Effectiveness of smoking cessation intervention based on the ABC Approach in patients with TB.

SETTING: Urban setting in the Philippines. OBJECTIVE: To assess the effectiveness of the ABC Approach developed by The Union as a tobacco-smoking cessation intervention for TB patients at a primary healthcare level in an urban setting in the Philippines. DESIGN: We set up an intervention group whose patients with TB received the ABC approach and a control group of patients with TB receiving only routine health education in Manila, The Philippines. We collected smoking status and the domestic secondhand-smoking (SHS) status data from patients with TB at months 0, 2, 4, 6, 8, and 12. TB treatment outcome data were also collected. RESULTS: Patients with TB (n = 2,174) were enrolled upon TB registration. Smoking rates were consistently low in the intervention group (3.9% vs. 8.7% at Month 6). The odds ratios of both tobacco-smoking status and domestic SHS status in the intervention group were significantly lower than those in the control group (tobacco-smoking status: P < 0.001, domestic SHS status: P < 0.01). TB treatment success rates were similar between the groups (85.0% vs. 87.3%; P = 0.201). CONCLUSION: The ABC approach successfully reduced tobacco-smoking rates, maintained low domestic SHS rates and TB treatment success rates in the Philippines.

CADRE: Cadre urbain aux Philippines. OBJECTIF: Évaluer l'efficacité de l'approche ABC développée par L'Union en tant qu'intervention de sevrage tabagique pour les patients atteints de TB au niveau des soins de santé primaires en milieu urbain aux Philippines. MÉTHODE: Nous avons mis en place un groupe d'intervention dont les patients atteints de TB ont reçu l'approche ABC et un groupe témoin de patients atteints de TB ne recevant qu'une éducation sanitaire de routine à Manille, aux Philippines. Nous avons recueilli des données sur le statut tabagique et le statut de tabagisme passif (SHS, pour l'anglais « secondhand-smoking ¼) domestique des patients atteints de TB aux mois 0, 2, 4, 6, 8 et 12. Des données sur les résultats du traitement de la TB ont également été recueillies. RÉSULTATS: Les patients atteints de TB (n = 2 174) ont été recrutés lors de l'enregistrement de la TB. Les taux de tabagisme étaient constamment faibles dans le groupe d'intervention (3,9% contre 8,7% au 6e mois). Les rapports de cotes du tabagisme et du statut SHS canadien dans le groupe d'intervention étaient significativement inférieurs à ceux du groupe témoin (tabagisme : P < 0,001, statut SHS national : P < 0,01). Les taux de réussite du traitement de la TB étaient similaires entre les groupes (85,0% contre 87,3% ; P = 0,201). CONCLUSION: L'approche ABC a permis de réduire les taux de tabagisme, de maintenir de faibles taux nationaux de SHS et de taux de réussite du traitement de la TB aux Philippines.

Pre-migration TB screening-the first step is always the hardest.

As the proportion of foreign-born persons among TB notifications continues to rise, Japan is preparing to introduce pre-migration TB screening for those coming from selected countries, who are intending to stay for more than 90 days. It has announced that the programme will commence in 2020. In this review, the authors examine the experiences from two countries which already have years of experience in operating pre-migration TB screening, namely the United Kingdom and Australia. The authors point out that both countries have developed strong health information system not only to collect and analyse screening results, but also to use the data to effectively monitor and evaluate the screening programme itself. The critical role which health information system plays within pre-migration screening is often overlooked. Here we argue that Japan, as with any other countries planning to introduce pre-migration screening for TB, must also plan for data management.

A cost-effectiveness study of tuberculosis and latent tuberculosis infection screening in prisons in Japan.

BACKGROUND: Prison inmates are considered a high-risk population for tuberculosis (TB) in Japan. However, they are currently only screened for active TB using chest X-ray (CXR) as part of an annual health check.OBJECTIVE: To evaluate the cost-effectiveness of screening for latent TB infection (LTBI) using interferon-gamma release assay (IGRA) on entry into prison institutions.METHOD: We developed a transmission model of TB, taking into consideration the TB and LTBI epidemiology among inmates in Japan. Using a decision tree, we compared and evaluated no screening, screening using CXR, and IGRA screening for LTBI with CXR upon entry for a hypothetical cohort of 10 000 persons, aged ≥20 years; active TB cases prevented was the health outcome.RESULTS: It was estimated that 314 active TB cases would occur in the absence of any screening policy. IGRA with CXR screening averted 176 cases, while just one case of active TB was averted with CXR only screening. The incremental cost-effectiveness ratio per active TB case prevented was respectively US$2672 and US$43 984 for IGRA + CXR screening and CXR only screening.CONCLUSION: Screening with IGRA should be considered as the most cost-effective screening policy for prison inmates.

Using surveillance data to simulate the impact of a hypothetical pre-entry tuberculosis screening programme in Japan.

BACKGROUND: Despite a growing burden of foreign-born tuberculosis (TB) patients, Japan does not currently practise pre-entry tuberculosis (TB) screening among foreign-born entrants. OBJECTIVE: To evaluate the impact of a hypothetical pre-entry TB screening programme among new foreign-born entrants into Japan. METHOD: Using publicly available sources, we estimated 1) the number of prevalent TB cases, defined as bacteriologically or clinically confirmed cases among new foreign-born entrants into Japan in 2015, and 2) the yield from a hypothetical pre-entry TB screening programme under three scenarios: Scenario A, in which screening would be required of all applicants intending to stay for 3 months; Scenario B, screening among applicants for visas for settlement purposes; and Scenario C, screening among student and technical intern visa applicants. RESULTS: The numbers of prevalent TB cases under Scenarios A, B and C were respectively 492, 54 and 248 out of a total of 328 791, 21 554 and 182 879 applicants, respectively 276, 29 and 137 of whom would be detected via the pre-entry screening programme, giving an yield of respectively 83.9, 134.5 and 74.9 per 100 000 screened under each scenario. CONCLUSION: The yield was the highest under Scenario B; however, the impact was greatest under Scenario A, in that it detected the greatest number of patients and thus contributed the most in reducing the burden of foreign-born TB cases in Japan.

[Impact of preoperative 64-row multislice computed tomography for congenital aortic stenosis; report of a case].

A 63-year-old woman was diagnosed as having severe aortic stenosis (AS) with 98 mmHg peak pressure gradient detected by echocardiography. Since, preoperative enhanced 64-row multislice computed tomography (MSCT) showed bicuspid aortic valve with only 2 sinuses of Valsalva, congenital aortic stenosis was suspected. The left and right coronary arteries originated from respective sinus of Valsalva, and severely thickened cusps of aortic valve were detected clearly by preoperative 64-row MSCT. Aortic valve replacement with a 21 mm ATS mechanical bileaflet prosthesis was performed without aortic annulus enlargement. The postoperative course was uneventful and postoperative 64-row MSCT indicated good performance of the ATS valve. Preoperative 64-row MSCT could be useful to detect complex aortic valve disease in detail. Moreover. 64-row MSCT might be a reliable tool to evaluate valvular heart disease.

[Mitral valve plasty for infective endocarditis associated with vertebral osteomyelitis].

Infective endocarditis (IE) associated with vertebral osteomyelitis (VO) is relatively rare, but needs long and careful therapy. We report a case of the patient who was incidentally diagnosed as having IE during therapy for VO. A 77-year-old man was hospitalized with a complaint of high fever and back pain. Because magnetic resonance imaging demonstrated osteomyelitis, antibiotic therapy was started. Persistent infectious signs and congestive heart failure indicated the diagnosis of infective endocarditis. Echocardiogram demonstrated sever mitral regurgitation due to perforation of anterior mitral leaflet but no vegetation. Surgery revealed perforation of the valvular aneurysm of the anterior mitral leaflet, which was successfully repaired with deberidement and patch closure. Antibiotic therapy was continued for 4 months postoperatively. In the case of VO, it is often necessary to consider an association of IE, although it is hardly possible to determine which the preceding infection is.

[A giant left atrial myxoma with severe mitral valve regurgitation: report of a case].

A 76-year-old female underwent operation with a diagnosis of a left atrial myxoma with accompanied mitral regurgitation. Although no clinical findings of mitral regurgitation were noticed preoperatively, degenerative changes to the anterior leaflet as well as chordae tendinae possibly due to mechanical damage by the movement of the giant tumor through the mitral valve complex were observed in operation. Resection of the tumor and mitral valve replacement were successfully performed. Our case suggests that it is indispensable to investigate the mitral valve during operation even in case of the left atrial tumor with no preoperative findings of mitral regurgitation.

[A tube retractor for cardiac surgery].

A retractor exclusively used to retract the tubes in cardiac surgery which needs cardiopulmonary bypass was developed. The half-cylinder-shaped end, the lightly curved handle and the flat and triangular grip enable easy and effective grasp of the tubes. This new instrument facilitates operative procedures by effectively retracting the tubes which persistently obstruct the operative field, in such a case of placement of a retrograde cardioplegia tube via the right atrium.

Effect of ATP-potassium channel opener nicorandil on long-term cardiac preservation.

BACKGROUND: ATP-sensitive potassium channels have been shown to be one of the important protective mechanisms for the ischemic myocardium. The purpose of this study was to evaluate the protective effect of nicorandil, an ATP-sensitive potassium channel opener, on myocardium during 6 hours hypothermic preservation. METHODS: Preserved rat hearts were randomly divided into 4 groups according to cardioplegia and preservation protocols as follows: (1) histidine-tryptophan-ketoglutarate solution (HTK) for both cardioplegic and immersing solutions (group A); (2) nicorandil-added HTK for cardioplegic solution and nicorandil-free HTK for immersing solution (group B); (3) nicorandil-free HTK for cardioplegic solution and nicorandil-added HTK for immersing solution (group C); and (4) nicorandil-added HTK for both cardioplegic and immersing solutions (group D). RESULTS: The recovery of postischemic cardiac function, including left ventricular developed pressure and end-diastolic pressure, was significantly improved in group B and group C as compared with the other groups (p<0.05). Postischemic intracellular calcium concentration was significantly lower in group B and group C than in group A (p<0.05). CONCLUSIONS: We concluded that nicorandil-induced hyperpolarizing arrest could reduce ischemia-derived myocyte injury and inhibit the influx of calcium into the myocytes in long-term cardiac preservation.

[A successful case of hybrid therapy for the left main trunk and triple coronary vessel lesions with acute myocardial infarction and cardiogenic shock].

A 86-year-patient who had acute myocardial infarction and critical cardiogenic shock was diagnosed to have the left main trunk (LMT) and triple vessel disease. Emergent coronary artery bypass grafting to the left anterior descending artery was performed using saphenous vein graft without cardiopulmonary bypass through median sternotomy. On the 41st postoperative day, catheter intervention was performed to the remaining lesions by stenting of LMT and percutaneous transluminal coronary angioplasty to the right coronary artery lesions. Tl scintigraphy showed remarkable reduction of myocardial ischemia. Hybrid therapy is the effective new strategy for critical cases which cannot be successfully and securely treated by medical or surgical approach alone.

Prolonged preservation of the blood-perfused canine heart with glycolysis-promoting solution.

BACKGROUND: Prolonged ischemia and inadequate myocardial preservation remain significant perioperative risk factors in cardiac transplantation. Long-term preservation techniques that have been effective in small rodent hearts have not been as effective in larger animal models or in clinical studies. We developed a cardioplegia solution formulated to promote high-energy phosphate production from glycolysis and determined its efficacy in a blood perfused canine heart model subjected to 24 hours of ischemia. METHODS: Hearts harvested from adult dogs (n = 6 per group) were flushed with a histidine-buffered cardioplegia solution containing glucose or University of Wisconsin solution. The hearts were maintained at 4 degrees C for 24 hours then reperfused with autologous blood. After reperfusion, left ventricular pressures were measured with an intracavitary balloon at varying balloon volumes and compared with control nonischemic hearts. Predicted stroke volume and ejection fraction were calculated at an end-systolic pressure of 70 mm Hg and end-diastolic pressure of 15 mm Hg. RESULTS: Developed pressure was better preserved in the hearts that received histidine-buffered solution (93+/-9 versus 38+/-7 mm Hg, p<0.05), along with a higher end-diastolic volume at 15 mm Hg (31+/-3 versus 22+/-2 mL histidine-buffered versus University of Wisconsin solutions, respectively, p<0.05). Stroke volume and ejection fraction were also higher in the histidine group (17+/-2.5 versus 2.3+/-1.2 mL and 50%+/-3.5% versus 9% +/-4.5%, respectively) in the presence of dobutamine. CONCLUSIONS: The highly buffered glycolysis-promoting cardioplegia solution provided effective preservation of the blood perfused canine heart with superior recovery of pump performance after 24 hours of hypothermic ischemia compared with University of Wisconsin solution in this model.

Evaluation of effect and distribution of heparin administered in vascular reconstructive surgery.

BACKGROUND: The aim of this study was to find out whether intravenously administered heparin is distributed equally not only proximal but also distal to the arterial occlusion level in vascular reconstructive surgery. METHODS: Ten consecutive patients (7 men and 3 women) with an average age of 69.9 years (range, 51 to 76 years) who underwent graft replacement for aortic abdominal aneurysm from April to December 1994 were studied. Mean aortic clamp time was 76 minutes. Heparin sodium (100 U/kg) was administered intravenously to keep activated clotting time (ACT) over 250 secs and was neutralized by protamine sulfate (1 mg/kg) just after reperfusion. ACT, blood lactate and CPK-MM in the brachial and dorsal pedis artery were measured before heparin administration (control), just after arterial occlusion, just before reperfusion and 10 minutes after protamine administration. RESULTS: ACT was significantly prolonged after arterial occlusion and recovered after protamine administration with no significant differences between proximal and distal values at each point. Lactate showed significant increase after arterial occlusion which was more remarkable distally. CPK-MM was all the way within the normal range. CONCLUSIONS: In vascular reconstructive surgery which requires temporary arterial occlusion for as long as 80 minutes, the effect of heparin is excellent and equal throughout the body by collateral vessels, and the metabolic influence due to blockade of the blood flow is not so critical as to lead to cellular damage although anaerobic glycolysis is promoted distally due to hypoxia.

[A case of Bentall's operation for an 11-year-old patient with Marfan syndrome].

An 11-year-old girl who was diagnosed to have Marfan syndrome in her infancy, visited us with complaints of easy fatigability and chest discomfort. She was pointed out to have acute development of annuloaortic ectasia with severe aortic regurgitation and mild mitral regurgitation. She underwent replacement of the ascending aorta and aortic valve using composite graft with prosthetic valve (Bentall's operation) and circular annuloplasty of the mitral valve. Bentall's operation for infants and children is remarkably rare because in this generation, acute development of aortic dilatation leading rupture and dissection is quite infrequent while main death is caused by mitral regurgitation.

Multivarious clinical manifestations of multiple pseudoaneurysms in Behçet's disease.

In Behçet's disease, an aneurysm is prone to progress rapidly to a pseudoaneurysm. Acute limb ischemia due to acute thrombosis of a femoral pseudoaneurysm and subsequent Horner's syndrome due to another subclavian pseudoaneurysm are very rare but acceptable complications in Behçet's disease. We present a case of Behçet's disease with multiple pseudoaneurysms, which also showed these other clinical manifestations. Over a short time span, the patient rapidly developed left femoral and right subclavian pseudoaneurysms, which were successfully resected with graft replacements.

Should the aortic valve homograft be recryopreserved?

BACKGROUND: The number of homograft donors is limited and the once-thawed homograft may be unsuitable for the recipient and obliged to be wasted. The purpose of this study was to investigate the possibility of recryopreserving and using the once-thawed homograft for another patient. METHODS: Canine aortic valve leaflets were frozen to -80 degrees C by a programmed freezer, stored in liquid nitrogen, and thawed after 1 week. A subgroup of leaflets was left at 4 degrees C for 15 minutes, re-cryopreserved, and thawed after 1 week. Pathologic and flow cytometric evaluations were performed. RESULTS: After thawing, by pathology, alignment of the fibers was acceptably maintained but the membrane and cytoplasm of the fibroblast were damaged. These findings were not significantly aggravated even after rethawing. By flow cytometry, fibroblast viability was 90.7%+/-1.7% immediately after thawing, 87.6%+/-1.0% after thawing for 15 minutes at 4 degrees C, 63.7%+/-2.7% during refreezing at 0 degrees C, and 39.4%+/-4.3% after rethawing. CONCLUSIONS: From the standpoint of fibroblast viability, it is not possible to recryopreserve the once-cryopreserved and thawed aortic valve homograft.

[Coronary artery bypass grafting to the left circumflex artery in the atrioventricular groove].

Coronary artery bypass graftings were performed to the left circumflex artery (LCX) system in the atrioventricular groove (#11 or #13) in addition to revascularization to the left anterior descending artery system using conventional technique in 10 patients with left main trunk lesion. Distal anastomosis was done at #11 of LCX in 6 patients using saphenous vein graft, and at #13 of LCX in 4 patients using 2 saphenous vein grafts and using 2 internal thoracic artery grafts. The mean flow rate of SVG operated by this technique showed larger values than that of SVGs by sequential bypass or individual bypass technique to #12 and/or #14 of LCX. Postoperative angiographies showed excellent graft patencies and symptomatic improvements were achieved. This technique of coronary artery revascularization is recommended and useful in patients whose #12 and #14 of LCX system is too small to make distal anastomosis.

Delayed diagnosis of anomalous origin of the left coronary artery 16 years after mitral valve replacement.

Mitral insufficiency caused by ischemia is frequently found in anomalous origin of the left coronary artery from the pulmonary artery. We report a case of a 25-year-old woman who was diagnosed to have anomalous origin of the left coronary artery from the pulmonary artery and had successful left internal mammary artery bypass grafting 16 years after mitral valve replacement for mitral insufficiency of an unknown cause in her childhood.

Clinical assessment of prolonged myocardial preservation for patients with a severely dilated heart.

BACKGROUND: The purpose of this study was to compare the myocardial protective effect of histidine-tryptophan-potassium and glucose-insulin-potassium cardioplegic solutions in patients with a dilated heart (left ventricular diastolic diameter > 55 mm, left ventricular systolic diameter > 45 mm) associated with prolonged cross-clamp time (longer than 200 minutes). METHODS: We selected 20 patients with dilated hearts due to severe aortic regurgitation. Glucose-insulin-potassium cardioplegia was used in 11 patients and histidine-tryptophan-potassium cardioplegia was used in 9 patients. RESULTS: After operation, the cardiac index was significantly increased in the histidine-tryptophan-potassium group (p < 0.05). Postoperative percent fractional shortening was 13.4% +/- 3.1% in the glucose-insulin-potassium group and 23.6% +/- 2.6% in the histidine-tryptophan-potassium group (p < 0.05). Creatine kinase levels were significantly lower in the histidine-tryptophan-potassium group than that in the glucose-insulin-potassium group (p < 0.05). The incidence of ventricular arrhythmia (higher than Lown's grade 2) was lower in the histidine-tryptophan-potassium group. CONCLUSIONS: These data support the superiority of the histidine-tryptophan-potassium method over the glucose-insulin-potassium method for protection of the dilated heart during prolonged ischemia in open heart operations.

Hypertrophic obstructive cardiomyopathy with abnormalities of the mitral valve complex.

The mechanism of obstruction of the left ventricular outflow tract (LVOT) in hypertrophic obstructive cardiomyopathy (HOCM) is mainly due to dynamic systolic anterior motion (SAM) of the mitral valve. We report a case of HOCM with mitral regurgitation (MR) associated with complicated abnormalities of the mitral apparatus which contributed to a high pressure gradient through the LVOT. A small, 53-year-old woman was admitted for chest pain and palpitation. Examinations revealed asymmetric septal hypertrophy of the left ventricle, MR, SAM of the mitral valve and a high pressure gradient (108 mmHg) through the LVOT. Operative findings revealed an abnormally hypertrophied interventricular septum, an extensively thickened and enlarged anterior mitral leaflet (AML), malposition of the origin of the anterior papillary muscle arising closer to the aortic annulus than normal, and its direct insertion into the AML without any distinguishable chordae tendineae. The hypertrophied septum and the large and protruding AML appeared to obstruct the LVOT, resulting in a loss of subaortic clearance that was recovered after mitral valve replacement and myectomy. Pathology of the papillary muscle was characteristic of HOCM, showing disorganization and disarray of myocardial fibers, bizarre-shaped nuclei, and intercellular fibrosis, while those of the mitral leaflets negated both rheumatic changes and endocarditis.