LONG‐TERM PROGNOSIS OF BILE DUCT STONES: ENDOSCOPIC PAPILLARY BALLOON DILATATION VERSUS ENDOSCOPIC SPHINCTEROTOMY

Aim: Endoscopic papillary balloon dilatation (EPBD), which allows preservation of papillary functions, is used as the first‐line therapy in our hospital for common bile duct (CBD) stones to reduce biliary complications. In the present study, we investigated causal factors for CBD stones and compared long‐term prognosis between EPBD and endoscopic sphincterotomy (EST). Methods: A total of 453 EPBD and 233 EST cases treated between April 1996 and May 2007 were examined. They were categorized into four groups: group 1, gallbladder (GB) with stones was resected after CBD stones were extracted (cholecystectomy for GB with stones); group 2, GB with stones was not resected after CBD stones were extracted (no cholecystectomy for GB with stones); group 3, only CBD stones were extracted while the GB without stones was not resected (GB without stones); and group 4, CBD stones with a history of cholecystectomy (absence of GB). Then, postoperative recurrence of CBD stones was compared. To examine changes in papillary functions by EPBD, Oddi's sphincter pressure was measured before and after EPBD. Results: Recurrence was observed in 31 EPBD and 40 EST cases. When recurrence rates by EPBD/EST were compared among the four treatment groups, they were lower with EPBD than with EST in all groups. Oddi's sphincter functions were preserved by 70% after EPBD. Conclusion: Low‐pressure EPBD in combination with isosorbide dinitrate enabled preservation of papillary functions by 70%, which would improve a long‐term prognosis.     

Relationship between anatomic location of the crista terminalis and double potentials recorded during atrial flutter: intracardiac echocardiographic analysis

INTRODUCTION: The activation sequence in typical atrial flutter (AFL) around the tricuspid annulus is well described. However, activation of the remainder of the right atrium (RA) is not well defined. Previous studies have shown a linear block at the crista terminalis (CT) during AFL. The aim of this study was to evaluate the relationship between the location of the CT and the line of block by intracardiac echocardiography (ICE). METHODS AND RESULTS: Twenty-one patients with typical AFL were included in the study. The ICE imaging catheter (9-French with 9-MHz ultrasound transducer) was advanced to the RA. Under ICE guidance, a 20-pole roving catheter was used to map double potentials (DPs) during AFL, and three-dimensional images of the RA were reconstructed. During counterclockwise (CCW), clockwise (CW) AFL, or both, a line of conduction block manifested by DPs was identified at a septal site adjacent to the CT in 12 patients and in the posteroseptal RA in 9 patients. CONCLUSION: The functional line of block in CCW and CW AFL is localized not at the CT but at the septal edge of the CT or in the posteroseptal RA.     

Effect of transdermal hormone replacement therapy on the monocyte chemoattractant protein-1 concentrations and other vascular inflammatory markers and on endothelial function in postmenopausal women

Monocyte chemoattractant protein-1 (MCP-1) is related to the progression of atherosclerosis. However, little is known about the effects of transdermal hormone replacement therapy (HRT) on circulating MCP-1, vascular inflammatory marker concentrations, and endothelial function in postmenopausal women. The effects of transdermal HRT on circulating MCP-1, vascular inflammatory marker concentrations, and endothelium-dependent vasodilation were investigated in postmenopausal women. Thirty-three women received transdermal HRT (continuous 17-beta estradiol patch 36 microg/day plus cyclic oral medroxyprogesterone acetate 2.5 mg/day for 12 days/month) for 12 months, and 27 control patients did not. Brachial artery flow-mediated vasodilation (FMD), assessed by ultrasound, and circulating MCP-1 and vascular inflammatory marker (C-reactive protein, intercellular adhesion molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1], and E-selectin) concentrations were measured before and after 12 months of treatment. In the HRT group, MCP-1 concentrations decreased significantly (p <0.001), and ICAM-1, VCAM-1, and E-selectin concentrations decreased significantly (p <0.01 for all), but C-reactive protein concentrations did not change. MCP-1 and other marker concentrations did not change in the control group. FMD increased significantly in the HRT group (p <0.001) but did not change in the control group. Nitroglycerin-induced vasodilation did not change in either group. In conclusion, transdermal HRT decreased MCP-1 and cell adhesion molecule concentrations and improved endothelial function in postmenopausal women. Transdermal HRT may exert an antiatherosclerotic effect by improving MCP-1 and cell adhesion molecule expression and endothelial function.     

Inducibility of atrial flutter in patients with atrioventricular nodal reentrant tachycardia.

BACKGROUND: Previous studies have shown that both atrioventricular nodal reentrant tachycardia (AVNRT) and atrial flutter (AFL) have an area of slow conduction located in the low posterior right atrium near the ostium of the coronary sinus. The aim of this study was to evaluate the inducibility of AFL in patients with AVNRT. METHODS AND RESULTS: One hundred and seventy patients were prospectively evaluated for inducibility of tricuspid valve - inferior vena cava isthmus-dependent AFL. Two groups of patients were analyzed: 71 patients with inducible AVNRT and 99 control patients without a history of AFL. AFL was induced in a greater percentage of patients with AVNRT (53%) than of control patients (27%, p<0.02). In all 21 patients with AVNRT and inducible AFL before slow pathway ablation, AFL was also inducible after slow pathway ablation. There was no difference in the cycle length of induced AFL before and after ablation. CONCLUSIONS: AFL was induced in a greater percentage of patients with AVNRT, suggesting that there may be a common area of posteroseptal perinodal atrium participating in the two-tachycardia circuits. However, radiofrequency ablation of the slow pathway of the AVNRT circuit does not influence the inducibility of AFL.     

Idiopathic left ventricular tachycardia with a change from left to right axis deviation during radiofrequency catheter ablation

A 62 year-old-woman presented with a right bundle branch block (RBBB) and left axis deviation (LAD) tachycardia. Radiofrequency (RF) energy was delivered to the left posterior fascicle (LPF) where 2 presystolic Purkinje potentials (P1 and P2) preceding onset of the QRS complex were recorded. During RF energy applications, the QRS morphology of the tachycardia changed from RBBB and LAD to RBBB and right axis deviation without termination of the tachycardia. The Purkinje potential was observed following the QRS complex during the tachycardia because of conduction block of the LPF distal to the reentry circuit due to RF catheter ablation.     

Orally administered eicosapentaenoic acid reduces and stabilizes atherosclerotic lesions in ApoE-deficient mice

Accumulating evidence demonstrates that dietary intake of n-3 polyunsaturated fatty acids (PUFAs) is associated with reduced incidence of cardiovascular events. However, the molecular mechanisms by which n-3 PUFAs prevent atherosclerosis are not fully understood. Here, we examined the effect of eicosapentaenoic acid (EPA), a major n-3 PUFA, on the pathogenesis of atherosclerosis in ApoE-deficient mice. Five-week-old ApoE-deficient male mice were fed on western-type diet supplemented with 5% (w/w) EPA (EPA group, n=7) or not (control group, n=5) for 13 weeks. An analysis of the fatty acid composition of liver homogenates revealed a marked increase of the n-3 PUFA content in the EPA group (n-3/n-6 ratio: 0.20+/-0.01 vs. 2.5+/-0.2, p<0.01). En face Sudan IV staining of the aorta and oil red O-staining of the aortic sinus revealed that EPA significantly suppressed the development of atherosclerotic lesions. We also observed anti-atherosclerotic effects of EPA in LDL-receptor-deficient mice. The lesions of the EPA group contained more collagen (19.6+/-2.4% vs. 32.9+/-3.9%, p<0.05) and smooth muscle cells (1.3+/-0.2% vs. 3.6+/-0.8%, p<0.05) and less macrophages (32.7+/-4.1% vs. 14.7+/-2.0%, p<0.05). Pretreatment with EPA attenuated the up-regulation of VCAM-1, ICAM-1 and MCP-1 in HUVECs as well as the expression of MMP-2 and MMP-9 in macrophage-like cells induced by TNF-alpha. The anti-inflammatory effects of EPA were abrogated when the expression of peroxisome proliferator-activated receptor alpha (PPARalpha) was suppressed. EPA may potentially reduce and stabilize atherosclerotic lesions through its anti-inflammatory effects.     

A male case of nonclassical 21-hydroxylase deficiency first manifested in his sixties with adrenocortical incidentaloma

Nonclassical form of 21-hydroxylase deficiency (NC 21OHD) as a frequent variant on the milder end of the disease spectrum has been widely acknowledged, but its potential contribution to adrenocortical tumorigenesis has not been fully elucidated. We report a 66-year old male case of bilateral adrenocortical incidentaloma, associated with partial 21OHD without any episodes of hypoadrenocorticism in his past history. He was demonstrated to be a compound heterozygous mutant of CYP21A2 gene (IVS2-13A/C>G/I172N). The two tumors in the left adrenal, which were interpreted as myelolipoma by imaging studies, were followed by sequential observation, whereas the contralateral large solid tumor associated with inhomogeneous radiological appearance was subsequently removed. The resected tumor was diagnosed an adrenocortical adenoma, which was devoid of P450c21 immunoreactivity. 21OHD is often associated with benign adrenocortical tumors, but bilateral adrenal tumors with heterogeneous components in both adrenals have not been reported to the best of our knowledge.     

Importance of oral fluid intake after coronary computed tomography angiography: An observational study

Background

The prevention of contrast-induced acute kidney injury (AKI) after coronary computed tomography angiography (CCTA) is important because patients referred for CCTA often need further contrast exposure such as an invasive coronary angiography. We aimed to examine the effects of oral volume intake on renal function in patients with preserved renal function referred for CCTA.

Methods

We enrolled 180 patients who were referred for CCTA. The serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) levels were measured before, 24 h, and a mean of 4.8 days after CCTA. The amount of unrestricted oral fluid intake for 24 h was checked. The patients were divided into two groups: 106 subjects with a rise in SCr after CCTA (group A); and 74 without (group B).

Results

Significant correlations were observed between the amount of oral fluid intake and the percentage changes in SCr (%SCr) (r = −0.66, p < 0.0001) as well as the absolute changes in eGFR (ΔeGFR) (r = 0.65, p < 0.0001). The percentage of patients showing hemoglobin-A1c (HbA1c) ≥ 6.5% was greater in group A than in group B (29% vs. 18%, p < 0.001). Patients with HbA1c ≥ 6.5% showed higher %SCr and lower ΔeGFR compared to those without it. Multiple regression analysis revealed that the amount of oral fluid intake was the only independent predictor for a rise in SCr (β = −0.731, p < 0.0001).

Conclusion

Oral volume intake after CCTA is a very simple but important prophylactic procedure for contrast-induced AKI especially in diabetic patients.     

Comparison of 3 Frailty Instruments in a Geriatric Acute Care Setting in a Low-Middle Income Country

Objective

Comparison of frailty instruments in low-middle income countries, where the prevalence of frailty may be higher, is scarce. In addition, less complex diagnostic tools for frailty are important in these settings, especially in acutely ill patients, because of limited time and economic resources. We aimed to compare the performance of 3 frailty instruments for predicting adverse outcomes after 1 year of follow-up in older adults with an acute event or a chronic decompensated disease.

Genetic polymorphisms of UGT1A6 in a Japanese population

Thirteen single nucleotide polymorphisms (SNPs), including 6 novel ones, were found in exon 1 and its flanking region of UDP-glucuronosyltransferase (UGT) 1A6 from 195 Japanese subjects. Several novel SNPs were identified, including 269G>A (R90H), 279A>G (S93S), and 308C>A (S103X) in exon 1, and IVS1+109C>T, IVS1+120A>G, and IVS1+142C>T in the intron downstream of exon 1. Among these SNPs, 308C>A confers termination of translation at codon 103, resulting in the production of an immature protein that probably lacks enzymatic activity. The allele frequencies were 0.003 for all the 6 SNPs. In addition, the 3 known nonsynonymous SNPs were detected: 19T>G (S7A), 541A>G (T181A), and 552A>C (R184S) with frequencies of 0.226, 0.218, and 0.226, respectively. High linkage disequilibrium was observed among 19T>G (S7A), 315A>G (L105L), 541A>G (T181A), 552A>C (R184S), and IVS1+130G>T, as reported in Caucasian and African-American populations. Then, 11 haplotypes in UGT1A6 were estimated. The novel nonsynonymous variant, 269A or 308A, was shown to be located on the same DNA strand together with 19G, 315G, 541G, 552C, and IVS1+130T. Our results provide fundamental and useful information for genotyping UGT1A6 in the Japanese, and probably Asian populations.