Percutaneous fluoroscopic removal of a knotted Swan–Ganz catheter in a patient with a persistent left‐sided superior vena cava

Knotting of intravascular catheters is an uncommon but a well‐recognized occurrence. The Swan–Ganz catheter (SGC) is the one that knots most commonly. A case of a knotted SGC is described in a patient with a persistent left‐sided superior vena cava, and we propose that the presence of a left‐sided superior vena cava is a risk factor for knot formation not previously reported. We review the published work on the risk factors for knot formation and on the techniques used to remove knotted SGC. We describe a technique using a gooseneck snare and Omni Flush catheter (Angiodynamics, Queensbury, NY, USA) to loosen and untie a knotted SGC.     

Criteria for definition of regional functional improvement on quantitative post-stress gated myocardial SPET after bypass surgery in patients with ischaemic cardiomyopathy

Myocardial viability can be defined as functional improvement of dysfunctional myocardium after revascularization. The purpose of this study was to define the optimal criteria for definition of regional functional improvement after coronary artery bypass graft (CABG) surgery on quantitative gated single-photon emission tomography (SPET). Thirty-two patients (26 men, 6 women; age 56 +/- 13 years) with coronary artery disease (three-vessel disease, 17; two-vessel disease, 15; previous history of myocardial infarction, 9) and severe left ventricular dysfunction (LVEF < or = 35%) underwent CABG. Rest thallium-201/dipyridamole stress technetium-99m methoxyisobutylisonitrile gated myocardial SPET was performed before and 3 months after CABG. Global LV functional improvement was defined as either an improvement in LVEF of 10% ( n = 15) or an improvement in LVEF of 5% combined with a decrease in end-systolic volume of 10 ml ( n = 2) after CABG on quantitative gated SPET. Postoperative regional wall thickening improvement (DeltaRWT), regional wall motion improvement (DeltaRWM) and regional resting (DeltaRP) and stress perfusion improvement (DeltaRstrP) were used to determine global functional improvement by ROC curve analysis, and the optimal criteria for definition of viable regional dysfunctional myocardium were defined on the ROC curves. Correlations were verified by determining the number of improved myocardial regions and LVEF improvement. LVEF was improved from 25% +/- 6% to 34% +/- 11% after CABG. A total of 229 segments were dysfunctional (wall motion < or = 2 mm, thickening < or = 20%) before CABG. On ROC curve analysis using global functional improvement as an indicator of viability, the areas under the ROC curves (AUCs) of DeltaRWT and DeltaRWM were 0.717 and 0.620, respectively. The AUC of DeltaRWT was significantly larger than that of DeltaRWM ( P = 0.009) and the optimal cut-off value of DeltaRWT was 15%. The AUCs of DeltaRP and DeltaRstrP were not significant. The correlation coefficients between summed DeltaRWT and DeltaRWM and LVEF improvement were 0.591 and 0.472, respectively. The number of segments with a DeltaRWT of more than 15% correlated with LVEF improvement (rho = 0.533 by Spearman rank correlation). Regional wall thickening improvement showed the best correlation with global LV functional improvement after CABG. The most reliable regional criterion of myocardial viability was improvement in regional wall thickening by > or = 15% on quantitative gated SPET.     

Time course of functional recovery after coronary artery bypass grafting surgery according to the preoperative reversibility of perfusion impairment on myocardial SPECT

Purpose Ischaemic myocardial dysfunction shows different time courses of functional recovery according to the pathophysiological characteristics of the dysfunction. In this study, we investigated the time course of functional recovery according to the preoperative reversibility of perfusion impairment on myocardial single-photon emission computed tomography (SPECT) after revascularisation surgery.Methods Forty-eight patients (42 men and 6 women; mean age 59±9 years) who underwent revascularisation surgery were included in the study. ²⁰¹Tl rest/dipyridamole stress ^99mTc-sestamibi gated SPECT was performed 10±8 days before (preoperative), 105±13 days after (early follow-up) and 497±66 days after (late follow-up) surgery. Using a 20-segment model, segmental perfusion and thickening were quantified with automatic software. As an indicator of the reversibility of perfusion impairment, a reversibility score (RevS) was defined as a measure of rest minus stress perfusion values. Segmental dysfunction and functional recovery were defined from quantified thickening values. Function-recovered segments were divided into early recovery and late recovery groups, and preoperative perfusion status was compared in these groups. Function-recovered segments were also re-classified into high-RevS and low-RevS groups according to the preoperative RevS, and the time courses of functional recovery were investigated in each group.Results A total of 502 segments were included in the analysis and 263 were finally classified as function-recovered segments. Of these, 172 were in the early recovery and 91 in the late recovery group. In terms of preoperative perfusion status, RevS was 8.9±10.8 in the early recovery group and 5.4±11.0 in the late recovery group (P=0.01). When all 502 segments were classified by RevS, no difference in the proportion of final function recovery was observed between the high-RevS and the low-RevS group (54% vs 51%). However, the proportion of early recovery was higher in the high-RevS group (73%) than in the low-RevS group (57%) (P=0.01).Conclusion Ischaemic dysfunctional myocardium with reversible perfusion impairment tends to recover function earlier after revascularisation surgery than myocardium with a persistent decrease in perfusion.     

Should patients with a pre-operative prostatespecific antigen greater than 15ng/ml be offered radical prostatectomy?

Background Patients with prostate cancer with a pre-operative prostate-specific antigen (PSA) τ;15ng/ml who undergo radical retropubic prostatectomy (RRP) generally do not have a good outcome, yet may have organ-confined cancer and should be offered the option of surgery. Aim To assess the outcome of patients who underwent RRP with a pre-operative PSA ≥ 15ng/ml. Methods Thirty-four patients, mean pre-operative PSA: 25.46ng/ml (15.03–76.6) and mean Gleason score: 6.4 (5–9) were assessed. Results Two groups were identified. Group I: 41% (14/34) have no biochemical recurrence to mean follow up of 58 months (30–106). Mean PSA: 18.8ng/ml (15.03–25.84). Mean Gleason score: 6.1 (5–7). Clinical stage: T1c in 80%. No patient had seminal vesicle or lymph node involvement. Group II: 59% (20/34) have biochemical recurrence or died (3) from their disease to mean follow up of 66 months (36–98). Mean PSA: 28.9ng/ml (15.28–76.6). Mean Gleason score: 6.7 (5–9). Clinical stage: T1c in 25%. Eleven patients had seminal vesicle (8) involvement or positive lymph nodes (3) or both (2). Conclusion RRP seems feasible in patients whose pre-operative PSA is between 15 and 25ng/ml with stage T1c, Gleason score ≤ 7 and negative lymph node frozen section.     

Increased urinary F(2)-isoprostanes levels in the patients with Alzheimer's disease

Isoprostanes, novel markers of oxidative injury, are generated by the free radical-mediated peroxidation of arachidonic acid (AA). They are thought to be important in the pathogenesis of neurodegenerative diseases such as Alzheimer's disease (AD). Using gas chromatography-mass spectrometry (GC-MS), we investigated the alteration of urinary F(2)-isoprostanes in AD patients compared to that of healthy subjects. Our results show that the levels of urinary F(2)-isoprostanes, sum of the prostaglandin F(2 alpha) isomer; prostaglandin F(2 alpha) (PGF(2 alpha)), prostaglandin F(2 beta) (PGF(2 beta)), and 8-isoprostaglandin F(2 alpha) (8-isoPGF(2 alpha)), significantly increased in AD patients (P < 0.05). The concentration of urinary 8-isoPGF(2 alpha), one of the biomarkers of oxidative stress, was not significantly different between 34 AD patients and 20 age-matched controls (P > 0.05). The PGF(2 alpha), formed by endoperoxide reductase from PGH(2), was significantly increased in AD patients, when compared with the levels of the normal controls (P < 0.05). The PGF(2 alpha), an enzymatic product of arachidonic acid, may affect the pathogenesis of AD. In addition, urinary F(2)-isoprostanes can play an important role as a biomarker in AD.     

Relationship between the chest radiograph, regional lung function studies, exercise tolerance, and clinical condition in cystic fibrosis

This study evaluated the accuracy of the interpretation of the chest film in delineating localised abnormalities of ventilation and perfusion, as well as the overall severity of airways obstruction, exercise tolerance, and clinical condition in children with cystic fibrosis. Radiographic findings in various regions of the chest film were compared with the functional values obtained with regional lung function tests which evaluated the arrival and disappearance of boluses of radioactive nitrogen given by inhalation and infusion. While the more severely affected areas on the chest radiograph were found to correlate with similar regions on the lung function tests, as did overall scores, errors occurred in some cases if the x-ray film alone was used as a judge of regional physiological derangement. In addition the degree of airways obstruction, the exercise tolerance on a cycle ergometer, and clinical grading, each correlated significantly with the radiographic score. We conclude that the chest radiograph is a good indicator of the overall severity of the lung disease and that it correlates well with exercise tolerance and clinical condition in cystic fibrosis.     

Endoplasmic reticulum stress is involved in hydrogen peroxide induced apoptosis in immortalized and malignant human oral keratinocytes

Background: Although hydrogen peroxide may play an important role in the development of cancer, it can be an efficient inducer of apoptosis in cancer cells; the exact mechanism by which this action occurs is not completely understood in oral cancer cells. Method: In this study, the mechanisms by which H₂O₂ inhibited growth and induced apoptosis were differentially investigated using HPV‐immortalized human oral keratinocytes (IHOK) and oral cancer cells (HN4). Results: H₂O₂ treatment sensitively and dose‐dependently induced growth inhibition and typical apoptosis in IHOK and HN4 cells, as demonstrated by a decreased level of cell viability, an increased population of cells in the sub‐G₀/G₁ phase, ladder formation of the genomic DNA, chromatin condensation and accumulation of Annexin V⁺/PI⁺ cells. Furthermore, the expression of Bax, p53 and p21^WAF1/CIP1 increased, whereas the expression of Bcl‐2 decreased in immortalized and malignant keratinocytes that were treated with H₂O₂. In addition, cytochrome‐c from the mitochondria was observed in H₂O₂‐treated IHOK and oral cancer cells, and this was accompanied by the activation of caspase‐3 and ‐9. Additionally, H₂O₂ treatment induced upregulation of CHOP, GRP78 and several representative endoplasmic reticulum (ER) stress‐responsive proteins, including heme oxygenase‐1. Conclusion: Overall, these results suggest that H₂O₂ triggers apoptosis via the mitochondrial and ER stress pathway in IHOK and HN4 cells, and that increasing the cellular levels of H₂O₂ sufficiently may lead to selective killing of oral cancer cells and therefore be therapeutically useful.