Stroke Patients with Nearly Independent Transfer Ability are at High Risk of Falling.

OBJECTIVES: To examine the relationship between patients' transfer ability and fall risk in stroke patients during hospitalization. MATERIALS AND METHODS: We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1-3, 4-5, and 6-7, and activity status at the falls, were investigated. In addition, changes of patients' transfer ability on admission, at the first fall, and at discharge were investigated among falling patients. RESULTS: The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of "on the bed" and "sitting", while three quarters of patients with a FIM score of 7 had falls during "standing" and "walking". No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge. CONCLUSIONS: Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.

Potential factors, including activities of daily living, influencing home discharge for patients with putaminal haemorrhage.

BACKGROUND: Convalescent rehabilitation wards assist stroke patients in acquiring skills for activities of daily living to increase the likelihood of home discharge. However, an improvement in activities of daily living does not necessarily imply that patients are discharged home. We investigated the characteristics of patients with putaminal haemorrhage who are discharged home following convalescence in rehabilitation wards. METHODS: The sample comprised 89 patients (58 men and 31 women) with putaminal haemorrhage hospitalised in the convalescent rehabilitation ward of our hospital between August 2012 and July 2013. Their age ranged from 29 to 88 years (61.9 ± 11.9 years). The lesion occurred on the right side in 48 and on the left in 41 patients. The mean period from onset to hospitalisation in the convalescent rehabilitation ward was 30.8 ± 17.2 days, and the mean hospitalisation period was 70.7 ± 31.8 days. We examined age, sex, haematoma volume, duration from onset to hospitalisation, neurological symptoms, cognitive function, functional independence measure, number of cohabitating family members and whether the patient lived alone before stroke, and the relationship among these factors and discharge destination (home or facility/hospital) was assessed. RESULTS: The discharge destination was home for 71 and a facility or hospital for 18 patients. Differences were observed in age, haematoma volume, neurological symptoms, cognitive function, functional independence measure score on admission and discharge, number of cohabitating family members and whether the patient lived alone before stroke for patients discharged home. Patients who required long-term care and were discharged home were more likely to be living with family members who were present during daytime. Home discharge was possible if functional independence measure score was ≥70 at the time of discharge for motor items and ≥24 for cognitive items, even if a patient lived alone before stroke. CONCLUSIONS: Although the presence of cohabitating family members was important, the factor most strongly influencing home discharge was the patient's activities of daily living status at the time of discharge. For patients who lived alone before stroke, physical and cognitive functions must be maintained for them to be discharged home after rehabilitation.

Low-Normal Serum Sodium and Heart Failure-Related Events in Patients With Heart Failure With Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Hyponatremia has been shown to be a prognostic factor in heart failure (HF) with preserved ejection fraction (HFpEF). Serum sodium (sNa) cut-off, however, is not defined in HFpEF. Therefore, we investigated the relationship between sNa and HF-related events (cardiovascular death and hospitalization for HF decompensation) in HFpEF patients. METHODS AND RESULTS: We assessed cardiac function using echocardiography and measured sNa in HFpEF patients with New York Heart Association class II (n=321) or III (n=84) in a compensated condition after implementing medical therapy for HF. During a mean follow-up of 27 months, 73 patients developed HF-related events. On multivariate Cox hazard analysis including established predictors in HF, sNa level as a continuous variable was identified as an independent predictor for HF-related events in HFpEF (per 1.0 mmol/L: HR, 0.93; 95% CI: 0.87-0.98; P<0.01). Kaplan-Meier analysis demonstrated significantly higher probability of HF-related events in the lower sNa group (sNa <140 mmol/L) than in the higher sNa group (sNa ≥140 mmol/L; P<0.001, log-rank test). Further, the low-normal sNa group (135 mmol/L

Prognostic Significance of Peripheral Microvascular Endothelial Dysfunction in Heart Failure With Reduced Left Ventricular Ejection Fraction.

BACKGROUND: Endothelial dysfunction plays a crucial role in heart failure (HF), but the association between peripheral microvascular endothelial function assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT) and prognosis remains unknown in HF with reduced left ventricular (LV) ejection fraction (HFREF). We prospectively investigated the association between peripheral microvascular endothelial function and HF-related near-future cardiovascular outcomes in HFREF patients. METHODS AND RESULTS: The 362 HFREF patients (LVEF <50%) were followed for HF-related events (composite of cardiovascular death and HF hospitalization) up to 3 years. A natural logarithmic-scaled RH-PAT index (Ln-RHI) was obtained for each patient. A total of 82 HF-related events were recorded. The lower-RHI group (Ln-RHI ≤0.49, median) experienced a higher rate of HF-related events compared with the higher-RHI group by Kaplan-Meier analysis (30.9% vs. 14.4%, log-rank test: P<0.001). Multivariable Cox hazard analysis identified Ln-RHI as an independent predictor for HF-related events (per 0.1, hazard ratio: 0.84, 95% confidence interval: 0.75-0.95, P=0.005). Adding Ln-RHI to the Meta-analysis Global Group in Chronic HF risk score (MAGGICs) and Seattle Heart Failure Model (SHFM), powerful prognostic predictors of HF, significantly improved the net reclassification index (MAGGICs: 20.11%, P=0.02, SHFM: 24.88%, P<0.001), and increased the C-statistics for prediction of HF-related events (MAGGICs+Ln-RHI: from 0.612 to 0.670, SHFM+Ln-RHI: from 0.662 to 0.695). CONCLUSIONS: Peripheral microvascular endothelial dysfunction assessed by RH-PAT was associated with future HF-related events in HFREF.

A comparison of knee-ankle-foot orthoses with either metal struts or an adjustable posterior strut in hemiplegic stroke patients.

BACKGROUND: We investigated differences in factors affecting judgments regarding the creation of new adjustable posterior strut knee-ankle-foot orthoses (APS-KAFO) and knee-ankle-foot orthoses with metal struts (traditional KAFO) for hemiplegic stroke patients for whom KAFO were created in rehabilitation wards. METHODS: Subjects were 50 patients with hemiplegia due to new-onset stroke (cerebral infarction: n = 25, cerebral hemorrhage: n = 25) who were prescribed KAFO. Patient ages ranged from 36 to 90 years, and the mean duration from stroke onset to hospitalization was 28.8 ± 13.8 days. Neurologic symptoms, cognitive function, activities of daily living, duration from hospitalization to orthosis creation, hospitalization duration, walking ability at discharge, outcome after discharge, and so forth were compared. RESULTS: Fourteen patients were prescribed APS-KAFO, and 36 were prescribed traditional KAFO. Those prescribed APS-KAFO had somewhat milder neurologic symptoms and cognitive dysfunction and a shorter hospitalization duration than those prescribed traditional KAFO. Patients prescribed APS-KAFO also had a higher score and efficiency on functional independence measure at admission and discharge. Walking independence at discharge was seen in 8 of the 14 patients for whom APS-KAFO were created and 8 of the 36 patients for whom traditional KAFO were created. CONCLUSIONS: APS-KAFO was chosen for patients with a high level of activity in the ward and with a higher likelihood of acquiring walking ability using APS-AFO at discharge, whereas traditional KAFO tended to be chosen for patients with relatively severe symptoms who were not expected to acquire practical walking ability.

Development of an ankle torque measurement device for measuring ankle torque during walking.

[Purpose] To develop a device for measuring the torque of an ankle joint during walking in order to quantify the characteristics of spasticity of the ankle and to verify the functionality of the device by testing it on the gait of an able-bodied individual and an equinovarus patient. [Subjects and Methods] An adjustable posterior strut (APS) ankle-foot orthosis (AFO) was used in which two torque sensors were mounted on the aluminum strut for measuring the anterior-posterior (AP) and medial-lateral (ML) directions. Two switches were also mounted at the heel and toe in order to detect the gait phase. An able-bodied individual and a left hemiplegic patient with equinovarus participated. They wore the device and walked on a treadmill to investigate the device's functionality. [Results] Linear relationships between the torques and the corresponding output of the torque sensors were observed. Upon the analyses of gait of an able-body subject and a hemiplegic patient, we observed toque matrices in both AP and ML directions during the gait of the both subjects. [Conclusion] We developed a device capable of measuring the torque in the AP and ML directions of ankle joints during gait.

Repetitive peripheral magnetic stimulation for preventing shoulder subluxation after stroke: a randomized controlled trial.

BACKGROUND: Shoulder subluxation caused by paralysis after stroke is a serious issue affecting shoulder pain and functional prognosis. However, its preventive treatment has not been fully investigated. AIM: To investigate the effects of repetitive peripheral magnetic stimulation (rPMS) on the prevention of shoulder subluxation. DESIGN: A single-center, parallel-group, prospective randomized, open-blinded, end-point study. SETTING: Convalescent rehabilitation ward. POPULATION: We included 50 inpatients in the convalescent rehabilitation ward with post-stroke, having upper limb paralysis, and the acromio-humeral interval (AHI) was within 1/2 finger-breadth. METHODS: A blinded computer-based allocation system was used to randomly assign patients into two groups: 1) conventional rehabilitation plus rPMS therapy (rPMS group, N=25); and 2) conventional rehabilitation alone (control group, N=25). Blinded assessors evaluated the patients before the intervention (T0), 6 weeks after (T1), and 12 weeks after (T2). The primary outcome was the change in AHIs from T0 to T1 between the groups. In contrast, the secondary outcomes were shoulder pain, spasticity, active range of motion, and Fugl-Meyer Assessment upper extremity (FMA-UE) score. RESULTS: Twenty-two patients in the rPMS group and 24 in the control group completed T1, whereas 16 in the rPMS group and 11 in the control group completed T2. The change in AHI was significantly lower in the rPMS group than in the control group ([95% CI, -5.15 to -0.390], P=0.023). Within-group analysis showed that AHI in the rPMS group did not change significantly, whereas it increased in the control group (P=0.004). There were no significant differences between T1 and T2 within or between the groups. Moreover, AHI did not show differences in patients with severe impairment but decreased in the rPMS group in patients with mild impairment (P=0.001). CONCLUSIONS: The rPMS may be a new modality for preventing shoulder subluxation. The association between motor impairment and the sustained effect needs to be further examined. CLINICAL REHABILITATION IMPACT: Applying rPMS to the muscles of the paralyzed shoulder after a stroke may prevent shoulder subluxation.

Dipeptidyl peptidase-4 inhibitor, sitagliptin, improves endothelial dysfunction in association with its anti-inflammatory effects in patients with coronary artery disease and uncontrolled diabetes.

BACKGROUND: Dipeptidyl peptidase 4 (DPP4) inhibitors are used for treatment of diabetes mellitus (DM). We hypothesized that sitagliptin, a DPP4-inhibitor, could improve endothelial dysfunction in DM patients with coronary artery disease (CAD). METHODS AND RESULTS: The 40 patients with CAD and uncontrolled DM, aged 68.7±9.4 years (mean±standard deviation) (50% males, hemoglobin A1c [HbA1c] 7.4±1.0%) were assigned to either additional treatment with sitagliptin (50 mg/day, n=20) or aggressive conventional treatment (control, n=20) for 6 months. Endothelial function was assessed by the reactive hyperemia peripheral arterial tonometry index (RHI). The clinical characteristics at baseline were not different between the groups. After treatment, fasting blood glucose and insulin levels, and lipid profiles were not different between the groups. HbA1c levels significantly improved similarly in both groups. The percent change in RHI was greater in the sitagliptin group than in the control group (62.4±59.2% vs. 15.9±22.0%, P<0.01). Furthermore, treatment with sitagliptin resulted in a significant decrease in the high-sensitivity C-reactive protein (hsCRP) level, but no such change was noted in the control group. Linear regression analysis demonstrated a significant negative relation between changes in RHI and hsCRP, but not between RHI and HbA1c. CONCLUSIONS: Sitagliptin significantly improved endothelial function and inflammatory state in patients with CAD and uncontrolled DM, beyond its hypoglycemic action. These findings suggest that sitagliptin has beneficial effects on the cardiovascular system in DM patients.

Incidents and Sudden Patient Deteriorations Occurring During Their Rehabilitation Sessions in an Acute Care Hospital: A Retrospective Cohort Study.

Objective: To investigate the occurrence of incidents and sudden deteriorations during rehabilitation in an acute care setting by disease category based on the International Classification of Diseases and Related Health Problems, 10th Revision. Design: Retrospective cohort study. Setting: University hospital in Japan with 1376 beds. Participants: A total of 49,927 patients who were admitted to the acute care wards and underwent rehabilitation over 8 years, from April 1, 2013, to March 31, 2021. Interventions: Rehabilitation in an acute care setting. Main Outcome Measures: Incidents and sudden deteriorations reported in medical charts. Results: Among 49,927 admissions, 455 incidents and 683 sudden deteriorations occurred during rehabilitation. The incidents and sudden deteriorations occurred at rates of 0.009/person (0.50 case/1000 h) and 0.012/person (0.75 case/1000 h), respectively. The 3 most frequent incidents were "route-related incidents" (178 cases, 39.1%), followed by "bleeding/abrasions" (131 cases, 28.8%) and "falls" (125 cases, 27.5%). Among 12 disease categories with over 500 admissions and 10,000 rehabilitation hours, the highest incident rate occurred in "certain infectious and parasitic diseases" (0.81 case/1000 h), followed by "diseases of the musculoskeletal system and connective tissue" (0.67 case/1000 h) and "diseases of the genitourinary system" (0.66 case/1000 h). The commonest sudden deterioration was "vomiting" (460 cases, 67.3%), followed by "decreased level of consciousness (with reduced blood pressure)" (42 cases, 6.1%) and "seizure" (39 cases, 5.7%). Furthermore, the highest sudden deterioration rate was in the "endocrine, nutritional, and metabolic diseases" (1.19 case/1000 h) category, followed by "neoplasms" (1.04 case/1000 h) and "certain infectious and parasitic diseases" (0.99 case/1000 h). Conclusions: An incident and sudden deterioration occurred every 2000 and 1333 h, respectively, during rehabilitation. Therefore, understanding the actual occurrence of incidents and sudden deteriorations during rehabilitation may provide valuable insights into preventing incidents and emergencies.

Effect of Post-stroke Depression on Functional Outcomes of Patients With Stroke in the Rehabilitation Ward: A Retrospective Cohort Study.

Objective: To investigate the prevalence of post-stroke depression in a rehabilitation ward and elucidate its effect on functional improvement and outcomes. Design: Retrospective cohort study. Setting: A convalescent rehabilitation ward at a University Hospital. Participants: A total of 114 patients with stroke (mean [SD] age, 67.2 [13.5] years; men, 76) assessed at 2 weeks after admission using the Mini-International Neuropsychiatric Interview were enrolled. Main Outcome Measure: Functional independence measure (FIM) efficiency during hospitalization in the ward. Results: Eleven patients (9.6%) had depression based on the Mini-International Neuropsychiatric Interview. Total FIM efficiency and FIM efficiency in the subtotal of motor items were significantly higher in the non-depression group than in the depression group (median [interquartile range]: 0.69 [0.39-0.95] vs 0.41 [0.24-0.63], P=.027; and 0.56 [0.38-0.80] vs 0.42 [0.18-0.49], P=.023, respectively). Patients in the non-depression group had higher FIM scores at discharge (median [interquartile range]: 116.0 [104.5-123.0] vs 104.0 [82.5-112.0], P=.013, respectively), and were more likely to be discharged home (80.6% vs 36.4%, P=.003). Furthermore, patients in the depression group also stayed significantly longer in the ward (71.0 [36.1] vs 106.1 [43.3], P=.010). Conclusions: Patients with post-stroke depression showed poorer efficiency of functional recovery than those without depression. A future multicenter study with a larger sample size is needed to verify these findings.

Rehabilitation of a Patient with COVID-19 Who Underwent Right Transfemoral Amputation Due to Acute Limb Ischemia: A Case Report.

Background: Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thrombotic complications. Nonetheless, there is a paucity of clinical knowledge regarding rehabilitation of patients with COVID-19 after lower-limb amputation. Case: A 74-year-old woman with COVID-19 was admitted to a university hospital. During hospitalization, she underwent right transfemoral amputation due to acute limb ischemia. Three months after admission, the patient was transferred to a convalescent rehabilitation ward in the same hospital. A femoral prosthesis was prescribed 2 weeks after her transfer to the rehabilitation ward. It featured ischial-ramal containment with a soft liner and belt suspension, 668-g multiple linkage-type safety knee joint (Imasen Engineering; M0781 SwanS), and a solid-ankle cushioned-heel foot. The total rehabilitation time during the patient's stay in the acute-care and rehabilitation wards was 65.5 h (0.99 h/day, 66 days) and 275.0 h (3.02 h/day, 91 days), respectively. In the rehabilitation ward, the patient underwent 54.4 h (19.8%) of muscle strength training, 48.1 h (17.5%) of comprehensive assessments, and 47.1 h (17.1%) of gait training. The patient was discharged home 6 months after admission, with a total Functional Independence Measure score of 120. The patient could walk slowly [44.2 s (0.23 m/s) in the 10 m-walk test] with a femoral prosthesis and a quad cane but exhibited limited endurance (75.0 m in the 6-min walk test). Discussion: Following appropriate rehabilitation, a patient was able to walk independently after lower-limb amputation despite the complication of COVID-19, although her walking ability was limited.

REHABILITATION OUTCOMES IN PATIENTS WITH LOWER LIMB AMPUTATION RECEIVING HAEMODIALYSIS: A RETROSPECTIVE COHORT STUDY.

Objective: To compare the functional outcomes of patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis. Design: A retrospective cohort study. Patients: Patients with lower limb amputation who were admitted to a convalescent rehabilitation ward between January 2018 and December 2021. Methods: The primary outcome was the effectiveness of the Functional Independence Measure (FIM) during hospitalisation in the ward. Secondary outcomes included the total and subtotal (motor/cognitive) FIM scores at discharge, gain in the total and subtotal (motor/cognitive) FIM scores, K-level at discharge, length of hospital stay in the ward, rehabilitation time, and discharge destination. Outcomes were compared between the non-haemodialysis and haemodialysis groups. Results: A total of 28 patients (mean [standard deviation] age, 67.0 [11.9] years; men, 20) were enrolled in this study. Among them, 11 patients underwent haemodialysis. The FIM effectiveness was significantly higher in the non-haemodialysis group than in the haemodialysis group (median [interquartile range], 0.78 [0.72 - 0.81] vs 0.65 [0.28 - 0.75], p = 0.038). The amount of rehabilitation and all secondary outcomes were not significantly different between the groups (p > 0.05). Conclusion: Patients with lower limb amputation who were receiving haemodialysis had poorer FIM effectiveness than those not receiving haemodialysis.

Feline digital phaeohyphomycosis due to Exophiala jeanselmei.

The black nodule measuring 1 cm in diameter developed in the base of nail of an 8-year-old Japanese domestic male cat. Histological examination of the excised nodule revealed a granulomatous lesion extending from the epidermis to adjacent bone. The lesion was consisted of diffuse infiltration of macrophages with epithelioid cells and multinucleated giant cells. These macrophages contained a few to numerous yeast-like brown pigmented fungus cells with a spherical shape and dark thick wall. The PCR amplification with universal primers of the 28S ribosomal RNA gene yielded a 628-bp fragment and the direct sequence confirmed that the diagnosis of the lesion was phaeohyphomycosis caused by the pathogenic dematiaceous fungus, Exophiala jeanselmei.

A case of lymphoma developing in the rabbit cecum.

A rare lymphoma that developed in the cecum of a domestic pet rabbit (6 years old, male, crossbred) was examined pathologically. The tumor consisted of proliferating neoplastic lymphoid cells, which were strongly stained with anti-CD79alpha monoclonal antibody. Electron microscopy revealed the tumor cells were composed of rough endoplasmic reticula and/or dilated rough endoplasmic reticula filled with moderately electron-dense material. These findings indicated the present case was rare digestive tract lymphoma originated from B-lymphocytic lineage in the cecum.

Pre-procedural peripheral endothelial function is associated with increased serum creatinine following percutaneous coronary procedure in stable patients with a preserved estimated glomerular filtration rate.

BACKGROUND: Worsening renal function, indicated by increased serum creatinine (SCr), is a common complication of percutaneous coronary procedures. Risk factors for increased SCr overlap with coronary risk factors involved in endothelial dysfunction. We hypothesized that endothelial dysfunction, measured using the reactive hyperemia peripheral arterial tonometry index (RHI), can predict periprocedure-increased SCr. METHODS: RHI was assessed before elective coronary procedures in 316 consecutive stable patients with a preserved estimated glomerular filtration rate (eGFR, >60mL/min/1.73m2). SCr was measured before and 2 days after procedures. RESULTS: There was no significant correlation between natural logarithmic transformations of RHI (Ln-RHI) and basal Ln-eGFR. Periprocedure increase in SCr was observed in 148 (47%) patients. The increased SCr group had significantly lower Ln-RHI [0.48 (0.36, 0.62) vs. 0.59 (0.49, 0.76), p<0.001]. Multivariate linear regression analysis identified body mass index (BMI) (ß=0.148, p=0.005) and Ln-RHI (ß=-0.365, p<0.001) as significant determinants of percent changes in SCr. Multivariate logistic regression analysis identified Ln-RHI (per 0.1) [odds ratio (OR) 0.672, 95% confidence interval (95% CI) 0.586-0.722; p<0.001], Ln-B-type natriuretic peptide (OR: 1.484, 95% CI: 1.130-1.974; p=0.004), current smoking (OR: 2.563, 95% CI: 1.379-4.763, p=0.003), BMI (OR: 1.113, 95% CI: 1.031-1.203; p=0.007), coronary intervention (OR: 1.736, 95% CI: 1.036-2.909; p=0.036), and Ln-hemoglobin A1c (OR: 6.728, 95% CI: 1.093-41.392, p=0.040) as independent determinants of increased SCr. Receiver-operating characteristics curve analysis showed that Ln-RHI correlated significantly with increased SCr (area under the curve, 0.684, 95% CI: 0.626-0.742, p<0.001). The optimum cut-off point of Ln-RHI for the periprocedure increased SCr was 0.545. CONCLUSIONS: Pre-procedure measurement of endothelial function by RHI is an effective strategy to assess the patient's risk conditions for worsening renal function after percutaneous coronary procedures.

Hemorrhagic Transformation in Patients with Cerebral Infarction Referred to a Rehabilitation Hospital.

PURPOSE: The aim of our study was to investigate the presenting conditions of patients with hemorrhagic transformation (HT), the frequency of HT and its treatments at a rehabilitation hospital. SUBJECTS AND METHODS: 165 patients with cerebral infarctions transferred to our rehabilitation hospital during the study period were enrolled. HT was diagnosed by two stroke specialists using computed tomography (CT) at the time of transfer to our rehabilitation hospital and other imaging data from previous consultations. Neurological status, activities of daily living, administered agents, patient age, duration from stroke onset to transfer and length of hospital stay were examined. RESULTS: 30 of the 165 patients (18.2%) were diagnosed with HT. Decreased activities of daily living at admission and discharge as well as longer hospitalization stays were more prevalent in HT patients than in those without HT. We did not change antiplatelet or anticoagulant agents, but continued rehabilitation over a defined period while monitoring blood pressure; we confirmed with CT that the patients' physical conditions did not deteriorate. CONCLUSION: With careful symptom and CT monitoring over a defined period, rehabilitation can be continued in patients who develop HT at the time of transfer to a rehabilitation hospital in the acute phase of cerebral infarction.

Advanced peripheral microvascular endothelial dysfunction and polyvascular disease in patients with high cardiovascular risk.

BACKGROUND: Polyvascular disease (PolyVD) refers to the coexistence of coronary artery disease (CAD), peripheral arterial disease (PAD), and/or cerebrovascular disease (CVD), and carries a high risk of cardiovascular mortality. Endothelial dysfunction plays a crucial role in cardiovascular pathophysiology. This study investigated the association between PolyVD and the presence of microvascular endothelial dysfunction. METHODS: Consecutive stable patients (n=533) with diabetes mellitus and/or multiple cardiovascular risk factors were enrolled. Peripheral microvascular endothelial function in the finger microvasculature was assessed using the reactive hyperemia peripheral arterial tonometry index (RHI), and ankle-brachial index was measured for diagnosis of lower-extremity PAD prior to coronary angiography. Diagnosis of CVD was based on clinical symptoms, carotid ultrasound, and magnetic resonance imaging. PolyVD was defined as two or more coexisting vascular diseases from CAD, lower-extremity PAD, and CVD. RESULTS: Natural logarithmic transformations of RHI (Ln-RHI) were significantly attenuated in 93 patients with PolyVD (0.44±0.20) compared with those in 440 patients without PolyVD (0.56±0.19; p<0.001) or in 299 patients with a single vascular disease (0.54±0.19; p<0.001). There was an independent correlation between Ln-RHI (per 0.1) and the presence of PolyVD in all high-risk patients [odds ratio (OR): 0.724; 95% confidence interval (CI): 0.610-0.859; p<0.001] and one or more vascular diseases (OR: 0.724; 95% CI: 0.605-0.867, p<0.001). Receiver-operating characteristics curve analysis showed that Ln-RHI correlated significantly with PolyVD (area under the curve, 0.682, 95% CI: 0.625-0.740, p<0.001). The optimum cut-off point of Ln-RHI for the existence of PolyVD was 0.479. CONCLUSIONS: Microvascular endothelial dysfunction is significantly associated with the presence of PolyVD. Severe impairment of endothelial function in peripheral microvasculature may be an important pathophysiological component of PolyVD.

A case of anaplastic meningioma in a dog.

A tumor sized in 2.0x2.0x2.5 cm developed in the cerebellum of a female Beagle was pathologically investigated. Histopathologically, the tumor grew by compression and partially by infiltration into the adjacent cerebellar parenchyma. There were a large number of necrotic lesions and proliferation of collagen fibers. The tumor cells had oval nucleus showing cellular atypia and a high mitotic index. The tumor cells were reacted with vimentin antibody on immunostain. Electron microscopic examination revealed the tumor cells interdigitated with cytoplasmic processus where the desmosomes developed on cell junction. This tumor was diagnosed as anaplastic meningioma, which is rarely observed in dogs.

Relationship between inter-arm blood pressure differences and future cardiovascular events in coronary artery disease.

OBJECTIVE: Recent studies have shown that inter-arm blood pressure differences (IAD) may be a risk factor for cardiovascular events; however, none have addressed them in patients with coronary artery disease (CAD). METHODS: We measured blood pressure bilaterally with the ankle brachial index (ABI) in 657 patients with suspected CAD and assessed the presence of CAD by coronary angiography, and the severity of coronary atherosclerosis with the Gensini score. RESULTS: Mean IADs were significantly greater in risk factor matched patients with CAD than in those without it (P = 0.01), whereas Gensini scores were significantly greater in those with high IAD (≥10  mmHg) than in those with low-IAD (P = 0.01) according to cross-sectional analysis. Patients with high IAD had a significantly greater probability of cardiovascular events than those in whom it was low (log-rank test, P < 0.01, mean follow-up range; 827.3 ±â€Š268.1 days). The presence of hypertension, ABI, usage of calcium channel blocker and high IAD were independent predictors of cardiovascular events according to longitudinal analysis (IAD; hazard ratio: 2.90, 95% confidence interval: 1.41-5.94, P < 0.01) in these patients. Patients with high IAD and peripheral artery disease had the highest Gensini scores according to cross-sectional analysis (P < 0.01) and highest probability of cardiovascular events according to longitudinal analysis (log-rank test, P < 0.001). CONCLUSION: IADs were increased in CAD patients and correlated with its severity. Greater than 10  mmHg of IAD was independently associated with future cardiovascular events. Assessing IAD by ABI measurement may facilitate risk stratification in CAD patients.