Stent expansion evaluated by optical coherence tomography and subsequent outcomes

Background

Regarding stent expansion indexes, previous optical coherence tomography (OCT) studies have shown minimal stent area (MSA) to be most predictive of adverse events.

Purpose

We sought to evaluate the impact of various stent expansion indexes by post-stent OCT on long-term clinical outcomes, and hence to find OCT-defined optimal stent expansion criteria.

Methods

Of the patients registered in the Yonsei OCT registry, a total of 1071 patients with 1123 native coronary artery lesions treated with new-generation drug-eluting stents under the OCT guidance and analyzable final post-stent OCT were included. Stent expansion indexes and different suboptimal stent expansion criteria were evaluated for their association with device-oriented clinical endpoints (DoCE) including cardiac death, target vessel-related myocardial infarction (TVMI) or stent thrombosis, and target lesion revascularization. Major safety events (MSE) included cardiac death, TVMI or stent thrombosis.

Results

The median follow-up period was 40.6 (interquartile range 22.0–50.0) months. As a continuous variable, MSA, adaptive volumetric stent expansion (stent volume/adaptive reference lumen volume) and overall volumetric stent expansion (stent volume/post-stent lumen volume) were significantly predictive of DoCE. As a categorical criteria, MSA <5.0 mm2 (hazard ratio [HR] 3.80; 95% confidence interval [CI] 1.53–9.45), MSA/distal reference lumen area <90% (HR 2.13; 95% CI 1.10–4.14), and overall volumetric stent expansion ≥96.6% (HR 2.38; 95% CI 1.09–5.22) were independently associated with DoCE after adjusting for confounders, and a total malapposition volume ≥7.0 mm3 (HR 3.38; 95% CI 1.05–10.93) was linked to MSE.

Conclusions

This OCT study highlights that sufficient stent expansion to achieve adequate absolute MSA and relative MSA by distal reference lumen area and alleviate significant malapposition is important to improve clinical outcome, but overall stent overexpansion may have deleterious effect.

Funding Acknowledgement

Type of funding sources: None.

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI >25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Clinical implications of post-stent optical coherence tomographic findings after drug-eluting stent implantation: severe malapposition and thrombotic events

Background

The clinical implications of optical coherence tomography (OCT) assessment following percutaneous coronary intervention are controversial.

Purpose

We sought to evaluate the impact of post-stent OCT findings, including significant malapposition, on long-term clinical outcomes.

Methods

A total of 1,290 patients with 1,348 lesions, in which OCT was performed immediately post-stent, were consecutively enrolled in the prospective OCT registry. Post-stent OCT findings were assessed to identify predictors of device-oriented clinical end points (DoCE), including cardiac death, target vessel-related myocardial infarction (MI), stent thrombosis, and target lesion revascularization (TLR). We also looked for significant malapposition criteria that may be associated with thrombotic events such as cardiac death, target vessel-related MI, and stent thrombosis.

Results

Incidences of stent edge dissection, tissue prolapse, thrombus, and malapposition after intervention were not associated with occurrence of adverse thrombotic events. However, patients with significant malapposition [total malapposition volume (TMV) ≥7.0 mm3 or TMV/stent volume ≥4.1%] exhibited more frequent thrombotic events. In multivariate analysis, smaller minimal stent area (MSA) was identified as an independent predictor for DoCE (hazard ratio [HR], 1.21 [1.01–1.45]; P=0.037). Malapposition with TMV ≥7.0 mm3 was found to be an independent predictor of thrombotic events (HR, 4.62 [1.29–16.47]; P=0.018).

Conclusions

Although most high-resolution OCT findings were not associated with clinical outcome, smaller MSA was associated with DoCE, driven mainly by TLR, and significant malapposition with TMV ≥7.0 mm3 was associated with more thrombotic events after drug-eluting stent implantation.

Kaplan-Meier curve

Funding Acknowledgement

Type of funding source: None

Machine learning for predicting fractional flow reserve based on optical coherence tomography in intermediate coronary stenosis

Background

Machine learning approaches using intravascular optical coherence tomography (OCT) to predict fractional flow reserve (FFR) have not been previously investigated. The objective of the study was to evaluate a machine learning method to estimate FFR based on intravascular OCT images in intermediate coronary lesions.

Methods

Data from both OCT- and wire-based FFR methods were obtained for lesions of the left anterior descending artery in 125 patients. Based on the total number of lesions, training and testing groups were partitioned at a ratio of 5:1. For the training group, 36 features, including 16 clinical and lesion characteristics, and 21 OCT features, were used to model machine learning-FFR. machine learning-FFR values were then derived for the testing group and compared with wire-based FFR values in terms of a diagnosis of ischemia (FFR <0.8).

Results

Clinical and lesion characteristics and OCT features between the training and testing groups were similar. During the machine learning modeling of the training group, six important features of machine learning-FFR were identified: minimal luminal area, percentage of the stenotic area, lesion length, proximal luminal area, pre-procedural platelet count, and hypertension. machine learning-FFR values showed a good correlation (r=0.853, P<0.001) with wire-based FFR values (Figure 1A). The diagnostic power of an FFR value less than 0.8, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of machine learning-FFR values for the testing group were 85.7%, 100%, 100%, 77.8%, and 90.5%, respectively (Figure 1B). Additionally, OCT-based machine learning-FFR values showed a good diagnostic accuracy compared with other image-based FFR values.

Conclusions

The OCT-based machine learning-FFR method can be used to simultaneously acquire information on both image and functional modalities using one invasive procedure, suggesting that it may be used to optimize treatments for intermediate coronary artery stenosis, as well as save time and cost.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Funded by the Korean government (MSIT) (no. 2017R1A2B2003191)

P4393Current smoking and gender difference in South Korean AMI patients who underwent PCI with DES

Background

There is some debate on whether or not there is a gender difference is present between current smoking and cardiovascular disease.

Purpose

We decide to evaluate the impact of sex difference on the 2-year clinical outcomes in Korean acute myocardial infarction (AMI) patients who currently smoke and who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Methods

The data of this study was obtained from the Korea Acute Myocardial Infarction (KAMIR) registry. More than fifty high-volume universites or community hospitals with facilities for primary PCI and onsite cardiac surgery participated in this KAMIR registry. A total of 12565 current smoker AMI patients were enrolled and divided into the male (n=11767, 93.6%) or female (n=798, 6.4%) group. The clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), and total repeat revascularization.

Results

Before risk adjustment, the cumulative incidences of MACE (7.2% vs. 10.0%, hazard ratio [HR], 1.419; 95% confidence interval [CI], 1.125–1.790; P=0.003), all-cause death (HR, 1.988; 95% CI, 1.417–2.789; P<0.001), and re-MI (HR, 1.885; 95% CI, 1.154–3.078; P=0.011) were significantly higher in the female group compared with the male group. However, after adjustment the cumulative incidences of MACE (adjusted HR, 1.047; 95% CI, 0.756–1.450; P=0.782), all-cause death, re-MI, total repeat revascularization, TLR, TVR, and non-TVR were similar between the two groups.

Clinical outcomes at 2-year Outcomes Cumulative Events at 2-year (%) Unadjusted Adjusted* Propensity-score adjusted Male Female Log-rank Hazard Ratio (95% CI) p value Hazard Ratio (95% CI) p value Hazard Ratio (95% CI) p value MACE 819 (7.2) 78 (10.0) 0.003 1.419 (1.125–1.790) 0.003 1.047 (0.756–1.450) 0.782 1.133 (0.871–1.473) 0.352 All-cause death 283 (2.5) 38 (4.8) <0.001 1.988 (1.417–2.789) <0.001 0.764 (0.457–1.279) 0.306 1.105 (0.744–1.641) 0.620 Cardiac death 224 (1.9) 25 (3.2) 0.016 1.654 (1.094–2.500) 0.017 0.512 (0.261–1.005) 0.052 0.822 (0.511–1.322) 0.419 Re-MI 142 (1.3) 18 (2.4) 0.010 1.885 (1.154–3.078) 0.011 1.741 (0.887–3.419) 0.107 1.835 (1.109–3.375) 0.062 Total revascularization 444 (4.0) 27 (3.6) 0.594 0.900 (0.610–1.327) 0.594 1.069 (0.654–1.748) 0.789 0.956 (0.627–1.458) 0.835 TLR 121 (1.1) 8 (1.1) 0.956 0.980 (0.479–2.004) 0.956 0.955 (0.366–2.497) 0.926 0.868 (0.395–1.910) 0.726 TVR 228 (2.1) 14 (1.9) 0.726 0.908 (0.529–1.558) 0.726 1.051 (0.518–2.135) 0.890 0.935 (0.519–1.684) 0.823 Non-TVR 223 (2.0) 13 (1.7) 0.602 0.862 (0.493–1.508) 0.602 1.060 (0.536–2.097) 0.867 0.942 (0.514–1.726) 0.847

Conclusion

Before risk adjustment, a gender difference was suggested in the female group compared with the male in these current smoker South Korean AMI patients during a 2-year follow-up period. However, after adjustment, gender difference was not observed in these AMI patients with a history of current smoking.

P833Two-year clinical outcomes between statin with ACE inhibitor or ARB in patients with ST-segment elevation myocardial infarction after successful PCI with DES

Background

Limited comparative data are available.

Purpose

We decided to compare 2-year major clinical outcomes between statin with ACEI and statin ARB therapy in patients with STEMI after PCI with drug-eluting stents (DES).

Methods

A total 11706 STEMI patients who underwent PCI with DES and who prescribed statin were enrolled and they were divided into two groups, the statin with ACEI group (n=8705) and the statin with ARB group (n=3001). The primary endpoint was the major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-TVR. The secondary endpoints were the cumulative incidences of individual components of MACE and target vessel failure (TVF), a composite of death related to the target vessel, re-MI, or clinically driven TVR.

Results

Two PSM groups (2835 pairs, n=5670, C-statistic = 0.680) were generated. The relative risk of MACE was higher in the statin with ARB group compared to statin with ACEI groups after propensity score-matched (PSM) analysis (hazard ratio [HR]: 1.323, 95% confidence interval [CI]: 1.085–1.613, p=0.006). The relative risks of cardiac death (HR: 1.831, 95% CI: 1.199–2.740, p=0.005), total repeat revascularization (HR: 1.487, 95% CI: 1.133–1.950, p=0.004), and non-TVR (HR: 1.696, 95% CI: 1.122–2.564, p=0.012) were also higher in the statin with ARB group after PSM.

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value Statin + ACEI Statin + ARB Log-rank Propensity score matched Patients MACE 173 (6.5) 225 (8.5) 0.006 1.323 (1.085–1.613) 0.006 All-cause death 58 (2.2) 80 (3.0) 0.054 1.391 (0.992–1.950) 0.056 Cardiac death 35 (1.3) 63 (2.3) 0.004 1.831 (1.199–2.740) 0.005 Re-MI 39 (1.5) 44 (1.7) 0.548 1.141 (0.742–1.756) 0.548 Total repeat revascularization 88 (3.4) 128 (4.9) 0.004 1.487 (1.133–1.950) 0.004 TLR 26 (1.0) 40 (1.5) 0.075 1.561 (0.953–2.558) 0.077 TVR 53 (2.0) 71 (2.8) 0.086 1.364 (0.955–1.946) 0.088 Non-TVR 36 (1.4) 60 (2.3) 0.011 1.696 (1.122–2.564) 0.012 TVF 140 (5.3) 173 (6.6) 0.050 1.249 (1.000–1.561) 0.050

Conclusions

In this study, we suggest that the combination of statin with ACEI may be beneficial for reducing the cumulative incidences of MACE, total repeat revascularization rate, and non-TVR rather than the statin with ARB after PCI with DES in STEMI patients.

P5362Impact of statin therapy on long-term clinical outcomes between STEMI and NSTEMI after stent implantation

Background

Although European guideline recommends that statin should be given to all patients with acute myocardial infarction (AMI), irrespective of cholesterol concentration, limited studies were focused on the long-term effects of statin therapy between ST-segment elevation MI (STEMI) and non-ST-segment elevation MI (NSTEMI).

Purpose

The authors conducted the study to compare the relative beneficial role of statin on 2-year major clinical outcomes between STEMI and NSTEMI in patients who underwent successful PCI with DES.

Methods

Finally, a total of 26317 AMI patients who underwent stent implantation and who were prescribed the statin were enrolled and they were separated into two groups; the STEMI group (n=15002) and the NSTEMI group (n=11315). The clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), total coronary revascularization (target lesion revascularization [TLR], target vessel revascularization [TVR], non-TVR) during 2-year follow-up period.

Results

After propensity score-matched (PSM) analysis, two PSM groups (7746 pairs, n=15492, C-statistic = 0.766) were generated. In the total study population, the cumulative incidences of MACE, all-cause death, and cardiac death were significantly higher in the NSTEMI group. However, after PSM, the cumulative incidence of all-cause death (Hazard ratio, 1.386; 95% CI, 1.133–1.696; p=0.002) was significantly higher in the NSTEMI group. The cumulative incidences of MACE, cardiac death, re-MI, total revascularization, TLR, TVR, and non-TVR were similar between the two groups (Table 1).

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value STEMI NSTEMI Log-rank Propensity score matched patients MACE 532 (7.2) 584 (8.1) 0.092 1.106 (0.984–1.244) 0.092 All-cause death 163 (2.2) 224 (3.1) 0.001 1.386 (1.133–1.696) 0.002 Cardiac death 121 (1.5) 148 (2.0) 0.088 1.232 (0.969–1.566) 0.089 Re-MI 117 (1.6) 107 (1.5) 0.545 0.922 (0.710–1.199) 0.545 Total revascularization 291 (4.1) 307 (4.4) 0.422 1.068 (0.910–1.254) 0.423 TLR 92 (1.3) 89 (1.2) 0.880 0.978 (0.731–1.309) 0.880 TVR 173 (2.4) 184 (2.6) 0.478 1.078 (0.876–1.327) 0.478 Non-TVR 123 (1.7) 130 (1.9) 0.593 1.070 (0.836–1.369) 0.539

Conclusion

The mortality reduction capability of statin was more prominent in the STEMI group compared with the NSTEMI group.

P5494Impact of the gender difference on long-term clinical outcomes in dyslipidemic South Korean AMI patients who underwent PCI with new-generation DES

Background

There are limited comparative data concerning long-term major clinical outcomes between male and female in dyslipidemic AMI patients after PCI with new-generation DES.

Purpose

We thought to investigate the impact of gender difference on the 2-year clinical outcomes.

Methods

Finally, a total of 2403 eligible dyslipidemic AMI patients who underwent PCI with new-generation DES were enrolled and they were separated into two groups; the male group (n=1800) and the female group (n=603). The primary endpoint was major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), target lesion revascularization (TLR), and target vessel revascularization (TVR). The secondary endpoints were the incidence of the individual components of MACE and target vessel failure (TVF), a composite of death related to the target vessel, re-MI, or clinically driven TVR

Results

Two propensity score-matched (PSM) groups (422 pairs, n=844, C-statistic = 0.850) were generated. In the total study population, the cumulative incidences of MACE, all-cause death, re-MI, and TVF were significantly higher in the female group compared with the male group. However, after propensity score-matched (PSM) analysis, the cumulative incidences of MACE (HR, 0.971; 95% CI, 0.628–1.501; p=0.895), all-cause death (HR, 1.061; 95% CI, 0.536–2.100; p=0.865), re-MI (HR, 1.212; 95% CI, 0.433–2.907; p=0.813), and TVF (HR, 0.764; 95% CI, 0.474–1.229; p=0.267) were similar between the two groups. In addition, the cumulative incidences of cardiac death, TLR, TVR were not significantly different between the two groups (Table 1).

Outcomes Cumulative Events at 2-year (%) Hazard Ratio (95% CI) p value Male Female Log-rank Propensity score matched patients MACE 41 (10.4) 40 (10.3) 0.895 0.971 (0.628–1.501) 0.895 All-cause death 16 (4.0) 17 (4.2) 0.865 1.061 (0.536–2.100) 0.865 Cardiac death 13 (3.3) 9 (2.2) 0.391 0.691 (0.295–1.616) 0.393 Re-MI 8 (2.0) 9 (2.4) 0.813 1.212 (0.433–2.907) 0.813 TLR 7 (1.8) 6 (1.6) 0.781 0.857 (0.298–2.550) 0.781 TVR 16 (4.3) 10 (2.7) 0.236 0.623 (0.283–1.373) 0.241 TVF 39 (10.2) 30 (7.8) 0.265 0.764 (0.474–1.229) 0.267

Conclusion

The gender difference was not apparent in these dyslipidemic South Korean AMI patients who underwent PCI with new-generation DES during 2-year follow-up period.

Repeated Measurement of Fractional Exhaled Nitric Oxide Is Not Essential for Asthma Screening

BACKGROUND AND OBJETIVE

Older guidelines recommend that fractional exhaled nitric oxide (FeNO) should be checked more than twice during the same session to confirm an asthma diagnosis. Recent studies show the excellent reproducibility of FeNO measurements. Objetive: We aimed to determine whether repeated FeNO measurements during the same session are necessary for asthma screening.

MATERIAL AND METHODS

We retrospectively reviewed the electronic medical records of adult outpatients who visited the respiratory medicine department for diagnosis of asthma and assessed FeNO measurements obtained from June 2016 to July 2017.

RESULTS

Of the 132 patients enrolled, 79 (59.8%) were diagnosed with asthma. Repeated FeNO measurements taken during the same session showed high reproducibility (intraclass correlation coefficient >0.9; P<.001) and a strong correlation (Pearson coefficient >0.9; P<.001), although reproducibility and correlation were slightly weaker in patients with low FeNO values. The value of repeated measurement was not significant; however, the second FeNO measurement was significantly higher than the first measurement in patients with the worst and best lung function. The predictive power of the first measurement of FeNO (sensitivity, 80.5%; specificity, 85.1%) was not inferior to the second (sensitivity, 76.6%; specificity 85.1%). The same was true of the geometric mean of the two.

CONCLUSIONS

Repeated FeNO measurement during the same session is not essential for asthma screening in cases where the first acceptable FeNO measurement is performed using the proper method.

Synthesis and in vitro antitumor activity of 2-alkyl, 2-aryl, and 2-piperazinyl benzimidazole-4,7-dione derivatives

A series of 2-alkyl, 2-aryl, and 2-piperazinyl benzimidazole-4,7-dione derivatives (7a-h) and 16m-o) were prepared, and their cytotoxicities were tested against three cancer cell lines (mouse lymphocytic leukemia cell line P388, and human gastric carcinoma cell lines SNU-1 and SNU-16). These compounds showed potent cytotoxicity against all of three cell lines tested, and especially SNU-16 was sensitive to them. 2-Aryl (7g,h) and 2-piperazinyl benzimidazole-4,7-dione derivative (16 m) were more potent than mitomycin C against P388 and SNU-16. Among benzimidazole-4,7-dione derivatives with alkyl group at position 2, 7a had the most potent cytotoxicity against all of the cell lines tested.

A leukocyte elastase inhibitor reduces thrombin-induced pulmonary oedema in the rat: mechanisms of action

The effect of a selective leukocyte elastase inhibitor, ICI 200,355, on thrombin-induced pulmonary oedema was studied in rats. Thrombin administration produced an increase in lung weight (P < 0.05), wet weight/ dry weight ratio (P < 0.05), and relative lung water content (P < 0.05). The lung weight increase was reduced by the elastase inhibitor in doses of 2000, 200 and 20 micrograms/kg per h (P < 0.05), but not by 2 micrograms/kg per h. A dose of 20 micrograms/ kg per h seems to be optimal, since 10-fold and 100-fold increases in dose did not further improve the effect. Free elastase activity in lung tissue was higher after thrombin infusion than in controls, but was not depleted by the elastase inhibitor in vivo (P < 0.05). This elastase activity in the lung was, however, inhibited by the elastase inhibitor in vitro, indicating that the inhibitor can block extracellular, but not intracellular elastase activity. Thrombin infusion resulted in a significant decrease in plasma elastase inhibitory capacity (P < 0.05), which was depleted by the elastase inhibitor (20 micrograms/kg per h) (P < 0.05). Myeloperoxidase activity was significantly increased in lung tissue after thrombin infusion (P < 0.05). Lung myeloperoxidase activity 5 min after thrombin infusion was not affected by the elastase inhibitor, but the inhibitor induced a further increase in myeloperoxidase as seen 90 min after thrombin infusion, indicating that the effect of this inhibitor on pulmonary oedema is not due to reduction of leukocyte infiltration in the lungs, but may partly be exerted by prevention of neutrophil destruction.

Synthesis of 6-aziridinylbenzimidazole derivatives and their in vitro antitumor activities

In search for new antitumor agents, twelve 6-aziridinylbenzimidazole derivatives were synthesized and their cytotoxicities were tested against three cancer cell lines (mouse lymphocytic leukemia P388 and B16, and human gastric carcinoma SNU-16). From 4-amino-3-nitrotoluene as the starting material, 2-(acetoxymethyl)benzimidazoles (5a-d) were obtained by Phillips reaction. These benzimidazoles were then reacted with Fremy's salt to give a mixture of three 2-(acetoxymethyl) (8a-c) and four 2-(hydroxymethyl)benzimidazole-4,7-diones (9a-d). Addition of these quinones with aziridine afforded 6-aziridinyl-2-(acetoxymethyl) (10a-c) and 6-aziridinyl-2-(hydroxymethyl)benzimidazole-4,7-diones (11a-d). Utilizing 2-(hydroxymethyl)benzimidazole-4,7-diones (9b,d), esters 10d and 13e-h were prepared by the sequential reactions of esterification and addition. The synthesized compounds show potent cytotoxicity against all of three cell lines tested. The cytotoxicities of 10a-d or 11a-d against SNU-16 were superior to those of 13e-h, and were equal to or slightly higher than that of mitomycin C. Compounds 11a-d were slightly more cytotoxic than 10a-d in all cell lines tested.

Localized mucosal involvement and severe pulmonary involvement in a young patient with paraneoplastic pemphigus associated with Castleman's tumour

We describe a 19-year-old female patient who developed recurrent ulcerations limited to the orogenital mucosa for the last 3 years. She also developed dyspnoea 5 months after the onset of the orogenital lesions. Castleman's tumour of the retroperitoneum was found incidentally during routine physical examination. The diagnosis of paraneoplastic pemphigus (PNP) was made by pathological and immunological studies. The orogenital ulceration responded well to corticosteroid therapy, but severe bronchiolitis obliterans progressed despite intensive care. The patient eventually died from respiratory failure. This case demonstrates the diversity of clinical features of paraneoplastic pemphigus.

Pulmonary asbestosis: radiologic-pathologic brief report

Pulmonary asbestosis is defined as bilateral diffuse interstitial fibrosis of the lungs caused by exposure to asbestos. Many occupations are at risk for asbestos exposure, particularly in the mining, milling, manufacturing, construction, shipbuilding, and automotive industries. Therefore, the prevalence of asbestosis should be fairly widespread. The diagnosis of asbestosis can be made on either clinical or pathological grounds. We recently encountered one case of asbestosis which was confirmed histologically. On HRCT, there was ground-glass opacity with irregular linear shadows, subpleural curvilinear lines and parenchymal bands. Neither plaque nor calcification were noted. The histologic findings observed on open-lung biopsy specimen were well in accord with those in HRCT. Many asbestos-coated bodies were present along with black dust.

Beneficial effects of a leukotriene receptor antagonist on thrombin-induced pulmonary edema in the rat

The effect of a selective leukotriene receptor antagonist, the peptide ICI 198,615, on thrombin-induced pulmonary edema was studied in rats. Administration of thrombin produced a significant increase in lung weight (p < 0.05), wet weight to dry weight ratio (WW/DW; p < 0.05), and relative lung water content (p < 0.05). These increases were all significantly reduced (p < 0.05) by ICI 198,615 (bolus 15 mg/kg, infusion 15 mg/kg/h). Thrombin infusion caused a significant increase in myeloperoxidase activity in the lung tissue (p < 0.05). This increase was further accentuated by ICI 198,615, indicating that the effect of this antagonist is not due to reduction of leukocyte infiltration in the lungs. The results thus show that a leukotriene receptor antagonist effectively counteracts the increase in lung vascular permeability to protein caused by thrombin, and indicate that leukotrienes are important mediators of thrombin-induced pulmonary edema in the rat.

Effect of indomethacin on thrombin-induced pulmonary edema in the rat

The preventive effect of indomethacin on thrombin-induced pulmonary edema was studied in rats. Administration of thrombin caused a significant increase in lung weight, wet weight to dry weight ratio (WW/DW), and relative lung water content. During infusion of thrombin, mean pulmonary artery pressure rose and mean systemic artery pressure fell, PaO2 decreased progressively and there was a continuous rise in pH and PaCO2. An inhibitor of cyclooxygenase, indomethacin, at a dose of 1 mg/kg body weight, induced a significant further increase in lung weight (p < 0.05), and a tendency towards an increase in WW/DW and water content compared with animals given thrombin alone. Treatment with indomethacin, however, counteracted the elevated pulmonary artery pressure occurring in the early phase after thrombin infusion, but not that in the late phase. Systemic artery pressure was not affected by indomethacin. The increases in pH and PaCO2 after thrombin infusion were attenuated and remained stable almost at baseline level after indomethacin administration. Indomethacin did not prevent the hypoxemia induced by thrombin infusion. In conclusion, although indomethacin prevented the early increase in pulmonary artery pressure due to thrombin and the decrease in pH and the increase in PaCO2, it caused lung vascular permeability to protein to increase more than with thrombin alone.

Effect of ibuprofen on thrombin-induced pulmonary edema in the rat

The effect of ibuprofen on thrombin-induced pulmonary edema was studied in rats. Thrombin infusion produced a significant increase in lung weight, wet weight/dry weight ratio and relative lung water content, a rise in mean pulmonary arterial pressure and a fall in mean systemic arterial pressure. It also caused a progressive decrease in PaO2 and a continuous increase in pH and PaCO2. Administration of either the S-isomer or R-isomer of ibuprofen at doses of 5 mg/kg body weight prior to thrombin infusion resulted in significant reduction in lung weight, wet weight/dry weight ratio and water content. The wet weight/dry weight ratio and the water content were somewhat lower after infusion of the S-isomer than of the R-isomer. Ibuprofen diminished the thrombin-induced increase in mean pulmonary arterial pressure and attenuated the early and late decrease in mean systemic arterial pressure caused by thrombin. Ibuprofen also stabilized thrombin-induced impairments in PaO2, PaCO2 and pH. The results thus indicate that ibuprofen effectively counteracts hemodynamic changes, stabilizes impairments in arterial blood gas variables and attenuates the increase in lung vascular permeability to protein with pulmonary edema caused by thrombin. The results also indicate a substantial R to S chiral inversion of ibuprofen in vivo in the rat.

Effect of a synthetic leukocyte elastase inhibitor on thrombin-induced pulmonary edema in the rat

The effect of a synthetic leukocyte elastase inhibitor on thrombin-induced pulmonary edema was studied in rats. The chloromethylketone human neutrophil elastase inhibitor, ICI 200,355, blunted rat leukocyte elastase activity in rat lung tissue. Administration of thrombin produced a significant increase (p < .01) in lung weight. The wet weight to dry weight ratio (WW/DW) and relative water contents were also significantly elevated (p < .01). Pretreatment with ICI 200,355 (200 micrograms/kg h-1) resulted in significant reductions (p < .05) in lung weight and a tendency to decrease WW/DW and water content compared with animals given thrombin alone. It is possible that the elastase inhibitor effectively reduced the rate of thrombin-induced pulmonary edema by attenuation of increased vascular permeability.

Natural killer activity and antibody-dependent cellular cytotoxicity in patients with primary lung cancer

The NK activity and ADCC of peripheral blood mononuclear cell were examined to evaluate the contribution of ADCC and NK activity to host immune response against lung cancer. The NK activity and ADCC were examined in 58 patients with primary lung cancer and 40 healthy volunteers as normal controls. The NK activity of patients with lung cancer was significantly subnormal, but ADCC was at a normal level. The NK activity was decreased in non-small cell lung cancer (NSCLC), but not in small cell lung cancer (SCLC) compared to normal controls. According to stage, the NK activity in stage II, III-M0 and III-M1 NSCLC showed low levels compared to that of stage I NSCLC, but there was no difference of NK activity in patients with SCLC. The NK activity was not affected by performance status. There was no significant difference of ADCC in patients with lung cancer according to cell type, stage and performance compared with that of normal controls. The NK activity and ADCC were not changed after chemotherapy and operation respectively.

A case of intrapericardial extralobar pulmonary sequestration--first case in Korea

Extralobar pulmonary sequestration, known as accessory lung, is a rare congenital anomaly and intrapericardial lung sequestration is extremely rare. To the best of our knowledge, only four reported cases were intrapericardial. We report a case with intrapericardial extralobar pulmonary sequestration confirmed by operation and morphologic basis.

Phase II study of cyclophosphamide, doxorubicin, and vincristine (CAV) and etoposide plus cisplatin (EP) alternating chemotherapy combined with radiotherapy in small cell lung cancer

The development of drug resistance is the major limiting factor influencing the survival of patients with small cell lung cancer (SCLC). We have thus examined the activity of cyclophosphamide, doxorubicin and vincristine (CAV) alternating with etoposide and cisplatin (EP) in 35 patients with SCLC. The treatment courses were alternated every 3 or 4 weeks. After induction chemotherapy, patients with limited disease (LD) received thoracic radiotherapy (5000 cGy), prophylactic cranial irradiation (3000 cGy) and maintenance chemotherapy and patients with extensive disease (ED) received maintenance chemotherapy only. In this group of 35 patients, 13 had limited disease (LD) and 22 had extensive disease (ED). After completion of the therapy, 100% of the patients with LD achieved complete plus partial remission (CR + PR) and 68% of the patients with ED achieved CR + PR. The median survival time was 66 weeks (15.3 months) in patients with LD and 44 weeks (10.2 months) in patients with ED. The over all survival for patients with LD was superior to that for patients with ED (p less than 0.05). Also, median response duration for patients with LD (35 wks) was longer than that for patients with ED (17 weeks) (p less than 0.05). The primary site was the most vulnerable site to relapse (18 patients). Toxicity was mild to moderate and acceptable, and there were no treatment-related deaths. These results suggest that the alternation of CAV and EP is effective treatment strategy in the management of SCLC. A randomized controlled study will be required to discriminate the actual effect of this alternating regimen.

Relationship between the result of preoperative pulmonary function test and postoperative pulmonary complications

Good preoperative screening and evaluation of patients undergoing surgery is necessary because it serves to identify the individual who is at risk of increased intra-operative and postoperative morbidity and mortality. The retrospective study was done in an attempt to determine if abnormalities in preoperative pulmonary function, detected by routine pulmonary function tests, would predict which patients would suffer from pulmonary complications following surgery. Pulmonary complications in the postoperative period included fever, atelectasis and respiratory failure. The overall incidence of pulmonary complications from our 78 patients undergoing surgery was 37 percent based on clinical criteria. This incidence was high in patients with FEV1 less than 1.0 L/sec, MVV less than 40% of predicted value and PCO2 more than 45 mmHg.