Hybrid Therapy of Radiofrequency Catheter Ablation and Percutaneous Transvenous Mitral Commissurotomy in Patients With Atrial Fibrillation and Mitral Stenosis

AF Ablation and PTMC. Background: The rhythm control of atrial fibrillation (AF) associated with mitral stenosis (MS) is often difficult using antiarrhythmic drugs (AADs), even after a percutaneous transvenous mitral commissurotomy (PTMC). Few studies have examined the efficacy and safety of simultaneously performing radiofrequency catheter ablation (RFCA) and a PTMC in patients with MS and AF. Methods: Twenty consecutive patients with drug‐resistant AF and rheumatic MS underwent RFCA combined with a PTMC (n = 10; persistent AF‐8, long‐lasting [>1 year] persistent AF‐2; RFCA group) or transthoracic direct cardioversion (DC) following a PTMC (n = 10; persistent AF‐7, long‐lasting persistent AF‐3; DC group). In all patients, the mitral valve morphology was amenable to a PTMC, and more than 2 AADs had been ineffective in maintaining sinus rhythm (SR). In the RFCA group, a segmental pulmonary vein isolation (PVI) was performed in the initial 5 patients, and an extensive PVI was performed in the remaining 5. Results: During a mean follow‐up period of 4.0 ± 2.7 years, 8 patients (80%) in the RFCA group were maintained in SR, as compared to 1 (10%) in the DC group (hazard ratio, 0.16; 95% confidence interval, 0.03 to 0.75; P = 0.008 by the log‐rank test). The prevalence of the concomitant use of class I and/or class III AADs was comparable between the 2 groups (P = 0.70). No complications occurred during the procedure or follow‐up period in either group. Conclusions: The hybrid therapy using RFCA and a PTMC was safe and feasible, and significantly improved the AF free survival rate compared to DC following a PTMC. (J Cardiovasc Electrophysiol, Vol. 21, pp. 284–289, March 2010)     

A Clinical Trial of Topical Bleaching Treatment with Nanoscale Tretinoin Particles and Hydroquinone for Hyperpigmented Skin Lesions

BACKGROUND: Although combined use of tretinoin (all-trans-retinoic acid; atRA) and hydroquinone improves various hyperpigmented lesions, the pharmacologic instability of atRA and atRA-induced irritant dermatitis are difficult unsolved problems. OBJECTIVE: The objective was to evaluate the efficacy and adverse effects of a newly formulated gel containing inorganic-coated atRA nanoscale particles (nano-atRA gel). METHODS: Nano-atRA gel was used in our two-phased bleaching protocol: 5% hydroquinone and 7% lactic acid ointment were used along with nano-atRA gel in the bleaching phase (2-8 weeks), and 5% hydroquinone and 7% ascorbic acid ointment were used alone during the healing phase (4-8 weeks). Eighty-four patients with facial hyperpigmented lesions were enrolled in this study, and 77 of them (88 lesions) followed up for more than 10 weeks were analyzed. RESULTS: Hyperpigmentation was improved in 84 of 88 lesions (95.5%) after a mean treatment period of 14.3 weeks and was almost eliminated in 52 lesions (59.1%). Nano-atRA gel caused exfoliation and scaling similar to that seen with conventional atRA gel, whereas the erythema seen in the bleaching phase appeared to be weaker. CONCLUSION: Nano-atRA gel can improve hyperpigmentation to a similar extent as conventional atRA gel. It also induces irritant dermatitis, but with less erythema.     

Selective depletion of neutrophils by a monoclonal antibody, RP-3, suppresses dextran sulphate sodium-induced colitis in rats

Administration of dextran sulphate sodium to animals induces acute colitis characterized by infiltration of large numbers of neutrophils into the colonic mucosa, which histologically resembles human active ulcerative colitis. It has been reported that neutrophils and the reactive oxygen metabolites produced by them are involved in the progress of ulcerative colitis. This study was intended to clarify their roles by using this animal model. First, possible sources and species of reactive oxygen metabolites were determined using luminol-dependent chemiluminescence with addition of enzyme inhibitors and reactive oxygen metabolite scavengers. Next, to examine whether neutrophils and hypochlorous acid derived from them contribute to tissue injury, we administered RP-3, a monoclonal antibody capable of selectively depleting neutrophils, and taurine, a hypochlorous acid scavenger, to rats treated with dextran sulphate sodium. Addition of azide, taurine, catalase, superoxide dismutase and dimethyl sulphoxide into colonic mucosal scrapings significantly inhibited chemiluminescence production, but allopurinol and indomethacin had no effects. These results suggest that excessive hypochlorous acid, hydrogen peroxide, superoxide anion and hydroxyl radical are generated by the inflamed colonic mucosa. Intraperitoneal injections of RP-3 significantly suppressed bleeding, tissue myeloperoxidase activity, chemiluminescence production and erosion formation. On the other hand, administration of taurine tended to inhibit bleeding and erosion formation to some extent, although it could not significantly suppress them. These data suggest that neutrophils play an important role in the development of this colitis and that hypochlorous acid might be one of the causes of tissue injury induced by neutrophils.     

Duration of inter-facility neonatal transport and neonatal mortality: Systematic review and cohort study

BACKGROUND: Regionalization of perinatal health services has been actively discussed, although important determinants such as effect of duration of neonatal transport on neonatal outcomes have not been investigated well as yet. Therefore the purpose of the present paper was to investigate the association between duration of inter-facility transport and perinatal mortality. METHODS: For the systematic review, six major databases were searched. Any comparative studies investigating associations between duration of inter-facility neonatal transport and their outcomes, published in the English language were selected. The studies were screened and reviewed by two independent researchers. For the cohort study, study subjects included every neonate transported to neonatal wards in Osaka, Japan between 1980 and 2000 in an existing surveillance called Neonatal Mutual Cooperative System. They are followed up until 28 days of age, or discharge if earlier. Other variables were also considered as effect modifiers or confounders, including calendar year, birthweight (BW), gestational age (GA), sex, maternal/paternal age, Apgar scores at 1 and 5 min, place of birth and personnel accompanying the neonate during transport (transport personnel), body temperature before transport and on admission, severity of illness, and intraventricular hemorrhage (IVH) grade. Cox regression analyses were performed to obtain principal results, and sensitivity analysis to support them. RESULTS: Systematic review: only one cross-sectional study conducted in an urban area in India was identified. That study showed that neonates with a long duration of transport had 79% higher odds of death than those transported for a short duration after adjusting for the confounding effects. For the cohort study, among 16 429 subjects, full data were available for 4966 neonates. There was strong evidence that those transported for >90 min had more than twice the rate of neonatal death (rate ratio [RR] 2.26, 95% confidence interval [CI]: 1.26-4.04), and some evidence that those transported for between 60 and 89 min had an 80% higher rate of neonatal death (RR 1.81, 95%CI: 1.07-3.06), both compared with those transported for between 30 and 59 min, after adjusting for the confounding effects. A sensitivity analysis on missing values also supported the results. CONCLUSION: There is evidence of an association between duration of transport and increased neonatal mortality, which can be applied to organization of perinatal health services. A prospective cohort study is needed for further investigation.     

Laparoscopic antegrade continence enema procedure for fecal incontinence in a patient with spina bifida

We report a laparoscopic procedure for antegrade continence enema (LACE) that was performed successfully in 39-year-old man patient with spina bifida suffering from severe fecal incontinence. The patient had been receiving regular follow-up at our clinic. He desired the antegrade continence enema procedure to improve his intractable fecal incontinence with a less invasive procedure. Following the placement of the first port at the umbilicus using an open access technique, two additional ports were introduced at the upper and lower abdomen in the midline. The appendix was laparoscopically mobilized to the right lower abdomen and brought out through another port. Next, an in situ appendicocutaneostomy was created. The patient began oral intake the day after surgery. Initial irrigation was performed on the second postoperative day. Convalescence was quick and there were no postoperative complications. Although a minor skin incision was required afterward for superficial stoma stenosis, the patient has been in a satisfactory condition with regular enemas. Laparoscopic appendicocutaneostomy can be a reasonable surgical alternative for antegrade continence stoma procedure. LACE has a clear advantage over conventional open procedures in view of its less invasive nature and better cosmetic results.     

Macroreentrant Atrial Tachycardia in Patients without Previous Atrial Surgery or Catheter Ablation: Clinical and Electrophysiological Characteristics of Scar‐Related Left Atrial Anterior Wall Reentry

Scar‐Related Left Atrial Anterior Wall Reentry. Introduction: Macroreentrant atrial tachycardia (MRAT) has been described most frequently in patients with prior cardiac surgery. Left atrial tachycardia and flutter are common in patients who undergo atrial fibrillation ablation; however, few reports describe left atrial MRAT involving the regions of spontaneous scarring. Here, we describe left atrial MRAT in patients without prior cardiac surgery or catheter ablation (CA) and discuss the clinical and electrophysiological characteristics of tachycardia and outcome of CA. Methods and Results: An electrophysiological study and CA were performed in 6 patients (3 men; age 76 ± 6 years) with MRAT originating from the left atrial anterior wall (LAAW). No patient had a history of cardiac surgery or CA in the left atrium. Spontaneous scars (areas with bipolar voltage ≤ 0.05 mV) were observed in all patients. The activation map showed a figure‐eight circuit with loops around the mitral annulus (4 counterclockwise and 2 clockwise) and a low‐voltage area with LAAW scarring. The mean tachycardia cycle length was 303 ± 49 milliseconds. The conduction velocity was significantly slower in the isthmus between the scar in the LAAW and the mitral annulus than in the lateral mitral annulus (0.17 ± 0.05 m/s vs 0.94 ± 0.35 m/s; P = 0.003). Successful ablation of the isthmus caused interruption of the tachycardia and rendered it noninducible in all patients. Conclusion: Spontaneous LAAW scarring is an unusual cause of MRAT, showing activation patterns with a figure‐eight configuration. Radiofrequency CA is a feasible and effective treatment in such cases. (J Cardiovasc Electrophysiol, Vol. 24, pp. 404‐412, April 2013)     

Cytogenetic studies in a patient with porokeratosis of Mibelli, multiple cancers and a forme fruste of Werner''s syndrome

A 49-year-old man with extensive porokeratosis of Mibelli (PM) developed a squamous cell carcinoma and several carcinomas-in-situ within the lesional skin. The patient also had diabetes mellitus and a short stature with a prematurely aged appearance. The patient's father and two siblings also had PM. The patient died from metastatic squamous cell carcinoma, and at autopsy an adenocarcinoma of the descending colon was also found. Fibroblasts cultured from both the PM-affected and unaffected skin showed chromosomal abnormalities and a decreased lifespan. Cellular sensitivity to ultraviolet rays measured by unscheduled DNA synthesis and colony-forming ability were within normal limits. An association with a forme fruste of Werner's syndrome was suspected.