Washout In Patients Research Articles

Predictive biomarkers of intra-ocular pressure decrease after cataract surgery associated with trabecular washout in patients with pseudo exfoliative glaucoma

To investigate biomarkers of intra-ocular pressure (IOP) decrease after cataract surgery with trabecular washout in pseudo-exfoliative (PEX) glaucoma. A single-center observational prospective study in PEX glaucoma patients undergoing cataract surgery with trabecular washout (Goniowash) was performed from 2018 to 2021. Age, gender, visual acuity, IOP, endothelial cell count, central corneal thickness, medications, were collected over 16-month follow-up. Multivariable binomial regression models were implemented. 54 eyes (35 subjects) were included. Mean preoperative IOP (IOPBL) was 15.9 ± 3.5 mmHg. Postoperative IOP reduction was significant at 1-month and throughout follow-up (p < 0.01, respectively). IOPBL was a predictive biomarker inversely correlated to IOP decrease throughout follow-up (p < 0.001). At 1 and 12 months of follow-up, IOP decrease concerned 31 (57.4%) and 34 (63.0%) eyes with an average IOP decrease of 17.5% (from 17.6 ± 3.1 to 14.3 ± 2.2 mmHg) and 23.0% (from 17.7 ± 2.8 to 13.5 ± 2.6 mmHg), respectively. Performance (AUC) of IOPBL was 0.85 and 0.94 (p < 0.0001, respectively), with IOPBL threshold ≥ 15 mmHg for 82.1% and 96.8% sensitivity, 84.2% and 75.0% specificity, 1.84 and 3.91 IOP decrease odds-ratio, respectively. All PEX glaucoma patients with IOPBL greater than or equal to the average general population IOP were likely to achieve a significant sustainable postoperative IOP decrease.

The study of respiratory function of the lungs in patients with Bronchial Asthma

The article discusses the possibilities of functional assessment of the state of the respiratory function of the lungs in patients with bronchial asthma.The purpose of the study: a comparative assessment of the information content of capnometry, spirometry, the method of multiple breath nitrogen washout and the diffusion test in patients with asthma.Results and conclusions: 2 groups of patients were examined: I — 30 patients with asthma of 3–4 degrees of severity, II — 30 healthy volunteers. Capnometry showed a statistically significant increase in the slope of the alveolar phase in patients with asthma compared to the control group with quiet breathing, both before and after the use of a bronchodilator. According to spirometry data, in patients, the FEV1 /FVC ratio was statistically significantly lower compared to the control group, both before and after bronchodilator use. In a comparative analysis of the diffusion capacity of the lungs, there was a trend towards lower DLCO values in patients with asthma. A statistically significant difference was obtained in relation to the lung clearance index between the group of patients with asthma and the control group, in which the index was significantly lower. There were no statistically significant differences between the FRC (%) estimates obtained using the diffusion test and the method of the multiple breath nitrogen washout in patients with asthma. Thus, the informative methods in patients with asthma were not only the method of spirometry, but also the method of capnometry and the method of multiple breath nitrogen washout, which revealed uneven ventilation and distribution of ventilation-perfusion ratios in the lungs.

Investigation of the Clinical Efficacy of 99mTc-Sestamibi Washout in Patients with Acute Myocardial Infarction and Comparison with Stress Myocardial Imaging with 99mTc-Sestamibi Using a Two-Day Protocol

Background: 99mTc-sestamibi myocardial perfusion imaging (MIBI) washout is associated with myocardial mitochondrial damage in patients with a successful percutaneous coronary intervention (PCI) following acute myocardial infarction (AMI) and may predict the functional improvement of the left ventricle in follow-ups. Objectives: This study aimed to investigate the clinical efficacy of 99mTc-MIBI washout in patients with AMI by measuring the mean defect area based on 99mTc-MIBI myocardial perfusion-single photon emission computed tomography (MP-SPECT) rest imaging in early and delayed phases and comparing it with the defect area based on 99mTc-MIBI MP-SPECT adenosine stress imaging based on a two-day rest/stress protocol. Patients and Methods: This study was conducted on 29 consecutive patients with AMI (23 males and 6 females; mean age, 71 ± 8.4 years), who underwent MP-SPECT using a standard two-day rest/stress protocol. The rest 99mTc-MIBI MP-SPECT images were acquired in the early phase at one hour after the injection of 99mTc-MIBI and in the delayed phase at three hours after the early phase. The total perfusion deficit (TPD) score for SPECT was measured to compare the defect area between the rest-early phase, rest-delayed phase, and post-stress imaging conditions. Results: Based on the results, the post-stress TPD score was significantly lower than the rest-delayed phase score (TPD: 22.2% ± 14.3% vs. 27.8% ± 14.0%; P &lt; 0.001). Also, the rest-early phase score was significantly lower than the rest-delayed phase score (TPD: 21.5% ± 14.9% vs. 27.8% ± 14.0%; P &lt; 0.001). However, no significant difference was observed between the post-stress score and the rest-early phase score. Conclusion: The combination of rest-early phase, delayed phase, and post-stress 99mTc-MIBI imaging using a two-day protocol after AMI reperfusion was a clinically useful method, which could identify residual ischemia and predict the left ventricular function improvement in the chronic phase of disease while reducing the exposure dose.

Quantitative washout in patients with hepatocellular carcinoma undergoing TACE: an imaging biomarker for predicting prognosis?

BackgroundThe delayed percentage attenuation ratio (DPAR) was recently identified as a novel predictor of an early complete response in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). In this study, we aimed to validate the role of DPAR as a predictive biomarker for short-, mid-, and long-term outcomes after TACE.MethodsWe retrospectively reviewed laboratory and imaging data for 103 treatment-naïve patients undergoing initial TACE treatment at our tertiary care center between January 2016 and November 2020. DPAR and other washin and washout indices were quantified in the triphasic computed tomography performed before the initial TACE. The correlation of DPAR and radiologic response was investigated. Furthermore, the influence of DPAR on the 6-, 12-, 18-, and 24-month survival rates and the median overall survival (OS) was compared to other established washout indices and estimates of tumor burden and remnant liver function.ResultsThe DPAR was significantly of the target lesions (TLs) with objective response to TACE after the initial TACE session was significantly higher compared to patients with stable disease (SD) or progressive disease (PD) (125 (IQR 118–134) vs 110 (IQR 103–116), p < 0.001). Furthermore, the DPAR was significantly higher in patients who survived the first 6 months after TACE (122 vs. 115, p = 0.04). In addition, the number of patients with a DPAR > 120 was significantly higher in this group (n = 38 vs. n = 8; p = 0.03). However, no significant differences were observed in the 12-, 18-, and 24-month survival rates after the initial TACE. Regarding the median OS, no significant difference was observed for patients with a high DPAR compared to those with a low DPAR (18.7 months vs. 12.7 months, p = 0.260).ConclusionsOur results confirm DPAR as the most relevant washout index for predicting the short-term outcome of patients with HCC undergoing TACE. However, DPAR and the other washout indices were not predictive of mid- and long-term outcomes.

Development of a pediatric liver CEUS criterion to classify benign and malignant liver lesions in pediatric patients: a pilot study.

To analyze the contrast-enhanced ultrasound (CEUS) characteristics of pediatric patients with focal liver lesions (FLLs) and develop a pediatric liver CEUS criterion to improve the diagnostic performance of CEUS in differentiating pediatric benign and malignant liver lesions. Between March 2011 and May 2020, patients < 18 years who underwent CEUS were retrospectively evaluated. The CEUS characteristics of FLLs were analyzed. A pediatric liver CEUS criterion categorized as CEUS-1 to CEUS-5 was developed. The diagnostic performance of thecriterion (i.e., sensitivity, specificity, PPV, and NPV) was assessed. Chi-square and Mann-Whitney tests were used. After exclusion, the study included 130 lesions (mean diameter, 7.1 cm; range, 0.8-17.0 cm) from 130 patients (mean age, 36.0 months; range, 0.03-204.0 months; 74 boys). Hyperenhancement with washout in patients < 5 years or with early washout (≤ 45 s) was used to predict hepatoblastoma, with a sensitivity and specificity of 90.7% (95% confidence interval [CI]: 77.9%, 97.4%) and 93.6% (95% CI: 84.3%, 98.2%), respectively. Peripheral discontinuous globular hyperenhancement was used to diagnose hemangioma, with a sensitivity and specificity of 84.6% (95% CI: 65.1%, 95.6%) and 100% (95% CI: 95.4%, 100.0%), respectively. The rates of malignancies within the pediatric liver CEUS-1, CEUS-2, CEUS-3, CEUS-4, and CEUS-5 categories were 0.0%, 0.0%, 5.6%, 50.0%, and 96.1%, respectively. Besides, the incidences of hepatoblastoma in pediatric liver CEUS-3, CEUS-4, and CEUS-5 were 5.6%, 16.7%, and 67.5%, respectively. The pediatric liver CEUS criterion is useful in differentiating benign focal liver lesions from malignancies, especially hepatoblastoma from hemangioma. • Hyperenhancement with washout in patients <v5 years or with early washout (≤ 45 s) were used to predict hepatoblastoma, with a sensitivity and specificity of 90.7% and 93.6%. • Peripheral discontinuous globular hyperenhancement was used to diagnose hemangioma, with a sensitivity and specificity of 84.6% and 100.0%. • The rates of malignancies within the pediatric liver CEUS-1, CEUS -2, CEUS-3, CEUS-4, and CEUS-5 categories were 0.0%, 0.0%, 5.6%, 50.0%, and 96.1%, respectively.

Intraocular pressure changes following topical ocular hypotensive medications washout

BackgroundTo review the changes in intraocular pressure (IOP) following topical hypotensive medications washout in patients with primary open angle glaucoma (POAG), ocular hypertension (OHT) and uveitic glaucoma (UG)/OHT.MethodsThe study included...

Characterizing Computed Tomography-Detected Arterial Hyperenhancing-Only Lesions in Patients at Risk of Hepatocellular Carcinoma: Can Non-Contrast Magnetic Resonance Imaging Be Used for Sequential Imaging?

ObjectiveTo test the feasibility of non-contrast magnetic resonance imaging (MRI) in a sequential imaging study for characterizing computed tomography (CT)-detected arterial-enhancing nodules that do not washout in patients at risk of hepatocellular carcinoma (HCC).Materials and MethodsIn this retrospective study, 134 patients (mean age ± standard deviation, 56.8 ± 10.0 years) with 151 arterial enhancing-only nodules measuring up to 2 cm during multiphasic CT that were subsequently evaluated using gadoxetic acid-enhanced MRI in treatment-naïve at-risk patients from three tertiary referral centers were included. Tentative diagnostic criteria for HCC and hepatic malignancy were defined as the presence of one of eight MRI features favoring HCC in combinations of the following sequences: T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), T1-weighted dual gradient-echo in-phase and out-of-phase imaging (Dual-GRE), and hepatobiliary phase imaging (HBP). Typical hemangiomas and arterioportal shunts were excluded from the analysis. Diagnostic performance for HCC and hepatic malignancy was calculated and compared between the abbreviated MRI and full-sequence gadoxetic acid-enhanced MRI.ResultsOf 151 nodules (mean size, 1.2 cm) 68 HCCs and 83 non-HCC benignities and malignancies were included. The combination of T2WI, DWI, and Dual-GRE showed per-lesion sensitivity, specificity, and accuracy of 88.2%, 90.4%, and 89.4%, respectively, comparable to those of full-sequence MRI. Applying the same sequence combination to diagnose hepatic malignancy had per-lesion sensitivity, specificity, and accuracy of 86.8%, 97.3%, and 92.1%. In nodules < 1 cm, adding HBP increased sensitivity by up to 13% without compromising the specificity or accuracy.ConclusionThe non-contrast MRI protocol comprising T2WI, DWI, and Dual-GRE showed reasonable and comparable performance to full-sequence MRI for discriminating HCC and primary liver malignancies in CT-detected indeterminate arterial enhancing-only nodules in at-risk patients, and can be potentially used for sequential imaging in place of a full-sequence MRI. In nodules < 1 cm, HBP may still be needed to preserve sensitivity.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy.

Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1days vs. 10.1 and 9.0days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0days vs. 3.3 and 5.2days, p <0.02). The morbidity and length of stay were similar. Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

Washout Duration of Prostaglandin Analogues: A Systematic Review and Meta-analysis.

Topic Prostaglandin analogues (PGAs) are first-line medical therapy for primary open angle glaucoma (POAG) and ocular hypertension (OHT). Intraocular pressure (IOP) lowering effects in full responders are known to be 25–33% for this class; however, partial responders and nonresponders do exist. In clinical trials or prospective series, discontinuation and washout of PGAs is necessary to evaluate true change in IOP from novel surgeries and medical therapies. Clinical Relevance To identify all relevant papers with pertinent data on washout of PGAs and quantify the duration and long-term effect of reported PGA washout periods in glaucoma and OHT patients. Methods A systematic review and meta-analysis was conducted to investigate the long-term effects on IOP after discontinuation of topical PGAs POAG and OHT patients. The main search was conducted in MEDLINE/PubMed, EMBASE, Cochrane Library, CINAHL, Web of Science, and BIOSIS Previews and conference proceedings. Results 1055 papers were identified, 548 were independently screened by two physicians., and 56 papers were analyzed for washout durations. The mean washout was found to be 4.56 weeks (±1.25), with the mode and median being 5 weeks. Five studies were analyzed as randomized control trials in which latanoprost was discontinued for 4 weeks prior to restarting another intraocular pressure-lowering drug. Meta-analysis revealed a 4-week discontinuation of latanoprost, on average, subjects returned to their baseline IOP. Conclusion A significant IOP-lowering effect of latanoprost was not observed beyond 4 weeks, suggesting this may be an appropriate washout period for latanoprost. We could not identify appropriate washout periods for either travoprost or bimatoprost, although a majority of articles had 4-week washout durations for the two drugs. Despite the widespread use of this class of medication, there is a paucity of literature on the effects of PGA washout in patients that are treatment naïve to other topical medications.

Single Center Experience with High Dose Melphalan and Two Day Washout in Patients with Multiple Myeloma on Hemodialysis Undergoing Autologous Stem Cell Transplant

Single Center Experience with High Dose Melphalan and Two Day Washout in Patients with Multiple Myeloma on Hemodialysis Undergoing Autologous Stem Cell Transplant

Natalizumab to fingolimod washout in patients at risk of PML

With more choices for multiple sclerosis (MS) disease-modifying therapies, data are urgently required to support clinical decisions regarding safe transitioning and sequencing of therapies. With more than 7 years of clinical experience, natalizumab has been confirmed as highly effective in reducing MS disease activity. However, natalizumab carries a risk of progressive multifocal leukoencephalopathy (PML),(1) with more than 400 cases of natalizumab-related PML to date.(2) Because 2 of the 3 initial natalizumab-associated PML cases were on the combination natalizumab plus interferon, the concern was that combining agents led to a heightened risk of infectious complications. In these early times, uncertainty revolved around 2 points: the theoretical risk of PML if natalizumab was transiently combined with another immune-altering agent and the value of transiently "reconstituting" CNS immune surveillance by washout of natalizumab in an effort to clear theoretical subclinical JC virus within the CNS.(3) The optimal length of natalizumab washout became the subject of intense consternation and debate, with no clear guidelines to inform practice. However, upon withdrawing natalizumab, resumption of disease activity was soon observed, beginning 3-4 months after the last dose of natalizumab.(4-10) Postnatalizumab return of disease raised concern that the washout may harm the patient by a severe relapse with incomplete recovery.

Analysis of outcomes of intra-operative rectal washout in patients with rectal cancer during anterior resection

Local recurrence is a major setback for patients with rectal cancer after surgery. Implantation of exfoliated malignant cells has been considered as a possible mechanism of tumor recurrence. Although still controversial, intra-operative rectal washout has been described as a method to remove exfoliated malignant cells and reduce recurrence rates. The current study was designed to assess the differences in outcomes of patients with or without rectal washout. Data of 144 patients with rectal cancer undergoing anterior resection between 2006 and 2007 were reviewed in our study. 69 patients received rectal washout with approximately 1,500 ml physiological saline before anastomosis, and 75 patients received no-washout. The washout samples were sent for cytological examination. The incidence of recurrence and 5-year disease-free survival rates of the two groups were compared. Three patients had local recurrence in the washout group compared with 5 patients with no-washout during a median follow-up of 48 months (p = 0.721). The 5-year disease-free survival rate was 79.7 and 74.7 % in washout and no-washout groups, respectively (p = 0.553). Our results demonstrated that exfoliated malignant cells were ubiquitous in the rectal lumen during anterior resection. The difference of prognosis was not statistically significant, though trended toward being improved in the washout group. A large-scale research with longer follow-up time is required to draw a significant conclusion.

Rectal washout and local recurrence in rectal resection for cancer: a meta‐analysis

The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate (P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only (P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection (P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P = 0.04; OR 0.62; 95% CI 0.39-0.98). Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

Medullary Thyroid Nodules by Measurement of Calcitonin (Ct) in Aspiration Needle Washout in Patients with Multinodular Goiter and Moderately Elevated Serum Ct

The accuracy of fine needle aspiration cytology (FNAC) is low in medullary thyroid carcinomas (MTC). Recently, a few papers analyzed the measurement of calcitonin (Ct) in washout of the needle after aspiration (WO-Ct) suggesting that this approach may be useful in patients with high serum Ct. Here we reported, for the first time in our best knowledge, 3 patients with multinodular goiter, moderately elevated serum Ct, high value of WO-Ct, and medullary outcome. These findings suggest that in presence of high serum Ct, FNAC should be performed in all nodules, and it should be combined with WO-Ct in all cases.

Predictors of response to sequential sunitinib and the impact of prior VEGF-targeted drug washout in patients with metastatic clear-cell renal cell carcinoma

Objective To identify factors that can be used to identify metastatic clear cell RCC patients more likely to benefit from sequential sunitinib. Patients and methods We identified patients who failed sorafenib or bevacizumab and subsequently received sunitinib. We looked at objective response rates (ORR), progression-free survival (PFS), and overall survival (OS) to sunitinib in relation to baseline clinical variables. Results Seventy-one patients received sunitinib sequential therapy. Median duration of follow-up after starting sunitinib was 9.3 months. Median PFS was 5.8 months; median OS was not reached. Significantly higher ORR was seen in patients with normal hemoglobin (25.6%) [defined as >12 gm/dl for female; >13 gm/dl for male]. In addition, a shorter PFS for patients with low hemoglobin, and patients with time from diagnosis to first treatment ≤1 year was found. There was a shorter OS for patients ≥60 years old, with brain metastasis, low hemoglobin, and time from diagnosis to treatment ≤1 year. There was no difference in ORR, PFS, or OS in patients who started sunitinib after or within a 30-day period. Conclusions Metastatic clear-cell RCC patients with anemia have less clinical benefit from sequential sunitinib after failure of bevacizumab or sorafenib. Other factors associated with poor outcome include brain metastases, older age, and <1 year between diagnosis and first treatment. Importantly, no difference in outcomes was observed if sequential therapy was initiated within or after 30 days. External validation and prospective evaluation are needed to confirm these findings.

Long-term Use of Antegrade Continence Enema

Source: Yardley IE, Pauniaho S, Baillie CT, et al. After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure. J Pediatr Surg.2009;44(5):1274–1277; doi:10.1016/j.jpedsurg.2009.02.030The antegrade continence enema (ACE) procedure involves the construction of an abdominal wall stoma using the appendix as the conduit from the skin level in the right lower quadrant into the cecum; this allows access for antegrade irrigations on a regular and scheduled basis to provide effective colonic washout in patients with refractory chronic constipation. Investigators from Alder Hey Children’s Hospital in Liverpool, England, sought to determine the long-term use of ACE. All children who had an ACE at a single tertiary care center between 1993 and 1997 were surveyed to determine if they were still using the ACE and, if not, why use had been discontinued.Of the 84 eligible patients, 61 could be contacted. The mean age was 22.4 years (15–35 years) with an average follow-up time of 11 years (8–14 years). Their underlying diagnoses included spina bifida (27), anorectal malformation (18), intractable constipation (11), sacral agenesis (2), trauma or tumor (2), and Hirschsprung’s Disease (1). Thirty-six of the 61 patients (59%) were still using their ACE. In those patients continuing to use their ACE, the overall satisfaction score was 4 (on a scale of 1 to 5, with 5 being very satisfied).Among the 25 patients (41%) who reported discontinuing use of their ACE, 14 stated they had done so because the washouts had proven ineffective for prevention of soiling. Five others described significant pain with washouts, stomal stenosis, or difficulty in using the stoma during pregnancy. Two patients stopped using the ACE because of psychological issues, one because of being disturbed at the appearance of the stoma and one secondary to depression. Two additional patients were unable to comply with the washout regimen, rendering the ACE ineffective. There was no association between diagnosis and non-use. Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood.The authors conclude that patients discontinue use of the ACE for a variety of reasons and suggest that newer refinements of the surgical procedure may lead to its greater long-term successful use. Most concerning, however, is the high level of discontent with the transitional care arrangements on reaching adulthood.Dr Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The ACE allows the patient to receive effective colonic irrigation via the right colon, thereby promoting cleanout of the entire colon at one time. The colon can then serve as a large reservoir for stool, permitting absence of soiling during the day. The usual regimen involves a mixture of water and either mineral oil or glycerin in volumes and concentrations necessary to obtain washout results.The principal complication of this procedure is painful catheter insertion as a result of stomal stenosis. Mucus leak can be a problem but this is usually temporary during the first several weeks following the surgery. Several changes in the washout regimen are usually necessary before a steady state is reached.2The operation is not terribly complicated and involves constructing a stoma via the tip of the still-attached appendix. An anti-refluxing wrap of cecal wall around the base of the appendix can usually prevent fecal reflux. Much attention must be paid to construction of the stoma itself, interdigitating skin and opened appendiceal lumen in such a way as to allow easy catheterization, yet it must remain fairly flat and dry of mucus.3This group report denotes two important points for surgeons and pediatricians alike. First, we have a good tool available to us when patients need this level of colon washout which cannot be managed with rectal irrigations, and would benefit from an intervention that offers some degree of social acceptance. Second, we must endeavor to provide seamless care as patients with lifelong problems move into the adult world of health care. These patients require ongoing support and care if maintaining continence is to be effective.

Simultaneous Occurrence and Interaction of Hypoperfusion and Embolism in a Patient With Severe Middle Cerebral Artery Stenosis

The coincidence of hemodynamic and embolic findings in patients with stroke from large artery stenosis has suggested an interaction of both pathologies. This has emerged into the hypothesis of an impaired washout of emboli in the presence of hypoperfusion. We propose an additional link between both pathologies. A 48-year-old woman presented with a recurrent symptomatic severe left middle cerebral artery stenosis. MRI depicted left hemispheric ischemic infarcts in the deep and subcortical white matter and in the cortical border zone. One-hour transcranial Doppler monitoring detected 64 microembolic signals distal to the arterial stenosis. Monitoring also revealed recurrent thrombus formation at the stenotic plaque with decline of poststenotic flow velocity followed by embolism with abrupt excessive flow velocity increase and subsequent normalization at the initial baseline level. Cerebrovascular reserve in the distribution territory of the stenosed artery as assessed by transcranial Doppler after carbon dioxide stimulation revealed a normal reserve capacity in periods with baseline poststenotic flow velocity and an exhausted reserve capacity when flow velocity was decreased due to stenotic thrombus formation. In our patient, adherent thrombus formation resulted in an increasing severity of the stenosis with subsequent vasodilatation and diminution of flow resistance in the depending vascular distribution territory. MRI suggested that adherent thrombi were predominantly washed into terminal supply and border zone brain regions, ie, into regions with supposed maximum vasodilatation and least flow resistance immediately before thrombus avulsion. Preferred wash-in of emboli into regions with low blood flow resistance might be an additional mechanism besides impaired washout in patients with severe large artery disease.

Sustained Effect of Travoprost on Diurnal and Nocturnal Intraocular Pressure

To assess the diurnal and nocturnal persistency of intraocular pressure (IOP) reduction after omission of up to two doses of once-daily topical travoprost in patients with open-angle glaucoma or ocular hypertension. Prospective, open-label study. Twenty subjects underwent three sessions of 24-hour IOP monitoring. The first session occurred before initiating treatment of newly diagnosed patients or after a four-week washout in patients already receiving medical therapy. The second session occurred after four weeks or more of travoprost treatment. The third session was performed 41 to 63 hours after the last travoprost dose. IOP lowering persisted after omission of one to two doses. Between 41 to 63 hours after the last dose, diurnal IOP reduction was attenuated, but nocturnal IOP reduction sustained. IOP lowering effect after omission of one to two doses of travoprost is attenuated in the diurnal period but sustained in the nocturnal period, the time corresponding to the highest baseline habitual IOP.

Effect of pharmacological wash-out in patients undergoing exercise testing after acute myocardial infarction

Study objectives: Pharmacological therapy can reduce diagnostic and prognostic accuracy of exercise stress testing. However, the risk of withdrawing drugs early after myocardial infarction (MI) has not been established. We assessed safety and clinical implications of drug withdrawal in patients undergoing stress testing after uncomplicated MI. Methods: A total of 362 MI patients underwent ECG Holter recording before and after withdrawing beta-blockers, calcium-antagonists and nitrates. QRS (QRS/h) and ventricular premature beats (VPB/h) count per hour, repetitive ventricular arrhythmias, ST segment changes and patient complaints were evaluated for reproducibility using kappa statistics and Bland–Altman method. Results: No major complications occurred. Forty-three patients complained of >1 symptom on and 37 off therapy. QRS/h and VPB/h count were significantly ( p<0.0001) higher off therapy but correlated with the corresponding values on therapy. A mean heart rate increase of 8 beats/min (agreement range −8 to +14 beats/min) and a five-fold increase in VPB/h (agreement range −141 to +151) were observed after withdrawing therapy. Repetitive ventricular arrhythmias and ST changes were also more frequent off therapy but intra-patient reproducibility was poor: kappa 0.12 (95% confidence interval (CI) −0.01 to 0.25) for arrhythmias, −0.02 (95% CI −0.46 to 0.39) for ST depression and −0.01 (95% CI −0.66 to 0.64) for ST elevation. Conclusions: The withdrawal of therapy is well tolerated soon after uncomplicated MI; however, a generic but not individual risk of ventricular arrhythmias and/or transient myocardial ischemia has to be taken into account.

Dipyridamole Tl-201 SPECT in Hypertrophic Cardiomyopathy with Asymmetric Septal Hypertrophy:Characteristics of Perfusion Abnormality and Correlation with Clinical Parameters

Background and Objectives:Exercise myocardial perfusion scans in patients with hypertrophic cardiomyo- pathy have shown reversible perfusion abnormalities with unknown clinical significance. We performed this study to characterize dipyridamole Tl-201 SPECT imaging and correlate with clinical findings in patients with hypertrophic cardiomyopathy. Methods:Tl-201 SPECT was performed in 25 patients of hypertrophic cardiomyopathy with asymmetric septal hypertrophy and 20 normal controls after dipyridamole infusion (0.56 mg/kg. Myocardial wall was divided into 8 segments. Tl-201 uptake and relative washout rate were calculated. Results:Tl-201 SPECT showed significantly lower Tl-201 uptake in basal septal (81.3±3.4% vs 78.2±6.4%, p<0.05 and apical septal wall on stress (88.2±4.7% vs 83.9±6.5%, p<0.05 and higher apical septal (86.6±5.2% vs 89.2±3.1%, p<0.05 and apical anterior wall uptake (88.7%±4.0% vs 91.4±4.9%, p<0.05 on redistribution images in patients with hypertrophic cardiomyopathy. Basal lateral wall uptake of hypertrophic cardiomyopathy was significantly lower than normal control on both stress (84.7±3.5% vs 81.2 ±7.3%, p<0.05 and redistribution images (85.0±5.8% vs 76.8±7.2%, p<0.0001. The septum/lateral uptake ratio of patients on rest image was significantly higher than that of normal controls (0.98±0.07 vs 1.07±0.10, p<0.001. There was no difference in age, sex, symptom, cardiac medication and the parameters of 2D-echo including left ventricular outflow obstruction between subgroups of normal vs abnormal washout in patients with hypertrophic cardiomyopathy. Conclusion:Dipyridamole Tl-201 myocardial SPECT shows reduced