Prediction for the prognosis of diffuse axonal injury using automated pupillometry

OBJECTIVE

Previous studies have reported various predictive indicators of diffuse axonal injury (DAI), but no consensus has not been reached. Although the efficiency of automated pupillometry in patients with consciousness disorder has been widely reported, there are few reports of its use in patients with DAI. This study aimed to investigate the significance of pupillary findings in predicting the prognosis of DAI.

PATIENTS AND METHODS

We included patients admitted to our center with a diagnosis of DAI from June 1, 2021 to June 30, 2022. Pupillary findings in both eyes were quantitatively measured by automated pupillometry every 2 hours after admission. We statistically examined the correlations between automated pupillometry parameters, the patients' characteristics, and outcomes such as the Glasgow Outcome Scale Extended (GOSE) after 6 months from injury, the time to follow command, and so on.

RESULTS

Among 22 patients included in this study, five had oculomotor nerve palsy. Oculomotor nerve palsy was correlated with all outcomes, whereas Marshall computed tomography (CT) classification, Injury severity score (ISS) and DAI grade were correlated with few outcomes. Some of the automated pupillometry parameters were significantly correlated with GOSE at 6 months after injury, and many during the first 24 hours of measurement were correlated with the time to follow command. Most of these results were not affected by adjustment using sedation period, ISS or Marshall CT classification. A subgroup analysis of patients without oculomotor nerve palsy revealed that many of the automated pupillometry parameters during the first 24 hours of measurement were significantly correlated with most of the outcomes. The cutoff values that differentiated a good prognosis (GOSE 5-8) from a poor prognosis (GOSE 1-4) were constriction velocity (CV) 1.43 (AUC = 0.81(0.62-1), p = 0.037) and maximum constriction velocity (MCV) 2.345 (AUC = 0.78 (0.58-0.98), p = 0.04). The cutoff values that differentiated the time to follow command into within 7 days and over 8 days were percentage of constriction 8 (AUC = 0.89 (0.68-1), p = 0.011), CV 0.63 (AUC = 0.92 (0.78-1), p = 0.013), MCV 0.855 (AUC = 0.9 (0.74-1), p = 0.017) and average dilation velocity 0.175 (AUC = 0.95 (0.86-1), p = 0.018).

CONCLUSIONS

The present results indicate that pupillary findings in DAI are a strong predictive indicator of the prognosis, and that quantitative measurement of them using automated pupillometry could facilitate enhanced prediction for the prognosis of DAI.

Massive Hemorrhage Associated With Upper Cervical Vertebral Fracture Treated Successfully With Transcatheter Arterial Embolization: A Case Report

Blunt vertebral artery injuries (BVAI) associated with cervical spine fractures are often problematic due to symptoms of occlusion. Denver grade V cases, in which the vertebral artery is transected, are rare but often fatal, and treatment has rarely been reported. We encountered a case of hemorrhagic shock due to an injury to a branch of the vertebral artery associated with an upper cervical spine fracture. Transcatheter arterial embolization was performed successfully to achieve hemostasis, requiring superselective arterial embolization to preserve the main trunk of the vertebral artery. It is important to be aware that vascular injuries to the branch vessels as well as the main trunk can cause complications.

Immediate Closed Reduction Technique for Cervical Spine Dislocations

STUDY DESIGN

Retrospective study.

PURPOSE

This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach.

OVERVIEW OF LITERATURE

Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration.

METHODS

For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position.

RESULTS

Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation.

CONCLUSIONS

Our closed reduction approach safely repaired traumatic cervical spine dislocations.

Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries

BACKGROUND

Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes.

METHODS

Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up.

RESULTS

Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis.

CONCLUSION

APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.

Effect of ionized calcium level on short-term prognosis in severe multiple trauma patients: a clinical study

Background

Hypocalcemia has been reported as an independent predictor of trauma mortality. We investigated the relationship between temporal variations in blood ionized calcium concentration (iCa) and prognosis in severe trauma patients who underwent massive transfusion protocol (MTP).

Methods

This single-center, retrospective, observational study investigated 117 severe trauma patients treated with MTP in the Department of Emergency Medicine and Critical Care, Saitama Medical Center, Saitama Medical University, between March 2013 and March 2019. Multivariate logistic regression analysis was performed, assigning pH-corrected initial and minimum blood ionized calcium concentration within 24 hours of admission (iCa_min), age, initial systolic blood pressure and Glasgow Coma Scale (GCS) score, and incidence of Ca supplementation as independent variables and 28-day mortality as dependent variable.

Results

The logistic regression analysis identified iCa_min (adjusted OR 0.03, 95% CI 0.002 to 0.4), age (adjusted OR 1.05, 95% CI 1.02 to 1.09), and GCS score (adjusted OR 0.84, 95% CI 0.74 to 0.94) as significant independent predictors of 28-day mortality. The receiver operating characteristic analysis identified optimal cut-off value of iCa_min for predicting 28-day mortality as 0.95 mmoL/L (area under the curve 0.74).

Conclusion

In the management of patients with traumatic hemorrhagic shock, aggressive correction of the iCa to maintain 0.95 mmol/L or higher within 24 hours of admission may improve short-term outcomes.

Level of evidence

Therapeutic/care management, level III.

Hemorrhagic Shock Due to Traumatic Anterior Cerebral Artery Aneurysm: A Case Report

Massive subdural hematomas are known to cause hemorrhagic shock in infants and young children. Traumatic cerebral aneurysms are rare and are often noticed in the subacute phase with disorientation due to the rupture of a pseudoaneurysm. No previous studies appear to have clarified the diagnosis of and therapeutic interventions for traumatic cerebral aneurysms identified from computed tomography (CT) on admission. The present case involved an open skull fracture resulting in hemorrhagic shock due to subcutaneous extravasation from an anterior cerebral artery (ACA) pseudoaneurysm. A seven-year-old boy was accidentally struck by a car after running out into a road. He had an open fracture of the skull and contrast-enhanced CT of the head showed subcutaneous extravasation from the ACA. The patient developed hemorrhagic shock that resolved following the embolization of the ACA with n-butyl-2-cyanoacrylate. Head trauma can cause hemorrhagic shock in the presence of an open wound due to a skull fracture. Contrast-enhanced CT of the head on admission is useful for diagnosis.

Successful artificial pneumothorax thoracoscopic repair of a right-sided diaphragmatic injury with hemothorax. A case report

INTRODUCTION AND IMPORTANCE

Right-sided blunt diaphragmatic injury (BDI) is rare and often missed initially. Recently, some studies reported increased use of minimally invasive repair. A case of unexplained hemothorax that led to early suspicion of right-sided BDI, which was confirmed by exploratory thoracoscopy with an artificial pneumothorax, and primary repair was completed, is presented.

CASE PRESENTATION

A 47-year-old woman had a moderate right hemothorax without rib fracture, vertebral fracture, or lung injury. A chest tube was inserted for the hemothorax, and approximately 470 mL of blood were evacuated initially. The right-sided BDI was not initially identified. Diagnostic thoracoscopy with an artificial pneumothorax confirmed diaphragmatic laceration. The liver was pushed back into the abdominal cavity with the use of the artificial pneumothorax. Primary closure of the diaphragmatic laceration was performed.

CLINICAL DISCUSSION

We must consider that a hemothorax without a lung injury or a chest wall injury may be a BDI. Thoracoscopy contributes to identifying and repairing a diaphragmatic injury. Additionally, an artificial pneumothorax provided a good operative field and spontaneously reduced the liver into the abdominal cavity, which facilitates the thoracoscopic repair of BDI.

CONCLUSION

Unexplained hemothorax may be due to diaphragmatic injury, and exploratory thoracoscopy with an artificial pneumothorax may contribute to identifying and repairing a diaphragmatic injury.

Limitations and Opportunities in Breath Research in the Face of the COVID-19 Pandemic

N/A (editorial)

Usefulness of echocardiographic parameters in predicting the incidence of ischemic stroke in Japanese patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) is a risk factor for ischemic stroke (IS). We developed a novel risk score of IS (HELT-E2S2 score) in non-valvular atrial fibrillation (NVAF) patients from the combined database of 5 major AF registries in Japan. However, this score does not include echocardiographic (Echo) parameters that have been reported to be risk factors of IS, such as left atrial diameter (LAD) enlargement or increased relative wall thickness (RWT) of left ventricle (LV).

Purpose

To investigate the predictive value of Echo parameters in Japanese patients with NVAF.

Methods

After excluding patients without the Echo data, 6,032 NVAF patients were analyzed in the present study. LAD was measured in the parasternal long axis view at the end-ventricular systole. RWT was calculated as (2x posterior wall thickness)/ LV end-diastolic dimension. We compared clinical characteristics and the incidence of IS between NVAF patients divided by LAD level (High/Low LAD group) and RWT level (High/Low RWT group). To balance the follow-up period among the registries, event data from individuals whose follow-up period exceeded 730 days were excluded from the analysis.

Results

The optimal cut-off value of LAD and RWT to predict the incidence of IS with the receiver operating characteristic analysis was 43.3 mm and 0.4167, respectively. Between the High/Low LAD groups (High LAD: n=2,640 vs. Low LAD: n=3,392), age (70.3±12.1 vs. 68.3±12.5 years; p<0.001), CHA2DS2-VASc score (3.02±1.84 vs. 2.57±1.78; p<0.001), HELT-E2S2 score (2.20±1.31 vs. 1.55±1.33; p<0.001), the prescription of oral anticoagulants (OACs) (69.5 vs. 51.5%; p<0.001), LV ejection fraction (60.4±13.4 vs. 64.4±10.7%; p<0.001) and RWT (0.401±0.091 vs. 0.396±0.082; p=0.02) were significantly different. Between the High/Low RWT groups (High RWT: n=2,293 vs. Low RWT: n=3,739), percentage of female (35.6 vs. 27.8%; p<0.001), age (71.2±12.1 vs. 68.0±12.4 years; p<0.001), CHA2DS2-VASc score (3.08±1.82 vs. 2.58±1.79; p<0.001), HELT-E2S2 score (2.10±1.39 vs. 1.67±1.31; p<0.001), the prescription of OACs (62.6 vs. 57.4%; p<0.001), LV ejection fraction (65.5±9.9 vs. 60.9±13.0%; p<0.001) and LAD (43.0±8.1 vs. 42.4±8.3; p=0.004) were significantly different. In Kaplan-Meier analysis, the incidence of IS was different between the groups during the median follow-up period of 730 days (High LAD vs. Low LAD; 1.82 vs. 1.00 per 100 person-years; p<0.001, by log-rank test, High RWT vs. Low RWT; 1.86 vs. 1.06; p<0.001) (Figure). Both High LAD (hazard ratio: 1.65, 95% CI: 1.12–2.46; p=0.01) and High RWT (hazard ratio: 1.43, 95% CI: 1.01–2.04; p=0.045) were independent predictors of the incidence of IS after adjustment by the components of the HELT-E2S2 score and other clinically relevant variables including co-existing diseases, gender, and the prescription of OACs (Table).

Conclusion

Echo parameters, LAD and RWT, were independently associated with the incidence of IS among Japanese patients with NVAF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Infant Caudate Lobe Injury With Retroperitoneal Hematoma: A Case Report

Liver injury, especially caudate lobe injury, is an extremely rare form of injury in infants. In most cases, liver injury results in intraperitoneal hemorrhage when the capsule is ruptured, and circulatory dynamics deteriorate early. Caudate lobe injuries, however, often present with a high retroperitoneal hematoma. The diagnosis is difficult to identify with a focused assessment with sonography for trauma (FAST) in the initial treatment of trauma and may even be delayed without contrast-enhanced CT imaging. A one-month-old postoperative boy with congenital heart disease was involved in a motor vehicle accident and presented with a single caudate lobe injury. He was not wearing a seatbelt, and it was thought that the caudate lobe was injured due to shearing forces in the cephalocaudal direction at the time of the accident. The patient did not go into shock when he first came to our hospital, but a few hours after admission, he went into shock and required surgical hemostasis. The postoperative course was good, and the patient was discharged alive one month later. The lesson to be learned from this case is that caudate lobe injuries are often associated with retroperitoneal hematoma and slow deterioration of hemodynamics, so it is important not to miss small changes in the child's vitals and to be willing to perform contrast-enhanced CT imaging depending on the type of injury.

Single-staged laparotomy versus multiple-staged laparotomy for traumatic massive hemoperitoneum with hemodynamic instability: a single-center, propensity score-matched analysis

Background

Currently, damage control surgery (DCS) employing multiple-staged laparotomy (MSL) is a standard hemostatic approach for treating trauma patients with unstable hemodynamics attributable to massive hemoperitoneum. Based on these findings, we had frequently employed MSL as a part of our hemostatic strategy for the patients, but with unsatisfactory outcomes. On the other hand, with the establishment of damage control resuscitation (DCR), it has become possible to avoid trauma-induced coagulopathy and to achieve adequate hemostasis with single-staged laparotomy (SSL). Consequently, our institutional strategy for surgical hemostasis of the patients has gradually shifted from MSL to SSL with implementation of DCR. The purpose of the study is to evaluate the impact of this shift in the strategy by comparing outcomes of the patients between those underwent MSL and those underwent SSL employing propensity score matching.

Methods

This retrospective, single-center, observational study evaluated outcomes of hemodynamically unstable patients with traumatic massive hemoperitoneum requiring surgical intervention between 2005 and 2020. The patient population was divided into two groups: a SSL group and a MSL group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups, a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each group. The primary outcome was in-hospital mortality, and secondary outcomes were 48-h mortality and 28-day mortality.

Results

A total of 170 patients met the inclusion criteria; 141 patients underwent SSL, and 29 underwent MSL. In the propensity-matched analysis with 27 pairs, the SSL group had significantly lower in-hospital mortality (odds ratio [OR] 0.154; 95% confidence interval (CI) 0.035 to 0.682) and 28-day mortality (OR 0.200; 95% CI 0.044 to 0.913) than the MSL group, but the 48-h mortality did not differ significantly between the two groups (25.9% vs. 44.4%; OR 0.375; 95% CI 0.099–1.414).

Conclusions

Single-staged laparotomy may be an effective surgical treatment for the traumatic massive hemoperitoneum cases with hemodynamic instability, if conducted following sufficient damage control resuscitation and performed by an experienced surgeon.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01660-6.

SARS-CoV-2 RNA load and detection rate in exhaled breath condensate collected from COVID-19 patients infected with Delta variant

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant is considered responsible for worldwide surges in coronavirus disease 2019 (COVID-19) cases in 2021, with increased infectivity compared to the wild type (Wuhan-1). In a previous study, we identified temporal changes in wild-type SARS-CoV-2 RNA load and detection rate in EBC collected from COVID-19 patients. The primary objective of this study was to clarify temporal changes in Delta-variant SARS-CoV-2 RNA load and detection rates in EBC collected from patients, and to validate the feasibility of Delta-variant SARS-CoV-2 RNA detection from EBC for diagnosing COVID-19. The secondary objective was to compare SARS-CoV-2 RNA loads in EBC between Delta-variant and wild-type. Subjects were 41 COVID-19 patients infected with the Delta-variant. EBC samples were collected from subjects on the day of or the day after admission using R-tube® (Respiratory Research, Austin, Texas, USA), as in our previous study. SARS-CoV-2 RNA in EBC samples was detected and quantified by RT-PCR assay targeting the E gene, using the same settings and reagents as in the previous study. The results indicated that SARS-CoV-2 RNA load in EBC collected from subjects infected with Delta-variant decreased exponentially with the passage of days from symptom onset. Sustained high detection rates support the feasibility of Delta-variant SARS-CoV-2 RNA detection from EBC by RT-PCR assay as a diagnostic test for COVID-19 within 8 days of onset. SARS-CoV-2 RNA load in EBC collected 2-8 days from onset was significantly higher in Delta-variant-infected subjects than in wild-type-infected subjects on a day-to-day basis (p=0.005-0.029). However, because of the heterogeneity of the study cohort, conclusions cannot be reached regarding differences in viral RNA load between strains, regardless of the timing of EBC collection.

A perspective on hospital-acquired (nosocomial) infection control of COVID-19: usefulness of spatial separation between wards and airborne isolation unit

The coronavirus disease 2019 (COVID-19) pandemic has imposed a considerable burden on hospitals and healthcare workers (HCWs) worldwide, increasing the risk of outbreaks and nosocomial transmission to 'non-COVID-19' patients, who represent the highest-risk population in terms of mortality, and HCWs. Since HCWs are at the interface between hospitals on the one hand and the community on the other, they are potential reservoirs, carriers, or victims of severe acute respiratory syndrome coronavirus 2 cross-transmission. In addition, there has been a paradigm shift in the management of viral respiratory outbreaks, such as the widespread testing of patients and HCWs, including asymptomatic individuals. In hospitals, there is a risk of aerosol transmission in poorly ventilated spaces, and when performing aerosol-producing procedures, it is imperative to take measures against aerosol transmission. In particular, spatial separation of the inpatient ward for non-COVID-19 patients from that designated for patients with suspected or confirmed COVID-19 as well as negative-pressure isolation on the floor of the ward, using an airborne infection isolation device could help prevent nosocomial infection.

RT-PCR diagnosis of COVID-19 from exhaled breath condensate: a clinical study

Current diagnostic testing for coronavirus disease 2019 (COVID-19) is based on detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal swab samples by reverse transcription polymerase chain reaction (RT-PCR). However, this test is associated with increased risks of viral dissemination and environmental contamination and shows relatively low sensitivity, attributable to technical deficiencies in the sampling method. Given that COVID-19 is transmitted via exhaled aerosols and droplets, and that exhaled breath condensate (EBC) is an established modality for sampling exhaled aerosols, detection of SARS-CoV-2 in EBC offers a promising diagnostic approach. However, current knowledge on the detection and load of the virus in EBC collected from COVID-19 patients remains limited and inconsistent. The objective of the study was to quantify the viral load in EBC collected from COVID-19 patients and to validate the feasibility of SARS-CoV-2 detection from EBC as a diagnostic test for the infection. EBC samples were collected from 48 COVID-19 patients using a collection device, and viral loads were quantified by RT-PCR targeting the E gene. Changes in detection rates and viral loads relative to patient characteristics and days since disease onset were statistically evaluated. Need for mechanical ventilation was significantly associated with higher viral load (p< 0.05). Need for oxygen administration or mechanical ventilation, less than 3 d since onset, and presence of cough or fever were significantly associated with higher detection rates (p< 0.05). Among spontaneously breathing patients, viral load in EBC attenuated exponentially over time. The detection rate was 86% at 2 d since onset and deteriorated thereafter. In mechanically ventilated patients, detection rate and viral load were high regardless of days since onset. These results support the feasibility of using RT-PCR to detect SARS-CoV-2 from EBC for COVID-19 patients within 2 d of symptom onset.

A short perspective on a COVID-19 clinical study: 'diagnosis of COVID-19 by RT-PCR using exhale breath condensate samples'

Diagnosis of SARS-COV-2 infection (COVID-19) is currently based on detection of the viral RNA in nasopharyngeal swab samples by reverse transcription polymerase chain reaction (RT-PCR). However, sampling via nasopharyngeal swabs frequently provokes sneezing or coughing, which results in increased risk of the viral dissemination and environmental contamination. Furthermore, the sensitivity associated with the PCR tests s limited to 60%-70%, which is mainly attributable to technical deficiency in sampling. Given that the disease is transmitted via exhaled aerosol and droplets, and that the exhaled breath condensate (EBC) is the established modality for sampling exhaled aerosol, detection of the viral RNA in EBC is a promising approach for safe and efficient diagnosis of the disease. Subjects are those patients who are diagnosed with COVID-19 by positive nasopharyngeal swab PCR test and admitted to Saitama Medical Center, Japan. EBC samples will be collected using an R-tube^® or R-tubeVent^® device. Collected EBC samples will be introduced into a nucleic acid purifier. The purified nucleic acids will undergo amplification through RT-PCR for detection and quantification of SARS-COV-2 RNA. To date we have collected eight samples from seven subjects. Among them, two samples from two subjects tested positive for SARS-COV-2 RNA by the RT-PCR. Reflecting the second wave of COVID-19 prevalence in Japan, new admissions of COVID-19 patients to the Saitama Medical Center are increasing, and we are expecting to collect at least 50 EBC samples from 25 patients before the end of this year.

P3755Left atrial enlargement as an independent risk factor for ischemic stroke in Japanese atrial fibrillation patients: pooled analysis of five major Japanese atrial fibrillation registries

Background

Atrial fibrillation (AF) increases the risk of ischemic stroke. It remains unknown whether left atrial diameter determined by routine trans-thoracic echocardiography is a risk factor for ischemic stroke in non-valvular AF (NVAF) patients.

Purpose

The aim of this study is to investigate the impact of left atrial enlargement (LAE) on the incidence of ischemic stroke in a large-scale cohort of Japanese NVAF patients.

Methods

We combined the data of 5 major AF registries in Japan, J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku AF Registry. After excluding patients without echocardiographic data, 7,672 NVAF patients were analyzed in the present study (mean age, 69.3±12.3 years; mean CHADS2 score, 1.6±1.3). We compared clinical characteristics and the incidence of ischemic stroke between NVAF patients with LAE (left atrial diameter >45 mm; LAE group) and those without (non-LAE group).

Results

The mean left atrial diameter was 43.1±8.6 mm, and the LAE group accounted for 40.0% (n=3,066) of the entire cohort. Compared with non-LAE group (60.0%, n=4,606), the LAE group was older (LAE vs. non-LAE; 70.3±12.0 vs. 68.0±12.5, p<0.01), more often non-paroxysmal type (73.7% vs. 32.1%, p<0.01), had higher CHADS2 (1.86±1.34 vs. 1.46±1.29, p<0.01) and CHA2DS2-VASc (3.02±1.83 vs. 2.53±1.78, p<0.01) scores, and more frequently received oral anticoagulant (72.9% vs. 55.0%, p<0.01).

During the median follow-up period of 774.5 days (interquartile range: 567–1466 days), ischemic stroke occurred in 241 patients (131 vs. 110 patients; 1.52 vs. 0.82 per 100 person-years). In Kaplan Meier analysis, LAE was associated with a higher incidence of ischemic stroke (unadjusted hazard ratio (HR): 1.83, 95% confidence interval (CI): 1.42–2.36; log rank p<0.01) (Figure). LAE was independently associated with increased risk of ischemic stroke (adjusted HR: 1.63, 95% CI: 1.25–2.11; p<0.01) after adjustment by the components of CHADS2 score and the use of oral anticoagulant, on multivariate Cox proportional hazard analysis.

Conclusion

In this large-scale cohort of Japanese patients with AF, LAE was an independent predictor of ischemic stroke, suggesting that this simple echocardiographic parameter could refine thromboembolic risk stratification of NVAF patients.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED

P684Long-term outcomes in patients with cancer undergoing percutaneous coronary intervention: analysis from a Japan multicenter registry

Background

Cancer and cardiovascular disease (CVD) is the most common cause of death in developed countries, and substantial overlap exist in their medical care. However, the detailed and updated information on outcome of cancer patients with cardiovascular disease (CVD), particularly in clinically significant coronary artery disease (CAD) remain unknown.

Purpose

We sought to describe the prevalence and long-term outcomes of cancer patients undergoing percutaneous coronary intervention (PCI), which has become a coronerstone in the management of CVD.

Methods

Patient data extracted from a regional prospectiveprocedure-based multicenter registry for PCI was analyzed. A total of 4,455 patients who underwent PCI at 15 hospitals within metropolitan Tokyo from September 2008 to 2012 were followed for 2 years. “Active” cancer patient was defined as having a history of cancer not cured or in remission. We analyzed in acute and stable presentation.The occurrence of clinical outcomes was assessed via Kaplan-Meier survival curve, and Cox-regression hazard model to adjust for known clinical predictors.

Results

Within the studied patients, 173 (3.9%) had a concomitant “active” cancer at the time of intervention. There was a significant difference between the patients with and without active cancer in each situation. In stable presentation, cancer group were older, lower BMI, frequently had silent ischemia, COPD and cerebrovascular/peripheral disease, and less often had dyslipidemia compared with non-cancer group. In acute presentation, cancer group were older, frequently had COPD, CKD, peripheral disease and history of HF compared with non-cancer group. The prescription rate of RAAS inhibitor was lower in the cancer group than in the non-cancer group in acute presentation. Notably, in both acute and stable presentation, these patients had significantly higher risk of all-cause mortality (HR 8.01: 95%, p<0.001 and HR5.53: 95%, p<0.001, respectively), and they were also at higher risk of major cardo- and cerebrovascular events (MACCE; HR2.38, p<0.001, HR2.33, p=0.001), when referenced to non-cancer patients after 2 year of follow-up.

Conclusion

Cancer patient was present in 3.9% of all PCI patients and was strongly associated with both non-cardiac and cardiac adverse events.

P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury

Background

Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking.

Purpose

Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry.

Methods

Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a >0.3mg/dl absolute or >1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores.

Results

Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P<0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P<0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575).

CV according to CKD/NCDR AKI risk score

Conclusions

Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI.

Acknowledgement/Funding

KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer

Two-Staged Circumferential Decompression and Fusion Surgery for Upper Thoracic Myelopathy Caused by Concurrent Beak-Type Ossification of the Posterior Longitudinal Ligament and Ligamentum Flavum at T1-T2 Level: A Case Report

BACKGROUND

Upper thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) is relatively rare. This clinical condition is difficult to treat, and a surgical method has not been fully established. We report an extremely rare case of severe thoracic myelopathy caused by concurrent beak-type OPLL and OLF at T1-T2.

CASE DESCRIPTION

A 53-year-old woman with paresthesia of both legs and an inability to hold a standing position presented to our hospital. Radiological images showed a large beak-type OPLL at T1-T2 and an OLF at T1-T7. The spinal cord was severely compressed at T1-T2. First, posterior decompression and instrumentation fusion at C6-T4 was performed, with a T1-T2 bilateral parallel gutter along the dural tube into the vertebral bodies covering the extent of the OPLL. Second, anterior decompression of the OPLL with corpectomy of T1-T2 and fusion using iliac bone grafting was performed after the sternal manubrium splitting approach. In the deep operating field of the second surgery, the gutters created during the first surgery were helpful for judging the width and thickness of the OPLL during the anterior decompression procedure. Postoperatively, her neurological symptoms greatly improved, the patient could walk independently, and the Japanese Orthopaedic Association score had improved from 3 preoperatively to 8 at the final follow-up examination at 16 months postoperatively.

CONCLUSIONS

Two-stage circumferential decompression and fusion surgery can be considered an effective surgical method for upper thoracic concurrent OPLL and OLF. The bilateral gutters created during the first surgery improved the safety and feasibility of this difficult operation.

A case series of pelvic fracture patients who developed lower urinary tract symptoms after transarterial embolization of bilateral internal iliac arteries

Cases

Transarterial embolization of bilateral internal iliac arteries (TAE) is a useful hemostatic method for the management of pelvic fracture patients, but its effects on urinary functions remain unclear. In this study, we evaluated the impact of TAE on lower urinary tract symptoms (LUTS) in 10 pelvic fracture patients.

Outcomes

Lower urinary tract symptoms before and after hospitalization were evaluated by International Prostate Symptoms Score, Overactive Bladder Symptoms Score, and Quality Of Life score. All scores showed significant worsening. The changes did not correlate with sex, age, injury severity score, or durations of unstable hemodynamics or urethral catheterization. Changes of International Prostate Symptoms Score and Quality Of Life score showed significant positive correlations with intervals between the evaluations.

Conclusion

Pelvic fracture patients treated with TAE showed significant worsening of LUTS. Risk for exacerbation of LUTS should be taken into consideration when deciding to use TAE.

Early administration of fibrinogen concentrates improves the short-term outcomes of severe pelvic fracture patients

Aim

Hemorrhage from pelvic fracture is a major cause of mortality after blunt trauma. Several studies have suggested that early fibrinogen supplementation improves outcomes of traumatic hemorrhage. Thus, we revised our massive transfusion protocol (MTP) in April 2013 to include early off‐label administration of fibrinogen concentrate. The objective of this study was to evaluate the impact of the revision on the short‐term outcomes of pelvic fracture patients.

Methods

This was a single‐center, retrospective, cohort study. A total of 224 consecutive pelvic fracture patients hospitalized in Saitama Medical Center (Saitama, Japan), 115 before the revision (Group E) and 109 after (Group L), were enrolled. Characteristics of the patients were compared between the groups. Impacts of the revision were evaluated by hazard ratios adjusted for characteristics, injury severity, and coagulation status using Cox's multivariate proportional hazard model. The impact was also evaluated by log–rank test and relative risk of 28‐day mortality between the groups.

Results

The characteristics were equivalent between the groups. The multivariate analysis revealed that the revision of MTP was significantly related to improved survival with an adjusted hazard ratio (95% confidence interval) of 0.45 (0.07–0.97). The log–rank test gave χ²‐test values of 5.2 (P = 0.022) and 6.7 (P = 0.009), and the relative risks were 0.37 (0.15–0.91) and 0.33 (0.13–0.84), in patients with all Injury Severity Scores and Injury Severity Score ≥21, respectively.

Conclusion

The revision of MTP to include aggressive off‐label treatment with fibrinogen concentrate was related to improved short‐term outcomes of severe pelvic fracture patients. However, due to the limitations of the study, the improvement could not be attributed totally to the revision.

Membranous tracheal stenosis in a patient with anorexia nervosa and self-induced vomiting- challenges in securing the airway

We report a rare case of acquired membranous tracheal stenosis in a patient with anorexia nervosa and a history of self-induced vomiting, but without a history of tracheal intubation or tracheostomy. A 50-year-old woman presented with difficulty in breathing and swallowing, self-expectoration, and impaired consciousness due to acute benzodiazepine intoxication. Bronchoscopic examination was performed after tracheotomy and placement of a tracheostomy tube failed to secure her respiratory tract and ventilation continued to deteriorate. A flap-like membranous structure was identified on the posterior tracheal wall, obstructing the tracheostomy tube. Physical compression of the membranous structure improved ventilation. Bronchoscopic examination is generally recommended prior to performing tracheostomy in patients suspected to have post-intubation tracheal obstruction. Based on our findings, we suggest that these examinations should also be performed in patients with conditions associated with chronic irritation of the respiratory tract, including those with a prolonged history of self-induced vomiting.

Pre-emptive administration of fibrinogen concentrate contributes to improved prognosis in patients with severe trauma

Background

Patients with severe trauma often present with critical coagulopathy, resulting in impaired hemostasis, massive hemorrhage, and a poor survival prognosis. The efficacy of hemostatic resuscitation in correcting coagulopathy and restoring tissue perfusion has not been studied. We assessed a novel approach of pre-emptive administration of fibrinogen concentrate to improve critical coagulopathy in patients with severe trauma.

Methods

We retrospectively compared blood transfusion volumes and survival prognosis between three groups of patients with trauma, with an Injury Severity Score (ISS) ≥26 over three consecutive periods: group A, no administration of fibrinogen concentrate; group B, administration of 3 g of fibrinogen concentrate after evaluation of trauma severity and a plasma fibrinogen level <1.5 g/L; group C, pre-emptive administration of 3 g of fibrinogen concentrate immediately on patient arrival based on prehospital information, including high-severity injury or assessed need for massive transfusion before measurement of fibrinogen.

Results

∼56% of patients with an ISS ≥26 and transfused with red blood cell concentrates ≥10 units, had hypofibrinogenemia (fibrinogen <1.5 g/L) on arrival. Patients who received fibrinogen concentrate in group C showed significantly higher fibrinogen levels after treatment with this agent than those in group B (2.41 g/L vs 1.88 g/L; p=0.01). Although no significant difference was observed in blood transfusion volumes between the groups, the 30-day survival of patients in group C (all, and those with an ISS ≥26) was significantly better than in group A (p<0.05). The 48-hour mortality rate in patients with an ISS ≥26 was significantly lower in group C than in group A (8.6% vs 22.9%; p=0.005). Further, among patients with an ISS ≥41, the overall mortality was significantly lower in group C than in group A (20% vs 50%; p=0.02).

Conclusion

Pre-emptive administration of fibrinogen concentrate for patients with trauma with critical coagulopathy may contribute to improved survival.

Level of evidence

Level IV.

Demonstration and quantification of the redistribution and oxidation of carbon monoxide in the human body by tracer analysis

Numerous studies have confirmed the role of endogenous carbon monoxide (CO) gas as a signal transmitter. However, CO is considered an intracellular transmitter, as no studies have demonstrated the redistribution of CO from the blood to tissue cells. Tracer analyses of ¹³CO₂ production following ¹³CO gas inhalation demonstrated that CO is oxidized to carbon dioxide (CO₂) in the body and that CO oxidation does not occur in the circulation. However, these results could not clearly demonstrate the redistribution of CO, because oxidation may have occurred in the airway epithelium. The objective of this study, therefore, was to definitively demonstrate and quantify the redistribution and oxidation of CO using time-course analyses of CO and ¹³CO₂ production following ¹³CO-hemoglobin infusion. The subject was infused with 0.45 L of ¹³CO-saturated autologous blood. Exhaled gas was collected intermittently for 36 hours for measurement of minute volumes of CO/CO₂ exhalation and determination of the ¹³CO₂/¹²CO₂ ratio. ¹³CO₂ production significantly increased from 3 to 28 hours, peaking at 8 hours. Of the infused CO, 81% was exhaled as CO and 2.6% as ¹³CO₂. Identical time courses of ¹³CO₂ production following ¹³CO-hemoglobin infusion and ¹³CO inhalation refute the hypothesis that CO is oxidized in the airway epithelium and clearly demonstrate the redistribution of CO from the blood to the tissues. Quantitative analyses have revealed that 19% of CO in the circulating blood is redistributed to tissue cells, whereas 2.6% is oxidized there. Overall, these results suggest that CO functions as a systemic signal transmitter.

Vitronectin enhances adhesion force and t-PA production of weakly adherent 293 cells exposed to a shear stress

The effects of shear stress on the adhesion andproductivity of 293 cells were studied quantitativelyand compared with those of Vero and human liver cells.These cells were cultured in polystyrene dishes byusing shear stress exposing equipment. 50% of 293cells cultured in 2% FBS supplemented medium detachedfrom the dish after 29 h of exposure to a shear stressof 0.10 Pa. On the other hand, 90% of Vero and humanliver cells remained on the dish under the samecondition. Observations with scanning electronmicroscopy about cell adhesion plaques on the surfaceof the dish showed that the area covered withlamellipodia and the number of microspikes for 293cells were found to be less than those of the othercell lines. Several attachment factors, especiallyvitronectin, were found to enhance the number ofmicrospikes and the adhesion force of 293 cells.Almost 100% of 293 cells remained on thevitronectin-coated dish after 40 h under 0.10 Pa ofshear stress. A higher shear stress (greater than 0.10Pa) caused a decrease in tissue plasminogen activator(t-PA) productivity of 293 cells. But 0.03 Pastimulated the t-PA secretion on the non-coated dish.Vitronectin also enhanced the t-PA secretion evenunder 0.10 Pa. These results indicate that theadhesion force of 293 cells is obviously weaker thanthat of the other cell lines, and vitronectin enhancesthe adhesion force and the productivity of 293 cellsexposed to a shear stress.

[How should we comprehend the guideline for the revised Organ Transplantation Law?]

In accordance with the revision of the "Organ Transplantation Law", the ordinances and the guideline for the law were also revised. The revision of the guideline, which finds legal basis on the circular notices, raises some issues about its position in the Japanese legislative system. It is quite ambiguous whether we should comprehend the guideline as the interpretation of the law, as the procedural guidance, or as the instruction within the administrative body. Thus, the legal obligation for the healthcare professionals to observe the guideline is also unclear. There are many issues about the transplantation law, the ordinances and the guideline. They include (1) Legal implication of the "brain death" (Is "brain death" absolutely synonymous with "death" ?), (2) Scientific relevance of the criteria for diagnosis of brain death, (3) Definition of the "adequate treatment" which is the prerequisite for diagnosis of brain death, (4) The time of death for the cases who were declared legally brain-dead but did not donate the organs, (5) By whom and when should the organ donation be proposed, and more. The ambiguity about the legal position of the guideline shall cause confusion in the scenes of clinical practice.

A tracer analysis study on the redistribution and oxidization of endogenous carbon monoxide in the human body

Past studies have suggested that some carbon monoxide (CO) moves from blood haemoglobin to tissue cells and that mitochondrial cytochrome c oxidase oxidizes CO to carbon dioxide (CO₂). However, no study has demonstrated this redistribution and oxidization of CO under physiological conditions. The objective of this study was to trace the redistribution and oxidization of CO in the human body by detecting ¹³CO₂ production after the inhalation of ¹³CO. In Experiment 1, we asked a healthy subject to inhale 50 ppm ¹³CO gas. In Experiment 2, we circulated heparinized human blood in a cardio-pulmonary bypass circuit and supplied 50 ppm ¹³CO gas to the oxygenator. We sequentially sampled exhaled and output gases and measured the ¹³CO₂/¹²CO₂ ratios. In Experiment 1, the exhaled ¹³CO₂/¹²CO₂ ratio increased significantly between 4 to 31 h of ¹³CO inhalation. In Experiment 2, the output ¹³CO₂/¹²CO₂ ratio showed no significant increase within 36 h of ¹³CO input. Experiment 1 demonstrated the oxidization of CO in the human body under physiological conditions. Experiment 2 confirmed that oxidization does not occur in the circulating blood and indicated the redistribution of CO from blood carboxyhaemoglobin to tissue cells.

Beneficial Effects of Cocoa in Perivascular Mato Cells of Cerebral Arterioles in SHR-SP (Izm) Rats

As previously reported, the cerebral arterioles are surrounded by unique perivascular Mato cells. They contain many inclusion bodies rich in hydrolytic enzymes, and have strong uptake capacity. They are thus considered scavenger cells of vascular and neural tissues in steady-state. In this study, employing hypertensive SHR-SP (Izm) rats, the viability of Mato cells was investigated. In hypertensive rats, the capacity for uptake of horse radish peroxidase (HRP) and the activity of acid phosphatase (ACPase) of Mato cells were markedly reduced, and on electron-microscopic examination Mato cells were found to include heterogeneous contents and appeared electron-dense and degenerated. Vascular cells exhibited some signs of pathology. However, in hypertensive rats fed chow containing 0.25% cocoa, the uptake capacity and ACPase activity of Mato cells for HRP were enhanced, and on electron-microscopic examination Mato cells appeared healthy, with mitochondria with nearly normal profiles. Signs of pathology in vascular cells were also decreased. Superoxides may impair Mato cells and vascular cells.

Bedside red cell volumetry by low-dose carboxyhaemoglobin dilution using expiratory gas analysis

BACKGROUND

We developed a non-invasive, continuous, high-resolution method of measuring carboxyhaemoglobin fraction (COHb%) using expiratory gas analysis (EGA). We assessed whether application of EGA to carboxyhaemoglobin dilution provides red cell volume (RCV) measurement with accuracy equivalent to that of CO-haemoximetry, with a smaller infusion volume of carbon-monoxide-saturated autologous blood (COB). Method. We assessed the agreement between repeated COHb% measurements by EGA and simultaneous measurement by CO-haemoximetry, using Bland and Altman plot, in healthy subjects and patients with artificially controlled ventilation and no radiological evidence of pulmonary oedema or atelectasis. We assessed the agreement between RCV measurements by EGA with infusion of 20 ml of COB (RCVEGA) and RCV measurements by CO-haemoximetry with infusion of 100 ml of COB (RCVHEM), in healthy subjects.

RESULTS

The 'limits of agreement' between COHb% measurement by EGA (1 min average) and CO-haemoximetry were -0.09 and 0.08% in healthy subjects, and -0.11 and 0.09% in patients. Given the resolution of CO-haemoximetry (0.1%), the accuracy of EGA was equivalent to or greater than that of CO-haemoximetry. The 'limits of agreement' between RCVEGA and RCVHEM were -0.14 and 0.15 litre. Given the average resolution of RCVHEM (0.14 litre), the accuracy of RCVEGA was equivalent to that of RCVHEM.

CONCLUSION

EGA provided non-invasive, accurate, continuous, high-resolution COHb% measurements. Applying EGA to carboxyhaemoglobin dilution, we achieved RCV measurements with accuracy equivalent to that of CO-haemoximetry, with one-fifth of the COB infusion volume. However, clinical application of the method is limited to patients with no radiological evidence of pulmonary oedema or atelectasis.

Troglitazone improves endothelial dysfunction in patients with insulin resistance

Insulin resistance is a possible major metabolic cause of atherosclerosis. Endothelial dysfunction is commonly found in patients with insulin resistance, and primary treatment of insulin resistance with troglitazone should improve such endothelial dysfunction. Thus, the effects of troglitazone on endothelial function were investigated. Thirteen non-diabetic male subjects with hyperinsulinemic response to oral glucose load (n = 7) and normal (n = 6) subjects were investigated. Flow-mediated dilatation (FMD) of the brachial artery was examined by high resolution ultrasonography before and after the administration of troglitazone of 400 mg for 4 weeks. In insulin resistant subjects, fasting glucose (4.9+/-0.3 to 4.7+/-0.3 mmol/L, p<0.05), insulin (45+/-30 to 25+/-15 pmol/L, p<0.05) and response to oral glucose load (AUC glucose: 15.0+/-3.5 to 13.0+/-2.2 mmol x h/L, p<0.05; AUC insulin: 965+/-560 to 475+/-275 pmol x h/L, p<0.05) were significantly reduced. FMD was significantly improved in insulin resistant subjects. A significant negative correlation was observed between FMD and AUC insulin (r=-0.64, p<0.05). The present study demonstrates that FMD is impaired in insulin resistant subjects, and troglitazone improves the blunted vascular response and impaired insulin response. This finding suggests that primary treatment of insulin resistance could prevent the development of atherosclerosis by improving endothelial dysfunction.

Potentially protective effects of the Ser447-Ter mutation of the lipoprotein lipase gene against the development of coronary artery disease in Japanese subjects via a beneficial lipid profile

Several DNA variants at the lipoprotein lipase (LPL) gene locus have been found to be associated with the plasma lipid levels and the prevalence of coronary artery disease (CAD). In particular, the Ser447-termination (Ter) mutation at the exon 9 of the LPL gene has the potential to elevate the plasma high-density lipoprotein (HDL) levels, but it remains unknown in the Japanese population. The present study investigated 93 CAD patients and 96 age- and sex-matched healthy controls. The Ser447-Ter mutation was determined by polymerase chain reaction restriction fragment length polymorphism method. The allelic frequency of the Ser447-Ter mutation was 0.103 in all subjects. The Ser447-Ter (GG and CG) group was associated with significantly higher levels of plasma HDL-cholesterol (p<0.001) and lower levels of plasma triglyceride than the CC group (p<0.02). The peak particle size of low-density lipoprotein (LDL) was significantly larger in the Ser447-Ter (GG and CG) group than in CC group (p<0.05). The frequency of the Ser447-Ter genotype in GG and CG was significantly lower in CAD than in the controls (11.9% vs 26%, odds ratio = 0.38; 95% confidence interval, 0.18-0.81; p<0.02). These results suggest that the Ser447-Ter mutation of the LPL gene is associated with high plasma HDL-cholesterol levels, low plasma triglyceride levels and a larger LDL particle size. This mutation may have a protective effect against the development of CAD via its favorable lipoprotein profile.

Association of seropositivity for antibody to Chlamydia-specific lipopolysaccharide and coronary artery disease in Japanese men

Recent studies suggest an association between Chlamydia pneumoniae infection and coronary artery disease (CAD). To examine this relationship in Japanese men, serum IgA and IgG antibodies to Chlamydia-specific lipopolysaccharide were measured by enzyme-linked immunosorbent assay in 507 patients with CAD and 200 age-matched controls. CAD patients were divided into (1) 269 patients with myocardial infarction (MI) and (2) 238 patients with chronic coronary heart disease (CCHD). Compared with the control group, the CAD group did not differ in the prevalences of both antibodies (IgA: 23.7 vs 18.0%, p=0.10; IgG: 52.7 vs 51.0%, p=0.6). The index of IgG antibody was not significantly different between CAD and control groups (median 1.19 vs 1.18, p=0.3), whereas the index of IgA antibody was significantly higher in CAD than control group (median 0.60 vs 0.46, p<0.0001). Compared with the control group, the MI group had a significantly higher prevalence of IgA antibody (28.6 vs 18.0%, p=0.007); however, there was no difference in the prevalence of IgG antibody (58.0 vs 51.0%, p=0.13). The CCHD group did not differ in the prevalences of both antibodies (IgA: 18.1 vs 18.0%, p=0.9; IgG: 45.6 vs 51.0%, p=0.2). After the adjustment for coronary risk factors, odds ratios (ORs) of seropositive antibodies for CAD were 1.59 [95% confidence interval (CI): 0.88-2.87, p=0.12] for IgA seropositivity and 0.92 (95%CI: 0.58-1.47, p=0.7) for IgG seropositivity in all cases. In the MI and control groups, ORs of seropositive antibodies for MI were 2.67 (95%CI: 1.32-5.38, p=0.007) for IgA seropositivity, and 1.36 (95%CI: 0.79-2.36, p=0.2) for IgG seropositivity. This study discovered that IgA antibody to Chlamydia was significantly associated with CAD, especially with MI, in Japanese Men and the findings suggest that chronic infection of Chlamydia may be linked to the pathogenesis of MI.

'Tako-Tsubo' transient ventricular dysfunction: a case report

During admission for investigation of dysphagia, an 82-year-old woman suddenly complained of dyspnea, which was followed by cardiogenic shock. Her symptoms, electrocardiogram, echocardiogram and laboratory data were compatible with an extensive acute anterior myocardial infarction. Emergency cardiac catheterization showed no atheromatous narrowing in any coronary artery. However, the contractions of the left and right ventricles were diffusely and severely impaired, except for some hyperkinesis of the basal area. The asynergy, as well as the abnormalities on the ECG, improved almost to normal by the 35th hospital day. An endomyocardial biopsy from the right ventricle during the acute phase showed atypical myocardial damage with proliferation of fine collagen fibers and small round-cell infiltration including polymorphologic leukocytes. This type of transient cardiac disorder has recently been described in Japan, and is called 'Tako-tsubo cardiomyopathy' because of the characteristic appearance of the left ventricular asynergy. In the present case, ventricular asynergy was not limited to the left ventricle, but was also present in the right ventricle.

Possible involvement of 65 kda MAP in elongation growth of azuki bean epicotyls

Although regulation of the dynamics of plant microtubules (MTs) by microtubule-associated proteins (MAPs) has been suggested, the mechanism has not yet been elucidated. As one candidate, a MAP composed of a 65 kDa polypeptide (65 kDa MAP) has been isolated from tobacco cultured cells [Jiang and Sonobe (1993), J. Cell Sci 105: 8911. To investigate the physiological role of the 65 kDa MAP in situ, we analyzed the changes in content and colocalization of this MAP with cortical MTs in relation to elongation growth, using azuki bean epicotyls (Vigna angularis Ohwi et Ohashi). All apical, intermediate, and basal segments prepared from 6 d seedlings showed high growth activity. In 12 d seedlings, growth activity of intermediate and basal segments was low, although that of apical segments was high. The relationship between the growth activity and the orientation of cortical MTs in the epidermal cells was analyzed. Cells could be classified into four types with respect to orientation of cortical MTs: transverse (T), oblique (O), longitudinal (L) to the vertical axis of cells, and random (R). In rapidly growing segments, three types of cells, T, O, L, were observed at similar ratios. In such segments, significant amounts of the 65 kDa MAP were expressed, and it colocalized well with cortical MTs. In segments showing low growth activity, most of the cells showed oblique and longitudinal orientation of cortical MTs. In such segments, the content of the 65 kDa MAP was low. These results suggested involvement of this 65 kDa MAP in regulation of the elongation growth of this epicotyl.

High prevalence of seropositivity for antibodies to Chlamydia-specific lipopolysaccharide in patients with acute coronary syndrome

BACKGROUND

Results of recent studies have demonstrated that there is an association between infection with Chlamydia pneumoniae and coronary artery disease (CAD). Inflammatory response caused by chlamydial infection has been considered to contribute to the development of atherosclerosis in coronary arteries.

OBJECTIVE

The aim of this study was to investigate the specific relations between chlamydial infection and coronary events in patients with CAD.

METHODS

We measured serum levels of immunoglobulin A and G antibodies against Chlamydia spp.-specific lipopolysaccharide in 155 patients with CAD and 60 age-matched and sex-matched healthy controls by enzyme-linked immunosorbent assay. CAD patients were divided into groups of the patients with acute coronary syndrome [(ACS), n = 35], old myocardial infarction [(OMI), n = 60] and chronic coronary heart disease [(CCHD), n = 60].

RESULTS

Prevalence of both seropositive antibodies in the control group and CCHD group were not different. In contrast, in ACS group there were significantly higher prevalences of seropositive immunoglobulin A (46 versus 12%, P = 0.0001) and G (74 versus 45%, P = 0.005) antibodies and in OMI group there was a significantly higher prevalence of seropositive immunoglobulin A antibodies (28 versus 12%, P = 0.02). Furthermore, compared with CCHD group, in ACS group there were significantly higher prevalences of seropositive immunoglobulin A (P = 0.00006) and G (P = 0.002) antibodies and in OMI group there was a higher prevalence of seropositive immunoglobulin A (P = 0.01). Adjustment for confounding factors did not change these findings.

CONCLUSIONS

Infection with Chlamydia is significantly associated with ACS and OMI, but not with CCHD. These findings suggest that chronic and reactive infection with Chlamydia can lead to disruption of vulnerable plaque in patients with ACS.

[Association between chlamydial infection and coronary artery disease]

Recent epidemiological studies have demonstrated the association between Chlamydia pneumoniae infection and coronary atherosclerosis. However, the relationship is less clear in the Japanese population. Serum IgA and IgG antibodies to Chlamydia-specific lipopolysaccharide were measured by enzyme-linked immunosorbent assay in 152 consecutive patients(112 males, 40 females, mean age 57 years)who underwent coronary angiography. Patients(n = 123)with coronary artery disease(CAD)were defined as having more than 50% diameter stenosis in at least one major coronary artery. The control group(n = 29) had normal coronary angiograms. In the CAD group, there was a high tendency of prevalence of IgA(20% vs 7%, p = 0.08)and IgG(54% vs 34%, p = 0.052). Prevalence of either IgA or IgG was significantly higher (59% vs 38%, p = 0.045) compared with the control group. Although the index of IgA antibody was not significantly different between the CAD and control groups(median 0.52 vs 0.36, p = 0.19), the index of IgG antibody was significantly higher in the CAD group than in the control group(median 1.29 vs 0.82, p = 0.026). The odds ratios for CAD were 3.4[95% confidence interval(CI)0.6-18.7]for the prevalence of IgA, 2.3(95% CI 0.9-5.2)for the prevalence of IgG, and 2.3(95% CI 1.0-5.2)for the prevalence of either IgA or IgG. Patients with CAD tended to have high prevalence of antibodies to Chlamydia spp, and these findings suggest an association between chlamydial infection and coronary atherosclerosis in the Japanese population.

Effects of troglitazone on atherogenic lipoprotein phenotype in coronary patients with insulin resistance

Insulin resistance is associated with atherogenic lipoprotein phenotype, including small dense LDL particle, hypertriglycemia and low HDL cholesterol levels. Troglitazone, a novel insulin sensitizing agent, may improve the associated lipid profile in patients with insulin resistance. We examined the effects of troglitazone (400 mg daily for 12 weeks) in 12 non-diabetic coronary patients (60+/-10 years), all of whom had hyperinsulinemic response to an oral glucose load. Troglitazone markedly reduced the insulin response. After the treatment, plasma triglycerides decreased by 32% (P<0.05), HDL cholesterol increased by 11%, (P<0.05) and LDL peak particle diameter increased from 24.7+/-0.3 to 25.5+/-0.5 nm (P<0.01). These lipidic improvements were associated with a significant rise in postheparin lipoprotein lipase levels (175+/-52 to 217+/-69 ng/ml, P<0.01). In patients with insulin resistance syndrome, troglitazone improved the atherogenic lipoprotein phenotype as well as hyperinsulinemia. Our data suggest that troglitazone therapy could reduce the atherosclerotic risk due to insulin resistance even in non-diabetic patients.