Usefulness of the synthesized 18-lead ECG in identify the origin of premature ventricular contractions

Background

There are have been reports on the 12-lead ECG waveforms used to identify ventricular premature contractions (VPCs), but there are not enough algorithms. On the other hand, the synthesized 18-lead ECG adds the right-side chest leads (V3R, V4R, and V5R) and back leads (V7, V8, and V9) to the 12-lead ECG.

Purpose

This aim of this study was to evaluate whether the waveforms of the 18-lead ECG are useful in predicting the origin of VPCs.

Methods

We studied 86 consecutive patients (age :61.8±16.0 years, male: 54.5%) enrolled from multicenter who underwent radiofrequency catheter ablation for VPCs. We retrospectively investigated the association between origin of the VPCs and characteristics of the synthetic 18-leads ECG.

Results

The 18-lead ECG showed a specific pattern for the VPC originating near the His-bundle. In 17 cases, the QRS morphology in V5R exhibited a QS pattern, and 13 of 17 cases had VPCs originating near the His-bundle. In the other 69 cases, V5R did not exhibit a QS pattern. ROC curve analysis showed that the QS pattern in V5R predicted VPC originating near the His-bundle with high accuracy: sensitivity 100.0%, specificity 94.5%, and AUC 0.98. Furthermore, the positive predictive value was 76.5% and negative predictive value 100.0%.

Conclusion

The QS pattern shown in V5R of the 18-lead ECG was a useful parameter for identifying VPCs originating near the His-bundle, which might be a good reference indicator during radiofrequency catheter ablation for VPCs.

Funding Acknowledgement

Type of funding sources: None.

Effect of diabetes mellitus on coronary plaque characteristics and progression by serial Coronary Computed Tomography Angiography (CCTA)

Background

Diabetes Mellitus (DM) is a major risk factor for coronary artery disease (CAD) and associated poor outcomes. There is a higher incidence of major adverse cardiac events in patients with DM than those without DM. Coronary plaque characteristics measured by CCTA are correlated with adverse cardiovascular (CV) outcomes.

Purpose

We sought to evaluate coronary plaque characteristics as well as rates of progression of coronary plaque burden as measured by serial CCTA in patients with DM and those without DM.

Methods

The study population included a total of 403 participants (mean age 61.4±11.4 years, 53% men; median scan interval 1.5 years) who were prospectively enrolled in serial CCTA trials. We identified 212 participants with DM and 191 participants without DM, who had undergone serial CCTA. Coronary Plaque volumes were measured and characterized as low attenuation plaque (LAP), total non-calcified plaque (TNCP) and total plaque (TP) using semi-automated plaque analysis software (Qangio medis). Multivariate linear regression was used to examine the effect of DM on coronary plaque progression.

Results

Patients with DM had greater rates of progression of normalized TP volume (median change in annualized plaque (IQR): 39.1 (9.9–114.4) in DM vs 23.5 (4.1–63.8) mm3 in non-DM, p=0.001), TNCP volume (21.6 (3.3–60.8) in DM vs 8.7 (0.1–35.6) mm3 in non-DM, p=0.003) and LAP volumes (0.7 (−0.6 to 7.8) in DM vs 0.1 (−0.4 to 1.9) mm3 in non-DM, p=0.04). After adjusting for relevant risk factors and baseline plaque, the annualized rates of progression were higher in patients with DM by 28% for TP (p=0.004), 27% for TNCP (p=0.011), 23% for fibrous plaque (p=0.026) and by 42% LAP (p=0.050), compared to those without DM.

Conclusion

Patients with DM have significantly higher rates of coronary plaque progression, including vulnerable LAP, than those without DM. Our findings reveal differences in rates, burden and characteristics of coronary plaque progression in patients with DM vs those without DM. These results provide mechanistic understanding of natural history of coronary atherosclerosis in this vulnerable population, that could explain the increased risk of CV events among patients with DM. Coronary atherosclerotic phenotyping by CCTA could serve as a potential surrogate measure for risk stratification and evaluation in clinical trials to examine therapeutic strategies in this vulnerable population.

Funding Acknowledgement

Type of funding sources: None.

Electrical detection of ppb region NO2 using Mg-porphyrin-modified graphene field-effect transistors

The trace detection of NO₂ through small sensors is essential for air quality measurement and the health field; however, small sensors based on electrical devices cannot detect NO₂ with the desired selectivity and quantitativity in the parts per billion (ppb) concentration region. In this study, we fabricated metalloporphyrin-modified graphene field-effect transistors (FETs). Mg-, Ni-, Cu-, and Co-porphyrins were deposited on the graphene FETs, and the transfer characteristics were measured. With the introduction of NO₂ in the ppb concentration region, the FETs of pristine graphene and Ni-, Cu-, and Co-porphyrin-modified graphene showed an insufficient response, whereas the Mg-porphyrin-modified graphene exhibited large voltage shifts in the transport characteristics. This indicates that Mg-porphyrin acts as an adsorption site for NO₂ molecules. An analysis of the Dirac-point voltage shifts with the introduction of NO₂ indicates that the shifts were well-fitted with the Langmuir adsorption isotherm model, and the limit of detection for NO₂ was found to be 0.3 ppb in N₂. The relationship between the mobility and the Dirac-point voltage shift with the NO₂ concentration shows that the complex of NO₂ and Mg-porphyrin behaves as a point-like charge impurity. Moreover, the Mg-porphyrin-modified graphene FETs show less response to other gases (O₂, H₂, acetic acid, trimethylamine, methanol, and hexane), thus indicating high sensitivity for NO₂ detection. Furthermore, we successfully demonstrated the quantitative detection of NO₂ in air, which is near the environmental standards. In conclusion, the results of the Mg-porphyrin-modified graphene FETs enable a rapid, easy, and selective detectability.

Significance of mitral L wave to predict late recurrence of atrial fibrillation after radiofrequency catheter ablation

Background

Mitral L wave, prominent mid-diastolic filling wave in echocardiographic examinations, is associated with severe left ventricular diastolic dysfunction, and that has been reported to predict recurrent atrial fibrillation (AF) after cardioversion. However, association between mitral L wave and the outcome of AF after radiofrequency catheter ablation (RFCA) has not been established.

Objective

The aim of this study is to evaluate the predictive value of mitral L wave on AF recurrence after RFCA.

Methods

250 patients including 164 paroxysmal AF (65.6%) and 86 non-paroxysmal AF (34.4%) who received RFCA in single center from January 2015 to December 2016 were enrolled consecutively. Echocardiographic examinations before RFCA were recorded, and the mitral L wave was defined as a distinct mid-diastolic flow velocity with a peak velocity ≥20 cm/s following the E wave. Systematic follow-up was conducted after RFCA. Univariate and multivariate analyses were carried out to determine the factors predicting late recurrence of AF (LRAF) which means AF recurrence after 3 months. Enrolled patients were divided into groups with the L wave (L-group; n=57) or without the L wave (NL-group; n=193) based on the findings of echocardiographic examinations.

Results

During a follow-up of 35.0±17.6 months, the ratio of LRAF in the L-group was significantly higher than that in the NL-group (32 (56.1%) vs. 41 (21.2%), Hazard ratio [HR]: 3.55, 95% confidence interval [CI]: 2.33 - 5.42, p<0.001). Among the clinical factors, presence of mitral L wave, BNP value, non-paroxysmal AF and moderate-severe mitral regurgitation were related to LRAF. A multivariate analysis using a Cox proportional hazard model found that presence of mitral L wave (HR: 2.67, 95% CI: 1.30 - 5.48, p=0.007) was significantly associated with LRAF.

Conclusion

This study revealed that mitral L wave predicts late recurrence of AF after RFCA.

Funding Acknowledgement

Type of funding sources: None.

Clinical usefulness of Lipoprotein(a) for the prevalence and severity of peripheral artery disease among patients with acute coronary syndrome

Background

Lipoprotein(a) [LP(a)] is known to be a robust lipid marker associated with cardiovascular events. Though coronary artery disease and peripheral artery disease (PAD) are often coexist, little is known about the relationship between LP(a) and PAD among patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study is to examine if LP(a) is of predictive value for PAD among ACS patients in Japanese population.

Methods

Of consecutive 238 ACS patient who received successful primary PCI, a total of 175 patients were enrolled in the current study. We excluded the patients who received hemodialysis (n=10), required multidisciplinary treatment (n=36) and incomplete data (n=17). PAD was diagnosed as ankle brachial index <0.9. Multiple lipid biomarkers [LP(a), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), malondialdehyde-modified LDL (MDA-LDL), docosahexaenoic acid and arachidonic acid] were compared between patients with PAD (n=21) and without PAD (n=154). Further, multivariable logistic regression models were used to assess if LP(a) was associated with PAD. In addition, serum LP(a) level were compared between 3 groups according to pattern of PAD [none (n=154), unilateral (n=10) and bilateral PAD (n=11), respectively].

Results

Compared to patients without PAD, those with PAD were older (74.4 vs. 65.4 years, p=0.003), and had a higher prevalence of chronic kidney disease (CKD) (61.9% vs. 20.1%, p<0.001), diabetes mellitus (DM) (66.7% vs. 27.3%, p<0.001). Serum LP(a) level was significantly higher in patients with PAD (36.4 vs. 18.5 mg/dl, p<0.001), whereas LDL-C and MDA-LDL were significantly lower in PAD (92.0 vs. 109.5 mg/dl, p=0.015 and 98.6 vs. 119.5 mg/dl, p=0.046, respectively). After adjusting for LDL-C and MDA-LDL, LP(a) >30 mg/dl was independently associated with a presence of PAD (OR 5.67, 95% CI 2.09–15.4, p=0.0006). When adjusting for CKD and DM in a different model, LP(a) >30 mg/dl was similarly associated with PAD (OR 4.98, 95% CI 1.66–14.9, p=0.004). Serum LP(a) levels were significantly higher in bilateral PAD group compared to none PAD group (Figure).

Conclusion

LP(a) was a useful lipid biomarker for the prevalence and severity of PAD among patients with ACS in Japanese population.

Funding Acknowledgement

Type of funding source: None

P175 Prognostic value of 99mTc-ECD brain perfusion SPECT in patients with atrial fibrillation and dementia

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and those afflicted have reduced quality of life, functional status, and cardiac performance. The patients with AF have a high risk of coronary heart disease and cardiovascular disease. Although the prevalence of AF is increasing, cognitive disorders are also on the rise in tandem with the aging of the population. The patients with dementia have also experienced lower the quality of life and have increased mortality. Technetium 99m ECD brain perfusion single photon emission computed tomography (99mTc-ECD brain perfusion SPECT) is a useful modality for diagnosing dementia and identifying high risk patients with mild cognitive impairment. However, there are few reports about the relationship between the value of Z score calculated by 99mTc-ECD brain perfusion SPECT and prognosis of patients with AF and dementia.

Purpose

The aim of this study was to evaluate the prognostic values of brain perfusion using 99mTc-ECD SPECT in patients with AF and dementia.

Methods

Among 405 consecutive patients who were diagnosed as AF in cardiac outpatients and subsequently diagnosed as dementia using Mini-Mental State Examination by neurologists or psychiatrists, we identified 170 patients (81 ± 10 years) who underwent 99mTc-ECD brain perfusion SPECT for the current study. Of those, 73, 73, and 24 were diagnosed as Alzheimer’s dementia (AD), vascular dementia (VD), and non-specified dementia respectively. Multivariate Cox model was used to assess if higher Z score by 99mTc-ECD brain perfusion SPECT and clinical parameters were associated with major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, hospitalization for heart failure, and stroke. Sub-analyses of multivariate Cox models by AD or VD were also assessed. The cut-off values of Z score were determined using area under the curve by a receiver operating characteristic analysis based on MACE occurrences.

Results

During a mean follow-up of 1258 ± 1044 days, 62 MACE occurred. There was not significant difference of MACE between AD and VD (33%, vs. 44%, p = 0.153). By multivariable Cox model, the higher Z score of temporal-occipital-pariental lobe was associated with increased MACE compared to the lower group (HR 2.521, 95% CI 1.465–4.337, p < 0.001). In a sub-analysis of patients with AD, Z score was the most significant prognostic factor for MACE (HR 3.969, 95% CI 1.374–11.468, p = 0.011). The similar trend was observed in those with VD (HR 2.247, 95% CI 1.028–4.913, p = 0.043). Conclusion: This study demonstrated that the Z score of temporal-occipital-pariental lobe by 99mTc-ECD brain perfusion SPECT could be a potential prognostic value among patients with AF and dementia, regardless of type of dementia.

A comparison of the effect of large and small metal-on-metal bearings in total hip arthroplasty on metal ion levels and the incidence of pseudotumour

Aims

The purpose of this study was to compare two different types of metal-on-metal (MoM) bearing for total hip arthroplasty (THA): one with a large femoral head (38 mm to 52 mm) and the other with a conventional femoral head (28 mm or 32 mm). We compared clinical outcome, blood metal ion levels, and the incidence of pseudotumour in the two groups.

Patients and Methods

Between December 2009 and December 2011, 62 patients underwent MoM THA with a large femoral head (Magnum group) and 57 patients an MoM THA with a conventional femoral head (conventional group). Clinical outcome was assessed using the Harris Hip score, University of California, Los Angeles (UCLA) activity score and EuroQol-5D (EQ-5D). Blood metal ion levels were measured and MRI scans were analyzed at a minimum of five years postoperatively.

Results

No acetabular component was implanted with more than 50° of inclination in either group. The Harris Hip Score, UCLA activity score, and EQ-5D improved postoperatively in both groups; no significant clinical differences were noted between the groups. The blood cobalt ion levels in the conventional group continued to rise postoperatively to five years while reaching a plateau at two years postoperatively in the Magnum group. At five years, the mean cobalt ion level of 1.16 μg/l (sd 1.32) in the Magnum group was significantly lower than the 3.77 μg/l (sd 9.80) seen in the conventional group (p = 0.0015). The incidence of moderate to severe pseudotumour was 4.7% in the Magnum group and 20.6% in the conventional group. There were no dislocations in the Magnum group and two in the conventional group. One patient in the Magnum group underwent revision for pseudotumour at 4.7 years postoperatively.

Conclusion

At five years, a well-positioned large head MoM THA has a significantly lower level of metal ion release and a lower incidence of moderate to severe pseudotumour than a MoM bearing of conventional size. Cite this article: Bone Joint J 2018;100-B:1018–24.

Abstract P3-08-11: The prognostic impact of retinoic acid-induced 2 (RAI2) expression in ERα-positive breast cancer patients

Background: Breast cancer cells disseminate to the bone marrow and form bone metastases in a large majority of late-stage patients. Retinoic Acid-Induced 2 (RAI2) was reported as a putative suppressor of early hematogenous dissemination of tumor cells to the bone marrow in breast cancer, particularly in estrogen receptor α (ERα)-positive breast cancer. Here, we investigated mRNA expression of RAI-2 in breast cancer patients during long-term follow-up.

Materials and methods: A total of 451 invasive breast cancer tissues was available for analysis of RAI2 mRNA using a TaqMan PCR system. We also sought correlations between clinicopathological factors and levels of RAI2 expression in these samples. The expression of markers associated with tumor-initiating capacity, such as SNAI1, SNAI2 and VIM was also analyzed. The median follow-up period was 9.0 years. Survival curves were analyzed using the Kaplan-Meier method. Cox proportional hazards regression analysis was used for univariate and multivariate analyses of prognostic values.

Results: We found positive correlations between low expression of RAI2 mRNA and shorter disease-free survival and overall survival in breast cancer patients (P=0.003, P<0.0001, respectively), which was limited to ERα-positive patients (P=0.04, P=0.0009, respectively), and not seen in ERα-negative patients (P=0.52, P=0.27, respectively). Low RAI2 mRNA levels were positively correlated with high grade, ERα-negativity and PgR negativity. Multivariate analysis indicated that low level RAI2 mRNA expression was an independent factor for survival both overall in breast cancer and in ERα-positive breast cancer patients

Multivariate analysis (ERα-positive breast cancer patients)  OS  Multivariate patientsp valueHR(95%CI)Tumor size≤2cm1390.83691 (Reference) >2cm207 1.08(0.54-2.28)Node statusNegative176<0.00011 (Reference) Positive144 4.72(2.33-10.34)Grade11240.95921 (Reference) 2•3218 0.98(0.50-2.14)RAI2 mRNA expressionhigh140<0.00011 (Reference) middle•low206 4.79(2.14-12.78)

.

Conclusion:We show that low expression of RAI2 is an independent factor predictive of a poor prognosis in ERα-positive breast cancer patients. RAI2 could be a promising candidate biomarker and therapeutic target in ERα-positive breast cancer to prevent dissemination to the bone marrow.

Citation Format: Nishikawa S, Kondo N, Endo Y, Hato Y, Hisada T, Nishimoto M, Dong Y, Okuda K, Kato H, Takahashi S, Nakanishi R, Toyama T. The prognostic impact of retinoic acid-induced 2 (RAI2) expression in ERα-positive breast cancer patients [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 P3-08-11.

Attempted suicide with liraglutide overdose did not induce hypoglycemia

We document the first reported case of attempted suicide with the GLP-1 receptor agonist, liraglutide: a 33-year-old Japanese woman with type 2 diabetes reported subcutaneously injected 72 mg of liraglutide. She experienced gastrointestinal symptoms but no hypoglycemia.

Video-assisted thoracoscopic lobectomy for clinical stage I non-small cell lung cancer: experience with 111 consecutive patients demonstrating comorbidity

AIM

The outcomes of video-assisted thoracoscopic lobectomy for clinical stage I non-small cell lung cancer (NSCLC) patients with comorbidities were examined to determine the technical feasibility and safety of this procedure.

METHODS

Between January 2002 and December 2007, 111 consecutive patients with suspected stage I lung cancer, who individually had one or more comorbidities cited in the modified Kaplan-Feinstein Index, were scheduled for a video-assisted thoracoscopic lobectomy. The demographic, perioperative, and outcome variables were assessed.

RESULTS

One hundred of 111 patients had non-small cell lung cancer. Ninety-nine patients underwent successful video-assisted thoracoscopic lobectomies, while there was one conversion because of a hemorrhage from the pulmonary artery in the early stage. Including this one conversion, no patients required a blood transfusion during surgery or postoperatively. There were no intraoperative or in-hospital deaths. No complications occurred in 78 (78.8%) of 99 patients. Only one patient (1.0%) with a Kaplan-Feinstein Index Score of severe grade contracted pneumonia indicating grade 3 (severe), whereas the remaining 20 patients had grade 1 (mild) or 2 (moderate) complications. At a median follow-up of 40 months, the overall 3-year survival rates for postoperative stage IA (N.=52); IB (N.=26); and II or more (N.=21) were 100%; 78%; and 71%, respectively.

CONCLUSION

A video-assisted thoracoscopic lobectomy is therefore considered to be a feasible and safe procedure for clinical stage I NSCLC even in patients with comorbidities.

Randomized phase II trial of the biweekly schedule of adjuvant chemotherapy with carboplatin plus paclitaxel versus carboplatin plus gemcitabine in patients with non-small cell lung cancer (NSCLC)

7562

Background: Carboplatin plus paclitaxel and carboplatin plus gemcitabine chemotherapy have shown a good response and an improved survival against advanced NSCLC. This phase II trial assessed the feasibility, safety and efficacy of a bi-weekly schedule for adjuvant chemotherapy. Methods: Patients with completely resected stage IB-IIIB NSCLC were randomized to either carboplatin (AUC3) plus paclitaxel (90mg/m2) (arm A) or carboplatin (AUC3) plus gemcitabine (1000 mg/m2) (arm B), q2w for 8 cycles within 8 weeks after surgery. The main inclusion criteria were no prior chemotherapy or radiotherapy, ECOG PS 0–1, an age of less than 80 years, and an adequate organ function. The primary endpoint was compliance, and secondary endpoints were the disease free survival (DFS) and toxicity. The patients were stratified by gender, histology (adenoca vs. non-adenoca) and disease stage. Results: Between 07/2005 and 06/2007, 76 patients were randomized and 75 were eligible (including 48 males, 27 females; median age 66 years) for intent-to-treat analysis (39 in arm A, 36 in arm B). The histologic types included adenocarcinoma (n=51), squamous cell carcinoma (n=18), large cell carcinoma (n=5), and adenosquamous cell carcinoma (n=1). The pathological stages were IB/IIA/IIB/IIIA/IIIB: 22/10/13/29/1. Twenty-one of 39 pts (54%) in arm A and 25 of 36 pts (69%) in arm B completed 8 cycles, and 59% in arm A and 81% in arm B completed ≥6 cycles. Grade 3/4 hematologic toxicities (%) in arms A/B were respectively; neutropenia 36/53, anemia 0/17, thrombocytopenia 3/0, nausea 3/3. No treatment related deaths were observed. Up to 12/2008, 11 of 39 pts in arm A and 13 of 36 pts in arm B had recurrent disease, but no significant difference was observed. Conclusions: This adjuvant bi- weekly scheduled chemotherapy in both arms resulted in a good compliance and feasible with acceptable levels of toxicity in completely resected NSCLC.

No significant financial relationships to disclose.

[Coronary artery bypass grafting in patients with dialysis-dependent renal failure]

From January 1995 to May 2003, 36 patients with dialysis-dependent renal failure underwent coronary artery bypass grafting. We performed the operation with cardiopulmonary bypass (group On) in 17 cases and without cardiopulmonary bypass (group Off) in 19 patients [off-pump coronary artery bypass grafting (OPCAB) 15, minimally invasive direct coronary artery bypass (MIDCAB) 4]. There were no statistical differences regarding mean age, sex, duration of dialysis, preoperative hypertension, diabetes and peripheral and cerebral vascular diseases. Mean operation time and the number of bypass grafts were 315 +/- 53 minutes, 2.8 +/- 0.8 grafts in group On and 284 +/- 78 minutes, 2.4 +/- 1.1 grafts in group Off, respectively (not significant). Seventeen patients (100%) of group On and 12 patients (63%) needed blood transfusion. Hospital stay after operation was significantly longer in group On (40 days) of group Off than that in group Off (26 days). After the operation, continuous hemodiafiltration (CHDF) was used in 10 cases (59%) in group On and 3 cases (16%) in group Off. In coronary artery bypass grafting (CABG) on dialysis patient, it is very effective to have various operation techniques, such as off-pump bypass and on-pump beating bypass. Also control of water-electrolyte balance using early postoperative CHDF is useful. However, off-pump cases could be controlled by conventional hemodialysis.

[Pneumonectomy for lung cancer in a patient with acute respiratory failure; report of a case]

A 58-year-old man had developed acute respiratory failure because of deterioration of the pneumonia, and had been on a mechanical ventilator. Bronchoscopy showed tumor occlusion of the left main stem of the bronchus. For the purpose of weaning from ventilatory support and prevention of progress of the pneumonia, we performed a pneumonectomy and systematic hilar and mediastinal lymph node dissection using a thoracoscopy. The patient could be weaned from ventilatory support, and we could improve his quality of life by minimally invasive surgery.

[Successful surgical management of papillary muscle rupture following acute myocardial infarction in an elderly patient]

Papillary muscle rupture is rare but catastrophic complication of acute myocardial infarction. We report a 91-year-old woman who underwent successful management of papillary muscle rupture following acute myocardial infarction. She was transferred to our hospital because of severe pulmonary edema and cardiogenic shock. Echocardiography revealed severe mitral valve regurgitation due to total rupture of anterolateral papillary muscle. After intubation, intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) insertion, mitral valve replacement was successfully performed. She was discharged 134 days after operation. In papillary muscle rupture deteriorating hemodynamics, early diagnosis and immediate cardiopulmonary support are required before surgical treatment. She was, to the best of our knowledge, the oldest among the reported cases of successful surgical treatment of papillary muscle rupture in Japan.

Retinal vascular findings and penile cavernosal artery blood flow

OBJECTIVE

To assess the correlation between retinal vascular findings and penile cavernosal arterial blood flow, as it is probable that systemic atherosclerotic vascular disease is important in male erectile dysfunction (ED), and being systemic, it might be possible to evaluate the extent of atherosclerosis from retinal vascular findings.

PATIENTS AND METHODS

The study included 75 patients with ED; any with a history of pelvic injury, pelvic surgery, or diabetes mellitus were excluded. All patients gave fully informed consent. Ocular fundus photographs were taken with an automatic-focus fundus camera under amydriatic conditions. Three ophthalmologists, unaware of the patients' detailed data, evaluated the photographs using Hyman's classification to evaluate retinal vascular findings. Blood flow in the penile cavernosal artery was measured with colour Doppler ultrasonography, and the peak systolic velocity used as a haemodynamic variable. Correlations among the peak systolic velocity, retinal vascular findings and vascular risk factors (including hypertension, age, cigarette smoking, and hyperlipidaemia) were investigated using multivariate analysis.

RESULTS

Of the 75 patients, 72 (96%) had both right and left retinal vascular images of sufficient quality for evaluation; 37 were classified as normal and 35 as Grade I, while no patient was Grade II. From a logistic regression multivariate analysis, the peak systolic velocity was the only significant factor correlating with retinal vascular findings, with an odds ratio of 3.34. In contrast, hypertension, age, cigarette smoking and hyperlipidaemia did not correlate significantly with the retinal vascular findings. Similarly, the retinal vascular finding was the only significant factor correlating with the peak systolic velocity of cavernosal blood flow (odds ratio 3.28) and again hypertension, age, cigarette smoking and hyperlipidaemia were not significant factors.

CONCLUSIONS

These findings support the assumption that penile erectile function is one of the diseases of atherosclerosis, and emerges nearly simultaneously with retinal vascular disease. It is possible to predict penile arterial conditions in patients with ED from their retinal vascular findings. Thus, amydriatic fundoscopy, a simple practical examination, may be helpful for primary physicians in diagnosing and treating ED.

Kinetics and steady-state of VO2 responses to arm exercise in trained spinal cord injury humans

STUDY DESIGN

Cross-sectional study comparing trained spinal cord injured (SCI) subjects (lesion level: L1 - T6) with healthy young subjects (CONT).

OBJECTIVE

To investigate the kinetics of response in oxygen uptake (VO(2)) in human upper-body skeletal muscles, nine trained SCI subjects underwent submaximal supine arm exercises.

METHOD

The SCI subjects underwent an incremental arm exercise test until exhaustion. The days after this first round of testing, breath-by-breath VO(2) and beat-by-beat heart rate (HR) on- and off-kinetics were determined during three repetitions of constant exercise at 50% of VO(2peak). The overall time course of response was determined from the half time (t(1/2)). Increased capillary blood lactate production (delta[La]b) at the onset of exercise was defined as the difference between at rest and at the end of exercise. Cardiac output (Q) was measured using the acetylene rebreathing method during the steady state of exercise. In accordance with the Fick principle, the difference in arterial-venous O(2) content (Ca-vO(2)) was defined as VO(2)/Q.

RESULTS

During the steady state of the submaximal arm exercise, a more significant increase in the steady state of Q was obtained in the CONT subjects than in the trained SCI subjects: respectively, 14.9+/-1.4 l/min versus (12.7+/-0.8 l/min). There was no difference in the steady state of VO(2) between the two groups; as a result, SCI subjects had the greater Ca-v(2). Meanwhile, VO(2) on- and off-kinetics became much faster in the trained SCI subjects than in the CONT subjects. In addition, t(1/2) HR on-kinetics was not significantly different between the SCI and CONT groups. Increased Delta[La]b was closely related to larger t(1/2) VO(2) on-kinetics (r = 0.624, P < 0.05).

CONCLUSION

It is concluded that the acceleration of VO(2) on- and off-kinetics in the trained SCI subjects was observed even though there was no difference in HR on- and off-kinetics between the SCI and CONT groups and a lower steady state of Q in the trained SCI subjects. VO(2) kinetics would therefore be the limiting factor in oxidative phosphorylation in the upper skeletal muscles, thereby providing a lower lactic O(2)-deficit (ie delta[La]b).

Effect of cryopreservation period on rat tracheal allografts

BACKGROUND

The effect of cryopreservation on tracheal allogenicity is still unclear. Therefore, in this study, we assessed the effect of cryopreservation period on tracheal allografts in 62 rats.

METHODS

Each transplant consisted of a 3-ring segment of the trachea harvested from 8 Lewis rats, immersed in preservation solution, and cryopreserved and stored in a Bicell biofreezing vessel in a deep freezer at -80 degrees C. Six tracheal grafts without cryopreservation that underwent a heterotopically syngeneic transplantation into the omentum served as controls. Forty-eight tracheal segments were randomly assigned to 8 groups according to period of cryopreservation, which ranged from 0 to 12 months (0, 0.5 [2 weeks], 1, 2, 3, 6, 9 and 12 months). The cryopreserved grafts were then thawed and heterotopically implanted into the omentum of recipient Brown-Norway rats. After 28 days, the tracheal segments were then evaluated histologically.

RESULTS

All isografts in Group 1 were intact, whereas the allografts undergoing a particularly shorter period of cryopreservation showed a more stenotic lumen. Prolonged periods of cryopreservation tended to show decreasing tendencies of viability of chondrocytes, mononuclear cell infiltration and sub-epithelial thickness, whereas all allografts showed a uniformly denuded epithelium, irrespective of the length of cryopreservation.

CONCLUSIONS

A longer period of cryopreservation may help to maintain a better patency of tracheal allografts by preventing an allogeneic response. Reduced tracheal allogenicity may be associated with a decreased viability of chondrocytes by cryopreservation.

Feasibility of cryopreserved tracheal xenotransplants with the use of short-course immunosuppression

OBJECTIVE

We evaluated the feasibility of discordant xenotransplantation of the cryopreserved trachea with intermittent immunosuppression to help solve the shortage of donor tracheas.

METHODS

Two experiments were performed with heterotopic transplantation models in 14 guinea pigs and 85 rats. So that the minimal dose of FK506 for viable fresh xenografts could be determined, FK506 was given in escalating doses (0, 1.5, 2.5, and 3.5 mg/kg) for recipient animals after xenogeneic transplantation. With the goal of obtaining a long-term survival of the xenografts, the effect of cryopreservation on xenografts was assessed and thereafter different cycles of immunosuppression every third week were evaluated in fresh or cryopreserved xenografts in the second experiment.

RESULTS

An FK506 dosage of more than 2.5 mg/kg per day was much more effective than smaller dosages, as demonstrated by morphologic assessment. A higher dosage of FK506 potentially delayed the rejection of xenografts and can thus maintain tracheal xenograft viability for less than 4 weeks in rat recipients. In experiment 2, the cryopreserved xenografts showed less histologic viability than fresh xenografts but greater patency of the lumen. The patency of cryopreserved xenografts was favorably maintained for a longer period than that of fresh xenografts with either the same number or more cycles of immunosuppression.

CONCLUSIONS

We conclude that the synergistic effect of cryopreservation and adequate intermittent immunosuppression may enable tracheal xenografts to remain viable over longer periods.

Prediction of pulmonary complications after a lobectomy in patients with non-small cell lung cancer

BACKGROUND

Although the preoperative prediction of pulmonary complications after lung major surgery has been reported in various papers, it still remains unclear.

METHODS

Eighty nine patients with stage I-IIIA non-small cell lung cancer (NSCLC) who underwent a complete resection at our institute from 1994-8 were evaluated for the feasibility of making a preoperative prediction of pulmonary complications. All had either a predicted postoperative forced vital capacity (FVC) of >800 ml/m(2) or forced expiratory volume in one second (FEV(1)) of >600 ml/m(2).

RESULTS

Postoperative complications occurred in 37 patients (41.2%) but no patients died during the 30 day period after the operation. Pulmonary complications occurred in 20 patients (22.5%). Univariate analysis indicated that the factors significantly related to pulmonary complications were FVC <80%, serum lactate dehydrogenase (LDH) level > or =230 U/l, and arterial oxygen tension (PaO(2)) <10.6 kPa (80 mm Hg). In a multivariate analysis the three independent predictors of pulmonary complications were serum LDH > or =230 U/l (odds ratio (OR) 10.5, 95% CI 1.4 to 77.3), residual volume (RV)/total lung capacity (TLC) > or =30% (OR 6.0, 95% CI 1.1 to 33.7), and PaO(2) <10.6 kPa (OR 5.6, 95% CI 1.4 to 22.2).

CONCLUSIONS

The above findings indicate that three factors (serum LDH levels of > or =230 U/l, RV/TLC > or =30%, and PaO(2) <10.6 kPa) may be associated with pulmonary complications in patients undergoing a lobectomy for NSCLC, even though the patient group was relatively small for statistical analysis of such a diverse subject as pulmonary complications.

Aggressive surgical treatment of multiple primary lung cancers

A case of triple primary lung cancers--squamous cell carcinoma, adenocarcinoma and large-cell carcinoma--is presented. Surgical treatment comprised, respectively, left pneumonectomy, partial resection of the right upper lobe and completion right upper lobectomy. The postoperative courses were uneventful and the patient remains well, with no sign of recurrence, 20 months after the third operation.