In infarct patients, the infarct region wall motion was initially -3.86 +/- 0.67 SD/chord. It significantly improved to -2.07 +/- 1.04 SD/chord at predischarge (p <0.01) and to -1.67 +/- 1.43 SD/chord at follow-up (p <0.01). However, there was no significant relation between coronary flow reserve and region wall motion after angioplasty (r = 0.10), at predischarge (r = 0.35), and at follow-up (r = 0.28). Thus, coronary flow reserve is severely impaired early after reperfusion. Coronary flow reserve improves over 2 weeks, but the impairment persists at 6 months after acute myocardial infarction. The impairment of coronary flow reserve cannot be predicted by left ventricular function. Small sample size is a potential limitation of this study, and a larger study should be performed to confirm these findings.

Attenuation of the no-reflow phenomenon after coronary angioplasty for acute myocardial infarction with intracoronary papaverine

The no-reflow phenomenon is observed as reduction of coronary blood flow on the angiograms (angiographic no-reflow) after immediate percutaneous transluminal coronary angioplasty (PTCA) in patients with acute myocardial infarction (AMI). To assess whether a potent coronary microvascular dilator--papaverine--could attenuate the no-reflow phenomenon, nine patients with AMI who were found to have angiographic no-reflow after PTCA were studied. Angiographic no-reflow was defined as the Thrombolysis in Myocardial Infarction flow grade 1 or 2 without any mechanical obstructions in the epicardial artery. A bolus dose of 10 mg of intracoronary papaverine was administered, and the flow grade was again evaluated. Intracoronary papaverine caused a significant improvement of the flow grade (p= 0.0152). The number of cineframes that were required for the contrast medium to pass two selected landmarks on the angiograms also significantly decreased (41 +/- 17 frames to 18 +/- 8 frames, p= 0.0039). Thus intracoronary papaverine attenuated angiographic no-reflow that occurred after PTCA for AMI.

[Evaluation of occult atherosclerosis in the left main coronary artery in patients with acute anterior myocardial infarction]

Intravascular ultrasound was performed in 30 patients with acute anterior myocardial infarction to evaluate occult atherosclerosis in the left main coronary artery which could not be detected by coronary angiography. The intravascular ultrasound catheter was positioned in the left main coronary artery after successful intracoronary thrombolysis, and cross-sectional coronary artery scanning was performed. Percentage area stenosis (%AS) was calculated as (plaque cross-sectional area/vessel cross-sectional area) x 100. Images of crescent-shaped eccentric plaque were obtained in all patients. The mean vessel cross-sectional area was 28.6 +/- 8.0 mm2, and mean plaque cross-sectional area was 7.7 +/- 4.2 mm2. Mean %AS was 27 +/- 15% (range from 6 to 58%). In five patients, intravascular ultrasound was repeated 3 months later, which showed increased %AS more than 15% in two patients. These findings indicate that occult atherosclerosis is present in the left main coronary artery in almost all the patients with acute anterior myocardial infarction and should be treated with caution when coronary intervention is performed.

Relapse and elevation of blood urea nitrogen in acute fenitrothion and malathion poisoning

We observed 6 patients with severe fenitrothion and/or malathion poisoning necessitating artificial ventilation and intensive care monitoring. Three developed relapse following acute cholinergic crisis. In these patients the blood urea nitrogen (BUN) abnormally elevated before the development of relapse and the initial high concentration of plasma organophosphate (OP) decreased only gradually. However, the patients who did not develop relapse showed no elevation of BUN and a relatively low concentration of plasma OP. This observation was confirmed in a retrospective search of 14 patients. In addition, erythrocyte cholinesterase (EChE) activities were more helpful to diagnose the development of relapse than plasma cholinesterase activities. Therefore, careful monitoring of BUN in addition to plasma OP concentration may be useful to predict the development of relapse.

[Efficacy and limitation of directional coronary atherectomy for acute myocardial infarction assessed by depth of tissue resection]

The efficacy and limitations of directional coronary atherectomy (DCA) for acute myocardial infarction were evaluated in 44 patients (left anterior descending artery : 27 lesions, left circumflex artery : 2 lesions, right coronary artery : 15 lesions) who underwent DCA within 24 hours after the onset of chest pain. Thirty-two patients underwent DCA for residual stenosis of > or = 75% with TIMI flow grade II or III after thrombolysis (immediate DCA), and 12 patients underwent DCA for suboptimal results after immediate percutaneous transluminal coronary angioplasty (rescue DCA). In all patients, DCA resulted in residual stenosis of <25% (15 +/- 8%), and the primary success rate was 100%. No major complications (death, emergency bypass grafting) occurred. Repeat angiography was performed in 41 patients before discharge (2.4 +/- 0.7 weeks later) and in 39 patients during follow-up (5 +/- 2 months later). Reocclusion was not found at the follow-up. Restenosis was not found before predischarge, but was found in 19 of the 39 patients (49%) at the follow-up. Histological analysis of atheroma samples was performed to evaluate the influence of subintimal resection on restenosis. Patients were divided into two groups according to the depth of tissue resection : intimal resection and subintimal resection. The restenosis rate associated with subintimal resection was significantly higher than that associated with intimal resection (80% vs 29%, p < 0.01). DCA is useful for persistent patency of the infarct-related coronary artery in patients with acute infarction, but subintimal resection may increase the restenosis rate during the follow-up period.

Increased incidence of proximal colon cancer in the elderly

To define the characteristics of colorectal cancer with regard to site distribution, age, and sex, due to the significantly increased incidence of colorectal cancer in Japan, we investigated 1,205 Japanese patients with colorectal cancer between 1975 and 1994. When we compared site distribution for age and sex in the entire 20-year period, tumors in the proximal colon were more frequent in elderly patients than in young ones (p < 0.05); this tendency was true only for females (p < 0.01), but not for males. The increased incidence of proximal colon cancer in elderly patients was also found in the second 10-year period (p < 0.05). Because elderly patients are characterized by an increasingly high incidence of proximal colon cancer in recent years, more concerted efforts for the early detection of proximal colon cancer, particularly in the elderly, are called for.

[Intra-arterial infusion chemotherapy for liver metastases from breast cancer]

Twelve patients with liver metastases of breast cancer were treated with hepatic arterial infusion chemotherapy using 20-30 mg/body of epi-adriamycin (epi-ADM) every 2 weeks and continuous infusion of 250 mg/body/day of 5-fluorouracil (5-FU). All patients were followed by systemic chemo-endocrine therapy with oral administration of 600-1,200 mg/day of me droxyprogesterone acetate (MPA) alone or with 600-800 mg/day of 5'-deoxy-5-flurouridine (5'-DFUR). The response rate was 41.7% (5/12 cases). Duration of response was 2-28 months (mean 10 months). At one year, the survival rate was 46.8% (Kaplan-Meier method). As for side effects, gastrointestinal disturbance, bone marrow depression and alopecia were mild. These results suggest that hepatic arterial infusion therapy in combination with MPA is safe and effective for controlling liver metastases of breast cancer.

Effects of various doses of intracoronary diltiazem on coronary resistance vessels in humans

We investigated the vasodilative effects of various doses of intracoronary diltiazem on coronary resistance vessels. Nine patients with normal angiograms were studied. A coronary Doppler guide wire was inserted into the left anterior descending coronary artery. Diltiazem, in doses of 0.1 mg, 0.5 mg, 1.0 mg, 2.0 mg and 4.0 mg, was injected into the left coronary artery at 10 min intervals and coronary blood flow velocity was measured. The coronary artery was pretreated with intracoronary nitroglycerin to avoid changes in the cross-sectional area. As a measure of the change in coronary vascular resistance, a coronary vascular resistance index (CVRI) was calculated as mean aortic pressure/coronary blood flow velocity. An injection of diltiazem into the left coronary artery caused a significant dose-dependent decrease in CVRI. A dose of 2.0 mg was the lowest dose on the plateau of the dose-response curve. In conclusion, the injection of diltiazem into the left coronary artery causes a dose-dependent dilatation of coronary resistance vessels, and the maximal effect can be produced with a dose of 2.0 mg.

Prognostic value of combination assays for CEA and CA 19-9 in gastric cancer

Preoperative serum CEA and CA 19-9 levels in 158 patients with gastric cancer were analyzed with respect to prognostic factors, using univariate and multivariate analysis. The incidence of high preoperative levels of both CEA and CA 19-9 was 10.1% (16/158). 13.9% (22/158) showed high CEA levels and normal CA 19-9 levels, whereas the reverse was true in 16.5% (26/158). Neither marker showed a high level in 59.5% (94/158). The multivariate analysis showed that in addition to tumor stage, the depth of invasion, liver metastasis and peritoneal dissemination, combination assays of preoperative serum CEA and CA 19-9 levels were an independent prognostic factor. Combination assays of preoperative serum CEA and CA 19-9 will allow us to conduct a more careful postoperative follow-up of high-risk patients, and also help determine the optimum adjuvant chemotherapy.