Gender-based differences in the job titles and lifestyles in the cataract and refractive surgery society in Japan

To investigate sex differences in the titles and lifestyles of Japanese ophthalmologists, we evaluated work places and private lives. Retrospective cross-sectional study. The study included 1721 members (1344 males and 377 females) of the Japanese Society of Cataract and Refractive Surgery. An online, anonymized questionnaire was distributed to the society members. The questionnaire included 40 questions to collect data on profiles, lifestyles, job title, families, spouses, children, household chores, child-rearing, and work satisfaction. In total, 219 members (144 males and 75 females; 53.4 ± 1.0 and 51.3 ± 9.9 years old, respectively) completed the questionnaire. The job title, working time, annual income, marriage rate, and the number of children significantly differed between male and female respondents. Female respondents had greater responsibilities toward house chores, child care, and nursing, whereas several male doctors had spouses who did not work or worked for shorter times, earned a lower income, and contributed greater toward family responsibilities. Female respondents changed their job titles after having children more frequently than male respondents. Both males and females had limited time available for community activities and volunteer work. There were no significant differences in daily sleep duration. Both sexes were equally satisfied with their career choice of ophthalmology; however, fewer females recommended ophthalmology as a career for students and children compared to males. There are significant sex differences among ophthalmologists in Japan in terms of family responsibilities; this topic has received insufficient attention.

Relationship between early drop in systolic blood pressure, worsening renal function, and in-hospital mortality in patients with heart failure: a retrospective, observational study

This study aimed to determine the optimal cut-off value of the early drop in systolic blood pressure (SBP) for worsening renal function (WRF) in hospitalized patients with heart failure (HF) and analyze predictors of WRF and the early drop in SBP at that threshold. We retrospectively enrolled 396 patients with acute decompensated HF. The early drop in SBP was defined as the difference between baseline and SBP measured 24 h after hospitalization. We performed receiver operating characteristic (ROC) analysis to determine the optimal cut-off value of the early drop in SBP for WRF and evaluated the effect of the early drop in SBP on in-hospital mortality by multivariate logistic regression analyses. The mean age of the patients was 73.4 ± 14.7 years, and 61.2% were men. A 14.0% drop in SBP was identified as the optimal cut-off value for WRF from the ROC curve analysis. An early drop in SBP ≥ 14.0% was associated with WRF in multivariate logistic regression analysis (odds ratio 7.84; 95% confidence interval 4.06-15.14; P < 0.0001). The dose of intravenous furosemide within 24 h of admission was one of the predictors of the early drop in SBP ≥ 14.0%, while no early drop in SBP was a predictor of in-hospital mortality in multivariate logistic regression models. In conclusion, the optimal cut-off value for WRF in patients with HF was a 14.0% drop in SBP within 24 h of admission. The early drop in SBP ≥ 14.0% was one of the predictors of WRF in patients with HF. However, no early drop in SBP was associated with in-hospital mortality. This study was registered with the University Hospital Medical Information Network in Japan (UMIN000035989).

Percutaneous coronary intervention in a patient with heparin resistance due to essential thrombocythaemia: a case report

Background 

Coronary artery disease is uncommon in patients with essential thrombocythaemia (ET); therefore, no treatment strategies have been established.

Case summary 

A 68-year-old man visited our hospital with worsening effort angina complicated with ET. Coronary angiography (CAG) revealed moderate stenosis of the left main trunk and left anterior descending artery (LAD). We planned to perform percutaneous coronary intervention (PCI) only after the patient’s platelet count had fallen below 600 000/μL. Platelet factor 4 levels were markedly elevated (355.0 ng/mL; the normal range is <20 ng/mL). We observed a de novo lesion in the proximal left circumflex artery and stenosis progression in the LAD at the time of the PCI, neither of which had been detected at the previous CAG. During the PCI procedure, argatroban was infused to maintain the activated clotting time (ACT) above 250 s. The PCI was performed successfully without any complications. Follow-up CAG showed no restenosis, and no bleeding complications were observed during the course.

Discussion 

In patients with ET, it may be useful to measure platelet factor 4 before PCI and to monitor ACT during the procedure. When heparin resistance is suspected based on blood coagulation tests, infusion of direct thrombin inhibitor during PCI may be considered, with anticoagulation monitoring by ACT.

Poor prognosis of heart failure patients with in-hospital worsening renal function and elevated BNP at discharge

Aims

Our purpose was to investigate the association between the B‐type natriuretic peptide (BNP) level at discharge, the occurrence of worsening renal function (WRF), and long‐term outcomes in patients with heart failure (HF).

Methods and results

We enrolled hospitalized acute HF patients. We divided patients into four groups on the basis of BNP <250 pg/mL (BNP−) or BNP ≥250 pg/mL (BNP+) at discharge and the occurrence of WRF during admission: BNP−/WRF−, BNP−/WRF+, BNP+/WRF−, and BNP+/WRF+. We evaluated the association between BNP at discharge, WRF, and cardiovascular/all‐cause mortality/hospitalization due to HF. Clinical follow‐up was completed in 301 patients. At discharge, percentages of the patients with clinical signs of HF were low and similar among four groups. The median follow‐up period was 1206 days (interquartile range, 733–1825 days). The composite endpoint of cardiovascular mortality and HF hospitalization was significantly different between the four groups [12.9% (BNP−/WRF−), 22.7% (BNP−/WRF+), 35.8% (BNP+/WRF−), and 55.4% (BNP+/WRF+), P < 0.0001]. All‐cause mortality was also different etween the four groups (15.1%, 38.6%, 28.7%, and 39.3%, respectively, P = 0.003). In the multivariate Cox proportional hazards model, the combination of BNP ≥250 pg/mL and WRF showed the highest hazard ratio (HR) for composite endpoint (HR, 5.201; 95% confidence interval, 2.582–11.11; P < 0.0001), and BNP−/WRF+ was associated with increased all‐cause mortality (HR, 2.286; 95% confidence interval, 1.089–4.875; P = 0.03). Patients in BNP+/WRF+ had a higher cardiovascular mortality (28.6%), and those in BNP−/WRF+ had a high non‐cardiovascular mortality (29.5%).

Conclusions

Heart failure patients with BNP ≥250 pg/mL at discharge and in‐hospital occurrence of WRF had the highest risk for the composite endpoint (cardiovascular mortality and HF hospitalization) among groups.

Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography

OBJECTIVES

Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions.

BACKGROUND

A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque.

METHODS

OCT was performed preintervention (if possible), post-RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round-shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared.

RESULTS

Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4-88.1] vs. 66.7% [IQR: 55.0-76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7-994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5-14.3, p = 0.04).

CONCLUSION

In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.

Serum zinc concentration in patients with acute myocardial infarction in percutaneous coronary intervention era

INTRODUCTION

There were few studies that investigated the association between serum zinc concentration and acute myocardial infarction (AMI) in percutaneous coronary intervention era.

OBJECTIVE

We assessed the relationships between serum zinc concentration, complications, and prognosis in AMI patients after primary percutaneous coronary intervention.

METHODS

We conducted a single-center, prospective, observational study including 50 patients with AMI. We divided patients into two groups (High-zinc group and Low-zinc group) by median serum zinc concentration and compared two groups about clinical outcomes up to 1 year follow up.

RESULTS

The mean age of patients was 66.2 ± 11.8 years old. Patients in the Low-zinc group had ST-segment elevation more frequently than those in the High-zinc group (96.0% vs. 72.0%, P = 0.02). All-cause mortality at 1 year was similar in both groups (P (log-rank) = 0.33). However, the lengths of hospital stay and in coronary care unit were longer in patients in the Low-zinc group than in those in the High-zinc group (15.6 ± 9.2 days vs. 11.9 ± 2.9 days, P = 0.06; 3.9 ± 2.8 days vs. 2.3 ± 0.8 days, P = 0.01). Multivariate regression analysis showed that low serum zinc concentration was associated with the use of cardiac or respiratory assist devices (adjusted odds ratio, 17.79; 95% CI 1.123 to 1216.5; P = 0.04).

CONCLUSIONS

Although there was no significance difference in mortality in Low-zinc and High-zinc groups, low serum zinc concentration was associated with longer stay in the coronary care unit, and was one of the independent predictors for the use of cardiac or respiratory assist devices.

Morphological assessment of chronic total occlusions by combined coronary computed tomographic angiography and intravascular ultrasound imaging

Aims

The relationship between CTO morphology and vessel remodelling is unclear. We described chronic total occlusion (CTO) morphology using coronary computed tomographic angiography (CCTA) combined with intravascular ultrasound (IVUS).

Methods and results

Pre-intervention CCTA and IVUS of 130 CTO lesions (128 patients) were evaluated. Based on CCTA, positive CTO lesion remodelling [PR, maximum CTO segment vessel diameter > proximal reference vessel diameter (RVD)] was seen in 44 (33.8%) lesions. In the other 86 lesions without PR, 74 (56.9%) had a minimum CTO segment vessel diameter >50% of the proximal RVD and were classified as non-PR; 12 (9.2%) lesions had a minimum CTO segment vessel diameter ≤50% of the proximal RVD and were classified as collapse. Comparing the three groups, CTO with PR had the greatest maximum atheroma cross-sectional area (CSA) while the collapse group had the least atheroma CSA (16.0 mm2 [12.0, 19.4] vs. 9.1 mm2 [6.0, 15.9], P < 0.001). The maximum arc of attenuated plaque was greatest in the PR group (51° [0, 167]); and the maximum arc of calcium was greatest in the non-PR group (91° [51, 174]). In the collapse group distal to the occluded segment, there was a normal-appearing vessel by IVUS that corresponded to the collapsed segment by CCTA; its minimum plaque burden was 33.2% [19.9, 38.1] with a smooth concave-shaped lumen surface, implying that the CCTA collapse segment was not occluded.

Conclusion

Not all CTOs are the same with regard to lesion remodelling and underlying morphology. The combination of IVUS and CCTA can help to categorize CTO morphology.

The association between high-dose loop diuretic use at discharge and cardiovascular mortality in patients with heart failure

AIMS

Few studies have reported the impact of high-dose loop diuretics at discharge on prognosis in Japanese patients with heart failure (HF). Our purpose was to assess the relationship between the dose of loop diuretics at discharge and cardiovascular mortality in patients with HF.

METHODS AND RESULTS

We enrolled decompensated HF patients who were admitted to our hospital between March 2010 and March 2015, and compared HF patients who received high-dose loop diuretics at discharge (HD group) with low-dose loop diuretics at discharge (LD group) with regard to risk of cardiovascular mortality, and all-cause mortality. High-dose loop diuretic was defined as ≥40 mg/day of oral furosemide at discharge. A total of 215 patients were enrolled to the study. The median follow-up duration was 641 days. All-cause and cardiovascular mortality were significantly lower in the LD group than in the HD group (10.4% vs. 31.6%, P < 0.001; 2.2% vs. 24.6%, P < 0.001, respectively). High-dose loop diuretics were associated with cardiovascular mortality in multivariate Cox proportional hazards model (hazard ratio, 16.06, 95% confidence interval 3.457 to 116.8; P < 0.001). The largest area under the receiver operating characteristic curve (0.85) for cardiovascular death was obtained with a threshold of 40 mg furosemide.

CONCLUSIONS

High-dose loop diuretic use at discharge was one of the predictors of cardiovascular mortality in patients with HF. An oral furosemide dose of 40 mg daily may be defined as 'high-dose' loop diuretics in Japanese patients with chronic HF.

Serial 3-Vessel Optical Coherence Tomography and Intravascular Ultrasound Analysis of Changing Morphologies Associated With Lesion Progression in Patients With Stable Angina Pectoris

Background—

Optical coherence tomographic (OCT) morphologies associated with lesion progression are not well studied. The aim of this study was to determine the morphological change for untreated lesion progression using both OCT and intravascular ultrasound (IVUS).

Methods and Results—

We used baseline and 8-month follow-up 3-vessel OCT and IVUS to assess 127 nonculprit lesions (IVUS plaque burden ≥40%) in 45 patients with stable angina after target lesion treatment. Lesion progression was defined as an IVUS lumen area decrease >0.5 mm 2 . A layered pattern was identified as a superficial layer that had a different optical intensity and a clear demarcation from underlying plaque. Lesion progression was observed in 19% (24/127) lesions, and its pattern was characterized into 3 types: type I, new superficial layered pattern at follow-up that was not present at baseline (n=9); type II, a layered pattern at baseline whose layer thickness increased at follow-up (n=7); or type III, no layered pattern at baseline or follow-up (n=8). The increase of IVUS plaque+media area was largest in type I and least in type III (1.9 mm 2 [1.6–2.1], 1.1 mm 2 [0.9–1.4], and 0.3 mm 2 [−0.2 to 0.8], respectively; P =0.002). Type III, but not types I or II, showed negative remodeling during follow-up (IVUS vessel area; from 14.3 mm 2 [11.4–17.2] to 13.5 mm 2 [10.4–16.7]; P =0.02). OCT lipidic plaque was associated with lesion progression (odds ratio, 13.6; 95% confidence interval, 3.7–50.6; P <0.001).

Conclusions—

Lesion progression was categorized to distinct OCT morphologies that were related to changes in plaque mass or vessel remodeling.

Relationship between worsening renal function and long-term cardiovascular mortality in heart failure patients

BACKGROUND

Recently several studies showed that worsening renal function (WRF) during hospitalization might be a strong independent predictor of poor prognosis in decompensated heart failure (HF) patients. However, these studies had a relatively short follow-up duration and their data were limited to in-hospital outcomes. Our purpose was to assess the relationship between WRF and long-term cardiovascular mortality in HF patients.

METHODS

We enrolled decompensated HF patients who were admitted to our hospital between April 2010 and March 2015. WRF was defined as a relative increase in serum creatinine of at least 25% or an absolute increase in serum creatinine ≥0.3mg/dL from the baseline. We assessed the cardiovascular mortality and all-cause mortality in HF patients with WRF (WRF group) and without WRF (no WRF group).

RESULTS

Among 301 patients enrolled, WRF developed in 118 patients (39.2%). During a median follow-up period of 537days [interquartile range, 304.3 to 1025.8days], cardiovascular mortality and all-cause mortality were significantly higher in the WRF group than in the no WRF group (23.2% vs. 6.1%, P<0.001; 30.3% vs. 14.7%, P<0.001, respectively). In the multivariate Cox proportional hazards model, age and serum B-type natriuretic peptide (BNP) level were associated with both cardiovascular death and all-cause death. However, WRF was not the independent predictor of cardiovascular death (P=0.19) nor all-cause death (P=0.57).

CONCLUSIONS

WRF was associated with cardiovascular death in patients with HF. Although not an independent predictor, WRF might be one of useful markers to identify patients who should be followed carefully after discharge.

Steroid pulse therapy was effective for cardiac sarcoidosis with ventricular tachycardia and systolic dysfunction

A 32‐year‐old man presented with palpitation. He was diagnosed with pulmonary sarcoidosis by lung biopsy. The electrocardiogram showed first‐degree atrioventricular block and complete right bundle branch block (CRBBB). We planned to examine laboratory data, echocardiography, Holter monitoring, and gallium‐67 scintigraphy. Before he went through all these exams, he developed ventricular tachycardia. After defibrillation was performed, his electrocardiogram revealed complete atrioventricular block. We observed elevation of serum angiotensin‐converting enzyme levels. In addition, both of gallium‐67 scintigraphy and ¹⁸F‐fluorodeoxyglucose positron emission tomography showed abnormal uptake in the ventricular septum. We diagnosed the patient with cardiac sarcoidosis associated with these arrhythmias. We started treatment with methylprednisolone pulse therapy (1 g daily). After 3 days of steroid pulse therapy, we administered prednisolone 30 mg daily. On day 15, electrocardiogram changed from complete atrioventricular block to first‐degree atrioventricular block and CRBBB. He was discharged with no progression with cardiac sarcoidosis for 2 years.

The Efficacy of Tolvaptan in Congestive Heart Failure Patients with and Without Hypoalbuminemia: A Pilot Study

BACKGROUND

Heart failure (HF) with hypoalbuminemia is associated with poor response to conventional therapy. We investigated whether tolvaptan, a potent aquaretic agent, might be of benefit in HF patients with hypoalbuminemia.

METHODS

We prospectively enrolled 40 patients hospitalized for HF. Patients received conventional therapy including loop diuretics. We subsequently added tolvaptan in the range of 3.75-15 mg daily and it was discontinued after improvement of HF symptoms. We compared clinical and laboratory data in HF patients with and without hypoalbuminemia (defined as serum albumin <3.0 g/dL).

RESULTS

Tolvaptan was administered in 18 HF patients with hypoalbuminemia (Group A) and 22 HF patients without hypoalbuminemia (Group B). The mean serum albumin was 2.63 ± 0.27 and 3.46 ± 0.25 g/dL, respectively. The average urine output on tolvaptan increased significantly in both groups (1644.4 ± 797.6-3011.6 ± 1453.8 mL/day, P = 0.004; 1459 ± 612.7-2112.2 ± 724.5 mL/day, P = 0.008; respectively). In addition, we observed higher urine output on therapy in Group A than in Group B (P = 0.015). There was a moderate negative correlation between serum albumin and average urine output on tolvaptan (r = -0.42, P = 0.007).

CONCLUSIONS

The addition of tolvaptan to low dose loop diuretics might be an effective strategy for treatment of HF patients with hypoalbuminemia.

Serial Intravascular Ultrasound Findings After Treatment of Chronic Total Occlusions Using Drug-Eluting Stents

Morphologic changes after chronic total occlusion (CTO) treatment with drug-eluting stents (DESs) have not been assessed in detail. Our aim was to use both baseline and follow-up intravascular ultrasound studies to evaluate the morphologic changes and, especially, the changes in distal vessel size and the effect of subintimal stenting after treatment of CTOs with DES. We analyzed serial follow-up intravascular ultrasound (baseline and follow-up at 9 ± 2 months) after DES implantation into 40 CTOs. Overall, 33 CTOs were treated by the anterograde approach; and 7 were treated by the retrograde approach. Minimum lumen cross-sectional area (CSA) trended toward a decrease from baseline to follow-up (4.8 ± 1.7 vs 4.5 ± 1.7 mm(2), p = 0.10), although the minimum stent CSA (4.8 ± 1.7 vs 4.9 ± 1.7 mm(2), p = 0.26) did not change. The distal reference, but not the proximal reference lumen CSA, increased significantly at follow-up (3.8 ± 2.0 to 5.1 ± 2.3 mm(2), p = 0.0004). Late-acquired stent malapposition was seen in 17 patients (42.5%). In 8 CTOs (20%), a part of the stent was implanted into a subintimal space; in these 8 patients, maximum percent neointimal hyperplasia and minimum lumen area was similar in the subintimal segment compared with the adjacent intraplaque segment. The frequency of late-acquired stent malapposition was similar. In conclusion, after CTO treatment with DES, distal vessel enlargement was detected. Subintimal stenting after recanalization of CTO was not inferior compared with stenting within the plaque in terms of long-term morphologic impact.

Mechanical complications of everolimus-eluting stents associated with adverse events: an intravascular ultrasound study

AIMS

Mechanical complications contribute to bare metal and first-generation drug-eluting stent (DES) failure. However, the importance of the mechanical complications of second-generation DES remains unclear. We report mechanical complications associated with everolimus-eluting stent (EES) failures.

METHODS AND RESULTS

We retrospectively analysed 177 consecutive EES-treated lesions in 136 patients who underwent intravascular ultrasound (IVUS) at follow-up. Mechanical complications were identified in 17 patients (five stable angina, 10 unstable angina, two non-ST-elevation myocardial infarction [NSTEMI] without angiographic thrombus). Fifteen (88.2%) were treated with repeat revascularisation. By IVUS, there were 16 focal (94.1%) and one diffuse (5.9%) in-stent restenoses. Complete stent fracture with separation was seen in only one, partial stent fracture with separation was seen in three, and in 13 there was longitudinal deformation (n=2) or stent strut fracture (n=11) with overlapping of the proximal and distal stent fragments. In 13 EES with evidence of overlapping in the setting of either fracture or deformation, there was a 35.5±12.2% smaller stent area compared to the adjacent proximal and distal stent fragments, and >50% neointimal hyperplasia in 12 (92.3%).

CONCLUSIONS

We found EES mechanical complications, often followed by longitudinal deformation or fracture leading to excessive neointimal hyperplasia, in-stent restenosis, and repeat revascularisation.

Association between increased epicardial adipose tissue volume and coronary plaque composition

To assess the relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in significant coronary stenosis using a 40-MHz intravascular ultrasound (IVUS) imaging system (iMap-IVUS), we analyzed 130 consecutive patients with coronary stenosis who underwent dual-source computed tomography (CT) and cardiac catheterization. Culprit lesions were imaged by iMap-IVUS before stenting. The iMAP-IVUS system classified coronary plaque components as fibrous, lipid, necrotic, or calcified tissue, based on the radiofrequency spectrum. Epicardial adipose tissue was measured as the tissue ranging from -190 to -30 Hounsfield units. EATV, calculated as the sum of the fat areas on short-axis images, was 85.0 ± 34.0 cm(3). There was a positive correlation between EATV and the percentage of necrotic plaque tissue (R (2) = 0.34, P < 0.01), while there was a negative correlation between EATV and the percentage of fibrous tissue (R (2) = 0.24, P < 0.01). Multivariate analysis revealed that an increased low-density lipoprotein cholesterol level (β = 0.15, P = 0.03) and EATV (β = 0.14, P = 0.02) were independently associated with the percentage of necrotic plaque tissue. An increase in EATV was associated with the development of coronary atherosclerosis and, potentially, with the most dangerous type of plaque.

Frequency, mechanisms, and implications of late peri-stent contrast staining: analysis (from the HORIZONS-AMI Trial)

Previous studies have suggested that angiographically detected persistent contrast staining (PSS) at follow-up may predict subsequent very late stent thrombosis. The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial was a dual-arm, factorial, randomized trial in patients with ST-segment elevation myocardial infarctions. All follow-up angiograms (1,330 lesions in 1,115 patients, median time 13.3 months) without major cardiovascular events before follow-up angiography were analyzed at a core laboratory blinded to clinical events for the presence of PSS (defined as contrast staining outside the stent contour extending to ≥20% of the stent diameter). Corresponding follow-up intravascular ultrasound (IVUS) data (275 lesions in 248 patients) were also evaluated to assess the mechanisms of PSS. PSS was present in 23 patients (2.1%) at follow-up and was not more common with paclitaxel-eluting than with bare-metal stents. All 6 PSS patients with follow-up IVUS had stent malapposition (vs 41.2% malapposition in the follow-up IVUS cohort). Comparing poststent and follow-up IVUS, 2 patients had late acquired and 4 had persistent malapposition; all 6 showed positive vessel remodeling from baseline to follow-up (mean vessel area 22.0 ± 8.0 to 32.4 ± 11.7 mm(2), p = 0.07). During 3-year follow-up, stent thrombosis developed in no patient with PSS compared with 8 PSS-negative patients (0% vs 0.8%, p = 0.68). The rates of revascularization and major adverse cardiovascular events were also not increased in PSS patients. In conclusion, in the large-scale HORIZONS-AMI trial, PSS at angiographic follow-up was infrequent and was associated with late stent malapposition and positive remodeling but was independent of stent type. Identification of PSS was not associated with subsequent stent thrombosis.

An intravascular ultrasound comparison of left anterior descending artery/first diagonal branch versus distal left main coronary artery bifurcation lesions

AIMS

We report the intravascular ultrasound (IVUS) analysis of plaque distribution in left anterior descending (LAD) artery/first diagonal (D1) and distal left main coronary artery (LMCA) bifurcation lesion location.

METHODS AND RESULTS

We reviewed 58 angiograms of LAD/D1 bifurcation lesions with pre-intervention IVUS of both the LAD and D1 and compared these data to a corresponding cohort (n=81) of LMCA bifurcations, dividing each bifurcation into three segments: MV (main vessel), MB (main branch distal to the carina), and SB (side branch). In the LAD/D1 cohort, D1 (SB) had less calcium and a smaller plaque burden compared to the other two segments. Continuous plaque from the LAD proximal to the carina (MV) into the LAD distal to the carina (MB) was seen in 90%, from the MV into the SB in 72%, and from the MV into both the MB and SB in 62%. In the LMCA cohort, ostial left circumflex (LCX) (SB) had less calcium and a smaller plaque burden compared to the distal LMCA (MV) and ostial LAD (MB). Continuous plaque from MV to MB was seen in 96%, from MV to the SB in 78%, and from MV to both branches in 74%.

CONCLUSIONS

The IVUS analysis of the LAD/D1 and LMCA bifurcations revealed that most lesions had diffuse plaques extending from the MV into the MB with the SB having the least amount of calcium and the smallest plaque burden, regardless of location.

Repeat drug-eluting stent implantation for in-stent restenosis: first- or second-generation stent

OBJECTIVE

To investigate the efficacy and safety of a second-generation drug-eluting stent (DES) for in-stent restenosis (ISR) after first-generation DES implantation.

BACKGROUND

The everolimus-eluting stent is a second-generation DES that is very effective for de novo coronary lesions.

METHODS

The subjects were 145 consecutive patients who underwent re-stenting, including 93 given a first-generation DES and 52 given a second-generation DES. The two groups were followed up for 37.8 ± 16.7 months and 13.8 ± 2.1 months, respectively. The primary endpoint was in-stent late luminal loss at 8-month angiographic follow-up.

RESULTS

Baseline clinical and angiographic parameters were similar in the 2 groups. Follow-up angiography showed that late luminal loss (0.26 ± 0.31 mm vs 0.58 ± 0.67 mm; P=.01), the binary restenosis rate (2.6% vs 16.7%; P=.03), and the target lesion revascularization (TLR) rate (1.9% vs 11.8%; log-rank = 0.04) were smaller in the second-generation group than in the first-generation group. There was no definite stent thrombosis in either group. During follow-up, there were no significant between-group differences of major adverse cardiac events without TLR, myocardial infarction, death, and death + myocardial infarction. Multivariate analysis demonstrated that using a first-generation DES was the only independent predictor of TLR after 1 year (odds ratio, 2.78; 95% confidence interval, 1.22-5.43; P=.03).

CONCLUSION

When ISR occurs after DES implantation, treatment with a second-generation DES reduces late luminal loss, binary restenosis, and TLR after 1 year compared with a first-generation DES.

Ventricular fibrillation diagnosed during electrophysiological study for non-sustained tachycardia

Ventricular fibrillation diagnoses such as Brugada syndrome pose a risk of sudden incapacitation or death in aircrew. This case report presents a 44-yr-old male fighter pilot who unexpectedly developed ventricular fibrillation (VF) during an electrophysiological study (EPS) prior to therapy for non-sustained ventricular tachycardia (nsVT). The initial aeromedical disposition for this case was "qualified for flying duties". with the restriction that he must fly with another pilot due to repeatedly observed nsVT. This pilot wanted to return to flight duty in single-seat aircraft without any restrictions. Therefore, this patient decided to undergo catheter therapy for nsVT. Unexpectedly, not VT but VF was induced by catheter manipulation during EPS. Pilsicainide-induced coved-type ST wave elevation consistent with Brugada syndrome was noted in this patient's electrocardiogram. He was ultimately disqualified due to the diagnosis of VF. This report suggests EPS on rare occasions may uncover another severe disease similar to this case report.

Detecting early oral cancer: narrowband imaging system observation of the oral mucosa microvasculature

The aim of this study was to analyze and describe the intrapapillary capillary loops (IPCL), which are a feature of early oral neoplastic lesions, using a narrowband imaging (NBI) system. Forty-one patients (26 men, 15 women; mean age, 52.34 years; range, 23-83 years) presenting with non-neoplastic or neoplastic lesions, and normal cases, were examined using the prototype Evis Lucera Spectrum (Olympus Co.). The images were analyzed and an IPCL classification was devised. All normal cases (n=10) had regularly distributed capillary loops of the same shape (type I). Non-neoplastic lesions (n=8) had mild changes of the capillary loops (types II and III) and neoplastic lesions (n=23) were irregularly distributed and had several loop shapes (types III and IV). The microvascular organization of non-neoplastic lesions was notably different from that of neoplastic lesions. A brownish area was found in five cases of early carcinoma. The narrowband imaging system is a potential approach for clinically analyzing microvascular organization and IPCL. It could be useful for diagnosing oral squamous cell carcinoma at an earlier stage and for determining the margin of resection.

Observation of strong low-lying E1 strength in the two-neutron halo nucleus 11Li

An exclusive measurement has been made of the Coulomb dissociation of the two-neutron halo nucleus 11Li at 70 MeV/nucleon at RIKEN. Strong low-energy (soft) E1 excitation is observed, peaked at about Ex = 0.6 MeV with B(E1) = 1.42(18) e2fm2 for Erel < or = 3 MeV, which was largely missed in previous measurements. This excitation represents the strongest E1 transition ever observed at such low excitation energies. The spectrum is reproduced well by a three-body model with a strong two-neutron correlation, which is further supported by the E1 non-energy-weighted cluster sum rule.

Small left atrium: an adjunctive sign of hemodynamically compromised massive pulmonary embolism

Pulmonary embolism (PE) is a common disease with a high mortality rate due to right ventricular dysfunction and underfilling of the left ventricle. We present a case of a 33-year-old man with hemodynamically compromised massive PE. His left atrium was collapsed with marked dilatation of the right atrium and ventricle on multi-detector-row CT scans. The patient was treated with an intracatheter injection of a mutant tissue-type plasminogen activator and subsequently showed clinical and radiological improvements. The small left atrial size in combination with a right ventricular pressure overload was considered to be an adjunctive sign of hemodynamically compromised massive PE.

Characterization of the expression of TLR2 (toll-like receptor 2) and TLR4 on circulating monocytes in coronary artery disease

TLRs are receptors involved in the recognition of pathogens by the innate immune system, and TLR2 and TLR4 play important roles in the activation of monocytes. A total of 105 consecutive patients who underwent coronary angiography comprised of 46 with stable effort angina (SA), 41 with unstable angina (UA), and 18 with no significant CAD (CNT) were enrolled. The baseline expression levels of TLR2 and TLR4 on monocytes in peripheral blood mononuclear cells (PBMCs) were determined by flow-cytometric analysis. Since TLR2 expression has been reported to be regulated by TLR4 signaling, we cultured PBMCs with or without lipopolysaccharide (LPS, 1 microg/ml). At baseline, TLR4 levels (mean of fluorescence intensity ) in SA (145 +/- 58, p < 0.05) and UA (164 +/- 65, p < 0.01) were higher than those in CNT (107 +/- 37). As for TLR2, levels were higher in UA (108 +/- 36, p < 0.05) than in SA (94 +/- 18) and CNT (87 +/- 22). After stimulation with LPS, TLR2 levels increased in SA but decreased in UA. In conclusions, TLR4 levels increased in both SA and UA. Monocytes in UA were characterized by elevated TLR2 levels and unresponsiveness of the TLR2 levels to TLR4 stimulation.

Analysis of a role for p16/CDKN2 expression and methylation patterns in human oral squamous cell carcinoma

The p16/CDKN2 (cyclin dependent kinase number 2) gene is known to be one of the negative regulators of the cell cycle. Aberrant 5'CpG island methylation is one of the most important mechanisms of p16/CDKN2 gene promoter region alteration. We studied 8 oral squamous cell carcinoma cell lines and 25 primary tumor tissues for the p16/CDKN2 gene and its expression by PCR-SSCP, MSP, RT-PCR, and immunohistochemical methods to determine the mechanism and the potential biological significance of p16/CDKN2 gene inactivation. In primary tumors, no p16/CDKN2 gene mutations were found by PCR-SSCP. However, hypermethylation of the CpG sites of p16/CDKN2 gene was observed in 48% (12/25) cases of primary tumors and in 50% (4/8) of cell lines. To verify the p16 mRNA expression, we employed RT-PCR and observed decreased or lacked p16 mRNA in 44% (11/25) of primary tumor tissues. In addition, hypermethylation was observed in 6 of the above 11 cases (55%). An immunohistochemistry assay was also performed with the primary tumor tissues, and a semi-quantitative method was used to evaluate the staining intensity of p16 protein. We observed 52% (13/25) negative nuclear staining. When we compared these results with clinicopathological stages, there was no statistical significance. These findings suggest that hypermethylation of p16/CDKN2 promoter region may be associated with p16/CDKN2 gene alteration.

Frequent allelic loss/imbalance on the short arm of chromosome 3 in tongue cancer

Frequent allelic imbalances including loss of heterozygosity (LOH) and microsatellite instability (MSI) on the short arm of chromosome 3 (3p) have been found in several types of human cancer. This study was designed to identify the tumor suppressor locus (or loci) on 3p associated with tongue squamous cell carcinoma (SCC). Among 16 patients with tongue SCC tested, 7 (44%) of 16 informative cases showed LOH at one or more loci. Deletion mapping of these 16 tumors revealed two discrete, commonly deleted regions on the chromosome arm. Our data support the notion that tumor suppressor gene(s) contributing to the progression of tongue squamous cell carcinoma reside on 3p24 and 3p25.

Analysis of the ANA gene as a candidate for the chromosome 21q oral cancer susceptibility locus

Loss of heterozygosity (LOH) on the long arm of chromosome 21 (21q) is observed in several human malignancies. We identified novel tumour suppressor loci on this region in primary oral squamous cell carcinomas (OSCCs). To further determine the role of 21q deletions in oral cavity tumorigenesis, 63 OSCCs were examined for LOH at 21q using 7 microsatellite markers. LOH was observed in 32 of 63 cases (50.8%) that were informative for at least one of the loci analysed. Two distinct deleted regions were identified at chromosomal region 21q11.1. The possible involvement of ANA (abundant in neuroepithelium area), a candidate tumour suppressor gene (TSG) located on 21q11.2--21.1, was also evaluated for 20 OSCCs and 9 OSCC-derived cell lines. 60% of tumours (12/20) and 88.9% (8/9 cell lines) showed absent or reduced mRNA gene expression; only one OSCC case had a nucleotide substitution in the ANA gene. Interestingly, the frequency of the suppressed ANA mRNA expression was greater in stage IV tumours than in earlier stages. In addition, re-expression of the ANA gene mRNA was induced in 4 cell lines after treatment with 5-aza-2'-deoxycytidine, a DNA demethylating agent. These findings demonstrate that there may be at least 2 distinct TSGs on 21q11.1; loss of ANA gene expression could be involved in the progression of human OSCC; and aberrant methylation of the ANA gene promoter may participate in the transcriptional silencing of the gene in oral cancer cells.

Capacity for epithelial differentiation in synovial sarcoma: analysis of a new human cell line

AIM

To analyse the capacity for epithelial differentiation in synovial sarcoma using a new human cell line.

METHODS

A new human cell line, KU-SS-1, was established from a monophasic, spindle cell type of synovial sarcoma by grafting those cells on to severe combined immunodeficient (SCID) mice and then transferring them to in vitro culture systems. The KU-SS-1 cells were characterised by light and electron microscopy, and by immunohistochemical, flow cytometric, and cytogenetic analysis.

RESULTS

Primary tumour and cultured cells at passage 20 showed a positive reaction for vimentin, which is a mesenchymal marker. After 40 passages, subcultured cells were injected into SCID mice to induce further tumours. These advanced subcultured cells and the tumour cells that they induced were positive for cytokeratin, an epithelial marker, and exhibited epithelial ultrastructural features such as intermediate junctions. Furthermore, two colour immunofluorescent analysis for proliferating nuclear cell antigen (PCNA) and intermediate filaments showed that a large number of PCNA expressing cells were positive for vimentin, and that part of this fraction also expressed cytokeratin. The existence of cells with reactivity for these three markers indicated that, in this cell line, a fraction with high proliferating capacity had both mesenchymal and epithelial markers. In addition, cytogenetically, this cell line expressed the SYT-SSX chimaeric transcript as a result of the t(X;18) (p11;q11) translocation.

CONCLUSIONS

A human synovial sarcoma cell line was established and stably maintained in cell culture for more than 70 passages. In addition, this cell line showed epithelial differentiation, which supports the hypothesis that synovial sarcoma is a carcinosarcoma like tumour with true epithelial differentiation. This cell line will be a useful tool for investigating the nature of this tumour and will contribute to clinical studies.

In vivo tumouricidal effect of T lymphocytes activated by liposomes containing adriamycin on chemically-induced rat malignant fibrous histiocytoma

The augmentative effect of liposomes containing adriamycin (LADM) in the host-tumour immune mechanism was assessed using 9,10-dimethyl-1,2-benzanthracene induced rat malignant fibrous histiocytoma (MFH). The antitumour effect of LADM was analyzed using a double grafted tumour system in which F344 rats first received simultaneous s.c. inoculations of MFH cells in both right and left flanks and were then injected with 0.2 mg of LADM into the right tumour on Day 10, 12, and 14. The growth of a remote, non-treated tumour was strongly inhibited, and the infiltration of CD8+ or CD4+ cells at the tumour periphery was histologically revealed. This inhibition was not observed in F344 nu/nu athymic rats. Winn neutralizing assay with T cell-rich splenic lymphocytes from each drug-treated MFH-bearing rat showed that complete regression of the tumour at a low effector/target ratio occurred only in the LADM-treated group. Furthermore, the tumouricidal effects were demonstrated in coexistence with CD8+ cells and CD4+ cells by assay with FACS sorting splenic lymphocytes. These results strongly suggest that intratumoural administration of LADM caused the systemic augmentation of the MFH-bearing host immune mechanism, and that the augmented response after LADM treatment was induced by the cytotoxic CD8+ lymphocytes dependent on the CD4+ lymphocytes.

Characterization of the K+ current mediated by 5-HT1A receptor in the acutely dissociated rat dorsal raphe neurons

The action of 5-hydroxytryptamine (5-HT) via the 5-HT1A receptor on dissociated rat dorsal raphe neurons was characterized under the whole-cell mode by using the nystatin-perforated patch-clamp technique. Under voltage-clamp conditions, 5-HT induced an inwardly rectifying K+ current (I5-HT) in a concentration-dependent manner. I5-HT was mimicked by 8-OH-DPAT and buspirone, which are both 5-HT1A receptor agonists. I5-HT was reversibly blocked by such 5-HT1A receptor antagonists as (S)-UH-301 a 5-HT4 receptor antagonist. I5-HT was antagonized concentration-dependently by such K+ channel blockers as quinine, Ba2+ and 4-aminopyridine but was relatively insensitive to both CS+ and tetraethylammonium. When the neurons were loaded with guanosine 5'-O-3-thiotriphosphate through a patch pipette, the K+ current induced by 5-HT became irreversible. N-ethylmaleimide (NEM), a sulfhydryl alkylating agent, irreversibly blocked I5-HT. The intracellular perfusion with 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA), a Ca2+ chelator, or neomycine, a phospholipase C inhibitor, never significantly affected the 5-HT-induced response. 12-Myristate 13-acetate diester (PMA), a protein kinase C (PKC) activator, had only a weak inhibitory effect on I5-HT, and staurosporine, a PKC inhibitor, failed to significantly occlude I5-HT. Therefore, the K+ conductance activated via the 5-HT1a receptor of dorsal raphe neurons was thus characterized by the sensitivity to such K+ channel blockers as quinine, Ba2+ and 4-aminopyridine. Moreover, G protein which is NEM-sensitive and can couple to the 5-HT1A receptor, is thus considered to activate the inwardly rectifying K+ conductance without being mediated by such second messengers as Ca2+ and PKC.