Association between blood pressure and mortality in 80-year-old subjects from a population-based prospective study in Japan.

Hypertension is one of the greatest risk factors for cardiovascular disease, but the contribution of high blood pressure to cardiovascular morbidity and mortality is weakened with aging. In the present study, we examined whether high blood pressure would be a risk factor for total and cardiovascular mortality in a group of very elderly Japanese. Six hundred and thirty-nine participants who were 80 years old in 1997 were enrolled. The subjects were divided into three groups on the basis of their systolic blood pressure (SBP) (below 140 mmHg [group 1, n=212], from 140 mmHg to 159 mmHg [group 2, n=217], over 160 mmHg [group 3, n=210]). During the 4-year follow-up period, 87 individuals died and 24 of these deaths were due to cardiovascular diseases. Cox multivariate regression analysis revealed that there was no association between total mortality and SBP levels (relative risk [RR] 1.71; confidence interval [CI] 0.81-3.58; group 3 compared with group 1, p=0.35). However, the subjects taking antihypertensive medication showed significantly higher mortality with increasing SBP level (RR 5.72, CI 1.03-31.6, p=0.04, group 3 compared with group 1). Furthermore, in the subjects with a cardiovascular disease such as angina or stroke, high SBP increased the total mortality (RR 13.4, CI 2.39-75.1, p=0.004, group 3 compared with group 1). The present study did not find an association between blood pressure and mortality in the very elderly. However, our results did suggest that high SBP increases the risk of mortality in patients with cardiovascular diseases and/or taking antihypertensive medication.     

Successful thrombolytic therapy for acute massive pulmonary thrombosis after total cavo-pulmonary shunt

A 4-year-old boy with massive pulmonary thrombosis after total cavo-pulmonary shunt was successfully treated by aggressive thrombolytic therapy. In the unique circulation involving total cavo-pulmonary shunt with azygous connection, the clinical manifestations of pulmonary thrombosis are somewhat different from those observed with ordinary biventricular circulation. The patient's hemodynamic state, including central venous pressure and systemic blood pressure, was relatively stable, but there was a dramatic decrease in oxygenation, possibly because azygous continuation allowed reversed blood flow from the superior vena cava to return to the atrium through collateral vessels between the azygous vein and the portal vein. Clinicians should be aware of this complication and unique circulation, and the importance of prompt diagnosis cannot be overemphasize. The effectiveness of the aggressive thrombolytic therapy in this case was noteworthy.     

Evaluation of Soluble Cell Adhesion Molecules in Atopic Dermatitis

Recent studies have indicated the importance of cell adhesion molecules (CAMs) between the vascular endothelium and activated leukocytes in various inflammatory skin diseases. Soluble forms of CAMs (sCAMs) have also been detected in sera from such diseases. In order to elucidate the role of the soluble forms in skin inflammation, we determined the serum levels of E-selectin, vascular cell adhesion molecule-1 (VCAM-1), and intercellular adhesion molecule-1 (ICAM-1) in patients with atopic dermatitis (AD). Using an enzyme-linked immunosorbent assay, we quantified sCAMs levels in 21 patients with atopic dermatitis and in 16 healthy controls. In severe AD patients, levels of these three types of sCAMs were markedly elevated. sE-selectin was significantly elevated in severe AD over the levels in mild AD. A positive correlation with individual clinical activity was found for changes in the sE-selectin and sVCAM-1 levels. sE-selectin levels were correlated with the serum IgE levels and the number of eosinophils. The sVCAM-1 level was also significantly correlated with the number of monocytes. Among these three molecules, sE-selectin appeared to be the most sensitive clinical parameter in monitoring the clinical course of AD patients.     

Thoracic surgery residency program and health care system in the United States

The Japanese Board of General Surgery as well as the Japanese Board of Thoracic Surgery voted to change the educational and training requirements for certification eligibility. The health care system has been modified due to a reduction of the budget for national health care, such as introduction of Diagnosis Related Groups (DRG)/Prospective Payment System (PPS). Several problems regarding the system have already been discussed in the United States, ranging from 30-year experience of residency program to 20-year experience of health care system. In a residency requirement, training period became longer in Japan than in the United States, although number of cases required is ten times less in Japan. The General Surgery Board now became mandatory in Japan, whereas optional in the United States. Inter-program transfer is possible in the United States, but not in Japan. Quality control has been organized for Thoracic Surgery in the United States, but the Japanese counterpart needs more work. In health care system, health insurance is mandatory and operated publicly in Japan while the United States counterpart is mostly optional and managed privately. Malpractice suits are 7–8 times more frequent in the United States. DRG/PPS health care system was temporarily useful in reducing the national budget for health care in the United States. However, an incentive to treat patients with uncomplicated diseases and short hospital stay increased the expenditure. In order to control this, Peer Review Organization has been established and restricted the physician’s activities. Because health insurance is optional in the United States, people opt for cheaper health insurance with greater benefits. So the health insurance companies with huge number of customers have had strong opinions over physicians and hospitals. This also has created restrictions on practice. These potential problems may occur shortly in the Japanese residency program and health care system as well. Thus, preventive strategies may be needed. Read at the Fifty-sixth Annual Meeting of the Japanese Association for Thoracic Surgery, Symposium, Tokyo, November 19–21, 2003.     

Chromosomal instability detected by fluorescence in situ hybridization in surgical specimens of non-small cell lung cancer is associated with poor survival.

PURPOSE: Chromosomal instability (CIN) in non-small cell lung cancer (NSCLC) has yet to be well studied. We examined the relationship between CIN detected by fluorescence in situ hybridization and survival in patients with NSCLC. EXPERIMENTAL DESIGN: Touch preparations from 50 surgical specimens of NSCLC were studied. Tumors included 34 adenocarcinomas, 15 squamous cell carcinomas, and 1 large cell carcinoma. The pathologic stage was IA in 14, IB in 17, IIB in 8, IIIA in 9, and IIIB in 2 cases. Enumeration of chromosomes 3, 10, 11, and 17 was used to determine which tumors carried CIN. The association between CIN and survival was also analyzed. RESULTS: Disomy was most common, but tetrasomy and trisomy of the examined chromosomes were seen frequently. Fourteen tumors (28%) showed heterogeneity of all four chromosomes examined and were judged to be carrying CIN. Both univariate and multivariate analyses revealed that two factors, lymph node metastasis and CIN, were significant poor prognostic factors. CONCLUSIONS: CIN in NSCLC detected by fluorescence in situ hybridization is an independent factor predicting a poor prognosis.     

Visualization of thoracic dissecting aortic aneurysm by transesophageal Doppler color flow mapping

Real-time color flow mapping by two-dimensional Doppler has now come into widespread use. However, its application via conventional transcutaneous approaches to dissecting aortic aneurysm has some limitations where visualization of the descending aorta is concerned. Its transesophageal approach to this disorder has hitherto remained unreported except by the authors. Transesophageal Doppler color flow mapping has been performed in twelve patients for diagnosis of dissecting aortic aneurysm, and the clinical significance of this method was evaluated. The system used for transesophageal color flow mapping was an Aloka SSD-880 ultrasound scanner with a 5 MHz probe. In all cases, the entire thoracic aorta except for the upper ascending aorta was visualized and both, real-time flow dynamics and structural information, were ascertained. Differentiation of the type of dissection, identification of the entry, and differentiation of the true and false lumina were performed in all cases. Information concerning the reentry was gained in seven cases (58%); aortic regurgitation was graded in three cases, in two of which prolapse of the intimal flap was observed. In five cases, aortography was needed in order to delineate the involvement of aortic branches in the dissection; and in the other seven cases, transesophageal Doppler information was sufficient. In four cases who were operated, the postoperative state was well evaluated. Transesophageal Doppler color flow mapping was found to be a useful method for visualization of the whole thoracic aorta apart from the upper ascending section, and for precise evaluation of the structure and hemodynamics of dissecting aortic aneurysms.     

In vitro and in vivo antibacterial activities of CS-023 (RO4908463), a novel parenteral carbapenem

CS-023 (RO4908463, formerly R-115685) is a novel 1beta-methylcarbapenem with 5-substituted pyrrolidin-3-ylthio groups, including an amidine moiety at the C-2 position. Its antibacterial activity was tested against 1,214 clinical isolates of 32 species and was compared with those of imipenem, meropenem, ceftazidime, ceftriaxone, ampicillin, amikacin, and levofloxacin. CS-023 exhibited a broad spectrum of activity against gram-positive and -negative aerobes and anaerobes, including methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis, penicillin-resistant Streptococcus pneumoniae (PRSP), beta-lactamase-negative ampicillin-resistant Haemophilus influenzae, and Pseudomonas aeruginosa. CS-023 showed the most potent activity among the compounds tested against P. aeruginosa and MRSA, with MICs at which 90% of isolates tested were inhibited of 4 microg/ml and 8 microg/ml, respectively. CS-023 was stable against hydrolysis by the beta-lactamases from Enterobacter cloacae and Proteus vulgaris. CS-023 also showed potent activity against extended-spectrum beta-lactamase-producing Escherichia coli. The in vivo efficacy of CS-023 was evaluated with a murine systemic infection model induced by 13 strains of gram-positive and -negative pathogens and a lung infection model induced by 2 strains of PRSP (serotypes 6 and 19). Against the systemic infections with PRSP, MRSA, and P. aeruginosa and the lung infections, the efficacy of CS-023 was comparable to those of imipenem/cilastatin and vancomycin (tested against lung infections only) and superior to those of meropenem, ceftriaxone, and ceftazidime (tested against P. aeruginosa infections only). These results suggest that CS-023 has potential for the treatment of nosocomial bacterial infections by gram-positive and -negative pathogens, including MRSA and P. aeruginosa.     

Comparison of chest CT findings between suspected and definite cases of primary pulmonary M. avium complex infection

It is very difficult to treat pulmonary infection with MAC, because we have few effective drugs against this organism. In this situation, an early diagnosis and treatment are very important to manage this disease. We evaluated chest CT scans of the primary pulmonary MAC infection which had no underlying lung diseases and no immunocompromised diseases such as HIV infection. We defined suspected cases of pulmonary MAC infection as cases in which abnormal features of chest CT scans were recognized but frequency of detection of organisms of MAC did not fulfil the diagnostic criteria for atypical mycobacteriosis according to Japanese Mycobacteriosis Research Group of the National Chest Hospitals. CT scans of suspected cases were compared with the definite cases. Results obtained were as follows: 1. In classification by CT scans of primary pulmonary MAC infection, the proportion of localized type and diffuse type was the same both in suspected and definite cases. In localized type, more tuberculosis-like pattern was seen in definite cases. 2. In suspected cases, characteristic features of CT scans of primary pulmonary MAC infection were recognized in the same frequency as in definite cases. 3. In pulmonary tuberculosis-like type, definite cases showed more cavitary lesions than suspected cases. These results showed that a careful long term follow-up of suspected cases with frequent bacteriological tests of sputum and chest CT scannings was important for early diagnosis of primary pulmonary MAC infection.