Cardiac diseases are the leading cause of death in population. Diagnostic tests to detect cardiac dysfunction at an early stage of the disease are desirable. The major focus has been centered on tests evaluating the perfusion of the heart with imaging techniques or detecting alterations in electrical or mechanical function of the heart. The heart generates magnetic fields that can be detected by body surface mapping utilizing super conducting quantum interference device sensors giving magnetocardiograms (MCGs). The advantages of MCG over traditional electrocardiograms (ECGs) are increased sensitivity to small signals and lack of conductivity in body tissues, presentation of direct component signals and primary currents. This review will highlight the basic principles and recent advantages of MCGs, and the application of MCG in clinical diagnosis, especially in cases whose ECGs are non-diagnostic or not specific, such as detecting baseline shift in ischemic heart disease, noninvasive His potential recording, detection of arrhythmic mechanism defining reentrant circuits vs non reentrant mechanism, diagnosis of fetal arrhythmias and prolongation of QT interval. Areas of future basic and clinical research are also discussed.
Objective In patients with chronic obstructive pulmonary disease (COPD), patient age and initial value of forced expiratory volume in 1 second (FEV1) have been considered the most accurate predictors of mortality among the parameters obtained from pulmonary exercise tests. However, few studies have examined the predictive variables of prognosis among exercise parameters in COPD. We therefore attempted to identify the best index for predicting long-term survival in patients with COPD among the cardiopulmonary variables obtained during exercise testing. Patients and Methods Fifty-eight patients with COPD (50 men and 8 women) without hypoxemia at rest or other serious complications performed resting pulmonary function tests followed by a symptom-limited ramp exercise test on a cycle ergometer with breath-by-breath gas analysis and arterial blood gas sampling. Results After 3,570±1,373 days follow-up (mean±SD), 21 died because of deaths by respiratory failure. The overall survival rates calculated by the Kaplan-Meier method were 92.9% and 75.8% at 5 years and 10 years, respectively. In univariate Cox hazards analysis, age, FEV1, VC, RV/TLC, V Emax, V O2max, V CO2max, PaO2max, PaCO2max, and PaO2 at rest were found to be significant prognostic indices of survival. However, multivariate analysis revealed only FEV1, PaO2max, and age as independent predictors of mortality. In severe COPD patients (FEV1 <50% predicted, n=35), PaO2max and age also correlated with prognosis, whereas FEV1 did not. Conclusion Pulmonary exercise testing is useful in predicting prognosis in patients with COPD.
Objective To clarify the clinical significance of vascular endothelial growth factor (VEGF) in Japanese patients with small cell lung cancer (SCLC). Materials and Methods We measured serum VEGF levels using an enzyme-linked immunosorbent assay in 45 patients with SCLC before treatment and in 38 patients with benign pulmonary disease and in 32 healthy subjects (71 non-malignant subjects). VEGF immunostaining was performed in tissue biopsies obtained from 23 SCLC patients during bronchoscopic examination. Results Median serum VEGF level was 332 pg/ml in patients with SCLC and 160 pg/ml in non-malignant subjects, respectively. The 95% cut-off level to exclude non-malignant subjects was 500 pg/ml. An elevated VEGF level (>500 pg/ml) was found more frequently in patients with extensive disease of SCLC than in those with the limited disease (p<0.01). A significant positive correlation was found between the serum VEGF level and platelet count in SCLC patients (r=0.389; p=0.0083). Serum VEGF level also correlated with serum lactate dehydrogenase in SCLC patients (r=0.381; p=0.0098). However, it did not correlate with serum neuron-specific enolase and pro-gastrin-releasing peptide level. Patients with the elevated VEGF levels had significantly shorter progression-free time than those with the normal VEGF levels (p<0.05). Patients with the elevated VEGF levels had a significantly shorter overall survival time than those with the normal VEGF levels in univariate survival analysis (p<0.05). Further, the elevated VEGF level remained as a significant determinant of poor survival in multivariate analysis (p<0.01). Serum VEGF level was significantly higher in patients with positive VEGF protein immunoreactivity in tumor tissue in SCLC. Conclusion Elevated serum VEGF levels were associated with poor outcome in SCLC.
Objective The advancement of hematopoietic stem cell transplantation techniques and the increase in frequency of hematological malignancy in older patients are expected to expand the indications to include more elderly patients. We investigated the problem of allogeneic bone marrow transplantation (allo-BMT) in patients over 40 years old. Patients and Methods We retrospectively analyzed 21 consecutive patients (13 males and 8 females) over 40 years old who underwent allo-BMT at our center during the past 12 years. ResultsThe patients had a median age of 46 years, and 5 patients were over 50 years old. There were 8 cases of acute myelogenous leukemia (AML), 5 cases of acute lymphocytic leukemia (ALL), 6 cases of chronic myelogenous leukemia (CML) and 2 cases of myelodysplastic syndrome (MDS). The 3-year overall survival rate was 43.0%. Overall survival was associated with recovery of platelets in less than 30 days and recovery of neutrophil counts in less than 15 days. We did not observe any severe graft-versus-host disease (GVHD) or regimen-related toxicities. Twelve patients died of transplantation-related diseases. Conclusion A faster recovery of the neutrophil and platelet counts was significantly associated with overall survival. Decreasing transplantation-related death, particularly by infection control, in allo-BMT in patients over age 40 is an important problem.
Objective Transmission between human and environmental contamination from colonized methicillin-resistant Staphylococcus aureus (MRSA) remains a controversial issue. We, therefore, investigated the differences between MRSA types which colonize in humans and in the environment. Methods A 4-week prospective culture survey for MRSA was performed for 12 patients as well as for the environment of the room of MRSA carriers in quarantine in the geriatric long-term care ward of a 270-bed hospital. Results A total of 97 S. aureus strains (80 MRSA and 17 methicillin-sensitive Staphylococcus aureus [MSSA]) was isolated during the periods of September 8 to 10, 23 to 25 and October 5 to 7, 1998; 25 strains were from the respiratory tract, 4 strains from feces and 11 strains from decubitus ulcers. Fifty-seven strains were from the patients' environment. Molecular typing by pulsed-field gel electrophoresis (PFGE) with the Sma I restriction enzyme demonstrated that the predominant type of MRSA isolated from the environment changed by the minute. The patterns of 42 MRSA strains isolated from the environment were identical in 26 (61.9%), closely related in 15 (35.7%) and possibly related in 1 (2.4%) of the cases of those isolated from patients simultaneously. There was no correlation between patients and the environment with the 17 MSSA isolates. Conclusion Our results demonstrated that MRSA from patients can contaminate the environment, whereas MRSA from the environment might be potentially transmitted to patients via health care workers under unsatisfactory infection control.
The endoscopic examination of a 61-year-old male patient revealed a protruding lesion in the greater curvature of the lower third area of the stomach. The lesion, 17 mm in size, was resected completely with endoscopic submucosal dissection using an insulated-tip diathermic knife (IT-ESD). Histological examination of the protruding lesion revealed proliferation of fibroblasts and infiltration of inflammatory cells in the mucosa and submucosa, and it was diagnosed as an inflammatory fibroid polyp (IFP). Gastritis cystica polyposa (GCP) was presented adjacent to the IFP. This may be the first report of GCP concomitant with gastric IFP occurring in an unoperated stomach.
A 64-year-old man diagnosed as lung adenocarcinoma with hepatic tumor was admitted to our hospital. He carried the hepatitis B virus but was negative for PIVKA-II and α-fetoprotein, and hence we diagnosed a case of stage IV lung adenocarcinoma. We planned to administer systemic chemotherapy, but he experienced sudden-onset abdominal discomfort accompanied with decreased blood pressure. We diagnosed hemorrhagic ascites due to spontaneous rupture of the liver tumor. Emergency angiography and therapeutic embolization stabilized his clinical condition. Hemorrhagic ascites due to metastatic liver tumor is rare and the sudden onset of abdominal symptoms is an indicator of rupture.
We describe three elderly patients with Brugada-type electrocardiographic abnormalities unmasked by a high plasma concentration of the Class IC antiarrhythmic drug pilsicainide, caused by renal dysfunction. The electrocardiograms showed right bundle branch block pattern and ST segment elevation in the precordial leads in patients 1 and 2, and a polymorphic wide QRS wave in patient 3. The serum concentrations of pilsicainide were 2.85, 2.50, and 4.18 μg/ml, which were much higher than the therapeutic range (0.16-0.24 μg/ml). Withdrawal of the drug reversed the electrocardiographic changes. Careful observation is necessary to avoid life-threatening arrhythmias whenever pilsicainide is administered to elderly patients.
A 67-year-old woman who presented with hypocalcemia compatible with idiopathic hypoparathyroidism gradually changed into a state of primary hyperparathyroidism. The left upper parathyroid gland, which was larger and harder than other glands, was resected. Despite the operation, hypercalcemia and high levels of intact PTH persisted. Six weeks later total parathyroidectomy was done to induce remission. The resected gland in the first operation had clusters of lymphoid follicles with germinal centers indicating a chronic autoimmune inflammation. This case suggests a transition from hypoparathyroidim to hyperparathyroidism associated with chronic parathyroiditis, possibly by a mechanism analogous to that observed in chronic thyroiditis.
A 54-year-old man suffered from a relapse of chronic inflammatory demyelinating polyneuropathy (CIDP), and developed quadriplegia and somnolence requiring mechanical ventilation for respiratory failure. Serum Na concentration remained at low levels during the clinical course, and a diagnosis of inappropriate secretion of antidiuretic hormone (SIADH) was made. The present case had not only acute aggravation of CIDP with autonomic dysfunction but also intracranial hypertension caused by increased CSF protein (maximum level, 1,315 mg/dl). It seemed likely that injury of the afferent fibers of the baroregulatory pathway or intracranial hypertension might have contributed to SIADH in this patient.
Interferonβ-1b (IFNβ-1b) is commonly used for relapsing-remitting multiple sclerosis (MS). We report a 23-year-old woman with childhood onset relapsing-remitting MS treated with IFNβ-1b who developed overt chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) immediately after therapy. A baseline conduction study before IFNβ-1b therapy revealed decreased motor conduction velocities and prolonged F wave latencies in several nerves, but there was no neurological sign indicating neuropathy. The existence of subclinical demyelinating neuropathy before IFNβ-1b treatment was suggested, although the clinical criteria for CIDP were unfulfilled. Following two months of IFNβ-1b therapy, numbness of her right upper and lower limbs progressively worsened and all tendon reflexes were depressed. Electrophysiologically, F waves were not evoked in any limbs except for the left ulnar and tibial nerves, which showed marked prolongation of F wave latencies. Moreover, subclinical hyperthyroidism developed in association with high titers of anti-thyroglobulin and anti-thyroid peroxydase antibodies, which were negative before IFNβ-1b therapy. These findings indicated that peripheral demyelination worsened at the nerve roots after IFNβ-1b therapy. In addition to the development of autoimmune thyroid disease, the patient now fulfilled the criteria for probable CIDP. Along with the results of a previous report demonstrating IFNβ-induced CIDP development in patients with childhood MS, this case underscores IFNβ as a potential risk factor for CIDP in patients with childhood onset MS.
A 68-year-old man developed pneumonia 2 days after nearly drowning in a bathtub of a hot spring spa. Chest radiography revealed bilateral consolidation shadows associated with adult respiratory distress syndrome. Initial treatment with antibiotics and pulse therapy with methylprednisolone was not effective. The patient died on the 4th hospital day. A urinary antigen test for Legionella was positive. Legionella pneumophila serogroup 3 was recovered from an intratracheal specimen. The same serotype of Legionella was isolated from the hot spring water. Restriction enzyme analysis by pulse-field gel electrophoresis revealed identical restriction fragments. We conclude that the water at the hot spring spa could have been the source of infection.