Peak Aortic Valve Jet Velocity is an Independent Predictor of Mortality of Dialysis Patients Undergoing Open Surgery for Chronic Limb Threatening Ischemia

BACKGROUND

To investigate the impact of peak aortic jet velocity (Vmax) on the prognosis of patients undergoing open surgery for chronic limb threatening ischemia (CLTI).

METHODS

Between April 2015 and March 2022, 352 patients underwent infrainguinal open surgery for CLTI. Patients who met the following exclusion criteria were excluded: subsequent infrainguinal surgeries in the registered period, no record of Vmax, history of aortic valve intervention, and Vmax ≥3.0 m/s (moderate or severe aortic valve stenosis). The remaining patients were dichotomized into 2 groups based on their Vmax values. The Youden index calculated from the receiver operating characteristic curve (ROC) was set as the cutoff value. The 2-year overall survival (OS), calculated using the Kaplan-Meier's method, was compared between the 2 groups. A Cox proportional hazards regression analysis was performed using perioperative factors including Vmax to identify independent predictors separately for dialysis and nondialysis patients and the quantitative relationship between Vmax and OS.

RESULTS

One hundred and ninety-one patients, including 100 dialysis and 91 nondialysis patients, were included in the analysis. The Youden index was 1.7 m/s. The 2-year OS rates of the group with Vmax >1.7 m/s and with Vmax ≤1.7 m/s were 49% and 76% (P = 0.007), respectively, in the dialysis cohort, while they were 71% and 78% (P = 0.680) in the nondialysis cohort, respectively. Multivariate analysis identified Vmax and ejection fraction as independent predictors in the dialysis cohort and the Barthel Index at admission in the nondialysis cohort. There was a stepwise increase in the risk of death in patients with Vmax of ≥1.5 m/s and a significantly higher risk of death in dialysis patients with Vmax >2.5 m/s.

CONCLUSIONS

Vmax was a significant independent predictor of all-cause death within 2 years after open surgery for CLTI in dialysis patients but not in patients managed without dialysis.

Evaluation of three nutritional indices as predictors of 2-year mortality and major amputation in patients with chronic limb-threatening ischemia

OBJECTIVE

The present study aimed to examine which nutritional index, such as the controlling nutritional status (CONUT), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI), is better for predicting prognosis in patients with chronic limb-threatening ischemia (CLTI) following revascularization.

METHOD

We retrospectively analyzed data of patients who underwent revascularization for CLTI between 2008 and 2020. The endpoints were 2-year overall survival and limb salvage. The optimal cutoff values of 2-year overall survival and major amputation were determined by receiver operating characteristic curve analyses.

RESULT

A total of 238 patients with CLTI and 289 limbs were analyzed. The 2-year overall survival rates were 48.9%, 54.6%, and 53.5% in patients with CONUT score ≥4, PNI score <42.6, and GNRI <98.4 compared with 80.0%, 80.0%, and 78.4% in patients with CONUT score <4, PNI score ≥42.6, and GNRI ≥98.4 (p < 0.01). Age, non-ambulatory status, hemodialysis, and nutritional indices were independent risk factors for 2-year mortality in the multivariate analyses. The 2-year limb salvage rates were 70.1%, 82.2%, and 81.9% in patients with CONUT score ≥7, PNI score <41.9, and GNRI <95.3 compared with 92.8%, 98.3%, and 94.2% in patients with CONUT score <7, PNI score ≥41.9, and GNRI ≥95.3 (p < 0.01). Wound, ischemia, and foot infection stage and each nutritional index (CONUT and PNI) were independent risk factors for major amputation in multivariate analyses. The overall survival and limb salvage rates of patients with malnutrition diagnosed by CONUT score were poor compared with those of normal nutrition or malnutrition diagnosed by PNI and/or GNRI scores.

CONCLUSION

The CONUT, PNI, and GNRI scores can predict the 2-year overall survival in patients with CLTI after revascularization. The CONUT and PNI scores were associated with major amputation.

Left Renal Vein Division during Open Surgical Repair for Abdominal Aortic Aneurysm May Cause Long-Term Kidney Remodeling

BACKGROUND

Left renal vein division (LRVD) is a maneuver performed during open surgical repair for abdominal aortic aneurysms. Even so, the long-term effects of LRVD on renal remodeling are unknown. Therefore, we hypothesized that interrupting the venous return of the left renal vein might cause renal congestion and fibrotic remodeling of the left kidney.

METHODS

We used a murine left renal vein ligation model with 8-week-old to 12-week-old wild-type male mice. Bilateral kidneys and blood samples were harvested postoperatively on days 1, 3, 7, and 14. We assessed the renal function and the pathohistological changes in the left kidneys. In addition, we retrospectively analyzed 174 patients with open surgical repairs between 2006 and 2015 to assess the influence of LRVD on clinical data.

RESULTS

Temporary renal decline with left kidney swelling occurred in a murine left renal vein ligation model. In the pathohistological assessment of the left kidney, macrophage accumulation, necrotic atrophy, and renal fibrosis were observed. In addition, Myofibroblast-like macrophage, which is involved in renal fibrosis, was observed in the left kidney. We also noted that LRVD was associated with temporary renal decline and left kidney swelling. LRVD did not, however, impair renal function in long-term observation. Additionally, the relative cortical thickness of the left kidney in the LRVD group was significantly lower than that of the right kidney. These findings indicated that LRVD was associated with left kidney remodeling.

CONCLUSIONS

Venous return interruption of the left renal vein is associated with left kidney remodeling. Furthermore, interruption in the venous return of the left renal vein does not correlate with chronic renal failure. Therefore, we suggest careful follow-up of renal function after LRVD.

Experience of Balloon Aortic Valvuloplasty for Severe Aortic Stenosis in Patients Scheduled for Open Surgery for Chronic Limb-Threatening Ischemia

Objectives: To estimate the effectiveness of balloon aortic valvuloplasty (BAV) for severe aortic stenosis (SAS) in patients scheduled for open surgery for chronic limb-threatening ischemia. Materials and Methods: Clinical data of patients from 2012 to 2018 were retrieved and summarized. The early outcomes and survival after BAV and open bypass were retrospectively investigated. Results: BAV was performed on seven dialysis patients. One patient died of mesenteric infarction 3 days after BAV; however, six patients were able to undergo open bypass at an average of 10 days (7-19 days) after BAV. One patient died of hemorrhagic shock before the wound healed; five patients underwent limb salvage. Four of these five patients could not undergo surgical aortic open valve replacement owing to advanced age or poor cardiac function and died within 2 years. Only one patient who underwent radical surgery after a bypass survived more than 4 years. Conclusion: BAV enabled open surgery and limb salvage in patients with SAS. Although BAV alone cannot ensure long-term survival, the procedure will continue to be important as a bridge technique to radical surgery, such as transcatheter aortic valve implantation and aortic valve repair, which are often avoided owing to infection.

Global Limb Anatomic Staging System Inframalleolar Modifier Predicts Limb Salvage and Wound Healing in Patients with Chronic Limb Threatening Ischaemia Undergoing Endovascular Infrainguinal Revascularisation

OBJECTIVE

This study aimed to analyse the influence of the Global Anatomic Staging System (GLASS) and inframalleolar (IM) disease on the treatment outcomes of patients with chronic limb threatening ischaemia (CLTI) who undergo endovascular treatment (EVT) METHODS: Data of patients who underwent infrainguinal endovascular therapy (EVT) for CLTI between 2015 and 2019 at two centres were analysed retrospectively. The endpoints were major amputation, major adverse limb events (MALE), and wound healing.

RESULTS

Overall, 276 patients and 340 limbs were analysed. The number of revascularisations for an infrapopliteal lesion was 48 (70.6%), 63 (63.0%), and 142 (82.6%) in the GLASS I, GLASS II, and GLASS III stages, respectively (p < .001). There was no statistically significant difference in limb salvage among the GLASS stages (p = .78). The limb salvage rates at one year were 94.6%, 88.0%, and 70.0% in the IM P0 P1, and P2 groups, respectively (p < .001). Multivariable analysis showed that Wound, Ischemia, and foot Infection (WIfI) stage, and IM grade were risk factors for major amputation. The freedom from MALE rates at two years were 60.5%, 45.3%, and 41.1% in the GLASS I, II, and III stages, respectively (p = .003) and 64.1%, 43.5%, and 18.4% in the IM P0, P1, and P2 groups, respectively (p < .001). Multivariable analysis demonstrated that WIfI stage, GLASS stage, IM grade, and infrapopliteal revascularisation were risk factors for MALE. There was no significant difference in wound healing among GLASS I - III (p = .75). The wound healing rates at 365 days were 78.6%, 68.6%, and 42.0% in the IM P0, P1, and P2 groups, respectively (p = .065). Multivariable analysis showed that WIfI stage and IM P2 were risk factors for incomplete wound healing.

CONCLUSION

GLASS IM was associated with major amputation, MALE, and wound healing, while GLASS stage was associated with only MALE.

Perioperative therapeutic antibiotics are beneficial to prevent exacerbation of limb-associated infection after bypass surgery in patients with critical limb-threatening ischemia and foot infection score of ≥1

OBJECTIVE

Postoperative limb infection is associated with a poor prognosis and a low amputation-free survival rate after surgical revascularization in patients with critical limb-threatening ischemia. The Global Vascular Guidelines 2019 recommend antibiotic therapy for patients with deep space foot infection or wet gangrene; however, no study is cited as evidence for this recommendation. The present study was performed to offer new evidence supporting the use of perioperative therapeutic antibiotics in patients with critical limb-threatening ischemia (CLTI) undergoing surgical revascularization.

METHODS

This single-center retrospective study was performed in Kyushu University Hospital and involved patients with CLTI who underwent surgical revascularization from 2003 to 2021. Ampicillin/sulbactam and cefazolin were defined as preventive antibiotics, and other types were defined as therapeutic antibiotics. Postoperative limb-associated infection was defined as an increased foot infection (fI) score in the Wound, Ischemia, and foot Infection (WIfI) classification system after surgical revascularization. The association between perioperative antibiotic therapy and postoperative limb-associated infection was assessed.

RESULTS

Among 286 limbs of 263 patients with CLTI, 27 (9%) limbs developed postoperative limb-associated infection after surgical revascularization. The fI scores were significantly higher in the patients with than without postoperative limb-associated infection (1.0 ± 0.2 vs 0.4 ± 0.1, respectively; p = 0.0033), indicating that an fI score of ≥1 was a risk factor for postoperative limb-associated infection. Perioperative therapeutic antibiotics significantly reduced the incidence of postoperative limb-associated infection compared with preventive antibiotics (0.0% vs. 44.8%, respectively; p = 0.0028) in the patients with CLTI who had an fI score of ≥1 after bypass surgery, although perioperative therapeutic antibiotics were not effective for patients with an fI score of 0.

CONCLUSION

Perioperative therapeutic antibiotics for patients with an fI score of ≥1 are beneficial for reducing the incidence of postoperative limb-associated infection after surgical revascularization.

Interleukin-38 suppresses abdominal aortic aneurysm formation in mice by regulating macrophages in an IL1RL2-p38 pathway-dependent manner

Macrophages play crucial roles in abdominal aortic aneurysm (AAA) formation through the inflammatory response and extracellular matrix degradation; therefore, regulating macrophages may suppress AAA formation. Interleukin-38 (IL-38) is a member of the IL-1 family, which binds to IL-36 receptor (IL1RL2) and has an anti-inflammation effect. Because macrophages express IL1RL2, we hypothesized that IL-38 suppresses AAA formation by controlling macrophages. We assessed a C57BL6/J mouse angiotensin II-induced AAA model with or without IL-38 treatment. RAW 264.7 cells were cultured with tumor necrosis factor-α and treated with or without IL-38. Because p38 has important roles in inflammation, we assessed p38 phosphorylation in vitro and in vivo. To clarify whether the IL-38 effect depends on the p38 pathway, we used SB203580 to inhibit p38 phosphorylation. IL1RL2+ macrophage accumulation along with matrix metalloproteinase (MMP)-2 and -9 expression was observed in mouse AAA. IL-38 reduced the incidence of AAA formation along with reduced M1 macrophage accumulation and MMP-2 and -9 expression in the AAA wall. Macrophage activities including inducible nitric oxide, MMP-2, and MMP-9 production and spindle-shaped changes were significantly suppressed by IL-38. Furthermore, we revealed that inhibition of p38 phosphorylation diminished the effects of IL-38 on regulating macrophages to reduce AAA incidence, indicating the protective effects of IL-38 depend on the p38 pathway. IL-38 plays protective roles against AAA formation through regulation of macrophage accumulation in the aortic wall and modulating the inflammatory phenotype. Using IL-38 may be a novel therapy for AAA patients.

A systematic review of management of uretero-arterial fistula

OBJECTIVE

Uretero-arterial fistula (UAF) is lethal condition. However, there is no consensus regarding diagnosis and treatment of UAF owing to its rarity. The aim of this paper was to present an actual case of UAF and to systematically review the symptoms, risk factors, diagnosis, and treatment of this condition.

METHODS

The case study included a 52-year-old woman who showed a massive hemorrhage during urinary stent replacement. For the systematic review of articles on UAF, those written in English and published from 1939 to 2020 were searched on PubMed using the keywords "uretero-arterial fistula," "arterio-ureteral fistula," and "hematuria".

RESULTS

We included 121 articles and 235 patients (mean age, 66.0 years; women, 139 [59.1%]) in this review. UAF occurred most frequently in the common iliac artery (112 patients [47.7%]). Almost all patients (232 patients [98.7 %]) complained of hematuria. The risk factors for UAF were pelvic surgery (205 patients [87.2%]), long-term use of urinary stents (170 patients [72.3%]), oncologic radiotherapy (107 patients [45.5%]), and malignancy (159 patients [67.7%]). Although computed tomography (CT) can detect various useful findings such as extravasation, pseudoaneurysm, hydronephrosis, and opacification of ureters, it was diagnostically useful in only one-third of the cases. Angiography was useful in diagnosing UAF in 124 (66.3%) of the 187 patients (80.0%) who underwent this procedure. With regard to treatment, endovascular approaches have been widely used in recent years because their invasiveness is lesser than that of open surgical repair. In the era of endovascular therapy, the indications for open surgical repair include ureteral-intestinal fistula, abscess formation, and graft infection after endovascular therapy.

CONCLUSIONS

CT was recommended as the first examination in patients with risk factors for UAF because of its usefulness. Subsequently, angiography should be considered because UAF can be treated using an endovascular approach following diagnostic angiography. Diagnosis and treatment of UAF can often be difficult; therefore, the important first step of diagnosis is suspecting UAF and employing a multidisciplinary approach.

The relation between Phase Angle as muscle function by BIA and physical function and nutrition states in cardiac patients

Funding Acknowledgements

Type of funding sources: None.

[Purpose] Phase angle (PhA) by BIA was studied as muscle function in various diseases. However the effects of nutrition states to phase angle is unclear especially in cardiac patients. This study examined the relationship between PhA, physical function and nutritional index in patients with heart disease.

Methods

PhA was measured using InBody770 for 33 heart disease patients (age: 71.6 ± 13.4 years, EF: 58.6 + 11.0%) who underwent cardiac rehabilitation during hospitalization. Short Physical Performance Battery (SPPB) was performed for physical function evaluation, and ALB, eGFR, and NT-ProBNP were evaluated for blood tests. calorie intake and GNRI were calculated as nutritional assessments.

Results

PhA was 4.1 ± 0.9 °. PhA has a positive correlation with SMI (r = 0.62), chair rise time (r = 0.62), dietary calorie intake (r = 0.49), GNRI (r = 0.50), NT-ProBNP (r = -0.631), ECW A negative correlation was found with / TBW (r = -0.91). As a result of multiple regression analysis with PhA as the dependent variable, ECW / TBW (β = -0.73), SMI (β = 0.33), and chair rise time (β = 0.10) were extracted as significant independent factors (β = -0.13). r² = 0.96).

[Conclusion] PhA in patients with heart disease was correlated with physical function and nutritional index, and a significant independent factor was physical function. In particular, lower limb muscle strength was extracted independently of extracellular water ratio and muscle mass. These results suggest that PhA may be a comprehensive index of physical function in cardiac patients.

Related factors and changes of angiopoietin-like protein 2 with chronic heart failure patients participating in phase III cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): the research grant D2 from Kansai Medical University

Objectives

Angiopoietin-like protein 2 (ANGPTL2) is a protein, whose structure is similar to that of angiopoietin, but binds to a different receptor. Overexpression of ANGPTL2 promotes chronic inflammation and relates to the development of aging-related diseases. ANGPTL2 has been reported to be mainly secreted by adipose tissue. Although ANGPTL2 has been implicated in the pathogenesis of heart failure, there are no studies about serum ANGPTL2 levels in patients with heart failure participating in cardiac rehabilitation program. The aim of this study was to investigate the characteristics, related factors and changes of ANGPTL2 in patients with chronic heart failure during phase III of cardiac rehabilitation program.

Methods

The subjects included 57 patients (70.1 ± 10.2 years old; 46 men) with chronic heart failure whose serum ANGPTL2 levels were measured during the maintenance phase of cardiac rehabilitation program. Furthermore, we classified 25 patients (70.6 ± 7.5 years old; 23 men) from the 6-month course into a reduced group and an unchanged group to characterize change in ANGPTL2. We excluded patients who were admitted or discharged within 3 months of the evaluation of serum ANGPTL2. We evaluated exercise tolerance using the cardiopulmonary exercise test, grip strength, body composition using a body composition analyzer, blood examinations, and echocardiography. Serum ANGPTL2 was measured by solid-phase sandwich enzyme-linked immunosorbent assay (ELISA).

Results

The median value of ANGPTL2 was 4.05 ng/ml. ANGPTL2 was positively correlated with body weight, body mass index, body fat mass, body fat percentage, C-reactive protein (CRP) and total protein (TP) levels, and negatively correlated with skeletal muscle mass percentage and anaerobic threshold (AT). From the result of the logistic regression analysis, AT (OR=0.68, 95% CI:0.47-0.97and TP (OR=20.1, 95% CI:2.52-160.63) were extracted as independent factors related to the level of ANGPTL2. In addition, overall serum ANGPTL2 levels decreased significantly after 6 months. Changes in ANGPTL2 in the reduced group showed a positive correlation between baseline peak VO2, left ventricular ejection fraction and skeletal muscle rate, and a negative correlation with baseline ANGPTL2, CRP, body fat mass. In an unchanged group, HbA1c increased, but no significant change was observed in other factors.

Conclusions

Exercise tolerance in patients with chronic heart failure during maintenance phase might be related to the inflammation marker ANGPTL2. Serum ANGPTL2 levels with stable chronic heart failure patients decreased significantly 6 months after continued cardiac rehabilitation.

Impact of abdominal aortic aneurysm sac shrinkage following endovascular repair on long-term outcomes between favorable and hostile neck anatomy

OBJECTIVE

The aim of the present study was to analyze the influence of abdominal aortic aneurysm sac shrinkage on long-term outcomes after endovascular aneurysm repair (EVAR) between patients with favorable and hostile neck anatomy.

METHODS

This study retrospectively analyzed data from 268 patients with fusiform aneurysm and sac behavior who were evaluated for ≥1 year after EVAR. Hostile neck anatomy was defined as a proximal aneurysmal neck length of <10 mm or proximal neck angle of ≥60°. The primary endpoint was sac shrinkage, and the secondary endpoints included re-intervention and a composite of rupture, type 1a endoleak, and late open conversion.

RESULTS

There was no difference in sac shrinkage between patients with favorable and hostile neck anatomy (P = .47). Multivariate analysis revealed that occluded inferior mesenteric artery (P = .04), presence of posterior thrombus (P < .01), and no antiplatelet therapy (P = .01) were positive factors for sac shrinkage. The re-intervention free survival rate was better in patients with sac shrinkage compared with those without sac shrinkage regardless of proximal neck anatomy (P < .01). The event-free survival rate of the composite endpoint at 5 and 10 years were 97.5% and 83.5% in patients with favorable neck, and 86.8% and 81.0% in those with hostile neck (P = .02). In the subgroup with sac shrinkage, the event-free survival rates at 5 and 10 years were 98.7% and 98.7% in patients with favorable neck, and 92,7% and 82.4% in those with hostile neck (P = .02). In contrast, the event-free survival of patients without sac shrinkage did not differ between those with favorable and hostile neck (P = .08). Multivariate analysis showed that hostile neck anatomy (Hazard ratio [HR], 3.32; 95% confidence interval [CI], 1.26-8.80; P = .02) and no sac shrinkage (HR, 3.88; 95% CI, 1.25-12.0; P = .02) were significant risk factors for composite of rupture, type 1a endoleak, and late open conversion.

CONCLUSIONS

Proximal neck anatomy did not affect sac shrinkage after EVAR. Sac shrinkage is a good surrogate marker of better long-term outcomes after EVAR in patients with favorable neck anatomy. In contrast, critical events such as rupture or type 1a endoleak may occur even after sac shrinkage has been achieved in patients with hostile neck anatomy.

Internal Iliac Artery Aneurysm Ruptures with No Visualized Endoleak 2 Years after Endovascular Repair

We report a case of an 83-year-old man with a ruptured internal iliac artery (IIA) aneurysm after endovascular repair, which was treated via the ligation of IIA and tight suture of the aneurysm sac. Although there were no findings of obvious endoleak after endovascular treatment, the IIA aneurysm increased in size and eventually ruptured. We presumed that pressure to IIA aneurysm via the embolized IIA led to rupture. Aneurysm sac expansion may lead to a rupture despite no endoleak being detected; therefore, close follow-up or re-intervention must be considered. Tight embolization of IIA may prevent endotension in the same case.

Iliac Artery Aneurysms Expand in Quadratically Proportion to the Diameter

BACKGROUND

Iliac artery aneurysms (IAAs) are life-threatening once ruptured. Although some studies have revealed the pathology of IAAs, clinical information on IAAs is still limited. Moreover, previous studies were conducted in Western countries; thus, we aimed to identify the natural history of iliac artery aneurysms in a Japanese cohort. The purpose of this study was to investigate the IAA expansion rate in a Japanese cohort to consider the management of small IAAs and to identify indications for surgical intervention.

METHODS

Patients with iliac artery aneurysms were retrospectively reviewed. The primary outcome was the expansion rate of IAAs. We also investigated the correlation between expansion rate and patients' characteristics. Natural histories, including surgical interventions and rupture, were also assessed.

RESULTS

The mean expansion rate in our study was 1.59 ± 1.16 mm/year. There was a positive correlation between expansion rate and aneurysm diameter, which was estimated by y = 0.0052 × (X - 23.270)² + 0.0632 × X - 0.0517, where y is the expansion rate, and X is aneurysm diameter. The freedom from surgical intervention rate of IAAs was 85.5% at 1 year, 54.0% at 3 years, and 41.5% at 5 years. No factors, except initial aneurysm diameter, were revealed as independent predictors of surgical intervention. We experienced one ruptured IAA, which showed unexpected rapid growth from 30.1 mm to 56.3 mm over 15 months during conservative management. This case demonstrated that IAAs ≥30 mm should be carefully followed up and considered for surgical intervention.

CONCLUSIONS

We conclude that larger aneurysms have greater expansion rates. Because IAAs ≥30 mm carry a risk of rapid expansion resulting in rupture, careful follow-up, and surgical intervention should be performed if iliac artery aneurysms are ≥30 mm in diameter.

Validation of the GLASS Staging Systems in Patients With Chronic Limb-Threatening Ischemia Undergoing De Novo Infrainguinal Revascularization

OBJECTIVES

The Global Limb Anatomic Staging System (GLASS) was proposed for evaluating the anatomic complexity of arterial disease in patients with chronic limb-threatening ischemia (CLTI). We aimed to examine the relationship between GLASS stage and treatment outcomes after infrainguinal revascularization in patients with CLTI.

METHODS

We retrospectively analyzed data of patients undergoing infrainguinal revascularization for CLTI between 2010 and 2018 to examine whether GLASS stage affects the limb salvage, wound healing, and overall survival (OS).

RESULTS

Throughout the study period, 153 CLTI patients and 190 limbs with Fontaine classification III and IV were analyzed for major amputation and OS, and 125 patients and 157 limbs of Fontaine classification IV were analyzed for wound healing. The number of patients with WIfI stage 1, 2, 3, and 4 was 14 (7.4%), 44 (23.2%), 65 (34.2%), and 67 (53.3%), respectively. The number of patients with GLASS stage I, II, and III was 23 (12.1%), 48 (25.3%), and 119 (62.6%), respectively. Among the 190 limbs, the number subject to bypass surgery, endovascular therapy, and hybrid therapy was 132 (69.5%), 39 (20.5%), and 19 (10.0%), respectively. A multivariate analysis showed that only WIfI stage and inframalleolar (IM) disease were risk factors for major amputation and impaired wound healing. There was no relationship between GLASS stage and limb salvage or wound healing. A multivariate analysis revealed that age, geriatric nutritional risk index and GLASS stage were risk factors for 2-year OS (P < 0.01). Patients with all risk factors had a poor prognosis (35.3% at 2 years).

CONCLUSION

WIfI stage and IM disease predicted limb salvage and wound healing after infrainguinal revascularization in patients with CLTI. Although GLASS stage did not affect limb salvage or wound healing, it was a prognostic factor for poor OS. The GLASS staging could be useful for deciding between bypass surgery and endovascular therapy in prediction of prognosis.

Effects of antithrombotic therapy on abdominal aortic aneurysm sac size after endovascular repair in patients with favorable neck anatomy

PURPOSE

To evaluate the influence of antiplatelet or anticoagulant therapy on sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) MATERIALS AND METHODS: This study retrospectively analyzed data from patients with favorable neck anatomy who underwent EVAR between 2007 and 2019. Patients with ruptured AAA and ≤1 year of sac behavior evaluation were excluded. Sac shrinkage after 1 year, persistent type II endoleak, and late sac expansion were examined.

RESULTS

In total, 182 patients with favorable neck anatomy were included in this study. Multivariable analysis identified occluded inferior mesenteric artery (IMA [P = .049]), presence of posterior thrombus (P = .009) and no antiplatelet therapy (P = .012) as factors positively associated with sac shrinkage at 1 year. Persistent type II endoleak was detected in 56 (30.8%) patients, with patent IMA (P = .006), lack of posterior thrombus (P = .004), number of patent lumbar arteries (P = .004), and antiplatelet therapy (P = .039) being identified as significant risk factors. Multivariable analysis identified larger initial AAA diameter (P < .001), lack of posterior thrombus (P = .038), and antiplatelet (P = .038) and anticoagulation therapies (P = .003) as risk factors for late sac expansion.

CONCLUSIONS

After EVAR in patients with favorable neck anatomy, antiplatelet therapy is associated with lack of sac regression at 1 year, whereas antiplatelet and anticoagulant therapies are risk factors for late sac expansion.

Analysis of prognostic factors for postoperative complications and reinterventions after open surgical repair and endovascular aneurysm repair in patients with abdominal aortic aneurysm

OBJECTIVE

A definitive treatment for patients with abdominal aortic aneurysm considering age and comorbidities has not been identified. In the present study, we retrospectively validated treatment outcomes in Japanese patients and proposed the treatment strategy of open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

We retrospectively analyzed data for patients undergoing EVAR or OSR between 2006 and 2017. Patients with ruptured abdominal aortic aneurysm were excluded. We examined post-operative complications, operative mortality, re-intervention and prognosis.

RESULTS

Throughout the study period, 405 patients underwent EVAR and 176 patients underwent OSR. The percentage of patients with post-operative complications was 35.8% in the OSR group, compared with 13.1% in the EVAR group (P < 0.01). The operative mortality rate was 0.49% in the EVAR group and 0.57% in the OSR group (P = 1.00). With a multivariate analysis, age, hemodialysis, modified Frailty Index (mFI), and OSR were risk factors for post-operative complications. The 5-year re-intervention free survival rate was 63.0 % with hostile neck EVAR compared with 83.1 % with favorable neck EVAR and 86.1 % with OSR group (P < 0.01). With a multivariate analysis, hemodialysis, mFI, and hostile neck EVAR were risk factors for re-intervention. The 5-year overall survival rate was 51.9 % with hostile neck EVAR compared with 73.2 % with favorable neck EVAR and 79.0 % with OSR group (P < 0.01). With a multivariate analysis, age, mFI, and hostile neck EVAR were poor prognostic factors.

CONCLUSION

Age, mFI, hemodialysis and hostile neck anatomy are useful predictors of post-operative complications, re-intervention and overall survival, and could be useful for informing treatment selection between OSR and EVAR.

Platelet Count Recovery after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm

Objective: To find a new predictor of endoleak (EL) and aneurysm sac expansion after endovascular aneurysm repair (EVAR), we evaluated the platelet count recovery (PCR) process after EVAR.

Materials and Methods: Two hundred five patients treated with elective EVAR from 2007 to 2015 were retrospectively analyzed. We compared the platelet count ratio until postoperative day (POD) 7 to the presurgical baseline between patients with and without persistent EL (≥ 6 months). Subsequently, we calculated the optimal platelet count ratio for distinguishing persistent EL using receiver-operating characteristics analysis. A platelet count ratio on POD7 ≥118% was defined as the PCR. We evaluated the PCR’s influence on the cumulative aneurysm sac expansion rate.

Results: The average platelet count ratio on POD7 rose above baseline (112%), and the ratio was attenuated by persistent EL (103%). Of 205 patients, 126 (61%) were assigned to the disturbed PCR group (PCR(−) group). Cumulative aneurysm sac expansion rate was higher in the PCR(−) group than the PCR(+) group (34.4% vs. 12.8% in 5 years, p=0.01).

Conclusion: Disturbed PCR after EVAR may be associated with ELs and eventual aneurysm sac expansion.

Influence of Internal Iliac Artery Embolization during Endovascular Aortic Repair Regarding Postoperative Sarcopenia and Midterm Survival

BACKGROUND

Postoperative sarcopenia is a risk factor for postoperative mortality. Internal iliac artery embolization (IIAE) during endovascular aortic repair (EVAR) has ischemic effects on pelvic skeletal muscles because IIAE causes buttock claudication. The long-term effects of IIAE on pelvic skeletal muscle, however, have not been well investigated. We hypothesized that IIAE after EVAR induces a decrease in skeletal muscle, which leads to postoperative sarcopenia.

MATERIALS AND METHODS

Patients with abdominal aortic aneurysms who underwent EVAR from 2009 to 2014 were retrospectively reviewed. Skeletal muscle areas (SMAs) at the third lumbar level and the mid-femoral level were measured on transverse computed tomographic images. Postoperative sarcopenia was defined as a >10% decrease in the L3 SMA as established in a previous study. We assessed the association between postoperative sarcopenia and IIAE.

RESULTS

Altogether, 102 eligible patients who underwent elective EVAR comprised the study group. The L3 SMA at the 3-year follow-up evaluation was significantly smaller in patients with than without IIAE (P < 0.05). The SMAs of the psoas, lumbar, and thigh muscles were significantly smaller on the IIAE than non-IIAE side (P < 0.05). IIAE was thus revealed as an independent risk factor for postoperative sarcopenia (hazard ratio, 4.69; P = 0.008). In addition, patients who developed postoperative sarcopenia had a lower overall survival rate than those without postoperative sarcopenia (P < 0.001).

CONCLUSIONS

IIAE during EVAR is a risk factor for postoperative sarcopenia, which is in turn associated with mortality. Hence, we should preserve the internal iliac artery whenever possible. Alternatively, if IIAE is deemed necessary, we should postoperatively institute protocols to prevent sarcopenia from developing.

Thigh sarcopenia and hypoalbuminemia predict impaired overall survival after infrainguinal revascularization in patients with critical limb ischemia

Objective

This study was performed to determine whether thigh sarcopenia can serve as a clinically relevant predictor of postoperative complications and overall survival after revascularization in patients with critical limb ischemia.

Methods

Patients who underwent preoperative computed tomography followed by infrainguinal revascularization from 2006 to 2015 were retrospectively analyzed. An axial computed tomography image was obtained at the midpoint of a line extending from the superior border of the patella to the greater trochanter of the femur. The thigh muscle area and bone area were measured. Thigh sarcopenia was defined as thigh muscle area/thigh bone area of <9.

Results

We included 117 patients with critical limb ischemia who underwent infrainguinal revascularization. The overall survival rates at two years were 86.5% and 55.1% in the thigh sarcopenia (−) and (+) groups, respectively ( p < 0.01). The multivariate analysis showed that thigh sarcopenia (hazard ratio, 2.64; 95% confidence interval, 1.11–6.70; p = 0.03), cerebrovascular disease (hazard ratio, 3.18; 95% confidence interval, 1.31–7.36; p = 0.01), and serum albumin level (1 g/dL per increments) (hazard ratio, 0.41; 95% confidence interval, 0.21–0.81; p = 0.01) were the risk factors for overall survival two years after revascularization.

Conclusion

Thigh sarcopenia is a risk factor for two-year overall survival in patients with critical limb ischemia after infrainguinal revascularization.

Therapeutic Arteriogenesis/Angiogenesis for Peripheral Arterial Disease by Nanoparticle-Mediated Delivery of Pitavastatin into Vascular Endothelial Cells

Two decades have passed since therapeutic angiogenesis was proposed to promote reparative collateral growth as an alternative therapy for ischemic diseases in patients for whom neither surgical revascularization nor endovascular therapy was suitable. When therapeutic angiogenesis first began, local administration was conducted using recombinant growth factor proteins or gene-encoding growth factors for endothelial cells. Since then, autologous stem cells and endothelial progenitor cell transplantation therapy have been developed. Although many clinical trials have been performed on patients, most therapies have not yet become standard treatments. We have developed a nanoparticle (NP)-mediated, drug-targeting delivery system using bioabsorbable poly-lactic/glycolic acid (PLGA) NPs. In several animal models, pitavastatin-incorporated (Pitava)-NPs showed significant therapeutic effects on critical limb ischemia. Because PLGA NPs are delivered selectively to vascular endothelial cells after intramuscular administration, it is suggested that therapeutic angiogenesis/arteriogenesis plays an important role in the mechanism by which Pitava-NPs exert beneficial therapeutic effects. To translate this to clinical medicine, we have performed studies and produced Pitava-NPs in compliance with good laboratory practice/good manufacturing practice regulations, and completed a phase I/II clinical trial, reporting the safety and efficacy of Pitava-NP intramuscular injection for patients with critical limb ischemia. This review will focus on therapeutic angiogenesis/arteriogenesis for peripheral arterial disease induced by Pitava-NPs.

Platelets reflect the fate of type II endoleak after endovascular aneurysm repair

OBJECTIVE

The management of type II endoleak (T2E) remains controversial because of the heterogeneous outcome. For blood-based screening to detect malignant T2E, we focused on platelets after endovascular aneurysm repair (EVAR) and compared them with the prognosis of T2Es.

METHODS

From 2007 to 2015, there were 249 patients treated with EVAR for abdominal aortic aneurysm who were evaluated retrospectively. The mean follow-up period was 3.5 ± 0.2 years. T2Es that had aneurysm sac enlargement or converted to type I or type III endoleak were defined as malignant; the other T2Es were considered benign. Cases without any complications, including T2E, were defined as completed. We compared the platelet count on postoperative days (PODs) 1 to 7 with preoperative baseline values among the three groups. Sequentially, we calculated the cutoff of the platelet ratio on POD 7 to the baseline value in relation to malignant T2E using receiver operating characteristic analysis, and the cutoff ratio was 113% (sensitivity, 79%; specificity, 58%). We then reclassified T2E patients into T2E-high platelet (T2E-HP; ≥113%) or T2E-low platelet (T2E-LP; <113%) groups. The influence of platelets on T2E was evaluated with reintervention rate and cumulative aneurysm sac enlargement rate using the Kaplan-Meier method.

RESULTS

T2Es were found in 70 patients (28%), and 179 patients were assigned to the completed group. Malignant and benign T2Es were found in 33 and 37 patients, respectively. No difference was found in the preoperative baseline values. On POD 7, the platelet count in the malignant T2E group was significantly lower than that in the completed and benign T2E groups (168 × 10³/μL vs 207 × 10³/μL and 201 × 10³/μL; P = .0124). Then, 27 and 43 patients were assigned to the T2E-HP and T2E-LP groups, respectively. The reintervention-free survival rate in the T2E-LP group was lower than that in the completed group (at 3 years, 66.4% ± 8.0% vs 71.9% ± 4.0%; P = .0031). Among T2E patients, the cumulative aneurysm sac enlargement rates in the T2E-LP group were significantly higher than those in the T2E-HP group (at 3 years, 34.6% ± 8.2% vs 20.6% ± 8.2%; P = .0105). Univariate Cox proportional hazards analysis for the cumulative aneurysm sac enlargement rates among T2E patients showed that sex, dual antiplatelet therapy, and lower platelet ratio (<113%) were significant predictors; multivariate analysis showed that T2E-LP was the only significant predictor (hazard ratio, 2.60; P = .0355).

CONCLUSIONS

The platelet count of patients with malignant T2Es on POD 7 was definitively lower than that of patients with completed EVAR or with benign T2Es. The lower platelet count on POD 7 could be a risk factor for aneurysm sac enlargement among patients with T2Es.

The Controlling Nutritional Status Score is Significantly Associated with Complete Ulcer Healing in Patients with Critical Limb Ischemia

BACKGROUND

It has been reported that the Controlling Nutritional Status (CONUT) score, calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration, is a valuable nutritional status index. In the present study, we assessed whether the CONUT score was a significant predictor of complete ulcer healing in patients with critical limb ischemia (CLI).

METHODS

In this retrospective, single center, cohort study, conducted from January 2013 to June 2018, we treated 112 limbs of 89 patients with Fontaine 4 CLI at the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan. The primary endpoint of the study was complete ulcer healing after revascularization, and the secondary endpoint was amputation-free survival (AFS).

RESULTS

The mean follow-up time was 17.8 months. Complete ulcer healing was achieved during the follow-up period in 91 (81.2%) limbs. The median ulcer healing time was 104 days (range, 16-574 days). In multivariate analysis, improvement of lower skin perfusion pressure ratio of <1, end-stage renal disease, and high CONUT score (>4) were predictive of incomplete ulcer healing in patients with Fontaine 4 CLI. In addition, the AFS rate was significantly better in patients with a CONUT score ≤4 than in those with a CONUT score >4.

CONCLUSIONS

The CONUT score was associated with postprocedure ulcer healing and long-term limb retention in patients who underwent revascularization. The management of CLI involving ischemic foot ulcers may require ongoing consideration of nutritional status.

Cystic Arterial Disease Located Only in the Media of the Popliteal Artery: A Case Report

Adventitial cystic disease of the popliteal artery is a rare non-atheromatous peripheral artery disease. In most cases, the cystic lesion is located in the adventitia of the popliteal artery. Herein, we present a rare case of cystic arterial disease in which the cyst was located only in the media of the popliteal artery. We successfully treated the cyst with resection of the affected popliteal artery and reconstruction with an autogenous vein graft.

True brachial artery aneurysm after arteriovenous fistula closure following renal transplantation: a case report and literature review

Background

A brachial artery aneurysm (BAA) is a rare condition accounting for 5% of all peripheral arterial aneurysms. More cases of true BAAs after arteriovenous fistula (AVF) closure have been reported in the past two decades.

Case presentation

A 60-year-old man who underwent AVF closure after renal transplantation had a true BAA on his left elbow that had grown within the past 6 months. We successfully performed an open repair with end-to-end anastomosis. No complications occurred for 1 year.

Conclusions

High flow due to AVF and some collateral factors such as the use of steroids and immunosuppressants after renal transplantation, arteriosclerosis, and chronic mechanical stimulation might contribute to BAA formation.

External validation of CLI Frailty Index and assessment of predictive value of modified CLI Frailty Index for patients with critical limb ischemia undergoing infrainguinal revascularization

Objectives

CLI Frailty is a useful diagnostic criterion of frailty in patients with critical limb ischemia (CLI). It is important to evaluate not only comorbidities but also frailty in decision making to select the type of treatment for CLI patients. The purposes of our study were to externally validate the CLI Frailty Index and to evaluate the modified CLI Frailty Index by measurement of skeletal muscle mass using computed tomography.

Methods

Patients who underwent preoperative computed tomography examination and infrainguinal revascularization between 2002 and 2015 were retrospectively analyzed. A patient was defined as CLI Frailty (+), if two or more of the following criteria were present: low Geriatric Nutritional Risk Index (GNRI), low skeletal muscle mass index (SMI) evaluated by prediction equations, and non-ambulatory status. For the modified CLI Frailty Index, skeletal muscle area was measured by computed tomography instead of prediction equations.

Results

During the study period, 226 patients with CLI underwent revascularization; we included 127 patients and excluded 99 patients who were treated only with iliac revascularization or did not undergo CT scans. The overall survival at two years after revascularization was 83.6% for the CLI Frailty (−) group versus 63.2% for the CLI Frailty (+) group ( P = .02). The overall survival at two years after revascularization was 89.7% for the modified CLI Frailty (−) group versus 60.5% for the modified CLI Frailty (+) group ( P < .01). Multivariate analysis 1 including CLI Frailty revealed that hemodialysis (HR, 3.71; 95% CI, 1.58–8.83; P < .01), CLI Frailty (HR, 3.22; 95% CI, 1.35–7.47; P < .01) and cerebrovascular disease (HR, 2.58; 95% CI, 1.09–5.91; P = .03) were risk factors for overall survival two years after revascularization. In multivariate analysis 2 including modified CLI Frailty, modified CLI Frailty (HR, 5.92; 95% CI, 2.49–15.7; P < .01), hemodialysis (HR, 4.03; 95% CI, 1.65–10.0; P < .01) and diabetes mellitus (HR, 0.41; 95% CI, 0.16–0.99; P = .05) were risk factors for overall survival two years after revascularization.

Conclusions

Both the CLI Frailty and the modified CLI Frailty Indexes were useful in predicting the two-year overall survival of patients with CLI after infrainguinal revascularization. Although the measurement of skeletal muscle mass using computed tomography may accurately predict two-year overall survival, SMI prediction is effective for patients with CLI who did not undergo preoperative CT.

Invasive meningococcal disease due to a non-capsulated Neisseria meningitidis strain in a patient with IgG4-related disease

Background

Invasive Meningococcal Disease (IMD) is a rare and critical disease in Japan. Most of these cases are caused by capsulated Neisseria meningitidis strains. Non-capsulated (non-typable) strains are considered relatively low-pathogenic and can colonize in the nasopharynx of healthy children and young adults. As far as could be ascertained, only twelve IMD cases due to non-capsulated strains have been reported in the literature. No clear risk factors could be identified in a literature review (unknown or immunocompetent, seven cases; C6 deficiency, three cases).

Case presentation

We report a Japanese male taxi driver with bacteremia and meningitis due to non-capsulated N. meningitidis. He had a fever and shaking chills. Ceftriaxone was administered, and the patient finally recovered. During the clinical course, relative adrenal insufficiency occurred and was treated with hydrocortisone. A hidden co-morbidity, immunoglobulin G4 (IgG4)-related disease, was revealed in the past surgical history (a resection of bilateral orbital tumors), which included symptoms (swelling lachrymal glands and lymph nodes), elevated IgG4, immunoglobulin E, and hypocomplementemia. He recovered finally and no recurrence was observed.

Conclusions

Our IMD case is the first reported in Japan, where IMD is not considered pandemic. The patient had a history of IgG4-related disease, although we could not establish a clear relationship between the patient’s IMD and co-morbidity. A collection of further clinical cases might establish the risk factors and characteristics of IMD that could be caused by this neglected pathogen, non-capsulated N. meningitidis.

Neurogenic thoracic outlet syndrome in whiplash injury

A prospective study of 110 patients was carried out to determine the pathogenic significance of trauma to the upper body in the development of neural compressive irritation at the thoracic outlet. Twenty-nine patients were reviewed as cervical strain injuries (N group), 25 patients as probable neurogenic thoracic outlet syndrome (NTOS) (PT group), 39 patients as definite NTOS (T group), and 17 patients as NTOS associated with cervical disc disease (CD-T group). The time lapse between accident and diagnosis and the duration of treatment were significantly longer in T patients or CD-T patients than those in the N group. Radiography of NTOS patients also showed a higher percentage of cervical spine-length/height ratio. Traumatic NTOS would suggest two types related to direct damage of scalene muscles that included some physical aspects of cervical disc disease. Pathogenesis provided a key to the resolution of more complex posttraumatic problems of whiplash injury.

Perturbations at the high spin heme b center in the membrane-bound nitric oxide reductase

The effects of lowering pH from 7 to 5 on the absorption, circular dichroism (MCD) and EPR spectra were studied for Paracoccus halodenitrificans nitric oxide reductase (NOR). Intensities of the characteristic bands for the high spin heme b, that at 592 nm in the absorption spectrum and those at 591 (+) and 606 (-) in the MCD spectrum decreased considerably. Concomitant cryogenic EPR spectrum indicated a drastic increase in the signal intensity due to the high spin heme b at g approximately 6, of which less than 5% had been EPR detectable at pH 7. Cyanide (x40) bound to the high spin heme b center in the reduced NOR irrespective of pH, while a much larger amount of azide (x1000) was necessary to bind to the reduced NOR at an acidic pH, ca. 5. Based on these results the structure and function of the high spin heme b center as the active site of NOR was discussed.

Effects of FTY720, a novel immunosuppressant, on experimental autoimmune uveoretinitis in rats

The immunosuppressive properties of FTY720, a novel immunosuppressant obtained by structural modification of ISP-I isolated from the fermentation broth of Isaria sinclairii, were studied in experimental autoimmune uveoretinitis (EAU) in rats. Lewis rats were immunized with S-antigen and treated with FTY720 (0. 03, 0.06, 0.1 mg kg(-1)day(-1)) or distilled water for 16 days after the immunization. FTY720 suppressed the incidence and intensity of EAU in a dose-dependent manner as demonstrated by clinical and histological examinations. The drug significantly suppressed the serum levels of antibodies to S-antigen and antigens-specific lymphocyte proliferation. The number of peripheral lymphocytes, but not neutrophils, was markedly reduced by FTY720 treatment. FTY720 also suppressed the intensity of EAU when it was given from the day of EAU onset. These results indicate that FTY720 has intense immunosuppressive effects on EAU in rats and may be a potential candidate for use in the treatment of patients with autoimmune uveitis.

Quality of life following surgery for vertebral metastases from breast cancer

BACKGROUND AND OBJECTIVES

The quality of life of patients with vertebral metastases from breast cancer treated with surgery was evaluated.

METHODS

Seven such patients underwent surgery for vertebral metastases following chemoendocrine treatment. They presented with pain and some with neurological compromise.

RESULTS

Following posterior stabilization with a segmental instrument, pain was alleviated in all seven women, two showed improvements in neurological compromise, and performance status was improved in five. In no patient was there neurological deterioration secondary to surgical intervention. They were out of bed on the 4th postoperative day and discharged on the 14th day on average.

CONCLUSIONS

The quality of life was improved for these surgically treated patients. We recommend surgical stabilization for selected patients with a vertebral metastasis from breast cancer.

Characteristics of quinolone-induced small colony variants in Staphylococcus aureus

Exposure of Staphylococcus aureus to 1 x MIC of the quinolone antibiotic pazufloxacin for 24 h, followed by plating on drug-free media, led to the emergence of small colony variants (SCVs) in addition to large colony variants (LCVs). However, following incubation with 0.25 or 4 x MIC of pazufloxacin, only LCVs were obtained. The SCVs were half as susceptible to pazufloxacin or ciprofloxacin as wild-type S. aureus, while the susceptibilities of LCVs were essentially unchanged. The reduced susceptibilities of SCVs did not result from mutations in the quinolone-resistance-determining regions of DNA gyrase and topoisomerase IV, since the sequences of these genes were identical to those of the wild-type. However, the SCVs accumulated pazufloxacin and ciprofloxacin to a lesser degree than did wild-type. Furthermore, their susceptibility to quinolones was almost unaffected by reserpine or verapamil, suggesting that the reduced uptake resulted from decreased permeability, rather than from an active efflux pump. The ability of various quinolones to induce emergence of SCVs in S. aureus, correlated with the presence of carbon-bonded substituents at the C-7 position of a quinoline or naphthyridine nucleus, or with the presence of a benzoxazine nucleus. In conclusion, pazufloxacin-induced SCVs represent a mutant that one might expect to be rapidly eliminated in vivo and, hence, not to survive as a quinolone-resistant pathogen. This finding suggests a novel approach for development of future quinolones.

Mutations in the gyrA and grlA genes of quinolone-resistant clinical isolates of methicillin-resistant Staphylococcus aureus

The mutations in the quinolone-resistance determining regions (QRDR) of the gyrA, gyrB and grlA genes and in the norA gene from five clinical isolates of methicillin resistant Staphylococcus aureus (MRSA) were examined by DNA sequencing. The mutation from Ser84 to Leu in GyrA was associated with relatively high-level resistance to quinolones, whereas the mutation from Glu88 to Gly or Lys in GyrA was associated with low-level resistance to quinolones. Mutations of the grlA gene were observed at codon 80 (Ser80) or 84 (Glu84), independent of the mutations of gyrA. No mutations were observed in either the gyrB or norA genes.

[Formation of experimental rat bladder calculus and adherence of Pseudomonas aeruginosa to the calculus]

The formation of experimental bladder calculus was studied. The calculus was formed by the uptake of ethylene glycolwater (1%) and retaining the silk thread in rat bladder with high frequency. The components of the calculus were calcium oxalate and calcium phosphate from the results of the electron prove micro analysis (EPMA) and ion chromatography. On the 7th day after the beginning of experiment, Pseudomonas aeruginosa was inoculated to the rat bladder via the urethra. Seven days after the infection, P. aeruginosa adhered to the surface of the calculus such as an aspect of a biofilm. It was considered that this experimental model was useful to study the adherence of bacteria, biofilm formation and its chemotherapy by antibacterial agents.

Age-related increase in neuropeptide Y-like immunoreactivity in cerebrospinal fluid in women

In order to investigate the age-related changes in neuropeptide Y (NPY) in cerebrospinal fluid (CSF) of men and women, we examined the concentration of NPY-like immunoreactivity (NPY-LI) in CSF of a large population of Japanese men and women by specific radioimmunoassay (RIA). The dilution curve of CSF extract paralleled the standard curve of RIA for human NPY. Gel chromatographic studies revealed the presence of two peaks of NPY-LI, one emerging at the elution position of synthetic NPY and another emerging at a higher-molecular-weight position. NPY-LI in the CSF in 201 men (aged 17 to 69y) and 118 women (aged 17 to 69y) was 124 +/- 4 and 136 +/- 6 pg/ml (mean +/- SE), respectively. NPY-LI in the CSF of women, but not of men, increased significantly with aging. This finding suggests that the level of NPY with aging in the central nervous system (CNS) may be regulated somewhat differently in men and women.

Canal-expansive laminoplasty in 83 patients with cervical myelopathy. A comparative study of three different procedures

We have reviewed 83 patients who had undergone canal-expansive laminoplasty for the treatment of cervical myelopathy between 1982 and 1991. The procedures used for laminoplasty were a Z-plasty in 35 patients, unilateral laminoplasty in 19, and sagittal splitting of the spinous processes in 29. At an average follow-up of more than two years and five months, there were no significant differences in clinical results among the three operations, and excellent or good results were obtained in more than 70% of the patients. However, Z-plasty was the least preferable because this procedure had the longest operating time and the greatest intraoperative blood loss. The sagittal splitting procedure is recommended in routine laminoplasty in order to avoid complications at the site of osteotomy, and to allow simultaneous posterior fusion to be easily performed.

Pancreastatin-like immunoreactivity of cerebrospinal fluid in patients with Alzheimer type dementia: evidence of aberrant processing of pancreastatin in Alzheimer type dementia

The concentrations of pancreastatin-like immunoreactivity (PST-LI) of the cerebrospinal fluid (CSF) were measured in the patients with Alzheimer type dementia (ATD) and in age-matched normal subjects. The mean PST-LI concentration in the CSF of ATD patients was significantly lower than that of normal subjects. Gel chromatographic analysis revealed that the main PST-LI peak of ATD's CSF eluted at molecular weight (MW) 13.5 kDa. However, the age-related change of the molecular forms of PST-LI in CSF was observed in normal subjects as following; PST-LI in neonatal CSF showed one peak at MW 13.5 kDa, that of 16-64-year-old showed two peaks at MW 13.5 and 5.4 kDa, however, only one main peak was shown at MW 5.4 kDa in the CSFs of 72-85-year-old. These findings suggest that the production of PST-LI was decreased and the proteolytic cleavage, which should process big PST to PST (1-52) in normal subjects, was altered to that of neonatal type in the CNS of the patients with ATD.

Unique change of pancreastatin-like immunoreactivity in cerebrospinal fluid by aging

Using a specific antiserum for the C-terminal glycine amide region of human pancreastatin (PST), pancreastatin-like immunoreactivity (PST-LI) was measured in cerebrospinal fluid (CSF) from 447 subjects (368 +/- 10.8 pmol/l, mean +/- S.E.M.) free from endocrine diseases. The CSF contents of PST-LI showed a mountain-shape type change which peaked at 40 years of age. The highest concentration was found in the group of ages 40-49 years old (412 +/- 22.9 pmol/l) and the lowest concentration was found in the group of ages 80-89 years old (293.2 +/- 45.2 pmol/l) among various age groups. Gel chromatographic examination revealed the presence of two major forms (MW 13,500 and 5,400) of PST-LI in CSF. Because of the character of this antibody, the large molecular form is possibly an N-terminally elongated PST and the other may be PST-52. This may be the first report on the unique age-related change of PST concentration in CSF.

Anterior cervical fusion with the Caspar instrumentation system

We reviewed 106 consecutive patients who had undergone anterior cervical fusion with the Caspar instrumentation system between 1984 and 1989. Preoperative diagnoses were cervical spondylosis in 73 patients, a traumatic lesion in 12, ossification of the posterior longitudinal ligament in 9, cervical disc herniation in 6, and tumour or miscellaneous lesions in 6. In the 106 patients, 56 had two levels fused and 27 had three levels fused. At an average duration of follow-up of 4 years and 7 months, nonunion occurred in 3 of the 83 patients with multiple level fusions. Screw loosening occurred in 8 of the 106 patients, but there was no oesophageal perforation.

Anti-Eye Muscle Antibodies and Hypothyroid Graves' Disease: A Case Report

We report the case of a 70-year-old man who developed hypothyroidism associated with TSH receptor antibodies and severe ophthalmopathy during lithium therapy. He had received lithium therapy for more than 20 years for manic depression, when ophthalmopathy (class VI of the American Thyroid Association classification) and mild hypothyroidism developed. Orbital magnetic resonance imaging indicated marked enlargement of the superior, medial and inferior rectus muscles in the left eye. He had anti-eye muscle antibodies in his serum, detected by Western blotting and quantified by chromatoscanning, as well as anti-TSH receptor antibodies. He was treated with supplementation of levothyroxine and four cycles of methylprednisolone pulse therapy. After the pulse therapy, both anti-eye muscle antibodies and anti-TSH receptor antibodies decreased and disappeared in parallel with the improvement in eye symptoms and signs. These observations suggest the importance of anti-eye muscle antibodies as clinical markers in the development of thyroid-associated ophthalmopathy.

Age-related change in 7B2 (a novel pituitary polypeptide) concentrations in human cerebrospinal fluid

Concentrations of 7B2 (a novel pituitary polypeptide) immunoreactivity (7B2-IR) were measured using a specific 7B2 radioimmunoassay (RIA) in cerebrospinal fluids (CSFs) from 87 humans. The mean (+/- S.E.M.) concentration of 7B2-IR in CSF was 2022 +/- 68 pM and a statistically significant decrease with aging was observed in those concentrations (R = -0.28, t = 2.73, P less than 0.01), although it was not a strong relation based on the R-value. In the gel permeation chromatography of CSF on Sephadex G-100, a major peak with an apparent mol. wt. of 43 kDa (43K) and a minor peak with that of 11 kDa (11K) were observed.