Outcome of carotid endarterectomy and stent insertion based on grading of carotid endarterectomy risk: a 7-year prospective study

OBJECT: The authors of this study prospectively compared periprocedural neurological morbidity and the appearance of lesions on diffusion-weighted (DW) magnetic resonance (MR) imaging in patients who had undergone carotid endarterectomy (CEA) or carotid artery stent placement (CASP) with distal balloon protection, based on a CEA risk grading scale. METHODS: Patients undergoing CEA (139 patients) and CASP (92 patients) were classified into Grades I to IV, based on the presence of angiographic (Grade II), medical (Grade III), and neurological (Grade IV) risks. Although not randomized, the CEA and CASP groups were well matched in terms of the graded risk factors except for a greater proportion of neurologically unstable patients in the CEA group (11 compared with 3%, p = 0.037). There were greater proportions of asymptomatic (64 compared with 34%, p = 0.006) and North American Symptomatic Carotid Endarterectomy Trial-ineligible patients (29 compared with 14%, p < 0.0001) in the CASP group. The overall rates of neurological morbidity with ischemic origin and the appearance of lesions on DW MR imaging after CEA were 2.2 and 9.3%, and those after CASP were 7.6 and 35.9% (nondisabling stroke only), respectively. The only disabling stroke was caused by an intracerebral hemorrhage attributable to hyperperfusion in one case (0.7%) of CEA. There were no deaths. There was no significant association between neurological morbidity and the risk grade in patients who had undergone CEA, although the incidence of lesions on DW imaging was significantly greater in the Grade IV risk group compared with that in the other risk groups combined (42.1 compared with 4.2%, p < 0.0001). After CASP, a higher incidence of neurological morbidity and lesions on DW imaging was noted for the Grade II and III risk groups combined as compared with that in the Grade I risk group, regardless of a symptomatic or an asymptomatic presentation (neurological morbidity: 10.5 compared with 3.1%, respectively, p = 0.41; and DW imaging lesions: 47.4 compared with 19.4%, p = 0.01). The incidence of lesions on DW imaging after CEA was significantly lower than that after CASP except for the Grade IV risk groups. CONCLUSIONS: Despite a higher incidence of DW imaging-demonstrated lesions in the Grade IV risk group, there was no significant association between the risk group and neurological morbidity rates after CEA. The presence of vascular and medical risk profiles conferred higher rates of neurological morbidity and an increased incidence of lesions on DW imaging after CASP. Considering that no serious nonneurological complications were noted, CEA and CASP appear to be complementary methods of revascularization for carotid artery stenosis with various risk profiles.     

Prostate cancer development after transurethral resection of the prostate--histopathological studies of radical prostatectomy specimens

PURPOSE: We investigated prostate cancer (ca.) development after transurethral resection of the prostate (TURP). PATIENTS AND METHODS: From 1995 to 2003, 430 patients (pts.) received TURP at Toshiba Rinkan Hospital. Of them, 23 pts. (5.3%) had incidental carcinoma (Stage A), which developed into clinically significant ca. after 1 to 5 years in 5 (22% of Stage A, 1.2% of TURP). In 13 (3.2%) of 407 Non-Stage A pts. (who had no ca. initially), prostate ca. developed after 1 to 7 yrs. A total of 21 pts. (including 3 Stage A pts. diagnosed before 1994) underwent radical prostatectomy. Stage A pts. received regular needle biopsy of prostate (Pbx). Non-Stage A pts. were followed by yearly PSA measurement and digital rectal examination (DRE). Detailed histopathological studies were done on 21 radical prostatectomy specimens. RESULTS: Clinically significant ca. developed in 8 Stage A pts. (all A2) after 1 to 14 yrs. Long term (5 or 10 years) MAB therapy changed moderately-differentiated adenocarcinoma (AC) to poorly-differentiated AC in 2 pts. during follow-up. When ca. developed PSA increased in only 3 of them, DRE was positive just in 1 pt. Tumor invasion was observed mainly in transition zone (TZ), especially anterior to urethra. In spite of no capsular penetration, surgical margin was positive in 2 pts. PSA failure occurred in another 2 pts. Thirteen Non-Stage A pts. showed aggressive ca. (6 moderately-differentiated AC, 6 poorly-differentiated AC, and 1 ductal carcinoma which showed metastasis later), most of which invaded widely in peripheral zone (PZ). Pbx before TURP was done to reveal that there was no cancer in 11 pts. Capsular penetration was seen in 4 pts. Surgical margin was positive in 4 pts. PSA (8.6 +/- 4.0 ng/ml) decreased after TURP but was kept in high level (4.8 +/- 2.2 ng/ml) after 1 year and increased (8.7 +/- 4.5) when cancer was diagnosed in all 13 pts. DRE was positive in 38% of them. Interval between TURP and diagnosis was short in pts. who had cancer of high Gleason Score (GS) or large prostate. CONCLUSIONS: As significant cancer developed in 22% of Stage A pts. (1.2% of TURP) in long term follow-up, regular Pbx (to get TZ tissue) is mandatory regardless of PSA value or DRE. Aggressive cancer developed in 3.2% of Non-Stage A pts. (3.0% of TURP). Pts. with high PSA or abnormal DRE after TURP must receive needle biopsy actively. Considering that more than 4% of TURP pts. eventually require radical prostatectomy, relatively younger pts. who received TURP have to be carefully followed for a long period.     

In vitro response time of continuous cardiac output measurement in STAT mode of Vigilance after controlled flow change

BACKGROUND: Continuous cardiac output measurement in STAT mode (STAT CCO) equipped with Vigilance displays cardiac output every 30 to 60 seconds. The aim of this study is to verify the hypothesis that each value with this system is computed only from the data collected in one update period. METHODS: The circuit was filled with normal saline and flowed by a roller pump in in vitro setting. The flow rate was set at either 2.5 l x min(-1) or 5.0 l x min(-1) and changed quickly to another state after each state had been maintained for 25 minutes. The change operation was repeated 10 times. The maximum difference was defined as the difference between the value at the start and the maximum change value. The response time was defined as the time from the start to the time to reach 80% of the maximum difference. In each operation, the response time of STAT CCO was calculated. RESULTS: The response time of STAT CCO was 9.7 +/- 1.3 min (mean +/- SD). CONCLUSIONS: The response time of STAT CCO was about 10 times longer than one update period. This result suggests that STAT CCO values are not computed only from the data collected in one update period.     

Alpha-adrenergic activity and urethral pressure in prostatic zone in benign prostatic hypertrophy

In order to examine to what extent adrenergic mechanism contributes to the urethral pressure in patients with benign prostatic hypertrophy, changes in the intraurethral pressure in the prostatic zone were measured in vivo by both the urethral pressure profile technique and the balloon method before and after administration of alpha-adrenergic stimulants and an alpha-adrenergic blocker. The effect of spinal anesthesia on the urethral pressure was also investigated. It is suggested that 40 per cent of the total urethral pressure in patients with benign prostatic hypertrophy is due to alpha-adrenergic tone, and the remaining 53 per cent is due to static pressure resulting from the hypertrophied prostatic bulk. The in vitro study indicates that the increase in urethral pressure and contraction of the prostate, prostatic capsule and prostatic urethra.     

Isolation of labeled triiodothyronine from serum using affinity chromatography: application to the extimation of the peripheral T4 to T3 conversion in rats.

A method for the isolation of small quantities of labeled 3,5,3' -triiodothyronine (T3) from serum or thyroid extracts is described. Conjugates of rabbit anti-T3 antibody to Sepharose 4B are incubated with 0.5 to 1 ml of human or rat serum at pH 8.6 for 1 hr. The tubes are centrifuged and washed with buffer followed by 6 M guanidine to remove nonspecifically bound labeled thyroxine (T4). The fraction of T3 and T4 bound to the Sepharose conjugate varies depending on the concentration of serum in the initial incubation tubes, the T3 and T4 content, and the specificity of the antiserum used. In a system that contains 0.5 ml of normal human serum, 1 ml of glycine-acetate buffer (pH 8.6), and 0.25 ml settled Sepharose-anti-T3 conjugate, the T3 to T4 binding ratio was generally 150-200, with up to as much as 50% of T3 bound to the pellet. The coefficient of variation of the method is less than 5%, and it may be performed in a matter of hours. There is no detectable conversion of T4 to T3 during the separation process. Using this technique, conversion of T4 to T3 was evaluated in euthyroid rats after injection of 125l-T4. Over the period of 36-72 hr after injection, a ratio of T3 to T4 of 0.74 +- 0.06 x 10-2 (mean +- SE) was present in the plasma. Using the calculated metabolic clearance rates for T3 and T4 in these animals, fractional conversion of T4 to T3 was estimated to be 27%, in good agreement with results obtained by other techniques. This method would appear to be of value for specific isolation of the small quantities of T3 produced from T4 after in vivo or in vitro T4 to T3 conversion.