non-CA Group Research Articles

Incremental Yield of Lower Endoscopic Ultrasound Following Endoscopic Polypectomy of High Risk Rectal Lesions

Purpose: The role of EUS after endoscopic polypectomy of high risk rectal lesions is unclear. Our purpose is to review the yield of EUS after polypectomy of high risk rectal lesions. Methods: Patients referred from 10/02-10/09 to our hospital for EUS following endoscopic polypectomy of high risk rectal lesions were included. High risk lesion: tubulovillous adenoma (TVA), tubular adenoma with high grade dysplasia (TA-HGD), carcinoid or carcinoma. Staging EUS for: 1) residual lesion in the rectal wall or; 2) lymph node (LN) involvement. Results stratified in 2 groups by presence or absence of cancer (CA). Incremental yield of EUS defined as: 1) residual neoplasia not seen on white light endoscopy (WLE) and biopsy (WLE/BX) and; 2) abnormal perirectal LNs. The sensitivity and specificity for detection of residual pathology was calculated for WLE/BX and EUS using results from biopsies, later surgery and/or follow up when possible. Results: 70 patients (mean age 64 yrs, 39% female) with a final CA (n=38) and non-CA (n=32) diagnosis were enrolled. Initial polypectomy pathology: adenocarcinoma in 36 (57%), TVA in 17 (24%), TA-HGD in 12 (17%), carcinoid in 3 (4%) and other in 2 (3%). EUS (mean 35±24 days after endoscopy): wall thickness in 45 (64%), residual mass in 14 (20%), normal in 11 (16%). WLE during EUS: ulcer in 22 (31%), scar in 21 (30%), polyp/mass in 19 (27%), normal in 8 (12%). Pinch biopsies during EUS in 21 (55%) CA and 20 (62%) non-CA patients: residual CA in 8 (21%); TA-HGD in 6 (9%) and CA in 1 (3%) non-CA. EUS of the rectal wall did not identify a residual mass that would have been missed by WLE/BX alone. A LN was seen in 5 (13%) CA patients; EUS-FNA confirmed CA in 1. No abnormal-appearing LNs were seen in the non-CA group. Follow-up (median 40 mos.; range: 1-93) in the CA patients (available in 55% [21/38]) included: transanal excision in six, laparotomy in four, chemoradiation in three and repeat endoscopy in eight. Of the 8 patients who underwent endoscopy alone without further treatment, no local recurrence occurred during a median follow-up of 40 mos (range 3-78). Follow-up (median 33 mos; range: 1-93) in the non-CA group (available in 62% [20/32] included: transanal resection in two, laparotomy in one and surveillance alone in 17. In the surveillance group (median follow-up: 45 months (range: 6-72), two recurrent adenomas were seen 8 and 17 months after EUS. For detection of residual lesions, the sensitivity/specificity of WLE/BX and EUS were 87%/86% and 60%/86%, respectively. Conclusion: Following endoscopic polypectomy of high risk rectal lesions, the incremental yield of EUS compared to WLE/BX for evaluation of residual intramural disease appears limited, particularly in benign lesions.

Multivessel versus single vessel spasm, as assessed by the intracoronary acetylcholine provocation test, in Korean patients

1. Coronary artery spasm (CAS) is known to be a major cause of myocardial ischaemia. Multivessel coronary spasm (MVS) in particular is likely to induce more severe and prolonged myocardial ischaemia than single vessel spasm (SVS). 2. In the present study, a total of 1082 consecutive patients without significant coronary artery disease who underwent an acetylcholine (ACh) provocation test between March 2004 and April 2009 were investigated. Patients were divided into three groups: an MVS group (n = 275), an SVS group (n = 376) and a non-CAS group (n = 431). Differences in clinical and angiographic characteristics following the ACh provocation test were evaluated between the MVS, SVS and non-CAS groups. 3. At baseline, patients in the MVS group had the highest prevalence of peripheral artery disease (PAD), hyperlipidaemia, smoking and old age, as well as the highest triglyceride levels. Calcium channel blockers were most frequently prescribed in MVS patients before the ACh test. During the ACh test, the highest prevalence of chest pain, ischaemic electrocardiogram changes, baseline spasms and diffuse and severe spasms were observed in the MVS group. The response rate to lower ACh doses that induce CAS was also higher in the MVS group. Multivariate analysis showed that the presence of PAD (odds ratio (OR) 2.0; P = 0.006) and baseline spasm (OR 1.4; P = 0.045) were independent predictors of ACh-induced MVS. 4. In conclusion, ischaemic symptoms, diffuse and severe spasm and baseline spasm were more frequently associated with MVS patients, suggesting more intensive medical therapies and close clinical follow up would be required for this patient group.

Efficacy of Coronary Angioplasty on Long-Term Outcome in Elderly Chinese Patients with ST Elevated Myocardial Infarction

The benefit and efficacy of interventional coronary therapies in elderly patients is still a controversial subject, especially in parts of the world where traditional and conservative medicine is still mainstream. In China, the benefit of intervention is still questionable, hence, this study investigated the prognostic significance of coronary angioplasty on outcomes of elderly patients presenting with ST-segment elevated myocardial infarction (STEMI). The study cohort comprised of 270 elderly (age >or= 75 years) patients who had confirmed STEMI. Some 116 patients underwent coronary angioplasty (called CA group) and their prognoses and survival over the short- and long-term periods (up to 80 months) were compared to 154 comparable patients who received a noninvasive, more conservative medical therapy (non-CA group). The subsequent Kaplan-Meier survival curves and statistical analyses were used to ascertain any difference between the groups. There was no significant differences between the two groups in terms of their clinical presentation, clinical risk, cardiac features, medications and medical procedures, except that the peak creatine kinase was significantly higher in the CA group. The success rate of interventional percutaneous coronary intervention observed in the CA group was 92.4% and during the hospitalization period, there were fewer deaths in the CA group (11 vs. 61 in the non-CA group). Furthermore, after 1-year and up to 7 years postsurgery, the CA group had a significant survival when compared to the non-CA cohort. Analysis of the longer-term data, using multivariate Cox regression analysis after 80 months indicated a hazard ratio of mortality for patients in CA group to be 0.283 (95% CI: 0.140-0.534, P < 0.001). Also, multivariate logistic regression analysis identified conservative treatment, chronic renal failure, cardiac arrhythmia, chronic lung disease and left ventricular ejection fraction, as predictors of higher long-term mortality in elderly patients with STEMI. In conclusion, this study clearly indicates that elderly Chinese patients with STEMI who undergo coronary angioplasty benefit and have a better survival rates in both the short- and long-term.

Computer-aided endoscopic sinus surgery: a retrospective comparative study

BACKGROUND AND OBJECTIVES:Endoscopic sinus surgery (ESS), markedly improved with the introduction of new preoperative imaging techniques, intraoperative visualization tools, and the use of surgical navigation systems. In this retrospective study we evaluated the usefulness of CT-guided endscopic sinus surgery and studied its advantages over conventional endscopic sinus surgery.METHODS:We retrospectively reviewed the records of 60 randomly chosen patients with chronic rhinosinusitis (CRS) and moderate-to-severe sinonasal polyposis, undergoing endoscopic sinus surgery with surgical navigation (n=30) and without navigation (n=30). Data on the operative note, time of surgery, complications, and recurrence rate were collected and analyzed.RESULTS:Of the 60 patients, 40 (66.7%) were diagnosed with CRS and 20 (33.3%) had allergic fungal sinusitis. Primary surgery was performed in 37 (61.7%) and revision surgery was performed in 23 (38.3%) cases. The computer-aided surgery (CAS) group included 28 (93.3%) patients with extensive disease and 12 (40%) with bone erosions, with intraorbital or extradural extension, while the non-CAS group included 24 (80%) patients with extensive disease and seven (23.3%) with bone erosions, with intraorbital or extradural extension. The average operative time was approximately 13 minutes greater in the navigation group, with significant improvement in the recurrence rate (n=11, 36.7% in the non-CAS group; n=5, 16.7% in the CAS group), and intraoperative complications were fewer in the CAS group (two exposures of orbital fat in the non-CAS group; no complications in the CAS group).CONCLUSION:Computer navigational systems appear to serve as a valuable adjunct in preoperative planning and safe intraoperative dissection.

Epidemiologic, Clinical, and Diagnostic Aspects of Coccidioidomycosis

MYCOLOGY The Coccidioides genus is considered dimorphic. Dimorphism is characterized by production of filamentous (mycelial) forms by certain fungi during their saprophytic phase in the environment or when incubated at lower temperatures on media. Conversion to yeast-like cellular forms occurs during their parasitic phase when invading an animal host or when incubated at elevated temperatures (11). Dimorphism in the genera Blastomyces, Histoplasma, Paracoccidioides, and Sporothrix, as well as in a single species of Penicillium (P. marneffei), is temperature dependent (thermal dimorphic). Dimorphism in Coccidioides is also characterized by the production of septate hyphae and thick-walled arthroconidia (2 by 4 m) that are formed along the length of the hyphae (enteroarthric development) during the saprophytic phase (6). The arthroconidia are commonly separated by empty, thin-walled, brittle cells (disjunctors) formed by autolysis of alternate conidia along the hyphae. Thus, arthroconidia are easily released into the air by soil disruption and wind. Upon inhalation into lungs or on rare occasion after percutaneous implantation into tissue, each arthroconidium transforms into a new multinucleated, spherical structure called the spherule. This structure increases in size and forms a thick outer wall. As it grows, the spherule begins to divide internally by invagination and formation of cleavage furrows, culminating in the production of numerous uninucleated endospores. Spherules vary from 60 to over 100 mi n diameter, while endospores remain 2 to 5 m in size. Mature spherules may contain 800 to 1,000 endospores, which are released into tissue upon the spherule’s rupture. In its parasitic phase, each endospore grows into a new spherule (1, 11). This phase of Coccidioides is influenced by more complex factors, including presence of phagocytic cells and increase in CO2, rather than temperature (10). Until the 1990s, the genus Coccidioides was thought to have only one species. No teleomorph (sexual form) has been described. Molecular phylogenetic methods have since shown that there are definite differences between isolates originating from diverse geographic locations, such as California (CA), Arizona (AZ), Texas (TX), Mexico, and South America (SA). The strains fall into two phylogenetic clades representing separate evolutionary species. One group (Group II) contains isolates originating from CA, while a second group (Group I) contains isolates from outside of CA (non-CA), inclusive of those from AZ, TX, Mexico, and SA. These clades have now been given species rank (4). The CA group (Group II) retained the species name of C. immitis, while the non-CA group (Group I) was named C. posadasii Fisher, Koenig, White, et Taylor, sp. nov. (2, 4).

Serum proteomics profiling for the detection of prostate cancer(PCa)

Mass spectrometric analysis of serum is a promising approach to biomarker discovery and PCa diagnosis. We determined serum protein expression patterns in 148 patients that were subsequently evaluated by biopsy of the prostate. Serum biomarkers were selected by metal affinity chromatography on copper-activated IMAC 30 chips and displayed by SELDI -TOF-MS using the PBS II analyzer (Ciphergen). Detected peaks with m/z ratios in the range of 1000 to 40,000, S/N ratios > 1.2, and intensities > 0.1 were grouped by m/z ratio so as to define 573 parameters of the serum biomarker profile. Parameters that discriminated the Ca from the non-Ca group were identified by binary logistic regression. Logistic regression models were evaluated in a randomly chosen set of 98 training cases (28 Ca, 70 Non-Ca), and tested in an independent set of 50 test cases (21 Ca, 29 Non-Ca). We derived a 10-parameter model that had a sensitivity (Se) of 0.79 and a specificity (Sp) of 0.89, for predicting the presence of PCa in a subsequent biopsy for the cases in the training set. However, Se and Sp for this model decreased to 0.50 and 0.76 respectively, in the test set. As the number of parameters in the models was reduced from 10 to 2, there was a progressive decrease in Se, but Sp remained at 0.70 or above in models that included the parameter corresponding to a protein peak with an m/z ratio of 14,900. This biomarker might prove to be useful for increasing the specificity of serum screening for PCa. Our results indicate that protein profiling by this method does not have the level of diagnostic accuracy required for routine clinical applications, possibly owing to excessive run-to-run analytical variability and/or to the limited number of cases that were analyzed.

Prevention of Pregnancy‐Induced Hypertension by Calcium Dietary Supplement: A Preliminary Report

The purpose of this study is to clarify whether the taking of a calcium dietary supplement is able to prevent the development of pregnancy-induced hypertension (PIH) in Japanese people. Forty-five nulliparous women (Ca-group) with various high-risk factors for PIH started to take a calcium supplement (1 g/day in the form of calcium salts) from the 12th gestational week (GW). Obstetrical outcome of Ca-group was compared to that of the nullipara (n = 453) who did not take a calcium supplement during pregnancy (Non-Ca Group) and that of the nullipara (n = 413) who did not develop PIH among Non-Ca group (normotensive group). The incidence of PIH in the Ca-group was 2.2%, compared to 8.8% of Non-Ca group. The decrease in blood pressure after taking calcium during the first half of the pregnancy was much greater in Ca-group than in the normotensive group. The urinary excretion of sodium and calcium and serum free calcium at the 28th GW were much lower in a woman with PIH, despite of the taking of a calcium supplement, than in the normotensive calcium group. Also, the parathyroid hormone level at the 28th GW was higher in the calcium-taking woman with PIH than in the normotensive calcium group. Our preliminary study suggests that among the possible effects of taking a calcium supplement are a decrease in blood pressure and the prevention of PIH in Japanese people, and that calcium metabolism might be related to the development of PIH. However, more study is needed before it will be possible to reach a final conclusion.

The relationship of serum cholesterol and vitamin A in hospitalized patients with and without cancer

Interrelationships among circulating levels of cholesterol, vitamin A, and selected transport proteins, as well as other nutritional variables were examined in a large population of hospitalized cancer (CA, n = 94) and noncancer (NONCA, n = 432) patients in order to help clarify a relationship between serum cholesterol and vitamin A. Serum cholesterol and vitamin A levels were positively correlated (r = 0.39; p < 0.001) in both CA and NONCA groups. One hypothesis that might explain such a relationship was investigated. Results suggest that serum-transport protein levels and nutritional status are important factors that lead to a correlation between serum cholesterol and vitamin A by virtue of their mutual associations with both substances. Results suggest also that NONCA patients may have a more complex relationship of variates to serum-vitamin A levels than CA patients and that low levels of both cholesterol and vitamin A in CA patients may be related more to nutritional status than to the presence of cancer.