A case of relapsing anti-GBM disease secondary to alemtuzumab therapy

We report the first case of relapsing anti-GBM disease secondary to alemtuzumab in a 24-year-old female with relapsing-remitting multiple sclerosis. Initial anti-GBM disease was detected 10 months after alemtuzumab was given and was diagnosed by demonstrating high anti-GBM antibody titers and with a confirmatory kidney biopsy. The patient presented with a rapidly progressive glomerulonephritis with no pulmonary involvement. After appropriate treatment, the patient went into remission with undetectable anti-GBM antibodies. However, 20 months later, the patient re-presented with relapsing anti-GBM disease. Despite aggressive treatment, the patient became dialysis-dependent.

Hospitalizations Among Adults With CKD in Public Renal Specialty Practices: A Retrospective Study From Queensland, Australia

Rationale & Objective

Little is known about hospital admissions in nondialysis patients with chronic kidney disease (CKD) before death or starting kidney replacement therapy (KRT).

Study Design

Retrospective observational cohort study.

Setting & Participants

Hospitalizations among 7,201 patients with CKD from 10 public renal clinics in Queensland (QLD), enrolled in the CKD.QLD registry starting in May 2011, were followed for 25,496.34 person-years until they started receiving KRT or died, or until June 30, 2018.

Predictors

Demographic and clinical characteristics of patients with CKD.

Outcomes

Hospital admissions.

Analytical Approach

We evaluated the association of demographic and clinical features with hospitalizations, length of hospital stay, and cost.

Results

Approximately 81.5% of the patients were admitted at least once, with 42,283 admissions, costing Australian dollars (AUD) 231 million. The average number of admissions per person-year was 1.7, and the cost was AUD 9,060, 10 times and 2 times their Australian averages, respectively. Single (1-day) admissions constituted 59.2% of all the hospital episodes, led by neoplasms (largely chemotherapy), anemia, CKD-related conditions and eye conditions (largely cataract extractions), but only 14.8% of the total costs. Approximately 41% of admissions were >1-day admissions, constituting 85.2% of the total costs, with cardiovascular conditions, respiratory conditions, CKD-related conditions, and injuries, fractures, or poisoning being the dominant causes. Readmission within 30 days of discharge constituted >42% of the admissions and 46.8% costs. Admissions not directly related to CKD constituted 90% of the admissions and costs. More than 40% of the admissions and costs were through the emergency department. Approximately 19% of the hospitalized patients and 27% of the admissions did not have kidney disease mentioned as either principal or associate causes.

Limitations

Variable follow-up times because of different dates of consent.

Conclusions

The hospital burden of patients with CKD is mainly driven by complex multiday admissions and readmissions involving comorbid conditions, which may not be directly related to their CKD. Strategies to prevent these complex admissions and readmissions should minimize hospital costs and outcomes.

Plain-Language Summary

We analyzed primary causes, types, and costs of hospitalizations among 7,201 patients with chronic kidney disease (CKD) from renal speciality clinics across Queensland, Australia, over an average follow-up of 3.54 years. The average annual cost per person was $9,060, and was the highest in those with more advanced CKD, higher age, and with diabetes. More than 85% of costs were driven by more complex hospitalizations with longer length of stay. Cardiovascular disease was the single largest contributor for hospitalizations, length of hospital stay, and total costs. Readmission within 30 days of discharge, particularly for the same disorder, and multiday admissions should be the main targets for mitigation of hospital costs in this population.

Chronic kidney disease in public renal practices in Queensland, Australia, 2011-2018

AIM

To describe adults with (non-dialysis) chronic kidney disease (CKD) in nine public renal practice sites in the Australian state of Queensland.

METHODS

7,060 persons were recruited to a CKD Registry in May 2011 and until start of kidney replacement therapy (KRT), death without KRT or June 2018, for a median period of 3.4 years.

RESULTS

The cohort comprised 7,060 persons, 52% males, with a median age of 68 yr; 85% had CKD stages 3A to 5, 45.4% were diabetic, 24.6% had diabetic nephropathy, and 51.7% were obese. Younger persons mostly had glomerulonephritis or genetic renal disease, while older persons mostly had diabetic nephropathy, renovascular disease and multiple diagnoses. Proportions of specific renal diagnoses varied >2-fold across sites. Over the first year, eGFR fell in 24% but was stable or improved in 76%. Over follow up, 10% started KRT, at a median age of 62 yr, most with CKD stages 4 and 5 at consent, while 18.8% died without KRT, at a median age of 80 yr. Indigenous people were younger at consent and more often had diabetes and diabetic kidney disease and had higher incidence rates of KRT.

CONCLUSION

The spectrum of characteristics in CKD patients in renal practices is much broader than represented by the minority who ultimately start KRT. Variation in CKD by causes, age, site and Indigenous status, the prevalence of obesity, relative stability of kidney function in many persons over the short term, and differences between those who KRT and die without KRT are all important to explore.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

BACKGROUND

End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.

OBJECTIVE

The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.

METHODS

A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.

RESULTS

We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p < 0.001), history of foot ulceration (OR 81 [18.20-360.48] p < 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p < 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p < 0.001), foot deformity (OR 23.62 [5.82-95.93] p < 0.001), retinopathy (OR 6.08 [2.64-14.02] p < 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p < 0.05).

CONCLUSION

There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

Methodological quality assessment of paper-based systematic reviews published in oral health

OBJECTIVES

This study aimed to conduct a methodological assessment of paper-based systematic reviews (SR) published in oral health using a validated checklist. A secondary objective was to explore temporal trends on methodological quality.

MATERIAL AND METHODS

Two electronic databases (OVID Medline and OVID EMBASE) were searched for paper-based SR of interventions published in oral health from inception to October 2014. Manual searches of the reference lists of paper-based SR were also conducted. Methodological quality of included paper-based SR was assessed using an 11-item questionnaire, Assessment of Multiple Systematic Reviews (AMSTAR) checklist. Methodological quality was summarized using the median and inter-quartile range (IQR) of the AMSTAR score over different categories and time periods.

RESULTS

A total of 643 paper-based SR were included. The overall median AMSTAR score was 4 (IQR 2-6). The highest median score (5) was found in the pain dentistry and periodontology fields, while the lowest median score (3) was found in implant dentistry, restorative dentistry, oral medicine, and prosthodontics. The number of paper-based SR per year and the median AMSTAR score increased over time (median score in 1990s was 2 (IQR 2-3), 2000s was 4 (IQR 2-5), and 2010 onwards was 5 (IQR 3-6)).

CONCLUSION

Although the methodological quality of paper-based SR published in oral health has improved in the last few years, there is still scope for improving quality in most evaluated dental specialties.

CLINICAL RELEVANCE

Large-scale assessment of methodological quality of dental SR highlights areas of methodological strengths and weaknesses that can be targeted in future publications to encourage better quality review methodology.

The expression of PD-L1 APE1 and P53 in hepatocellular carcinoma and its relationship to clinical pathology

OBJECTIVE

To study the expression of programmed death-ligand1 (PD-L1) in hepatocellular carcinoma and its relationship with clinicopathological characteristics and, prognosis of hepatocellular carcinoma and APE1, P53 protein expression levels.

PATIENTS AND METHODS

A total of 128 patients with hepatocellular carcinoma were enrolled in this study. The expression of PD-L1, APE1 and P53 were detected by immunohistochemistry.Use immunohistochemical ABC staining method to detect the expression levels of PD-L1, APE1 and P53 protein in the hepatocellular carcinoma of 128 cases.

RESULTS

Positive The positive expression rates levels of PD-L1, APE1, and P53 protein in hepatocellular carcinoma tissues are were 82.03%, 92.19%, and 60.94%. PD-L1 positive expression were significantly associated with clinical stage, The PD-L1 protein has a high expression in patients with I ~ II stage liver cancerHBV infection positive and nonportal vein thrombosis (p=0.041; p=0.030; p=0.014). It is inversely correlated with P53 and PD-L1 expression (correlation coefficient -0.227, p=0.010), and positively correlated with APE1 expression (correlation coefficient 0.189, p=0.032). The expression of PD-L1 is associated with the survival time of patients with hepatocellular carcinoma, and the median survival time of patients with high expression of PD-L1 is ten months. The median survival time of patients with low expression is five months (p=0.001). The relationship between the expression of APE1 and P53 protein and overall survival time of patients with hepatocellular carcinoma has not been found.

CONCLUSIONS

The PD-L1 and APE1 expression in hepatocellular carcinoma are related to the level of the expression of P53 protein. The expression state of PD-L1 may be a prognostic factor in hepatocellular carcinoma.

Differential effects of maternal nutrient restriction through pregnancy on kidney development and later blood pressure control in the resulting offspring

The mechanisms whereby maternal nutritional manipulation through pregnancy result in altered blood pressure in the offspring may include changes in fetal and newborn and adult renal prostaglandin (PG) synthesis, metabolism, and receptor expression. Since the postnatal effects of nutrient restriction on the renal PG synthesis and receptor system during nephrogenesis in conjunction with nephron numbers and blood pressure have not been evaluated in the rat, the present study examined the effect of reducing maternal food intake by 50% of ad libitum through pregnancy on young male rats. Six control-fed mothers and eight nutrient-restricted pregnant rats with single litter mates were used at each sampling time point, most of which occurred during nephrogenesis. Offspring of nutrient-restricted dams were lighter from birth to 3 days. This was accompanied by reduced PGE2, with smaller kidneys up to 14 days. Nutrient restriction also decreased mRNA expression of the PG synthesis enzyme, had little effect on the PG receptors, and increased mRNA expression of the degradation enzyme during nephrogenesis and the glucocorticoid receptor in the adult kidney. These mRNA changes were normally accompanied by similar changes in protein. Nephron number was also reduced from 7 days up to adulthood when blood pressure (measured by telemetry) did not increase as much as in control offspring during the dark, active period. In conclusion, maternal nutrient restriction suppressed renal PG concentrations in the offspring, and this was associated with suppressed kidney growth and development and decreased blood pressure.

Neutrophil priming by cytokines and vitamin D binding protein (Gc-globulin): impact on C5a-mediated chemotaxis, degranulation and respiratory burst

At the site of acute inflammation, leukocytes are confronted with multiple mediators which are expected to modulate each other with respect to cell responses to the individual ligand. Previous contact of neutrophils with pro-inflammatory cytokines, such as TNF-alpha or GM-CSF, or with the vitamin D binding protein (Gc-globulin) leads to the alteration of either multiple or rather distinct C5a-mediated neutrophil functions. Gc-globulin, the transport protein for 25-(OH)-D3, serves selectively as a cochemotactic factor for C5a/Ca(des)Arg. In contrast, TNF-alpha and GM-CSF, previously shown to modulate FMLP-induced neutrophil responses, are able to reduce C5a-mediated neutrophil chemotaxis, but augment their degranulation and respiratory burst activity. Cytokine priming was shown to be accompanied by a down-regulation of C5a receptors (CD88) whereas vitamin D binding protein had no impact on the level of neutrophil C5a receptors. C5a itself diminishes chemotaxis as well as degranulation and oxidative burst in response to a second dose of the same ligand (homologous desensitization). A similar effect, termed heterologous desensitization, occurs, if cell responses to a given mediator (e.g. to C5a) are reduced or even abolished upon the activation of another receptor of the same G-protein coupled chemoattractant receptor subfamily (e.g. receptors for FMLP or IL-8). In concert with C5a, certain molecules may either augment chemotaxis or shift neutrophil effector functions from migration to exocytosis, an essential step within the sequence of events in a coordinated inflammatory response.

Improved cardiovascular variables during acetate free biofiltration

BACKGROUND AND AIM

Acetate free biofiltration (AFB) provides a well-tolerated and efficient renal replacement therapy. Replacement of most of the acetate by bicarbonate in standard hemodialysis has resulted in a decrease in intradialytic hypotensive episodes. This has been attributed to a decrease in the acetate-induced impairment of myocardial contractility. The aim of the present study was to investigate whether the total absence of acetate in AFB would further enhance dialysis stability and improve cardiovascular status.

PATIENTS AND METHODS

In a long-term, randomized trial we included 11 patients on AFB and 9 patients on bicarbonate hemodialysis (HD) for one year. Patients were matched for age, sex and urea reduction rate, but not for the presence of hypertension or cardiovascular history. During each dialysis session blood pressure was measured automatically and the presence of significant hypotension was recorded. Antihypertensive medication was registered every three months. Before and at the end of the study M-mode echocardiography was performed and left ventricular mass index (LVMi) was calculated. Every six months serum lipids were measured.

RESULTS

At baseline, mean arterial pressure (MAP) before and after dialysis, the percentage of hypotensive dialyses, LVMi and serum lipids did not differ between AFB and HD. Pre-dialysis MAP decreased in AFB (from 112.5 to 107 mmHg) and increased in HD (from 101.7 to 105.3 mmHg; p = 0.01, HD versus AFB). Postdialysis MAP remained stable in both groups (AFB 91.6 mmHg at 0 months and 90.6 mmHg at 12 months, for HD respectively 83.9 and 86.5 mmHg, NS). The percentage of hypotensive dialyses did not differ significantly between the groups during the study. LVMi decreased in AFB from 195.4 to 162.1 gr/m2 and increased in HD patients from 153.8 to 182.5 gr/m2 (p = 0.03 HD versus AFB). The number of antihypertensive medications per patient did not differ between groups. Serum lipids remained unchanged during the trial.

CONCLUSION

In conclusion, AFB provided better control of pre-dialysis MAP compared to HD, and stable postdialysis MAP. The percentage of dialysis sessions with hypotension did not differ. LVMi decreased significantly in AFB, but rose in HD.

[Changes of bone cytokines and compensating regulation in tail suspended rats]

The aim of the study was to determine the relationship between the changes in bone metabolism and insulin-like growth factor--I(IGF-I) as well as epidermal growth factor (EGF). 10 Male S.D. rats were tail-suspended for 28 d with another 10 free active rats as control. The results showed that mineral content increased significantly, osteocalcin and albumin content had no significant change, but IGF-I and EGF content increased significantly in L3 in the suspended rats. The results suggest that although there are no change in osteocalcin and albumin content, the phenomenon of bone mineral loss still exists in the suspended rats. The increase in IGF-I and EGF content may be one of the compensation responses of the bone in the suspended rats.

[Fifteen years' experience in reformed Beijing tuberculosis control programme]

Since 1978 a new tuberculosis control programme based on WHO recommended modern concept has been started in Beijing. A sound network of tuberculosis control service has been organized. Fully supervised intermittent chemotherapy with newly diagnosed cases of smear-positive pulmonary tuberculosis as top priority has achieved satisfactory high rates of compliance and sputum conversion in all 18 districts and counties of the city. Sputum examination was emphasized as the main tool for diagnosis and determination of criterion of cure. Drugs are provided free to those who are needy. On the basis of good implementation of fully supervised chemotherapy for newly diagnosed smear-positive cases, fully supervised retreatment for chronic infectious cases was started, and it resulted in a rapid reduction of the prevalence of chronic infectious tuberculosis from 69.9 in 1979 to 6 in 1985 per 100,000. The prevalence of smear-positive tuberculosis of Beijing during the 3 National Surveys of Tuberculosis was 127, 56 and 16 per 100,000 in 1979, 1985 and 1990 respectively, with an average annual reduction rate of 17%.

Esophageal dysfunction as a cause of angina pectoris ("linked angina"): does it exist?

PURPOSE

The differentiation between cardiac and esophageal causes of retrosternal chest pain is notoriously difficult. Theoretically, cardiac and esophageal causes may coexist. It has also been reported that gastroesophageal reflux and esophageal motor abnormalities may elicit myocardial ischemia and chest pain, a phenomenon called linked angina pectoris. The aim of this study was to assess the incidence of esophageal abnormalities as a cause of retrosternal chest pain in patients with previously documented coronary artery disease.

PATIENTS AND METHODS

Thirty consecutive patients were studied, all of whom had undergone coronary arteriography. The patients were studied after they were admitted to the coronary care unit with an attack of typical chest pain. On electrocardiograms (ECGs) taken during pain, 15 patients (group I) had new signs of ischemia; the other 15 patients (group II) did not. In none of the patients were cardiac enzymes elevated. As soon as possible, but within 2 hours after admission, combined 24-hour recording of esophageal pressure and pH was performed. During chest pain, 12-lead ECG recording was carried out.

RESULTS

In group I, all 15 patients experienced one or more pain episodes during admission, 25 of which were associated with ischemic electrocardiographic changes. The other two episodes were reflux-related. Only one of the 25 ischemia-associated pain episodes was also reflux-related, ie, it was preceded by a reflux episode. In group II, 19 chest pain episodes occurred in 11 patients. None of these was associated with electrocardiographic changes, but 8 were associated with reflux (42%) and 8 with abnormal esophageal motility (42%).

CONCLUSION

Linked angina is a rare phenomenon.

Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recording of the esophagus

Twenty-four-hour recording of esophageal pressure and pH was performed successfully in 41 patients admitted to the coronary care unit of a general hospital who had an episode of acute, prolonged retrosternal chest pain and who were initially suspected of suffering from coronary artery disease (severe angina pectoris, myocardial infarction), but in whom the pain was subsequently shown not to be of cardiac origin. The recordings were analyzed with fully automated techniques. A pain episode was considered to be related to abnormal esophageal motility when contraction amplitudes or durations in the pain episode exceeded the patient's upper limit of normal (97.5th percentile) or when the proportion of abnormal propagated contractions (simultaneous, nontransmitted) in the pain episode was significantly increased (chi 2 test). Thirty patients (73%) had one or more pain episodes (in total 63 pain episodes) during the 24-hour recording. Forty-three percent of the pain episodes was related to abnormal motility and 30% to reflux, and 27% was not related to esophageal function disturbance. Using the criterium that the symptom index had to be greater than or equal to 75%, it was found that the pain was related to reflux in 13 patients (43%) and to motor abnormalities in 10 patients (33%). It is concluded that in the majority of patients acutely admitted with noncardiac chest pain, esophageal motor abnormalities and reflux can be shown to be the likely cause of the symptoms.

Short and long term predictive value of admission wall motion score in acute myocardial infarction. A cross sectional echocardiographic study of 345 patients

A score of left ventricular segmental wall motion was used as a convenient rapid way to assess overall left ventricular function in acute myocardial infarction. Its success in risk stratification at admission was assessed by a blind review of cross sectional echocardiographic tape recordings from multiple acoustic windows. Sixty nine (20%) of the 345 patients died during hospital stay or within a one year follow up. The mean (SD) wall motion score in those who died was significantly higher than in those who survived (16.2 (5.9) vs 5.7 (3.9)). There were no differences between the group that died in hospital within three months of discharge and the group that died between three months and one year after discharge. Among the 31 patients who died in hospital, however, wall motion score was highest in 15 patients dying of cardiogenic shock (19.2 (4.2)). In 16 patients with lethal ruptures it was 13.5 (6.1). The nine patients with free wall ruptures had higher wall motion scores than those with ventricular septal rupture or papillary muscle rupture (15.7 (6.9) vs 8.5 (5.3)). Eight (3.3%) of 245 patients with a score less than 10 died, compared with 61 (61%) of 100 scoring greater than or equal to 10. The sensitivity of a score of greater than or equal to 10 in predicting death within one year was 88%, the specificity was 86%, the positive predictive value was 61%, and the negative predictive value was 97%.

Two-dimensional echocardiography during percutaneous transluminal coronary angioplasty

In order to study myocardial and clinical events during transient coronary occlusion in humans, two-dimensional echocardiography was continuously performed in 15 patients undergoing 49 balloon inflations during percutaneous transluminal coronary angioplasty (PTCA). Transient segmental asynergy developed in all patients 8 +/- 3 seconds after balloon inflation and returned to baseline 19 +/- 8 seconds after balloon deflation. Segmental dyskinesis was seen in only 8 of 11 patients undergoing PTCA of the left anterior descending artery (LAD). A wall motion score, based on degree of asynergy of 13 segments of the left ventricle, was significantly higher during LAD than during right coronary artery inflation (7.9 +/- 1.3 vs 4.0 +/- 1.4, p less than 0.01). Left ventricular size index increased significantly during balloon inflation, from 179 +/- 9 to 196 +/- 10 mm (p less than 0.01). Four patients developed transient ST segment changes in the extremity leads of the ECG and five patients had angina pectoris. The very first sign of ischemia in three patients, who developed all of these symptoms together, was consistently asynergy, followed by ECG changes, and last, angina pectoris. Thus during PTCA, transient asynergy and left ventricular dilatation develop, which are often clinically silent.

Incidence, timing and prognostic value of left ventricular aneurysm formation after myocardial infarction: a prospective, serial echocardiographic study of 158 patients

Serial 2-dimensional echocardiography was performed prospectively in 158 consecutive patients with first acute myocardial infarction (AMI) to determine the incidence of left ventricular (LV) aneurysm formation and the time course required for, and the clinical significance of, onset of LV aneurysm formation. Studies were performed throughout the first 5 days and after 3 months and 1 year. LV aneurysm was defined as an abnormal bulge in the LV contour during both systole and diastole. Eighty-four patients had anterior, 68 posterior and 6 anteroposterior AMI defined echocardiographically. During the study period, LV aneurysm was found in 35 of 158 patients (22%): in anterior AMI in 27, in posterior AMI in 6 and in anteroposterior AMI in 2. No new aneurysm developed after 3 months. Early aneurysm formation, during the first 5 days after AMI, was seen in 15 patients with anterior infarction. Twelve of these 15 (80%) died within 1 year (10 within 3 months), in contrast to 5 (25%) of the remaining 20 patients with LV aneurysm (p less than 0.05). Dyskinesia of the anterior wall in the acute stage usually resulted in aneurysm formation. Thus, LV aneurysm formation is seen in 22% of mostly anterior AMI and occurs within 3 months after AMI. Early aneurysm formation is associated with a high 3-month (67%) and 1-year (80%) mortality rate.

Assessment of left ventricular aneurysm resectability by two-dimensional echocardiography

Mortality of surgical resection of a left ventricular (LV) aneurysm is largely determined by size and function of nonaneurysmal or residual myocardium. A residual myocardial index was determined using 2-dimensional echocardiography (2-D echo) in 56 consecutive patients scheduled for LV aneurysmectomy, and these results were correlated with surgical outcome. The index was calculated using 3 apical cross sections: the 2- and 4-chamber views and the long-axis view. These views were recorded at mutual angles of 60 degrees. In each view the end-diastolic length of normally moving endocardium of the 2 opposite walls was expressed as a fraction of the end-diastolic LV long axis. The index was assessed by averaging the 6 ratios obtained. In 41 survivors the index ranged from 40 to 71% (mean +/- standard deviation 53 +/- 7.8) and in 15 nonsurvivors from 29 to 67% (mean 38 +/- 8.5, p less than 0.01). With 1 exception, this echocardiographic index sharply separated survivors from nonsurvivors. The lower limit to survive aneurysmectomy was 40%.

Quantification of myocardium at risk in unstable angina: comparison of patients with and without previous infarction

We studied two subgroups of patients with unstable angina pectoris: 35 without (Group A) and 73 with (Group B) previous myocardial infarction. The severity of coronary artery disease was assessed by means of a previously described scoring system. This scoring system was used to calculate the proportion of left ventricular myocardium fed by significantly (greater than 75% luminal area reduction) stenosed coronary arteries (called percent myocardium threatened). To estimate the amount of myocardium lost by previous infarction we used a four-point wall motion score for each of seven left ventricular wall segments: a value of 2 was given to normokinetic segments, 1 for hypokinetic segments, 0 for akinetic and -1 for dyskinetic segments. The deficit in wall motion score was used to estimate the amount of myocardium infarcted. This was then subtracted from the proportion of myocardium threatened to yield the proportion of myocardium still in jeopardy. We found a different extent and severity of coronary artery disease between the two subgroups. In the group without previous infarction, the numbers of patients with one-, two- and three-vessel disease were 15, 9, and 11, respectively (or 43, 26, and 31%). In those with a previous infarction, the respective numbers were 11, 23, and 39 (or 15, 31.5, and 53.5%). This difference is statistically significant (P less than 0.01). The mean number of stenotic arteries was 1.9 +/- 0.9 in the patients without previous infarction and 2.4 +/- 0.7 in those with an infarction (P less than 0.05). Using the above-mentioned scoring system the score was 3.2 +/- 1.4 in patients without previous infarction and 4.0 +/- 1.6 in those with previous infarction (P less than 0.05). The percent myocardium threatened was 53.6 +/- 24.1 vs. 68.7 +/- 24.7 (P less than 0.01). Wall motion score was 13.8 +/- 0.6 in Group A and 10.6 +/- 3.1 in Group B (P less than 0.01), which gives values for the proportion of myocardium infarcted of 1.6 +/- 4.2 and 24.2 +/- 22.0%, respectively. The percentage still in jeopardy (after subtracting that infarcted from that threatened) was 51.8 +/- 22.7 in those without and 44.2 +/- 31.1 in those with a previous infarction: this difference is not statistically significant. We conclude that patients with unstable angina pectoris who have sustained a previous myocardial infarction have more severe coronary artery disease than similar patients without previous infarction. The amount of left ventricular myocardium still in jeopardy of becoming infarcted is, however, the same.

Embolic potential of left ventricular thrombus after myocardial infarction: a two-dimensional echocardiographic study of 119 patients

Left ventricular thrombus complicating myocardial infarction was diagnosed by two-dimensional echocardiography in 119 patients. The infarct site was anterior in 98 patients and inferior in 11. Systemic embolism occurred in 26 patients (stroke in 18, lower limb embolism in 7 and mesenteric embolism in 1). A protruding configuration of the thrombus was more common in the patients with embolism than in those without (23 [88%] of 26 versus 17 [18%] of 93) (p less than 0.01). Free mobility of the thrombus was found in 15 (58%) of 26 and 3 (3%) of 93 cases, respectively (p less than 0.01). In predicting embolism, protruding thrombus configuration had a sensitivity of 88% and a specificity of 82%, and positive and negative predictive accuracy was 57 and 96%, respectively. For free mobility of the thrombus, sensitivity was 58%, specificity 97%, positive predictive accuracy 85% and negative predictive accuracy 89%. In the 46 patients whose echocardiogram was obtained during the hospital admission for the index infarct, repeat echocardiograms were obtained during oral anticoagulant therapy. Twelve of these 46 patients had embolism and 2 of the 12 died. In seven of these patients, full dose oral anticoagulant therapy had been given before embolism occurred and in five it was started after an embolic event. The thrombus decreased in size or disappeared in six patients; in four the thrombus showed no change, and in two of these four emboli recurred despite anticoagulation. It is concluded that two-dimensional echocardiography may help delineate the embolic potential of left ventricular thrombus complicating myocardial infarction and may be of value in weighing the benefits and disadvantages of oral anticoagulant therapy.

Immediate and long-term effects of nicardipine, at rest and during exercise, in patients with coronary artery disease

Haemodynamic effects of nicardipine were studied in 12 patients with documented coronary artery disease. Following nicardipine 10 mg, given intravenously to patients at rest, the heart rate increased, mean arterial pressure decreased, cardiac index increased, and systemic vascular resistance decreased significantly. Compared with the control exercise values, significant increases in heart rate and cardiac index and significant decreases in mean arterial pressure, systemic vascular resistance, and left ventricular end diastolic pressure occurred when nicardipine, 10 mg i.v., was given to the patients during exercise. All 12 patients complained of angina during the exercise phase, but following treatment with nicardipine, 10 mg i.v., only four patients reported angina when exercising to the same level. Exercise capacity on oral nicardipine treatment tended to increase whilst the ejection fraction response to exercise did not change. Thus, nicardipine was a potent vasodilator, which produced a marked reduction of systemic vascular resistance and left ventricular end diastolic pressure during exercise.

Long-term follow-up of left ventricular thrombus after acute myocardial infarction. A two-dimensional echocardiographic study in 96 patients

To determine the incidence, natural history, and relation to anticoagulant therapy of left ventricular thrombus (LVT) following acute myocardial infarction (MI), we performed two-dimensional echocardiography in 96 consecutive patients with isolated MI during the acute episode and after four and 12 months. Only patients with anterior MI received oral anticoagulant therapy on admission and throughout the study period. The LVT was identified in 21/65 patients with anterior and in 1/31 patients with inferior MI. The large majority of LVT cases were seen for the first time during the acute phase of MI. LVT was associated with a significantly higher peak value of CK-MB (118 +/- 24 vs 76 +/- 35, p less than 0.001) and Killip class (2.5 +/- 0.8 vs. 1.5 +/- 0.7, p less than 0.002). Patients with anterior MI and LVT more frequently had segmental dyskinesia during acute MI than patients without LVT (86 percent vs 18 percent, p less than 0.001). In four patients LVT resolved during the study period. Discontinuation of anticoagulant therapy in four patients with an aneurysm led to LVT formation in three. Two patients suffered a clinically recognized embolic event; one never had LVT demonstrated by echocardiography. Thus, LVT usually develops in the early days following large anterior MI, complicated by pump failure and segmental dyskinesia, even when patients receive oral anticoagulant therapy. Surprisingly, the incidence of embolic events was low (1/22) in our LVT patients.

Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction

To test the hypothesis that left ventricular (LV) thrombi that project into the lumen and are mobile are more likely to embolize than those that do not have these characteristics, the 2-dimensional echocardiograms of 16 patients with LV thrombi after myocardial infarction were retrospectively reviewed. Ten had evidence of peripheral embolization and 6 did not. The studies were reviewed in random order by an observer blinded to the clinical data. Each echocardiogram was graded as showing a protruding or nonprotruding thrombus and the presence or absence of increased mobility. The thrombus projected into the lumen on the echocardiograms of 8 of 10 patients who had had emboli and in 0 of 6 who had not. The thrombus had increased mobility in 4 of 10 patients with emboli and 0 of 6 without. Thus, LV thrombi that project into the lumen and have increased mobility are more likely to embolize than those without these characteristics.

Serial left ventricular ejection fraction in acute myocardial infarction by cross-sectional echocardiography: correlation of changing ejection fraction with clinical course

Left ventricular volume and ejection fraction were measured in 22 survivors of acute myocardial infarction by means of two-dimensional echocardiography and using a Simpson's rule algorithm. Ten of the 22 patients experienced complications. For the group as a whole, there were no significant trends in left ventricular volume and ejection fraction between the first and third days and the third month after infarction. In the subgroups with uncomplicated and complicated infarction, there were trends towards increasing and decreasing ejection fractions, respectively, which failed to attain statistical significance, however. The difference in ejection fraction between both subgroups had become significant at 3 months; 55.2 +/- 11.1% in uncomplicated v. 41.3 +/- 6.9% in complicated cases (P less than 0.01). Individual changes in ejection fraction falling outside the limits of reproducibility of the method as assessed previously were observed between day 1 and day 3 in only 2 patients with uncomplicated and in 2 patients with complicated infarction. Between day 1 and 3 months such changes occurred in 8 patients with uncomplicated infarction (upward in 5 and downward in 3), and in 8 patients with complicated infarcts (upward in 3 and downward in 5). We conclude that changes in ejection fraction as measured by two-dimensional echocardiography tend to correlate with complications.

Measurement of left ventricular ejection fraction after acute myocardial infarction. A serial cross sectional echocardiographic study

Left ventricular ejection fraction was assessed by biplane cross sectional echocardiography in 65 patients with a first acute myocardial infarction on the first day. In 30 patients (group 1) measurements were repeated on the third day and in another 35 patients (group 2) at three months. Changes in ejection fraction of 0.05 or less were arbitrarily called insignificant. In group 1 only two patients showed a decrease of more than 0.1 between days 1 and 3, and both had an enzymatically confirmed infarct extension. The remaining patients had no complications. In group two 11 patients had decreases of more than 0.1 between day 1 and three months: three of them had an enzymatically confirmed reinfarction (perioperative in one) and four a possible reinfarction, and in two an angiographically confirmed left ventricular aneurysm developed. In two no complications occurred. The other complications that occurred were an enzymatically confirmed but small reinfarction, an angiographically confirmed but circumscript aneurysm, and an uncomplicated bypass operation in one patient each. These three patients had a small increase (between 0.05 and 0.1) in ejection fraction. Reproducibility of the method of measuring the ejection fraction was assessed concurrently in 20 outpatients with a previous myocardial infarction who were studied twice on the same day (with a 30 minute interval) by two different observers. The mean absolute difference in ejection fraction between the paired observations was 0.036 +/- 0.023 with a range of 0 to 0.07. Thus only changes in ejection fraction of more than 0.1 correlate with clinically recognised complications. Changes between 0.05 and 0.1 may be due to spontaneous variability or to the limited reproducibility of the method.

Early two-dimensional echocardiographic measurement of left ventricular ejection fraction in acute myocardial infarction

Left ventricular volume and ejection fraction were measured by 2-dimensional echocardiography from 2 orthogonal apical long axis views in 90 patients admitted with acute transmural myocardial infarction. Results were correlated with worst Killip class during hospital stay, enzymatic infarct size (peak CK-MB) and mortality. We used two algorithms, a biplane area-length algorithm and a modification of Simpson's rule. Both algorithms yielded essentially the same results: there were statistically significant trends towards higher end-diastolic and end-systolic volumes and lower ejection fraction with higher Killip -class. Ejection fraction was lower (P less than 0.01) in the 6 patients dying from cardiogenic shock (28.0 +/- 7.8% v. 46.6 +/- 10.1% in survivors with the area--length algorithm; 28.1 +/- 6.2% v. 48.1 +/- 10.2% with modified Simpson's rule). In 5 patients dying from other causes ejection fraction was 46.0 +/- 14.9% with the area-length method or 46.2 +/- 14.5% with Simpson's rule (not different from survivors). Correlation with peak CK-MB was only modest, though statistically significant: the regression equation was: y = -0. 39x + 54 (r = -0.35; P less than 0.01) with the area-length method; and y = -0. 41x + 55 (r = -0.37; P less than 0.01) with Simpson's rule. Left ventricular ejection fraction measured at the bedside in patients with acute myocardial infarction, can provide useful clinical information. Patients likely to develop shock can be identified shortly after admission.

Thallium-201 scanning to decide CCU admission in patients with non-diagnostic electrocardiograms

To determine the value of thallium-201 scintigraphy as a decisive factor in admission policy for patients with acute chest pain and nondiagnostic electrocardiograms, we undertook a prospective study in 149 such patients. The interval between pain and scan never exceeded 12 hr. Of 57 patients in whom a defect was seen, 34 had an acute infarction, 7 developed infarction within 2 months, and in 11 coronary heart disease was proven by angiography or strongly suggested by stress tests (ECG and thallium-201 scan). In 13 patients with an equivocal scan, coronary heart disease was proven or strongly suggested in 5. Of 79 patients with a normal scan, only 1 had acute infarction, and stress tests were positive in 6 and negative in 72. In these 72 no cardiac event occurred during a 1-year follow-up. Thallium-201 scintigraphy can help to select those patients with acute chest pain and nondiagnostic electrocardiograms who need observation in a CCU.

Comparison of two-dimensional echocardiography with radionuclide angiography during dynamic exercise for the detection of coronary artery disease

Two-dimensional echocardiography (2DE) was performed during 30-degree left lateral decubitus bicycle exercise in 52 patients who underwent cardiac catheterization for suspected coronary artery disease (CAD). Adequate echocardiograms were obtained in 39 patients (75%). Thirty-five of these patients underwent radionuclide angiography (RNA) with the same exercise protocol as for echocardiography. Exercise-induced or increased initial asynergy was considered to be a positive test by both 2DE and RNA. Echocardiographic, scintigraphic, and coronary angiographic data were compared to each other. Significant CAD (greater than 50% luminal obstruction) was present in 26 patients (66%). One of 15 patients with exercise-induced asynergy by 2DE had no CAD. Six 2DE and two RNA studies during exercise were falsely negative, sensitivity 76% versus 91%. Inclusion of RNA ejection fraction data would increase the sensitivity but decrease the specificity of RNA. Exercise-induced septal asynergy was far more frequently present by 2DE than by RNA (11 versus 6) in the 17 patients who had exercise-induced anterior asynergy by both methods. We conclude that it was possible to perform exercise 2DE in 75% of our patients. Exercise-induced asynergy on 2DE was specific (92%) for CAD. The sensitivity of 2DE in detecting CAD was less than that of RNA.

Left ventricular thrombus following acute myocardial infarction: a prospective serial echocardiographic study of 96 patients

In a prospective serial study of 96 patients with acute myocardial infarction, two dimensional echocardiography identified left ventricular thrombus in 18 patients. The majority of thrombi (15) developed within the first 4 days after admission. In three patients thrombi were identified for the first time 4 months after the acute episode. All 18 patients had received therapeutic anticoagulants on admission and had large anterior wall infarctions complicated by severe pump failure and motion abnormalities echocardiographically. None of the patients had systemic embolisation during the study period. Thus, left ventricular thrombus is a not uncommon though silent complication of acute anterior wall infarction even when patients receive therapeutic anticoagulants.

Two dimensional echocardiography in the diagnosis of left ventricular thrombus. A prospective study of 67 patients with anatomic validation

Seventy-two patients, in whom a high prevalence of left ventricular thrombus (LVT) was anticipated, were studied prospectively by two-dimensional echocardiography (2DE). Adequate echocardiograms were obtained in 67 patients (93 percent). Presence or absence of LVT was verified at surgery in 51 patients undergoing aneurysmectomy, and at autopsy in 16 patients dying from acute myocardial infarction. Twenty-six patients had LVT and 41 did not. The LVT was defined echocardiographically as an echo-dense mass adjacent to asynergic left ventricular wall and distinct from the endocardial surface. Twenty-four of 26 LVT were correctly predicted by 2DE (sensitivity 92 percent). Absence of LVT was correctly predicted in 36 of 41 patients (specificity 88 percent). In five patients, LVT by 2DE was not anatomically confirmed (17 percent false positives). Thus, 2DE can detect or exclude the presence of LVT with a good sensitivity and specificity.

Echocardiographic-cineangiographic correlation in detecting left ventricular aneurysm: a prospective study of 422 patients

Four hundred twenty-two consecutive patients with a documented myocardial infarction underwent cardiac catheterization and echocardiographic examination. Adequate two dimensional echocardiograms were obtained in 386 patients (91 percent). Left ventricular aneurysm was defined echocardiographically and cineangiographically as a well demarcated bulge in the contour of the left ventricular wall during both diastole and systole, demonstrating dyskinesia or akinesia. Cineangiography was considered as the standard for the diagnosis of left ventricular aneurysm. The site of aneurysm was mainly anteroapical. An aneurysm was judged present on cineangiography in 111 patients and on echocardiography in 118 patients. The presence and absence of an aneurysm echocardiographically correlated in 103 and 260 patients, respectively, with cineangiography. In 8 patients a cineangiographically identified aneurysm was not manifested echocardiographically, whereas in 15 patients an aneurysm identified on echocardiography was not evident on cineangiography. Thus two dimensional echocardiography can detect or exclude a left ventricular aneurysm with a high level of sensitivity (93 percent) and specificity (94 percent).

Apex two dimensional echocardiography. Alternative approach to quantification of acute myocardial infarction

Apex echocardiography has been chosen as an approach to detect and quantify acute myocardial infarction because the usual parasternal acoustic windows are often occluded. Fifty-three patients were studied, all within 12 hours after the onset of symptoms of their first myocardial infarction. Three apical long axis views were obtained, that is the two and four chamber views, and the right anterior oblique equivalent or three chamber view. Satisfactory echocardiograms were obtained in 48 patients (91%). The individual apical views were divided into equal segments and the area of asynergy was estimated in each view. Left ventricular asynergy was present in all 48 patients. In 46 patients a positive correlation between the electrocardiogram and the echocardiogram was obtained, as far as infarct localisation was concerned. The estimated asynergic area correlated well with the peak value of the isoenzyme of creatine kinase (CK MB). Apex echocardiography is a reliable alternative method of detecting and quantifying myocardial infarction soon after the onset of symptoms.

Variation in fecal pollution indicators through tidal cycles in the Fraser River estuary

Daily fluctuations in fecal pollution indicators in the Fraser River estuary were examined by sampling through 24 h at four sites; water levels, currents, and salinities were observed simultaneously. Fecal coliforms were measured on shipboard using the membrane filter technique, and coprostanol and cholesterol were extracted using hexane and analyzed by gas chromatography. Maximum concentrations of fecal sterols and coliforms occurred after high tide at the station upstream of major sewage outfalls and on the ebb or at low tide at the stations downstream of major sewage outfalls. Fecal coliform counts were highly correlated with coprostanol and cholesterol levels at sites near sewage treatment plants. Coprostanol was highly correlated with cholesterol except where concentrations approached detection limits. In receiving waters, fecal coliform counts but not sterol concentrations were reduced by chlorination of sewage treatment plant effluents during the summer months. We concluded that, dependent on the objectives of a future monitoring program, samples should be collected either randomly in time such that the seasonal or annual mean includes tidal variability or systematically during the ebb tide to assess contributions to bathing beaches and shellfish harvesting areas. Fecal sterols deserve consideration as potentials indicators of fecal contamination from chlorinated sewage effluents.

Detection and quantification of acute, isolated myocardial infarction by two dimensional echocardiography

Ninety consecutive patients with acute, isolated myocardial infarction were evaluated with two dimensional echocardiography. Satisfactory echocardiograms were obtained in 66 patients (73 percent). All patients were studied 2 to 12 hours after the onset of symptoms. Sixty patients had additional studies at 48 and 72 hours. Long axis views were obtained at the base, body and apex of the left ventricle. Five short axis views of the left ventricle were obtained at different levels from the cardiac base to the apex. The individual short axis views, corrected for the end-diastolic internal diameter of the left ventricle, were divided into equal segments and the area of asynergy in each view was estimated. Infarct localization was similar on electrocardiography and echocardiography in 62 of 66 patients. In two dimensional echocardiography in one patient. The results of an echocardiographic study in one patient were false negative. During the study period the individual asynergic area remained stable. The initial asynergic area correlated well (r = 0.87, p less than 0.01) with the peak value of the isoenzyme of creatine kinase (CK-MB), which occurred hours later. Thus, two dimensional echocardiography is a reliable method to localize and quantify, early after the onset of symptoms, the eventual extent of myocardial involvement in patients with acute, isolated infarction.

Steroid-nucleosides

A new class of potential chemotherapeutic agents consisting of steroids coupled with nucleoside bases is described. Such structures may be viewed as nucleosides in which the sugar moiety is replaced by a steroid molecule. We may therefore expect the nucleoside characteristics to give interference at the DNA level, resulting in the desired antitumor activity, whereas the steroid moiety may provide target specificity. A number of such coupling products were prepared and preliminary biologic studies are reported.