Evaluation of the direct protective effects of Canagliflozin on the Isoproterenol-induced cell injury in rat cardiomyocytes

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are agents that act by inhibiting glucose and sodium reabsorption in the proximal renal tubule which promotes urinary glucose excretion. More recently, significant benefit data of SGLT2 inhibitors in patients with heart failure, independent of the presence of type 2 diabetes has been reported. We have previously demonstrated that Canagliflozin (Cana), a SGLT2 inhibitor, reduced the ventricular effective refractory period in isoproterenol (ISP)-induced myocardial injury rat model accompanied with the suppression of reactive oxygen species and the elevation of ketone bodies, suggesting the effect of Cana on electrical cardiac remodeling. The direct effect of Cana to the cardiomyocytes and its underlying molecular mechanism was remained to be clarified. We therefore established an ISP-induced neonatal rat ventricular cardiomyocyte (NRVCM) in vitro model, pretreated with Cana and/or ketone bodies.

Methods

Primary NRVCM were isolated from Wistar rats, were pretreated by Cana with or without βOHB (the most abundant ketone body in circulation), followed by a stimulation of ISP (10μM). Cells without drug or ketone body pretreatment were used as control. We then analyzed its effect on cell viability, apoptosis, and mitochondrial membrane potential using MTT assay, TUNEL assay, and mitochondrial membrane potential assay, respectively. MTT assay was also performed with or without PI3k inhibitor, LY294002. The end-labeling of DNA fragmentation were labelled with FITC, followed by the nuclei counterstain with DAPI and were observed with confocal microscope. The apoptotic index was defined as the percentage of TUNEL positive cells / total nuclei.

Results

Cana rescued the reduction of NRVCM cell viability induced by ISP stimulation for 24 hours which was inhibited by LY294002 compared to cells without pretreatment. Interestingly, pretreatment of βOHB with or without Cana improved also the NRCVM cell viability whereas there was no significant difference between these two conditions or with cells treated with Cana only, suggesting the direct protective effect of Cana. In 48 hours of ISP stimulation, the apoptotic index intends to decrease in Cana and/or βOHB compared to cells without pretreatment (Figure 1). Although the mitochondrial function was maintained in Cana-pretreated cells compared to cells without pretreatment, there was no significant difference in βOHB-pretreated cells.

Conclusions

Cana has a direct protective effect on cardiomyocytes cell viability, apoptosis as well as the mitochondrial function impaired by ISP through the cell survival signaling PI3K/Akt pathway. This brings a new insight to the therapeutic target of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Preoperative evaluation of pleural adhesions with dynamic chest radiography: a retrospective study of 146 patients with lung cancer

AIM

To assess the utility of dynamic chest radiography (DCR) during the preoperative evaluation of pleural adhesions.

MATERIALS AND METHODS

Sequential chest radiographs of 146 patients with lung cancer were acquired during forced respiration using a DCR system. The presence of pleural adhesions and their grades were determined by retrospective surgery video assessment (absent: 121, present: 25). The maximum inspiration to expiration lung area ratio was used as an index for air intake volume. A ratio of ≥0.65 was regarded as insufficient respiration. Two radiologists assessed the images for pleural adhesions based on motion findings. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared for each adhesion grade and patient group (patients with sufficient/insufficient respiration). Pearson's chi-squared test compared the group. Statistical significance was set at p<0.05.

RESULTS

DCR correctly identified 22/25 patients with pleural adhesions, with 20 false-positive results (sensitivity, 88%; specificity, 83.5%; PPV, 52.4%; NPV, 97.12%). Although the diagnostic performances for the various adhesion grades were similar, specificity in patients with sufficient respiration increased to 93.9% (31/33), identifying all cases except for those with loose adhesions.

CONCLUSIONS

DCR images revealed restricted and/or distorted motions in lung structures and structural tension in patients with pleural adhesions. DCR could be a useful technique for routine preoperative evaluation of pleural adhesions. Further development of computerised methods can assist in the quantitative assessment of abnormal motion findings.

AB0186 IMPROVEMENT OF RADIOGRAPHIC JOINT DESTRUCTION IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS IN THE LAST DECADE

Background

The paradigm shift has caused in the treatment for rheumatoid arthritis (RA) before the last decade [1]. The advent of high-dose MTX and biologics has maked it possible to treat RA with early and aggressive therapy, and prevent the joint destruction [2].

Objectives

To aim of this study, we investigated the joint destruction and clinical outcomes in patients with early RA every 5 years in the last decade.

Methods

81 patients with early RA (within 1 year from their onset of RA) enrolled retrospectively in this study. The number of patients with early RA were 21 in 2009, 23 in 2014, and 37 in 2019, respectively. They had 17 males and 64 females. Mean age was 59 years (19-92) at the first visit to our department. The following items were investigated: age, disease duration from onset to consultation, anti-cyclic citrullinated peptide antibody (ACPA) positivity (positivity was defined as >4.5 U/ml), CRP, DAS28CRP4, medications, and modified total sharp score (mTSS) at the time of initial consultation and 1 year later. Kruskal-Wallis test was used for statistics (PASW 25 software, SPSS Institute Inc., Chicago, IL, USA, p<0.05).

Results

The ACPA positivity rates were 71.4% (15/21) in 2009, 78.3% (18/21) in 2014, and 78.4% (29/37) in 2019, respectively. The mean value of DAS28CRP4 was 4.7 (2.4-6.8) in 2009, 4.2 (1.2-6.2) in 2014, and 4.2 (2.1-6.7) in 2019 at the time of the first visit to our department respectively. DAS28CRP4 under 2.6 was 29% (6/21) in 2009, 61% (14/23) in 2014, and 54% (20/37) in 2019 1 year after the first visit. The mean improvement of DAS28CRP4 (ΔDAS28CRP4) was -1.2 (-3.9 - 2.1) in 2009, -1.5 (-4.0 - 1.7) in 2014, and -1.7 (-4.1 - 0.4) in 2019, respectively. It had tended to improve gradually, however, it was not significantly different (p= 0.20, Figure 1).

Figure 1.

Mean value of improvement of mTSS and DAS28CRP4 (ΔmTSS and ΔDAS28CRP4) from initial visit to 1 year later at 2009, 2014 and 2019.

The changing of mTSS for a year (ΔmTSS) was 4.2 (0-17) in 2009, 0.9 (0-10) in 2014, and 0.6 (0-4) in 2019, respectivly. ΔmTSS in 2014 and 2019 was significantly lower compared to that in 2009 (p<0.05, Figure 1).

One year after the first visit to our department, the mean dose of MTX increased to 9.2 mg/week (2-14) in 2014 and 8.7 mg/week (4-16) in 2019 compared to 6.6 mg/week (2-8) in 2009 (p=0.19). The mean dose of PSL decreased 4.2 mg/day (1-8) in 2014, and 3.8 mg/day (1-10) in 2019 compared to 4.9 mg/day (2-10) in 2009, respectively (p=0.11). On the other hand, biological DMARDs were introduced in 24% (5/21) in 2009, 13% (3/23) in 2014, and 13% (1/37) in 2019, respectively.

Conclusion

Jonit destruction has been already reported to begin in patients with early-stage of RA [1, 2]. Based on the results of this study, joint desctruction in early RA was decreased in the last decade, because of more early and aggressive therapy for early RA with increasing mean dose of MTX gradually, not biologic DMARDs in real world. In addition, the mean dose of PSL in 2014 and 2019 decreased compared to that in 2009. The intensive therapy for early RA at our hospital has shown the improvement of joint destruction in the last decade.

References

[1]Emery P, Breedveld FC, Dougados M, et al. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002;61:290–297.

[2]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-699.

Disclosure of Interests

None declared

AB0181 RADIOGRAPHIC DESTRUCTION OF CARPAL BONE IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS

Background

The pharmacotherapy for rheumatoid arthritis (RA) has changed dramatically and caused a paradigm shift with the advent of methotrexate (MTX) and biological disease-modifying antirheumatic drugs (bDMARDs).

Before the paradigm shift of RA therapy, the frequency of carpal collapse was high in patients with RA.

It has been reported that certain numbers of patients with RA rapidly advance the destruction of the carpal bones during the early onset in the natural course of it [1].

Another report showed that hand function was positively correlated with disease activity[2]

In Japan, bDMARDs were approved in 2003, and the maximum allowable dose of MTX was raised from 8 mg/week to 12 mg/week in 2012.

We hypothesize early aggressive therapy for the patients with early RA may have improved outcomes of carpal bone destruction in this last decade.

In this study, we investigated the change of drug therapy and carpal height ratio (CHR) in patients with early RA in the last decade.

Objectives

The aim of this study was to investigate CHR and drugs for the patients with early RA who developed it and started the therapy in 2009, 2014, and 2019.

Methods

Patients with early RA diagnosed in our department in 2009, 2014, and 2019 were included in the study.

The CHR was measured at the first visit and two years later on radiographs of both hands.

The drug history for RA was obtained in the medical records retrospectively.

All statistical analyses were performed with EZR version 1.55.

Results

This study included 43 cases (36 females, 7 males). The number of cases in 2009, 2014, and 2019 was 16, 13, and 14, respectively.

The mean age at the time of initial examination was 55 years (30-72).

There was no significant difference in the mean value of DAS28-CRP at the time of the first visit in each year.

The left hand CHR of initial diagnosis was 0.554 (0.484-0.632), 0.551 (0.490-0.618), and 0.567 (0.517-0.632) in 2009, 2014, and 2019, respectively, with no significant difference.

Two years later, the left-hand CHR was 0.541 (0.475-0.651), 0.549 (0.502-0.617), and 0.562 (0.528-0.591), respectively, with no significant difference.

There was also no significant difference in the amount of change.

The right hand CHR of initial diagnosis was 0.525 (0.475-0.607), 0.539 (0.459-0.589), and 0.557 (0.506-0.635) in 2009, 2014, and 2019, respectively, with no significant difference.

Two years later, the right-hand CHR was 0.532 (0.444-0.627), 0.529 (0.478-0.588), and 0.548 (0.491-0.593), respectively, with no significant difference.

There was also no significant difference in the amount of change.

The DAS28-CRP of initial diagnosis for cases in 2009, 2014, and 2019 was 4.68 (3.11-6.83), 4.19 (1.21-6.15), and 4.23 (2.41-6.38), respectively.

The DAS28-CRP at 2 years after treatment for cases in 2009, 2014, and 2019 was 2.12 (0.96-3.60), 2.25 (1.13-4.81), and 2.04 (0.99-3.45), respectively.

Although DAS28-CRP was improved, there was no significance among the three groups.

The usage rate of MTX was 56.3% in 2009, 76.9% in 2014, and 50% in 2019, with mean doses of 6.2 mg (2-8 mg), 8.6 mg (4-12 mg), and 9.1 mg (4-16 mg), respectively. There was no significant difference in the rate and dosage of MTX use in each year.

bDMARDs were used in one case in 2009, two cases in 2014, and one case in 2019.

Conclusion

In this study, DAS28-CRP showed a trend of improvement in this decade, but there was no obvious improvement in the progression of carpal collapse.

Further early aggressive therapy may be necessary to prevent the destruction of the carpal bones.

References

[1]Ochi T, Iwase R, Yonemasu K, Matsukawa M, Yoneda M, Yukioka M, et al. Natural course of joint destruction and fluctuation of serum C1q levels in patients with rheumatoid arthritis. Arthritis and rheumatism. 1988 Jan; 31(1):37-43.

[2]Palamar D, Er G, Terlemez R, Ustun I, Can G, Saridogan M. Disease activity, handgrip strengths, and hand dexterity in patients with rheumatoid arthritis. Clinical rheumatology. 2017; 36(10):2201-2208.

Disclosure of Interests

None declared

Prognostic impact of atrial fibrillation under oral anticoagulation therapy in patients with type B acute aortic dissection

Background

Patients with acute aortic dissection (AAD) sometimes are complicated with atrial fibrillation (AF). However, the impact of AF and the use of oral anticoagulation (OAC) on the prognosis of AAD remains unclear. In this study, we evaluated the prognostic impact of AF and OAC therapy in patients with type B AAD.

Methods

Consecutive patients diagnosed with type B AAD between January 2010 and December 2020 in our university hospital were retrospectively analyzed. All patients were divided into 2 groups based on the concomitance with or without AF. The primary endpoint was set as major adverse cardiovascular events (MACEs), including all-cause death, enlargement of aortic diameter, aortic ruptures, and cerebral infarction. Kaplan-Meier survival curves were constructed, and Cox proportional hazards analysis was performed to identify independent predictors of clinical events at 1 year.

Results

A total of 146 patients diagnosed with type B AAD were enrolled, with a mean age of 66±12 years, and 81% of male. Thirty-two patients (22%) experienced MACEs during 272±142 days-observation. Concomitant AF was observed in 27 patients (18%). In the Kaplan-Meier curve analysis, the patients with AF showed significantly higher events than those without AF (log-lank p&lt;0.001). In the multivariate Cox proportional hazards models, presence of AF (HR: 2.402, 95% CI: 1.099–4.978 p=0.029), maximum descending aorta diameter (HR: 1.0366, 95% CI: 1.005–1.064 p=0.023), and age&gt;75 years (HR: 2.635, 95% CI: 1.268–5.388 p=0.011) were independent predictors of MACEs. Regarding OAC in patients with AF, Kaplan-Meier analysis showed that usage of OAC was associated with a higher incidence of MACEs than those without (log-rank, p=0.036)

Conclusion

Presence of AF, enlargement of descending aorta diameter, and age were independent predictors of future MACEs in patients with type B AAD. Additionally, usage of OAC is associated with MACEs in patients with type B AAD complicated with AF.

Funding Acknowledgement

Type of funding sources: None.

Catheter contact angle influences local impedance drop during radiofrequency catheter ablation: insight from a porcine experimental study

Background

Local impedance (LI) at a distal tip of the ablation catheter can indirectly measure catheter contact and tissue temperature during radiofrequency catheter ablation (RFCA). LI decreases by RFCA, and a degree of LI drop is correlated with lesion size. However, data on the effects of catheter contact angle on lesion size and LI drop were scarce. This study aimed to evaluate the influence of catheter contact angle on lesion size and LI drop in a porcine experimental study.

Methods

Lesions were created on porcine myocardial left ventricles by the LI-sensing ablation catheter (IntellaNav MiFi OI®). Contact force (CF) was measured using pressure to current transducer (load cell). Radiofrequency ablation was performed with a power of 30 Watt and a duration of 30 seconds. CF (0g, 5g, 10g, 20g, and 30g) and catheter angle (30°, 45°, and 90°) were changed in each set (total 120 lesions, n=8 each). LI rise, LI drop by RF application, and lesion size (maximum lesion width, maximum surface width, and maximum lesion depth) were evaluated.

Results

There was no angular dependence in LI rise in all CF. The values of LI rise increased as CF increased. The LI drop also increased as CF increased in all contact angles. Regarding the difference of catheter angles, LI drop with 90° was lower than those with 30° and 45°in CF 10g, 20g, and 30g, respectively. Maximum lesion width and surface width were larger in 30° and 45° than those in 90°, whereas there were no differences in maximum lesion depth.

Conclusion

LI drop in 90° were significantly lower than those in 45° and 30°. Although lesion depths were not different among the three angles, the absolute values of LI drop were different. Caution should be exercised to comprehend the LI drop with catheter angles.

Funding Acknowledgement

Type of funding sources: None.

Remote monitoring can predict lethal arrhythmic events through time-domain analysis of heart rate variability in patients with implantable cardioverter defibrillator

Background

We prospectively collected device and heart rate data, i.e. heart rate variability (HRV), through remote monitoring (RM) of patients with implantable cardioverter defibrillator (ICD). Several studies have demonstrated usefulness of RM in implanted device patients, however, reports concerning the predictors of lethal ventricular arrhythmias are limited.

Purpose

The objective was to identify the predictors of lethal arrhythmic events (VT/VF).

Methods

Thirty-three patients (mean age: 50 years) with ICDs [with functionality of HRV analysis] were divided into 2 groups [VT/VF(+), VT/VF(−)]. Clinical, device (ventricular lead impedance; amplitude of ventricular electrogram), and HRV data were compared between the 2 groups. As the index of time-domain HRV analysis, NN intervals-index (SDNNi) was calculated for every 5 minutes, and the mean, maximum, and minimum SDNNi during the 24-hour period were used.

Results

During the observation period (median 12 months), 10 patients experienced VT/VF events. In HRV data, the mean, max, and min SDNNi were higher in VT/VF(+) than VT/VF(−) group (132.9±9.3 v.s. 93.5±6.1, p=0.0013; 214.6±10.6 v.s. 167.0±7.0, p=0.0007; 71.2±7.5 v.s. 43.9±4.9, p=0.0047). The other parameters did not exhibit significant difference. On logistic regression analysis, the mean SDNNi of 100.1, max SDNNi of 185.0 and min SDNNi of 52.0 as cut-off values for prediction of VT/VF event demonstrated significant receiver operating characteristics (ROC) curves (AUC=0.86, p=0.0007; AUC=0.84, p=0.0005; AUC=0.78, p=0.0030). Furthermore, in cases of VT/VF(+) group, the max ΔSDNNi, i.e., difference from baseline SDNNi, and min ΔSDNNi in 7 and 28 days preceding VT/VF events exhibited time course changes in comparison with baseline values. They were significant predictors of VT/VF events (max ΔSDNNi cut-off: 46.8, AUC=0.91, p=0.0002; min ΔSDNNi cut-off: −42.4, AUC=0.88, p=0.0014).

Conclusion

Time-domain analysis of HRV through RM may help identify patients at high risk of lethal arrhythmic events, and predict occurrence of such arrhythmic events.

Funding Acknowledgement

Type of funding source: None

P178 Sinus rhythm restoration by catheter ablation improved cognitive function in elderly patients with atrial fibrillation

Background

Atrial fibrillation (AF) may cause cognitive impairment. However, the impact of sinus rhythm (SR) restoration by catheter ablation on the improvement of cognitive function remains to be elucidated.

Methods

A total of 57 consecutive elderly patients (70.8 ± 4.8 years old) who underwent catheter ablation for AF were prospectively enrolled. The change of cognitive function for 6 months was compared between patients with SR restoration (at least 3 months; n = 49) and patients with AF recurrence (n = 8). Cognitive function was evaluated by the mini-mental state examination (MMSE).

Results

There was no significant difference in baseline characteristics between the 2 groups, including MMSE score (27.3 ± 2.6 vs. 27.6 ± 1.5 points; p = 0.793). The change of MMSE score was significantly greater in patients with SR restoration than those with AF recurrence (0.28 ± 0.70 vs. − 0.50 ± 0.75 points; p = 0.006; Figure). The general liner modeling revealed that SR restoration (effect estimate, 0.369; 95% confidence interval, 0.110 to 0.627; p = 0.006) was independently associated with the change of MMSE score.

Conclusion

In elderly AF patients, successful restoration of SR by catheter ablation was associated with the improvement of cognitive function.

Abstract P178 Figure

Low Consultation Rate of General Population with Atrial Fibrillation

In order to prevent ischemic stroke, it is important to identify and treat patients with atrial fibrillation (AF) who do not consult a doctor in a medical institution. The aim of this study was to determine the consultation rate at medical institutions for patients with AF in group medical examinations conducted in a city in western Japan. Of 6101 examinees of group medical examinations (40 years of age or older) conducted in Ibara City, Okayama Prefecture, Japan, from 2012 to 2014, 4338 participants (71.1%) who were evaluated by electrocardiogram (ECG) gave written informed consent and responded to surveys in the form of questionnaires through a personal interview conducted by nurses were included in the Ibara-AF study. A cumulative total of 82 subjects were diagnosed as having AF by ECG (prevalence of AF = 1.89%), and 51 individuals had AF during the three-year period.15 (29.4%) of the 51 patients with AF did not regularly visit medical institutions. Among them, 46.7% (n = 7) and 53.3% (n = 8) of the patients were symptomatic and asymptomatic, respectively, and 73.3% of the patients had a CHADS₂ score of more than one point. There were no significant differences in patients' characteristics between regular and non-regular visit groups. In conclusion, about one-third of the patients with AF did not regularly see a doctor in a medical institution and most of them had a CHADS₂ score of more than one point in a Japanese rural area. Educating the public about the risks of AF is required.

P5623Plaque characteristics, slow flow during percutaneous coronary intervention, and clinical outcomes of irregular protrusion by optical coherence tomography

Introduction

In pathological studies, penetration of the lipid core into the stent strut is associated with neointimal growth and stent thrombosis. Irregular protrusion on optical coherence tomography (OCT) is associated with clinical events and target lesion revascularization. However, there are few reports about the relationship among irregular protrusion, plaque characteristics, and slow flow during percutaneous coronary intervention. We investigated clinical and procedure characteristics, plaque characteristics, slow flow after stent implantation, and clinical outcomes with irregular protrusion by using OCT.

Methods

Eighty-four lesions in 76 patients undergoing OCT before percutaneous coronary intervention were evaluated. Irregular protrusion was defined as protrusion of material with an irregular surface into the lumen between stent struts with a maximum height of ≥100 μm. Major adverse clinical outcomes were defined as death, acute myocardial infarction, acute coronary syndrome, or target lesion revascularization.

Results

Lesions with irregular protrusion were found in 56% (47/84). Compared with lesions without irregular protrusion, those with irregular protrusion had significantly higher low-density lipoprotein cholesterol (LDL-C) levels (108±31 mg/dL vs. 95±25 mg/dL, P=0.044); a tendency toward decreased use of statins (44% [19/43] vs. 67% [22/33], P=0.065); significantly larger reference vessel diameter (3.12±0.53 mm vs. 2.74±0.63 mm, P=0.004); significantly larger stent diameter (3.23±0.43 mm vs. 3.00±0.49 mm, P=0.025); a tendency toward longer total stent length (29.3±14.2 mm vs. 23.7±11.4 mm, P=0.056); significantly larger maximum balloon diameter (3.56±0.55 mm vs. 3.22±0.63 mm, P=0.010); significantly higher incidence of slow flow after stent implantation (38% [18/47] vs. 11% [4/37], P=0.006); significantly higher ΔTIMI flow from pre-stenting to post-stenting (0.4±0.6 vs. 0.1±0.3, P=0.009); significantly higher incidence of lipid-rich plaque (70% [33/47] vs. 35% [13/37], P=0.002); thin-cap fibroatheromas (TCFAs: 49% [23/47] vs. 5% [2/37], P<0.001); plaque rupture (40% [19/47] vs. 16% [6/37], P=0.018); macrophage accumulation (51% [24/47] vs. 24% [9/37], P=0.015); internal running vasa vasorum (51% [24/47] vs. 11% [4/37], P<0.001); thrombus (32% [15/47] vs. 3% [1/37], P<0.001); and a tendency higher incidence of one-year adverse clinical outcomes (12% [5/43] vs. 0% [0/33], P=0.075: log rank). The multivariable analysis showed that TCFA was an independent predictor of irregular protrusion (odds ratio 9.00, 95% CI 1.32–61.36, P=0.025).

Conclusions

Irregular protrusion on OCT was associated with high plaque vulnerability, higher LDL-C, less frequent use of statin, larger vessel diameter, longer total stent length, slow flow after stent implantation, and one-year adverse clinical outcomes.

Sex difference of in-hospital mortality in patients with acute myocardial infarction

Factors contributing to the sex difference of in-hospital mortality after acute myocardial infarction (MI) are still unknown. We compared the clinical characteristics on admission and in-hospital outcome of consecutive 1,354 patients with acute MI between the 2 sexes. Age on admission was about 7 years older in women than in men. In-hospital death was significantly more frequent in women. Pulmonary congestion and hypertension were more likely in women with higher serum levels of total cholesterol and LDL cholesterol. A higher prevalence of current smoking and inferior wall involvement and lower serum HDL cholesterol level were observed in man. After adjusting for age, adverse in-hospital mortality for women was observed in both younger and older patients. Multivariate logistic regression analysis demonstrated that age, location of infarction, recanalization and serum C-reactive protein (CRP) concentration were independent predictors for in-hospital mortality for overall patients, while age and recanalization were independent predictors for male gender, and pulmonary congestion and serum CRP concentration were independent predictors for female gender. In-hospital outcome after acute MI was worse in women. A multivariate logistic regression model revealed that the sexually different factors affected in-hospital mortality in females.

Clinical features of acute myocardial infarction in elderly patients

The aim of this study was to clarify the prevalence of coronary risk factors in order to characterize the prognostic factors in elderly patients and to also identify any factors beneficial for the prevention of further cardiac events and death. We studied 888 patients with ST-elevation acute myocardial infarction who were admitted within 48 h of symptom onset. The patients were divided into 3 groups according to age for comparison of variables:a younger group (n＝99) aged ≤ 50, a middle-aged group (n＝435) ≥ 51 years but＜70 years and an elderly group (n＝354) aged ≥ 71 years. The elderly group had higher rates of female gender, pulmonary congestion, in-hospital mortality, and atrial fibrillation and a higher plasma concentration of high-sensitivity CRP (hs-CRP) (p＜0.05). Hypertension, diabetes mellitus, and dyslipidemia were more common in the middle-aged group (p＜0.05). The prevalence of smokers and the plasma level of total cholesterol, LDL-cholesterol and triglycerides were lower in the elderly group (p＜0.05). The grade of collateral circulation was highest in the elderly group, but the success rate of reperfusion therapy was lowest. Multiple regression analysis showed that age, pulmonary congestion, CKD and hs-CRP were predictors of in-hospital mortality. This investigation indicated that elderly patients with acute myocardial infarction have different clinical characteristics than younger patients. A specific algorithm might be needed in elderly patients, and could use hs-CRP, eGFR and atrial fibrillation as factors.

[One-stage coronary artery bypass grafting and revascularization in a patient with ischemic heart disease and arteriosclerosis obliterans]

With the overall increase in ischemic heart disease (IHD), cases combining arteriosclerosis obliterans (ASO) of the lower extremities and IHD are on the rise. Therefore, it is necessary to consider methods and timing of operation. These cases have occasionally large collateral pathways from the internal thoracic artery (ITA) to the femoral artery via the epigastric artery. To prevent irreversible ischemia of the lower limbs after harvesting of ITA, we planned to perform a one-stage operation for ASO-combined IHD. Revascularization of the lower extremities was performed 1st. Subsequently coronary artery bypass grafting with ITA was completed. The operative courses were uneventful.

Intermittent administration of a sustained-release prostacyclin analog ONO-1301 ameliorates renal alterations in a rat type 1 diabetes model

Diabetic nephropathy is the most common pathological disorder predisposing end-stage renal disease. ONO-1301 is a novel sustained-release prostacyclin analog possessing thromboxane (TX) synthase inhibitory activity. Here, we aimed to investigate the therapeutic efficacies of ONO-1301 in a rat type 1 diabetic nephropathy model. Streptozotocin (STZ)-induced diabetic rats received injections of slow-release form of ONO-1301 (SR-ONO) every 3 weeks. Animals were sacrificed at Week 14. SR-ONO significantly suppressed albuminuria, glomerular hypertrophy, mesangial matrix accumulation, glomerular accumulation of monocyte/macrophage, increase in glomerular levels of pro-fibrotic factor transforming growth factor (TGF)-beta1 and the number of glomerular alpha-smooth muscle actin (SMA)(+) cells in diabetic animals. The glomerular levels of hepatocyte growth factor (HGF) were significantly increased in SR-ONO-treated diabetic animals. Taken together, these results suggest the potential therapeutic efficacy of intermittent administration of SR-ONO in treating diabetic nephropathy potentially via inducing HGF, thus counteracting the pro-fibrotic effects of TGF-beta1.

Prognostic significance of right bundle branch block in patients with acute inferior myocardial infarction

There is little information available concerning the influence of right bundle branch block (RBBB) on the prognosis of patients with inferior myocardial infarction (MI). In this study we evaluated the influence of RBBB on the short-term prognosis of patients with inferior MI. Our study subjects were 1,265 hospitalized patients with Q wave MI. Patients were divided into 4 groups based on the presence or absence of RBBB and on the location of the infarction. RBBB was classified into 4 categories according to the timing of its appearance and its duration as new permanent, transient, old and age indeterminate. In-hospital death and pulmonary congestion were observed more frequently in patients with RBBB than in those without RBBB. Moreover, in inferior MI as in anterior MI, in-hospital death and pulmonary congestion occurred more frequently in new permanent RBBB patients than in patients with other types of RBBB. Multivariate regression analysis reveals that new permanent RBBB was a strong independent predictor for an adverse short-term prognosis in patients with inferior MI, as well as in patients with anterior MI. New permanent RBBB during inferior MI is a strong independent predictor for increased in-hospital mortality, regardless of the infarction location.

Treatment strategy after non-curative endoscopic resection of early gastric cancer

BACKGROUND

Endoscopic resection (ER) is indicated for patients with early gastric cancer who have a negligible risk of lymph node metastasis (LNM). Histological examination of the resected specimen may indicate a possible risk of LNM or a positive resection margin. These patients are considered to have undergone non-curative ER. The aim of this study was to determine the appropriate treatment strategy for such patients.

METHODS

A total of 298 patients who had non-curative ER were classified into those with a positive lateral margin only (group 1; 72 patients) and those with a possible risk of LNM (group 2; 226 patients).

RESULTS

Surgery was performed within 6 months of non-curative ER in 19 patients in group 1 and 144 in group 2. In group 1, nine patients were found to have local residual tumours, all limited to the mucosal layer without LNM. In Group 2, 13 patients had residual disease, including four local tumours without LNM, two local tumours with LNM and seven cases of LNM alone. The rate of LNM after surgery was 6.3 per cent in group 2.

CONCLUSION

Surgery remains the standard treatment after non-curative ER in patients with a possible risk of LNM.

The oro-ileal transit of cellulose

The effects of cellulose and the interindividual variations on the transit time in the small intestine remain unclear, but no previous study has to date taken these factors into sufficient consideration. We assessed the oro-ileal transit time and the recovery percentage of cellulose in the terminal ileum looking at interindividual variations. Seven healthy males received 100 mL of a dietary fiber-free basal diet with 5 g cellulose and 5 g of polyethylene glycol 4000. The ileal contents were aspirated every 30 min via an experimental tube placed in the terminal ileum to assess the oro-ileal transit time and the recovery percentage of cellulose. The mean percentage (with standard deviation) of the amounts of cellulose collected in the terminal ileum was 98.4%+/- 16.5% (ranging from 67.4% to 114.5%) with a coefficient variation of 16.8%. The average times (in hours) taken for 20%, 40%, 60%, and 80% of cellulose to reach the terminal ileum were 5.5 +/- 1.1, 6.7 +/- 0.7, 8.5 +/- 1.3, and 8.8 +/- 1.2, respectively, with large interindividual variations. In conclusion, the averaged recovery percentage of cellulose in the terminal ileum was approximately 100%, in accordance with the present generally accepted definition of dietary fiber. However, there were large interindividual variations in the oro-ileal transit time and the percentage of cellulose recovered.

Complete atrioventricular block secondary to lithium therapy

Sinus node dysfunction has been reported most frequently among the adverse cardiovascular effects of lithium. In the present case, complete atrioventricular (AV) block with syncopal attacks developed secondary to lithium therapy, necessitating permanent pacemaker implantation. Serum lithium levels remained under or within the therapeutic range during the syncopal attacks. Lithium should be used with extreme caution, especially in patients with mild disturbance of AV conduction.

The effect of age on Web-safe color visibility for a white background

This paper investigates the effect of subject's age on Web-safe color visibility on a white background. An evaluation of Website accessibility is necessary because of the rapid dissemination of information on the World Wide Web. One important factor to be considered when developing accessible Websites is the foreground color and the background color combination. In this study, the visibility of 21 chromatic Web-safe colors on a white background was examined using a psychological methodology, i.e. a paired comparison. The participants in the experiment were 12 young adults, 17 middle-aged adults and 11 elderly adults. The young adults conducted three tests involving 420 paired-comparison trials while the other groups' participants conducted the test in consideration of the physical burden. It was found that the chromaticity of the foreground color influenced the assessment of the page's visibility by the young adult group more strongly than that by the other groups. It was also found that the contrast between the foreground and background colors affected the assessment of the page's visibility by the middle-aged and elderly groups more strongly than that by the young adult group. This indicated that the ageing effect in the visibility increases the effect of the contrast and decreases the effect of the chromaticity.

Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection--an analysis of risk factors

BACKGROUND AND STUDY AIM

Endoscopic submucosal dissection (ESD) has been reported to be associated with a higher complication rate than standard endoscopic mucosal resection. We aimed to clarify the risk factors for delayed bleeding after ESD for early gastric cancer (EGC).

METHODS

1083 EGCs in 968 consecutive patients undergoing ESD during a 4-year period were reviewed. Post-ESD coagulation (PEC) preventive therapy of visible vessels in the resection area, using a coagulation forceps, was introduced and mostly performed during the later 2 years. Various factors related to patients, tumors, and treatment including PEC were investigated using univariate and multivariate analysis with regard to delayed post-ESD bleeding, evidenced by hematemesis or melena, that required endoscopic treatment.

RESULTS

Delayed bleeding occurred after ESD of 63 lesions (5.8 % of all lesions and 6.5 % of patients), controlled in all cases by endoscopic hemostasis; blood transfusion was required in only one case. Tumor location in the upper third of the stomach and PEC were independent factors indicating a lower rate of delayed bleeding according to both univariate and multivariate analysis.

CONCLUSIONS

This retrospective study suggested that preventive coagulation of visible vessels in the resection area after ESD may lead to a lower bleeding rate.

Evaluation of 18F-2-deoxy-2-fluoro-glucose positron emission tomography for gastric cancer screening in asymptomatic individuals undergoing endoscopy

(18)F-2-deoxy-2-fluoro-glucose Positron Emission Tomography (FDG-PET) has been recently proposed as a promising cancer-screening test. However, the validity of FDG-PET in cancer screening has not been evaluated. We investigated the sensitivity of FDG-PET compared with upper gastric endoscopy in gastric cancer screening for asymptomatic individuals. A total of 2861 consecutive subjects (1600 men and 1261 women) who were asymptomatic and who underwent both FDG-PET and upper gastrointestinal endoscopy between 1 February 2004 and 31 January 2005 were included in this study. Both endoscopists and a radiologist were unaware of the results of the other diagnostic tests. The FDG-PET images were examined using criteria determined by the pattern of FDG accumulation. Sensitivity and specificity of FDG-PET were calculated compared with endoscopic diagnosis as the gold standard. Among 2861 subjects enrolled in the study, there were 20 subjects with gastric cancer, of whom 18 were T1 in depth of cancer invasion. Positive FDG-PET results were obtained only in 2 of the 20 cancer subjects. The calculated sensitivity and specificity for overall gastric cancers were 10.0% (95% confidence interval (CI): 1.2-31.7%) and 99.2% (95% CI: 98.8-99.5%), respectively. (18)F-2-deoxy-2-fluoro-glucose Positron Emission Tomography was poorly sensitive for detection of gastric cancer in the early stages.

Postprandial hypotension due to a lack of sympathetic compensation in patients with diabetes mellitus

Postprandial hypotension is an important hemodynamic abnormality in diabetes mellitus, but few reports are available on the relationship between autonomic dysfunction and postprandial hypotension. Ten diabetic patients and 10 healthy volunteers were recruited for this study. Postural blood pressure and heart rate changes were measured before lunch, and then the hemodynamic responses to a standardized meal were investigated. Holter electrocardiogram (ECG) monitoring was conducted for assessing spectral powers and time-domain parameters of RR variations. Postural changes from the supine to the upright position decreased the systolic blood pressure of the diabetics from 133(+/-)16 to 107(+/-)20 mmHg (p<0.01), but did not decrease the systolic blood pressure of the controls. The heart rate remained constant in the diabetics but was increased in the controls. Food ingestion decreased systolic blood pressure in the diabetics, with a maximum reduction of 25(+/-)5 mmHg. This decrease was not associated with any changes in the ratio of low frequency to high frequency, and yet the heart rate remained almost constant. Indexes involving parasympathetic tone were not affected. Food ingestion did not affect blood pressure in the control group. These findings suggest that lack of compensatory sympathetic activation is a factor contributing to postprandial hypotension in diabetics, and that parasympathetic drive does not make a significant contribution to this condition.

Gastric perforation during endoscopic resection for gastric carcinoma and the risk of peritoneal dissemination

BACKGROUND

The potential risk of peritoneal seeding following perforation caused by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is unknown.

METHODS

Between January 1991 and December 2003, 90 patients suffered gastric perforation during EMR or ESD at the National Cancer Centre Hospital, Tokyo. The clinical and pathological evidence for peritoneal dissemination in these patients was assessed retrospectively.

RESULTS

Eighty-four patients were followed up at this hospital for a median of 53.6 (range 7.0-136.6) months; the remaining six patients were followed up at other institutions. In 83 patients the perforation was repaired by endoscopic clip application and seven patients underwent emergency surgery. Gastrectomy was carried out in 33 patients who had non-curative endoscopic surgery. Among these, peritoneal fluid was sampled during operation in nine patients and was cytologically negative for malignancy. The other 24 patients who had a gastrectomy did not have ascites so cytology was not performed. No peritoneal dissemination was noted during follow-up.

CONCLUSION

This study suggests that perforation associated with EMR and ESD does not lead to peritoneal dissemination even in the long term.

Clinical outcome after endoscopic mucosal resection for esophageal squamous cell carcinoma invading the muscularis mucosae--a multicenter retrospective cohort study

BACKGROUND AND STUDY AIMS

Endoscopic mucosal resection (EMR) is now commonly indicated for esophageal squamous cell carcinoma (ESCC) within the lamina propria mucosa. However, EMR for ESCC that has invaded the muscularis mucosa is controversial because the risk of lymph node metastasis is not negligible. We conducted a multicenter retrospective cohort study to investigate the incidence of lymph node metastasis and survival after EMR for ESCC invading the muscularis mucosa.

PATIENTS AND METHODS

A total of 104 patients with 111 lesions invading the muscularis mucosa, were retrospectively studied at eight institutes. No patients exhibited evidence of metastasis of lymph nodes or distant organs prior to EMR. Overall and cause-specific survival rates were calculated from the date of EMR to the date of death or the most recent follow-up visit. Survival curves were plotted according to the Kaplan-Meier method.

RESULTS

In total, 86 patients (82.7%) who did not receive further treatment such as chemotherapy, irradiation therapy, chemoradiotherapy, or esophagectomy after EMR were followed up. Only two patients (1.9%) developed lymph node metastasis after EMR. With a median follow-up period of 43 months (range, 8-134 months), overall and cause-specific survival rates at 5 years after EMR were 79.5% and 95.0%, respectively.

CONCLUSIONS

EMR for ESCC that invades the muscularis mucosa has curative potential as a minimally invasive treatment option.

Determining the treatment strategy for colorectal neoplastic lesions: endoscopic assessment or the non-lifting sign for diagnosing invasion depth?

BACKGROUND AND STUDY AIMS

Assessment of the invasion depth of colorectal neoplasia is important in deciding between endoscopic and surgical resection treatment methods. Prior to attempting endoscopic resection, the lesion is lifted by submucosal injection, and a positive "non-lifting sign" is usually considered to indicate deeper submucosal infiltration. The purpose of this prospective multicenter study was to assess the predictive value of the non-lifting sign for differentiating between adenoma and early cancer (up to discrete submucosal infiltration [sm1]) and cancer with deeper infiltration (sm2).

PATIENTS AND METHODS

During an 11-month period, a total of 271 colorectal neoplastic lesions in 239 patients were included in the study. Apart from the location, size, and macroscopic type of the lesion, the presence or absence of the non-lifting sign was recorded and compared with the endoscopic assessment of invasion depth.

RESULTS

The non-lifting sign had a sensitivity of 61.5 %, a specificity of 98.4 %, a positive predictive value of 80.0 %, a negative predictive value of 96.0 %, and an accuracy of 94.8 %. Endoscopic diagnosis of deeper infiltration had a sensitivity of 84.6 %, a specificity of 98.8 %, a positive predictive value of 88.0 %, a negative predictive value of 98.4 %, and an accuracy of 97.4 %. Statistically significant differences were found in terms of sensitivity and accuracy.

CONCLUSION

Because of its lower sensitivity and accuracy, the non-lifting sign will not replace endoscopic assessment. If a lesion does not lift, this can make resection technically difficult, but does not reliably predict deeper cancerous invasion.

Identification of prognostic biomarkers for gastric cancer by gene expression analysis

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Background: Endoscopic biopsy before chemotherapy provides an excellent opportunity for studying biomarkers related to therapy-induced tumor responses or overall survival. This study was designed to identify prognostic biomarkers in patients with unresected gastric cancer. Methods: Samples were taken from histologically proved primary gastric cancers in 40 patients before chemotherapy. Microarray analysis was performed using Affymetrix HG-U133Plus2.0 GeneChips after RNA quality checks of the samples. Correlations between gene expression data and survival time were statistically evaluated with a univariate Cox proportional-hazards model. Identified genes were validated by real time RT-PCR analysis in same 40 test-set samples. Then, PCR-validated genes were evaluated for independent samples (validation set) to predict survival. Results: We obtained 185 candidate genes that were significantly associated with survival (p<0.005) on univariate testing in the 40 test-set sample. Real time RT-PCR analysis identified 5 genes that were reproducibly related to survival on the log-rank test (p<0.01). PCR analysis with each of these 5 genes discriminated short-term survivors with a sensitivity of 71% and a specificity of 46–77% in the test set. For the independent 19-sample validation set, single-gene PCR analysis had a sensitivity of 50–81% and a specificity of 38–62%. A multi-gene prediction panel will be evaluated. Conclusions: Gene expression profiling by microarray and real time RT-PCR is useful for predicting overall survival in gastric cancer.

No significant financial relationships to disclose.

Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum

BACKGROUND

Laterally spreading tumours (LSTs) in the colorectum are usually removed by endoscopic mucosal resection (EMR) even when large in size. LSTs with deeper submucosal (sm) invasion, however, should not be treated by EMR because of the higher risk of lymph node metastasis.

AIMS

To determine which endoscopic criteria, including high magnification pit pattern analysis, are associated with sm invasion in LSTs and clarify indications for EMR.

METHODS

Eight endoscopic criteria from 511 colorectal LSTs (granular type (LST-G type); non-granular type (LST-NG type)) were evaluated retrospectively for association with sm invasion, and compared with histopathological findings.

RESULTS

LST-NG type had a significantly higher frequency of sm invasion than LST-G type (14% v 7%; p<0.01). Presence of a large nodule in LST-G type was associated with higher sm invasion while pit pattern (invasive pattern), sclerous wall change, and larger tumour size were significantly associated with higher sm invasion in LST-NG type. In 19 LST-G type with sm invasion, sm penetration determined histopathologically occurred under the largest nodules (84%; 16/19) and depressed areas (16%; 3/19). Deepest sm penetration in 32 LST-NG type was either under depressed areas (72%; 23/32) or lymph follicular or multifocal sm invasion (28%; 1/32 and 8/32, respectively).

CONCLUSIONS

When considering the most suitable therapeutic strategy for LST-G type, we recommend endoscopic piecemeal resection with the area including the large nodule resected first. In contrast, LST-NG type should be removed en bloc because of the higher potential for malignancy and greater difficulty in diagnosing sm depth and extent of invasion compared with LST-G type.

Predominant presence of Streptococcus anginosus in the saliva of alcoholics

Chronic alcohol consumption is known to be a major risk factor for cancers of the upper aerodigestive tract. The incidence of esophageal cancer (4.4%) in alcoholics is reported to be much higher than that in the Japanese population as a whole (0.0001%). This suggests the presence of specific factors in chronic alcohol consumption-related carcinogenesis. Recently, data showing a significant correlation between Streptococcus anginosus and carcinogenesis in the upper aerodigestive tract have been reported. In this study, the ratio of S. anginosus to oral bacteria in the saliva of 38 alcoholic patients was investigated to determine if there is an association between alcoholic patients and S. anginosus infection. The level of S. anginosus in the saliva from 22 healthy people, 41 esophageal cancer patients, 32 gastritis patients, and 24 periodontitis patients was also investigated and compared to the level in alcoholic patients. In the saliva from esophageal cancer patients, the level of S. anginosus was not significantly different from that of healthy people. The levels of S. anginosus in periodontitis and gastritis patients were also similar. In alcoholics, however, there was an extremely high level of S. anginosus, suggesting that they, rather than healthy people and general esophageal cancer patients, have a high risk for S. anginosus infection.

[Highly concentrated vascular endothelial growth factor in Crow-Fukase syndrome with high output heart failure: a case report]

Crow-Fukase syndrome is a disease of plasma cell dyscrasia. Congestive heart failure is the biggest complication affecting the prognosis. A 57-year-old male was admitted with edema and low grade fever. Globe and stocking type polyneuropathy, increased levels of adrenocorticotropic hormone and thyroid-stimulating hormone, serum M-protein component of the immunoglobulin A-lambda type, skin polypoid lesion, and organomegaly including cardiomegaly were observed. The diagnosis was Crow-Fukase syndrome based on these clinical features. High output heart failure and pulmonary hypertension were determined with a cardiac catheter. Diuretics and angiotensin converting enzyme inhibitor were effective to control his overhydration. The level of serum vascular endothelial growth factor was markedly increased and might be responsible for the manifestation of this syndrome with cardiac involvement.

Effect of short-term administration of high dose L-arginine on restenosis after percutaneous transluminal coronary angioplasty

BACKGROUND

A single and local administration of L-arginine after balloon angioplasty enhances nitric oxide (NO) generation and inhibits lesion formation in animals.

OBJECTIVES

The present study assessed the effect of increasing NO to inhibit restenosis after percutaneous transluminal coronary angioplasty (PTCA) in humans by local and systemic administration of L-arginine, a precursor of NO in humans.

METHODS

L-arginine was administered to 34 consecutive patients with angina pectoris or old myocardial infarction via a cardiac catheter (500 mg/4 min) before PTCA, and via a peripheral vein (30 g/4 hr, for 5 days) after PTCA. Patients were treated between December 1998 and December 2000. Plasma concentrations of L-arginine, NO (as nitrite + nitrate) and cyclic guanosine monophosphate (cGMP) were measured before and after L-arginine administration. The control group consisted of 90 patients who underwent PTCA successfully without L-arginine administration in the period between July 1996 and November 1998. Baseline clinical and angiographic characteristics were compared between the two groups. All patients were followed by coronary angiography for 3 months after PTCA. Quantitative coronary angiography and restenosis rate were studied.

RESULTS

Baseline clinical and angiographic characteristics were not different between the two study groups. Despite a significant elevation in plasma L-arginine concentration after L-arginine administration, NO and cGMP did not increase significantly. After PTCA, the difference in restenosis rates between L-arginine and control subjects (34% vs 44%) was not significantly different.

CONCLUSIONS

Short-term administration of high dose L-arginine did not significantly change the restenosis rate after PTCA.

Functional organization of preoptic vasotocin and isotocin neurons in the brain of rainbow trout: central and neurohypophysial projections of single neurons

Preoptic magnocellular neurosecretory cells (NSCs) in the brain of rainbow trout show synchronization of periodic Ca(2+) pulses, patterns of which differ between vasotocin (VT) and isotocin (IT) neurons. To provide neuroanatomical bases of the synchronized periodic Ca(2+) pulses and their biological implications, we examined the organization of preoptic VT and IT neurons in the brain of rainbow trout. The cytoarchitecture of the preoptic neurosecretory system was characterized by a confocal double-color immunofluorescence. Two to five VT neurons, and also IT neurons, aggregate to form cell-type specific clusters. VT clusters tend to localize medially, while IT clusters laterally. VT neurons are closely apposed at the proximal neuronal processes. A Golgi-like immunohistochemistry demonstrated that VT and IT fibers distribute widely in the brain, such as ventral telencephalon, diencephalon, and various mesencephalic structures, in addition to the neurohypophysial projections. Projections from single VT and IT neurons were examined by an intracellular staining with biocytin injection in a sagittally hemisected brain preparation, which contains the entire forebrain region. Single VT and IT neurons project toward the pituitary and the extrahypothalamic regions. Some IT neurons, but not VT neurons, were dye-coupled. These results support the idea that the same types of NSCs are connected to form cell-type-specific networks responsible for the synchronization of periodic Ca(2+) pulses. The organization of the preoptic neurosecretory system shown in the present study is suitable for the simultaneous control of neurohypophysial and extrahypothalamic outputs through the synchronization of electrical activity.

Risk factors indicating recurrent myocardial infarction after recovery from acute myocardial infarction

Little is known of the risk factors of recurrent myocardial infarction (MI) among Japanese patients who have survived their first MI. The risk factors for the second MI were studied in 808 of 1,042 consecutive patients who recovered from an acute MI in Iwakuni National Hospital. Multivariate logistic regression analysis revealed that only 3 of 21 variables measured were closely related with the recurrence of MI during a follow-up period of 3.2 +/- 4.3 years: (1) transient atrial fibrillation (relative risk (RR) 3.16), (2) previous cerebrovascular accident (RR 3.05), and (3) dyslipidemia (RR 2.19). Of the parameters of dyslipidemia, a low ratio of high-density lipoprotein-cholesterol (HDL-C) to low-density lipoprotein-cholesterol (LDL-C) alone indicated subsequent MI. None of age, gender, location of the infarction, hypertension, diabetes mellitus, pulmonary congestion (Killip's class > or = 2), peak serum creatine kinase activity, serum total-cholesterol, HDL- and LDL-cholesterol levels, nor smoking habit on admission was a statistically significant predictor for the second MI. The result suggests that more intensive treatment is needed for patients with the 3 risk factors.

A case of hyperplastic polyposis of the colon with adenocarcinomas in hyperplastic polyps after long-term follow-up

A 66-year-old woman had been receiving follow-up since 1990 for hyperplastic polyposis, which remained unchanged endoscopically and radiologically. In 1999, a small (28 x 22 mm) superficial adenocarcinoma was detected in the ascending colon. Histologically, this was a hyperplastic polyp containing a well-differentiated adenocarcinoma invading into the submucosa. A review of the English and Japanese literature identified 32 cases of "hyperplastic polyposis." In about half of the 32 cases, an adenocarcinoma was also found amongst the hyperplastic polyps. Half of the adenocarcinomas were located in the right colon. Although hyperplastic polyposis is uncommon, it warrants regular surveillance, as it appears to be associated with an increased risk of colorectal cancer.

Development of an aggressive depressed cancer in a case of familial adenomatous polyposis

In 1977, Kariya et al. reported a case of a small depressed cancer in a patient with familial adenomatous polyposis (FAP) raising the possibility that not all cancers in FAP develop from polypoid adenomas. It is now becoming widely recognized that colonic adenomas may appear as flat or depressed lesions. However, colorectal cancers developing in patients with familial adenomatous polyposis (FAP) are still thought to evolve from adenomatous polyps following the polyp-carcinoma sequence. We report the case of a patient with FAP in whom rectal carcinoma developed 23 years after subtotal colectomy and ileorectal anastomosis. We suggest that this malignancy may have developed de novo because of the depressed shape of the lesion and the aggressive growth pattern. This case raises the possibility that carcinomas may not always evolve from polyps in FAP. Aggressive cancers with a depressed appearance should be searched for when surveying the rectal stump in patients with FAP.