Hyperventilation and cold-pressor stress echocardiography for noninvasive diagnosis of coronary artery spasm.

We report the usefulness of 2-dimensional echocardiography during the cold-pressor test immediately after hyperventilation for noninvasive diagnosis of coronary vasospasm in 43 patients with suspected vasospastic angina. The stress test consisted of hyperventilation for 6 minutes, followed by cold water pressor stress for 2 minutes under continuous electrocardiographic and echocardiographic monitoring. Coronary angiography with an intracoronary injection of acetylcholine was performed within 2 weeks after the stress test. Coronary spasm was observed in 33 patients by angiography. Multivessel spasm was diagnosed in 26 patients by stress echocardiography and in 23 patients by angiography. The stress-induced wall motion abnormalities occurred earlier than the ST-segment changes and chest pain. The wall motion abnormalities shown on the echocardiogram correlated well with the vascular territories of the coronary artery that had the spasm. The sensitivity, specificity, and diagnostic accuracy of hyperventilation and cold-pressor stress echocardiography for detecting vasospastic angina against coronary angiography with an intracoronary injection of acetylcholine were 91%, 90%, and 91%, respectively. However, the sensitivity, specificity, and diagnostic accuracy of hyperventilation and cold-pressor stress electrocardiography for detecting vasospastic angina were 48%, 100%, and 60%, respectively. No major side effects were observed during or after the stress test. Echocardiographic monitoring during the stress test detected spasm unaccompanied by either ST- segment changes or chest pain and revealed the location of multivessel coronary spasm. Hyperventilation and cold-pressor stress echocardiography is thus a noninvasive and useful tool for the diagnosis of vasospastic angina.

[A management for severe acquired stuttering in a case of pure akinesia syndrome].

We reported a 73-year-old man with pure akinesia syndrome who showed severe acquired stuttering and paradoxical kinesia on speech. He was evaluated in another hospital for bradykinesia and frozen gait at age of 67 when his cranial MRI disclosed ischemic changes in bilateral basal ganglia and periventricular deep white matter. The treatment with L-dopa and L-threo DOPS was not effective. His symptoms were slowly progressive and got worse gradually. At age of 72, he began to have difficulty in speech due to severe acquired stuttering, and one year later, he visited our hospital. The diagnosis of pure akinesia syndrome was made because of akinesia, micrographia, marked frozen gait with paradoxical kinesia and disturbance of postural reflex without tremor and rigidity. His speech showed severe acquired stuttering with marked blocking and repetition of initial phonemes at the beginning of speech. But intelligible speech recurred with pointing the characters by his finger or with writing an initial letter of word, although his speech was small and monotonous. Surface EMG findings of muscles participating speech in acquired stuttering showed the similar tonic discharge to those of muscles of lower extremity in frozen gait. These results implied that freezing phenomenon and festination of muscles participating speech in our patient may result in acquired stuttering.

[A case of pneumocystis carinii pneumonia after chemotherapy of bladder tumor].

This is a case report on a 70-year-old male patient. During chemotherapy treatment after a bladder tumor operation, the patient had a complication of pneumonia which did not respond to various antibiotics. From clinical observations and chest X-ray, it was diagnosed as pneumocystis carinii (PC) pneumonia and was cured by medication of Co-trimoxazole.

Effect of triangular ligament tears on distal radioulnar joint instability and evaluation of three clinical tests: a biomechanical study.

Using 11 fresh/frozen cadaver specimens, instability of the distal radioulnar joint (DRUJ) during passive wrist motion was measured by motion analysis and three clinical tests (ulno-carpal stress test, piano-key test, and DRUJ ballottement test) were performed. Release of the triangular ligament from the palmar approach was performed to simulate instability of the DRUJ. Displacement of the distal radius against the ulnar head was measured at various degrees of forearm rotation. Release of the triangular ligament at the ulnar fovea and around the base of the ulnar styloid process caused various degrees of DRUJ instability during passive wrist motion. After complete triangular ligament release, only the DRUJ ballottement test demonstrated a statistically significant degree of accuracy in the evaluation of distal radioulnar joint instability.

Risk factors for cigarette smoking among high school students in Okinawa, Japan.

The purpose of this study was to examine the relationships between risk factors and smoking status among high school students in Okinawa, Japan. We also examined if there is a dose-response relation between the number of risk factors and smoking status. Self-reported questionnaires including smoking status and potential risk factors were conducted using a sample of 1,029 students of a public senior high school in Okinawa. The percentage of smokers was 40.0% for males and 10.6% for females, and it was significantly higher for males than females. As a result of multivariate analysis, we identified four significant risk factors; peer smoking, attitude of peer toward subject smoking, intention to smoke at the age 20, and alcohol drinking. The number of these risk factors was linearly associated with increased percentage of smokers, and a linear trend was significant for both gender students. Additionally, magnitude of risk for smoking among females became considerably great compared with those of males as the number of risk factors increased. In conclusion, this study was the first study in Japan to indicate a significant dose-response relationship between the number of risk factors and smoking status among high school students. We also found that females with many risk factors had extremely increased vulnerability to smoking compared to male counterpart. These findings may be useful to identify high-risk students who need more intensive smoking prevention programs and to develop the content of effective interventions.

Pigmented villonodular synovitis secondary to laceration of the perforating branch of the peroneal artery.

A case of peroneal artery injury subsequently developed into a lesion resembling an extra-articular tenosynovial giant cell tumor, which is a type of pigmented villonodular synovitis (PVNS). This case supports the hypothesis that accident trauma, such as a vascular injury, can be the etiology of PVNS.

Can the proximal isovelocity surface area method calculate stenotic mitral valve area in patients with associated moderate to severe aortic regurgitation? Analysis using low aliasing velocity of 10% of the peak transmitral velocity.

To assess the ability of the proximal isovelocity surface area (PISA) method to accurately measure the stenotic mitral valve area (MVA), and to assess whether aortic regurgitation (AR) affects the calculation, we compared the accuracy of the PISA method and the pressure half-time (PHT) method for determining MVA in patients with and without associated AR by using two-dimensional echocardiographic planimetry as a standard. The study population consisted of 45 patients with mitral stenosis. Seventeen of the 45 patients had associated moderate-to-severe AR. The PISA method was performed using low aliasing velocity (AV) of 10% of the peak transmitral velocity, which provided the most accurate estimation of MVA when compared with planimetry. The maximal radius r of the PISA was measured from the orifice to blue-red aliasing interface. Using the PISA method, MVA was calculated as (2pir(2)) x theta / 180 x AV/Vmax, where theta was the inflow angle formed by mitral leaflets, AV was the aliasing velocity (cm/sec), and Vmax was the peak transmitral velocity (cm/sec). MVA by the PISA method correlated well with planimetry both in patients with AR (r = 0.90, P < 0.001, SEE = 0.17 cm(2)) and without AR (r = 0.92, P < 0.001, SEE = 0.16 cm(2)). However, MVA by the PHT method did not correlate as well with planimetry (r = 0.57, P < 0.05, SEE = 0.37 cm(2)) in patients with associated AR, and the PHT method produced a significant overestimation (24%) of MVA obtained by planimetry in these patients. We conclude that the PISA method allows accurate estimation of MVA and is not influenced by AR.

[Contrast agent improves diagnostic value of dobutamine stress echocardiography].

OBJECTIVES: Suboptimal endocardial definition reduces the diagnostic value of stress echocardiography for coronary artery disease, but intravenous infusion of a left ventricular contrast agent (Albunex) may enhance endocardial border delineation and improve the diagnostic value of dobutamine stress echocardiography. METHODS: Fifty-six patients, 38 with myocardial infarction, 16 with angina pectoris and two normal subjects, were enrolled in this study. Dobutamine was infused in scalar doses of 5 to 40 micrograms/kg/min. Intravenous infusion of Albunex (0.15 ml/kg) was administered at rest and during peak dobutamine stress during monitoring of the apical four-chamber view. The left ventricle in the apical four-chamber view was divided into six segments and an endocardial delineation score of 0 to 3 (none to excellent visualization) was given to each segment. RESULTS: Endocardial delineation score was increased after Albunex infusion from 2.0 to 2.3 in the basal-septal, 2.0 to 2.4 in the mid-septal, 1.1 to 1.8 in the apical-septal, 0.7 to 1.2 in the apical-lateral, 0.9 to 1.6 in the mid-lateral, and 1.2 to 1.9 in the basal-lateral segments during peak dobutamine administration. Endocardial border resolution in the lateral wall showed greater improvement than in the septal wall after Albunex infusion. Diagnostic values in the left anterior descending artery territory failed to improve with Albunex infusion (sensitivity 82% to 89%, specificity 94% to 89%, and accuracy 86% to 89%), whereas a higher diagnostic accuracy was noted in the left circumflex artery territory with Albunex compared to without Albunex (sensitivity 63% to 81%, specificity 88% to 98%, and accuracy 80% to 93%, p < 0.05). CONCLUSIONS: Contrast agent improves the diagnostic accuracy of dobutamine stress echocardiography in the left circumflex artery territory.

[Diagnosis of myocardial viability by exercise echocardiography].

This study determined whether the diagnosis of myocardial viability could be established on the basis of the contractile reserve during low level exercise with an ergometer using echocardiography. The study involved 22 patients with transmural old myocardial infarction who underwent exercise echocardiography, followed by coronary intervention after a mean 4 days. Exercise echocardiography was started from 50 W and stepped up by 25 W every 3 min up to a maximum of 150 W. Low level exercise was administered for 1 to 2 min at 50 W. A 16-segment model was used for the left ventricular wall motion, which was evaluated by five-grade scoring, ranging from normokinesis to dyskinesis. If patients showed improvement by one point or more in the score for segments of dyskinesis, akinesis, or severe hypokinesis on the exercise echocardiography, they were considered to have positive viability. The golden standard for the diagnosis of myocardial viability was that wall motion abnormalities before exercise echocardiography should be improved by one point or more after coronary intervention. Before exercise echocardiography, there were 152 segments showing wall motion abnormalities assessed as severe hypokinesis or more. After coronary intervention, improvement of the wall motion by one grade or more was found in 2 of the 18 segments (11%) for dyskinesis, in 38 of the 96 segments (40%) for akinesis, and in 22 of the 38 segments (58%) for severe hypokinesis; improvement for the segments of severe hypokinesis was significantly better than those for dyskinesis and akinesis. Out of 19 segments with akinesis before exercise echocardiography in which wall motion was improved during low level exercise, 16 segments (84%) showed improvement in wall motion after coronary intervention. Out of 77 segments with akinesis before exercise echocardiography in which no change or worsening was seen during low level exercise, 22 segments (29%) showed improved wall motion after coronary intervention. There were 38 segments with severe hypokinesis before exercise echocardiography; out of 12 segments in which wall motion was improved during low level exercise, 7 segments (58%) showed improved wall motion after coronary intervention. Out of 26 segments with severe hypokinesis before exercise echocardiography in which no change or worsening was seen during low level exercise, 11 segments (42%) showed improved wall motion after coronary intervention. Wall motion was improved after coronary intervention in 20 of 25 segments (80%) that showed the biphasic response, in 4 of 7 segments (57%) that showed improvement, in 14 of 43 segments (33%) that showed worsening, in 24 of 77 segments (31%) for no change; the biphasic response showed a significantly higher improvement compared to worsening or no change. If segments in which wall motion was improved during low level exercise are regarded as positive viability segments, occurrences of the sensitivity, specificity and diagnostic accuracy of myocardial viability were 50%, 84%, and 71%, respectively.