Prediction of morbidity after lung resection with risk factors using treadmill exercise test.

OBJECTIVE: To predict accurate morbidity after lung resection using treadmill exercise test. METHODS: A total of 130 patients (108 men and 22 women, with mean age 67.1+/-11.4 years (range, 34-78 years)) of 1129 patients underwent standard lobectomy were performed both treadmill exercise test and spirometry preoperatively. We measured maximum oxygen uptake/body weight (VO2max/BW) and change in arterial blood oxygen pressure from rest to symptom-limited maximum loading (delta aPaO2) and calculated exercise-induced hypoxemia (delta PaO2/delta VO2/BW), and retrospectively compared these parameters for patients with and without complications. RESULTS: There were five patients with severe postoperative complications, including three requiring use of a respirator, two with home oxygen therapy. %Vital capacity, VC (%, 80.2+/-13.2 vs. 92.5+/-20.9, P=0.026), delta PaO2 (Torr, -29.3+/-4.3 vs. -13.2+/-10.8, P=0.0004), VO2max/BW (ml/min/kg, 16.5+/-2.9 vs. 20.6+/-5.1, P=0.018) and delta PaO2/delta VO2/BW (Torr/ml/min/kg, -1.98+/-0.26 vs. -0.57+/-0.47) were significantly associated with worse outcome. All the five patients with complications had delta PaO2/delta VO2/BW<-1.7. CONCLUSIONS: Treadmill exercise testing is a good method for assessment of cardiopulmonary reserve. Limited resection must be performed if delta PaO2/delta VO2/BW is under -1.7.     

Gliding Distance of the Extensor Pollicis Longus Tendon with Respect to Wrist Positioning: Observation in the Hands of Healthy Volunteers Using High-Resolution Ultrasonography

Study DesignCross-sectional experimental bench.IntroductionOptimal tendon gliding is necessary for normal thumb function.Purpose of the StudyMeasure the gliding distance of the extensor pollicis longus (EPL) tendons during passive thumb flexion from high-resolution echo images at four wrist positions.MethodsGliding distance of the EPL tendon in zone 4 of the thumb was measured during passive flexion in four different wrist positions in 25 healthy female volunteers. Tendon gliding was evaluated from high-resolution ultrasonography in a frame-by-frame cross-correlation analysis.ResultsMean gliding distance of the EPL tendon was 1.79, 2.45, 1.09, and 1.36 mm with the wrist positioned in neutral, 30 degrees of extension, 30 degrees of flexion, and 20 degrees of ulnar deviation, respectively. There were statistically significant differences in the gliding distance of the EPL tendon among all of four wrist positions except for that between the wrist flexion and wrist ulnar deviation conditions.ConclusionsWrist extension induces the greatest magnitude EPL tendon gliding.     

Border between N1 and N2 stations in lung carcinoma: lessons from lymph node metastatic patterns of lower lobe tumors

OBJECTIVE: Distinction of lymph node stations is one of the most crucial topics still not entirely resolved by many lung cancer surgeons. The nodes around the junction of the hilum and mediastinum are key points at issue. We examined the spread pattern of lymph node metastases, investigated the prognosis according to the level of the involved nodes, and conclusively analyzed the border between N1 and N2 stations. METHODS: We reviewed the records of 604 consecutive patients who underwent complete resection for non-small cell lung carcinoma of the lower lobe. RESULTS: There were 390 patients (64.6%) with N0 disease, 127 (21.0%) with N1, and 87 (14.4%) with N2. Whereas 11.3% of patients with right N2 disease had skip metastases limited to the subcarinal nodes, 32.6% of patients with left N2 disease had skip metastases, of which 64.2% had involvement of N2 station nodes, except the subcarinal ones. The overall 5-year survivals of patients with N0, N1, and N2 disease were 71.0%, 50.8%, and 16.7%, respectively (N0 vs N1 P = .0001, N1 vs N2, P < .0001). Although there were no significant differences in survival according to the side of the tumor among patients with N0 or N1 disease, patients with a left N2 tumor had a worse prognosis than those with a right N2 tumor (P = .0387). The overall 5-year survivals of patients with N0, intralobar N1, hilar N1, lower mediastinal N2, and upper mediastinal N2 disease were 71.0%, 60.1%, 38.8%, 24.8%, and 0%, respectively. Significant differences were observed between intralobar N1 and hilar N1 disease ( P = .0489), hilar N1 and lower mediastinal N2 disease (P = .0158), and lower and upper mediastinal N2 disease (P = .0446). Also, the 5-year survivals of patients with involvement up to station 11, up to station 10, and up to station 7 were 41.4%, 37.9% and 37.7%, respectively (difference not significant). CONCLUSIONS: N1 and N2 diseases appeared as a combination of subgroups: intralobar N1 disease, hilar N1 disease, lower mediastinal N2 disease, and upper mediastinal N2 disease. Interestingly, the survivals of patients with involvement up to interlobar nodes (station 11), main bronchus nodes (station 10), and subcarinal nodes (station 7) were identical. These data constitute the basis for a larger investigation to develop a lymph node map in lung cancer.     

Morphology and barrier function of the corneal epithelium after penetrating keratoplasty: association with original diseases, tear function, and suture removal.

PURPOSE: To study changes in structure and barrier function of the corneal epithelium after penetrating keratoplasty. METHODS: Sixty-nine eyes of 56 patients undergoing penetrating keratoplasty were studied. Fifty-six age-matched normal eyes served as controls. Corneal epithelial structure was studied by using specular microscopy. Barrier function of the corneal epithelium was examined by slit-lamp fluorophotometry. Vital staining, tear function, and corneal sensitivity also were examined. RESULTS: Fluorescein and rose bengal staining scores, incidence of elongated cells, the mean epithelial area, and mean fluorescein uptake were significantly increased in postkeratoplasty eyes compared with controls. Original disease influenced the results of barrier function, where keratoconus revealed better function than bullous keratopathy or corneal scar. However, no such differences were noted in epithelial structure. Six eyes with absence of palisades of Vogt had revealed significantly increased epithelial area and fluorescein uptake. Removal of the running suture caused a decrease in elongated cells and epithelial cell area without significant changes in barrier function. CONCLUSION: Corneal epithelial structure was significantly impaired in postkeratoplasty eyes. Epithelial barrier function of postkeratoplasty eyes was influenced by original diseases. Removal of sutures improves epithelial structure but not barrier function.     

Detection of cyclotorsional rotation during excimer laser ablation in LASIK

PURPOSE: Positionally induced cyclotorsion could be an important factor in the correction of astigmatism during refractive surgery. We analyzed the change in cyclotorsional rotation during excimer laser ablation in LASIK surgery using the NIDEK Torsion Error Detector (TED). METHODS: One hundred ten patients (192 eyes) who underwent LASIK for myopic astigmatism, using the NIDEK Advanced Vision Excimer Laser (NAVEX) were measured for cyclotorsion during surgery using the TED system. The manifest refraction of these patients was -6.80+/-2.74 diopters (D) (range: -1.00 to -13.75 D). The iris pattern of the patient's eyes in the supine position was recorded via a CCD camera in the EC5000CXII excimer laser system, and it was compared to the iris pattern acquired during OPD-Scan measurement in the sitting position. RESULTS: During laser ablation, the degree of cyclotorsional rotation detected by TED was 1.33+/-1.88 degrees (range: -6.33 to 2.99 degrees) clockwise and 1.00+/-1.79 degrees (range: -3.70 to 7.34 degrees) counterclockwise. The absolute degree of torsion error detected by the TED system was 2.33+/-1.16 degrees (range: 0 to 6.21 degrees). CONCLUSIONS: The effectiveness of the cylinder treatment can be reduced due to torsion errors. The degree of cyclotorsion constantly changes during laser ablation. Therefore, a monitoring system should be developed for the measurement of torsion error, and this will enable the maximum possible correction of the error during laser ablation.     

Transcorneal electrical stimulation of retina to treat longstanding retinal artery occlusion

Purpose To report the outcome of transcorneal electrical stimulation (TES) of the visual system on long-standing retinal artery occlusion (RAO). Design Open labeled, case series. Patients and methods Two patients with central RAO (15 and 33 months respectively) and one with branch RAO (26 months) underwent TES therapy. Subjective and objective ophthalmological evaluations were performed before and after the TES. The ages of the patients were 38, 49, and 63 years. The TES (20 Hz biphasic pulses, 30 minutes, up to 1100 uA) was delivered by a bipolar contact lens electrode once a month for 3 months. Perimetric and/or electrophysiological examinations were performed as outcome measures. Results The visual acuity improved by more than 0.2 logMAR units in two cases, and the visual fields were improved in all three cases. The multifocal ERGs which had been reduced in the loci corresponding to the ischemic retinal area were improved after the treatment in two cases. Neither ocular nor systemic adverse effects were observed except for transient superficial keratitis. Conclusions TES of the retina can improve retinal function in eyes with long-standing RAOs. None of the authors have any financial or proprietary interest in any material or methods mentioned. This study was supported by Researches on Sensory and Communicative Disorders from the Ministry of Health, Labor, and Welfare, Japan.     

Role of heat shock protein 47, a collagen-binding chaperone, in lacrimal gland pathology in patients with cGVHD

PURPOSE: Uncontrolled fibrosis due to excessive accumulation of extracellular matrix proteins in the lacrimal glands of patients with chronic graft-versus-host disease (cGVHD) is well documented. Heat-shock protein 47 (HSP47) is involved in the molecular maturation of collagen and has been shown to have a fibrogenic role in various fibrotic diseases. In this study, the role of HSP47 in the pathogenesis of lacrimal gland of patients with cGVHD was investigated. METHODS: The expression of HSP47, Ki67 (a proliferation marker), types I and III collagen, and alpha-smooth muscle actin (alpha-SMA) was examined in tissue sections and in primary cultures of fibroblasts obtained from the lacrimal glands of patients with cGVHD (n = 8) and Sj?gren's syndrome (SS; n = 7). RESULTS: Tissue sections of the lacrimal glands of patients with cGVHD showed markedly increased expression of HSP47 in fibroblasts around the medium-sized ducts than did those from patients with SS. The elevated expression of HSP47 in patients with cGVHD was mostly detected in Ki67-positive fibroblasts and was associated with increased accumulation of types I and III collagen in and around the fibrotic areas. Primary fibroblast cultures generated from cGVHD lacrimal gland showed higher HSP47 mRNA expression than did fibroblasts isolated from SS biopsy tissue, as determined by RT-PCR (P < 0.05). In contrast, alpha-SMA was higher in the SS than cGVHD fibroblasts at both mRNA and protein levels, and more lacrimal gland fibroblasts in the SS were positive for alpha-SMA than cGVHD (P < 0.01). CONCLUSIONS: In cGVHD, increased expression of HSP47 may promote excessive collagen assembly in and around the periductal areas where fibroblasts are mostly in an active state. The less alpha-SMA in the cGVHD lacrimal gland fibroblasts suggests a relative lack of myofibroblastic transformation. It is likely that fibroblasts incapable of myofibroblastic transformation are the main source of HSP47 and collagen production, and the resultant effect is the periductal fibrotic changes seen in lacrimal glands of patients with cGVHD.     

Revised Japanese criteria for Sjögren's syndrome (1999): availability and validity

The Japanese criteria for diagnosing Sjögren's syndrome (SS) were revised in 1999, and consist of four major areas: histopathology, oral examination, ocular examination, and serological examination. A diagnosis of SS can be made when the patient meets at least two of these four criteria. This report describes how the revised Japanese criteria were established. After the publication of the revised Japanese criteria (1999), a research study which focused on evaluating its availability and validity was carried out in 2001 using funds from Grant-in-Aids for Scientific Research supported by the Japan Society for the Promotion of Science. The availability of the revised criteria was investigated by a questionnaire study through the Japanese Medical Society for Sjögren's Syndrome, and the use of the revised criteria for diagnosing SS in these medical facilities was found to be 76%. To evaluate the validity of the revised criteria, the records of 900 patients, including SS patients and non-SS controls, from 54 clinical centers were registered and analyzed to calculate the accuracy of the criteria. The revised Japanese criteria were found to have 96.0% sensitivity, 90.5% specificity, and 94.5% accuracy for diagnosing SS.     

Infection with hepatitis B virus genotype A in Tokyo, Japan during 1976 through 2001

Background Because genotype A of hepatitis B virus (HBV) is not indigenous, there have been only few data on infection with it in Japan.Methods We examined clinical and virological features of the 66 Japanese patients who admitted Toranomon Hospital in Tokyo, Japan, between 1976 and 2001, who were found to have HBV/A infection. HBV genotype A was classified into subtype A (European type) and A (South African type) by phylogenetic analysis of the preS1 and preS2 regions, and the S gene sequences.Results Of the 66 patients infected with HBV/A, 14 (21%) were asymptomatic carriers, 26 (39%) presented with acute hepatitis, 22 (33%) with chronic hepatitis, and 4 (6%) with liver cirrhosis. HBV/A infection persisted for more than 6 months in 5 of the 26 (19%) patients with acute hepatitis. The frequency of acute hepatitis in patients infected with HBV/A was higher after than before 1991 (2/22 [9%] vs 24/44 [55%]; P < 0.0001). The frequency of nucleotide 1858 of T was higher in asymptomatic carriers than in patients with acute hepatitis in whom infection was resolved (5/14 [36%] vs 0/21 [0%]; P = 0.008). Of the 57 patients for whom subtypes of genotype A were determined, subtype A was identified in 53 (93%) and subtype A in only 4 (7%). All patients infected with subtype A were persistently infected with HBV.Conclusions HBV/A infection has become more frequent during recent years, predominantly presenting as acute hepatitis, and subtype A is uncommon in the Tokyo metropolitan area.