Usefulness of a simple self-administered joint condition assessment sheet to predict the need for orthopaedic intervention in the management of haemophilic arthropathy.

INTRODUCTION: Detecting signs of joint deterioration is important for early effective orthopaedic intervention in managing haemophilic arthropathy. AIM: We developed a simple, patient self-administered sheet to evaluate the joint condition, and assessed the predictive ability of this assessment sheet for the need for an orthopaedic intervention. METHODS: This was a single-centre, cross-sectional study. The association between the score of each of the four items of the assessment sheet (bleeding, swelling, pain and physical impairment) and the results of radiological findings and physical examinations based on Haemophilia Joint Health Score 2.1 was assessed. An optimal scoring system was explored by the area under the curve (AUC). The cut-off value for the need for surgery or physiotherapy was determined using the receiver operating characteristic curve procedure. RESULTS: Forty-two patients were included. The 'physical impairment' item showed the highest correlation coefficient with the results of radiographic and physical examinations (range: 0.57-0.76). The AUC of finally adjusted scoring indicates good ability to discriminate between patients with and without a need for orthopaedic intervention. The positive predictive value was the highest at a cut-off value of 4 points for knees (63.0%) and ankles (70.0%), at 5 points for elbows (66.7%) and the highest predictive accuracy at the cut-off value of 4 points for all the joints. The linear trend of the need for an orthopaedic intervention was observed with an increasing score. CONCLUSION: The joint condition assessment sheet can help clinicians assess the need for orthopaedic intervention for haemophilic arthropathy in Japanese patients with haemophilia.

Actinomyces denticolens colonisation identified in equine tonsillar crypts.

Recently, submandibular abscesses associated with Actinomyces denticolens have been reported in horses. The actinomycotic clumps have been observed in the tonsillar crypts. The aim of this study was to demonstrate colonisation of A denticolens in equine tonsils. Twelve equine tonsils obtained from a slaughterhouse were divided into two parts for histopathological examination and for isolation of A denticolens. When actinomycotic clumps were found in these tonsillar crypts, immunohistochemistry using hyperimmune serum against A denticolens (DMS 20671) was performed on the serial sections. To determine whether Actinomyces-like bacteria isolated using immunoantigenic separation technique were A denticolens, the isolates were analysed for the 16S rRNA gene sequence. Actinomycotic clumps were found in the tonsillar crypts of 11 (91.7 per cent) horses. The clumps were of the saprophytic type accompanied with the feedstuffs, but a few clumps were surrounded by inflammatory cells. A denticolens antigens were immunodetected not only in the clumps of 11 (100 per cent) tonsils, but also in the tonsillar parenchyma. Six isolates obtained from four tonsils showed 99.7-99.9 per cent similarity to A denticolens in the 16S rRNA gene sequence. In horses, the colonisation sites of A denticolens are the tonsils, thus the authors suggest that the tonsils provide the intrinsic infection site for A denticolens.

Inactivation differences of microorganisms by low pressure UV and pulsed xenon lamps.

UV disinfection has been applied to water treatment in recent years with low-pressure and medium-pressure UV lamps mainly used as the light source. In general, UV disinfection is considered to be inefficient with water of high turbidity because of inhibition of light penetration. Additionally, photoreactivation may be a problem that should be considered in case a disinfected water is discharged to the environment where sunlight causes reactivation. Recently, other types of lamps have been proposed including a flush-type lamp (such as a pulsed-xenon lamp) that emits high energy and wide wavelength intermittently. In this study, the difference between inactivation efficiencies by low-pressure UV (LPUV) and pulsed-xenon (PXe) lamps was investigated using two coliphage types and three strains of Escherichia coli. PXe had a suppressive effect on photoreactivation rate of the E. coli strains even though there was no significant effect on inactivation rate and maximum survival ratio after photoreactivation. PXe also had a benefit when applied to high turbidity waters as no tailing phenomena were observed in the low survival ratio area although it was observed in LPUV inactivation. This efficiency difference was considered to be due to the difference in irradiated wavelength of both lamps.

Hyperthyroidism causes mechanical insufficiency of myocardium with possibly increased SR Ca2+-ATPase activity.

Hyperthyroidism is known to affect multiple organ functions, and thyroid hormone has been known to improve myocardial function in a failing heart. The purpose of this study is to elucidate the functional and metabolic effects of thyroid hormone on myocardium in a rat model exposed to long-term excess thyroid hormone, particularly focusing on the SR Ca(2+)-ATPase (SERCA2) function. 3,5,3'-Triiodo-L-thyronine (T3), or the vehicle, was subcutaneously given for 4 weeks (T3 and control [C] group). Bolus I.V. Thapsigargin (TG) was used to test the SERCA2 function (C-TG and T3-TG) in Langendorff perfused heart. Myocardial functions such as LV-developed pressure (LVDP; mmHg), +/- dP/dt (mmHg/s), tau (ms), and oxygen consumption (MVO(2); ml/min/g wt) were measured. SERCA2 and GLUT4 protein level were also evaluated by Western immunoblotting. Left ventricle to body weight (LV/BW) ratio was significantly higher in the T3 group. Both negative dP/dt and tau were significantly decreased by TG. It is interesting that the decrement of negative dP/dt and tau attained by TG was significantly larger in the hyperthyroid group (T3-TG) than in a normal heart (C-TG). SERCA2 and GLUT4 protein levels were not significantly different between control and the T3 group. We conclude that prolonged exposure to thyroid hormone causes hypertrophy of the myocardium and an augmentation of the SR Ca(2+) ATPase activity. Care must be taken in hyperthyroid heart during the ischemia-reperfusion process where the SRECA2 function is inhibited.

Off-pump coronary bypass grafting to double vessel disease with the pharmacological assist of esmolol. An experimental study.

BACKGROUND: To demonstrate the surgical efficacy and safety of off-pump coronary bypass grafting to double- or triple-vessel disease, we performed off-pump double bypass grafting using a brief local coronary occlusion with the pharmacological assist of esmolol. METHODS: These experiments were conducted in 30 canine hearts with the left internal thoracic artery (ITA) grafted to the circumflex coronary artery (CFX) and the right ITA grafted to the left anterior descending coronary artery (LAD), off pump, using a brief local coronary occlusion through the left minithoracotomy. The coronary anastomosis was performed using a brief local occlusion of the coronary artery. An anastomosis between the left ITA and the CFX was done first, and then the right ITA and the LAD were anastomosed. Thirty animals were divided into 2 groups, group A (n=15) receiving esmolol just before (10 mg/kg on a bolus) and during the coronary artery occlusion (500 microg/kg/min continuously), and group B (n=15) without administrating esmolol as a control. RESULTS: Operative deaths were 4 in group B and all of group A animals survived (p<0.05). All deaths were attributable to ventricular arrhythmias during/after coronary occlusion. Group B animals necessitating longer coronary occlusion time (more than 15 min) were more likely to fibrillate and more difficult to resuscitate than group A animals requiring coronary occlusion time more than 15 min. Segmental shortening on the echocardiogram demonstrated no significant difference between group A and B in both anterior and posterior wall segment. However, echocardiogram in animals necessitating coronary occlusion time more than 15 min demonstrated that segmental shortening in group A were better than in group B (18 vs 11%, p<0.05), and comparatively greater but not significant in the posterior wall (19 vs 14%). CONCLUSIONS: The use of esmolol may be recommended to off-pump coronary bypass even to the double-vessel bypass, in order to make off-pump approach safer.

Surgical treatment of pacemaker induced left innominate vein occlusion using a spiral vein graft.

Superior vena cava syndrome due to transvenous pacing leads is an uncommon but potentially life-threatening complication. This case involves a 54-year-old man who developed left innominate vein occlusion due to a pacemaker lead. This complication induced a progressive swelling on the left side of his face, neck, arm, and upper chest. The left innominate vein occlusion was surgically treated using a composite spiral saphenous vein graft. Postoperatively, the patient has received anticoagulation therapy with warfarin to prevent thrombosis and, thereby, the long-term patency of the graft. He has undergone follow-up on a regular outpatient basis without showing any recurrence of clinical symptoms.

Should the supplemental vein graft be anastomosed upstream or downstream of the internal thoracic artery (ITA) for ITA hypoperfusion?

BACKGROUND: This study was designed to compare internal thoracic artery (ITA) flow in different settings of supplemental vein grafting for ITA hypoperfusion. METHODS: Fourteen dogs each received two coronary bypass grafts to the circumflex artery (CFX), using left ITA and vein grafts, and then the proximal CFX was ligated. The animals were divided into two groups. G-I dogs receiving the vein graft proximally to the ITA graft and G-II receiving the vein distally. ITA flow was evaluated regarding 1) effects of competition from the vein graft, and 2) pharmacological or physiological effects on the ITA's contribution to distal perfusion. Flow is expressed as a mean (ml/min). RESULTS: ITA flow was 44.2+/-5.9 in G-I, and 45.7+/-6.5 in G-II (p=ns), when the vein graft was occluded. With a vein graft open, ITA flow decreased to 7.5+/-1.6 in G-I, and 6.8+/-1.8 in G-II (p=ns), and ITA's contribution to total perfusion requirements was 18% in G-I and 16% in G-II. Adenosine (0.2 mg/min/kg) increased the ITA flow in both groups, 18.4+/-3.2, and 16.3+/-3.8, respectively (p=ns), and ITA's contribution to distal perfusion was increased to 32% in G-I and 27% in G-II. In contrast, phenylephrine (0.003 mg/min/kg) decreased ITA flow and ITA's contribution to distal flow in both groups (6.1+/-1.1, 11% vs 6.2+/-1.4, 11%, p=ns), but increased vein flow significantly. Cardiac pacing (150 bpm) increased the ITA flow and ITA's contribution to distal perfusion equally in both groups (8.4+/-1.5, 16% vs 7.6+/-2.6, 15%, p=ns). CONCLUSIONS: Supplemental vein grafting, whether it is placed distally or proximally, limits ITA flow and ITA's contribution to distal perfusion both in the resting heart and during the increased myocardial oxygen demand.

Follow-up study of coronary artery bypass grafting in patients with Kawasaki disease.

BACKGROUND: The purpose of this study was to assess the long-term clinical outcome of coronary artery bypass grafting in pediatric patients with Kawasaki disease. METHODS: Six patients (mean age, 9.3 +/- 1.6 years) underwent coronary artery bypass grafting between September 1985 and December 1992. The number of bypass grafts placed was 1 to 2 per patient (mean 1.3 +/- 0.5). The left internal mammary artery (IMA) was used as a bypass graft in 3 patients, bilateral IMA in 1, and saphenous vein in 3. All patients underwent postoperative evaluations after 1 month and between 5 and 10 years. RESULTS: Follow-up ranged between 9 and 16 years (mean 12.6 +/- 2.7 years). Stress myocardial scintigraphy identified 2 patients with transient ischemia, one of whom died suddenly after 16 postoperative years. Coronary angiography demonstrated that the grafts of 5 patients were patent at both the short- and long-term follow-up. However, in 1 patient, the IMA that was grafted to the diagonal artery was occluded 1 month after surgery. Five survivors are in good health, without clinical angina. CONCLUSIONS: We consider that coronary revascularization with bilateral IMA grafts may provide a more favorable prognosis in patients with severe Kawasaki coronary artery disease. Stress myocardial scintigraphy and echocardiography can be used effectively to follow such patients.

Treatment of deep infection following thoracic aorta graft replacement without graft removal.

Deep infection following thoracic aortic replacement constitutes an extremely serious and life-threatening complication, and its treatment remains a challenge to surgeons. We report our experience involving five patients in whom deep infection occurred around the graft. Four of the five patients were treated by emergency surgery and one was treated by elective surgery. Surgical procedures performed including hemiarch replacement in one case, total arch replacement in one case, suspension of aortic valve and ascending aorta replacement in one case, Bentall procedure in one case, and descending aorta re-replacement in one case. Methicillin-resistant Staphylococcus aureus was detected in four patients, methicillin-resistant Staphylococcus epidermidis in one, and Aspergillus in one patient from purulent discharge at the operative site. Reoperative debridement and irrigation drainage were carried out at an early phase of infection. Intermittent irrigation following the reoperation was performed in all cases. In addition, muscle flap filling or omental translocation was carried out in three patients. Although the reported principle of treatment for arterial graft infection is extraanatomical bypass or rereplacement after removal of the infected graft, such procedures may be technically difficult and have a high risk at the thoracic level. Local anti-septic irrigation, administration of antibiotics, and vascular-rich tissue filling are useful procedures, and it appears that it is not always necessary to remove prosthetic grafts.

Ischemic preconditioning and nicorandil pretreatment improve donor heart preservation.

The present study investigated the effects of ischemic preconditioning (IPC) and nicorandil pretreatment on myocardial storage in a donor heart preservation model. Isolated rat hearts were separated into groups: group 1, non-preconditioned control group; group 2, 2.5 min of normothermic ischemia followed by 15 min of normothermic Langendorff perfusion (one IPC cycle); and group 3, 2 cycles of IPC. All hearts were subsequently stored in University of Wisconsin solution at 4 degrees C for 2, 4 and 6h, and the concentrations of high-energy phosphate metabolites were measured for each time point. Heart function parameters (aortic flow, coronary flow and cardiac output) were measured when the heart was reperfused following the 2, 4 or 6 h of preservation. The effects of nicorandil, an ATP-sensitive potassium channel opener, on heart function following preservation were also evaluated. Nicorandil was injected intravenously before heart harvesting. The results showed that the energy status was well preserved in the IPC groups. The 2-cycle IPC group showed better recovery of heart function following preservation. Pretreatment with nicorandil also improved functional recovery of the heart following preservation. The present study showed that IPC of the rat heart resulted in improved myocardial energy metabolism and functional recovery after hypothermic preservation, and that nicorandil has potential for pharmacological preconditioning in heart preservation for transplantation.

A novel homologue of the TIAP/m-survivin gene.

The inhibitor of apoptosis (IAP) proteins comprise a highly conserved gene family that prevents cell death in response to a variety of stimuli. TIAP/m-survivin, a murine homologue of human Survivin, is a member of the IAP family. TIAP/m-survivin has one baculovirus IAP repeat (BIR) and lacks a C-terminal RING finger motif. Here we identified the genomic DNA region (TIAP-2) that is homologous to the TIAP/m-survivin gene by a low stringency genomic DNA hybridization. The region is on the chromomsome 9 which is distinct from that (chromosome 11) of the TIAP/m-survivin gene, and contains DNA sequence similar to a part of the BIR and the 3' side of the TIAP/m-survivin gene and the sequence homology between them is 92%. Expression of TIAP-2 mRNA was detected in various murine tissues by RT-PCR. Although expression of TIAP/m-survivin mRNA is upregulated in synchronized cells at S to G2/M phase of the cell cycle, expression of TIAP-2 mRNA was constant in the cell cycle, suggesting the different role of TIAP-2 from that of TIAP/m-survivin.

Direct and indirect inactivation of Microcystis aeruginosa by UV-radiation.

Excessive algal growth in drinking water sources like lakes and reservoirs is responsible for filter-clogging, undesirable taste and odor, disinfection-by-product formation and toxin generation. Although various methods are currently being used to control algal bloom, their successes are limited. Some water utilities routinely use copper sulfate to control excessive algal growth. But there is a growing concern against its use mainly because it is non-specific to target algae and kills many non-target species. In this study, the scope of using UV-radiation to control algal growth was assessed using Microcystis aeruginosa as test species. A UV-dose of 75 mW s cm(-2) was found to be lethal to M. aeruginosa. A smaller dose of 37 mW s cm(-2) prevented growth for about 7 days. It was found that UV-radiation may increase the specific gravity of the cells and thus may adversely affect the ability of the cells to remain in suspension. Three days after a UV-dose of 75 mW s cm(-2), almost all the cells settled to the bottom of the incubation tubes, whereas all the unirradiated cells remained in suspension. It was also observed that UV-radiation on algal extracellular products has a significant residual effect and can contribute to algal growth control. The extent of residual effect depends on the UV-dose and can continue even for 7 days. UV-radiation was found to produce H2O2 in the microM level concentration. But at such level, H2O2 itself is not likely to cause the residual effect that was found in this study.

Experimental heterotopic heart transplantation without cardiopulmonary bypass: auxiliary support for the recipient heart.

BACKGROUND: Auxiliary cardiac support using heterotopic heart transplant is of considerable interest, but the outcome is not known. To investigate technical feasibility and the possibility of using auxiliary support from heterotopic heart transplantation without cardiopulmonary bypass, we evaluated hemodynamics including the pressure-volume relationship in experimental animals. METHODS: In heterotopic heart transplantation, we tailored the donor heart by removing the pulmonary and tricuspid valves, and by wide removal of the inter-atrial septum. Next, we anastomosed the descending aorta and left atrium of the donor heart to the descending aorta and left atrium of the recipient, without using cardiopulmonary bypass. Consequently, declamping the recipient's descending aorta allowed the donor heart to fill with blood and to start beating. We performed hemodynamic assessments including the effects of adrenergic stimulation. We measured the pressure and volume relationship of the recipient heart by closing and opening inflow of the donor left atrium to change the pre-load of the donor left ventricle. RESULTS: The donor left ventricle produced a systolic blood pressure that was augmented by the recipient blood pressure and responded to adrenergic stimulation. When inflow of the donor left atrium was opened, the pressure-volume loop of the recipient heart shifted to the left and pressure-volume area decreased. Simultaneously, the mechanical efficiency and E(max) (the slope of the end-systolic pressure-volume relationship) of the recipient heart increased when inflow of the donor left atrium was opened. CONCLUSIONS: This transplant model, without cardiopulmonary bypass, is feasible and can be applied to transplant investigations as a working heart model on the basis of the response of adrenergic stimulation. The increased pre-load of the donor left atrium from the recipient left atrium resulted in a recipient leftward shift of the pressure-volume relationship, suggesting that this transplant model with adequate pre-load acts as auxiliary assistance in the recipient intrathoracic cavity.

A case of Standford type B aortic dissection involving a right-sided aortic arch with mirror-image branching and right-sided descending aorta.

Isolated right aortic arch with mirror-image branching is a rare congenital anomaly. To date, no case has been reported for aortic dissection involving a right aortic arch with mirror-image branching. We report here on a case involving a 58-year-old man in whom expanding type B aortic dissection was demonstrated in the right aortic arch with mirror-image branching and a right descending aorta. The patient was successfully treated by interposition of a prosthetic graft via a right posterolateral thoracotomy approach. We also reviewed the literature.

Mycotic aneurysm of the palmar artery associated with infective endocarditis. Case report and review of the literature.

A 26-year-old man was diagnosed with mycotic aneurysm of the left hand associated with active infective endocarditis. Preoperative arteriography of the hand revealed aneurysm of the radial side of the deep arch of the palmar artery. We approached the aneurysm from the dorsal side of the hand in order to avoid damage to the collateral vascular supply of the superficial arch of the palmar artery and neurological structures. As a result, the aneurysm was excised simply by proximal and distal ligation of the vessel. During follow-up over 14 months, no evidence of recurrent aneurysm formation or ischemia of the fingers has been obtained.

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction.

BACKGROUND: Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial. METHODS: Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation. RESULTS: One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%. CONCLUSIONS: Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.

Disseminated cholesterol embolism after coronary artery bypass grafting.

Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life-threatening condition. We describe here the case of a 71-year-old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patient's toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off-pump bypass and use of arterial grafts are recommended.

Expanded polytetrafluoroethylene monocuspid valve for right ventricular outflow tract reconstruction.

BACKGROUND: Numerous materials have been used for reconstruction of the right ventricular outflow tract (RVOT) in patients with complex congenital heart defects. METHODS: Between January 1982 and March 1999, 19 patients (10 boys and 9 girls; mean age, 8.5 years) with severe RVOT obstruction underwent reconstruction using a transannular patch and expanded polytetrafluoroethylene (ePTFE) monocuspid valve. RESULTS: There were no perioperative deaths. Postoperatively, the mean +/- standard deviation RVOT gradient was 12 +/- 9 mm Hg. Echocardiography showed good motion of all cusps, and most had no or trivial pulmonary regurgitation. The difference between the preoperative and postoperative mean ratio of right-to-left ventricular peak systolic pressure was significant (p = 0.0001). In the 8 patients followed for 3 years or longer, pulmonary regurgitation was mild or better in 5 and moderate in 2, and the mean peak systolic RVOT gradient was 16.3 +/- 5.9 mm Hg. Five patients had good mobility of the monocusps. Two patients needed reoperation because of stenosis at the distal anastomosis of the transannular patch; 1 patient died. CONCLUSIONS: The ePTFE monocuspid valve may be useful in reconstruction of the RVOT.

Cell cycle-dependent regulation of TIAP/m-survivin expression.

TIAP, a murine homologue of human survivin, is a member of the inhibitor of apoptosis (IAP) family and is specifically expressed at G2/M phase of the cell cycle. To elucidate regulatory mechanisms of the cycle-dependent expression, we have analyzed the promoter region of TIAP/mouse survivin (m-survivin). The 5'-flanking region of the TIAP/m-survivin gene contained a TATA-less promoter, two AP2 sites, three NF-kB sites, one Sp1 site, many cell cycle-dependent elements (CDEs) and one cell cycle gene homology region (CHR). Primer extension and 5'-rapid amplification of cDNA ends identified one transcription start site at position -100 upstream of the ATG start site (+1). TIAP/m-survivin promoter-luciferase analysis identified a minimal promoter region within the most proximal -271 bp upstream of the ATG start site, and the region between -410 and -272 was critical for the enhancer activity. The combination between the CHR at -51 and the CDE at -57 is also essential for the cell cycle-dependent expression. Mutation of the CDE/CHR element and the enhancer elements may cause disordered expression of TIAP/m-survivin to affect cell survival and oncogenesis.