Is warfarin associated with higher risk of thrombus in left atrial appendage than direct oral anticoagulants?

Funding Acknowledgements

Type of funding sources: None.

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke, and anticoagulation therapy is utilized to prevent thromboembolism.

Purpose

This study is to investigate the incidence of thrombus in left atrial appendage detected by transoesophageal echocardiography (TOE) under anticoagulation therapy with warfarin or direct oral anticoagulants (DOAC).

Methods

Between 2005 and 2016, the patients who underwent TOE under anticoagulation therapy due to atrial fibrillation more than one month were enrolled in this study. The patients were divided into 2 groups according to whether treated with warfarin or DOAC and baseline characteristics and incidence of LAA thrombus were assessed.

Results

Among the 313 study patients, 243 (78%) were treated with warfarin. The patients treated with warfarin were elder (median 73 y vs. 67 y [interquartile range 66 – 78 y vs. 58 – 72 y], P < 0.01), the body mass index was lower (23.2 vs. 24.0 [21.0 – 25.4 vs. 21.3 – 26.9], P = 0.03). The prevalence of male sex (64% vs. 71%, P = 0.26) were similar between the 2 groups. The previous history of hypertension (69% vs. 59%, P = 0.10), diabetes (24% vs. 19%, P = 0.32), vascular disease (30% vs. 26%, P = 0.52), and ischemic stroke were similar between the 2 groups (30% vs. 23%, P = 0.22). The prevalence of CHA2DS2-VASc score > 1 (84% vs. 59%, P < 0.01) and the d-dimer level (0.7 vs. 0.5 mcg/ml [0.5 – 1.8 vs. 0.5 – 0.5 mcg/ml], P < 0.01) were higher in the warfarin groups than those of the DOAC. The velocity of LAA was slower in the warfarin group than those of DOAC (35 vs. 55 cm/s [21 – 54 vs. 38 – 68 cm/s], P < 0.01). The incidence of detection of LAA thrombus was 19% in the warfarin group and 3% in the DOAC group (P < 0.01). In the warfarin group, the PT-INR were lower in the patients with LAA thrombus (1.38 vs. 1.66 [1.11 – 1.92 vs. 1.34 – 2.03], P = 0.03).

Conclusions

The higher risk of ischemic stroke and out of range PT-INR may be the cause of the higher incidence of LAA thrombus in the patients treated with warfarin than those with DOAC.

Abstract Figure.

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE).

Purpose

This study is to investigate the prognosis of patients with LAA thrombus and their cause of death.

Methods

Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed.

Results

Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P<0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P<0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P<0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P<0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P<0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P<0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively.

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy.

Figure 1

Funding Acknowledgement

Type of funding source: None

P684 Paradoxical cerebral infarction due to massive pulmonary embolism in extracorporeal cardiopulmonary resuscitation and surgical embolectomy

Introduction

Paradoxical cerebral infarction is a mechanism of acute ischemic stroke; however, definitive images to diagnose paradoxical embolism are not often obtained. We report a case of paradoxical cerebral embolism complicated with cardiac arrest due to massive pulmonary embolism.

Case report

A 40-year-old man presented due to sudden-onset chest pain, and was admitted to our hospital. He was restless and had cold sweat; we could not measure blood pressure. Electrocardiography showed wide QRS complex with right bundle branch block, and T wave inversion in leads V1 and III. Transthoracic echocardiography showed diffuse severe left ventricular hypokinesis, with slightly better inferior wall motion compared to other segments. Few minutes after arriving, he experienced cardiac arrest; chest compression was initiated. He was transported to the catheter laboratory, and veno-arterial extracorporeal membrane oxygenation was initiated subsequently. To diagnose the cause of arrest, we performed coronary angiography, which revealed no occluded coronary artery. Pulmonary angiograms showed bilateral proximal pulmonary artery occlusion with massive thrombi (panel A). Surgical embolectomy was performed after cardiac team discussion. After ICU admission post-surgery, pericardial effusion was increased, and the blood drained continuously from the chest tube; a large amount of blood transfusion was required. Reopen chest haemostasis was utilised. After the second ICU admission, anisocoria was observed; subsequent computed tomography showed low density and midline shift in almost the entire left cerebral hemisphere (Panel B). Carotid duplex ultrasound revealed a large thrombus saddled at the left carotid artery bifurcation (Panel C and D). We rechecked the transthoracic echocardiogram at arrival to reveal the cause of the cerebral infarction, which showed the thrombus to be at the ascending aorta (Panel E). We thought that the thrombi had moved from the lower limb to the right atrium. The massive pulmonary embolism increased the pulmonary artery and right atrial pressure, resulting in the lower pressure of the left atrium compared to that of the right atrium. The thrombi passed through the patent foramen ovale into the left atrium, moved into the left ventricle, and embolised the left internal carotid artery (Panel F). He expired due to severe neurologic injury from brain herniation.

Conclusion

In this case, although the pulmonary embolism was massive and led to cardiac arrest, the deteriorated haemodynamics improved by extracorporeal cardiopulmonary resuscitation and surgical embolectomy. However, we could not rescue the patient because of the severe neurological injury due to paradoxical embolism. Paradoxical cerebral infarction in pulmonary embolism is rare; however, we should pay careful attention to early detection of paradoxical cerebral infarction in pulmonary embolism and treatment for return of the patient to the former lifestyle.

Abstract P684 figure

P765 Does detection of thrombus in left atrial appendage increase risk of ischemic stroke and mortality?

Background

Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival.

Methods

The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared.

Results

Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p < 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p < 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p < 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p < 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p < 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p < 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B).

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue.

Abstract P765 Figure

P4548Early drop in systolic blood pressure and worsening renal function in the elderly acute heart failure: how does heart rate interact?

Background

Renal dysfunction is a frequent finding in patients hospitalized for acute heart failure (AHF). Worsening renal function (WRF) during hospitalization was found to be related with a poor outcome independently of baseline renal function. Early drop in systolic blood pressure (SBP) has shown to predict WRF in AHF. However, there have been few studies that reported the impact of on-admission heart rate (HR) on the relationship between early SBP drop and WRF in the elderly AHF.

Purpose

We assessed the hypothesis that early SBP drop predict WRF in the elderly patients with AHF, and investigated that on-admission HR might have an interaction with that relationship.

Methods

SBP and HR were measured on admission and 6 times during 48 hours in the 245 elderly AHF inpatients (82.9±6.0 years old, male 49.4%). WRF was defined as a serum creatinine increase of ≥0.3 mg/dL by Day 5. Early drop in SBP was calculated as the difference between admission and the lowest value measured during the first 48 hour of hospitalization.

Results

Early SBP drop (51.3 vs 32.5mmHg, p<0.01) and on-admission HR (79.3 vs 89.6bpm, p<0.05) were significantly different between the group with WRF (n=36) and the group without WRF (n=209). In the multiple logistic regression analysis adjusted for the confounders including age, gender, hypertension, left ventricular ejection fraction, total cholesterol, BNP, baseline creatinine, beta-blockade use, intravenous loop diuretic, isosorbide dinitrate and carperitide use, early SBP drop (OR: 1.003, 95% CI: 1.003–1.03, p<0.04) and on-admission HR (OR: 0.98, 95% CI: 0.96–0.99, p<0.01) were significantly associated with WRF. The interaction term of early SBP drop by on-admission HR did not have a significant association with WRF (p=0.3).

Conclusions

In the elderly AHF patients, exaggerated early SBP drop and lower on-admission HR were shown as significant independent predictors of WRF. These two factors were additively associated with WRF. Too much reduction in SBP and that in HR might be harmful to renal circulation in AHF.

Abstract P6-11-17: Nanoparticle albumin-bound paclitaxel-induced peripheral neuropathy in patients receiving neoadjuvant or adjuvant chemotherapy for breast cancer

A brief background discussion.

Nanoparticle albumin-bound paclitaxel (nab-PTX) has been developed under the concept of improved drug delivery. nab-PTX has been shown to significantly increase progression-free survival compared with solvent-based paclitaxel (PTX) in metastatic breast cancer. However, the long-term outcomes of nab-PTX induced peripheral neuropathy (nPIPN) have not yet been fully elucidated.

Trial design: observational cohort study (UMIN20852)

Primary objective: The long-term outcome of nPIPN

Secondary objectives

(1)The validity of the Neuropathic Pain Screening Questionnaire (Japan–Q, Ishikawa et al. Pain Research 2016 )

(2) To evaluate the effect of frozen gloves and elastic stockings for nPIPN

nPIPN was assessed by the Japan-Q (J-Q) and Common Toxicity Criteria for Adverse Events ver 4.0 (CTC). The J-Q is an assessment tool for patient-reported pain severity, which consists of seven items, each rated on a five-point scale 0-4; grade 0 (no symptoms) to grade 4 (verysevere symptoms). Pricking pain, electric shock pain, burn like pain, tingling pain with numbness, allodynia, reduced or hyper sensitivity and hand-foot syndrome. Assessment was performed every day during chemotherapy, six months and one year after completion of nab-PTX therapy. Total of 28 points for each day and 588 points for each cycle, higher point correlates with severity. Frozen gloves during administration of nab-PTX and/or elastic stockings were optionally used.

Statistical methods

Kruskal Wallis test was used and p&lt;0.05 was considered as significant.

RESULTS:

Between May 2013, and April 2016, 105 patients were enrolled from 7 hospitals. In 73 patients (69.5%) nab-PTX was administered as primary and in 32 patients (30.5%) as adjuvant therapy. Forty three (41.0%) patients received nab-PTX as first line and 62 (59.0%) received after anthracycline contained regimen. Trastuzumab was administered as combination therapy with nab-PTX for Her2 positive patients. Both frozen gloves and stockings were used in 21 patients (20.0%) and frozen gloves only were used in 21 patients (20.0%) according to patient preference.

One hundred patients (95.2%) completed four courses, and overall relative dose intensity was 91.4%.

During chemotherapy, J-Q scores go elevated from day 1 to day 5 and gradually declined throughout the rest of the cycle. Without using frozen gloves, there was a significant increase according to courses (1st: 45.0 ± 5.7, 2nd: 76.7 ± 8.6, 3rd: 94.3 ± 11.8, 4th: 95.4 ± 11.8). Using frozen gloves, there was a significant increase from 1st course to 2nd, but no further increase was observed(1st: 37.4 ± 8.1, 2nd: 61.9 ± 12.4, 3rd: 62.9 ± 10.4, 4th: 55.3 ± 10.6). After six month and one year, the scores were significantly lower compared with the last day of the fourth cycle (4.28 ± 0.50, 2.53 ± 0.25, 2.85 ± 0.39, respectively). CTC, grade 2 or more sensory disturbance was observed in 57.9% after four cycles, but improved to 9.5% and 5.4% after six month and one year respectively.

CONCLUSIONS:

Patient-reported nPIPN was significantly getting worse without frozen gloves during chemotherapy, however be largely reversible within 1 year of PST or adjuvant treatment. The J-Q findings support that nab-PTX treatment is tolerable.

Citation Format: Yoshidome K, Morimoto T, Matsunami N, Tsunashima R, Tsukamoto F, Ryo T, Nishida Y, Shimo T, Anno K, Shimada M, Udo M, Kagawa M, Morishima H, Oda N. Nanoparticle albumin-bound paclitaxel-induced peripheral neuropathy in patients receiving neoadjuvant or adjuvant chemotherapy for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-17.

Impaired Visual Suppression of Manually Rotated Vestibuloocular Reflex Indicates the Need of Further Evaluation by MRI and MRA in Patients with Vertigo

OBJECTIVE: MRI and MRA are accepted as valuable methods for diagnosing vertigo, although they are costly and time-consuming. Thus, some indicator of the necessity of a detailed evaluation by MRI and MRA is desirable.

STUDY DESIGN AND SETTING: To assess the usefulness of an impairment of the visual suppression (VS) as an indicator, the relation between abnormal findings on MRI and/or MRA and impairment of the VS of manually rotated vestibuloocular reflex (VOR) was retrospectively examined in 40 consecutive patients suffering from vertigo.

RESULTS: 12 of 23 patients with a low VS% were found to have a pathologic condition on MRI and/or MRA, however, no abnormality was found in any of the patients with a normal VS%. The rates of abnormality on MRI and/or MRA significantly differed between the 2 groups ( X2, P = 0.0004).

CONCLUSION: The VS% is thought to be a good indicator of the need for further evaluation by MRI and MRA in vertiginous patients.

Unexpected radiation laryngeal necrosis after carbon ion therapy using conventional dose fractionation for laryngeal cancer

Carbon ion therapy is a type of radiotherapy that can deliver high-dose radiation to a tumor while minimizing the dose delivered to organs at risk. Moreover, carbon ions are classified as high linear energy transfer radiation and are expected to be effective for even photon-resistant tumors. A 73-year-old man with glottic squamous cell carcinoma, T3N0M0, refused laryngectomy and received carbon ion therapy of 70 Gy (relative biological effectiveness) in 35 fractions. Three months after the therapy, the patient had an upper airway inflammation, and then laryngeal edema and pain occurred. Five months after the therapy, the airway stenosis was severe and computed tomography showed lack of the left arytenoid cartilage and exacerbation of laryngeal necrosis. Despite the treatment, 5 and a half months after the therapy, the laryngeal edema and necrosis had become even worse and the surrounding mucosa was edematous and pale. Six months after the therapy, pharyngolaryngoesophagectomy and reconstruction with free jejunal autograft were performed. The surgical specimen pathologically showed massive necrosis and no residual tumor. Three years after the carbon ion therapy, he is alive without recurrence. The first reported laryngeal squamous cell carcinoma case treated with carbon ion therapy resulted in an unexpected radiation laryngeal necrosis. Tissue damage caused by carbon ion therapy may be difficult to repair even for radioresistant cartilage; therefore, hollow organs reinforced by cartilage, such as the larynx, may be vulnerable to carbon ion therapy. Caution should be exercised when treating tumors in or adjacent to such organs with carbon ion therapy.

Behavioural Genetics of Early Childhood: Fears, Restlessness, Motion Sickness and Enuresis

Seventy-nine pairs of same-sex twins were examined at the age of three years at a municipal clinic and their mothers were interviewed to assess the twins' current and past behaviours. The zygosity was determined after the interview by fingerprints and/or bloodtyping in the majority of cases. The following significant differences in concordance between monozygotic and dizygotic twins were found: 1) fear of strangers during observation at the clinic; 2) marked fear of strangers in the first year of life; 3) whether or not the child was startled by sudden noises during infancy; 4) whether or not the child was able to sleep alone at three years without a parent sitting nearby; 5) susceptibility to motion sickness; 6) nocturnal enuresis; 7) short attention span or restlessness during the test.

Prospective study comparing the new sclerotherapy and hemorrhoidectomy in terms of therapeutic outcomes at 4 years after the treatment

PURPOSE

Recently, sclerotherapy using a new sclerosing agent (aluminum potassium sulfate and tannic acid) has become widespread in Japan as a treatment for hemorrhoids. In the present study, we investigated whether sclerotherapy or surgical therapy (hemorrhoidectomy) is superior in terms of the therapeutic outcomes at 4 years.

METHODS

We sent a questionnaire on symptoms and the degree of satisfaction to patients who underwent sclerotherapy or hemorrhoidectomy for grade 3 or 4 hemorrhoids in 2007, and compared the two therapies based on the responses, with respect to superiority of the therapeutic outcomes at 4 years. To identify the factors affecting the symptom-free and satisfaction rates, the univariate and multivariate analyses were performed for the following seven parameters: age, sex, degree of hemorrhoids, presence of external hemorrhoids, past history of treatment for hemorrhoids, number of hemorrhoids treated and the type of treatment.

RESULTS

Overall, 75 % of the patients (195/260) responded to the questionnaire. In this study, the symptom-free rates were 53 % (30/57 patients) in the sclerotherapy group and 80 % (111/138 patients) in the hemorrhoidectomy group, and the satisfaction rates were 70 % (40/57 patients) in the sclerotherapy group and 88 % (121/138 patients) in the hemorrhoidectomy group. The results revealed that the type of treatment was the only factor affecting these two outcomes.

CONCLUSIONS

Our results indicate that hemorrhoidectomy is superior to sclerotherapy. These findings may be useful in the treatment of hemorrhoid patients.

Evaluation of animal models for intestinal first-pass metabolism of drug candidates to be metabolized by CYP3A enzymes via in vivo and in vitro oxidation of midazolam and triazolam

1. To search an appropriate evaluation methodology for the intestinal first-pass metabolism of new drug candidates, grapefruit juice (GFJ)- and vehicle (tap water)-pretreated mice or rats were orally administered midazolam (MDZ) or triazolam (TRZ), and blood levels of the parent compounds and their metabolites were measured by liquid chromatography/MS/MS. A significant effect of GFJ to elevate the blood levels was observed only for TRZ in mice. 2. In vitro experiments using mouse, rat and human intestinal and hepatic microsomal fractions demonstrated that GFJ suppressed the intestinal microsomal oxidation of MDZ and especially TRZ. Substrate inhibition by MDZ caused reduction in 1'-hydroxylation but not 4-hydroxylation in both intestinal and hepatic microsomal fractions. The kinetic profiles of MDZ oxidation and the substrate inhibition in mouse intestinal and hepatic microsomal fractions were very similar to those in human microsomes but were different from those in rat microsomes. Furthermore, MDZ caused mechanism-based inactivation of cytochrome P450 3A-dependent TRZ 1'-hydroxylation in mouse, rat and human intestinal microsomes with similar potencies. 3. These results are useful information in the analysis of data obtained in mouse and rat for the evaluation of first-pass effects of drug candidates to be metabolized by CYP3A enzymes.

Toxicity test using medaka (Oryzias latipes) early fry and concentrated sample water as an index of aquatic habitat condition

The aim of the present study was to show a relationship between toxicity of 100-fold concentrated water and aquatic habitat conditions. Environmental waters are 100-fold concentrated with solid-phase extraction. Medaka early fry was exposed in these waters for 48 h. The number of death and disorder was counted at 1, 2, 3, 6, 12, 24, and 48 h; toxicity was expressed using inverse median effect time and median lethal time (ET (50)(-1), LT (50)(-1)). Average score per taxon (ASPT) for benthic animals and Index of Biotic Integrity (IBI) for fish were applied as indices of aquatic habitat conditions. The results of toxicity test were compared using ASPT and IBI. The different levels of toxicity were detected in the seawater of Japan. At the Husino River area, toxicity cannot be detected. In rivers, high toxicity appeared at urban districts without sewerage. By Spearman coefficient, the relationship between toxicity and high biochemical oxygen demand (BOD) were obtained. BOD household wastewater contains hydrophobic toxic matters; otherwise, seawater in industrial area does not show clear relationship between toxicity and chemical oxygen demand. Gas chromatography to mass spectrometry simultaneous analysis database may give an answer for the source of toxicity, but further test is required. Ratio of clear stream benthic animal sharply decreased over 0.25 of LT (50)(-1) or 0.5 of ET (50)(-1). Tolerant fish becomes dominant over 0.3 of LT (50)(-1) or 0.5-1.0 of ET (50)(-1). By Pearson product-moment correlation coefficient, correlation coefficient between toxicity and ASPT was obtained at -0.773 (ET (50)(-1)) and -0.742 (LT (50)(-1)) at 1 % level of significance with a high negative correlation. Toxicity (LT (50)(-1) ) has strong correlation with the ratio of tolerant species. By Pearson product-moment correlation coefficient, correlation coefficient between toxicity and IBI obtained were -0.155 (ET (50)(-1)) and -0.190 (LT (50)(-1)) at 1 % level of significance and has a low or no correlation between toxicity and IBI. Even with low toxic environmental waters, toxicity test using 100-fold concentrated and medaka early fly could detect acute toxicity. The detected toxicity seemed to limit the inhabiting aquatic species in the water body.

Effect of tiotropium bromide on airway inflammation and remodelling in a mouse model of asthma

BACKGROUND

Tiotropium bromide, a long acting muscarinic receptor inhibitor, is a potent agent for patients with bronchial asthma as well as chronic obstructive pulmonary disease.

OBJECTIVE

The aim of this study was to evaluate whether tiotropium bromide can inhibit allergen-induced acute and chronic airway inflammation, T helper (Th)2 cytokine production, and airway remodelling in a murine model of asthma.

METHODS

Balb/c mice were sensitized and challenged acutely or chronically to ovalbumin (OVA). The impact of tiotropium bromide was assessed using these mice models by histologic, morphometric, and molecular techniques. Moreover, the effect of tiotropium bromide on Th2 cytokine production from purified human peripheral blood mononuclear cells (PBMCs) was assessed.

RESULTS

Treatment with tiotropium bromide significantly reduced airway inflammation and the Th2 cytokine production in bronchoalveolar lavage fluid (BALF) in both acute and chronic models of asthma. The levels of TGF-beta1 were also reduced by tiotropium bromide in BALF in a chronic model. The goblet cell metaplasia, thickness of airway smooth muscle, and airway fibrosis were all significantly decreased in tiotropium bromide-treated mice. Moreover, airway hyperresponsiveness (AHR) to serotonin was significantly abrogated by tiotropium bromide in a chronic model. Th2 cytokine production from spleen cells isolated from OVA-sensitized mice was also significantly inhibited by tiotropium bromide and 4-diphenylacetoxy-N-methylpiperidine methiodide, which is a selective antagonist to the M3 receptor. Finally, treatment with tiotropium bromide inhibited the Th2 cytokine production from PBMCs.

CONCLUSION

These results indicate that tiotropium bromide can inhibit Th2 cytokine production and airway inflammation, and thus may reduce airway remodelling and AHR in a murine model of asthma.

Heterogeneity of regional systolic function detected by tissue Doppler imaging is linked to impaired global left ventricular relaxation in hypertrophic cardiomyopathy

OBJECTIVE

To evaluate regional and global left ventricular (LV) function and LV wall thickness (LVWT) in patients with hypertrophic cardiomyopathy (HCM).

DESIGN AND SETTING

Observational study at the National Cardiovascular Centre and Nagoya University Hospital in Japan.

PARTICIPANTS

Thirty-six patients with HCM and 16 patients with hypertensive LV hypertrophy (LVH).

MAIN OUTCOME MEASURES

Conventional echocardiography and strain rate (SR) imaging derived from tissue Doppler imaging were performed. Systolic strain (epsilon(sys)), peak systolic SR (SR(sys)), peak early diastolic SR (SR(dia)) and LVWT were obtained from eight LV segments. LV pressure was simultaneously recorded with a high-fidelity micromanometer.

RESULTS

The regional epsilon(sys) and SR(sys) were correlated with LVWT in patients with HCM (r = 0.50, p<0.001 and r = 0.63, p<0.001, respectively) but not in patients with hypertensive LVH. The standard deviations of LVWT, epsilon(sys) and SR(sys) obtained from the eight LV segments of each subject were greater for patients with HCM than for patients with hypertensive LVH. The standard deviation of LVWT was correlated with those of epsilon(sys) and SR(sys) (r = 0.55, p<0.001 and r = 0.56, p<0.001, respectively). The standard deviations of LVWT, epsilon(sys) and SR(sys) were correlated with tau (r = 0.35, p<0.05; r = 0.47, p<0.001; and r = 0.39, p<0.005, respectively).

CONCLUSIONS

Heterogeneity of regional LV systolic function detected by SR imaging is in part attributable to heterogeneity of LVH and may be linked to impaired global LV relaxation in HCM.

Severe hypoglycaemia in a person with insulin autoimmune syndrome accompanied by insulin receptor anomaly type B

AIMS

A rare case of the insulin autoimmune syndrome (IAS) accompanied by insulin receptor anomaly is reported.

METHODS

Antibodies to insulin and insulin receptor were determined in the patient with severe hypoglycaemia before and after the treatment with prednisolone.

RESULTS

Titers of antibody to insulin and insulin receptors were 73.0% and 41.5%, respectively. Drug-induced lymphocyte stimulation tests were all negative for the suspicious drugs. Her HLA-DR was DRB1*0403/04051. Following steroid therapy, the formation of antibodies was suppressed and alleviated her symptoms. Scatchard analysis yielded findings specific to polyclonal antibodies.

CONCLUSIONS

The changes in autoantibodies resulted in alleviation of the hypoglycemic symptoms as a result of steroid therapy.

Inhibitory effects of suplatast tosilate on the differentiation and function of monocyte-derived dendritic cells from patients with asthma

BACKGROUND

Dendritic cells (DCs) are antigen-presenting cells that efficiently activate T cells.

OBJECTIVE

We examined the effects of suplatast tosilate, which prevents T-helper type 2 responses, on the differentiation and function of monocyte-derived DCs (moDCs).

METHODS

DCs were differentiated in vitro from peripheral monocytes from patients with asthma by the addition of granulocyte macrophage colony-stimulating factor and IL-4 in the presence or absence of suplatast tosilate. Cell surface molecules (CD1a, CD14, CD80, CD83, CD86, HLA-DR) on immature and mature DCs were analysed with flow cytometry, and the secretion of CC chemokine ligand (CCL)17 (thymus and activation-regulated chemokine), IL-12p70, IL-12p40, and IL-10 was measured with an ELISA. We also studied the proliferative responses of allogeneic CD4(+) T cells from healthy subjects to DCs differentiated in the presence of suplatast tosilate. In addition, the production of IFN-gamma and IL-5 by CD4(+) T cells after coculture with untreated DCs or suplatast tosilate-treated DCs was measured with ELISA.

RESULTS

Suplatast tosilate significantly inhibited the expression of CD1a, CD80, and CD86 on immature DCs and of CD1a, CD80, CD83, and CD86 on mature DCs. Suplatast tosilate also significantly inhibited the secretion of CCL17, IL-12p70, and IL-12p40; however, the secretion of IL-10 was not affected. The proliferative responses of allogeneic CD4(+) T cells to suplatast tosilate-treated DCs were suppressed. Moreover, suplatast tosilate-treated DCs had an impaired capacity to stimulate CD4(+) T cells to produce IFN-gamma and IL-5.

CONCLUSION

Suplatast tosilate inhibits the differentiation, maturation, and function of moDCs.

A cone-beam volume CT using a 3D angiography system with a flat panel detector of direct conversion type: usefulness for superselective intra-arterial chemotherapy for head and neck tumors

BACKGROUND AND PURPOSE

The development of flat panel detectors (FPDs) has made cone-beam CT feasible for practical use in a clinical setting. Our purpose was to assess the usefulness of cone-beam CT using the FPD in conjunction with conventional digital subtraction angiography (DSA) for performing superselective intra-arterial chemotherapy for head and neck tumors.

MATERIALS AND METHODS

Twenty-three consecutive patients (43 feeding arteries) were prospectively examined. All of the patients underwent intra-arterial rotational angiography using an FPD system, and the cone-beam CT was reconstructed from the volume dataset. Two radiologists evaluated the quality of the cone-beam CT and then evaluated whether the additional information provided by the cone-beam CT was useful for the interventional procedures.

RESULTS

In 41 (95%) of 43 arteries, the extent of contrast material perfusion was sufficiently visualized on cone-beam CT. In 20 (47%) of 43 arteries, the DSA plus cone-beam CT was superior to the DSA alone regarding the precise understanding of vascular territory of each artery. This information was helpful for predicting the drug delivery for superselective intra-arterial chemotherapy, especially in deeply invasive tumors with multiple feeding arteries.

CONCLUSION

In superselective intra-arterial chemotherapy for head and neck tumors, cone-beam CT with FPD provides useful additional information, which allows interventional radiologists to determine the feeders, as well as the dose of antitumor agent for each feeder.

The relationship between cerebral T2 hyperintensity and fixation suppression of vestibulo-ocular reflex in elderly patients with dysequilibrium symptoms

OBJECTIVES

To evaluate the relationship between cerebral T2 hyperintensity on MRI and visual suppression of vestibulo-ocular reflex (VOR) in elderly patients with dysequilibrium symptoms.

METHODS

Eighty-nine elderly patients with no MRI abnormalities in the infratentorial region aged 60-89 years complaining dysequilibrium symptoms were studied. Cases with whom a definitive diagnosis of peripheral or central disease could be established were not included. T2 hyperintense lesions in the cerebrum: basal ganglia, subcortical white matter and periventricular white matter were evaluated. VOR in darkness and fixation-suppressed VOR using pseudo-sinusoidal rotation stimuli were recorded to calculate visual suppression rate. Correlation between visual suppression rate and semi-quantitative scores for severity of T2 hyperintensity in the cerebrum was investigated.

RESULTS

Patients with T2 hyperintensity in the cerebrum exhibited significantly lower visual suppression rate than those without lesions in the cerebrum. Multiple regression analysis showed that visual suppression rate was significantly and negatively correlated with severity of lesions in the basal ganglia, but not with patient age, severity of subcortical white matter lesions, or that of periventricular white matter lesions.

CONCLUSIONS

In elderly patients with dizziness with a non-specific history and otoneurological findings, fixation suppression of vestibular nystagmus was associated with T2 hyperintensities in the basal ganglia.

3D digital subtraction angiography of intracranial aneurysms: comparison of flat panel detector with conventional image intensifier TV system using a vascular phantom

BACKGROUND AND PURPOSE

Compared with the image intensifier (I.I.)-TV system, the flat panel detector (FPD) system of direct conversion type has several theoretic advantages, such as higher spatial resolution, wide dynamic range, and no image distortion. The purpose of this study was to compare the image quality of 3D digital subtraction angiography (DSA) in the FPD and conventional I.I.-TV systems using a vascular phantom.

MATERIALS AND METHODS

An anthropomorphic vascular phantom was designed to simulate the various intracranial aneurysms with aneurysmal bleb. The tubes of this vascular phantom were filled with 2 concentrations of contrast material (300 and 150 mg I/mL), and we obtained 3D DSA using the FPD and I.I.-TV systems. First, 2 blinded radiologists compared the volume-rendering images for 3D DSA on the FPD and I.I.-TV systems, looking for pseudostenosis artifacts. Then, 2 other radiologists independently evaluated both systems for the depiction of the simulated aneurysm and aneurysmal bleb using a 5-point scale.

RESULTS

For the degree of the pseudostenosis artifacts at the M1 segment of the middle cerebral artery at 300 mg I/mL, 3D DSA with FPD system showed mild stenoses, whereas severe stenoses were observed at 3D DSA with I.I.-TV system. At both concentrations, the FPD system was significantly superior to I.I.-TV system regarding the depiction of aneurysm and aneurysmal bleb.

CONCLUSION

Compared with the I.I.-TV system, the FPD system could create high-resolution 3D DSA combined with a reduction of the pseudostenosis artifacts.

Reduction of radiation dose for cerebral angiography using flat panel detector of direct conversion type: a vascular phantom study

BACKGROUND AND PURPOSE

Compared with image intensifier television (I.I.-TV) system, an angiography system using the flat panel detector (FPD) of direct conversion type has a high spatial resolution, which may improve image quality, reduce patient exposure, or both. Our purpose was to evaluate the detection of simulated aneurysmal blebs under dose reduction with the FPD system in comparison with the I.I.-TV system.

MATERIALS AND METHODS

A vascular phantom was designed to simulate various intracranial aneurysms with and without blebs, and this phantom was filled with 3 different concentrations of contrast material (300, 150, and 100 mg I/mL). 2D digital subtraction angiography (DSA) at low-dose mode of FPD system was compared with 2D DSA at a standard-dose mode of FPD system and a conventional mode of I.I.-TV system. Data analysis was based on 171 observations (57 aneurysms [20 with bleb and 37 without bleb] x 3 contrast material concentrations) by each of 7 radiologists, and the detection performances of blebs were compared using a receiver operating characteristic (ROC) analysis.

RESULTS

The mean dose measurements with a phantom during 2D DSA were 0.36 mGy/frame with low-dose mode of FPD system, 0.72 mGy/frame with standard-dose mode of FPD system and 0.76 mGy/frame with I.I.-TV system. The mean Az at 100 mg I/mL was significantly higher for low-dose mode of FPD than for conventional-dose mode of I.I.-TV mean Az, 0.85 versus 0.56; P < .01), though differences were not significant with 150 and 300 mg I/mL between both systems.

CONCLUSION

The FPD system allows a considerable dose reduction during 2D DSA without loss of the image quality.