non-HD Group Research Articles

Abstract 2458: Admission Hyperglycemia Causes Infarct Volume Expansion In Patients With ICA And MCA Occlusion: Association Of Collateral Grade On Cerebral Angiography.

Background: The collateral circulation sustains the ischemic penumbra to limit growth of infarct volume. Recent study showed hyperglycemia was associated with infarct volume expansion in acute ischemic stroke patients. The aim of present study is to investigate whether admission hyperglycemia is related with enlargement of infarct volume and poor outcome based on the collateral circulation grade. Methods: From April 2004 to July 2011, acute ischemic stroke patients with ICA and MCA occlusion on cerebral angiography within 24 h of onset were retrospectively studied. We excluded the patients treated with iv t-PA or endovascular therapy. Hyperglycemia was defined as admitting blood glucose value>140mg/dl. Angiographic collateral was evaluated with the ASITN/SIR collateral flow grading system. Grade 0 to 1 was designated as poor collateral and grade 2 to 4 as good collateral. Infarct volume was measured on admission and follow-up (<7days after admission) diffusion weighted imaging on MRI. We compared Δinfarct volume (follow-up-baseline) and patient outcome between hyperglycemic (HG) group and non-HG group according to each collateral grade. Results: 93 patients (65 males, 67.7±13.3 years old, ICA occlusion in 52 and MCA in 41 patients) were enrolled in the present study. Collateral grade was poor in 34 patients (36.6%) and good in 59 patients (63.4%).In poor collateral grade (16 patients in HG group and 18 patients in non-HG group) , there was no significant difference in baseline infarct volume (66.2±93.7 mL vs. 61.8±81.5 mL, P=0.746). However, Δinfarct volume was markedly larger in HG group than non-HG group (106.0±101.4 mL vs. 22.7±54.9 mL, P=0.002). Poor outcome (mRS 5 to 6) at discharge was more frequent in HG group than non-HG group, but the differences were not significantly (56.3% vs. 27.8%, P=0.163). In good collateral grade (34 patients in HG group and 25 patients in non-HG group), the baseline infarct volume did not differ between HG group and non-HD group (17.1±39.2 mL vs. 17.9±37.2 mL, P=0.569). However, Δinfarct volume was more larger in HG group than non-HG group (53.3±74.1 mL vs. 10.9±24.3 mL, P=0.047). Moreover, poor outcome at discharge was frequently observed in HG group than non-HG group (38.2% vs. 12.0%, P=0.038). Conclusion: In patients with ICA and MCA occlusion, admission hyperglycemia should affect infarct volume expansion in poor as well as good collateral circulation.

Cholesterol Metabolism in Patients With Hemodialysis in the Presence or Absence of Coronary Artery Disease

Little is known about the interrelationship between the lipid profile, cholesterol metabolism, and coronary risk factors in patients with hemodialysis (HD) in the presence or absence of coronary artery disease (CAD). Ninety-five patients with HD were selected (HD group). Fifty-eight age-, gender-, and body mass index (BMI)-matched patients who had at least 1 cardiovascular risk factor were selected as a non-HD group. Total cholesterol (TC), triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and the ratio of LDL-C to HDL-C (L/H) in the HD group were significantly lower than those in the non-HD group. All markers of cholesterol absorption (campesterol/TC, sitosterol/TC, and cholestanol/TC) and the ratio of campesterol to lathosterol in the HD group were significantly higher. In addition, in the HD group, L/H was negatively correlated with lathosterol/TC, campesterol/TC, sitosterol/TC, and cholestanol/TC. Finally, CAD was significantly associated with lathosterol/TC (P=0.028), which was positively associated with BMI in the HD group, whereas CAD was significantly associated only with hypertension (P=0.020) in the non-HD group. HD patients showed lower cholesterol concentrations than non-HD patients, and, as compensation, their cholesterol absorption might be accelerated. However, higher cholesterol synthesis, which was correlated with higher BMI, might be an independent predictor for the presence of CAD in HD patients.

Coronary Artery Bypass Grafting in Hemodialysis-Dependent Patients

Perioperative risk during coronary artery bypass grafting (CABG) is reportedly high in patients with chronic renal disease. We aimed to determine postoperative mortality and morbidity and identify the perioperative risk factors of mortality during CABG in hemodialysis (HD)-dependent patients. From the Japan Adult Cardiovascular Surgery Database, we compared 1,300 HD-dependent chronic renal failure patients with 18,387 non-HD patients who all underwent isolated CABG between January 2005 and December 2008. The operative mortality and mortality, including major morbidity, was 4.8% vs. 1.4% and 23.1% vs. 13.7% in the HD and non-HD groups, respectively. Preoperative predictors of operative mortality included age, chronic obstructive pulmonary disease, peripheral arterial disease, congestive heart failure, arrhythmia, preoperative inotropic agent requirement, New York Heart Association class IV, urgent or emergency operation, poor left ventricular function, aortic valve regurgitation (>2), and mitral valve regurgitation (>3). Postoperative predictors of operative mortality included stroke, infection, prolonged ventilation, pneumonia, heart block, and gastrointestinal complications. Compared with non-HD patients, CABG in HD patients was associated with high mortality and morbidity rates. An appropriate surgical strategy and careful perioperative assessment and management for prevention of respiratory and gastrointestinal complications might contribute to improved clinical outcomes after CABG in these patients.

Mid-term clinical outcome of critical limb ischemia after infrapopliteal bypass surgery.

Critical limb ischemia caused by peripheral arterial occlusive disease of the infrapopliteal segment is best managed by bypass surgery with an autogenous vein conduit. Yet there remains confusing heterogeneity in the strategy, utilization, techniques, and outcomes in current practice. We reviewed our 7-year experience of infrapopliteal bypass surgery to analyze early and mid-term clinical outcomes. From May 2003 through May 2010, 63 bypasses to the infrapopliteal artery were performed in 59 patients. This comprised 32.4% of the 194 infrainguinal arterial reconstructions performed during that period. Of the 63 bypasses, 57 were performed with an autologous vein and 6 with a composite graft. For the autologous vein bypasses, a single-segment great saphenous vein (GSV) was used in 39 bypasses, which included 23 reversed, 5 in situ, and 11 non-reversed free grafts. "Spliced" vein grafts, constructed by splicing the GSV or lesser saphenous veins (LSV) together, were utilized in 18 bypasses. No deaths occurred within 30 days of surgery. Two patients (3.5%) died while hospitalized . Five grafts failed within 30 days of surgery due to thrombosis or bleeding. The primary graft patency, secondary graft patency, amputation-free survival (AFS) and overall survival were 73.7%, 82.4%, 84.7%, 88.1%, respectively at 1 year and 65.4%, 76.3%, 71.0%, 74.6% at 3 years. When patients were divided into groups based on the presence of end-stage renal disease on hemodialysis (HD), the 3-year secondary patency, AFS, and overall survival were 82.5%, 49.2, 49.2% in the HD group and 74.1%, 84.2%, 88.8% in the non-HD group. The overall survival in the HD group was significantly worse compared with the non-HD group. Infrapopliteal arterial bypass is a safe, durable and highly effective procedure in patients with CLI, with excellent mid-term patency and amputation-free survival. Renal insufficiency may be associated with a poorer limb salvage rate and long-term survival.

Angiographic and clinical outcomes of 100 consecutive severe calcified lesions requiring rotational atherectomy prior to sirolimus-eluting stent implantation in hemodialysis and non-hemodialysis patients

Both severe calcified lesions and hemodialysis (HD) are predictors for high rates of restenosis, even in the drug-eluting stent era. We sought to investigate the angiographic and clinical outcome in a population of HD versus non-hemodialysis (non-HD) patients with severe calcified lesions requiring rotational atherectomy. One hundred consecutive lesions (28 lesions in the HD group, 72 in the non-HD group) from 82 patients (19 patients in the HD group, 63 in the non-HD group) requiring rotational atherectomy prior to sirolimus-eluting stent (SES) implantation were analyzed post-procedure and at 8months. Clinical outcomes were assessed at 12months. Inclusion criteria were calcified lesions with >270° of superficial calcification on the intravascular ultrasound (IVUS), lesions that the IVUS could not cross, or undilatable lesions. There were no differences in patient characteristics except for age. Although both baseline and post-procedure angiographic findings were similar between the two groups, late loss in stented segment was significantly greater in the HD group than in the non-HD group (HD vs. non-HD: 0.69±0.74mm vs. 0.34±0.50; P=0.030). Also, the HD group revealed significantly worse clinical outcomes. In conclusion, mid-term results of highly complex, severely calcified lesions requiring rotational atherectomy in non-HD patients were permissible as compared to on-label lesions. However, in HD patients, both angiographic and clinical outcomes were still suboptimal in this lesion subset, even using SES.

Interstitial Foxp3‐positive T cells may predict renal survival in patients with myeroperoxidase anti‐neutrophil cytoplasmic antibody‐associated glomerulonephritis

1. Regulatory T cells (T(reg)) and cytotoxic T cells (CTL) are involved in various immune diseases. However, the prognostic impact of T(reg) and CTL in patients with myeroperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis (MPO-ANCA-GN) is not well known. Therefore, in the present study, we examined the relationship between expression of forkhead box P3 (Foxp3) and T cell intracytoplasmic antigen (TIA)-1, T(reg) and CTL markers and renal survival in patients with MPO-ANCA-GN. 2. Forty patients with MPO-ANCA-GN and 10 patients with minimal change nephrotic syndrome (MCNS) underwent physical examination, determination of blood chemistry and renal biopsy. Immunohistochemical staining for Foxp3 and TIA-1 was performed on paraffin-embedded renal sections. 3. Although almost all patients received standard immunosuppressive treatment for 6 months, seven MPO-ANCA-GN patients needed maintenance haemodialysis (HD), whereas 33 patients did not (non-HD). Both Foxp3- and TIA-1-positive cells were detected in the interstitium and glomeruli of MPO-ANCA-GN patients, whereas they were rarely detected in patients with MCNS. The total crescent rate was significantly higher in the HD group than in the non-HD group (35.9 +/- 3.5 vs 65.8 +/- 7.4, respectively). In the interstitium, the age-adjusted Foxp3/TIA-1 ratio was significantly higher in the non-HD group than in the HD group (0.016 +/- 0.016 vs 0.004 +/- 0.008, respectively; P < 0.05). The Foxp3/TIA-1 ratio, but not the Foxp3/CD3 ratio, remained significantly higher in the non-HD group than in the HD group even after adjustment for crescent rate. Age- and total crescent rate-adjusted renal survival rates were higher in patients with a Foxp3/TIA-1 ratio > or = 0.06 than in patients with a Foxp3/TIA-1 ratio < 0.06 (P = 0.02). 4. The results of the present study suggest that T(reg) could play a protective role against MPO-ANCA-GN and that a decreased Foxp3/TIA-1 ratio in interstitial areas may predict future renal failure in patients with MPO-ANCA-GN.

Six-month clinical outcomes after below-the-knee angioplasty for critical limb ischemia in patients on hemodialysis

To evaluate 6-month clinical outcomes after below-the-knee (BTK) angioplasty for critical limb ischemia (CLI) in patients on hemodialysis (HD). Subjects were 69 serial patients (81 limbs, 123 vessels) who underwent percutaneous transluminal angioplasty (PTA) for primary treatment of infrapopliteal lesions in CLI from June 2004 to December 2008. Subjects were classified into two groups for the comparative study of clinical outcomes: the patients on HD: the HD group (35 patients, 45 limbs, 71 vessels, 66±11years) and the patients not on HD: the non-HD group (34 patients, 36 limbs, 52 vessels, 69±9years). A non-randomized retrospective comparative study was conducted to obtain clinical outcomes at 6months. In clinical results at 6months, a higher percentage of tendency toward repeat PTA for the treated leg in the HD group (28.9 vs. 11.1%, p=0.059), but it was not statistically significant. There was no significant difference in the rate of major amputation (11.1 vs. 5.5%) between the two groups. However, the percentage of repeat PTA performed twice or more times (13.3 vs. 0%, p=0.031) and all-cause mortality (17.1 vs. 0%, p=0.012) in the HD group was significantly higher than in the non-HD group. The HD group had a significantly lower rate of freedom from all-cause mortality, major amputation, or repeat PTA in the 6-month follow-up compared to the non-HD group, with the HD group 51.4% and the non-HD group 85.3% (logrank test p=0.003). Although there are more HD patients requiring repeat revascularization compared to the general population, the 6-month outcomes of limb salvage after BTK angioplasty for CLI in HD patients were not significantly different from the general population.

Enhanced platelet activation following coronary stent implantation in patients on hemodialysis

Hemodialysis ("HD") has been suggested as a risk factor for stent thrombosis. However, platelet function in HD patients after coronary stent implantation remains unclear. The aim of this study was to evaluate platelet function following coronary stent implantation in HD patients. A total of 10 HD and 31 non-HD patients who underwent a first coronary stent implantation were studied. All patients received 100 or 200mg of asprin and thienopiridine (either ticlopidine 200mg or clopidogel 75mg) daily. Platelet function was assessed 2-6weeks (21±8days) after stent implantation by: (1) platelet maximal aggregation, using light transmittance aggregometry; (2) platelet aggregation threshold index, which was defined as putative concentration of agonist giving 50% maximum aggregation using whole-blood aggregometry; and (3) platelet activation markers (PAC-1 and CD62p), using whole blood flow cytometry. There were no differences between the two groups in baseline and procedure characteristics, except for a greater prevalence of hypertension and calcification in the HD group. Early stent thrombosis and bleeding did not occur in either group. Although no differences in platelet maximal aggregation or whole-blood aggregation were observed, expression of PAC-1 (39.6±9.1 vs 24.2±13.2%) and CD62p (10.4±5.5 vs 5.4±2.3%) were significantly increased in the HD group compared with the non-HD group. HD patients exhibited enhanced platelet activation after coronary stent implantation, but suppression of platelet aggregation was achieved by the current dual antiplatelet therapy.

Prediction of Hemodynamically Significant Coronary Artery Disease Using Troponin I in Hemodialysis Patients Presenting with Chest Pain: A Case-Control Study

Objectives: Controversy exists regarding utility of cardiac troponin I (cTnI) in predicting significant coronary artery disease (CAD) in hemodialysis (HD) patients with chest pain and no acute ischemia on electrocardiogram (non-ST segment elevation myocardial infarction, non-STEMI). We sought to determine if cTnI elevation predicts significant CAD (>70% stenosis) in these patients. Methods: Ninety patients with non-STEMI referred for cardiac catheterization were included, divided equally into HD and non-HD groups. Results: Mean age and baseline characteristics were not significantly different between groups, except for left ventricular hypertrophy which was higher in HD patients (56 vs. 27%, p = 0.012). Initial cTnI correlated with obstructive CAD and was stratified into <0.3 and >0.3 ng/ml. By logistic regression, cTnI >0.3 ng/ml was not predictive of CAD in HD patients [odds ratio = 0.87 (95% CI 0.19–4.0), p = 0.8], while non-HD patients had an increased risk of CAD if first cTnI was >0.3 ng/ml [odds ratio = 1.461 (95% CI 1.01–2.11), p = 0.04] as expected. Sensitivity, specificity, negative and positive predictive values of cTnI in predicting obstructive CAD were better in non-HD patients. Conclusion: cTnI in these patients had no predictive value for obstructive CAD. This contrasts with the general population, suggesting a higher index of suspicion for high-grade CAD irrespective of cTnI levels in HD patients.

Pharmacokinetics of olmesartan medoxomil in hemodialysis patients: little effect of dialysis upon its pharmacokinetics

Olmesartan medoxomil is a new angiotensin-2 receptor blocker (ARB). Its pharmacokinetics in hemodialysis patients has not been investigated. We evaluated the pharmacokinetics of olmesartan medoxomil in six patients on maintained hemodialysis. We divided these six patients into two groups; one group (n = 3) took the drug when hemodialysis started (HD day group), and the other group (n = 3) took in the morning on non-dialysis day (non HD day group). In each group, plasma concentrations of olmesartan were evaluated seven points after drug administration. In each point, blood pressure and heart rate were also measured. On HD day group, plasma concentrations in upstream of dialyser were compared with those in downstream of dialyser in three points. The area under the plasma concentration-time curve (AUC) in HD day group had no remarkable difference from those in non-HD day group. Another pharmacokinetic parameter, such as maximum plasma drug concentration (C (max)), biological half-life (t (1/2)) and time to reach C (max) (t (max)), were almost similar in both groups. Blood pressure and heart rate showed the same consequence as well. This result suggests that plasma concentration of olmesartan medoxomil does not decrease during hemodialysis, and that it is not necessary to change prescription on hemodialysis day or not.

Hirschsprung’s disease: Is there a relationship between mast cells and nerve fibers?

To define the topography of mast cells and their numbers in cases of Hirschsprung's disease (HD) and non-HD, assess neural hypertrophy using imaging software and to study the relationship between mast cells and nerve fibers. HE stained sections of 32 cases of chronic constipation in the age group of 0-14 years were reviewed for ganglion cells. AChE staining was performed on frozen sections of colonic and rectal biopsies. Based on their findings cases were divided into HD and non-HD and mast cells stained by toluidine blue were evaluated. Image analysis by computerized software was applied to S-100 stained sections for assessment of neural hypertrophy. Difference between number of mast cells in HD group (mean = 36.44) and in non-HD group (mean = 14.79) was statistically significant. Image analysis morphometry on S-100 stained sections served as a useful adjunct. The difference between number, size, and perimeter of the nerve fibers between HD and non-HD group was statistically significant. Mast cells are significantly increased in HD and their base line values are much higher in Indian children than that reported in Western literature. Their role in HD needs further research. Morphometry of S-100 stained nerve fibers is a useful adjunct to conventional methods for diagnosis of HD.

Evaluation of serum chondroitin sulfate and hyaluronan: biomarkers for osteoarthritis in canine hip dysplasia

Hip dysplasia (HD) is one of the most important bone and joint diseases in dogs. Making the radiographic diagnosis is sometime possible when the disease has markedly progressed. Chondroitin sulfate (CS) and hyaluronan (HA) are the most important cartilage biomolecules that are elevated in the serum taken from dogs with osteoarthritis. The serum CS and HA can be detected by an ELISA technique, with using monoclonal antibodies against CS epitope 3B3 and WF6 and the HA chain as the primary antibodies. The aim of this study was to compare the levels of serum CS (both epitopes) and HA in non-HD and HD dogs. All 123 dogs were categorized into 2 groups. The non-HD group was composed of 98 healthy dogs, while the HD group was comprised of 25 HD dogs. Blood samples were collected for analyzing the serum CS and HA levels with using the ELISA technique. The results showed that the average serum level of the CS epitope WF6 in the HD group (2,594 ± 3,036.10 ng/ml) was significantly higher than that in the non-HD group (465 ± 208.97 ng/ml) (p < 0.01) while the epitope 3B3 in the HD group (105 ± 100.05 ng/ml) was significantly lower than that in the non-HD group (136 ± 142.03 ng/ml) (p < 0.05). The amount of serum HA in the HD group (134.74 ± 59.71 ng/ml) was lower than that in the non HD group (245.45 ± 97.84 ng/ml) (p < 0.05). The results indicate that the serum CS and HA levels might be used as biomarkers for osteoarthritis in HD dogs.

Effect of End‐Stage Renal Failure and Hemodialysis on Mortality Rates in Implantable Cardioverter‐Defibrillator Recipients

Most defibrillator (ICD) trials have excluded patients on hemodialysis (HD). It is therefore not known whether the ICD, when indicated, confers the same mortality benefit to HD and non-HD patients. HD patients implanted with an ICD from July 2001 to June 2004 were matched by age, gender, left ventricular ejection fraction (LVEF), and class of heart failure to non-HD ICD recipients. Forty-six (16 on HD) patients (age = 65 +/- 15 yrs, LVEF = 30 +/- 14%, 44% in class III-IV HF) were followed for a mean of 30 +/- 16 months (range, 4-61 months) after ICD implantation. During this period, 12/16 HD versus 9/30 non-HD patients died (P = 0.006). The two-year mortality rates were 54% and 29% in the HD and non-HD groups, respectively (P = 0.01). After correcting for age, gender, race, LVEF, class of HF, and ICD indication (primary vs. secondary prevention) in a Cox regression model, HD remained a significant predictor of the time to death (HR = 2.9, adjusted P = 0.023). Despite having an ICD, HD patients have approximately a three-fold increase in total mortality and may therefore not extract the same survival benefits from the ICD as their non-HD counterparts. If duplicated in larger randomized trials, these results may demonstrate the futility of implanting defibrillators in HD patients.

Comparison of Long-Term Clinical Outcome After Sirolimus-Eluting Stent Implantation in Patients With and Without Hemodialysis

Poor clinical outcomes for hemodialysis (HD) patients compared to non-HD patients after coronary intervention have been reported. Although coronary intervention using sirolimus-eluting stents (SESs) might be expected to reduce restenosis in HD patients, little is known about the efficacy of the SESs. The purpose of the present study was to compare the clinical and angiographic outcomes of HD patients with non-HD patients after SES implantation. The study population consisted of 170 consecutive patients (234 lesions) who had undergone successful coronary SES implantation. The patients were classified into 2 groups, an HD group (18 patients, 27 lesions) and a non-HD group (152 patients, 207 lesions). The incidence of any clinical event was significantly higher in the HD group than in the non-HD group (50.0% versus 12.5%, P < 0.0001). Target lesion revascularization was necessary in 6 patients (33.3%) in the HD group and in 7 patients (4.6%) in the non-HD group (P < 0.0001). The Cox proportional-hazards regression model on cardiac events identified HD patients (P = 0.0301, hazard ratio = 2.704) as an explanatory factor. Moreover, the Cox proportional-hazards regression model on target lesion revascularization identified HD (P = 0.0004, hazard ratio = 6.921) and in-stent re-stenosis lesion (P = 0.0293, hazard ratio = 3.323) as explanatory factors. The present study suggests that compared with non-HD patients, HD patients with coronary artery disease treated by SESs have a poorer clinical outcome.

Normal hypocretin-1 (orexin-A) levels in the cerebrospinal fluid of patients with Huntington's disease

A significant atrophy and loss of hypocretin neurons in the brains of human patients with Huntington's disease (HD) and in R6/2 mice have been reported. We included 10 patients with HD and 12 patients with chorea-like hyperkinetic movement disorders (non-HD). All patients of the HD group and eleven patients of the non-HD group showed normal hypocretin-1 levels. Thus, hypocretin-1 may not serve as an additional diagnostic marker for HD.

Short- and long-term renal outcomes of immediate prophylactic hemodialysis after cardiovascular catheterizations in patients with severe renal insufficiency

Background The short- and long-term effects of prophylactic hemodialysis (HD) immediately after cardiovascular catheterizations on renal function in patients with severe baseline renal insufficiency remain unknown though previous studies reported non-beneficial very-short-term effect in less severe patients. Methods and results Patients who had pre-procedural serum creatinine (Scr) between 2.5 and 5.5 mg/dl were retrospectively studied. Twenty of them (14 M/6 F, aged 69±2 years) had received prophylactic HD after radiocontrast exposure and constituted the HD group. Another 20 patients were case-matched to the baseline demographics of the HD group and served as the non-HD group. The baseline Scr were 3.9±0.2 and 3.5±0.2 mg/dl, respectively ( p=NS). Although the Scr at 3 months was significantly higher in the HD group (4.3±0.3 vs. 3.4±0.2 mg/dl, p=0.02), the absolute and percentage increments from baseline to 3 months (0.4±0.2 vs. 0.0±0.2 mg/dl, p=NS, and 11±5% vs. 1±7%, p=NS, respectively) and 6 months (0.6±0.3 vs. 0.4±0.4 mg/dl, p=NS, and 18±8% vs. 8±10%, p=NS, respectively) were not statistically different. Patients who developed end-stage renal disease requiring permanent HD at 1 year were also similar in both groups (four vs. three, respectively, p=NS). Conclusions Our study confirmed that prophylactic HD immediately after contrast media administration in catheterizations failed to affect the short- and long-term renal and clinical outcomes even in patients with severe baseline renal insufficiency.

Retrospective analysis of hemodialyzed diabetic patients in Japan

We retrospectively analyzed the courses of 37 non-insulin dependent diabetics (hemodialyzed:HD group) with endstage renal disease (ESRD), to identify factors predisposing to renal failure. The factors analyzed were: diabetic (non-proliferative and proliferative) retinopathy, family histories of diabetes and hypertension, smoking, dyslipidemia, first examination proteinuria and non-compliance. These factors were statistically compared in 37 NIDDM without renal failure (non-HD group). There were no significant differences in age or duration of diabetes between the two groups. Significant differences ( P < 0.001) were, however, recognized in diabetic proliferative retinopathy and hypertension between the two groups. Hypertension was present in 35 36 (97.2%) HD patients and in 21 36 (58.3%) non-HD patients. A family history of hypertension was recognized in 16 37 HD (43.2%) and in 7 33 (21.2%) non-HD ( P < 0.05). Differences were recognized in HDL-cholesterol, LDL-cholesterol and TG levels (38.2 ± 12.5 mg/dl and 56.7 ± 18.5 mg/dl, 140.4 ± 57.1 mg/dl and 115.6 ± 33.6 mg/dl, 169.9 ± 89.4 mg/dl and 115.7 ± 75.1 mg/dl, in HD and non-HD, respectively, P < 0.05). First visit proteinuria was found in all HD patients, and in 6 34 (17.6%) non-HD. The difference in previous treatment refusal, for 7 or more years, was significant with 23 36 (58.9%) HD patients and only 1 25 (4.0%) non-HD patients ( P < 0.001) having a history of prolonged non-compliance with diabetic treatment. Diabetic retinopathy, non-proliferative and proliferative, hypertension and a family history of hypertension, elevated triglyceride and LDL-cholesterol, low HDL-cholesterol, first visit proteinuria, and prolonged non-compliance correlated with progression to ESRD. We advocate expanding diabetic education to include prevention of complications such as diabetic nephropathy.

Emotional and functional impact of DNA testing on patients with symptoms of Huntington's disease.

The potential impact of DNA testing on asymptomatic subjects at risk for Huntington's disease (HD) has been addressed by numerous studies, but the effect of revealing the genetic results to patients with a clinically established diagnosis of HD has not been previously evaluated. We studied 36 patients, with equal distribution of men and women, mean age 53.9 (SD 12.3) years (range 25-76) and mean duration of symptoms of 11.2 (SD 7.7) years (range 2-33), whose clinical diagnosis of HD was confirmed by expanded CAG repeats (> 40). Coping strategies and depression levels were assessed before the results of DNA testing were imparted. The assessments were repeated two weeks and three months after the results were explained to the patients and their relatives and were compared to the baseline assessments. This group of HD patients was compared with 10 patients who had similar symptoms but the diagnosis of HD was excluded by normal CAG repeats (< 30). Although some patients with HD expressed a subjective reaction to the positive result (four were "surprised", one was "frustrated", and one "devastated"), there were no differences in any psychological scores including Beck Depression Inventory, functional capacity, symptom interference, independence scale, and other measures of mood and behaviour two weeks and three months later. Similarly, no change was noted in any of these measures in the non-HD group. These results suggest that mood and coping strategies are unaffected by DNA confirmation of diagnosis in symptomatic patients with HD.

Hemodynamic responses to dobutamine during acute normovolemic hemodilution

The effects of dobutamine (DOB) on myocardial performance, systemic hemodynamics, and oxygen delivery during acute normovolemic hemodilution in anesthetized rats were studied. Forty-two Sprague Dawley rats (body weight 375 to 425 g) were divided into six equal groups. Hemodynamic and cardiac indices were measured or calculated at baseline, 30 minutes after the initiation of hemodilution (HD), and 15 minutes after DOB or saline infusion. Myocardial performance in response to acute pressure or volume loads was studied in all groups of animals. HD to a hematocrit (Hct) value of 20% resulted in no change in heart rate (HR), increased CI, SVI, and LV dP/dt, and decreased MAP, SVRI, and oxygen delivery index (O 2DI). HD increased peak SV and Cl after preload stress while the left ventricular developed pressure (LVDP) was unchanged. Infusion of DOB as 7.5 or 15 μg/kg/min increased HR, CI, and LV dP/dt as well as LVDP. At the same time, DOB decreased MAP and SVR, whereas the SVI remained unchanged. In non-HD animals both doses of DOB increased LVDP, but only the larger dose increased CI, whereas peak SV decreased with the smaller dose. Arterial carbon dioxide tension (PaCO 2) increased, whereas pH and arterial oxygen tension (PaO 2) decreased; however, O 2DI remained unchanged. Concomitant hemodilution and DOB infusion resulted in attenuation of HR response to DOB, exaggerated the drop in MAP and SVR, and increased LV dP/ dt. Only the larger dose of DOB increased the CI, whereas neither dose could alter the SVI in HD animals. Whereas HD increased the peak CI and SVI, administration of DOB to HD animals did not change LVDP, peak Cl, or peak SVI. Administration of DOB to HD animals decreased pH and increased PaCO 2)but O 2DI was not changed. The study demonstrated that the use of DOB to increase the physiologic compensatory mechanisms induced by HD was not effective, and the hemodynamic profile of DOB obtained in HD rats was significantly different from that observed in the non-HD groups. Therefore, it could be suggested that in normovolemic HD, DOB may fail to increase myocardial performance against sudden increase in afterload or preload although DOB can increase the CI in the resting or unstressed state.

Hodgkin disease in patients 60 years of age or older. Histologic and clinical features of advanced-stage disease

This article reviews the salient pathologic and clinical features of 171 patients with Stage III-IV disease who were 60 years of age or older who were treated on four Hodgkin disease (HD) protocols from 1969 to 1988. Pretherapy sections were reviewed centrally for correlation of the histologic classification with anatomic sites of involvement and survival. The diagnosis of HD was confirmed in 114 (66.7%) patients. Non-Hodgkin lymphomas (NHL) and a miscellaneous non-HD group accounted for 52 (30.4%) and 5 (2.9%) of the cases. The overall median survival times of patients with Stage III-IV HD and NHL who were 60 years of age or older in the four protocols were not significantly different (1.5 versus 1.3 years, respectively; P = 0.28). There also was no significant correlation between the survival of these patients with HD and either the Rye classification, 19 specific histologic parameters, or the British National Lymphoma Investigation grading system for HDNS. In the last protocol, the 5-year survival rate of patients with HD who were 60 years of age or older was lower than that of patients 40-59 years of age or that of those younger than 40 years of age (31% versus 63% versus 79%, respectively, P < 0.0001). Patients with HD entered into the two most recent protocols showed lower incidences of involvement of cervical and iliac-inguinal-femoral lymph nodes and skin-subcutaneous tissues than the patients with NHL who were misdiagnosed as HD. Moreover, patients with Stage III-IV HD in the most recent protocol who were 60 years of age or older had lower rates of involvement of the cervical and mediastinal-hilar lymph nodes and a higher rate of involvement of the gastrointestinal tract than younger patients. Patients with Stage III-IV HD and NHL who are 60 years of age or older differ with respect to the rates of involvement of specific anatomic sites but not in survival when treated with HD protocols. In contrast, patients of different age groups with Stage III-IV HD disease differ with regard to the rates of involvement of anatomic sites and survival.