Cardiometabolic predictors of quantitative high-risk plaque features in a diverse patient population

Background/Introduction

Little is known about the prevalence of high-risk plaque features or cardiometabolic predictors in diverse patient populations with underrepresented minorities, in the setting of stable chest pain.

Purpose

The goals of our study are to 1) describe plaque characteristics in a diverse patient population with underrepresented minorities and 2) characterize cardiometabolic risk factors associated with high prevalence of high-risk quantitative low attenuation noncalcified plaque (LDNCP) burden.

Methods

Our study included patients with chest pain undergoing CCTA between June 2016 and October 2021 for stable chest pain, who had a complete cardiometabolic panel including lipoprotein(a) and lipid panel, and at least one blood pressure recording before CCTA. Patients with prior PCI or CABG where excluded. CACS was performed before CCTA as per Agatston method and quantified in Agatston Units (AU). Stenosis was graded as per SCCT guidelines by cardiologists and radiologists with level 3 cardiac CT expertise. Plaque measurements were performed using previously validated semiautomated software (AutoPlaque version 2.5) in all patients with CAD-RADS >0 by expert readers blinded from patients' characteristics. Coronary atherosclerotic plaque volumes were measured. Independent predictors for plaque on CCTA among patients were examined using Wilcox multivariate logistic regression.

Results

A total of 227 consecutive patients were included in our study (see table; age 55.00 [47.50–62.00] years, 63% female, 16% diabetes, 44% hypertension, 40% hyperlipidemia and 32% with current or previous smoking history). Majority of patients were Hispanic (64%) and the rest were Black (27%), White (6%) and Asian (3%).

Patients with LDNCP burden >4% were older (60.00 [52.00–66.50] vs 53.00 [43.75–61.00]; p<0.001), more likely to be diabetic (27.7 vs 11.5%; p=0.005), hypertensive (67.7 vs 33.8%; p<0.001), hyperlipidemic (64.6 vs 29.9%; p<0.001) and present smokers (31.3 vs 13.9%; p=0.003). Almost all patients (63/67) with LDNCP burden >4% had non-obstructive disease (CAD-RADS<4).

Patient with LDNCP burden >4% were more likely to be on statin therapy (46.0 vs 30.4%; p=0.041). There was no differences in ethnicity, hemoglobin A1C, TC, LDL-C, HLD-C, TGs, lipoprotein(a), SBP or DBP.

By logistic regression analysis, age (OR [CI]: 1.06 [1.01–1.08]), hypertension (2.20, [1.06–4.63]) and hyperlipidemia (2.73 [1.37–5.47]) increased the likelihood of LDNCP burden >4%, but not Lipoprotein (a)>175 nmol/L (OR [CI]: 1.07 [0.48–2.31].

Conclusions

In our cohort of patients with high number of unrepresented minorities presenting with stable chest pain, almost all patients (94%) with LDNCP burden >4% had non-obstructive CAD (CAD-RADS<4). There were no differences in prevalence of LDNCP or CAD-RADS among different ethnic groups. Age, hypertension and hyperlipidemia, were the cardiometabolic factors related to LDNCP burden >4%.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary artery pressure-guided therapy in patients with heart failure using the CardioMEMS device and HF readmissions: analysis of the National Readmissions Database

Background

Pulmonary artery pressure (PAP)-guided therapy in patients with heart failure (HF) using the CardioMEMS device (CMM), an implantable PAP sensor, has shown to reduce HF hospitalizations in previous studies. We sought to evaluate the clinical benefit of the CMM device in regard to 30-day, 90-day and 180-day readmission rates in real-world usage.

Methods

We queried the National Readmission Database (NRD) to identify patients who underwent CMM implantation (ICD 9 & 10 codes) between the years 2014 to 2019 and studied their HF readmissions. We compared CMM patients and their readmissions with a matched cohort of patients with HF without CMM. Multivariable Cox regression analysis was performed to adjust for other predictors of readmissions.

Results

Prior to matching we identified 5,326,530 weighted HF patients without CMM and 1842 patients with CMM. After propensity score matching for several patients and hospital related characteristics, the cohort consisted of 1839 patients with CMM and 1924 with HF without CMM. Before matching, CMM patients were younger (67.0±13.5 years vs 72.3±14.1 years, P<0.001), more frequently males (62.7% vs 51.5%, P<0.001), with higher rates of prior percutaneous coronary intervention (16.9% vs 13.2%, P=0.002), peripheral vascular disease (29.6% vs 17.8%, P<0.001), pulmonary circulatory disorder (38.7% vs 23.2%, P<0.001), atrial fibrillation (51.2% vs 45.3%, P=0.002), prior left ventricular assist device (1.8% vs 0.2%, P<0.001), high income (32.2% vs 16.4%, P<0.001) and acute kidney disease (43.8% vs 29.9%, P<0.001). Readmission rates at 30-days were 17.3% vs. 20.9% for patients with vs. without CMM respectively and remained statistically significant after matching (17.3% vs. 21.5%, p=0.002). The rates of 90-day (29.1% vs 36.5%, p=0.002) and 180-day (39.6% vs. 46.6%, p=0.009) readmissions were lower in the CMM group. In a multivariable regression model, CMM was associated with lower risk of readmissions (HR, 0.75, 95% CI 0.63–0.89, p=0.001).

Conclusion

The CMM device was associated with reduced HF rehospitalization rates in a nationally representative cohort of HF patients.

Funding Acknowledgement

Type of funding sources: None.

Trisomy 8-positive Polycythemia Vera Complicated with Intestinal Behçet's-like Disease: A New Perspective for a Clinical Approach

Behçet's disease (BD) is a multisystem inflammatory disease of unknown origin. It rarely but occasionally occurs together with myelodysplastic syndrome and primary myelofibrosis. Trisomy 8 is one of the most common cytogenetic abnormalities in myeloid neoplasms; however, the association of BD with polycythemia vera (PV) and trisomy 8 has not been reported. A 70-year-old woman, diagnosed with PV and treated with hydroxyurea, had bloody stool due to multiple ulcers in the ileocecal region. Considering the lack of a response to treatment and other features, we suspected complication with intestinal Behçet's-like disease. Our case suggests relationships among BD, trisomy 8, and PV.

Comparison of valve durability among different transcatheter and surgical aortic valve prostheses: a network meta-analysis

Background

Durability of different transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve replacement (TAVR) expands to patients with longer life-expectancy.

Purpose

We aimed to compare the durability of THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis.

Methods

PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVR and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and longest available follow-up data for clinical outcomes.

Results

Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV 2,863; SAVR:3,963) were included. Follow-up ranged from 1–6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-years compared to BE-THV and SAVR (Figure 1). Structural valve deterioration (SVD) was less frequent in SE-THV compared to BE-THV and SAVR (HR 0.14, 95% CI 0.07–0.27; HR 0.34, 95% CI 0.24–0.47, respectively) (Figure 1). Total moderate-severe aortic regurgitation and re-intervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40–7.39; HR 2.22, 95% CI 1.16–4.26, respectively) and SE-THV (HR 7.51, 95% CI 3.89–14.5; HR 2.86, 95% CI 1.59–5.13, respectively) compared to SAVR.

Conclusion

TAVR with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared to BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of aortic regurgitation and re-intervention, and long-term data from newer generation valve is warranted.

Funding Acknowledgement

Type of funding sources: None.

The 30-day readmission of same-day discharge following pulmonary vein isolation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database

Introduction

The complication rate following pulmonary vein isolation (PVI) for atrial fibrillation (AF) has improved in recent decades with the increasing number of PVI worldwide. The effectiveness and safety of same-day discharge for PVI has not been elucidated well using a large nationwide database.

Purpose

The aim of our study was to evaluate the readmission rates within 30-days among patients receiving PVI for AF with the same-day discharge compared with the usual overnight observation protocol.

Methods

We performed a retrospective cohort study using the US Nationwide Readmission Database. Patients were divided into the two groups: the same-day discharge group and the overnight observation group (those who stayed at least one night following PVI). The primary outcome was an all-cause 30-day readmission rate following discharge in patients receiving PVI and a secondary outcome of total healthcare cost. A 1:3 propensity score matching was used to compare the safety within both protocols. Patients with peri-procedural complications such as pericardial, vascular, bleeding requiring transfusion, were excluded from the analysis.

Result

Among 30,776 patients (mean 67.2±11.4 years, 18,004 male (58.5%)) who received PVI from 2016 through 2018, 440 (1.42%) patients were discharged the same-day following PVI (same-day discharge group), and the remaining 30,336 patients stayed at least one night in the hospital (the overnight observation group). A propensity score analysis generated 1,751 matched pairs (440 in the same-day discharge group; 1311 in the observation overnight group). The 30-day readmission following discharge was not significantly higher in the same-day discharge group, compared to the overnight observation group (same-day discharge vs. overnight observation group: 12.7% vs. 9.7%, p=0.23; odds ratio [OR]:1.39, 95%confidence interval [CI]: 0.87–2.22) (Figure). Healthcare cost was significantly higher in the overnight observational group. ($25,237±14,036 vs. $30,749±16,383; p<0.01).

Conclusion

In this large nationwide study using a propensity score matching analysis, there was no significant difference in 30-day readmission rates following the same-day discharge in patients receiving PVI for AF compared with the overnight observation protocol.

Funding Acknowledgement

Type of funding sources: None.

P2Y12 inhibitors in patients with non-ST-segment elevation acute coronary syndrome: systematic review and network meta-analysis of randomized trials

Background

Based on a recent randomized control trial (RCT), prasugrel is recommended in preference to ticagrelor for patients with non-ST-segment elevation ACS (NSTE-ACS), however, limited data exists.

Objectives

We aimed to investigate the effect of P2Y12 inhibitors on ischemic and bleeding events in NSTE-ACS patients.

Methods

Clinical trials enrolling NSTE-ACS patients were identified and relevant data was extracted. We performed a network meta-analysis on efficacy and safety outcomes.

Results

Our study including a total of 37, 268 patients with NSTE-ACS from 11 RCTs. Prasugrel decreased major adverse cardiovascular events (MACE) when compared to clopidogrel (Hazard ratio (HR): 0.84; 95% confidence interval (CI) [0.71–0.99]). For MACE, prasugrel showed the highest likelihood of event reduction (P-score=0.97) in comparison to ticagrelor (P-score=0.29) and clopidogrel (P-score=0.24). Prasugrel decreased myocardial infarction (HR: 0.82; 95% CI [0.68–0.99]) but increased major bleeding without statistical significance (HR: 1.30; 95% CI [0.97–1.74]) when compared to clopidogrel. Ticagrelor reduced cardiovascular death (HR: 0.79; 95% CI [0.66–0.94]) but increased major bleeding (HR: 1.33; 95% CI [1.00–1.77], p=0.049) in comparison to clopidogrel. There was no significant difference between prasugrel and ticagrelor for each endpoint, but prasugrel had higher likelihood of event reduction than ticagrelor for all endpoints except cardiovascular death.

Conclusions

Prasugrel and ticagrelor had comparable risk for each endpoint, but prasugrel had the highest probability being the best treatment in reducing the primary endpoint. This study highlights the need for further large-scale RCTs to investigate the optimal P2Y12 inhibitor selection in NSTE-ACS patients.

Funding Acknowledgement

Type of funding sources: None.

Pancreatic cancer secondary to intraductal papillary mucinous neoplasm with collision between gastric cancer and B-cell lymphoma: A case report

BACKGROUND

Patients with intraductal papillary mucinous neoplasm (IPMN) have an increased risk of pancreatic and extrapancreatic malignancies. Lymphomas are rare extrapancreatic malignancies, and in situ collisions of early gastric cancer and diffuse large B-cell lymphoma (DLBCL) are even rarer. Here, we report the first case of pancreatic cancer comorbid with in situ collision of extrapancreatic malignancies (early gastric cancer and DLBCL) in a follow-up IPMN patient. Furthermore, we have made innovations in the treatment of such cases.

CASE SUMMARY

An 81-year-old Japanese female diagnosed with IPMN developed elevated carbohydrate antigen (CA) 19-9 levels during follow-up. Because her CA19-9 levels continued to rise, endoscopic ultrasound (EUS) was performed and revealed a suspicious lesion at the pancreatic tail. However, lesions in the pancreas were not found by computed tomography, magnetic resonance imaging, or endoscopic retrograde cholangiopancreatography. To make an exact patho-logical diagnosis, EUS-guided fine needle aspiration was performed. To our supprise, early gastric cancer was found in preoperative gastroscopy. The gastric cancer was completely resected through endoscopic submucosal dissection before postoperative pathology identified early adenocarcinoma collided with DLBCL. Subsequent EUS-guided fine needle aspiration provided pathological support for the pancreatic cancer diagnosis, and then laparoscopic distal pancreatectomy and splenectomy were performed. CA19-9 levels returned to normal postoperatively.

CONCLUSION

Endoscopic submucosal dissection is appropriate for submucosal lymphomas in patients intoleratant of chemotherapy. EUS can detect small IPMN-related pancreatic tumors.

Role of magnifying endoscopy with narrow-band imaging in the diagnosis of noninvasive gastric neoplasia

Background and Aim

There are no globally approved, distinguishing criteria enabling the classification of gastric adenomas and intramucosal carcinomas for differential diagnosis of noninvasive neoplasia (NIN).

Methods

Next‐generation sequencing of 50 cancer‐related genes was undertaken on 68 pathologically diagnosed microdissected gastric neoplasms (25 adenomas, 27 intramucosal carcinomas, and 16 submucosal carcinomas) obtained during endoscopic submucosal dissection. Findings from magnifying endoscopy with narrow‐band imaging (M‐NBI) of 52 NINs (the 25 adenomas and 27 intramucosal carcinomas) were compared with these data.

Results

Among all 68 neoplasms, the most frequently mutated genes were APC (76% in adenoma, 11.1% in intramucosal carcinoma, and 0% in submucosal carcinoma; P < 0.001) and TP53 in intramucosal and submucosal carcinomas (8% in adenoma, 48.1% in intramucosal carcinoma, and 75% in submucosal carcinoma; P < 0.001). Dividing the NIN neoplasms into five groups according to their mutational status (A1: APC mutation, A2: APC + α mutation, B: APC + TP53 mutation, C: TP53 mutation, D: no mutation in either APC or TP53) resulted in almost identical diagnoses by pathology and M‐NBI for groups A1 (12/13, 92%), C (12/13, 92%), and D (16/17, 94%) but not for groups A2 (3/7, 43%) or B (0/2, 0%). This finding implies that NINs with the APC + α mutation have carcinoma‐like endoscopic features despite most being judged as adenomas by pathology.

Conclusion

A diagnosis of NINs by pathology or M‐NBI in the subset of gastric tumors classified by cancer‐related mutations is not completely identical, suggesting the possible additional role of M‐NBI in diagnosing NINs. Further studies are needed to confirm this.

Fractionated small cell-free DNA increases possibility to detect cancer-related gene mutations in advanced colorectal cancer

Background and Aim

Liquid biopsy is a method that can efficiently detect tumor genetic abnormalities from body fluids such as blood and urine. Detection sensitivity and the available number of mutations in cell-free DNA (cfDNA) are limited. In this study, we develop a highly sensitive and comprehensive method to detect mutations from cfDNA by concentrating tumor fractions of small cfDNA in advanced colorectal cancers.

Methods

Biopsied specimens and 37 serum samples were collected from 27 patients with advanced colorectal carcinoma. A serum-extracted cfDNA was divided into enriched fractionated small cfDNA and unfractionated cfDNA. Both cfDNAs were subjected to digital polymerase chain reaction (PCR) to evaluate their KRAS, BRAF, CDKN2A, and TP53 status. Consequently, their mutant allele frequencies (MAFs) were compared and analyzed by next-generation sequencing (NGS) in conjunction with tissue-derived DNA.

Results

NGS analyses revealed mutations in TP53 (63%), KRAS (63%), APC (30%), and PIK3CA (22%). Digital PCR could detect mutations in 25 of 27 samples (93%) of unfractionated cfDNA, a rate that increased to 100% when samples were enriched with fractionated small cfDNA (6.8 vs 10.7%, P < 0.001). NGS also showed increased MAFs in fractionated small cfDNA compared to unfractionated cfDNA (16.3 vs 18.8%, P = 0.012) and a tendency to detect a greater number of cancer-related genes in fractionated cfDNA.

Conclusions

Fractionated small cfDNA increased MAFs of gene mutations and increases the possibilities to detect cancer-related genes even in advanced cancer patients from whom it is difficult to obtain tissue samples.

Long-term outcome after surgery in a patient with intestinal Behçet's disease complicated by myelodysplastic syndrome and trisomy 8

Behçet's disease (BD) is a multisystem inflammatory disease of unknown origin. Rarely, BD occurs together with myelodysplastic syndrome (MDS). Interestingly, it is speculated that these are not simple coexistence but that the etiology of intestinal BD is at least partly derived from MDS itself. Furthermore, there is a relationship between MDS in patients with intestinal BD and trisomy 8. Immunosuppressive agents alone are insufficient to control MDS-associated BD, and many of these patients die of infection or hemorrhage. Surgery is considered for intestinal BD patients who are unresponsive to medical treatment or those with bowel complications such as perforation or persistent bleeding. We report a case of intestinal BD associated with MDS and trisomy 8. The patient was unresponsive to oral steroids and immunosuppressive treatment; the patient improved by surgical repair of a bowel perforation. Five years after the surgery, the patient is free of recurrence and not on medication. Our experience suggests that surgery may provide an effective therapeutic option for the treatment of MDS-related BD.

Mortality after transcatheter versus surgical aortic valve replacement: an updated meta-analysis of randomised trials

Background

To determine whether transcatheter aortic valve implantation (TAVI) improves early (30-day) and midterm (1-year) mortality compared with surgical aortic valve replacement (SAVR), we performed an updated meta-analysis of all the currently available randomised controlled trials (RCTs).

Methods

To identify all RCTs providing both 30-day and 1‑year mortality after TAVI versus SAVR, PubMed and ClinicalTrials.gov were searched up to and including July 2019. A risk difference (RD) and its 95% confidence interval were generated using data of prespecified outcomes in both the TAVI and SAVR groups. Study-specific estimates were pooled using inverse variance-weighted averages of RDs in the random-effects model.

Results

We identified seven eligible high-quality RCTs including a total of 7631 as-treated patients. Pooled analyses demonstrated significantly lower 30-day (RD −0.60%; p = 0.046) and 1‑year all-cause mortality (RD −1.12%; p = 0.03) after TAVI than after SAVR. No funnel plot asymmetry was detected for 30-day and 1‑year mortality. Meta-regression analyses indicated that RDs of 30-day and 1‑year mortality between TAVI and SAVR were not modulated by mean Society of Thoracic Surgeons Predicted Risk of Mortality score. Bleeding complications at 30 days and 1 year and stage 2/3 acute kidney injury at 30 days were significantly less frequent after TAVI than after SAVR, whereas major vascular complications and new permanent pacemaker implantation at 30 days and 1 year were significantly more frequent after TAVI than after SAVR.

Conclusion

The best evidence from the present meta-analysis of all the currently available RCTs suggests that TAVI may reduce 30-day and 1‑year all-cause mortality compared with SAVR.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01378-1) contains supplementary material, which is available to authorized users.

[Refractory eosinophilic gastroenteritis with gastritis, duodenal ulcer, and colitis: a case report]

Eosinophilic gastroenteritis is a rare disease that causes various abdominal symptoms that result from the infiltration of eosinophils in the digestive tract. However, this condition has been poorly explored, and the treatment criteria and prognosis after treatment are still unclear. A 20-year-old man with a refractory duodenal ulcer had been undergoing treatment since 14 years of age at another hospital. He was admitted to our hospital with abdominal pain and anemia (hemoglobin:6.3g/dL). His blood test showed elevated serum immunoglobulin E levels, considering that he was allergic to many foods. Furthermore, endoscopic biopsy detected the occurrence of eosinophilic gastroenteritis with gastritis, duodenal ulcer, and colitis. We treated him by avoiding allergenic foods and prescribing antihistamine and vonoprazan;however, duodenal ulcer and gastrointestinal tract inflammation did not show improvement. Thus, he was diagnosed with wide-ranging and refractory eosinophilic gastroenteritis and treated with 40mg/day of steroids. After 2 months, he recovered from gastritis and duodenal ulcer, and his eosinophil level decreased, as assessed using endoscopic biopsy. Eosinophilic gastroenteritis is poorly investigated, and its treatment standards have not yet been determined. Nonetheless, steroid treatment is often applied in severe cases.

Genetic alterations related to endoscopic treatment of colorectal tumors

Background and Aim

Genetic indicators of endoscopic resection for colorectal carcinoma remain inconclusive. This study analyzed genetic changes in early colorectal tumors that could inform decisions for endoscopic procedures.

Methods

A total of 83 colorectal tumors from 81 patients, including adenoma (n = 7), Tis–T1a (n = 22), T1b (n = 14), and advanced carcinoma (n = 40), were analyzed. Tis tumors (n = 16) and some T1 carcinomas (n = 11) were analyzed as mixed adenomas and carcinomas. Lesions were laser‐capture microdissected for DNA extraction, and targeted sequencing of 50 cancer‐related genes was performed. Genetic data were then correlated with clinical records, including magnifying endoscopic findings.

Results

Numbers of gene alteration rates in TP53 and SMAD4 increased with tumor progression from adenoma to carcinoma. Frequencies of mutant variants in TP53 (P = 0.004) and rates of copy number loss in SMAD4 (P = 0.006) increased in carcinoma components of mixed tumors compared to adenoma components. Moreover, adenoma components of T1b carcinomas had higher TP53 mutation rates than Tis or T1a carcinomas (P = 0.011) and pure adenomas (P = 0.026). Gene alterations in TP53 (P = 0.0055) and SMAD4 (P = 0.0055) increased in cases with irregular surface patterns of magnifying endoscopic findings.

Conclusions

Numbers of copy number variations and TP53 and SMAD4 alterations were related to colorectal tumor progression. TP53 alteration rates in adenoma components were high in T1b carcinomas, warranting complete treatment with en bloc resection. Magnifying endoscopic findings might reflect the genetic status of colorectal tumors.

Prediction of disease activity of Crohn's disease through fecal calprotectin evaluated by balloon-assisted endoscopy

BACKGROUND AND AIM

Fecal calprotectin (FC) is a useful marker for assessing the activity of intestinal inflammation. However, most studies have used ileocolonoscopy to evaluate the association of FC with intestinal inflammation, and it is not clear whether FC is useful for the evaluation of small-bowel Crohn's disease (CD). This study aimed to determine the usefulness of FC for predicting intestinal inflammation evaluated by balloon-assisted endoscopy (BAE), which can visualize the deep small intestine.

METHODS

This was a cross-sectional, observational study involving 69 CD patients, 39 of whom had only small-bowel disease. The extended simplified endoscopic activity score for Crohn's disease (eSES-CD) was calculated based on the findings of BAE. Mucosal healing was defined as an eSES-CD of 0.

RESULTS

In all CD patients, FC levels were correlated with the eSES-CD (r = 0.663, P < 0.001). The cutoff value to predict mucosal healing was 92 mg/kg, with a sensitivity of 94%, specificity of 88%, positive predictive value of 98%, negative predictive value of 64%, and the area under the curve of 0.91. Even in small-bowel CD patients, FC levels were correlated with the eSES-CD (r = 0.607, P < 0.001). The cutoff value was 92 mg/kg, with a sensitivity of 87%, specificity of 88%, positive predictive value of 96%, negative predictive value of 64%, and area under the curve of 0.85.

CONCLUSIONS

Fecal calprotectin showed a significant correlation with the intestinal inflammation evaluated with BAE even in patients with only small intestinal disease. FC is useful for the evaluation of CD including both the small and large intestines.

Client-Centered Therapy in Japan: Fujio Tomoda and Taoism

Fujio Tbmoda played a major role in introducing client-centered therapy (CCT) into Japan. This article discusses the reception, transformation, and cultural implications of CCT, focusing on the work of Tomoda, which was deeply influenced by Chinese and Japanese classics. Section 1 introduces Tbmoda and his activities. Section 2 (Hayashi) features how Tomoda has come to equate the nondirective aspect of CCT with the not-doing-and-being-natural paradigm of Taoism. Section 3 (Suetake) analyzes Tbmoda's self-theory based on ancient Chinese philosophy. Section 4 (Morotomi) calls attention to the word "vacuum," uttered by Rogers' client. Section 5 (Osawa) compares Tomoda's theory on personality change with the Focusing approach by Gendlin. Section 6 (Shimizu) features Ibmoda's application of the CCT approach to his group programs. Section 7 (Kuno) highlights Tbmoda's finding in renku (Japanese linked poetry) a means of facilitating human development. Section 8 critically examines Tbmoda's work.

I believe it expresses well the observations which for me have crystallized into two important themes: my confidence in the human organism, when it is functioning freely; and the existential quality of satisfying living, a theme presented by some of our most modem philosophers, which was however beautifully expressed more than twentyfive centuries ago by Lao-tzu when, he said, 'The way to do is to be."

(Rogers, 1961, p. 163).

The Client-Centered Therapy and Person-Centered Approach in Japan

This article summarizes the historical development of client-centered therapy (CCT) and the person-centered approach (PCA) in Japan and their current status and future outlook there. CCT was enthusiastically accepted, especially at the beginning of its initial development in the late 1950s and the early 1960s. This initial enthusiasm, however, has gradually been eroded by some critical, suspicious, or conflicting attitudes due to the introduction of a multitude of other theories and approaches. CCT and/or PCA have been applied to a variety of educational, clinical, or business settings. But it can be fairly said that CCT and/or PCAhave now lost their initial influence. The authors believe that Rogers's way of thinking and his approach is one of the crucial ways of studying and understanding human beings and helping relationships. It is meaningful for us now to review CCT and PCA again to clarify their significance so that their new and better applications to Japanese culture can be found.

Japanese Psychology in Crisis: Thinking Inside the (Empty) Box

In part because of the information revolution, Japan is experiencing a crisis in culture. Because it is more sensitive to culture than other approaches, humanistic psychology may have much to offer in this time of crisis, particularly because of the Japanese value of inner privacy. Tomoda has explored ways of translating Rogers’s approach into a Japanese context of Zen, including the use of renku, a form of poetry collectively written by members of a group exploring their process in “a vague atmosphere of togetherness.” Another approach to bridging the East/West gap is explored in Naikan therapy in which an empathic therapist visits the client who sits and meditates on the dynamics of his or her personal relationships during a weeklong retreat. In the end, it is thinking inside the box, contrary to Western contemporary values, that seems to make humanistic psychology work for the Japanese, whose aesthetic values have persevered through the ages.

Factors Predicting Subsequent Hospitalization in Patients with Ulcerative Colitis: Total Colonoscopic Findings are the Strongest Predictor

BACKGROUND/AIMS

Patients with ulcerative colitis suffer from long term impairment of quality of life, especially when subjected to repeated hospitalization. We aimed to identify factors that may predict future hospitalization.

METHODOLOGY

We followed 139 consecutive patients with ulcerative colitis for average of 11.2 years (2.8 to 49.5 years) from the onset. Clinical and endoscopic stagings were determined by Japanese staging system, the extent of colitis by Montreal classification and endoscopic grading by Matts' grade.

RESULTS

Overall hospitalization rate was 37% at 5 years, 47% at 10 years and 60% at 20 years from the onset. Of 5 parameters including demographic and staging scores, univariate analysis revealed clinical severity at onset (p = 0.003), total colonoscopic findings on severity (Matts' grade, p = 0.003), and total colonoscopic findings on sites of abnormality (p = 0.012) were significantly correlated with hospitalization. By multivariate analysis, total colonoscopic findings on sites of abnormality was the only baseline character significantly related to the need of hospitalization (p = 0.0007). In fact, 5/10/20 years hospitalization rates were only 18/26/33 percent for proctitis type, whereas those were 61/72/90 for total colitis type.

CONCLUSIONS

The total colonoscopic finding on sites of abnormality at the onset is the only predictdr of hospitalization in patients with ulcerative colitis.

Factors contributing to the overall survival in patients with hepatocellular carcinoma treated by sorafenib

BACKGROUND/AIMS

In both SHARP and Asia-Pacific Study, sorafenib was proved to improve the overall survival of the patients with hepatocellular carcinoma. However, factors contributing to the improvement of overall survival of the patients treated by sorafenib have not been fully evaluated. In this study, patient-derived, background liver disease-derived and tumor-derived factors before treatment were evaluated whether they have contributed to the improvement of the overall survival.

METHODOLOGY

Forty-seven cases with HCC treated by sorafenib between Sept 2009 and Feb 2011 were included in this analysis. The survival of these cases was analyzed by Kaplan-Meier Method. Factors used for univariate analysis were two patient-derived parameters, two background liver disease-derived, five tumor-derived. Factors related to the over-all survival were analyzed by multivariate analysis using Cox regression model.

RESULTS

In the multivariate analysis, only background liver disease-derived parameter Child-Pugh class A vs. B, (p=0.007, HR=0.21 (0.07-0.65)) was significant. No other parameters including tumor-derived factors were statistically significant by multivariate analysis.

CONCLUSIONS

We undertook the statistical analysis on the three categories. Surprisingly, no tumor derived parameter contributed to the overall survival. Background liver disease-derived parameter rather than tumor-derived parameter was found to define the prognosis of patients with advanced HCC treated by sorafenib.

Autotransplantation of a maxillary first premolar to replace an ankylosed maxillary incisor: 7-year follow-up

AIM

To present the combined endodontic, surgical and orthodontic treatment of an autotransplanted maxillary first premolar for the replacement of an ankylosed maxillary incisor.

SUMMARY

This case report describes the autotransplantation of a maxillary premolar after the extraction of an ankylosed incisor in a 13-year-old boy. To allow better adaptation of the donor tooth, the buccal root of the first premolar was removed using a diamond bur and the denuded root site was filled with acid-etched composite resin. The palatal root canal was dressed with calcium hydroxide for 2 months before filling with gutta-percha. Autotransplantation of a remodelled maxillary first premolar was achieved to substitute for the ankylosed maxillary central incisor. Orthodontic treatment was performed to correct an Angle Class II malocclusion. Seven years after root canal treatment, the autotransplanted tooth and supporting tissues appeared healthy both clinically and radiographically and were functioning well.

KEY LEARNING POINTS

• Autotransplantation is a viable option for the treatment of a missing tooth or for the replacement of a traumatized tooth when there is a donor tooth available. • Autotransplantation of a premolar for replacement of a missing anterior tooth is sometimes a suitable alternative to conventional prosthetic rehabilitation or implant treatment in young individuals. • Proper combined endodontic and orthodontic treatment of autotransplanted teeth might be possible without periodontal complications.

Equivocal colonic carcinogenicity of Aloe arborescens Miller var. natalensis berger at high-dose level in a Wistar Hannover rat 2-y study

A 2-y carcinogenicity study of Aloe, Aloe arborescens Miller var. natalensis Berger, a food additive, was conducted for assessment of toxicity and carcinogenic potential in the diet at doses of 4% or 0.8% in groups of male and female Wistar Hannover rats. Both sexes receiving 4% showed diarrhea, with loss of body weight gain. The survival rate in the 4% female group was significantly increased compared with control females after 2 y. Hematological and biochemical examination showed increase of RBC, Hb, and Alb in the 4% males. The cause of these increases could conceivably have been dehydration through diarrhea. AST and Na were significantly decreased in the males receiving 4%, and Cl was significantly decreased in both 4% and 0.8% males. A/G was significantly increased in the 4% females, and Cl was significantly decreased (0.8%) in the female group. Histopathologically, both sexes receiving 4% showed severe sinus dilatation of ileocecal lymph nodes, and yellowish pigmentation of ileocecal lymph nodes and renal tubules. Adenomas or adenocarcinomas in the cecum, colon, and rectum were observed in 4% males but not in the 0.8% and control male groups. Similarly, in females, adenomas in the colon were also observed in the 4% but not 0.8% and control groups. In conclusion, Aloe, used as a food additive, exerted equivocal carcinogenic potential at 4% high-dose level on colon in the 2-y carcinogenicity study in rats. Aloe is not carcinogenic at nontoxic-dose levels and that carcinogenic potential in at 4% high-dose level on colon is probably due to irritation of the intestinal tract by diarrhea.

Antioxidant effects of flavonoids used as food additives (purple corn color, enzymatically modified isoquercitrin, and isoquercitrin) on liver carcinogenesis in a rat medium-term bioassay

To clarify the effects of purple corn color, enzymatically modified isoquercitrin (EMIQ), and isoquercitrin (IQ), registered as natural food additives in Japan, on liver carcinogenesis in vivo, a medium-term bioassay was employed. A total of 100 male F344 rats were divided into 5 groups; groups 1 to 4 were given a single intraperitoneal injection of diethylnitrosamine (200 mg/kg b.w.) on day 1. From weeks 2 to 8, they were administered basal diet purple corn color, EMIQ, or IQ as containing test chemicals at doses of 1.0% (groups 1 and 5), 0.1% (group 2), 0.01% (group 3), or 0% (group 4) (experiments 1, 4, and 5). All rats were subjected to two-thirds partial hepatectomy at week 3 and were sacrificed at week 8. Purple corn color exerted no significant modifying effects on GST-P positive foci, preneoplastic foci, development in the liver. However, serum of rats treated with purple corn color provided evidence of antioxidant power significantly by potential antioxidant (PAO) test in vivo (experiment 2). And microarray analyses showed purple corn color to induce RNA expression such as P450 (cytochrome) oxidoreductase, phosphatidylinositol 3-kinase, and phospholipase A2 (experiment 3). Higher doses of EMIQ or IQ with strong antioxidant power in vivo by PAO test treated groups were correlated with smaller numbers of GST-P positive foci, with Spearman's rank correlation coefficients of P= 0.002 and P= 0.049, respectively (experiments 4 and 5). Therefore, the tested food additives may be effective as antioxidants in vivo and have chemopreventive potential against liver preneoplastic lesion development.

Endodontic and orthodontic treatment of a cross-bite fused maxillary lateral incisor

AIM

To describe combined endodontic and orthodontic treatment of a maxillary lateral incisor fused with a supernumerary.

SUMMARY

A rare case is presented in which combined endodontic and orthodontic treatment was performed on a cross-bite fused tooth. Clinical and radiographic examination showed the maxillary lateral incisor fused with a supernumerary and an impacted canine. The fused tooth required nonsurgical and surgical endodontic treatment for functional and aesthetic reasons. The root canals were dressed with calcium hydroxide for 2 months before they were obturated with thermoplasticized injectable gutta-percha. Then, the distal part of the fused tooth was removed and the mesial part of the tooth was replanted and fixed. Three months after the completion of orthodontic therapy, the impacted canine erupted between the remaining tooth and the first premolar. Recall examination, 3 years after completion of root canal treatment, showed clinical and radiographic evidence of healing.

KEY LEARNING POINTS

Fusion has been described as a development anomaly characterized by the union of two adjacent teeth. Proper combined endodontic and orthodontic treatment resulted in maintaining one tooth half and solving the aesthetic and functional problem of a fused tooth.

Chemoprevention of large bowel carcinogenesis; the role of control of cell proliferation and significance of beta-catenin-accumulated crypts as a new biomarker

Control of cell proliferation is important for cancer prevention since cell proliferation has essential roles in carcinogenesis in the processes of both initiation and promotion. In large bowel carcinogenesis, carcinogens produce hyperproliferation of cells in the target sites and the cell proliferation persists even after the cessation of carcinogen exposure. Chemopreventive agents principally control the increased cell proliferation when given in the initiation as well as post-initiation phases. Aberrant crypt foci (ACF) which appear soon after carcinogen exposure in large bowel carcinogenesis in rodents have been used as a reliable biomarker for screening of potential chemopreventive agents. Recently, our group demonstrated the presence of probable premalignant lesions with frequent beta-catenin gene mutations and accumulation of the corresponding protein in the colonic epithelium of rats given a large bowel carcinogen. Such early-appearing lesions lack the morphological appearance of ACF. Expression of these beta-catenin-accumulated crypts (BCAC) is markedly suppressed by a chemopreventive cyclooxygenase-2 inhibitor, celecoxib. BCAC are suggested to be more reliable biomarkers than ACF for screening effective chemopreventive agents for colorectal cancer and for investigating the mode of action of the agents.

Downregulation of vascular soluble guanylate cyclase induced by high salt intake in spontaneously hypertensive rats

1. Cyclic guanosine monophosphate (cyclic GMP)-mediated mechanism plays an important role in vasodilatation and blood pressure regulation. We investigated the effects of high salt intake on the nitric oxide (NO) - cyclic GMP signal transduction pathway regulating relaxation in aortas of spontaneously hypertensive rats (SHR). 2. Four-week-old SHR and normotensive Wistar-Kyoto rats (WKY) received a normal salt diet (0.3% NaCl) or a high salt diet (8% NaCl) for 4 weeks. 3. In aortic rings from SHR, endothelium-dependent relaxations in response to acetylcholine (ACh), adenosine diphosphate (ADP) and calcium ionophore A23187 were significantly impaired by the high salt intake. The endothelium-independent relaxations in response to sodium nitroprusside (SNP) and nitroglycerin were also impaired, but that to 8-bromo-cyclic GMP remained unchanged. On the other hand, high salt diet had no significant effects on the relaxations of aortic rings from WKY. 4. In aortas from SHR, the release of NO stimulated by ACh was significantly enhanced, whereas the production of cyclic GMP induced by either ACh or SNP was decreased by the high salt intake. 5. Western blot analysis showed that the protein level of endothelial NO synthase (eNOS) was slightly increased, whereas that of soluble guanylate cyclase (sGC) was dramatically reduced by the high salt intake. 6. These results indicate that in SHR, excessive dietary salt can result in downregulation of sGC followed by decreased cyclic GMP production, which leads to impairment of vascular relaxation in responses to NO. It is notable that chronic high salt intake impairs the sGC/cyclic GMP pathway but not the eNOS/NO pathway.

Flk-1 specific kinase inhibitor (SU5416) inhibited the growth of GS-9L glioma in rat brain and prolonged the survival

BACKGROUND

Accumulating evidences suggest that tumor growth and metastasis depend on angiogenesis. At present, plenty of efforts are made to discover a chemical compound that specifically inhibits tumor angiogenesis either by reducing pro-angiogenic factor or increasing anti-angiogenic factors.

OBJECT

SU5416, a novel, synthetic, potential inhibitor of angiogenesis specifically blocks the Flk-1/KDR tyrosine kinase activity. In vivo effect of SU5416 in the treatment of intracranial tumors has not been previously described.

METHODS

We transplanted GS-9L cells into the right caudate nucleus of male Fisher 344 rats and administrated SU5416 intraperitoneally (i.p.) to investigate the impact of SU5416 on tumor angiogenesis and growth in vivo. Starting on Day 1 or Day 8, forty-two animals were treated with SU5416 at three different doses (e.g. 12.5, 25.0 and 50.0 mg/kg body weight) via i.p. injection every day until the end-point. As a control, seven animals received no treatment and after implant fourteen animals were treated with vehicle (DMSO) only.

RESULTS

SU5416 prolonged the survival in the treated groups without any significant systemic adverse effect. Median survival in the treated group started on Day.1 was statistically longer compared to that in the control groups (p<0.01). Histological analysis of the treated tumors showed an increase in necroses and reduced in vascularity compared to the control tumors. Furthermore, the number of apoptotic cells increased in the treated tumors on a TUNEL stain.

CONCLUSION

Small molecular compounds, such as SU5416 may be useful therapeutics that specifically inhibits the enzymatic activity of Flk-1 kinase and downstream events of tumor angiogenesis.

Quantitative evaluation of thalami and basal ganglia in infants with periventricular leukomalacia

Quantitative analyses of cross-sectional areas of the thalami, caudate nuclei, and lentiform nuclei were performed in 29 preterm infants (16 males, 13 females; mean age 29.6 weeks, age range 27 to 24 weeks,) with periventricular leukomalacia (PVL). MRI was carried out in the infants between 9 and 18 months of corrected age and in 16 control infants. Bilateral thalami, caudate nuclei, lentiform nuclei, cerebral hemispheres, and cerebellum were measured by computer. Ratios of the areas of the thalami (Th), caudate nuclei (Ca), lentiform nuclei (Le), and cerebral hemispheres (CH) to that of the cerebellum (Ce) were calculated in each infant. The ratio of Th:Ce was significantly smaller in infants with moderate and severe PVL than in the control group bilaterally. Abnormal intensity areas were not observed in the thalami in any infants with PVL. CH:Ce was also smaller in infants with severe PVL than in the control group. No significant difference was observed between the groups in ratios Le:Ce or Ca:Ce. Results of our study suggest that the volume of the thalami is reduced and that thalamic involvement is present in infants with white matter lesions who have moderate to severe PVL.

Suppression of occurrence and advancement of beta-catenin-accumulated crypts, possible premalignant lesions of colon cancer, by selective cyclooxygenase-2 inhibitor, celecoxib

Suppression of occurrence and advancement of premalignant lesions is important for cancer prevention. Our previous studies clarified that beta-catenin-accumulated crypts, independent of aberrant crypt foci (ACF), are probably direct precursors of colon cancers in rats. Here we investigated the effects of a selective cyclooxygenase-2 inhibitor, celecoxib, on the development of beta-catenin-accumulated crypts in comparison with those on ACF. Male F344 rats were divided into 4 groups. Groups 1 - 3 were administered azoxymethane (AOM) s.c. at a dose of 15 mg / kg body weight, once weekly for 3 weeks to induce beta-catenin-accumulated crypts. Groups 2 and 3 also received experimental diet containing celecoxib (500 and 1500 ppm, respectively) for 8 weeks, starting a week before the first dosing of AOM. At termination, the frequency and crypt multiplicity (number of crypts / lesion) of beta-catenin-accumulated crypts of groups 2 and 3 were significantly less than that of group 1. Furthermore, numbers of silver-stained nucleolar organizer regions (AgNORs) / nucleus in beta-catenin-accumulated crypts were also decreased by exposure to celecoxib. In this study, celecoxib had greater effects on the frequency and growth of beta-catenin-accumulated crypts than on those of ACF. These findings represent additional evidence that beta-catenin-accumulated crypts are premalignant lesions of colon cancer. The results also suggest that beta-catenin-accumulated crypts could be a novel target for evaluation of possible chemopreventive agents against colon carcino-genesis, and indicate that possible chemopreventive effects of celecoxib on the initial stage of colon carcinogenesis may be related to modulation of cell proliferation activity in such early lesions.

Its8, a fission yeast homolog of Mcd4 and Pig-n, is involved in GPI anchor synthesis and shares an essential function with calcineurin in cytokinesis

In fission yeast, calcineurin is required for cytokinesis and ion homeostasis; however, most of its physiological roles remain obscure. To identify genes that share an essential function with calcineurin, we screened for mutations that confer sensitivity to the calcineurin inhibitor FK506 and high temperature and isolated the mutant its8-1. its8(+) encodes a homolog of the budding yeast MCD4 and human Pig-n that are involved in glycosylphosphatidylinositol (GPI) anchor synthesis. Consistently, reduced inositol labeling of proteins suggested impaired GPI anchor synthesis in its8-1 mutants. The temperature upshift induced a further decrease in inositol labeling and caused dramatic increases in the frequency of septation in its8-1 mutants. BE49385A, an inhibitor of MCD4 and Pig-n, also increased the septation index of the wild-type cell. Osmotic stabilization suppressed these morphological defects, indicating that cell wall weakness caused by impaired GPI anchor synthesis resulted in abnormal cytokinesis. Furthermore, calcineurin-deleted cells exhibited hypersensitivity to BE49385A, and FK506 exacerbated the cytokinesis defects of the its8-1 mutant. Thus, calcineurin and Its8 may share an essential function in cytokinesis and cell viability through the regulation of cell wall integrity.

Sequential analysis of morphological and biological properties of beta-catenin-accumulated crypts, provable premalignant lesions independent of aberrant crypt foci in rat colon carcinogenesis

Our previous study (Cancer Res., 60: 3323-3327, 2000) showed that frequent beta-catenin gene mutations are present in beta-catenin-accumulated crypts, which occur early in rodent colonic carcinogenesis, with a lack of the appearance of aberrant crypt foci (ACF). To clarify the nature of such lesions, we performed a sequential analysis of the morphological and biological properties of beta-catenin-accumulated crypts. Azoxymethane was administered s.c. to male F344 rats (15 mg/kg body weight) once a week for 3 weeks, and the animals were sacrificed at 5, 10, and 20 weeks after the carcinogen treatment. Both the number of crypts/lesion and the diameter of beta-catenin-accumulated crypts were significantly increased with time courses of 5, 10, and 20 weeks from carcinogen exposure (P < 0.01). Likewise, the histological abnormality in those crypts, assessed by semiquantitative analyses, was also increased with time (P < 0.01). Conversely, ACF did not show any increase in histological abnormality during the time course and maintained a monotonous histology throughout the experiment. The histological abnormality score for beta-catenin-accumulated crypts was significantly higher than for ACF at every time point (P < 0.001). The number of AgNOR/nucleus in beta-catenin-accumulated crypts was significantly higher than in ACF (P < 0.001). Beta-catenin-accumulated crypts were accompanied frequently by Paneth cells and had decreased hexosaminidase activity. Such data, together with the results in our previous report, strongly suggest that beta-catenin-accumulated crypts, which are independent of ACF, are truly premalignant lesions for colon cancer.

The inhibitory effects of mangiferin, a naturally occurring glucosylxanthone, in bowel carcinogenesis of male F344 rats

Mangiferin, 1,3,6,7-tetrahydroxyxanthone-C2-beta-D-glucoside, is one of xanthone derivatives and C-glucosylxanthones, is widely distributed in higher plants and is one of constituents of folk medicines. Recent studies showed that mangiferin has a potential as an anti-oxidant and an anti-viral agent. In this study, we examined the effects of mangiferin in rat colon carcinogenesis induced by chemical carcinogen, azoxymethane (AOM). We performed two experiments: a short-term assay to investigate the effects of mangiferin on the development of preneoplastic lesions by AOM, aberrant crypt foci (ACF), and the following long-term assay for the influence of mangiferin on tumorigenesis induced by AOM. In the short-term assay, 0.1% mangiferin in a diet significantly inhibited the ACF development in rats treated with AOM compared to rats treated with AOM alone (64.6+/-22.0 vs. 108.3+/-43.0). In the long-term assay, the group treated with 0.1% mangiferin in initiation phase of the experimental protocol had significantly lower incidence and multiplicity of intestinal neoplasms induced by AOM (47.3 and 41.8% reductions of the group treated with AOM alone for incidence and multiplicity, respectively). In addition, the cell proliferation in colonic mucosa was reduced in rats treated with mangiferin (65-85% reductions of the group treated with AOM alone). These results suggest that mangiferin has potential as a naturally-occurring chemopreventive agent.

Molecular genetic analysis of the calcineurin signaling pathways

Calcineurin is a Ca2+- and calmodulin-regulated protein phosphatase that is important in Ca2+-mediated signal transduction. Recent application of the powerful techniques of molecular genetics has demonstrated that calcineurin is involved in the regulation of critical biological processes such as T cell activation, muscle hypertrophy, memory development, glucan synthesis, ion homeostasis, and cell cycle control. Notably, specific transcription factors have been shown to play a key role in regulating these functions, and their calcineurin-mediated dephosphorylation and nuclear translocation appear to be a central event in the signal transduction pathways. This review focuses on recent progress in these areas and discusses the evidence for cross-talk between calcineurin and other signaling pathways.

Intravascular ultrasound imaging before and after angioplasty for stenosis of arteriovenous fistulae in haemodialysis patients

BACKGROUND

Complications of haemodialysis vascular access have emerged as a major cause of patient morbidity. Intravascular ultrasound imaging is a new technical modality providing visualization of the vessel lumen and wall structure in a cross-sectional fashion. Percutaneous transluminal angioplasty has long been used in the treatment of stenoses of arteriovenous fistulae. However, there is no detailed quantitative information on the stenotic lesion and the morphological change by angioplasty.

METHODS

Intravascular ultrasound studies were performed in 40 haemodialysis patients with 63 stenoses in arteriovenous fistulae who had percutaneous transluminal angioplasty. The patients were qualitatively and quantitatively evaluated for echogenic patterns and morphological changes before and after angioplasty.

RESULTS

Morphological plaque features in stenotic lesions were classified as 37 soft (58%), five hard (8%), 20 mixed (32%), and one calcified sites. Plaque fractures after angioplasty were detected in 45/63 (71%) instances. The lumen cross-sectional area was found to be dilated approximately threefold (from 3.8+/-2.4 to 11.1+/-4.5 mm(2)) and the external elastic membrane cross-sectional area was dilated approximately twofold (from 11.1+/-5.3 to 19.8+/-8.1 mm(2)) after angioplasty.

CONCLUSION

These results indicate that intravascular ultrasound allows both qualitative and quantitative assessments of arteriovenous fistulae in haemodialysis patients. The results further suggest that the mechanism of expansion of arteriovenous fistulae stenoses by percutaneous transluminal angioplasty involves stretching of the vessel wall as well as plaque fractures.