Aortic valve/root replacement using a stentless bioprosthesis (Medtronic Freestyle valve)

BACKGROUND: The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis. METHODS: Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography. RESULTS: There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II. CONCLUSION: The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.     

Chronic necrotizing pulmonary aspergillosis complicated by a cavitary lesion caused by Pulmonary Mycobacterium-avium complex disease

A 66-year-old woman who had undergone one year's treatment for pulmonary nontuberculous mycobacterial disease due to Mycobacterium avium (rifampicin, ethambutol, clarithromycin, streptomycin-->levofloxacin) five years earlier was admitted to our hospital because of continuous fever and a newly detected abnormal chest shadow, which was like a fungus ball in the right upper lobe on chest computed tomography in the giant cavitary lesion caused by pulmonary Mycobacterium-avium complex (MAC) disease. A diagnosis of chronic necrotizing pulmonary aspergillosis (CNPA) complicated by pulmonary MAC disease was made because Aspergillus niger was isolated from several sputum specimens, anti-aspergillus antibody was positive, and clinical symptoms such as fever, were disclosed with the radiological finding of a fungus ball-like shadow and an infiltration shadow around the cavity. The patient had received various forms of antifungal chemotherapy, but the clinical effect had been poor. Since then, she had been slowly worsening. Although mycetomas, with the typical appearance of a fungus ball on a chest radiograph, have been reported to easily form in cavitary lesions caused by previous pulmonary tuberculosis, we believe, as illustrated by the present case, that they could also form in such lesions caused by pulmonary MAC disease, since the frequency of pulmonary nontuberculous mycobacterial disease has recently been increasing in comparison with that of pulmonary tuberculosis.     

Adiponectin inhibits endothelial synthesis of interleukin-8

Adiponectin is an antiatherogenic adipokine that inhibits inflammation by mechanisms that are not completely understood. We explored the effect of adiponectin on endothelial synthesis of interleukin-8 (IL-8), a pro-inflammatory chemokine that plays a role in atherogenesis. Adiponectin decreased the secretion of IL-8 from human aortic endothelial cells (HAEC) stimulated with tumor necrosis factor-alpha (TNF-alpha). Adiponectin also inhibited IL-8 mRNA expression induced by TNF-alpha. Phosphorylation of IkappaB-alpha was decreased by adiponectin, but phosphorylation of ERK, SAPK/JNK, and p38MAPK were unaffected. Adiponectin increased intra-cellular cAMP levels in HAEC in a dose-dependent manner; PKA activity was also increased. The inhibitory effect of adiponectin on TNF-alpha-induced IL-8 synthesis was inhibited by pretreatment with Rp-cAMP, a PKA inhibitor. These observations suggest that adiponectin inhibits IL-8 synthesis through inhibition of a PKA dependent NF-kappaB signaling pathway. We also showed that adiponectin enhances Akt phosphorylation. The inhibitory effect of adiponectin on TNF-alpha-induced IL-8 synthesis was abrogated in part by pretreatment with the PI3 kinase inhibitor LY294002 or by Akt siRNA transfection, suggesting that Akt activation might inhibit IL-8 synthesis induced by TNF-alpha. We conclude that inhibition of NF-kappaB and activation of Akt phosphorylation may mediate adiponectin inhibition of atherosclerosis.     

Countermeasures against non-specific reactions in the measurement of beta-glucan in plasma by alkaline treatment, chromogenic automated kinetic assay

We investigated the detection of non-specific reactions in the measurement of plasma (1-->3)-beta-D-glucan (beta-glucan) and countermeasures against them using alkaline treatment, chromogenic automated kinetic assay (alkaline-kinetic assay). In this study, we reexamined the values of beta-glucan using the alkaline-kinetic assay with and without laminaran oligosaccharides (LO) as a kind of beta-glucan that blocks the Limulus reaction. The materials for this study were 584 plasma samples in which beta-glucan had been measured. These were taken from 232 patients in Kawasaki Medical School Hospital between January 2002 and March 2002. Non-specific reactions were judged by a calculated value under a LO additive condition. Determination as to whether or not the each time course of the Limulus reaction was influenced by a non-specific reaction was also studied by applying a non-specific reaction index set up independently. Non-specific reactions were recognized in 51.9% of the samples (81/156). The amount of non-specific reaction was 9.9 pg/ml or less in major samples. On the other hand, when the cut off value of the index for detection of non-specific reactions was set at 0.5, the sensitivity was 88.9% and specificity was 73.7%. The positive and negative predictive values were 93.5% and 60.9% respectively. Non-specific reactions can be approximately distinguished by applying the non-specific reaction index. By so doing, unnecessary initiation of anti fugal therapy in response to non-specific reactions can be avoided. Further prospective and radical studies of non-specific reactions in the alkaline-kinetic assay are necessary.     

A case of nonspecific interstitial pneumonia with reversed halo sign on chest HRCT]

A 39-year-old man was referred to our hospital with anterior chest discomfort, dry cough and shortness of breath. His blood test revealed mild inflammatory change and high serum KL-6 levels. Chest radiograph and computed tomography (CT) showed ground glass attenuation with volume loss in both lower lung fields, and in particular a reversed halo sign was shown on high-resolution CT (HRCT). As transbronchial lung biopsy and bronchoalveolar lavage did not enable a diagnosis, video-assisted thoracic surgery was performed. The histological findings of the resected specimen showed cellular nonspecific interstitial pneumonia. This suggested the possibility of collagen vascular disorder (CVD) associated with interstitial pneumonitis, but no criteria of CVD were fulfilled. Although the reversed halo sign is relatively specific for cryptogenic organizing pneumonia, we report a case of cellular nonspecific interstitial pneumonia showing this sign on chest HRCT.     

Diffuse intrahepatic recurrence after resection of hepatocellular carcinoma

BACKGROUND/AIMS: An early diffuse type in the pattern of the postoperative intrahepatic recurrence of hepatocellular carcinoma has been recognized. The purpose of this study was to elucidate risk factors for diffuse recurrence of hepatocellular carcinoma. METHODOLOGY: The subjects involved in the present study were 114 patients with hepatocellular carcinomas resected in Tenri Hospital during the past 12 years. Univariate analysis was used for retrospective determination of the factors related to diffuse recurrences after surgery in 10 cases among 114 patients. RESULTS: The risk factors linked to diffuse recurrence were microscopical portal infiltration (P < 0.01), elevated alpha-fetoprotein (more than 1000 ng/mL) (P < 0.05), the absence of preoperative transcatheter arterial embolization (P < 0.01), and two or more segmentectomies of the liver (P < 0.01). Six of 10 patients with microscopical portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL) had diffuse recurrence (P < 0.01). Six of 8 patients with two or more segmentectomies without preoperative TAE had diffuse recurrence (P < 0.01). CONCLUSIONS: When patients with the diagnosis of operable hepatocellular carcinoma have portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL), two or more segmentectomies of the liver without preoperative transcatheter arterial embolization should be avoided.     

Association between a variant of the glutathione S-transferase P1 gene (GSTP1) and hypertension in pregnancy in Japanese: interaction with parity, age, and genetic factors

Hypertension in pregnancy (HP), including preeclampsia (PE), is known to be a multifactorial disease. Recently, an Ile105Val variant of the glutathione S-transferase P1 gene ( GSTP1) was shown to be associated with PE in The Netherlands. We therefore performed an association study of the Ile105Val variant comparing 131 patients with HP and 327 normal pregnant controls in Japan. We analyzed the data in the context of other risk factors before pregnancy. The frequency of the Ile/Val+Val/Val genotype of the GSTP1 was not significantly different between the HP (26%) patients and the controls (28%). However, in primiparous patients, the frequency was significantly different in elderly pregnancy (63% in severe HP vs. 18% in controls; P < 0.05), in the subgroup with the MM+MT genotypes of the angiotensinogen gene (50% in severe HP vs. 26% in controls; P < 0.05), and in the subgroup with the GA+AA genotypes of the endothelial nitric oxide synthase gene (42% in severe HP vs. 13% in controls; P < 0.05). These results suggest that this variant of the GSTP1 may play a role in the manifestation of HP together with other independently and/or synergistically acting factors, particularly in primiparous pregnancy.     

A case of primary pulmonary MALT lymphoma as a nodular shadow on CT scan, and relapsed with diffuse micronodular shadows after surgical resection at 7 years ago]

A 76-year-old man without symptoms was admitted to our hospital for investigation of an abnormal chest shadow in 1994. His chest radiograph showed a nodular shadow in the lingual lobe. Segmentectomy was performed and the histological diagnosis was MALT (mucosa-associated lymphoid tissue) lymphoma. In June 2001, there were no abnormal shadows on the chest radiograph or in 10 mm slice CT. However, high-resolution CT with 2-mm slice thickness revealed diffuse micronodular shadows in both lungs. A relapse of MALT lymphoma was diagnosed by immunohistochemical analysis of tissue specimens obtained by transbronchial lung biopsy. It was observed that the patterns of radiological findings in primary pulmonary MALT lymphoma cases may differ between the initial state and a relapse.     

Prediction of functional recovery of the left ventricle after coronary revascularization in patients with prior anterior myocardial infarction: a myocardial integrated backscatter study.

Cyclic variation (CV) of myocardial integrated backscatter (IBS), which reflects intrinsic contractile performance, can predict myocardial viability in patients with a reperfused acute myocardial infarction (MI), but the use of this method has not been validated for chronic left ventricular (LV) dysfunction. The aim of this study was to examine whether myocardial IBS was useful for predicting LV functional recovery after coronary revascularization in 17 patients with prior anterior MI and LV dysfunction (ejection fraction <50%). Within 24 h of the revascularization procedure (percutaneous transluminal coronary angioplasty or coronary stenting), IBS curves were obtained by placing the region of interest on the anterior wall on the short-axis IBS image. The patients had repeat left heart catheterization at 3 or 6 months after the revascularization procedure, and were grouped according to the patterns of the IBS curve within the anterior wall. In 8 patients (group A), the IBS curve had a synchronized pattern with the magnitude of CV > or = 3.5, and in the remaining 9 patients (group B), the curve had either an asynchronized pattern or the magnitude of CV was less than 3.5 dB even in the case of synchronized pattern, or both. At baseline, there were no significant differences in LV functional indices between the 2 groups. After the follow-up period, the LV end-systolic volume decreased (75 +/- 21 ml to 56 +/- 20ml, p = 0.05), LV ejection fraction increased (35 +/- 12% to 50 +/- 14%, p = 0.014), and LV end-diastolic pressure decreased (19 +/- 10 mmHg to 13 +/- 6 mmHg, p = 0.02) in group A, whereas only the LV ejection fraction increased (34 +/- 9% to 40 +/- 11%, p = 0.03) in group B; LV end-systolic volume (72 +/- 19 ml to 66 +/- 16 ml, p = 0.126) and LV end-diastolic pressure (18 +/- 12 mmHg to 14 +/- 8 mmHg, p = 0.184) showed no significant changes. In conclusion, IBS is valuable for predicting LV functional recovery after coronary revascularization in patients with LV dysfunction caused by a remote anterior MI. A large-scale study is be needed to establish these data.