Characteristics affecting cervical sagittal alignment in patients with chronic low back pain.

BACKGROUND: Sagittal spino-pelvic malalignment in patients with chronic low back pain (CLBP) have been reported in the past, which may also affect cervical spine lesions. The purpose of this study is to investigate the cervical alignment in patients with CLBP. METHOD: Of the patients who visited an orthopedic specialist due to low back pain lasting more than three months, 121 cases (average 71.5-years-old, 46 male and 75 female) with whole standing spinal screening radiographs were reviewed (CLBP group). Cervical parameters included cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-7 SVA), and the T1 slope minus CL (T1S-CL). Cervical spine deformity was defined as C2-7 SVA >4 cm, CL <0°, or T1S-CL ≧20°. We compared the cervical alignment of these patients with 121 age and gender matched volunteers (control group). RESULTS: The prevalence of cervical spine deformity was significantly higher in the CLBP group than in the control group (20.7% vs. 10.7%, P = 0.034). The mean CL was smaller in the CLBP group than in the control group (16.1° vs. 21.4°, P = 0.002). The mean C2-7 SVA was 17.6 mm vs. 18.7 mm in the CLBP group and in the control group, respectively (P = 0.817). The mean T1S-CL was larger in the CLBP group than in the control group (9.1° vs. 3.5°, P < 0.001). Multivariate analysis showed that people with CLBP were more likely to have cervical deformities than people without CLBP (odds ratio 2.16, 95% confidence interval 1.006 to 4.637). CONCLUSIONS: This study results suggest that people with CLBP present with worse cervical sagittal alignment and higher prevalence of cervical spine deformities than age and gender matched volunteers with no CLBP. This means CLBP impacts cervical spine lesions negatively. LEVEL OF EVIDENCE: Ⅳ.

Maternal and fetal outcomes in pregnancy complicated with Eisenmenger syndrome.

OBJECTIVE: The goal of the study was to clarify the risk factors for pregnancy complicated with Eisenmenger syndrome (ES). MATERIALS AND METHODS: A retrospective study was performed in 15 patients with ES who were managed throughout pregnancy at one institution from 1982 to 2013. Cases associated with congenital heart diseases other than atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) were excluded. RESULTS: The congenital heart diseases in ES included ASD (n = 3), VSD (n = 9), and PDA (n = 3). Ten women chose termination and 5 continued with their pregnancies. In the 5 continuation cases (PDA 1, VSD 4), worsening of cyanosis, exertional fatigue and dyspnea appeared between 25 and 30 weeks gestation and cesarean section was performed at 30 (28-33) weeks. LVEF, PaO2, and SpO2 decreased and heart rate increased significantly from before pregnancy to 25-30 weeks gestation. From before to during the pregnancy, there were no significant changes in mean PABP or pulmonary vascular resistance (PVR) in four cases with data (582-592, 885 to 868, 1280 to 1291, 1476-1522 dyn × s/cm2). PVR at conception had a negative relationship with delivery weeks. NYHA classes before, during and 1 year after pregnancy were II, III and II. In one recent case, epoprostenol and tadalafil were administered during pregnancy. CONCLUSIONS: Pregnancy with ES has a high risk due to hypooxygenation, cyanosis, and cardiac failure, which can appear as common complications as early as the 2nd trimester. Early interventions with meticulous care are required for these complications during pregnancy and delivery.

Antifungal susceptibility of Candida isolates at one institution.

Species distribution and antifungal susceptibility of Candida isolates at one institution were evaluated. Detection rates of fungi were examined for 5 years between 2007 and 2011. Sensitivities of fungi to amphotericin B, flucytosine, fluconazole, micafungin, itraconazole, and voriconazole were evaluated in blood culture-positive patients. A total of 3,832 fungal isolates were detected, including Candida albicans 66.5%, Candida glabrata 20.3%, Candida parapsilosis 6.2%, Candida tropicalis 5.5%, and others 1.5%. Candidemia was diagnosed in 131 patients, and C. albicans, C. parapsilosis, C. glabrata, C. tropicalis, and others were present in 42.0%, 27.5%, 16.0%, 8.4%, and 6.1% of these patients, respectively. Voriconazole had the lowest MIC90s against C. albicans and C. parapsilosis (0.015 and 0.25). Micafungin had a low MIC90 against C. glabrata and C. tropicalis. C. albicans was the most common fungus in patients with candidemia. Voriconazole and micafungin were effective against C. albicans. Amphotericin B was effective for C. parapsilosis, and micafungin showed good efficacy against C. glabrata and C. tropicalis.

Risk factors for maternal and fetal outcome in pregnancy complicated by Ebstein anomaly.

OBJECTIVE: The goal of the study was to examine risks in pregnancy in patients with Ebstein anomaly. STUDY DESIGN: Data were examined retrospectively for 13 patients (27 pregnancies, 21 live births) with Ebstein anomaly during pregnancy who were treated at our institution from 1985 to 2011. The associated anomalies in these patients were atrial septal defect (ASD) (n = 4) and the Wolff-Parkinson-White syndrome (n = 6). RESULTS: Before pregnancy, 2 patients underwent ASD closure and 1 received tricuspid valve replacement (TVR). In all patients, the cardiothoracic ratio increased from 55.1 at conception to 57.0 during pregnancy and 58.0 postpartum (P < .05). Cesarean sections were performed in 3 cases: 1 with ventricular tachycardia and orthopnea (New York Heart Association [NYHA] III) preterm; at full term, and the third in a patient with a mechanical tricuspid valve who developed maternal cerebellum hemorrhage at 27 weeks. The baby died of prematurity in the third case. In all other cases (20 of 21), neonatal prognoses were good without congenital heart diseases. There were 6 spontaneous abortions. Recurrent paroxysmal supraventricular tachycardia occurred during pregnancy in 2 cases and was treated with adenosine triphosphate or verapamil. In 17 pregnancies, NYHA remained in class I and all had full-term vaginal delivery. CONCLUSION: Maternal and fetal outcomes are good in patients with Ebstein anomaly and NYHA class I. However, pregnancy in Ebstein anomaly can be complicated with tachyarrhythmia or cardiac failure. In post-TVR cases, meticulous care is required for these complications during pregnancy and delivery.

Safety and efficacy of implantable cardioverter-defibrillator during pregnancy and after delivery.

BACKGROUND: There are few studies of pregnancy and delivery in patients with an implantable cardioverter-defibrillator (ICD). The purpose of this study was to investigate maternal and fetal outcome in these patients. METHODS AND RESULTS: Six pregnant women with an ICD were retrospectively reviewed. All women underwent implantation of an ICD before pregnancy and delivered at the National Cerebral and Cardiovascular Center. The mean age at pregnancy and the mean follow-up period after ICD implantation were 28±3 years old and 5±3 years, respectively. There was no device-related complication during pregnancy. In 4 women, the number of tachyarrhythmias such as non-sustained ventricular tachycardia increased after the end of the second trimester of pregnancy and anti-arrhythmic medications were gradually increased. No patient received discharges or shocks from the ICD during pregnancy, however, and only one required anti-tachycardia pacing at 27 weeks' gestation. Mean gestational age at delivery was 37±2 weeks and all deliveries were by cesarean section, including 5 as emergency deliveries due to a fetal indication. After delivery, 2 mothers had reduced cardiac function and 1 received an ICD shock for the first time. CONCLUSIONS: Pregnancy did not increase the risk of an ICD-related complication under appropriate management. Additional caution might be required in the postpartum period as well as during pregnancy and labor.

Maternal outcome in pregnancy complicated with pulmonary arterial hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH), including Eisenmenger syndrome, has a risk of mortality in pregnancy of 10-40%. The aim of this study was to investigate whether pulmonary artery blood pressure (PABP) is a prognostic factor for pregnancy outcome in patients with PAH. METHODS AND RESULTS: The subjects were 42 patients with PAH during pregnancy. Severe and mild cases were defined by PABP before and during the first 14 weeks of pregnancy, with severe cases having mean PABP >40 mmHg by catheterization or systolic PABP >50 mmHg on echocardiography. Eighteen women chose termination of pregnancy before 14 weeks, leaving 24 women (10 mild, 14 severe) for analysis. The women with severe PAH delivered earlier (35.4 vs. 31.5 weeks, P<0.05) and had higher rates of small-for-gestational-age infants (0/10 vs. 7/14, P<0.01). Among the women with severe PAH, the New York Heart Association class dropped by 1 in 9 cases, by 2 in 3 cases, and remained the same in 2 cases as pregnancy progressed, whereas among the women with mild PAH, the class dropped by 1 in 1 case and 9 women remained in the same class. Among the severe cases, 1 woman died and there was 1 fetal death; PABP markedly increased in later pregnancy from 54 to 74 mmHg (catheter measurement) and from 78 to 93 mmHg (echocardiography) (P<0.05). CONCLUSIONS: The level of PABP before or in the early stage of pregnancy is an important predictor of pregnancy outcome.

Pregnancy-associated aortic dilatation or dissection in Japanese women with Marfan syndrome.

BACKGROUND: Aortic dilatation and dissection are severe complications of pregnancy that may cause maternal death. The purpose of the present study was to investigate risk factors for aortic dilatation or dissection in pregnant Japanese women with Marfan syndrome. METHODS AND RESULTS: A total of 28 patients with Marfan syndrome were investigated retrospectively during pregnancy and after delivery at 1 institution. These patients were divided into 2 groups: those who experienced aortic dilatation or dissection (group D, n=11) and those who did not (group ND, n = 17). In group D, aortic dilatation or dissection occurred in 7 cases during pregnancy (2 in the 2(nd) trimester, 5 in the 3(rd) trimester) and 4 cases after birth. The 2 cases in the 2nd trimester involved aortic dilatation > 60mm and those patients underwent hemiarch replacement and a David operation, respectively. Delivery by cesarean section (64% vs. 18%, P < 0.05), sinus of Valsalva ≥ 40mm (86% vs. 21%, P < 0.05), aortic size index (size of sinus of Valsalva/body surface area) ≥ 25 mm/m² (7/7, 100% vs. 0/14, 0%, P < 0.0001), and faster growth of the sinus of the Valsalva (median, [interquartile range]: 0.41 mm/month [0.23-0.66 mm/month] vs. 0.05 mm/month [-0.13 to 0.22 mm/month]; P < 0.05) were significantly higher in group D than in group ND. CONCLUSIONS: A large sinus of Valsalva, increased aortic size index, and rapid growth of the sinus of Valsalva are risk factors for aortic dilatation or dissection in pregnant Japanese women with Marfan syndrome.

A radiographic classification of massive rotator cuff tear arthritis.

BACKGROUND: In 1990, Hamada et al. radiographically classified massive rotator cuff tears into five grades. Walch et al. subsequently subdivided Grade 4 to reflect the presence/absence of subacromial arthritis and emphasize glenohumeral arthritis as a characteristic of Grade 4. QUESTIONS/PURPOSES: We therefore determined (1) whether patient characteristics and MRI findings differed between the grades at initial examination and final followup; (2) which factors affected progression to a higher grade; (3) whether the retear rate of repaired tendons differed among the grades; and (4) whether the radiographic grades at final followup differed from those at initial examination among patients treated operatively. PATIENTS AND METHODS: We retrospectively reviewed 75 patients with massive rotator cuff tears. Thirty-four patients were treated nonoperatively and 41 operatively. RESULTS: Patients with Grade 3, 4, or 5 tears had a higher incidence of fatty muscle degeneration of the subscapularis muscle than patients with Grade 1 or 2 tears. In 26 patients with Grade 1 or 2 tears at initial examination, duration of followup was longer in patients who remained at Grade 1 or 2 than in those who progressed to Grade 3, 4, or 5 at final followup. The retear rate of repaired supraspinatus tendon was more frequent in Grade 2 than Grade 1 tears. In operated cases, radiographic grades at final followup did not develop to Grades 3 to 5. CONCLUSIONS: We believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al. LEVEL OF EVIDENCE: Level III, Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intrapartum fetal heart rate monitoring in cases of congenital heart disease.

OBJECTIVE: We evaluated the intrapartum fetal heart rate (FHR) patterns in fetuses with congenital heart disease (CHD). STUDY DESIGN: One hundred sixteen cases of fetal CHD were identified at our institute between 2000-2007; 464 fetuses without CHD were used as controls. The incidences of abnormal FHR patterns and umbilical blood gases were compared. RESULTS: More fetuses with CHD showed variant FHR than did control fetuses (46.6% vs 17.7%; P < .01). Cesarean section deliveries that were based on fetal indications were performed more frequently in fetuses with CHD than in control fetuses (12.9% vs 3.2%; P < .01). Isomerism and tetralogy of Fallot were observed frequently with variant FHR. When chromosomal abnormalities and intrauterine growth restriction were excluded, the fetuses with CHD showed more variant FHR than did the control fetuses. CONCLUSION: Fetuses with CHD are more likely to show abnormal FHR patterns than are control fetuses. We suggest that cardiac abnormalities are associated with abnormalities in FHR patterns.

Risks and pregnancy outcome in women with prosthetic mechanical heart valve replacement.

BACKGROUND: Pregnancy after mechanical heart valve replacement is highly risky for both mother and child because of the aggravation of maternal heart function and adverse effects of anticoagulation therapy. In Japan, however, the risks and pregnancy outcomes in women with prosthetic mechanical heart valve replacement remain to be elucidated. METHODS AND RESULTS: In the present study 16 pregnancies in 12 women with prosthetic mechanical heart valve replacement were identified between 1983 and 2005. At 6-13 weeks of gestational age, warfarin, an anticoagulant agent, was changed to heparin and administration was continuously adjusted according to the activated partial thromboplastin time level up to the time of delivery. Major maternal complications and pregnancy outcomes were retrospectively investigated. The valve replaced was mitral (n=7), tricuspid (n=7), and aortic (n=2). Eight (50%) of 16 had cesarean live births. One case was delivered at full term, and 7 cases were delivered preterm (26-36 weeks) because of maternal indications. Two babies died in the neonatal period. Therapeutic abortion was performed in 3 cases, 4 cases ended in early miscarriage, and 1 case ended in intrauterine fetal death (30 weeks). Three mothers developed valve (mitral, tricuspid, aortic) thrombosis. There was 1 maternal death from heart failure. CONCLUSIONS: Pregnancy after mechanical heart valve replacement requires strict control of coagulation. Special attention should be paid to the occurrence of complications during anticoagulation therapy.

Force- and relaxation-frequency relations in patients with diastolic heart failure.

BACKGROUND: Chronotropic effects on myocardial contractility (the positive force-frequency relation) and relaxation (the positive relaxation-frequency relation) are impaired in patients with congestive heart failure and depressed left ventricular (LV) ejection fraction (systolic heart failure [SHF]). However, the force- and relaxation-frequency relation and LV-arterial coupling in patients with diastolic heart failure (DHF) has not been fully investigated. METHODS AND RESULTS: To examine inotropic and lusitropic responsiveness to atrial pacing, LV pressure-volume relations were measured using a conductance catheter and microtip manometer in patients with DHF (n = 18) and SHF (n = 11). In patients with SHF, an increase in heart rate by 40 beat/min did not affect LV end-systolic elastance (Ees), which reflects LV contractility, or the time constant of LV relaxation. By contrast, in patients with DHF, an increase in heart rate by 40 beat/min significantly enhanced Ees (2.1 vs 2.9 mm Hg/mL, P < .05) but not the time constant. Furthermore, LV-arterial coupling, quantified as Ees/arterial elastance, was impaired during pacing in patients with DHF (1.1 vs 0.8, P < .05) as well as SHF. CONCLUSIONS: In patients with DHF, the force-frequency relation was preserved, but the relaxation-frequency relation was impaired. Furthermore, LV-arterial coupling was impaired as heart rate increased, which may be related to the impaired LV function. These results suggest that the impaired relaxation-frequency relation and exacerbated LV-arterial coupling during tachycardia may be an important therapeutic target in patients with DHF.