Gated myocardial perfusion single photon emission computed tomography in the clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial, Veterans Administration Cooperative study no. 424

Background  Stress gated myocardial perfusion single photon emission computed tomography (gSPECT) is increasingly used before and after intercurrent therapeutic intervention and is the basis for ongoing evaluation in the Department of Veterans Affairs clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial. Methods and Results  The COURAGE trial is a North American multicenter randomized clinical trial that enrolled 2287 patients to aggressive medical therapy vs percutaneous coronary intervention plus aggressive medical therapy. Three COURAGE nuclear substudies have been designed. The goals of substudy 0 are to examine the diagnostic accuracy of the extent and severity of inducible ischemia at baseline in COURAGE patients compared with patient symptoms and quantitative coronary angiography and to explore the relationship between inducible ischemia and the benefit from revascularization when added to medical therapy. Substudy 1 will correlate the extent and severity of provocative ischemia with the frequency, quality, and instability of recurrent symptoms in postcatheterization patients. Substudy 2 (n _ 300) will examine the usefulness of sequential gSPECT monitoring 6 to 18 months after therapeutic intervention. Together, these nuclear substudies will evaluate the role of gSPECT to determine the effectiveness of aggressive risk-factor modifications, lifestyle interventions, and anti-ischemic medical therapies with or without revascularization in reducing patients’ ischemic burdens. Conclusions  The unfolding of evidence on the application of gSPECT in trials such as COURAGE defines a new era for nuclear cardiology. We hope the evidence that emerges from the COURAGE trial will further establish the role of nuclear imaging in the evidence-based management of patients with stable coronary disease. The COURAGE trial was supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development in collaboration with the Canadian Institutes of Health Research. Unrestricted research grants were obtained from Merck & Co; Pfizer Pharmaceuticals; Bristol-Myers Squibb Medical Imaging; Astellas Pharma; Kos Pharmaceuticals; Data Scope; Astra Zeneca Pharmaceuticals; Astra-Zeneca-Canada; Schering-Plough Coorporation, Ltd; Sanofi-Aventis, Inc; First Horizon; and GE Healthcare. All industrial funding for this trial was directed through the Department of Veterans Affairs. Additional funding for this substudy was provided by grants to the Department of Veterans Affairs and Canadian Institutes of Health Research from Astellas Pharma and Bristol-Myers-Squibb Medical Imaging.     

Compositional sugar analysis of antitumor polysaccharides by high performance liquid chromatography and gas chromatography

Carbohydrate analysis is important in studying structure and activity of complex polysaccharides. New analytical method was applied to get an information on the composition of polysaccharides showing antitumor activity. Monosaccharides were labeled with 7-amino-1,3-naphthalenedisulfonic acid (7-AGA) by reductive amination and separated by HPLC. Five kinds of polysaccharides fromBasidiomycetes were hydrolyzed and analyzed in combination with electrophoresis and HPLC. At the same time, alditol acetate derivatives were prepared and analyzed by gas chromatography. Two different techniques using different derivatization methods showed very similiar results. The monosaccharides fromCoriolus versicolor andLentinus eodes were mainly composed of D-glucose, while those fromGanoderma lucidium andCordyceps militaris were glucose and galactose.Phellinus linteus composed of glucose, galactose, mannose, arabinose and fucose. The HPLC method with fluorescence detector was very sensitive compared to other methods.     

Paired kidney analysis of tacrolimus and cyclosporine microemulsion-based therapy in Chinese cadaveric renal transplant recipients

Few studies used paired kidneys for comparison between tacrolimus and cyclosporine in renal transplantation. Most of the published data used whole blood trough levels for drug monitoring. However, the use of limited sampling strategy and abbreviated formula to estimate the 12-h area under concentration-time curve (AUC(0-12)) allowed better prediction of drug exposure. Sixty-six first cadaveric renal transplant recipients receiving paired kidneys were randomized to receive either tacrolimus-based (n = 33) or cyclosporine microemulsion (Neoral)-based therapies (n = 33). Abbreviated AUC(0-12) was used for drug monitoring and dose titration. Mean follow-up duration was 2.8 +/- 2 years. The patient and graft survival were comparable. Fewer incidence of acute rejection was observed in tacrolimus group (15% vs. 27.3%) though the difference was not significant (P = 0.23). The absolute value and the rate of decline of creatinine clearance were both significantly better in tacrolimus-treated patients. Prevalence of hypertension, post-transplant diabetes mellitus, infection, and malignancy were similar in both groups. Prevalence of hypercholesterolemia (11/33 vs. 4/33) and gum hypertrophy (6/33 vs. 1/33) was more common in cyclosporine-treated patients (P = 0.04 in both parameters). This was the first prospective, randomized study with paired kidney analysis showing the renal function was significantly better in tacrolimus-treated patients than in cyclosporine-treated patients.     

非角度稳定性钢板固定治疗桡骨远端关节内背侧移位骨折的结果

Objective Intra-articular fractures of the distal radius in young adults comprise a distinet fracture pattern that is diffficuh to manage and associated with a high frequency of post-traumatic arthritis.Restoration of articular congruency and alignment should improve the outcome.Methods In this study we prospectively re- viewed the results of 21 consecutive cases of dorsally displaced intra-articular distal radius fractures which were treated with internal fixation after failing to achieve articular congruency with closed reduction.Results 3 patients were lost to follow-up.For the rest of 18 patients,follow-up time ranges from 18 to 75 weeks the fractures had healed with highly satisfactory radiographic and functional results.The final volar tilt averaged 4.9°;radial inclination 23.9°;radial length 14mm;and articular incongruity,0.1 mm.Wrist motion at final follow-up examination aver- aged flexion 62°,extension 60°,radial deviation 16°,ulnar deviation 27°,pronation 77°and supination 74°.Grip strength averaged 83% of the uninjured side.The overall outcome of 18 patients(94.4%)had a good or excellent result according to the system of Gartland and Werley and 18 patients(72.2%)had a good result according to the modified system of Green and O'Brien at the most recent evaluation.The only complication in this series was a superficial pin tract infection,which was rapidly resolved with removal of pins at 5th week of external fixation. Conclusion Thus restoration of articular congruency and alignment is possible with minimal complication using modern non-angular stable methods of internal fixation.     

Viral infections in the mouth

Oral hairy leukoplakia (OHL) and Kaposi's sarcoma (KS) are commonly encountered in the HIV-infected patient. A unique feature of OHL is non-cytolytic high level of replication of Epstein–Barr virus (EBV) in the glossal epithelium. The expression of viral-encoded anti-apoptotic proteins concomitant to replicative proteins probably underlies this phenomenon. The question of whether OHL arises from activation of EBV latent in the tongue, or from superinfection by endogenous EBV shed via non-glossal sites or by exogenous EBV remains unresolved. Human herpesvirus 8 (HHV8) is now seen as necessary but not sufficient cause of KS. Expression of HHV8-encoded oncogenic proteins in endothelial cells probably explains the aberrant proliferation of these cells in KS lesions. Studies into why KS is so commonly observed at the palate in HIV-infected patients may provide important clues to its pathogenesis.     

Endoscopic-assisted sciatic nerve exploration.

A sciatic nerve lesion is uncommon. We report the utility of the endoscope in an 18-year-old female with multiple lesions of her sciatic nerve. Somatosensory evoked potentials and MRI were indicative of a sciatic nerve lesion. We describe a simple technique of endoscopic exploration of the sciatic nerve to assist intraoperative decision making.     

Cardiac rehabilitation referral and attendance: not one and the same.

Despite empirical evidence that cardiac rehabilitation programs can play a significant role in enhancing recovery following a primary cardiac event and in enacting secondary prevention measures, attendance rates remain remarkably low. Referral and attendance at cardiac rehabilitation programs are not one and the same. Recognizing this, issues related to the referral of eligible patients to cardiac rehabilitation and factors that affect patients' decisions regarding attendance must be identified and addressed. This article presents an overview of the potential benefits of cardiac rehabilitation programs, describes salient issues related to referral and attendance, and identifies directions for future research.     

Emergence of occult minority genotype 2b hepatitis C infection in an HIV-1-co-infected patient treated for genotype 5a HCV infection with 48 weeks of pegylated-interferon-alpha 2b and ribavirin.

An HIV-1/hepatitis C virus (HCV) co-infected patient with haemophilia received a 48-week course of pegylated interferon-alpha-2b and ribavirin therapy for genotype 5a HCV infection. Virological response was achieved at week 24. At the end of treatment, HCV RNA in serum was detected and identified to belong to genotype 2b, rather than genotype 5a. A sensitive method for identifying minority HCV genotypes in pre-treatment serum showed genotype 2b HCV carriage prior to treatment. Sequencing the interferon sensitivity-determining region of the HCV NS5A gene obtained from pre-, intra- and post-treatment sera revealed emergence of quasispecies bearing R-->K and M-->A/T mutations at codons 2222 and 2223, respectively. Occult presence of minority HCV subpopulations and their acquisition of mutations following therapy can result in poor treatment outcome.