Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Endoscopic management of malignant biliary obstruction by means of covered metallic stents: primary stent placement vs. re-intervention

BACKGROUND AND STUDY AIMS

Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Occlusion of covered metallic stents now occurs in about half of all patients with malignant biliary strictures. The removal of metallic stents followed by placement of a second stent has been attempted, but outcomes remain controversial. The aim of the current study was to evaluate the effectiveness and safety of the primary placement and secondary placement (re-intervention) of covered metallic stents and to assess the feasibility and safety of stent removal.

PATIENTS AND METHODS

The study included 186 patients with unresectable malignant biliary strictures who underwent primary stent placement between October 2001 and March 2010.  Covered biliary self-expandable metal stents (SEMSs) were removed in 39 of these patients, and 36 underwent re-intervention. The patency times, occlusion rates of the first stent and re-intervention, success rates of stent removal, and complications were investigated.

RESULTS

Covered SEMSs were placed in 186 patients. The median patency time of the first stent was 352 days. Stent occlusion occurred in 48.9 % of the patients and was mainly caused by debris or food residue (37 %), dislocation (19 %), and migration with hyperplasia (19 %). Stent removal was attempted in 50 patients and was successful without complication in 39 (78 %). Most of the patients in whom stent removal was unsuccessful had migration with hyperplasia. The median patency time of the second stent was 263 days. The stent patency time did not significantly differ between the first and the second stent.

CONCLUSIONS

Covered SEMSs could be safely removed at the time of stent occlusion. Patency rates were similar for initial stent placement and re-intervention.

Influence of endoscopic papillary balloon dilation and endoscopic sphincterotomy on sphincter of oddi function: a randomized controlled trial

BACKGROUND AND STUDY AIM

Endoscopic papillary balloon dilation (EPBD) is assumed to have a theoretical advantage over endoscopic sphincterotomy (EST) in preserving sphincter of Oddi function because it does not involve cutting the biliary sphincter. Although attempts have been made to study the influence of EPBD and EST on sphincter of Oddi function, there is little agreement on this issue. In this study we used a method different from those described in previous reports to clarify whether EPBD or EST preserves sphincter of Oddi function better.

PATIENTS AND METHODS

200 patients with bile duct stones who met the eligibility criteria were randomly assigned to EPBD (n = 104) or an EST (n = 96) group. Sphincter of Oddi function was estimated by measurement of the activity of pancreatic enzymes in the common bile duct (CBD). Pure bile was collected immediately before EPBD or EST, at 1 week and at 1 year after the procedure. We also statistically investigated 14 factors other than EPBD or EST that might have the potential to affect sphincter of Oddi function.

RESULTS

There was no significant difference between the baseline characteristics of the EPBD and EST groups. A total of 91 patients (46 in the EPBD group and 45 in the EST group) remained in the trial. Pure bile was collected from the CBD of 86 patients (43 EPBD and 43 EST) 1 week after the procedure. CBD stones were extracted successfully in all cases. Before the procedure, there were no significant differences in the levels of the five pancreatic enzymes between the EPBD and EST groups. At 1 week after the procedure, in both groups, there were significant increases in the levels of the five pancreatic enzymes. At 1 year after the procedure a complete series of pancreatic enzyme analyses was done in 33 patients (12 EPBD and 21 EST). There was no significant difference between the levels of the five pancreatic enzymes immediately before and 1 year after EPBD and EST. When the pancreatic enzyme levels of the two groups were directly compared, there was no significant difference at 1 year after the procedure, but the EPBD group had significantly higher levels at 1 week following the procedure.

CONCLUSION

In this study it was found that in patients with CBD stones both EPBD and EST preserve sphincter of Oddi function.

An assay method for nitric oxide-related compounds in whole blood

Recent evidence suggests that nitric oxide (NO) generated in vivo will be converted into the forms of nitrite/nitrate, nitrosyl hemoproteins, nitrosyl metal complexes, and S-nitroso-compounds in the circulation. Nitrosothiols have also been reported to be relatively stable metabolites with micromolar levels in plasma. We hypothesized, therefore, that the determinations of all the NO-related compounds in blood would be of diagnostic significance. The assay method described here consists of the thermolysis of all the NO-related compounds in whole blood and the detection of resulting nitrate by fluorometry or chemiluminescence after an enzymatic reduction. S-Nitroso-albumin and nitrosyl hemoglobin can be easily thermolysed to nitrate, and relatively stable S-nitroso-glutathione is also degraded to nitrate in the presence of blood constituents with high molecular mass (above 30 kDa). Concentrations of NO-related compounds in blood from healthy human as well as control or lipopolysaccharide-stimulated rats were determined. We found that membrane-bound NO which showed the augmented levels under the pathophysiological states could also be detected. Together with electron spin resonance spectra, our data indicate that the fraction of NO diffused and metabolized within red cells and the other NO-metabolites in plasma such as nitrite/nitrate and S-nitroso-compounds, both of which can reflect NO-production in vivo, would be recovered and detected quantitatively by this method.

Thyroid hormone-free albumin: charcoal treatment or resin treatment

Free thyroid hormone measurement by means of immunoassay kits is greatly influenced by the altered serum albumin and free fatty acid (FFA) levels. In the evaluation of these kits, it is therefore essential to study the interferences due to these factors by adding FFA or thyroid hormone-free human serum albumin (HSA) to the assay mixture, but little attention has been paid to the selection of albumin. In the present study, FFA content in various preparations of thyroid hormone-free HSA was compared. Charcoal-treated HSA was free from both thyroid hormone and FFA, whereas anion exchange resin-treated HSA was only free from thyroid hormone. Commercially available "FFA-free HSA" was also free from thyroid hormone. Our results suggest that attention must be paid to the nature of albumin when studying the interference by albumin in free thyroid hormone measurement and that commercially available "FFA-free HSA" is a ready-to-use thyroid hormone-free HSA when HSA free from both FFA and thyroid hormone is desired.

Recognition and neural plasticity responding to deficient nutrient intake scanned by a functional MRI in the brain of rats with L-lysine deficiency

Each L-amino acid (AA) in plasma and brain remains unchanged while normal diet is available. Once L-lysine (Lys) deficient diet was offered to rats, Lys in plasma and brain declined, and anorexia occurred. When solutions of AAs were offered, they selected the Lys solution, and their food intake and growth normalized. The single neuron activity in the lateral hypothalamic area of these rats suggested that neural plasticity occurred, specifically responding to Lys, both by iontophoretic application and during ingestion of AA. The recognition site for deficient nutrient intake in the brain of rats with Lys deficiency was identified by non-invasive magnetic resonance imaging (MRI 4.7 tesla, 40 cm bore in diameter) developed to monitor changes in cerebral blood flow and oxygenation in rat brain. Wistar strain young male rats fed with Lys deficient diet for 4 days, were adapted to be settled in the center of the bore. When they received a Lys injection intraperitoneally (0.2 M, 10 mL/kg), a signal intensity decrease in the medial and lateral hypothalamus appeared 30 minutes later in T2 weighted images, reflecting increased oxygenation which lasted for 30 minutes, and then gradually recovered. These changes never occurred in any other areas of the brain of rats with Lys deficiency, i.e., the thalamus, the cortex, the hippocampus, etc. There were no changes in the signal intensity with control injection of saline. In addition, oxygen consumption in the brain of rats without Lys deficiency was not altered by intraperitoneal Lys injection. The present results suggest that in essential AA deficiency, the medial and lateral hypothalamus may play important roles in recognition responses to particular deficient nutrients in order to maintain homeostasis.

Value of thallium-201 early reinjection for assessment of myocardial viability

To assess the efficacy of early reinjection for predicting post intervention improvement in thallium-201 (T1) uptake and regional wall motion, we reinjected a small dose of T1 following post-stress imaging and obtained reinjection early images (10 min after early reinjection) and reinjection delayed images (3 hr afterwards) in 40 patients who were referred to us for revascularization (group I). Twenty-nine patients in group I also underwent conventional stress-redistribution T1 scintigraphy (group II). Conventional stress-redistribution T1 scintigraphy was repeated after intervention. Contrast left ventriculography was performed before and after intervention and changes in regional wall motion were assessed in 22 of 40 patients. In group I, the predictive value for improvement and no improvement (the accuracy) of reinjection early images in perfusion was 83%, while that of reinjection delayed images was 91%. Furthermore, the accuracy of reinjection early images in regional wall motion was 80%, while it was 91% for reinjection delayed images. In group II, the accuracy in perfusion was 78% and the value in regional wall motion was 70%. Both accuracy in perfusion and in regional wall motion obtained from reinjection delayed images were significantly higher than the values in group II (p < 0.05). These data suggest that early reinjection is useful for predicting postintervention thallium uptake and regional wall motion.

Circulating myosin light chain I levels after coronary reperfusion: a comparison with myocardial necrosis evaluated from single photon emission computed tomography with pyrophosphate

This study was performed to assess the influence of coronary reperfusion on the serial serum myosin light chain (LC)I levels and to evaluate the relationship between the peak LCI level and the infarct size calculated from single photon emission computed tomography (SPECT) with technetium-99m pyrophosphate (Tc-99m PYP) in 11 patients who underwent coronary reperfusion. Blood was drawn before reperfusion, immediately after reperfusion, and once a day for 14 days, to estimate the time course of serum LCI release. The infarct size estimated by Tc-99m PYP ranged from 7.3 to 62.4 ml. The LCI levels obtained before reperfusion were less than 2.5 ng/ml but those obtained immediately after reperfusion were much higher. The value ranged from 2.7 to 9.7 ng/ml and that expressed as a percentage of peak LCI (% peak LCI) ranged from 19 to 83%. Collateral circulation, reperfusion arrhythmia and the degree of residual stenosis had no influence upon the % peak LCI. The correlation between peak LCI levels and SPECT-determined infarct size was good, with a correlation of 0.76 (p less than 0.01, regression line by least squares method y = 3.31 + 1.53x). Early serum LCI might be influenced by coronary reperfusion but the peak LCI value reflected acute myocardial necrosis in patients who underwent coronary reperfusion.

[Scintigraphic quantification of myocardial necrosis using "hot spot" imaging agents in acute myocardial infarction]

Both technetium-99m pyrophosphate/thallium-201 dual nuclide SPECT and indium-111 antimyosin antibody/thallium-201 dual nuclide SPECT were performed in identical 11 patients with acute myocardial infarction. Infarct size was calculated by both hot spot imaging agents on dual nuclide SPECT. Antimyosin accurately accumulated in the infarcted area in all 11 patients on SPECT images corresponding with the electrocardiography, but pyrophosphate accumulated at the site of infarct in 10 of 11 patients. The mean volume obtained from pyrophosphate was 32.5 ml and that from antimyosin was 21.9 ml. The relationship between infarct volume calculated by pyrophosphate and that by antimyosin was linear and correlated well (r = 0.98, p less than 0.001). However the volume of infarction determined with pyrophosphate exceeded that with antimyosin SPECT by 1.64 (p less than 0.001). The reason for this difference is not yet known, but may relate to pyrophosphate uptake in border zones that may or may not be irreversibly injured.

Clinical application of indium-111 antimyosin antibody and thallium-201 dual nuclide single photon emission computed tomography in acute myocardial infarction

The significance of indium-111 antimyosin antibody and thallium-201 dual nuclide single photon emission computed tomography (SPECT) was evaluated in 7 patients with acute myocardial infarction (AMI) who underwent emergency coronary angiography with successful revascularization by intracoronary thrombolysis. Indium-111 antimyosin antibody and thallium-201 dual nuclide SPECT was performed 11 to 36 days after the onset of AMI. Antimyosin SPECT images delineated areas of myocardial necrosis in all 7 patients (100%), but planar images detected necrotic areas in only 4 of 7 patients (57%). Peak CPK-MBs of the 3 patients in which no necrotic area was detected by indium-111 planar image showed a tendency to be smaller. Indium-111 antimyosin antibody/thallium-201 overlap was observed in all patients. The area of overlap was at the center of necrosis in 4 patients (2 anterior infarction, 1 inferior infarction, 1 inferolateral infarction) and at the peripheral portion in 3 patients (all 3 had inferior infarction). Indium-111 antimyosin antibody and thallium-201 dual nuclide SPECT is useful in identifying the localization of myocardial infarction and the overlap of these tracers might reflect the presence of salvaged myocardium adjacent to the necrotic myocardium.

High performance liquid chromatography determination of cyanide in urine by pre-column fluorescence derivatization

A method for the determination of cyanide in human urine has been developed. The method is based on the reaction of cyanide with 2,3-naphthalenedialdehyde and taurine to give a fluorescent product for reversed-phase HPLC separation and fluorometric detection. After centrifugation followed by dilution of urine samples, the specimens could be analysed directly by this method. The recovery of cyanide added to urine at concentration levels of 50-1000 pmol/mL was 85-96%. The detection limit of cyanide was 30 pmol/mL in urine. The method was successfully applied to the analysis of urine from smokers and nonsmokers. The mean concentrations of cyanide were found to be 215 pmol/mL for the former and 84 pmol/mL for the latter.

Prediction of three-dimensional structure of Escherichia coli ribosomal RNA

A model for the tertiary structure of 23S, 16S and 5S ribosomal RNA molecules interacting with three tRNA molecules is presented using the secondary structure models common to E. coli, Z. mays chloroplast, and mammalian mitochondria. This ribosomal RNA model is represented by phosphorus atoms which are separated by 5.9 A in the standard A-form double helix conformation. The accumulated proximity data summarized in Table 1 were used to deduce the most reasonable assembly of helices separated from each other by at least 6.2 A. Straight-line approximation for single strands was adopted to describe the maximum allowed distance between helices. The model of a ribosome binding three tRNA molecules by Nierhaus (1984), the stereochemical model of codon-anticodon interaction by Sundaralingam et al. (1975) and the ribosomal transpeptidation model, forming an alpha-helical nascent polypeptide, by Lim & Spirin (1986), were incorporated in this model. The distribution of chemically modified nucleotides, cross-linked sites, invariant and missing regions in mammalian mitochondrial rRNAs are indicated on the model.

Purification and characterization of erythroid differentiation factor (EDF) isolated from human leukemia cell line THP-1

We isolated a protein, from a cell line of human origin, which exhibits extensive differentiation inducing activity toward Friend leukemia cells. The protein, called Erythroid Differentiation Factor (EDF), was found in a 4 day culture of THP-1 cells performed in the presence of 4 beta-phorbol 12-myristate 13-acetate(PMA). EDF is a homodimer of a molecular weight of 25,000, with an NH2-terminal sequence identical to that of the beta A-chain of porcine Inhibin. It was suggested that a single protein species is responsible for the activities of both EDF and FRP, a FSH releasing protein isolated from porcine ovarian follicular fluid.

[Observation of magnetic fields from three directions, and the moving image of the heart in a normal subject]

Three components of the magnetic field generated by the heart over the anterior aspect of the chest in a normal subject were detected using a Superconducting Quantum Interference Device (SQUID) magnetometer with a single detecting coil in a magnetically shielded room. Contour maps and color density maps of the field were prepared by computer. Movies of sequential magnetic fields of the vertical component on the anterior aspect of the chest were made from these maps. In the movies, the maximum moved from the upper central portion to right lower portion in the early stage of ventricular excitation. It moved to the central portion in the middle stage, then returned to the upper central portion in the late stage. Three-dimensional maps of instantaneous magnetic fields over the anterior portion of the chest were derived from maps of three components of the field, and from presumed heart vectors and were drawn as arrows, based on the Viot-Savart theorem. Heart vectors from these field maps corresponded well with septal forces in the early stage, left ventricular free wall force in the middle stage and the basal force in the late stage, respectively. However, large circulating vectors in the form of clockwise rotation in the central portion were also presumed. These circulating heart vectors did not correspond with the sequence of cardiac excitation as reported by Durrer et al. This discrepancy may have been caused by the fact that the vertical electric current could not be expressed from our display for presuming an electric force. Therefore, new displays and interpretations may be required for the expression of heart vectors.

[Hypereosinophilic syndrome associated with extensive asynergy of the left ventricular wall: a case report]

This is a report of a case of the hypereosinophilic syndrome associated with extensive asynergy of the left ventricular wall. This 41-year-old man's hospital admission in March, 1982 was for congestive heart failure, with marked eosinophilia (34%). Slight depression of the ST segments and flatness of the T waves were observed in electrocardiographic leads I, II, III, a VF, and V 5-6. Digitalis and diuretics were ineffective, but supplementary prednisone therapy resulted in a decrease in eosinophilia and improvement of congestive heart failure. He was transferred to our hospital for further examination in May, 1982. There were no signs of congestive heart failure, but a third heart sound was detected on admission. Marked ST segment depression and inverted T waves were observed in the left precordial leads. Echocardiography cardiography showed extensive asynergy of the left ventricular wall, and progressive enlargement of the left atrium and left ventricle. High density area near the apex of the left ventricle suggested the presence of mural thrombi. A left endocardial biopsy showed organized thrombi sparsely invaded by eosinophils. There were no signs nor symptoms of peripheral emboli. Tapering of the dose of prednisone was attempted twice, but each time eosinophilia resulted. The patient is now free of symptoms, and is being maintained on 25 mg of prednisone daily.

[Rhabdomyosarcoma of the heart involving the left ventricle and left atrium]

A case of rhabdomyosarcoma of the left atrium and left ventricle demonstrated by echocardiography was reported. A 31-year-old man was admitted to our hospital for evaluation of recently developed exertional dyspnea. A holosystolic murmur and a protodiastolic sound were audible at the apex. A chest X-ray showed pulmonary congestion without cardiomegaly. The two-dimensional echocardiogram showed a dense stratified mass of echoes occupying the medial half of the left ventricular cavity, and a part of the abnormal mass of echoes was observed to move toward the left ventricular outflow tract during systole. Another small mass attached to the anterior mitral leaflet was also observed to prolapse partly into the left atrium during systole. The interatrial septum showed a thick and hard band of echo in the short-axis view. Right cardiac catheterization revealed pulmonary hypertension and the levogram of the pulmonary angiography showed left atrial and left ventricular filing defects. The repeated echocardiographic study showed the growth of the abnormal mass. The patient underwent operation, but he died of congestive heart failure thereafter. The necropsy diagnosis was rhabdomyosarcoma of the heart, involving the left atrium and left ventricle.

[Comparative studies on right ventricular pressure and volume overloading by thallium-201 myocardial scintigraphy]

Thallium-201 myocardial scintigraphy was performed in 44 patients with various heart diseases including mitral stenosis (MS), atrial septal defect (ASD), primary pulmonary hypertension (PPH), and left atrial myxoma. The morphological findings of right ventricular (RV) free wall on the scintigram and RV/IVS (interventricular septum) uptake ratio of the images obtained from the left anterior oblique projection were studied in the patients with RV pressure or volume overloading. The RV free wall was visualize by scintigraphy in 13 out of 22 patients (59%) with MS, and in 15 out of 17 patients (88%) with ASD. In 5 patients with PPH or left atrial myxoma, the RV free wall was visualized in all cases. The patterns of RV free wall image were classified into three types. Type I with the smaller right ventricle than left ventricle was mainly seen in cases of MS, and type II with the dilated right ventricle was seen in cases of ASD and PPH. The RV free wall was visualized in most of the patients with MS whose RV systolic pressure (RVSP) was higher than 35 mmHg and mean pulmonary artery pressure (PAMP) was 20 mmHg or more, and with ASD whose RVSP was higher than 30 mmHg and PAMP was 10 mmHg or more. The ratio of radioactivity on the RV free wall and interventricular septum (RV/IVS uptake ratio) was calculated using 45 degree left anterior oblique view images. The RV/IVS uptake ratio ranged from 0.38 to 0.73 in the cases with MS, from 0.40 to 0.77 in the cases with ASD, and from 0.64 to 0.79 in the cases with PPH. In two cases with left atrial myxoma, the ratio was 0.50 and 0.55, respectively. The RV/IVS uptake ratio was compared to various hemodynamic parameters in right ventricular overloading. In the cases with MS, the RV/IVS uptake ratio was closely correlated with RVSP (r = 0.93: p less than 0.001), PAMP (r = 0.92; p less than 0.001), pulmonary capillary wedge pressure (PCWP) (r = 0.83: p less than 0.01), RV work index (RVWI) (r = 0.82: p less than 0.001), and pulmonary vascular resistance (PVR) (r = 0.71: p less than 0.01), respectively. In the cases with ASD, the RV/IVS uptake ratio was closely correlated with RVSP (r = 0.89: p less than 0.001), PAMP (r = 0.68: p less than 0.01), PVR (r = 0.77: p less than 0.01), and a left-to-right shunt ratio (r = 0.785: p less than 0.001). It was concluded that the analysis of thallium-201 myocardial scintigraphy is valuable as a non-invasive technique for the qualitative and quantitative estimation of RV pressure or volume over-loading.U

[Clinical evaluation of cefotiam in internal medicine, with special reference to infectious disease associated with hematological disorders (author's transl)]

Clinical evaluation of cefotiam (panspolin), a new cephem antibiotics, was performed in the infectious disease associated with hematological disorders and in the respiratory system. In hematological dis orders, 40% of good and 25% of fair results were obtained in clinical effects. In respiratory infections, however, 92% of good results were obtained. Opportunistic infection due to Gram-negative bacilli are often experienced in patients with leukemia. Since cefotiam has sufficient bacteriocidal effects in broad spectrum, it would be a good therapeutic agent against infectious diseases associated with hematological disorders.