Randomized Multicenter Clinical Trial Comparing 0.1% Brimonidine/0.5% Timolol Versus 1% Dorzolamide/0.5% Timolol as Adjuncts to Prostaglandin Analogues: Aibeta Crossover Study.

INTRODUCTION: This multicenter, randomized, comparative, and investigator-masked crossover clinical trial sought to compare the efficacy and tolerability of fixed combinations of 0.1% brimonidine/0.5% timolol (BTFC) versus 1% dorzolamide/0.5% timolol (DTFC) as adjunctive therapies to prostaglandin analogues. METHODS: A total of 110 patients with open-angle glaucoma or ocular hypertension previously treated with prostaglandin analogue monotherapy were randomized to receive either BTFC or DTFC as adjunctive therapy for 8 weeks. These patients were then crossed over to the alternative treatment arm for another 8 weeks. The reduction in intraocular pressure (IOP) (primary outcome), occurrence of adverse events, ocular discomfort after instillation, and patient preference (secondary outcomes) were recorded through patient interviews. RESULTS: BTFC instillation for 8 weeks reduced IOP by 3.55 mmHg, demonstrating non-inferiority to DTFC instillation (3.60 mmHg; P < 0.0001, mixed-effects model). Although adverse events were rare with both combinations, patients reported greater discomfort with DTFC than with BTFC (P < 0.0001). More patients preferred BTFC (P < 0.0001) over DTFC, as BTFC caused minimal or no eye irritation. CONCLUSION: As BTFC offered better tolerability than DTFC with comparable reduction in IOP, we recommend it as an alternative for patients who experience ocular discomfort with DTFC-prostaglandin analogue combination therapy. TRIAL REGISTRATION NUMBER: jRCTs051190125.

Patients with glaucoma who require further reduction in intraocular pressure while undergoing monotherapy with prostaglandin analogue ophthalmic solution have been prescribed two enhanced treatment options: 0.1% brimonidine/0.5% timolol fixed combination ophthalmic solution (BTFC) and 1% dorzolamide/0.5% timolol fixed combination ophthalmic solution (DTFC). The Aibeta Crossover Study Group in Japan compared the efficacy and tolerability of fixed combinations of BTFC versus DTFC when an additional fixed combination ophthalmic solution was prescribed in patients with open-angle glaucoma or ocular hypertension who had been treated with prostaglandin analogue monotherapy. We recruited 110 patients previously treated with prostaglandin analogue monotherapy at 20 clinical centers in Japan, then randomly assigned them to two alternative treatment groups: the BTFC to DTFC group or the DTFC to BTFC group, as an adjunctive therapy to prostaglandin analogues for total of 16 weeks. We compared the reduction in intraocular pressure, occurrence of side effects, eye discomfort after instillation, and patient preference between BTFC versus DTFC instillations. The intraocular pressure reduction of BTFC instillation was comparable to that of DTFC instillation, showing non-inferiority to DTFC (3.55 mmHg vs. 3.60 mmHg; P < 0.0001, mixed-effects model). Both eye drops caused few side effects; however, patients felt greater eye discomfort with DTFC than with BTFC (P < 0.0001). Because of less eye irritation, more patients preferred BTFC (P < 0.0001) over DTFC. We can recommend using BTFC for patients who feel eye discomfort with DTFC­prostaglandin analogue combination therapy.

Effects of Switching from Timolol to Brimonidine in Prostaglandin Analog and Timolol Combination Therapy.

PURPOSE: To assess the efficacy and safety of switching from timolol 0.5% to brimonidine 0.1% in patients with glaucoma treated with a prostaglandin analog (PGA) and timolol combination. METHODS: This prospective, open-label multicenter study enrolled patients with open-angle glaucoma or ocular hypertension who were being treated with a PGA and timolol. After baseline measurements, timolol was switched to brimonidine 0.1%, and patients were followed for 12 weeks. Patients visited at 4 and 12 weeks after switching. The main outcome measure was the change in intraocular pressure (IOP). For safety evaluations, hyperemia, formation of conjunctival follicles, superficial punctate keratopathy as a local side effect, blood pressure (BP), and heart rate (HR) were evaluated. RESULTS: One hundred seven patients participated in this study. Among them, 103 patients completed the study. The IOP values at baseline, 4 weeks, and 12 weeks after the transition were 15.7 ± 2.7, 14.3 ± 2.8, and 14.0 ± 2.8 mmHg, respectively. IOP was significantly reduced at 4 and 12 weeks compared with baseline (p<0.001). There were no significant changes in hyperemia or follicle formation. The superficial punctate keratopathy score was significantly reduced at 12 weeks compared with baseline (p<0.05). Systolic and diastolic BP values were significantly reduced and HR significantly increased after switching (p<0.05). CONCLUSION: Switching from timolol 0.5% to brimonidine 0.1% may not change IOP in the combination use of timolol 0.5% and a PGA and was well tolerated by patients without severe ocular or systemic side effects.

Primary cardiac malignant fibrous histiocytoma with abdominal wall metastasis.

We present a rare case of cardiac malignant fibrous histiocytoma (MFH; undifferentiated pleomorphic sarcoma); to date, fewer than 100 cases of cardiac MFH have been reported. In this case, transthoracic echocardiography revealed cardiac tumors in the left atrium (LA) of a 53-year-old woman with a 3-month history of worsening dyspnea; the largest tumor was found to protrude through the mitral valve in diastole, causing stenosis. Three of the four tumors were resected during emergency surgery; however, the residual tumor extension into the left pulmonary vein could not be removed. Histological findings of the resected tumors, such as organized thrombus and myxomatous tissue changes, indicated that the tumors were benign. After 3 months, the patient underwent total resection for a small mass that developed on her right abdominal wall, which was revealed histologically to be MFH; additionally, the residual mass in the LA had enlarged progressively. After undergoing radiation therapy without further surgery, she died of cerebral bleeding 6 months after cardiac surgery. Postmortem examination revealed that the tumor in the LA was an MFH. Thus, cardiac MFH should be considered as a differential diagnosis for tumors on the posterior wall of the LA. .

Combining multiple HRT parameters using the 'Random Forests' method improves the diagnostic accuracy of glaucoma in emmetropic and highly myopic eyes.

PURPOSE: To combine multiple Heidelberg Retina Tomograph (HRT) parameters using the Random Forests classifier to diagnose glaucoma, both in highly and physiologically myopic (highly myopic) eyes and emmetropic eyes. METHODS: Subjects consisted of healthy subjects and age-matched patients with open-angle glaucoma in emmetropic (-1.0 to +1.0 diopters [D], 63 and 59 subjects, respectively) and highly myopic eyes (-10.0 to -5.0 D, 56 and 64 subjects, respectively). First, area under the receiver operating characteristic curve (AUC) was derived using 84 HRT global and sectorial parameters and the representative HRT raw parameter (largest AUC) was identified. Then, the Random Forests method was carried out using age, refractive error, and 84 HRT parameters. The AUCs were also derived using the following: (1) Frederick S. Mikelberg discriminant function (FSM) score, (2) Reinhard O.W. Burk discriminant function (RB) score, (3) Moorfields regression analysis (MRA) score, and (4) glaucoma probability score (GPS). RESULTS: In combined emmetropic and highly myopic population, AUC with Random Forests method (0.96) was significantly larger than AUCs with the representative HRT raw parameter (vertical cup-to-disc ratio [global], 0.89), FSM (0.90), RB (0.83), MRA (0.87), and GPS (0.81) (P < 0.001). Similarly, AUC with the Random Forests method was significantly (P < 0.05) larger than these other parameters, both in emmetropic and highly myopic groups. Also, the Random Forests method achieved partial AUCs above 80%/90% significantly (P < 0.05) larger than any other HRT parameters in all populations. CONCLUSIONS: Evaluating multiple HRT parameters using the Random Forests classifier provided accurate diagnosis of glaucoma, both in emmetropic and highly myopic eyes.

Glaucoma-induced optic disc morphometric changes and glaucoma diagnostic ability of Heidelberg Retina Tomograph II in highly myopic eyes.

PURPOSE: This study was performed to first investigate the morphological differences in the optic nerve head between highly myopic non-glaucomatous controls and highly myopic glaucomatous eyes in comparison with the differences between emmetropic non-glaucomatous controls and emmetropic glaucomatous eyes using confocal scanning laser ophthalmoscopy. Further, the ability of the apparatus in glaucoma diagnosis in highly myopic eyes was compared with that in emmetropic eyes. METHODS: Healthy subjects and age-matched patients with early-stage open-angle glaucoma were divided into two groups: emmetropic eyes (-1.0 to +1.0 diopters) and highly myopic eyes (-12.0 to -5.0 diopters).The participants were comprised of 65 emmetropic normal eyes, 59 emmetropic glaucomatous eyes, 62 highly myopic normal eyes, and 68 highly myopic glaucomatous eyes and eyes with pathologic myopia were carefully excluded. Confocal scanning laser tomographic parameters were compared among all subjects after adjustment for age and disc area. The ROC curves and sensitivity and specificity for glaucoma detection using several clinical methods were then compared between the emmetropic and highly myopic eyes. RESULTS: Rim area, cup/disc area ratio, mean cup depth, and cup shape measure of glaucoma eyes are significantly different from those of normal eyes in both highly myopic eyes and emmetropic eyes. Methodological overestimation of retinal nerve fiber layer cross sectional area due to optic disc tilting was suggested in the highly myopic eyes. The diagnostic performance of glaucoma using several discriminant methods significantly deteriorated in the highly myopic eyes. CONCLUSIONS: In the highly myopic glaucomatous eyes, confocal scanning laser tomographic parameters were significantly different from that of non-glaucomatous highly myopic eyes but diagnostic performance of glaucoma was deteriorated than that in emmetropic eyes. These findings demonstrate the utility and limitations of the apparatus in diagnosing glaucoma in highly myopic patients.

Use of Scheimpflug corneal anterior-posterior imaging in ray-tracing intraocular lens power calculation.

PURPOSE: To examine improvement with the use of Scheimpflug imaging of the anterior and posterior corneal surfaces in the accuracy of ray-tracing intraocular lens (IOL) power calculation for normal cataractous eyes. METHODS: Prospective case series comprised 136 eyes of 136 consecutive patients who had undergone cataract surgeries. Scheimpflug imaging of the cornea was included with routine preoperative examinations. Postoperative refractions were predicted using three methodologies; ray-tracing calculation using Scheimpflug imaging and Placido topography, ray-tracing calculations using Placido topography, and the SRK/T formula using autokeratometry. Prediction errors from the manifest refraction at 1 month postoperatively were compared between the methods. Influence of the posterior corneal curvature was also evaluated. RESULTS: Mean prediction errors were 0.008, -0.103 and -0.042 D, respectively without significant difference between the three methods (p = 0.23). The prediction errors were significantly correlated with the posterior corneal curvature when the Scheimpflug imaging was not used (p < 0.03). CONCLUSION: Use of Scheimpflug imaging in ray-tracing IOL power calculation was as accurate as the other calculations in normal cases, showing no bias in the posterior corneal curvature, as is the case with the other calculations.

Effect on visual acuity of increased surface light scattering in intraocular lenses.

PURPOSE: To assess the long-term increase in surface light scattering of foldable hydrophobic acrylic intraocular lenses (IOLs) and to evaluate its effect on visual acuity. SETTING: Miyata Eye Hospital, Miyazaki, Japan. DESIGN: Cross-sectional study. METHODS: The clinical records of patients who received an Acrysof IOL (study group) or a Sensar AR40 or AR40e IOL (control group) were reviewed retrospectively. Surface light scattering of IOLs was measured 1 year postoperatively or later. The corrected distance visual acuity (CDVA) at the surface-light-scattering examination was compared with the CDVA 1 month after IOL implantation. The changes in CDVA over time were compared with the increase in surface light scattering. RESULTS: The study evaluated 466 eyes of 337 patients. Surface light scattering in the study group continued to increase up to 15 years postoperatively. The light scattering was higher on the anterior IOL surface after 4.5 years. Increased surface light scattering had no significant impact on CDVA; however, there were more cases with decreased CDVA when the surface light scattering exceeded 50 computer-compatible tape steps. CONCLUSION: Surface light scattering with the implanted foldable hydrophobic acrylic IOL continuously increased during the postoperative years and was a risk for decreased visual acuity.

Long-term effect of BAK-free travoprost on ocular surface and intraocular pressure in glaucoma patients after transition from latanoprost.

PURPOSE: To assess the efficacy and tolerability of benzalkonium chloride (BAK)-free travoprost after transition from BAK-preserved latanoprost. METHODS: This was a prospective, open-label, multicenter study in patients with open-angle glaucoma or ocular hypertension who had been treated with latanoprost monotherapy for at least 3 months. The main outcome measures were superficial punctate keratopathy (SPK), hyperemia, and intraocular pressure (IOP). At baseline, 1, 3, and 12 months, hyperemia, SPK, and IOP were consecutively assessed. Hyperemia was assessed using a 4-grade scale. SPK was assessed by fluorescence staining observed by Area-Density classification. The IOP was measured by Goldmann applanation tonometry. RESULTS: One hundred and fourteen patients participated in this study. Twenty-eight patients discontinued medications by 1 month. Sixty-seven patients completed the study. Transition from latanoprost to BAK-free travoprost showed no significant effect on hyperemia at 1 month, but showed significant decreases at 3 and 12 months compared with baseline (P<0.05). The prevalence of SPK, especially its severity score, at all points were significantly reduced compared with baseline (P<0.05). The IOP at baseline and at 12 months after transition was 14.9±3.4 and 14.3±3.3 mm Hg, indicating a significant reduction after the change in regimen compared with baseline (P<0.05). CONCLUSIONS: Treatment for 12 months with BAK-free travoprost after BAK-preserved latanoprost resulted in fewer ocular surface complications, as indicated by the reduced prevalence of SPK and decreased hyperemia, and no clinically relevant changes in IOP. BAK-free travoprost may have beneficial effects on the ocular surface while showing IOP-lowering efficacy comparable with BAK-preserved eye drops.

The gravitation of the moon plays pivotal roles in the occurrence of the acute myocardial infarction.

Acute myocardial infarction (AMI) is a social burden. However, being able to predict AMI could lead to prevention. A previous study showed only the relation between the lunar phase and the occurrence of AMI, but the period it takes for the moon to orbit around the earth and the period of the lunar phase differ. This study investigated the effect of the gravitation of the moon on AMI. Data was comprised of 1369 consecutive patients with first AMI at 5 hospitals from October, 1984 to December, 1997. The universal gravitation of the moon was calculated and compared to the earth onset time of AMI. Universal gravitation of the moon was derived by G*m/d(2) (G: universal gravitation constant, m: the mass of the moon, d: the distance between the center of the moon and the center of the earth). The relationship between m/d(2) and the cases of AMI was determined. There was an increase in cases, when there is a distance of more than 399864 km from the center of the earth to the center of the moon. The gravitation of more than 399864 km was determined to be weaker gravitation. It is confirmed that the number of AMI patients significantly increases at weaker gravitation periods in this multicenter trial. In conclusion, these results suggest that the gravitation of the moon may have an influence on the occurrence of AMI.

Reduced and delayed untwisting of the left ventricle in patients with hypertension and left ventricular hypertrophy: a study using two-dimensional speckle tracking imaging.

AIMS: Newly developed two-dimensional ultrasound speckle tracking imaging allows measurements of left ventricular (LV) rotation and twist. Because LV untwisting predominantly occurs during the isovolumic relaxation period, its assessment reflects the process of LV relaxation. The aim of this study was to examine whether LV hypertrophy (LVH) adversely affects LV untwisting and abnormalities in LV untwisting could become a novel marker in assessing LV relaxation abnormalities. METHODS AND RESULTS: We acquired basal and apical LV short-axis images in 49 hypertensive patients. Using two-dimensional strain software, a time-domain speckle tracking was performed, and the mean value of LV rotation was obtained at each plane. LV twist was defined as apical rotation relative to the base. In order to adjust for inter-subject differences in heart rate, the time sequence was normalized to the percentage of systolic and diastolic duration. The degree of LV untwisting was calculated as the percentage of systolic twist : untwisting = (TwistES-Twistt/TwistES) x 100, where Twistt is twist at time t and TwistES is twist at end-systole. Although peak systolic twist was not different, early diastolic LV untwisting and untwisting rate during isovolumic relaxation period was significantly delayed and reduced in parallel to the severity of LVH, as assessed by LV mass index. CONCLUSION: The observed delayed and reduced diastolic untwisting during the isovolumic relaxation period noted in hypertensive patients with LVH may contribute towards the LV relaxation abnormality. Two-dimensional speckle tracking imaging is a novel tool which can be used for the non-invasive assessment of LV relaxation.

Hypertrophic cardiomyopathy is associated with more severe left ventricular dyssynchrony than is hypertensive left ventricular hypertrophy.

OBJECTIVE: To evaluate left ventricular (LV) dyssynchrony in patients with left ventricular hypertrophy (LVH), and to compare abnormalities associated with hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD) using 2D speckle tracking imaging. METHODS: Basal, middle, and apical 2D LV short-axis images were acquired in 43 patients with LVH including 20 with HCM and 23 with HHD, and in 15 age-matched controls. Radial strain, circumferential strain, time interval from the R-wave to peak radial strain (Trs), and time to peak circumferential strain (Tcs) were measured in six equidistant segments at each level of the 3 LV short-axis views using 2D speckle tracking analysis. To assess LV dyssynchrony, Trs(cs)-18SD, the standard deviation (SD) of Trs(cs) in all 18 segments, was calculated. RESULTS: Regional radial strain in the middle and apical short-axis segments was significantly less in patients with HCM than in those with HHD. Regional circumferential strain in the apical short-axis segments was also less in HCM. Trs-18SD and Tcs-18SD were significantly longer in patients with HCM than in age-matched controls and patients with HHD (Trs-18SD: HCM: 88 +/- 32 ms, HHD: 51 +/- 20 ms, control: 45 +/- 12 ms P < 0.001, Tcs-18SD: HCM: 71 +/- 27 ms, HHD: 46 +/- 14 ms, control: 45 +/- 14 ms P < 0.001). CONCLUSIONS: The presence of LVH is thus not always associated with LV dyssynchrony. However, the greater reduction of regional strain and severe LV dyssynchrony in HCM may contribute to the adverse cardiovascular outcomes associated with this disease.

The mitral L wave: a marker of advanced diastolic dysfunction in patients with atrial fibrillation.

BACKGROUND: The prominent mid-diastolic filling wave (mitral L wave) indicates advanced diastolic dysfunction in patients in sinus rhythm. The aim of the present study was to determine the clinical implications of the mitral L wave in patients with atrial fibrillation (AF). METHODS AND RESULTS: Ninety-nine consecutive non-valvular chronic persistent AF patients were enrolled. The mitral L wave was defined as a distinct mid-diastolic flow velocity following the E wave with a peak velocity>20 cm/s. The prevalence of the L wave in AF patients (34/99, 34%) was significantly higher than that observed in patients in sinus rhythm during the same study period (23/946, 2.4%, p<0.001). Patients with AF and L wave were older, more frequently female and had a slower heart rate, shorter isovolumic relaxation times, larger E wave velocities and lower early diastolic mitral annulus velocity (E') resulting in the higher E/E' compared to those without L waves. The left atrial volume index was significantly larger in patients with an L wave. The Valsalva maneuver decreased, and leg elevation increased, the amplitude of the L wave in the subset of patients who received these procedures. CONCLUSIONS: The appearance of the mitral L wave in AF is relatively common, and its presence indicates advanced diastolic dysfunction, including elevated filling pressures and distended noncompliant LA.

Interlamellar flap edema due to steroid-induced ocular hypertension after laser in situ keratomileusis.

BACKGROUND: Several recent studies have reported post-laser in situ keratomileusis (LASIK) complications related to a steroid-induced increase in intraocular pressure, including interface fluid and elevated intraocular pressure-induced interlamellar stromal keratitis. CASES: We examined two cases of interlamellar flap edema due to steroid-induced ocular hypertension after uneventful laser in situ keratomileusis. OBSERVATIONS: Oral acetazolamide and discontinuance of topical steroids were effective for treating interlamellar stromal edema in both cases. CONCLUSION: A rise in intraocular pressure should be considered a cause of interlamellar stromal edema after LASIK.

The assessment of left ventricular twist in anterior wall myocardial infarction using two-dimensional speckle tracking imaging.

BACKGROUND: Two-dimensional speckle tracking imaging allows noninvasive measurement of left ventricular (LV) strain, rotation, and displacement. We investigated whether LV twist would be depressed in anterior wall myocardial infarction (MI) as a result of reduced apical rotation. METHODS: Basal and apical LV short-axis images were acquired in 30 patients with anterior wall MI. Using commercially available 2-dimensional strain software, time domain speckle tracking was performed, and regional LV strain, rotation, and radial displacement were obtained in each plane. LV twist was defined as apical LV rotation relative to the base. Patients were divided into two groups according to global LV systolic function (normal LV ejection fraction [LVEF] group [LVEF > or = 45%, n = 16] and abnormal LVEF group [LVEF < 45%, n = 14]). RESULTS: Circumferential strain in the apex was significantly reduced in abnormal LVEF group compared with normal LVEF group (-7.3 +/- 2.6 vs -13.5 +/- 4.1, P < .001). Peak LV twist was significantly reduced in abnormal LVEF group (5.6 +/- 2.6 vs 9.8 +/- 4.0 degrees, P < .005) mainly because of reduced apical rotation. Peak positive and negative twist velocity was also significantly depressed (38.8 +/- 11.3 vs 52.1 +/- 19.3 degree/s, P < .05, and -42.6 +/- 17.8 vs -63.4 +/- 28.0 degree/s, P < .05, respectively). Significant correlation was noted between peak twist and LVEF (r = 0.73, P < .001) and LV end-systolic volume (r = 0.56, P < .001). The twist-displacement loop was markedly distorted in abnormal LVEF group. CONCLUSIONS: Systolic twist was decreased and diastolic untwisting was depressed in accordance with LV systolic dysfunction in anterior wall MI. These results suggest the significant impact of global LV systolic function on LV twist and twist-displacement loops in patients with anterior wall MI.

Age-related changes in left ventricular twist assessed by two-dimensional speckle-tracking imaging.

The aim of this study was to determine the normal value of left ventricular (LV) twist, and to examine the effects of aging on LV twist by newly developed 2-dimensional ultrasound speckle-tracking imaging. We acquired basal and apical LV short-axis second harmonic images in 118 healthy volunteers. Using commercially available 2-dimensional strain software, time-domain speckle tracking was performed, and mean value of LV rotation obtained at each plane. LV twist was defined as apical rotation relative to the base. Adequate data were obtained in 113 volunteers. During systole, the LV performs a wringing motion with a counterclockwise rotation at the apex and a clockwise rotation at the base. The mean value of peak twist was 7.7 +/- 3.5 degrees. Immediately after end systole, rapid untwisting develops. Different LV twist profiles are noted according to age. Peak LV twist was significantly higher, and the rate of LV untwisting significantly reduced and delayed, with advancing age. LV twist can be measured noninvasively by 2-dimensional ultrasound speckle-tracking imaging. The observed reduced and delayed diastolic untwisting with aging may contribute toward the tendency of diastolic dysfunction. This novel method allows the detailed study of diastolic function in various cardiovascular diseases.

Role of contrast-enhanced dobutamine stress echocardiography in predicting outcome in patients with known or suspected coronary artery disease.

Although the application of intravenous contrast agents during stress echocardiography has been shown to improve diagnostic accuracy for detecting coronary artery disease, less information exists regarding its prognostic value. The aim of this study was to determine the role of contrast-enhanced dobutamine stress echocardiography (DSE) for predicting future cardiac events in patients with coronary artery disease (CAD). We studied 893 patients (mean age: 66, 581 men) with known or suspected CAD undergoing contrast-enhanced DSE. Positivity was defined as new/worsened wall motion abnormality or fixed abnormality during stress. All patients were followed for 15 +/- 10 months to evaluate hard cardiac events (cardiac death and nonfatal myocardial infarction) and total cardiac events (hard cardiac events, congestive heart failure, unstable angina, and late revascularization). Three patients were lost to follow-up, and 128 patients developed cardiac events, including 21 hard cardiac events. The 3-year event free survival rate was significantly lower in patients with positive DSE results than in those with negative DSE results. Stepwise Cox multivariate analysis revealed that positivity of DSE (P < 0.0001, Hazard ratio (HR): 2.48) and peak wall motion score index (WMSI) >1.5 (P < 0.0001, HR: 2.41) were independent predictors for total cardiac events. Considering hard cardiac events, the independent predictors were peak WMSI > 1.5 (P < 0.0001, HR: 6.65) and age > 70 years (P < 0.005, HR: 3.27). We conclude that contrast-enhanced DSE provides important prognostic information for future cardiac events.

Effect of aging on twist-displacement loop by 2-dimensional speckle tracking imaging.

BACKGROUND: Newly developed 2-dimensional (2D) speckle tracking imaging provides simultaneous information on both cardiac rotation and radial displacement throughout the cardiac cycle, thus, providing the opportunity to noninvasively construct twist-displacement loops. The aim of this study was to examine the effect of aging on twist-displacement loops. METHODS: Basal and apical 2D left ventricular (LV) short-axis images with high frame rates were acquired in 59 asymptomatic healthy volunteers. Using commercially available software, LV rotation and radial displacement were obtained at each plane by 2D speckle tracking analysis. LV twist was defined as apical LV rotation relative to the base. To adjust intersubject differences in heart rate, the time sequence was normalized to the percentage of systolic and diastolic duration. Volunteers were divided into 3 groups according to age. RESULTS: Twist-displacement loops were characterized by a figure of 8 configuration. There was a linear relation between twist and displacement during systole (r = 0.97), with its slope being significantly larger in the older group compared with the young group. During early diastole, a substantial degree of untwisting developed despite a relatively small reversal of systolic radial displacement, resulting in a much steeper twist-displacement relationship observed in all groups. Subsequent diastolic expansion occurred with more gradual additional untwisting. CONCLUSION: We found that 2D speckle tracking imaging successfully provides twist-displacement loop, noninvasively. Aging affects the systolic component of the twist-displacement loop. The assessment of twist-displacement loop may be useful for evaluating LV function.

Comparison of contrast-enhanced real-time live 3-dimensional dobutamine stress echocardiography with contrast 2-dimensional echocardiography for detecting stress-induced wall-motion abnormalities.

BACKGROUND: Two-dimensional (2D) contrast-enhanced dobutamine stress echocardiography (DSE) is used clinically to diagnose stress-induced wall-motion abnormality (WMA). We hypothesized that contrast-enhanced real-time 3-dimensional (3D) DSE could improve the detection rate of WMA, because from a single full-volume acquisition, multiple segments can be visualized. METHODS: We acquired both 2D and 3D DSE in 78 patients with known or suggested coronary artery disease (mean age: 65 years; 44 men). Dobutamine was infused using a standard protocol, and atropine added, if required. For 2D DSE, the intravenous contrast agent was injected at each stage and images displayed in a quadscreen format. For 3D DSE, contrast harmonic 3D data sets (full volumes) were acquired at baseline and peak stress. Using custom software, 3 short-axis views (from apex to base) were created, and wall motion scored using a wall-motion score index using a 16-segment model. A positive stress test was defined as new or worsened WMA or fixed abnormality during stress. RESULTS: Heart rate increased from 72 +/- 13 to 133 +/- 15/min (86 +/- 11% of age-predicted). A total of 1248 segments were analyzed at each stage for both modalities. A single segment at baseline and 5 segments at peak stress could not be assessed with contrast 2D DSE. In contrast, 88 segments at baseline and 39 segments at peak stress could not be assessed with contrast 3D DSE. With 3D DSE, the majority of uninterpretable segments were in the anterior and lateral walls. Significant correlations were noted between wall-motion score index by 2D and 3D DSE at baseline (r = 0.78) and peak stress (r = 0.83). The concordance rate (positive/negative findings) between modalities was 69% (54/78) on a patient basis and 88% (206/234) on a perfusion territory basis. When using 2D DSE results as the gold standard, sensitivity and specificity for detecting WMA by 3D DSE was 58% and 75%, respectively. Sensitivity and specificity values were 67% and 94% for the right coronary artery, 53% and 81% for the left anterior descending coronary artery, and 88% and 100% for the left circumflex coronary artery territory, respectively. CONCLUSION: Contrast-enhanced 3D DSE was feasible in the majority of patients. However, the moderate concordance between both modalities was a result of: (1) difficulties in visualizing the anterolateral segments because of the relatively large imprint of the transducer; and (2) lower frame rates with 3D DSE resulting in the erroneous diagnosis of dyssynchrony.

Atelocollagen punctal occlusion in dry eye patients.

PURPOSE: To evaluate the efficacy and safety of atelocollagen punctal occlusion for dry eye patients. DESIGN: Prospective noncomparative interventional case series. METHODS: Atelocollagen was injected into the superior and inferior canaliculi of 52 eyes of 28 dry eye patients. Vital staining of the ocular surface, breakup time of tears (BUT), tear volume, and corneal epithelial permeability to fluorescein were examined before and 1, 2, 4, and 8 weeks after treatment. RESULTS: Rose bengal stain, fluorescein stain, BUT, and corneal epithelial permeability to fluorescence were significantly improved 1 week after atelocollagen punctal occlusion, and the improvement was maintained for up to 8 weeks after treatment. CONCLUSIONS: Atelocollagen punctal occlusion effectively improves ocular surface disorders in dry eye patients.

Direct demonstration by transthoracic Doppler echocardiography of adenosine-induced coronary steal in the collateral-dependent vessel.

Coronary flow velocity reserve was measured to assess the frequency of coronary steal in the collateral-dependent coronary arteries using transthoracic Doppler echocardiography. Coronary steal occurred in half the vessels studied. There was no significant difference between coronary flow velocity reserve in poorly and well-developed collaterals.