[Mid-ventricular Hypertrophic Obstructive Cardiomyopathy in a Patient Whose Hemodynamics Were Exacerbated by Forward Shift of the Posterior Leaflet Caused by Mitral Annular Calcification]

A 82-year-old woman came to our hospital because of orthopnea and cardiac cachexia. Echocardiography revealed a pressure gradient of 50 mmHg at the left ventricular outflow tract and that of 78 mmHg at the mid-ventricle. Systolic anterior motion of the mitral leaflet caused by mitral annular calcification and severe mitral regurgitation( MR) were observed. On the basis of the patient's age and poor general conditions, we resected abnormal myocardium on the septum from the outflow tract down to the apex via aortic valve and we left the mitral annular calcification. The pressure gradient in the left ventricle, systolic anterior motion and mitral regurgitation were relieved, and her postoperative course was uneventful. Two years after the surgery, she remains in New York Heart Association( NYHA) class Ⅰ and is well.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Transmitral thrombectomy to treat a patient with Takotsubo cardiomyopathy

A 68-year-old woman with a history of bipolar disorder was admitted to another hospital with a gastric ulcer. On admission, Takotsubo cardiomyopathy was suspected because her electrocardiogram was abnormal and the characteristic left ventricular wall motion was apparent. On hospital day 11, echocardiography revealed a thrombus in the apex of the left ventricle. She was transferred to our hospital and heparin treatment was commenced. On follow-up echocardiography, the left ventricular wall motion had normalized but thrombus mobility had increased. Thrombectomy was performed via a transmitral approach with endoscopic assistance. Endoscopy allowed excellent visualization of the intracardiac structure.

Interrupted commissural band annuloplasty prevents mitral stenosis

BACKGROUND

Mitral annuloplasty is an important component of the treatment of degenerative mitral valve disease. However, postoperative echocardiography reveals elevated mitral gradients in some patients. We developed a technique that we termed interrupted commissural band annuloplasty (iCBA), which does not shorten either the anterior or posterior annulus and is not associated with the development of a mitral gradient. We compared the echocardiographic characteristics of patients treated using this method versus Cosgrove ring (COS) placement, both at rest and during exercise.

METHODS

ICBA features placement of three sutures in the commissures using two bands and shortens the commissural annular length by 60 %. We used this method to treat 63 patients and placed Cosgrove bands in 58. Of all patients, 48 who underwent iCBA and 34 with COSs passed the exercise echocardiographic test.

RESULTS

The maximal transmitral pressures at rest in the iCBA and Cosgrove groups were 8.04 ± 0.74 and 11.30 ± 0.88 mmHg (P = 0.0029), respectively, and the mean transmitral pressures at rest were 2.46 ± 0.74 and 3.61 ± 0.32 mmHg (P = 0.0037), respectively. The maximal transmitral pressures during exercise were 11.79 ± 0.97 and 18.37 ± 1.16 mmHg (P < 0.0001), and the mean transmitral pressures during exercise were 4.95 ± 0.45 and 7.76 ± 0.53 mmHg (P < 0.0001).

CONCLUSIONS

ICBA prevents postoperative mitral stenosis both at rest and importantly during exercise.

Double triangular resection for a widely prolapsed posterior mitral leaflet

A wide and redundant prolapse of the posterior mitral leaflet in active infective endocarditis cannot be easily repaired. A sliding plasty can be attempted, but the range of annular plication is often too large. Chordal replacement is another option, but is prone to long-term degeneration because the redundant leaflet still exists. Here, we describe a simple resection technique that utilizes only two small triangular resections. The resections are sutured with no need to shorten the annulus. The leaflet tissue between the two triangular resections must be preserved to make an appropriately shaped posterior leaflet.

[New concept of mitral valve repair for posterior leaflet prolapse]

BACKGROUND

Conventional repair of posterior mitral valve prolapse involves quadrangular resection and sliding plasty. However, these 2 methods require annular plication and useful leaflet tissue is sacrificed.

METHODS

Our concept is to make an ideally shaped posterior leaflet without annular plication. When the leaflet is not high, we select triangular resection( TRR). For a high leaflet, we developed hourglass resection (HGR). The hourglass shape consists of 2 triangles:the upper inverted triangle is resected and the lower triangle is resected and sutured to the annulus. From 2007 to 2012, 65 patients with mitral regurgitation (MR) with leaflet prolapse were repaired. 49 patients who had posterior leaflet prolapse were analized in this study. The mean age was 61.7±11.5 years and 67.3% were men.

RESULTS

All patients underwent successful repair. There were no hospital deaths, or no systolic anterior motion. In 1 patient, repair was repeated 1 month post-operatively. The mean follow-up period was 2.6±1.5 (0.1 ~ 4.9) years. There were no late deaths. The most recent echocardiogram revealed no MR in 36, mild MR in 12, and moderate MR in 1 cases.

CONCLUSION

The short-term results of our strategy for posterior leaflet repair are good.

Giant sinus of valsalva aneurysm with severe aortic incompetence treated with a valve-sparing operation

Typically, a sinus of Valsalva aneurysm with severe aortic incompetence is repaired with patch closure and aortic valve replacement. Here, we describe a very rare case of a giant nonruptured right Valsalva aneurysm, combined with severe aortic incompetence, treated with a valve-sparing aortic root replacement. During surgery we noted that the lengths of the free margin of the cusps and annuli were not uniform. As a result, we placed the first layer of sutures for the Valsalva graft in the same ratio as the annuli. It is difficult to preserve the geometry of the aortic annulus and position the commissures in the graft. One surgical tip for valve-sparing aortic root replacement for a sinus of Valsalva aneurysm with severe aortic incompetence is to suture the commissures inside the graft in the same ratio as the length of the cusp free margins.

A single papillary muscle with chordal rupture in an adult

A single papillary muscle (SPM) is a rare anomaly in normal adults. It is sometimes associated with a complete common atrioventricular canal. Chordal rupture combined with a single papillary muscle in an adult has not been reported. We repaired the mitral valve with chordal replacement, although this was technically difficult, because the decision to place an artificial chordal attachment on the papillary muscle plays an important role. This report presents successful chordal replacement and band annuloplasty in a case of chordal rupture with a single papillary muscle. A surgical tip for chordal replacement with a single papillary muscle is to suture artificial chords on the same side of the SPM head as the affected side of the mitral valve, considering the direction of pull of the artificial chords.

Chordal replacement for leaflet prolapse in a posterior mitral valve with a calcified mitral annulus

Mitral annular calcification (MAC) is sometimes associated with Carpentier type 2 mitral valve regurgitation and is a challenge to repair. Complete annular decalcification and mitral valve reconstruction is considered the ideal treatment. This report demonstrates the success of chordal replacement and band annuloplasty without resection of the leaflet and MAC. We have followed the patient for 7 years postoperatively, with no progression of MAC and no regurgitation by echocardiography.

[How to repair a mitral valve prolapse;an assessment of operative techniques dependent on late results]

BACKGROUND

In this study, we assessed the repair techniques employed for mitral valve prolapse.

PATIENTS AND METHODS

Between 1992 and 2011, we repaired 173 consecutive patients with mitral valve prolapse. The mean age of the patients was 60.1 years and 68.6% were male. For anterior leaflet (AL) prolapse, 27 patients with fibroelastic deficiency (FED) were treated with chordal replacement (CR). In 21 patients with Barlow type, 2 were repaired with CR and the remaining 19 were repaired with resection. In 130 patients with a prolapse of the posterior leaflet (PL), we selected quadrangular resection( QR:44), sliding plasty( SP:12), folding plasty and CR. More recently, triangular resection (TrR:22) was selected for ≤18 mm height leaflets, and an hourglass resection( HgR:21) for high leaflets.Hourglass represents the shape of the resection.

RESULTS

In 1 patient of the AL CR group, the expanded polytetrafluoroethylene (ePTFE) was broken. Other patients in this group showed no mitral regurgitation (MR) and no re-operation during 16 years. Two patients receiving CR for AL Barlow received re-repair, whilst the other 19 patients in this group displayed good results over the following 19 years. In the QR and SP groups, 1 patient was rerepaired,whilst 3 patients displayed complicated mitral stenosis. In the TrR and HgR groups, no MR,no re-operation and no late deaths occurred during the following 4.5 years.

CONCLUSIONS

CR for AL FED, resection for AL Barlow and TrR or HgR for PL were durable techniques for the treatment of mitral valve prolapse.

[The formula of the aortic valve repair for bicuspid aortic valve]

BACKGROUND

The treatment of aortic regurgitation( AR) with bicuspid aortic valve( BAV) repair is still uncommon as the reproducibility of the repair is low and the 5-year durability is poor. In this study, we examined a method of cusp suspension after triangular resection. In addition, the relationship between the length of the cusp margin and diameter of the sino-tubular( ST) junction was evaluated.

PATIENTS AND METHODS

We repaired 8 regurgitant BAVs between 1997 and 2011. The mean patient age was 35±14 years and 87.5% were male. All lesions were raphe type:7 were anterior-posterior type and 1 was left-right type. The basic technique was triangular resection of the pseudo-commissure.When the annulus or ST junction was dilated, annuloplasty or ST junction plication was added. Cusp suspension was performed in 7 patients. In 2 patients, the half-length of the cusp margin (d) was related to the diameter of the ST junction( D) as described by d=D/2+1.

RESULTS

Two cases were on a 2nd pump run because of residual AR. The valve was replaced in 1 case, while the cause of AR was found to be symmetric prolapse in the analysis. The coaptation depth was 6.2 mm. Another case was re-repaired because AR was caused by an untied suspension suture.Seven cases( 87.5%) were repaired successfully. No in-hospital deaths or complications occurred. The mean follow-up period was 5.42 years (range 1~15). No patients required re-operation and no recurrent AR greater than moderate occurred. The mean coaptation depth of the 7 successful patients was 11±3 mm.

CONCLUSION

When repairing a regurgitant BAV, triangular resection alone is sometimes ineffective due to the occurrence of symmetric prolapse. For reproducible repair, it is useful to add cusp suspension.Lastly, the rate of suspension is related to the diameter of the ST junction.

Aspergillus fumigatus regulates mite allergen-pulsed dendritic cells in the development of asthma

BACKGROUND

The role in allergic asthma development of the immune response against fungi with concomitant exposure to other common aeroallergens has yet to be determined. In particular, there is little understanding of how inhaled fungi affect the host response to mite allergens.

OBJECTIVE

To characterize the in vitro and in vivo effects of concurrent exposure of Aspergillus fumigatus (Af) and Dermatophagoides farinae (Derf) on dendritic cells (DCs) in the development of allergic asthma.

METHODS

Murine bone marrow-derived DCs were pulsed with Derf and/or live or heat-inactivated Af. Cytokine production and the expression of pathogen recognition receptors (PRRs) were determined in vitro. Subsequently, these DCs were inoculated into the airway of naïve mice to assess the development of allergic airway inflammation in vivo. The effect of antibodies against PRRs was also evaluated.

RESULTS

Live Af significantly enhanced IL-10 production and the expression of Toll-like receptor (TLR) 2 and Dectin-1 in Derf-pulsed DCs. Live Af infection significantly attenuated Derf-pulsed DC-induced allergic airway inflammation in vivo. Antibodies against either TLR2 or Dectin-1 significantly reversed the inhibitory effects of live Af in the development of Derf-pulsed DC-induced allergic airway inflammation.

CONCLUSION

Concurrent exposure of DCs to fungal antigens has profound influences on the subsequent mite allergen-induced allergic airway inflammation. Live Af could regulate the functions of airway DCs in the development of mite allergen-induced allergic airway inflammation via regulation of their PRRs. Our results suggest that concurrent exposure to pathogens such as fungi and mite allergens has profound influences on the subsequent allergen-induced allergic airway inflammation. Furthermore, modulating PRR signalling could provide a therapeutic regimen for the development of asthma.

Development of a new data entry system suitable for the Japan Adult Cardiovascular Surgery Database

PURPOSE

Patient data related to cardiovascular surgery are usually managed separately by surgeons and clinical engineers in their respective data files. Recently, with our participation in the Japan Adult Cardiovascular Surgery Database (JACVSD), we newly prepared JACVSD-ready cardiovascular surgery data files by combining two data entry systems.

METHODS

We constructed a cardiovascular surgery database system using FileMaker Pro and FileMaker Server. When preparing the data files, we attempted to eliminate excessive labor during data input and to enable easy distinction of items for which input has not been completed. In addition, we added some items required for clinical work so the files could be used not only for registration with the JACVSD but also for clinical work.

RESULTS

All the items for the cases in 2005 and 2006 were input by the end of each year. Registration in the JACVSD in 2005 and 2006 was completed by the set deadline, except in one case in which the patient remained hospitalized at the time of the deadline.

CONCLUSIONS

Our newly developed JACVSD-ready data files have increased the interest of surgeons in data entry and in collecting data. With the new system, we can manage patient data more easily and more effectively at low cost.

Effects of various anti-asthmatic agents on mite allergen-pulsed murine bone marrow-derived dendritic cells

BACKGROUND

Dendritic cells (DCs) play an important role in the immune response and are critically involved in asthma. beta2-agonists could potentially exacerbate type 2 T helper (Th2) cell-mediated immune response.

OBJECTIVES

To determine the effects of various anti-asthmatic agents on DCs function both in vitro and in vivo.

METHODS

Murine bone marrow-derived DCs were pulsed with mite allergen in the presence of pranlukast, salbutamol, salmeterol or fluticasone. These DCs were then inoculated intranasally into naïve mice to induce allergic airway inflammation in vivo.

RESULTS

Pranlukast reduced IL-10 and increased IL-12, while fluticasone reduced both IL-10 and IL-12 production by mite allergen-pulsed DCs. Allergic airway inflammation in pranlukast- and fluticasone-treated and mite allergen pulsed DCs-harbouring mice was attenuated and such response was associated with inhibition of Th2 response in the airway. Salbutamol did not alter cytokine production, while salmeterol reduced IL-12 production by mite allergen-pulsed DCs. Lung pathology in beta2-agonist-harbouring mice was comparable with those of mite allergen-pulsed DCs-harbouring mice.

CONCLUSIONS

Our results indicate that leukotriene receptor antagonists and corticosteroids inhibit DCs-induced Th2 skewed immune response, and that short- and long-acting beta2-agonists do not modify DCs-induced allergic airway inflammation.

Effects of primary and secondary low-grade respiratory syncytial virus infections in a murine model of asthma

BACKGROUND

Respiratory syncytial virus (RSV) infection is known to develop and exacerbate asthma in young children. In adult, RSV causes recurrent but asymptomatic infections. However, the impact of asymptomatic RSV infection on adult asthma is yet to be determined. The present study is designed to determine the effects of primary and secondary low-grade RSV infections on allergic airway inflammation in a murine model of allergic asthma.

METHODS

A low-grade RSV (2 x 10(3) plaque-forming units/mouse) was inoculated, and this caused neither pulmonary inflammation nor symptoms but induced significant IFN-gamma production in thoracic lymph nodes. To investigate interaction between low-grade virus and Dermatophagoides farinae (Df), airway hyper-responsiveness, lung inflammation and cytokine production from thoracic lymph nodes were compared after primary and secondary low-grade RSV infections in four groups of mice; control, Df allergen-sensitized, RSV-infected and Df-sensitized RSV-infected mice. A direct comparison between low- and high-grade RSV infections was also performed in primary infection. To investigate the role of IL-5 during secondary RSV infection, anti-IL-5 monoclonal antibody (anti-IL-5 mAb) was injected in mice and similar parameters were compared in four groups of mice.

RESULTS

Primary high-grade RSV infection increased allergen-induced airway inflammation, while primary low-grade RSV infection attenuated allergen-induced airway inflammation concomitant with significant IFN-gamma production in lung-draining lymph nodes. In marked contrast, secondary low-grade RSV infection increased both IFN-gamma and IL-5 production, resulting in exacerbation of allergen-induced airway inflammation. Anti-IL-5 mAb treatment in secondary low-grade RSV infection and Df allergen-sensitized mice attenuated virus and allergen-induced airway inflammation.

CONCLUSIONS

Low-grade RSV infection per se does not cause pulmonary inflammation, whereas it induces a significant immunological response in the allergen-sensitized host. These results indicate that subclinical and recurrent RSV infection may play an important role in exacerbation and maintenance of asthma in adults, wherein IL-5 is critically involved.

Glomerular crescents predominantly express cadherin-catenin complex in pauci-immune-type crescentic glomerulonephritis

AIMS

To investigate the expression of the cadherin complex in human crescentic glomerulonephritis to elucidate the role of intercellular adherens junction molecules in crescent formation.

METHODS AND RESULTS

Immunostaining revealed cadherin complexes localized in Bowman's epithelial cells, but not in podocytes, of normal human glomeruli. Eight adult cases with myeloperoxidase anti-neutrophil cytoplasmic autoantibodies (MPO-ANCA)-related (pauci-immune type) crescentic glomerulonephritis were examined on immunofluorescence microscopy with anti-pan cadherin, p120 catenin, and beta-catenin antibodies. The specimens provided six cellular crescents, 12 fibrocellular crescents, and four fibrotic crescents. Immunofluorescence was semiquantitatively estimated by the rate of the field of localization within the whole area of the crescent, according to the four-grade system [(-) - (++)]. All the tested molecules consisting of the cadherin complex were abundantly observed in cytokeratin-positive epithelial components in crescents, each with an equivalent area of localization. The expression of the cadherin complex was closely associated with that of cytokeratin and both diminished as the crescents developed from cellular to fibrotic.

CONCLUSIONS

The cadherin-catenin complex is a specific marker of Bowman's epithelial cells in human glomeruli. The cellular crescents in pauci-immune-type crescentic glomerulonephritis possess adherens junction molecules, indicating a principle parietal epithelial cell phenotype.

Pranlukast, a cysteinyl leukotriene receptor 1 antagonist, attenuates allergen-specific tumour necrosis factor alpha production and nuclear factor kappa B nuclear translocation in peripheral blood monocytes from atopic asthmatics

BACKGROUND

The cysteinyl leukotriene receptor 1 (cysLTR1) antagonists are useful for oral treatment of bronchial asthma. The underlying mechanism of cysLTR1 antagonists on inhibition of inflammatory cytokine production is yet to be determined.

OBJECTIVE

The present study was designed to determine the effect of pranlukast, a cysLTR1 antagonist, on production of inflammatory cytokines by allergen-stimulated peripheral blood monocytes (PBM) from atopic asthmatics.

METHODS

PBM were obtained from normal control (n = 10) and Dermatophagoides farinae (Der f) allergen-sensitized atopic asthmatics (n = 12), and were cultured in the presence of Der f allergen. The production of TNF-alpha and nuclear-translocation of nuclear factor kappa B (NF-kappa B) was determined. In atopic asthmatics, pranlukast, tacrolimus or dexamethasone was added before stimulation by Der f. The additive effect of pranlukast and dexamethasone was also determined.

RESULTS

PBM from atopic asthmatics cultured with Der f exhibited a significant increase in TNF-alpha production and nuclear translocation of NF-kappa B compared with normal control (P < 0.01). Pranlukast, tacrolimus and dexamethasone significantly inhibited production of TNF-alpha and nuclear-translocation of NF-kappa B in PBM of atopic asthmatics (P < 0.01). An additive effect of pranlukast on low-dose dexamethasone was also demonstrated. However, LTD4 did not induce TNF-alpha production or NF-kappa B nuclear translocation.

CONCLUSION

Our results suggest that pranlukast may inhibit TNF-alpha production via suppression of NF-kappa B activation through pathways distinct from cysLTR1 antagonism.

Bronchial hyperresponsiveness and airway inflammation in adolescents with asymptomatic childhood asthma

BACKGROUND

About 70% of childhood asthmatics become free of asthma-related symptoms during adolescence. Little is known about bronchial hyperresponsiveness (BHR) and airway inflammation in young adults with "outgrown" childhood asthma.

METHODS

We studied 61 nonsmoking medical students (18 intermittent mild asthmatics, 23 students with outgrown childhood asthma but free of asthma-related symptoms for 10 years (asymptomatic asthmatics) and 20 healthy students). BHR and lung function were measured, and induced sputum samples analyzed for eosinophil count, eosinophilic cationic protein (ECP), granulocyte-macrophage colony stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha).

RESULTS

BHR was still present in most asymptomatic asthmatics, but it was milder compared with healthy students. Only three subjects with previous asthma had no BHR and no signs of airway inflammation. Percentages of eosinophil, and ECP, TNF-alpha and GM-CSF concentrations in induced sputum of mild asthmatics and asymptomatic asthma groups were higher than in the healthy group. In asymptomatic asthmatics group, the duration of asthma, sputum eosinophil percentage, and the level of TNF-alpha in sputum correlated significantly with BHR.

CONCLUSIONS

Only a few subjects with longstanding asymptomatic asthma could be considered as cured; most asymptomatic asthmatics continued to exhibit BHR and signs of airway inflammation. The outcome of childhood asthma and BHR was associated with the degree of airway inflammation and the duration of childhood asthma.

Effects of amphotericin B gargles on oral colonization of Candida albicans in asthmatic patients on steroid inhalation therapy

BACKGROUND

Early use of inhaled steroids is recommended for bronchial asthma. The side effects are rare, but oral discomfort and candidiasis are clinically important complications. Most previous studies reported that the use of spacer and water gargling was necessary to prevent oral complications. However, in some patients, this may fail to prevent such complications.

OBJECTIVE

To compare the effects of water gargling with those of amphotericin B, in the prevention of oral complications in asthmatics using inhaled steroids.

METHODS

Pharyngeal swab samples were obtained aseptically from the posterior pharyngeal wall of 128 asthmatics who have been using inhaled steroids (beclomethasone dipropionate) for more than 1 year. The amount of Candida albicans in cultured swabs was evaluated based on the following criteria: oral symptoms, method of gargling, dose of inhaled steroids, type of spacer and serum cortisol level.

RESULTS

The number of isolated C. albicans was significantly higher in asthmatics with oral symptoms than in those free of symptoms. It was also significantly higher in patients who gargled with water or 1,000 times dilution than in those who gargled with 100 or 50 times dilutions of amphotericin B. Moreover, it was significantly higher in patients with low levels of serum cortisol than in those with normal serum cortisol.

CONCLUSION

We demonstrated that at least in a subgroup of asthmatics using steroid inhalers, gargling with water or even weak concentrations of amphotericin B does not prevent colonization of the throat with C. albicans. This group at high risk of developing oral candidiasis should gargle with amphotericin B at concentrations higher than 100 times dilution that can prevent clinically detectable oral candidiasis.

Screening for acetaldehyde dehydrogenase 2 genotype in alcohol-induced asthma by using the ethanol patch test

BACKGROUND

We have previously reported that alcohol-induced asthma in Japanese patients is caused by increased blood acetaldehyde concentration resulting from abnormalities of acetaldehyde dehydrogenase 2 (ALDH2) enzyme activity on the basis of ALDH2 genotype differences.

OBJECTIVES

The purpose of the present study was to determine whether the ethanol patch test could predict the ALDH2 genotype in Japanese asthmatic subjects.

METHODS

An ethanol patch test on the upper arm and a questionnaire survey addressing the past history of alcohol-induced asthma were administered to 148 adult Japanese asthmatic subjects. The ALDH2 genotypes in these 148 subjects were also determined by means of PCR.

RESULTS

The genotype distribution of ALDH2 determined by PCR in 68 subjects with positive ethanol patch test results was 4 (5.9%), 56 (82.4%), and 8 (11.8%) for genotypes NN (normal homozygote), NM (mutant heterozygote), and MM (mutant homozygote). The ALDH2 genotype in 80 subjects with a negative test result was only NN. The distribution of ALDH2 genotype in 78 (52.7%) subjects who had experienced alcohol-induced asthma symptoms on the basis of the questionnaire was 27 (34.6%), 44 (56.4%), and 7 (9.0%) for genotypes NN, NM, and MM, respectively. On the other hand, 70 subjects had never experienced alcohol-induced asthma symptoms. In these subjects the ALDH2 genotype was NN in 51 (72.9%), NM in 18 (25.7%), and MM in 1 (1.4%).

CONCLUSIONS

Our results indicate that the results of ethanol patch testing correlate well with ALDH2 genotype, as determined by means of PCR, suggesting that the ethanol patch test is useful for the screening of alcohol-induced asthma.

Effects of pranlukast, a cysteinyl leukotriene receptor 1 antagonist, combined with inhaled beclomethasone in patients with moderate or severe asthma

BACKGROUND

Although inhaled steroids are used as the first line of therapy in asthmatic patients, symptoms of asthma do not improve completely in some patients.

OBJECTIVE

To investigate the effects of pranlukast, a cysteinyl leukotriene receptor 1 antagonist, in patients with moderate/severe asthma, when combined with beclomethasone dipropionate (BDP).

METHODS

Protocol 1: After a 2-week observation period, 41 patients with moderate asthma were divided into those receiving BDP at 1,600 microg/day or 800 microg/day + pranlukast (450 mg/day). The effect of treatment was evaluated by measuring AM peak expiratory flow rate, symptom score, frequency of beta2-agonists, and daily variability of peak expiratory flow rate. Protocol 2: 39 patients participated in this study including those with moderate asthma on 800 microg/day BDP (group I), severe asthma on BDP at 1,600 microg/day (group II), and severe asthma on 1,600 microg/day BDP + 5 to 20 mg prednisolone (group III). Patients of all groups were additionally treated with pranlukast.

RESULTS

Protocol 1: Both treatment regimens resulted in improvement in each clinical parameter. There were no significant differences in the effects of two treatment regimens. Protocol 2: Pranlukast was effective in group I and II, but not in group III. In groups I and II, pranlukast tended to be more effective when BDP was introduced within the first year of onset of asthma.

CONCLUSIONS

Pranlukast is effective for patients with moderate asthma and those patients with severe asthma who are not treated with oral steroids. Pranlukast is more effective in patients treated with BDP early after onset.

Effects of pranlukast on aspirin-induced bronchoconstriction: differences in chemical mediators between aspirin-intolerant and tolerant asthmatic patients

BACKGROUND

Aspirin inhibits cyclooxygenase activity and modifies production of the arachidonate cascade in aspirin-induced asthma. The aim of the present study was to examine the effects of leukotriene (LT) receptor antagonist on aspirin challenge on eosinophil activity and chemical mediators released into the airway of asthmatic patients.

METHODS

Aspirin oral provocation test was performed in aspirin-intolerant asthmatic patients (AIA; N = 7) and aspirin-tolerant asthmatic patients (ATA; N = 7). In AIA, LT receptor antagonist (pranlukast) was administered orally 2 hours before the test, and its inhibitory effects on sputum LTC4+C4, eosinophil cationic protein (ECP), eosinophil count, urinary LTE4/creatinine (Cr), 11-dehydrothromboxane (11-dhTX) B2/Cr, serum LTC4+D4, ECP, and peripheral blood eosinophil count were compared with the findings in ATA subjects.

RESULTS

In AIA, aspirin induced an immediate reaction associated with increased urinary LTE4/Cr and sputum ECP and a fall in urinary 11-dhTXB2/Cr. Pranlukast inhibited the bronchial reaction and an increase in sputum ECP after threshold dosed of ASA, but failed to change aspirin-induced LT production in sputum and urine. In ATA, aspirin challenge was only associated with a fall in urinary 11-dhTXB2.

CONCLUSIONS

Our results indicated that aspirin-induced asthma is associated with overproduction of LT with a shift to the 5-lipoxygenase series of the arachidonate cascade and that leukotriene receptor antagonist are useful for AIA through inhibition of production of LT and eosinophilic inflammation in the airway.

Efficacy and safety of long-term treatment of asthmatic patients with pranlukast, a cysteinyl-leukotriene-receptor antagonist: four-year followup study

BACKGROUND

There are few studies that have examined the long-term efficacy and safety of pranlukast, a leukotriene receptor antagonist, in asthmatic patients.

METHODS

Sixty-three asthmatic patients were entered in this 4-year study [group 1, mild or moderate (N = 22); group 2, severe without using oral prednisolone (N = 22); group 3, severe with using oral prednisolone (N = 19)]. Pranlukast was administered at 225 mg twice daily to 14 subjects in group 1 (group 1p), 14 in group 2 (group 2p), and 11 in group 3 (group 3p), chosen for pranlukast additional therapy at random. Another group of 24 asthmatic patients was assigned to conventional therapy group (groups 1c, 2c, and 3c). Efficacy was determined by improvement in symptom score, peak expiratory flow rate (PEFR) percentage predicted, reduced daily variability of PEFR (percentage), and reduced frequency of use of rescue beta2-agonist (times per week).

RESULTS

In groups 1p and 2p, PEFR percentage predicted began to improve from 2 weeks after commencement of treatment. The symptom score, daily variability of PEFR, and use of rescue beta2-agonist diminished significantly. In group 3p, pranlukast was ineffective in improving PEFR percentage predicted. All but two patients continued to receive pranlukast and no adverse effects were noted, at least during the 16-week therapy. Further, 22 patients continued to receive pranlukast for 4 years, and none experienced any adverse effects.

CONCLUSIONS

We showed in this study that long-term treatment with pranlukast is effective for asthmatic patients without any adverse effects.

Airway foreign body with clinical features mimicking bronchial asthma

A 56-year-old Japanese male with persistent cough, stridor and diffuse wheezing for 6 months had obstructive pulmonary dysfunction and airway hyperresponsiveness (AHR) to inhaled methacholine. Because of a poor response to glucocorticoid therapy and neutrophilia in the peripheral blood and sputum, chest computed tomography was performed and a plate-like tumor in the truncus intermedius was identified. Fiberoptic bronchoscopy demonstrated a plate-like green-colored tumor firmly impacted into the truncus intermedius and diffuse inflammatory changes spreading to both main bronchi. A piece of 'kombu' (Japanese kelp) was successfully removed by fiberoptic bronchoscopy under general anesthesia. Pulmonary function and methacholine inhalation tests became normal after the removal of the foreign body. In this case, it is suggested that asthma-like symptoms were due to localized airflow limitation in the right bronchus as well as to AHR associated with diffuse airway neutrophilic inflammation.

Transplantation of the en bloc vascular system for coronary revascularization

OBJECTIVES

Use of the free gastroepiploic artery graft for coronary revascularization has not been very popular because of its inclination toward vasospasm. We hypothesized that the cause of free gastroepiploic artery spasm was the graft damage caused by an interruption of venous drainage from the graft. To solve this problem, we developed a new method of free gastroepiploic artery grafting.

METHODS

From January 1997 to October 1999, 33 patients underwent coronary artery bypass grafting with the free gastroepiploic artery according to our new method. The gastroepiploic artery graft was harvested en bloc with its satellite veins. The gastroepiploic vein was anastomosed to the right atrial appendage for venous drainage simultaneously with the gastroepiploic artery being grafted in the aortocoronary position.

RESULTS

A total of 96 distal anastomoses were performed, including 33 free gastroepiploic artery grafts according to our method, 33 in situ left internal thoracic artery grafts, 26 saphenous vein grafts, and 4 radial artery grafts. Neither operative nor hospital death occurred. Early postoperative angiography revealed that all of the 33 free gastroepiploic artery grafts performed with our method were patent without spasm, and flow competition occurred only in 2 of those grafts. On late angiography, all 15 free gastroepiploic artery grafts were patent without spasm.

CONCLUSIONS

The free gastroepiploic artery grafting with venous drainage technique we developed can prevent graft spasm, leading to improved patency rate.

Hexamethylene diisocyanate causes contraction of canine tracheal smooth muscles through activation of muscarinic receptors

BACKGROUND

Asthma caused by occupational exposure to hexamethylene diisocyanate (HDI) is well known; however, the exact pathogenic mechanisms remain unclear.

METHODS

Experiments were performed using a standard canine tracheal smooth muscle (CTSM) strip preparation in an isolated bath to determine the effect of HDI on tracheal smooth muscle contraction. HDI concentration-response curves were constructed and the effects of different receptor antagonists on HDI-induced smooth muscle contraction were determined. To determine whether HDI and acetylcholine (ACh) bind to a common muscarinic receptor, ACh concentration-response curves in the absence or presence of HDI and concentration-response curves for HDI and ACh in the presence or absence of atropine were plotted.

RESULTS

HDI caused contraction of CTSM, with a threshold concentration of 10(-7) M. The EC(50) (HDI concentration that produced 50% of the maximal response) was 6.2+/-0.7 x10(-7) M and the maximal contractile response (174+/-55 g/g of tissue) occurred at a concentration of 5.0+/-0.8 x 10(-6) M. Atropine, a muscarinic blocker, significantly inhibited HDI-induced contractile responses. HDI shifted the ACh concentration-response curve to the right. The mean pA(2) for atropine against ACh (8.93+/-0.27) was not significantly different from that against HDI (8.03+/-0.12).

CONCLUSIONS

Our results indicated that HDI causes contraction of CTSM through the activation of muscarinic receptors. Direct stimulation of muscarinic receptors by HDI may play an important role in HDI-induced asthma.

[Coronary artery bypass grafting by warm blood cardioplegia and normothermic cardiopulmonary bypass]

Warm blood cardioplegia and normothermic cardiopulmonary bypass (CPB) have been used in coronary artery bypass grafting (CABG). The method of myocardial protection was intermittent combined antegrade and retrograde warm blood cardioplegia with terminal warm blood cardioplegia. We performed elective CABG in 30 patients above the age of 70 years (elderly group). These patients were compared with 30 patients below 70 years who underwent elective CABG (young group). No significant differences were observed about the preoperative data between two groups. No significant differences were obtained in the postoperative cardiac function, cerebral or renal complication between two groups. Warm blood cardioplegia and normothermic CPB were not associated with adverse effects on postoperative recovery in elderly as well as young patients. We may conclude that warm blood cardioplegia with normothermic CPB is a safe procedure for CABG in elderly as well as young patients.

Coronary artery bypass grafting for spontaneous coronary artery dissection: a case report and a review of the literature

A 37 year-old woman underwent coronary angiography because of chest pain at rest. Selective coronary angiography demonstrated dissection and stenosis with a filling delay from the left main trunk to the left anterior descending coronary artery. The patient was successfully managed with urgent coronary artery bypass grafting. Spontaneous coronary artery dissection is relatively rare and threatens both elderly and young patients with acute coronary disturbances. Patients can be divided etiologically into three groups. The first was comprised of those in the postpartum period. The second was those with atherosclerotic coronary artery disease, and the third was those associated with coronary vasospasm. Dissections are frequently fatal and most of the known cases have been diagnosed at autopsy. Only a few cases have been documented by coronary angiography, and operative cases of spontaneous coronary artery dissection have rarely been reported.

[Short-course chemotherapy of tuberculosis with pyrazinamide]

A 6-month regimen consisting of isoniazid (INH. 0.3-0.5 g).rifampicin (RFP. 0.3-0.45 g).pyrazinamide (PZA. 1.2-2.0 g) and streptomycin (SM. 0.75 g) or ethambutol (EB. 0.75-1.0 g) given for 2 month followed by isoniazid and rifampicin for 4 month is the preferred treatment for patients with fully susceptible organism, who adhere to treatment. Consideration should be given to treating all patients with directly observed treatment.

[Valve replacement concomitant with anulus reconstruction]

It is important that surgical treatment of infective endocarditis involves complete debridement of the affected tissue. In case of abscess formation in the mitral anulus and/or aortic root, disruption of the anulus occurs because of radical resection of the abscess. David et al. reported a new technique for mitral and aortic anulus reconstruction. The novel part of the technique was the endocardial repair, i.e., suturing of a pericardial patch to the endocardium of the left ventricle. We were surprised to learn that the left ventricular endocardium and muscle are capable of tolerating the stress induced by the prosthetic ring, especially in the mitral position. Since 1992, we treated eight cases of anulus disruption using this technique ; 5 cases involved the mitral anulus, 1 involved the aortic, and 2 involved both. We used a slightly different technique involving suturing of a patch not only to the left ventricular endocardium but also to left atrial wall for reinforcement. Two patients died in the perioperative period. One had a brain abscess ; the other had methicillin-resistant Staphylococcus aureus sepsis and mediastinitis. There was 1 late (sudden, unknown) death 3 years after the operation. No perivalvular leakage, dehiscence of the patch, hemolysis, prosthetic valve endocarditis, or thromboembolism have been observed in the other 5 patients.

[Repair of mitral valve prolapse by resection and sliding plasty]

There have been many techniques applied to the repair of mitral valve prolapse, and the method used in a particular case is usually selected according to the position and extent of the lesion. To simplify and standardize the technique of mitral valve repair, we have adopted the resection, sliding plasty and ring annuloplasty methods since December 1992. Of 10 consecutive surgical cases, 2 involved prolapse of the anterior leaflet, 1 the posteromedial commissural, and 7 the posterior leaflet. One patient with posterior leaflet prolapse required valve replacement due to dehiscence of the plastied site on the 3rd postoperative day, and one died because of sepsis. However, the remaining patients were doing well without mitral regurgitation at a mean of 20 months (range: 8-32) after the operation. The advantages of these techniques include easy adjustment of the height of the leaflet and a good chance of long-term durability, since the affected lesion is resected.

[Surgical repair of post-infarction ventricular septal defects--reconstruction with pericardial patch]

Despite improvements in the pre- and postoperative management of patients with post-infarction ventricular septal defects, the results after surgery have been variable. This is in part due to advanced patient age, multi-vessel coronary disease. In addition, resection of the infarcted ventricular septum results in significant compromise in left ventricular function. Since January of 1993, we have used a new technique for the reconstruction of the left ventricle using a single pericardial patch. In this method, which was introduced by Komeda and David in 1990, a single patch is sutured to the interventricular septum and the lateral ventricular wall, excluding the infarcted muscle from the left ventricular cavity. This method was used in the treatment of four patients. There was no bleeding along the suture lines at operation, all of the patients survived. Postoperatively, all four were functional New York Heart Association Class 1. One patient underwent re-operation on the 12th day using the same technique because of a residual shunt. Another two patients had small residual shunts, which spontaneously resolved in 2 to 7 months. Left ventricular function evaluated 1 month after the operation utilizing cardiac catheterization revealed a mean stroke volume index of 40 (range: 32-45 ml/m2, and a mean left ventricular ejection fraction of 71 (range: 70-73%). An excellent functional outcome has thus been achieved with the reconstruction of post-infarction ventricular septal defects using a single pericardial patch.

[Reoperation for complications of mitral valve surgery]

Among the early postoperative complications of mitral valve surgery. Mitral Regurgitation (MR) is one of the most dangerous complications, which has to be diagnosed and to be treated as early as possible. Four reoperations-two of which are of paraprosthetic regurgitation, and two of recurrent MR after mitral valve plasty-are reported. Their clinical courses and transesophageal echocardiographic findings are shown. And the differences their MR has when it is compared with the physiologic MR of the prosthetic valve and with the acceptable MR after mitral valve plasty are described.