Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis

Background

In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure–derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated.

Objectives

The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory–based environment.

Methods

In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease.

Results

Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUC_{diastolic FFR}: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUC_FFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113).

Conclusions

Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906)

A High Serum Cortisol/DHEA-S Ratio Is a Risk Factor for Sarcopenia in Elderly Diabetic Patients

Context

Elderly patients with type 2 diabetes mellitus (T2DM) have a high prevalence of frailty and/or sarcopenia. Sarcopenia is thought to be related to discordant secretions of the adrenal hormones cortisol and dehydroepiandrosterone (DHEA), as well as the sulfate ester of DHEA (DHEA-S). The current study sought to evaluate the risk factors for sarcopenia in elderly patients with T2DM.

Design and Patients

We enrolled 108 consecutive elderly patients aged ≥65 years with T2DM (mean age, 76.2 ± 7.3 years; 43.5% males). Sarcopenia was assessed and diagnosed based on the Asian version of the diagnostic criteria regarding muscular strength, physical function, and muscle mass. We assessed various physical parameters, blood tests, and atherosclerosis markers and statistically determined the risk factors for sarcopenia.

Results

Multiple regression analysis showed that the independent risk factors for sarcopenia were a serum cortisol/DHEA-S ratio ≥0.2, diastolic blood pressure <70 mm Hg, Hb concentration <13 g/dL, and an ankle brachial index <1.0. The strongest risk factor for sarcopenia was a serum cortisol/DHEA-S ratio ≥0.2. An increase in the serum cortisol/DHEA-S ratio reflected higher cortisol values and lower DHEA-S values in patients with sarcopenia compared with those in nonsarcopenic patients. The concentrations of cortisol and DHEA-S, as well as the cortisol/DHEA-S ratio, changed in accordance with the severity of sarcopenia.

Conclusions

A relative increase in cortisol may reflect the presence of stress and stimulate muscle catabolism, whereas a relative decrease in DHEA-S may cause a decrease in the anabolic action of DHEA on muscle; the combination of these factors may lead to sarcopenia.

Low glycated hemoglobin level is associated with severity of frailty in Japanese elderly diabetes patients

AIMS/INTRODUCTION

Previously, a study using a narrowly defined (physical base) frailty scale reported that both good and bad (U-shaped curve) glycated hemoglobin (HbA1c) levels were frailty risk factors in patients with type 2 diabetes mellitus. However, no such studies in Japan have shown this. We aimed to evaluate the frailty risk factors including HbA1c in elderly Japanese patients with type 2 diabetes mellitus using a broadly defined (both physical and psychosocial base) frailty scale, the Clinical Frailty Scale (CFS).

MATERIALS AND METHODS

We randomly enrolled 132 elderly patients with type 2 diabetes mellitus (aged ≥65 years) and categorized the patients into nine stages of frailty using CFS. Because no patient had CFS 9, patients with a CFS score of 1-4 and 5-8 were defined as non-frail and frail, respectively. We attempted to identify the risk factors of frailty by investigating the association between CFS stage and various patient factors.

RESULTS

Multiple regression analysis showed that an increase in age, low levels of albumin, high-density lipoprotein cholesterol, systolic blood pressure, HbA1c, total cholesterol, and bodyweight were statistically significant and strong independent risk factors for frailty, suggesting that reverse metabolism owing to malnutrition in elderly type 2 diabetes mellitus patients might be involved.

CONCLUSIONS

HbA1c level was not a U-shaped risk for frailty, suggesting that relatively good glycemic control might be more important for frailty than poor control in elderly type 2 diabetes mellitus patients.

[A case of Pneumocystis carinii pneumonia with pulmonary cysts and increased level of serum KL-6]

In August, 1999, a 46-year-old man with fever, cough, and dyspnea was admitted to a hospital. On the basis of the clinical and radiographic findings, bacterial pneumonia was suspected. Antibiotics were not effective, because of atypical lymphocytes in the peripheral blood and positive anti-human T-cell leukemia virus antibody, and he was transferred to our hospital. A chest radiograph and a CT scan revealed bilateral ground-glass opacities with huge multiple cysts. Intensive treatment of Pneumocystis carinii pneumonia associated with human T-cell leukemia was unsuccessful. Pneumocystis carinii was found in the bronchoalveolar lavage fluid. Human T-cell leukemia and Pneumocystis carinii pneumonia were diagnosed. In this case, numerous pulmonary cysts were progressing rapidly, the largest cyst being 8.7 cm in diameter, and the largest cyst in our experience either in clinical practice or in reading of the literature in Pneumocystis carinii pneumonia. The maximum serum KL-6 was markedly increased to 15,200 U/ml, which is the highest level reported for Pneumocystis carinii pneumonia.

[A case of lymphangioleiomyomatosis with carcinomatous lymphangiosis]

A 66-year-old woman had a history of partial gastrectomy and resection of the residual stomach because of early gastric cancer and its recurrence. She had been suffering from dyspnea on effort, hemosputum, and cough since the age of 52 years. Chronic pulmonary emphysema and bronchial asthma were diagnosed when she was 59. On January 31, 1996, she was admitted to UOEH hospital with a complaint of increased dyspnea. In spite of treatment with oxygen, steroid, and inhaled anti-cholinergic agent, her condition deteriorated. Subsequently, she had DIC, respiratory failure and reticulolinear opacities were seen on chest radiographs, and she died 2 weeks after admission. At autopsy, the lung specimen revealed numerous cystic spaces surrounded by a proliferation of smooth muscle cells. Immunohistological examination showed these cells to be positive for HMB-45. Signet cells were seen in the lymphatics and vessels, and hemosiderin-laden macrophages were found in the alveolar spaces. This was a rare case of lymphangioleiomyomatosis with carcinomatous lymphangiosis.

Paradoxical pleural response to antituberculous chemotherapy and isoniazid-induced lupus. Review and report of two cases

Among 28 inpatients receiving antituberculous chemotherapies including isoniazid (INH) and rifampicin, we found 2 patients with newly developing pleural effusion in the hemithorax during the initial phase of successful chemotherapy. The analysis of the effusion fluids revealed an elevated level of antinuclear antibody and a decreased level of total component, which are findings compatible with lupus pleuritis. The peripheral lymphocyte stimulation test using INH was positive in 1 patient. To the best of our knowledge, there has been no published discussion of the relationship between a paradoxical response to antituberculous treatment and INH-induced lupus.

Clinicopathological study on liver dysfunction in measles

We analyzed the clinical course of eight patients with liver dysfunction in measles. All of the patients showed an elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH), but no jaundice. These levels returned to normal about 3 weeks after the onset of the rash. A percutaneous liver biopsy was done in two cases. Histological examination showed slight necrosis of liver cells but no significant changes in portal area. On electron microscopy, virus particles were not detected. We detected measles virus RNA in the liver specimen by RT-PCR, which suggests that the measles virus affects liver cells directly in measles.

[Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients. 5. The management of the patients excreting tubercle bacilli in a university hospital without isolation ward for tuberculosis]

The Japanese low ruled that the patients excreting tubercle bacilli should be treated in the isolated ward for tuberculosis. However, it is often difficult to transfer a patient with serious illness to the isolated ward with insufficient medical facilities. We investigated retrospectively the manner of the management of patients excreting tubercle bacilli in the Aichi Medical University Hospital without the isolation ward for tuberculosis. Materials were 166 patients (0.17%) out of 97,275 in-patients during 11 years since 1986 to 1996. Respiratory symptoms were observed in 114 patients (68.7% of 166 patients) on admission. The initial bacteriological examination was ordered by the attendant doctor within a week in 93 patients (81.6%) of 114 patients with respiratory symptoms. On the other hand, a half of the 52 patients without respiratory symptoms on admission were not examined for sputum bacteriology beyond a week. Anti-tuberculous treatment was started within a week after positive bacteriological results in 129 patients (77.7% of the whole 166 patients), while the treatment was not carried out or delayed in 21 patients (12.6%) because of the communication failure of the bacteriological report to the physicians. Some complications were observed in 101 patients: 21 diabetes mellitus, 20 cancers, 15 hematological disorders, 9 collagen diseases, 6 renal failures on dialysis. Serious illnesses were observed in 33 patients (20.6% of the 166 patients). Twenty-four patients (73% of the seriously ill patients) were died of renal failure, pancytopenia, cancer or respiratory failure. We considered that an isolated room for infectious tuberculosis with independent air conditioning system in a general hospital or a educational hospital was very convenient not only to the treatment of the patients with serious complications, but also to the education and training on tuberculosis for the medical student or medical stuffs.

[Differential diagnosis of pulmonary tuberculosis]

Differential diagnosis of pulmonary tuberculosis is discussed. Chest X-ray findings of pulmonary tuberculosis may be greatly varied, because tuberculosis may cause three different lesions: an exudative lesion, a proliferative lesion, and a fibrotic lesion, and because it may invade all the structure. Thus, the differential diagnosis of pulmonary tuberculosis includes very many diseases. The most important differential diagnosis of nodule is tuberculoma and lung cancer. The clue of the diagnosis is the feature of the nodule and surrounding structure, such as pleural indentation, or knotching. There is, however, the limitation of the diagnosis by imaging: some tuberculoma may show the identical feature with the pulmonary adenocarcinoma. It is important to gather the pathological or bacteriological evidences by means of suitable procedures.

[Pulmonary thromboembolism that developed during an airplane flight "economy-class syndrome"]

The occurrence of thromboembolic phenomena during long-duration airplane flights is called "economy-class syndrome". Recently it has become more popular for Japanese to go abroad by airplane, and an increase in the prevalence of pulmonary thromboembolism should be expected. However, there are few reports of the economy-class syndrome in Japan. A 52-year-old woman was admitted to our hospital because of chest discomfort and dyspnea that developed during an airplane flight. We suspected pulmonary thromboembolism, on the basis of a chest X-ray film and on electrocardiogram. A ventilation-perfusion lung scan disclosed mismatching between ventilation and perfusion in the right upper lung field. Pulmonary thromboembolism was confirmed by pulmonary arteriography. The patient was treated with heparin and urokinase. A phlebogram of the legs showed no significant findings. There was no history of thromboembolic disease or of consumption of oral contraceptives. We conclude that the pulmonary thromboembolism might have been caused by stasis of blood in the lower limb veins during the airplane flight. We emphasize the importance of including pulmonary thromboembolism in the differential diagnosis of patients with chest discomfort and dyspnea that develop during airplane flights. No noninvasive test can lead to a definitive diagnosis of pulmonary thromboembolism. Early pulmonary angiography should be recommended when pulmonary thromboembolism is suspected.

A case of pulmonary reaction with skin eruption showing a positive peripheral lymphocyte stimulation test result for ethambutol

We report a case of an elderly male whose pulmonary reaction with skin eruption occurred in the initial phase of chemotherapy composed of isoniazid, rifampicin, and ethambutol (EB). A peripheral lymphocyte stimulation test (LST) showed a positive reaction only to EB. The blood serum analysis of the patient when this reaction occurred revealed an elevated titer of antinuclear antibody. Computed tomography (CT) scan films of the chest when the pulmonary reaction occurred showed multifocal subpleural consolidations. There has been only one reported case of EB-induced pulmonary reaction and its clinical course was very similar to ours. However, LST results and computed tomography (CT) scan findings of the chest were not documented in that case.

Interstitial pneumonitis and fibrosis associated with the inhalation of hair spray

We describe a 49-year-old female Japanese hairdresser who presented with a 5-year history of exertional dyspnea, a nonproductive cough, and occasional febrile episodes. Histological analysis revealed interstitial fibrosis with mononuclear cell infiltration, foreign body granuloma, and numerous intra-alveolar macrophages and multinucleated giant cells of foreign body type. Arterial blood gas, pulmonary function studies and computed tomographic findings demonstrated improvement 6 months after cessation of exposure to the salon. Bronchoalveolar lavage fluid findings suggested that the development of lung disease in this case was triggered by an allergic mechanism rather than the storage of hair spray ingredients in the lung.

[Usefulness anti-PPD antibody in the medical practice of tuberculosis]

The decline rate of tuberculosis has decreased recently in Japan. One of the problems is the tendency of increasing doctor's delay in the diagnosis of tuberculosis. One of measures against this problem is to develop a new laboratory diagnostic method. We studied anti-PPD (Purified Protein Derivative of tuberculin) antibody in serum, pleural effusion, and bronchoalveolar lavage fluid (BAL), and found its clinical usefulness in the medical practice of tuberculosis. Firstly the methods of enzyme linked immunosorbent assay (ELISA) for the antibody to PPD were examined. The expression of antibody titer in optical density was found to be the most accurate and most simple method, and was applied in this study. IgG, IgM and IgA antibody to PPD were measured in serum, BAL and pleural effusion obtained from 122 patients with pulmonary tuberculosis, 54 patients with tuberculous pleurisy, 39 patients with lung cancer, 39 patients with malignant pleurisy, 37 patients with pneumonia, 26 patients with chronic bronchitis, 51 patients with sarcoidosis, or 49 control subjects. Serum level of IgG, IgM, and IgA antibody to PPD was elevated in tuberculosis compared with those in other diseases or control subjects. The difference was most distinctive in IgG antibody. Serum IgG antibody was higher in chronic case than in acute case and IgM antibody was higher in acute case than in chronic case. IgG, IgM and IgA antibody in pleural effusion was elevated in tuberculous pleurisy compared with those in malignant pleurisy. IgG antibody was higher in chronic tuberculous pleurisy than in acute tuberculous pleurisy and IgM antibody was higher in acute pleurisy than in chronic one.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolism of 2,6-dinitrotoluene in male Wistar rat

1. Unchanged 2,6-dinitrotoluene (2,6-DNT), 2-amino-6-nitrotoluene, 2,6-dinitrobenzyl alcohol, 2-amino-6-nitrobenzyl alcohol, conjugated 2,6-dinitrobenzyl alcohol and conjugated 2-amino-6-nitrobenzyl alcohol were detected in urine of male Wistar rats dosed with 2,6-DNT. The major metabolite was conjugated 2,6-dinitrobenzyl alcohol, which accounted for about 1.5% of the dose. 2. Unchanged 2,6-DNT, 2-amino-6-nitrotoluene, 2,6-dinitrobenzyl alcohol, and conjugates of 2,6-dinitrobenzyl alcohol, 2-amino-6-nitrotoluene and 2,6-dinitrobenzaldehyde were detected in the bile of rats dosed with 2,6-DNT. The major metabolite was conjugated 2,6-dinitrobenzyl alcohol, which accounted for 30% of the dose. Conjugates of 2,6-dinitrobenzyl alcohol (major) and 2,6-dinitrobenzaldehyde (minor) were common biliary metabolites in rats dosed with 2,6-dinitrobenzyl alcohol or 2,6-dinitrobenzaldehyde. 3. 2,6-Dinitrobenzyl alcohol and 2,6-dinitrobenzaldehyde were detected by incubating bile from rats given 2,6-DNT with rat intestinal contents under N2. 4. Incubation of 2,6-DNT with hepatic microsomal preparations gave 2,6-dinitrobenzyl alcohol. Incubation of 2,6-dinitrobenzyl alcohol with microsomal plus cytosol preparations gave 2,6-dinitrobenzaldehyde. Incubation of 2,6-dinitrobenzaldehyde with cytosol preparations gave 2,6-dinitrobenzyl alcohol and 2,6-dinitrobenzoic acid. The activities of 2,6-DNT oxidation to 2,6-dinitrobenzyl alcohol, 2,6-dinitrobenzyl alcohol oxidation to 2,6-dinitrobenzaldehyde, 2,6-dinitrobenzaldehyde oxidation to 2,6-dinitrobenzoic acid, and 2,6-dinitrobenzaldehyde reduction to 2,6-dinitrobenzyl alcohol were 22.0, 4.7, 1.3, and 23.3 nmol formed/g liver per min, respectively. 5. These results indicate that 2,6-dinitrobenzaldehyde, an intermediary metabolite of 2,6-DNT in male Wistar rats, is produced either by oxidation of 2,6-DNT in the liver, or by oxidation of 2,6-dinitrobenzyl alcohol formed by hydrolysis of 2,6-dinitrobenzyl alcohol conjugates excreted in the bile, and further indicate that enterohepatic circulation of 2,6-dinitrobenzyl alcohol and 2,6-dinitrobenzaldehyde occurs. This result, together with previous findings, shows that there are metabolic differences, including the biliary excretion of a diol glucuronide of 2,6-dinitrobenzaldehyde and the lack of urinary excretion of 2,6-dinitrobenzoic acid, between 2,4-DNT and 2,6-DNT in male Wistar rat.

Metabolism of 2,4-dinitrotoluene and 2,6-dinitrotoluene, and their dinitrobenzyl alcohols and dinitrobenzaldehydes by Wistar and Sprague-Dawley rat liver microsomal and cytosol fractions

The metabolism of 2,4-dinitrotoluene (2,4-DNT), 2,4-dinitrobenzyl alcohol (2,4-DNB), 2,4-dinitrobenzaldehyde (2,4-DNBAl), 2,6-DNT, 2,6-DNB and 2,6-DNBAl in the microsomal and cytosol fractions prepared from unfortified male Wistar and male Sprague-Dawley (S.D.) rat livers was investigated. Data obtained by high-performance liquid chromatography (HPLC) indicated that the products of dinitrotoluenes (2,4-DNT and 2,6-DNT), dinitrobenzyl alcohols (2,4-DNB and 2,6-DNB), and dinitrobenzaldehydes (2,4-DNBAl and 2,6-DNBAl) in the microsomal and cytosol preparations containing nicotinamide adenine dinucleotide phosphate (NAD(P] and reduced NAD(P)(NAD(P)H) were dinitrobenzyl alcohols (2,4-DNB and 2,6-DNB), dinitrobenzaldehydes (2,4-DNBAl and 2,6-DNBAl), and dinitrobenzoic acids (2,4-DNBA and 2,6-DNBA), and dinitrobenzyl alcohols (2,4-DNB and 2,6-DNB), respectively. From these results, it was concluded that the dinitrobenzaldehydes (2,4-DNBAl and 2,6-DNBAl) were intermediates in the oxidations of dinitrobenzyl alchols (2,4-DNB and 2,6-DNB) to dinitrobenzoic acids (2,4-DNBA and 2,6-DNBA), and that the oxidations of dinitrobenzyl alcohols (2,4-DNB and 2,6-DNB) to dinitrobenzaldehydes (2,4-DNBAl and 2,6-DNBAl) and the reductions of dinitrobenzaldehydes to dinitrobenzyl alcohols (2,4-DNB and 2,6-DNB) were reversible.(ABSTRACT TRUNCATED AT 250 WORDS)