Current status of palliative care delivery and self-reported practice in ICUs in Japan: a nationwide cross-sectional survey of physician directors.

BACKGROUND: It is currently unknown how widespread is the practice of palliative care in intensive care units (ICUs) in Japan. This study aimed to determine evaluate the delivery and self-reported practice of palliative care in ICUs in Japan. METHODS: A self-administered questionnaire was sent to the physician directors of all 873 ICUs in Japan in August 2020. RESULTS: Of the 873 institutions, 439 responded the questionnaire (response rate: 50%) and 413 responses were included in the analysis. The responding physicians thought palliative care was appropriate for physical symptoms (36%, 95% Confidence Interval [CI] 32-41), the provision of information (32%, 95% CI: 28-37), psychological distress (25%, 95% CI: 21-29) and in Post Intensive Care Syndrome (PICS) prevention (20%, 95% CI: 17-24). Only 4% (95% CI: 2-6) of participants indicated that they always provided palliative care screening for the patients admitted to the ICU. The most common method to determine eligibility for palliative care was the "prediction of prognosis by clinician's experience" (54%, 95% CI: 50-59). Thirty-one percent (95% CI: 27-36) of participants responded that there was no clear method used to decide which patients need palliative care. Fifty-four percent of the participants answered they had no standardized protocols for symptom management at all. Less than 5% answered they had standardized protocols for end-of-life symptom management or terminal weaning off mechanical ventilation including extubation of endotracheal tubes. CONCLUSIONS: In Japan, the dissemination of palliative care and its integration into ICU care appears insufficient. To improve the quality of life of patients who are admitted to ICU, it may be useful to implement palliative care screening and multidisciplinary conferences, to develop standardized protocols for symptom management and withholding or withdrawing of life-sustaining treatment, and to educate primary palliative care for all ICU physicians.

Attitudes of Physicians toward Palliative Care in Intensive Care Units: A Nationwide Cross-Sectional Survey in Japan.

CONTEXT: Palliative care is an essential component of comprehensive care for patients with critical illnesses. In Japan, little is known about palliative care in intensive care units (ICUs), and palliative care approaches are not widespread. OBJECTIVE: This study aimed to better understand the attitudes of physicians toward palliative care and the utilization and needs of specialized palliative care consultations in ICUs in Japan. METHODS: A nationwide, self-administered questionnaire was distributed ICU physician directors in all hospitals with ICUs. RESULTS: Questionnaires were distributed to 873 ICU physician directors; valid responses were received from 436 ICU physician director (50% response rate). Among the respondents, 94% (n = 411) felt that primary palliative care should be strengthened in ICUs; 89% (n = 386) wanted ICU physicians to collaborate with specialists, such as palliative care teams (PCTs); and 71% (n = 311) indicated the need for specialized palliative care consultations; however, only 38% (n = 166) actually consulted, and only 6% (n = 28) consulted more than 10 patients in the past year. Physicians most commonly consulted PCT for patients with serious end-of-life illness (24%) (n = 107), intractable pain (21%) (n = 92), and providing psychological support to family members (43%, n = 187). The potential barriers in providing primary and specialized palliative care included being unable to understand the patients' intentions (54%, n = 235), lack of knowledge and skills in palliative care (53%, n = 230), and inability to consult with PCTs in a timely manner (46%, n = 201). CONCLUSIONS: These data suggest a need for primary palliative care education in ICUs and improved access to specialized palliative care consultations.

Effectiveness and safety of opioids for dyspnea in patients with lung cancer: secondary analysis of multicenter prospective observational study.

Background: Patients with lung cancer are more likely to have comorbidities [e.g., interstitial lung disease (ILD)], chronic obstructive pulmonary disease) and metastases that may affect dyspnea and the effectiveness and safety of opioids for dyspnea than other cancer types. Therefore, this study examined the effectiveness and safety of opioids for dyspnea, among the patients with lung cancer. Methods: The present study is a secondary analysis of a multicenter prospective observational study examining the effectiveness and safety of opioids for dyspnea in patients with cancer in Japan. For this secondary analysis, patients with lung cancer with a documented dyspnea Numerical Rating Scale (NRS) at baseline were included. The primary outcome was dyspnea NRS, and Integrated Palliative care Outcome Scale/Support Team Assessment Schedule (IPOS/STAS) scores change between baseline and 24 hours after baseline. As secondary outcomes, we investigated the predictors of opioid effectiveness for dyspnea improvement and adverse events (nausea, somnolence, and delirium). Results: This study analyzed 124 patients with lung cancer with known dyspnea NRS at baseline. The median age was 74, and the Eastern Cooperative Oncology Group performance status of 107 patients were 3-4. Both NRS and IPOS/STAS score of dyspnea significantly improved 24 hours after opioid initiation [-1.64, 95% confidence interval (CI): -2.12 to -1.17, P<0.001; -1.03; 95% CI: -1.21 to -0.85, P<0.001; respectively]. Moreover, the improvement of NRS score was greater than the minimal clinically important difference of 1 point. In the multivariate logistic regression analysis, ILD was significantly associated with a better improvement [(hazard ratio (HR): 3.39, 95% CI: 1.34-11.09, P=0.043]. Somnolence was the most common grade 3-4 adverse event (n=16), followed by delirium (n=9). Conclusions: Opioids were effective and safe for treating dyspnea in patients with lung cancer. Furthermore, lung cancer patients with ILD may benefit more from opioids.

Relationships among personality traits, metabolic syndrome, and metabolic syndrome scores: The Kakegawa cohort study.

OBJECTIVE: Metabolic syndrome and the presence of metabolic syndrome components are risk factors for cardiovascular disease (CVD). However, the association between personality traits and metabolic syndrome remains controversial, and few studies have been conducted in East Asian populations. METHODS: We measured personality traits using the Japanese version of the Eysenck Personality Questionnaire (Revised Short Form) and five metabolic syndrome components-elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose-in 1322 participants aged 51.1±12.7years old from Kakegawa city, Japan. Metabolic syndrome score (MS score) was defined as the number of metabolic syndrome components present, and metabolic syndrome as having the MS score of 3 or higher. We performed multiple logistic regression analyses to examine the relationship between personality traits and metabolic syndrome components and multiple regression analyses to examine the relationship between personality traits and MS scores adjusted for age, sex, education, income, smoking status, alcohol use, and family history of CVD and diabetes mellitus. We also examine the relationship between personality traits and metabolic syndrome presence by multiple logistic regression analyses. RESULTS: "Extraversion" scores were higher in those with metabolic syndrome components (elevated waist circumference: P=0.001; elevated triglycerides: P=0.01; elevated blood pressure: P=0.004; elevated fasting glucose: P=0.002). "Extraversion" was associated with the MS score (coefficient=0.12, P=0.0003). No personality trait was significantly associated with the presence of metabolic syndrome. CONCLUSIONS: Higher "extraversion" scores were related to higher MS scores, but no personality trait was significantly associated with the presence of metabolic syndrome.

Application of pressure-derived myocardial fractional flow reserve in chronic hemodialysis patients.

BACKGROUND: Although fractional flow reserve (FFR) measurements during coronary angiography are performed in routine clinical practice, few studies have evaluated FFR measurements in dialysis patients. METHODS: We retrospectively studied 42 hemodialysis patients with suspected or known coronary artery disease (CAD) who underwent stress myocardial perfusion imaging and coronary angiography with FFR measurements for 61 coronary lesions. The cut-off value for FFR to detect myocardial ischemia was determined by receiver operating characteristic (ROC) curve analysis. RESULTS: There were 61 coronary vessels measured by FFR. The FFR range was 0.34-0.93 with a mean of 0.74±0.13. The ROC curve analysis revealed that the best cut-off value of FFR for detecting myocardial ischemia was 0.76 (p<0.0001), with 70% sensitivity, 86% specificity, and 76% accuracy for myocardial ischemia. Compared with patients who had positive myocardial ischemia and an FFR≤0.76, those who had negative myocardial ischemia despite an FFR≤0.76 had less left ventricular (LV) mass index, whereas patients who had positive myocardial ischemia despite an FFR>0.76 had greater LV mass indexor serum calcium-phosphorus product. CONCLUSIONS: The cut-off value of FFR for myocardial ischemia in chronic hemodialysis patients is similar to that in other CAD patients. However, caution is necessary when FFR measurements are applied to dialysis patients with significantly increased LV mass index or serum calcium-phosphorus product.

Randomized controlled trial of the effects of consumption of 'Yabukita' or 'Benifuuki' encapsulated tea-powder on low-density lipoprotein cholesterol level and body weight.

Background: Previous studies have reported controversial results for the association between green tea consumption and low-density lipoprotein (LDL)-cholesterol and body weight. Objective: The objective of this trial was to determine the effects of two kinds of green tea on LDL-cholesterol and body weight. Methods: We randomly assigned 151 participants (98 men, 53 women) aged 30-70 years into three groups: Yabukita green tea group, Benifuuki green tea group, or placebo group. Participants consumed 1.8 g/day of green tea extract powder or placebo for 12 weeks. The primary outcomes were LDL-cholesterol level and body weight, and the secondary outcomes were risk factors for cardiovascular disease. Results: Both Yabukita and Benifuuki green tea significantly lowered LDL-cholesterol. The magnitudes of the lipid-lowering effect of both types of tea were significantly larger than that of placebo. No differences with respect to changes in LDL-cholesterol were observed between the Yabukita and Benifuuki green tea groups. Neither Yabukita nor Benifuuki green tea had any effect on body weight and no difference was observed among groups regarding changes in body weight. Conclusion: Both Yabukita and Benifuuki green tea lowered LDL-cholesterol, and the lipid-lowering effects of these two green teas were not different. Neither tea lowered body weight.

Diagnostic Performance of a Cadmium-Zinc-Telluride Single-Photon Emission Computed Tomography System With Low-Dose Technetium-99m as Assessed by Fractional Flow Reserve.

BACKGROUND: Although stress single-photon emission computed tomography (SPECT) using a cadmium-zinc-telluride (CZT) camera facilitates radiation dose reduction, only a few studies have evaluated its diagnostic accuracy in Japanese patients by applying fractional flow reserve (FFR) measurements. METHODS AND RESULTS: We prospectively evaluated 102 consecutive patients with suspected or known coronary artery disease with a low-dose stress/rest protocol ((99m)Tc radiotracer 185/370 MBq) using CZT SPECT. Within 3 months, coronary angiography was performed and a significant stenosis was defined as ≥90% diameter narrowing on visual estimation, or as a lesion of <90% and ≥ 50% stenosis with FFR ≤0.80. To detect individual coronary stenosis, the respective sensitivity, specificity, and accuracy were 86%, 75%, and 82% for left anterior descending artery stenosis, 76%, 81%, and 79% for left circumflex artery stenosis, and 87%, 92%, and 90% for right coronary artery stenosis. When limited to 92 intermediate stenotic lesions in which FFR was measured, stress SPECT showed 77% sensitivity, 91% specificity, and 84% accuracy, whereas the diagnostic value decreased to 52% sensitivity, 68% specificity, and 58% accuracy based only on visual estimation of ≥75% diameter narrowing. CONCLUSIONS: CZT SPECT demonstrated a good diagnostic yield in detecting hemodynamically significant coronary stenoses as assessed by FFR, even when using a low-dose (99m)Tc protocol with an effective dose ≤5 mSv. (Circ J 2016; 80: 1217-1224).

Direct identification of Streptococcus agalactiae and capsular type by real-time PCR in vaginal swabs from pregnant women.

Most group B streptococcus (GBS) infections in newborns are with capsular type Ia, Ib, or III. To prevent these infections more effectively, we developed a real-time PCR method to simultaneously detect GBS species and identify these 3 capsular types in vaginal swab samples from women at 36-39 weeks of gestation. DNA to be detected included those of the dltS gene (encoding a histidine kinase specific to GBS) and cps genes encoding capsular types. PCR sensitivity was 10 CFU/well for a 33-35 threshold cycle. Results were obtained within 2 h. Direct PCR results were compared with results obtained from cultures. Samples numbering 1226 underwent PCR between September 2008 and August 2012. GBS positivity rates by direct PCR and after routine culture were 15.7% (n = 192) and 12.6% (n = 154), respectively. Sensitivity and specificity of direct PCR relative to culture were 96.1% and 95.9%. Of GBS positive samples identified by PCR, capsular types determined directly by real-time PCR were Ia (n = 24), Ib (n = 32), and III (n = 26). Real-time PCR using our designed cycling probe is a practical, highly sensitive method for identification of GBS in pregnant carriers, allowing use of prophylactic intrapartum antibiotics in time to cover the possibility of unexpected premature birth.

Diagnostic performance of a novel cadmium-zinc-telluride gamma camera system assessed using fractional flow reserve.

BACKGROUND: Although the novel cadmium-zinc-telluride (CZT) camera system provides excellent image quality, its diagnostic value using thallium-201 as assessed on coronary angiography (CAG) and fractional flow reserve (FFR) has not been validated. METHODS AND RESULTS: To evaluate the diagnostic accuracy of the CZT ultrafast camera system (Discovery NM 530c), 95 patients underwent stress thallium-201 single-photon emission computed tomography (SPECT) and then CAG within 3 months. Image acquisition was performed in the supine and prone positions after stress for 5 and 3 min, respectively, and in the supine position at rest for 10 min. Significant stenosis was defined as ≥90% diameter narrowing on visual estimation, or a lesion with <90% and ≥50% stenosis and FFR ≤0.75. To detect individual coronary stenosis, the respective sensitivity, specificity, and accuracy were 90%, 64%, and 78% for left anterior descending coronary artery stenosis, 78%, 84%, and 81% for left circumflex stenosis, and 83%, 47%, and 60% for right coronary artery (RCA) stenosis. The combination of prone and supine imaging had a higher specificity for RCA disease than supine imaging alone (65% vs. 47%), with an improvement in accuracy from 60% to 72%. CONCLUSIONS: Using thallium-201 with short acquisition time, combined with prone imaging, CZT SPECT had a high diagnostic yield in detecting significant coronary stenosis as assessed using FFR.

A novel frameshift mutation in exon 4 causing a deficiency of high-molecular-weight kininogen in a patient with splenic infarction.

High-molecular-weight kininogen (HMWK) deficiency is a very rare hereditary disorder. We herein report a case of HMWK deficiency with splenic infarction. The HMWK activity of the proband was markedly decreased (0.9%). Direct sequencing of his HMWK gene showed a homozygous "TC" insertion at c523-524 in exon 4. This insertion led to an amino acid substitution, Ser175Ser, resulting in a frameshift mutation and a premature stop codon in amino acid 183. Furthermore, the HMWK activity was also reduced in the patient's three children, who exhibited the heterozygous "TC" insertion at c523-524 in exon 4. This is the first report of this gene alteration in a patient with HMWK deficiency.

Usefulness of phase analysis to differentiate ischemic and non-ischemic etiologies of left ventricular systolic dysfunction in patients with heart failure.

BACKGROUND: The detection of significant coronary artery disease (CAD) in patients with heart failure (HF) from left ventricular (LV) systolic dysfunction is crucial. We evaluated the usefulness of LV mechanical dyssynchrony as assessed by phase analysis compared with conventional gated single-photon emission computed tomography to identify ischemic etiology in patients with HF. METHODS AND RESULTS: Forty-one consecutive patients who were initially admitted to hospital due to HF resulting from systolic dysfunction were evaluated. All patients underwent cardiac catheterization. LV mechanical dyssynchrony was evaluated using SyncTool™ to obtain the phase SD and histogram bandwidth. The changes in phase SD and histogram bandwidth with stress were calculated. The summed stress score, summed difference score, and changes in phase SD and histogram bandwidth with stress were greater in 26 patients with CAD than in 15 patients without CAD (P=0.001 and P=0.01). On multivariate analysis a phase SD of >14° (odds ratio [OR], 16.7) and a summed stress score of >17 (OR, 8.0) best differentiated LV dysfunction of ischemic and non-ischemic etiologies, with a sensitivity of 89% and a specificity of 87% (χ(2)=20), compared with summed stress score only (sensitivity, 46%; specificity, 87%; χ(2)=4.5). CONCLUSIONS: The addition of phase analysis to conventional perfusion analysis enables better differentiation of the etiology of HF in patients with systolic dysfunction.

Relationship of SYNTAX score to myocardial ischemia as assessed on myocardial perfusion imaging.

BACKGROUND: Although the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score is used to characterize coronary anatomy based on 9 anatomic criteria such as lesion location and complexity, the relationship between SYNTAX score and myocardial ischemia has yet to be elucidated. METHODS AND RESULTS: A total of 158 consecutive patients with suspected or known coronary artery disease (CAD), who underwent both (99m)Tc-sestamibi single-photon emission computed tomography (SPECT) and coronary angiography, were evaluated. Stress SPECT was assessed using a 17-segment model, and the percentage of the myocardial defect scores (DS) was calculated. In 37 patients with intermediate-high SYNTAX scores (>22), the number of men and the prevalence of multi-vessel CAD were significantly higher, and the % stress and ischemic DS were significantly greater than in 121 patients with low SYNTAX scores (≤22). Coronary risk factors, however, were similar between the 2 groups. The % stress and ischemic DS significantly correlated with SYNTAX score. In patients with a low SYNTAX score, % stress and ischemic DS also significantly correlated with the SYNTAX score, whereas no such correlation was observed in the intermediate-high SYNTAX score group. CONCLUSIONS: SYNTAX score correlated well with myocardial ischemia as assessed on stress SPECT in general. The higher the SYNTAX score, however, the less clear was the correlation with the extent of myocardial ischemia.

Comparison of myocardial perfusion imaging between the new high-speed gamma camera and the standard anger camera.

BACKGROUND: Cadmium-zinc-telluride (CZT) solid-state detectors have been recently introduced into the field of myocardial perfusion imaging. The aim of this study was to prospectively compare the diagnostic performance of the CZT high-speed gamma camera (Discovery NM 530c) with that of the standard 3-head gamma camera in the same group of patients. METHODS AND RESULTS: The study group consisted of 150 consecutive patients who underwent a 1-day stress-rest (99m)Tc-sestamibi or tetrofosmin imaging protocol. Image acquisition was performed first on a standard gamma camera with a 15-min scan time each for stress and for rest. All scans were immediately repeated on a CZT camera with a 5-min scan time for stress and a 3-min scan time for rest, using list mode. The correlations between the CZT camera and the standard camera for perfusion and function analyses were strong within narrow Bland-Altman limits of agreement. Using list mode analysis, image quality for stress was rated as good or excellent in 97% of the 3-min scans, and in 100% of the ≥4-min scans. For CZT scans at rest, similarly, image quality was rated as good or excellent in 94% of the 1-min scans, and in 100% of the ≥2-min scans. CONCLUSIONS: The novel CZT camera provides excellent image quality, which is equivalent to standard myocardial single-photon emission computed tomography, despite a short scan time of less than half of the standard time.

Age-specific nomogram of brachial-ankle pulse wave velocity in Japanese adolescents.

To obtain data on the brachial-ankle pulse wave velocity (baPWV) distribution during adolescence, a total of 3215 Japanese adolescents ranging from 12 to 18 years of age were studied. The brachial-ankle pulse wave velocity increased substantially with age and was significantly higher in males than in females. Multivariate regression analysis revealed that age, weight, and systolic and diastolic blood pressures were the major determinants of baPWV for both genders. Age-specific centile curves of baPWV were constructed for males and females by regression curve analysis. The proposed distribution curves of baPWV and its derived cutoff values may allow the atherosclerotic risk profile among adolescents of different ages to be more precisely estimated.

[Non-invasive ophthalmic liposomes for nucleic acid delivery to posterior segment of eye].

Nucleic acids like siRNA and pDNA are remarkable for treatment of ophthalmic diseases in posterior segment of eye such as age-related macular degeneration (AMD). However, hydrophilic and high molecule compounds are restricted in intraocular distribution through anterior segment of the eye. In addition, the ocular tissue has a blood-retinal barrier which restricts drug delivery thorough systemic administration. Therefore the invasive intravitreal injection has been generally applied for treatment of retinal diseases. The objective in this study is to prepare nucleic acid-loaded liposomes for effective gene delivery to posterior segment of eye by non-invasive ophthalmic administration such as eye-drops. The pDNA/PEI-complex loaded liposomes were prepared using detergent removal method. The obtained liposomes were lyophilized with optimal amount of a cryoprotectant to avoid changes in physical properties and, followed by adjustment of an appropriate volume and osmotic pressure as ophthalmic solution. The liposomes show high pDNA encapsulation efficiency and good cellular uptake ability in human retinal pigment epithelial cells (ARPE-19 cells). We further demonstrate that the modification of ligand which binds to specific receptor on the RPE cells to the liposomes may improve gene delivery efficacy to the posterior segment of eye by non-invasive ocular instillation.

Diagnostic value of left ventricular dyssynchrony after exercise and at rest in the detection of multivessel coronary artery disease on single-photon emission computed tomography.

BACKGROUND: Although stress-induced left ventricular (LV) wall motion abnormality is a well-known marker for extensive coronary artery disease (CAD), no study has yet analyzed whether phase analysis of exercise-induced LV mechanical dyssynchrony may have enhanced diagnostic value over conventional perfusion analysis in the detection of multivessel CAD. METHODS AND RESULTS: A total of 278 patients with suspected or confirmed CAD underwent both exercise stress (99m)Tc-sestamibi gated single-photon emission computed tomography and coronary angiography. LV mechanical dyssynchrony was evaluated using the SyncTool to obtain the phase SD and histogram bandwidth. In the detection of 128 patients with multivessel CAD, a summed stress score (SSS) of ≥9 showed a sensitivity of 84% and a specificity of 53%, while an increase in phase SD of ≥4.4° and a bandwidth of ≥14° after exercise had sensitivities of 74% and 68%, and specificities of 84% and 91%, respectively. On multivariate analysis the combination of post-stress increases in phase SD, histogram bandwidth, transient ischemic dilation (TID) ratio and SSS best identified multivessel CAD (sensitivity 77%, specificity 88%, χ(2)=181.8), compared with TID ratio and SSS only (sensitivity 70%, specificity 76%, χ(2)=68.9). CONCLUSIONS: The addition of phase analysis to evaluate exercise-induced LV mechanical dyssynchrony on conventional perfusion analysis enabled better identification of patients with multivessel CAD.

Postischemic myocardial stunning is superior to transient ischemic dilation for detecting multivessel coronary artery disease.

BACKGROUND: Although poststress myocardial stunning is regarded as a marker for severe coronary artery disease (CAD), no study has yet compared the diagnostic value of poststress stunning with transient ischemic dilation (TID) of the left ventricle (LV) for detecting multivessel CAD. METHODS AND RESULTS: A total of 271 patients with suspected or known CAD underwent adenosine triphosphate (ATP) loading and at-rest gated single-photon emission computed tomography. We assessed myocardial perfusion with a 20-segment model, and analyzed the changes in LV volumetric analysis induced by ATP and an automatically derived TID ratio. In 147 patients with multivessel CAD, the prevalence of multi-territorial ischemia was higher, and the post-ATP increase in end-systolic volume (ESV) and TID ratio were greater, than in the 124 with insignificant or single-vessel CAD (P<0.0001, for all cases). The receiver-operating characteristic curves analysis revealed cutoff values for ESV of 5 ml and a TID ratio of 1.11. Multivariate logistic regression analysis revealed that the combination of a poststress increase in ESV of ≥5 ml and multi-territorial ischemia best identified multivessel CAD, with a sensitivity of 78% and a specificity of 84%, whereas the TID ratio was not shown to be an independent predictor. CONCLUSIONS: Post-ATP stress myocardial stunning is superior to the TID ratio for detecting multivessel CAD.

[A case report of long-term survival of endocrine cell carcinoma of the esophagus with chemo-radiation therapy].

The patient was an 84-year-old man, who was diagnosed with cT3N2 (101L, 109L) M0, stage III esophageal cancer. The tumor, immunohistochemically, was stained positive for CD56 and NSE yielding a definitive diagnosis of endocrine cell carcinoma of the esophagus. We selected chemo-radiation therapy (5-FU/CDDP and 2 Gy/day total 60 Gy) for this patient. As adjuvant chemotherapy, 7 courses of chemotherapy with 5-FU/CDDP, was performed. At 8 months from the chemo-radiation therapy, the disease was diagnosed as cCR. But two years later, lung metastasis appeared, so we started chemotherapy with docetaxel/CDDP/5-FU. After 2 courses, lung metastasis was almost disappeared. He has been survived for four years and five months after chemo-radiation. This case suggests that chemo( FP) -radiation therapy and adjuvant chemotherapy could be an effective treatment for endocrine cell carcinoma of the esophagus.

Importance of the ankle-brachial pressure index in the diagnosis of coronary artery disease in women with diabetes without anginal pain.

BACKGROUND: Clinical symptoms of coronary artery disease (CAD) are often atypical in women, particularly in those with diabetes mellitus. Therefore, a simple diagnostic test to identify a high-risk subset of women with diabetes who are likely to have CAD is important. METHODS AND RESULTS: A total of 407 consecutive patients (319 men and 88 women, age range 68 ± 11 years) with suspected CAD, who were not complaining of anginal pain, were evaluated. Among these patients, 170 had diabetes. Stress myocardial perfusion imaging and simultaneous brachial and ankle blood pressure measurements were performed to obtain the ischemic total perfusion deficit (TPD) and ankle-brachial pressure index (ABI), respectively. Ischemic TPD was not significantly different between men and women, whereas ischemic TPD was significantly greater in diabetic patients than in non-diabetic patients (6.9 ± 7.7% vs. 4.9 ± 6.1%; P = 0.005). In diabetic patients, ischemic TPD was not significantly different between men and women. However, women with ABI<0.9 showed significantly greater ischemic TPD than those with ABI≥0.9 (12.1 ± 10.8% vs. 5.1 ± 5.9%; P=0.04), whereas no difference in ABI was observed in men. CONCLUSIONS: ABI was useful in evaluating CAD in asymptomatic women with diabetes to detect a high-risk subset showing the ischemic TPD of >10%, which is regarded as a scintigraphic indicator for coronary revascularization.

Severe vasospastic angina with ventricular fibrillation suggested by iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid in a young woman.

Iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) imaging is useful to diagnose recent myocardial ischemia. A 27-year-old woman was admitted to our hospital because of aborted cardiac arrest due to ventricular fibrillation. She underwent BMIPP imaging in order to rule out ischemic heart disease. Reduced BMIPP uptake was observed in the inferoseptal segments. Coronary angiography revealed insignificant lesions, and a severe coronary spasm was provoked in the right coronary artery by an intracoronary injection of acetylcholine. The etiology of ventricular fibrillation in this case was considered to be vasospastic angina. The application of BMIPP imaging helped diagnose fatal vasospastic angina in this case.