Transient pacing pulse on the T-wave: What is the mechanism?

A patient with a dual-chamber pacemaker for sick sinus syndrome was hospitalized for heart failure. The electrocardiography (ECG) during hospitalization displayed seemingly abnormal pacing artifacts. This report focuses on the problem-solving of an abnormal-looking paced ECG and identifies the pacemaker's operational behavior as the underlying reason.

Two pacing pulses at short interval on premature ventricular contraction: What is the mechanism?

To understand the seemingly complex behavior of a pacemaker, it is important to carefully read the ECG and understand the manufacturer-specific behavior. This report focuses on the interesting ECG acquired from a patient with a pacemaker operating in DDD mode during a routine outpatient clinic examination.

Feasibility of rapid on-site cytological evaluation of lung cancer by a trained pulmonologist during bronchoscopy examination.

OBJECTIVE: Rapid on-site cytological evaluation (ROSE) in bronchoscopy is a useful ancillary technique. ROSE is usually performed by a cytopathologist or cytotechnologist. However, because of staff shortages and reduced availability, ROSE cannot be performed in every hospital. We aimed to evaluate the accuracy of ROSE when performed by a trained pulmonologist, comparing the diagnosis results with the final diagnosis of cytopathologists. METHODS: We performed a retrospective cohort study on 125 patients who underwent bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endobronchial ultrasonography with a guide sheath (EBUS-GS) for peripheral pulmonary lesions by conventional bronchoscopy at Sapporo Medical University Hospital between March 2012 and September 2018. ROSE was performed by a pulmonologist who was trained by a cytotechnologist for a total of 1 month. DiffQuik® staining for ROSE was used to prepare cytology slides. The results of ROSE were compared with the final diagnosis obtained using Papanicolaou staining by cytopathologists. RESULTS: In all procedures, the sensitivity, specificity and diagnostic accuracy of ROSE were 88.5%, 83.0% and 86.4%, respectively. There was no significant difference in the sensitivity, specificity, positive predictive value, negative predictive value or accuracy between EBUS-TBNA and EBUS-GS. CONCLUSIONS: ROSE of lung cancer by a trained pulmonologist can be highly accurate and deemed as feasible and useful for not only EBUS-TBNA but also EBUS-GS.

Usefulness of Lipoprotein(a) for Predicting Clinical Outcomes After Endovascular Therapy for Aortoiliac Atherosclerotic Lesions.

PURPOSE: To evaluate the usefulness of serum lipoprotein(a) as a biomarker of clinical outcomes after endovascular therapy (EVT) for atherosclerotic aortoiliac lesions. METHODS: Serum lipoprotein(a) concentrations were measured at admission in 189 consecutive patients (median age 72 years; 160 men) with peripheral artery disease who underwent EVT for aortoiliac occlusive disease. The patients were dichotomized into 2 groups based on serum lipoprotein(a) levels ≤40 mg/dL (LOW; n=135) or >40 mg/dL (HIGH; n=54). After EVT, the incidences of major adverse limb events (MALE) were analyzed. Predictors of MALE were sought with a Cox proportional hazards analysis; results are presented as the hazard ratio (HR) and 95% confidence interval. RESULTS: At the median follow-up of 33 months (interquartile range 11, 54), MALE occurred in 44 (23.3%) patients. The MALE-free survival estimate was significantly lower in patients in the HIGH group (55.6% vs 85.2%, p<0.001). Independent predictors of MALE after EVT were hemodialysis (HR 2.23, 95% CI 1.04 to 4.78, p=0.039) and high lipoprotein(a) levels (HR 2.80, 95% CI 1.44 to 5.45, p=0.003). CONCLUSION: High lipoprotein(a) levels were associated with a higher incidence of MALE after EVT for patients with aortoiliac lesions.

Moderate vasomotor response to acetylcholine provocation test as an indicator of long-term prognosis.

The acetylcholine (ACh) provocation test (ACh-test) is used for the diagnosis of vasospastic angina (VSA). However, subjects often show a moderate spasm (MS) response for which diagnosis of VSA is not definitive, and the clinical significance of this response is unknown. We assessed moderate coronary vasomotor response to the ACh test as an indicator of long-term prognosis. A total of 298 consecutive patients who underwent the ACh test for suspected VSA were retrospectively investigated. Coronary spasm severity after intracoronary administration of isosorbide dinitrate was evaluated by measuring epicardial coronary artery diameter reduction after ACh injection. Patients were divided into three groups according to the diameter reduction during the ACh test: severe spasm (SS) showing ≥75 % diameter reduction, MS showing ≥50 % diameter reduction, and others (N). In Kaplan-Meier analysis, the major adverse cardiac event (MACE) rates with a median follow-up of 4.6 years were significantly worse in SS (11.1 %) and MS (8.5 %) than N (1.9 %), (SS vs N; P = 0.009, MS vs N; P = 0.029). Significant difference in MACE rates was not observed between SS and MS (P = 0.534). Cox regression analysis revealed that MS remained an independent predictor of MACE after adjustment for other confounders (HR: 7.18, 95 % CI 1.42-36.4, P = 0.017). Patients with MS by ACh test had a cardiac event rate comparable with that of patients with SS and significantly worse than that of patients with normal vasomotor responses.

The "Old yet New" Echocardiographic Finding for Constrictive Pericarditis Following Purulent Pericarditis: A Case Report.

Purulent pericarditis (PP) is a localized infection of the pericardial cavity with suppuration that can be life-threatening. Treatment for PP consists of pericardial drainage and antimicrobial therapy. Constrictive pericarditis (CP), a form of diastolic heart failure that arises because an inelastic thickened pericardium, is a possible related dreadful complication of PP. Several echocardiographic findings suggestive of CP have been reported, but some require measurements or are difficult to reproduce. This case report presents a simple echocardiographic finding that reflects the clinical course of transient CP (TCP). A 76-year-old Japanese man presented to our hospital with chest pain and dyspnea. He was diagnosed with PP caused by Streptococcus pyogenes and treated with pericardial drainage and benzylpenicillin. The response to the treatment of the infection was favorable, but subsequent echocardiography and cardiac catheterization revealed a CP complication. Treatment with colchicine and ibuprofen was initiated, with improvement in CP within three months. During CP, a restricted right ventricular (RV) motion and movement of the liver towards the heart were observed before other echocardiographic findings suggestive of CP. Furthermore, this echocardiographic finding disappeared and normalized as CP improved. In this case of TCP following PP, changes in the echocardiographic "RV sliding" sensitively reflected the clinical course of CP. This simple finding may indicate inflammation of the pericardium and could be useful for the diagnosis and follow-up of CP.

Rapid daily expansion of highly mobile intracardiac calcified tissue: a case report.

Background: A calcified amorphous tumour (CAT) is a non-neoplastic mass lesion arising within the cardiac chamber. CATs are rare but are a common cause of organ embolism. In the present study, we experienced a case of an intracardiac mass with calcification that, in contrast to a typical CAT, suddenly appeared and rapidly expanded without an inflammatory response based on pathological findings. Case summary: A 58-year-old Japanese man undergoing peritoneal haemodialysis had a high-echoic mobile mass (15 × 6 mm), which was not visible on the transthoracic echocardiography (TTE) approximately a month earlier, in the left ventricular outflow tract noted on TTE performed during a close examination for fever. Although multiple blood cultures were negative, ampicillin/sulbactam and ceftriaxone were initially administered because of suspected blood culture-negative endocarditis. The mass rapidly enlarged (22 × 5 mm) over the following days. A CAT was suspected and resected based on imaging findings with calcification; however, the pathological findings did not indicate inflammation and fibrin that are typically found in CATs. Echocardiography performed 12 months after the resection showed no recurrence. Discussion: This intracardiac calcified tissue had several similar features to a CAT. However, the initial presentation, enlargement rate, and pathological features of the tissue differed from that of a typical CAT. Although it is unknown whether this mass is a subtype of CAT, when an intracardiac calcified tissue is detected using an imaging test, careful follow-up or early surgical resection should be considered given the possibility of rapid tissue enlargement and embolism caused by the mass.

Enantiopure 2-(2-ethylhexyl)dinaphtho[2,3-b:2',3'-f]thieno[3,2-b]thiophenes: synthesis, single-crystal structure and a surprising lack of influence of stereoisomerism on thin-film structure and electronic properties.

Starting from a chiral resolution of 2-ethylhexanoic acid followed by conversions of functional groups without interfering with the enantiopurity, we have successfully introduced an enantiopure 2-ethylhexyl group on to dinaphtho[2,3-b:2',3'-f]thieno[3,2-b]thiophene (DNTT) via a Negishi-coupling reaction to synthesize 2-(R)-(2-ethylhexyl)- and 2-(S)-(2-ethylhexyl)-DNTT (R- and S-EH-DNTT, respectively). Then, the crystallinities, thin-film structures, and the organic field-effect transistors (OFETs) based on R-, S- and racemic EH-DNTT (rac-EH-DNTT) were studied to elucidate the effect of stereoisomerism in the 2-ethylhexyl group. The crystal structures of the R- and S-EH-DNTTs are classified as herringbone packing and contain two crystallographically independent molecules connected by edge-to-face CH-π intermolecular interactions, and the molecules' directly opposite directions avoid steric repulsion between the 2-ethylhexyl groups. Thin films of the EH-DNTTs fabricated using both the spin-coating and vacuum-deposition methods were revealed to have similar but slightly different packing structures to that in the single crystal. Intriguingly, the packing structures in the thin-film state depend on the deposition method, and not on the stereoisomers of EH-DNTT. Consistent with the packing structures in the thin-film state, the performance of OFETs based on the thin films of the R-, S- and rac-EH-DNTTs were affected by the deposition method, and not by the stereoisomerism. This means that the stereoisomerism in the alkyl side chain has a marginal effect on the packing structure and electronic properties in the thin-film state. This is endorsed by the theoretical calculations using the functional-group symmetry-adapted perturbation theory (F-SAPT), which indicated that the intermolecular interactions between the DNTT cores are dominant in the total intermolecular interaction energies, and implies that the crystallization process in the thin-film deposition could be governed by intermolecular interactions between the DNTT cores. We conclude that in 2-ethylhexyl-substituted organic semiconductors with a large and highly aggregative π-conjugated core, like EH-DNTT, the enantiopurity in the 2-ethylhexyl group does not significantly affect the thin-film structure and thus the performance of thin-film OFETs.

Maple syrup urine disease due to a paracentric inversion of chr 19 that disrupts BCKDHA: A case report.

Maple syrup urine disease (MSUD) is a rare autosomal recessive inherited disorder of branched-chain amino acid metabolism caused by mutations in BCKDHA, BCKDHB, and DBT that encode the E1α, E1ß, and E2 subunits of the branched-chain α-ketoacid dehydrogenase (BCKD) complex. Various MSUD-causing variants have been described; however, no structural rearrangements in BCKDHA have been reported to cause the classic MSUD phenotype. Here, we describe the classic patient with MSUD with compound heterozygous pathogenic variants in BCKDHA: a missense variant (NM_000709.3:c.757G > A, NP_000700.1:p.Ala253Thr) and a paracentric inversion disrupting Intron 1 of BCKDHA, which was identified by whole-genome sequencing and validated by fluorescence in situ hybridization. Using the sequence information of the breakpoint junction, we gained mechanistic insight into the development of this structural rearrangement. Furthermore, the establishment of junction-specific polymerase chain reaction could facilitate identification of the variant in case carrier or future prenatal/preimplantation tests are necessary.

High-output heart failure associated with primary plasma cell leukaemia due to arteriovenous shunting: a case report.

BACKGROUND: Primary plasma cell leukaemia is rarely associated with high-output heart failure, and the underlying mechanism is not well understood. We encountered a rare case of high-output heart failure caused by primary plasma cell leukaemia. Its underlying mechanism was clarified through imaging studies. CASE SUMMARY: A 49-year-old man with no specific medical history was admitted to our hospital because of heart failure that did not improve with diuretic therapy. His condition was diagnosed as high-output heart failure and primary plasma cell leukaemia after admission. Extensive bone involvement in primary plasma cell leukaemia and arteriovenous shunts in the same lesion were suspected after various imaging studies. The first cycle of chemotherapy with bortezomib, adriamycin, and dexamethasone led to remission of primary plasma cell leukaemia and improved heart failure symptoms. The patient received further chemotherapy in addition to autologous peripheral blood stem cell transplantation and maintenance therapy and had no recurrence of pPCL or heart failure for 1 year to date. DISCUSSION: Primary plasma cell leukaemia can be associated with high-output heart failure, which is caused by arteriovenous shunting at the lesion site with diffuse bone involvement. Imaging studies may lead to the early diagnosis of aetiology and treatment of patients with high-output heart failure associated with primary plasma cell leukaemia.

Repeated treatment with gefitinib and alectinib in a patient with multiple EGFR-mutant and ALK-mutant lung adenocarcinomas: A case report.

Multiple EGFR-mutant and ALK-mutant lung cancers are rare, and standard treatment has not been established because of the small number of cases. A 79-year-old man was found to harbor nodular shadows in right S1, right S5, and left S3. He was surgically diagnosed with stage IIB (pT3N0M0) EGFR G719X-mutant lung adenocarcinoma in left S3 and stage IA1 (pT1aN0M0) ALK-mutant lung adenocarcinoma in right S5. Owing to the relapse of the EGFR-mutant adenocarcinoma, gefitinib treatment was commenced 3 months postoperatively. The tumor shrank temporarily; however, the nodular shadow in the right S1 and #3a lymph nodes were found to increase in size. He was diagnosed with adenosquamous carcinoma in right S1 and relapsing ALK-mutant adenocarcinoma in #3a lymph node. Gefitinib treatment was continued, but due to a renewed increase in the size of the #3a lymph node, the drug was changed to alectinib 16 months postoperatively. Subsequently, the EGFR-mutant adenocarcinomas were found to increase in left S1 despite the decrease in the #3a lymph node size. Nineteen months after the first surgery, the treatment was changed to gefitinib, and repeated treatment with this drug and alectinib administered every 2 months was continued. This approach enabled 39 months of progression-free survival, and no serious adverse events were observed.

Prognostic value of 6-min walk stress echocardiography in patients with interstitial lung disease.

BACKGROUND: The 6-min walk test (6MWT) provides prognostic information for patients with interstitial lung disease (ILD). Parameter determined by Doppler echocardiography after the 6MWT (6 MW stress echocardiography) is shown to be a predictor of future development of pulmonary hypertension in patients with connective tissue disease. However, the clinical utility of 6 MW stress echocardiography in predicting cardiopulmonary events in patients with ILD remains unknown. We examined whether parameters determined by 6 MW stress echocardiography independent predictors of adverse events in patients with ILD. METHODS: Echocardiographic examinations were performed in 68 consecutively enrolled patients with ILD (age, 65 ± 10 years, 65% men). A pressure gradient of tricuspid regurgitation (TRPG) and pulmonary vascular resistance (PVRecho) calculated using the following formula [PVRecho = (peak velocity of TR × 10/time-velocity integral of right ventricular outflow (RVOT-VTI)) + 0.16] were measured at baseline and at post 6MWT. Data for parameters of pulmonary functional tests and for 6MWT were collected. RESULTS: During a mean follow-up period of 22 ± 12 months, 22 patients experienced cardiopulmonary events. In univariate analysis, %VC, TRPG, PVRecho, TRPG post 6MWT, and PVRecho post 6MWT were significantly associated with cardiopulmonary events. Multivariate analysis using the Cox proportional hazards model indicated that %VC [hazard ratio (HR): 0.97, p = 0.009] and PVRecho post 6MWT (HR: 1.77, p = 0.004) were independent predictors of cardiopulmonary events in patients with ILD. CONCLUSIONS: In addition to parameters of pulmonary function tests, increased PVRecho post 6MWT is a significant predictor of cardiopulmonary events in patients with ILD. A 6 MW stress echocardiography is useful in assessing the risk of adverse events in patients with ILD.

Restenosis of a Polytetrafluoroethylene-Covered Stent Visualized by Coronary Angioscopy and Optical Coherence Tomography: A Case Report.

An expandable polytetrafluoroethylene (PTFE)-covered stent graft is beneficial for the treatment of coronary perforations. However, several reports have shown that restenosis and thrombotic occlusion occasionally occur in the stented segment after PTFE-covered stent implantation. A restenosis case after treatment with PTFE-covered stent against saphenous vein graft (SVG) perforation has never been evaluated with optical coherence tomography (OCT) or coronary angioscopy (CAS). This case report presents a 75-year-old man treated with a PTFE-covered stent after he suffered from SVG perforation 6 months ago. He was found to have a focal restenosis of the distal edge of the PTFE-covered stent and underwent percutaneous coronary intervention. OCT showed focal restenosis with homogeneous neointima and exposed struts in the middle and proximal part of the PTFE-covered stent. CAS showed white neointima with a smooth surface at the restenosis site and a sharp border against proximal exposed struts with characteristic links. This case study showed, for the first time in vivo and in a human, the neointimal characteristics of restenosis and uncovered stent struts in a PTFE-covered stent which had been implanted 6 months before. The delayed endothelialization was sustained until 12 months after implantation.

Three Adolescents With Primary Human Herpesvirus 7 Infection During a Measles Outbreak.

During local small measles outbreak in Japan, 3 adolescents with febrile skin rash suspected as having measles were diagnosed with primary human herpesvirus (HHV)-7 infection. Primary HHV-7 infection can cause exanthem subitum in not only young children but also adolescents. HHV-7 should be considered as a possible causative agent for adolescent febrile skin rash during the measles outbreak.

Occult ovarian clear-cell carcinoma diagnosed as primary adenocarcinoma of the lung: A case report of a diagnostic pitfall for clinicians and pathologists.

We present a case of ovarian clear-cell carcinoma that was initially diagnosed as adenocarcinoma of lung origin. This is an instructive diagnostic pitfall for clinicians and pathologists because of the unusual clinical course, small biopsy material, and noteworthy immunophenotype of the carcinoma. Imaging analysis identified only lung and liver lesions. In addition, the biopsy specimen from the lung was TTF-1 negative and napsin A positive, which is still possible for cancer of lung origin. Postmortem examination found that the cancer should be classified as ovarian clear-cell carcinoma distinguished by positive staining for napsin A and paired-box gene 8 (PAX8). Although PAX8 may not be usually investigated when tumoral lesions are identified in only the lung and liver, it is important to keep the necessity of PAX8 in mind to excluding carcinoma of Müllerian, renal, or thyroid origin.

Urinary Liver-Type Fatty Acid-Binding Protein Level as a Predictive Biomarker of Acute Kidney Injury in Patients with Acute Decompensated Heart Failure.

BACKGROUND: There are no biological markers to predict the onset of acute kidney injury (AKI) in patients with acute decompensated heart failure (ADHF). Liver-type fatty acid-binding protein (L-FABP) levels are markedly upregulated in the proximal tubules after renal ischemia. We investigated whether urinary L-FABP is a suitable marker to predict AKI in ADHF patients. METHODS: We examined 281 consecutive patients with ADHF. Serum creatinine (Cr) and L-FABP levels were measured at admission and 24 and 48 h after admission. RESULTS: AKI developed in 104 patients (37%). Urinary L-FABP levels at admission were significantly higher in patients with AKI than in those without (33.0 vs. 5.2 µg/g Cr; p < 0.001). Multivariate analysis showed that baseline urinary L-FABP level was an independent predictor of AKI in ADHF patients (odds ratio 1.08, 95% confidence interval 1.05-1.12; p < 0.001). Receiver operating characteristic analysis showed that baseline urinary L-FABP level exhibited 94.2% sensitivity and 87.0% specificity at a cutoff value of 12.5 µg/g Cr. CONCLUSIONS: Urinary L-FABP level is useful for predicting the onset of AKI in patients with ADHF. The results of our study could help clinicians diagnose AKI in ADHF patients earlier, leading to possible improvements in the treatment of this group of patients.

Effect of influent COD/SO4(2-) ratios on UASB treatment of a synthetic sulfate-containing wastewater.

The effect of the chemical oxygen demand/sulfate (COD/SO4(2-)) ratio on the anaerobic treatment of synthetic chemical wastewater containing acetate, ethanol, and sulfate, was investigated using a UASB reactor. The experimental results show that at a COD/SO4(2-) ratio of 20 and a COD loading rate of 25.2gCODL(-1)d(-1), a COD removal of as high as 87.8% was maintained. At a COD/SO4(2-) ratio of 0.5 (sulfate concentration 6000mgL(-1)), however, the COD removal was 79.2% and the methane yield was 0.20LCH4gCOD(-1). The conversion of influent COD to methane dropped from 80.5% to 54.4% as the COD/SO4(2-) ratio decreased from 20 to 0.5. At all the COD/SO4(2-) ratios applied, over 79.4% of the total electron flow was utilized by methane-producing archaea (MPA), indicating that methane fermentation was the predominant reaction. The majority of the methane was produced by acetoclastic MPA at high COD/SO4(2-) ratios and both acetoclastic and hydrogenthrophic MPA at low COD/SO4(2-) ratios. Only at low COD/SO4(2-) ratios were SRB species such as Desulfovibrio found to play a key role in ethanol degradation, whereas all the SRB species were found to be incomplete oxidizers at both high and low COD/SO4(2-) ratios.

Validation of prone myocardial perfusion SPECT with a variable-focus collimator versus supine myocardial perfusion SPECT with or without computed tomography-derived attenuation correction.

OBJECTIVE: The purpose of this study is to evaluate whether prone myocardial perfusion single-photon emission computed tomography (MPS) with thallium-201 acquired through a variable-focus collimator (IQ-SPECT) can correct for soft-tissue attenuation. METHODS: Thirty-nine patients underwent thallium-201 stress MPS with IQ-SPECT. Delayed images acquired with the patients in the prone position were compared with delayed images obtained with the patients in the supine position with computed tomography-derived attenuation correction (CTAC) (S-CTAC images) or without CTAC (S-NCTAC images). Quantitative tracer uptake (QTU) and semi-quantitative defect scores were determined for the 17 standard myocardial segments. Segments were categorized into anterior-anteroseptal, lateral, inferior, and apex, and areas with defect decision were determined by using the defect scores. RESULTS: Image quality in the prone images was similar to that of S-NCTAC and S-CTAC images. In male patients, QTU in prone images was equivalent to that in S-CTAC images in the anterior-anteroseptal area, but was significantly lower than that in S-CTAC images in the inferior area. In female patients, QTU in prone images was similar to that in S-CTAC images in the anterior-anteroseptal, lateral, and inferior areas. In male and in female patients, QTU in the apex was significantly greater in the prone images than that in the S-CTAC images. In the combined male and female patient group, the defect decision for prone images was similar to that for S-CTAC images in the anterior-anteroseptal, lateral, and inferior areas. Apical defects were observed more frequently in S-CTAC images than in prone or S-NCTAC images. CONCLUSIONS: Fewer artificial defects were observed in the apex of images acquired by prone imaging than by S-CTAC imaging. Prone images improved attenuation and had similar defect decision as S-CTAC images in the anterior-anteroseptal, lateral, and inferior areas.