Diagnostic utility and safety of intracoronary nicorandil as a hyperemic agent for the measurement of fractional flow reserve.

We investigated the diagnostic utility and safety of intracoronary bolus administration of nicorandil compared with intravenous administration of adenosine for evaluating FFR in patients with intermediate (40-70%) coronary stenosis. The FFR values obtained with nicorandil and adenosine showed linear relationship. This correlation is statistically significant with regression coefficient of 0.932 (R2 = 0.834, p < 0.001). The side effects such as bronchospasm, hypotension, and bradycardia were significantly higher after administration of adenosine compared to nicorandil (20% vs. 1.66%, p = 0.001). Intracoronary use of nicorandil seems to be promising in offering the advantages of lesser side effects, similar efficacy, and lesser cost as compared to adenosine.

Argatroban anticoagulant therapy in patients with heparin-induced thrombocytopenia.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an immune-mediated syndrome caused by heparin. Complications range from thrombocytopenia to thrombocytopenia with thrombosis. We report a prospective, historical- controlled study evaluating the efficacy and safety of argatroban, a direct thrombin inhibitor, as anticoagulant therapy in patients with HIT or HIT with thrombosis syndrome (HITTS). METHODS AND RESULTS: Patients with HIT (isolated thrombocytopenia, n=160) or HITTS (n=144) received 2 microgram. kg(-1). min(-1) IV argatroban, adjusted to maintain the activated partial thromboplastin time 1.5 to 3.0 times baseline value. Treatment was maintained for 6 days, on average. Clinical outcomes over 37 days were compared with those of 193 historical control subjects with HIT (n=147) or HITTS (n=46). The incidence of the primary efficacy end point, a composite of all-cause death, all-cause amputation, or new thrombosis, was reduced significantly in argatroban-treated patients versus control subjects with HIT (25.6% versus 38.8%, P=0.014). In HITTS, the composite incidence in argatroban-treated patients was 43.8% versus 56.5% in control subjects (P=0.13). Significant between-group differences by time-to-event analysis of the composite end point favored argatroban treatment in HIT (P=0.010) and HITTS (P=0.014). Argatroban therapy, relative to control subjects, also significantly reduced new thrombosis and death caused by thrombosis (P<0.05). Argatroban-treated patients achieved therapeutic activated partial thromboplastin times generally within 4 to 5 hours of starting therapy and, compared with control subjects, had a significantly more rapid rise in platelet counts (P=0.0001). Bleeding events were similar between groups. CONCLUSIONS: Argatroban anticoagulation, compared with historical control subjects, improves clinical outcomes in patients who have heparin-induced thrombocytopenia, without increasing bleeding risk.

Evaluation of mild bleeding disorders and easy bruising.

The diagnostic approach to easy bruising or a suspected mild bleeding disorder includes a careful history and physical examination as well as laboratory investigations. The history should determine whether or not a bleeding disorder exists and help elucidate possible causes. The physical examination should evaluate evidence of bleeding and identify systemic illness. The laboratory investigation should include both screening and more specific diagnostic tests depending on the results of the screening tests and clinical findings. The review will provide a framework for generating a differential diagnosis in patients with suspected bleeding disorders and will categorize them into abnormalities of coagulation factors, platelets and those related to blood vessels and supporting tissues.

Simple and efficient system for fast interchange of low-energy collimators.

The inconvenience and time required for changing collimators on a scinticamera are major problems in the efficient use of the apparatus. A system is described, based on the lightweight, reversible DIVCON collimator made by Searle Radiographics for the Pho/Gamma camera that solves this problem. The core of a straight-bore, low-energy collimator is adapted to fit the DIVCON outer ring and a low-energy pinhole collimator is constructed to fit the same mounting system. Finally, an adapter using a bayonet-mount slot system is added to make collimator changing by hand possible in a minute or less.

Cytarabine-induced pericarditis: a case report and review of the literature of the cardio-pulmonary complications of cytarabine therapy.

Pericarditis is a rare complication of chemotherapy. This report describes a patient who developed symptoms, signs, and electrocardiographic evidence of pericarditis following treatment with high dose cytarabine. The patient had no clinical or echocardiographic evidence of infection or leukemic involvement of the pericardium. Isolated pericarditis associated with high dose cytarabine has been rarely reported. This therapy is frequently used and, therefore, it seems prudent to alert physicians to this potential complication of cytarabine. The cardiopulmonary complications of cytarabine are also reviewed.

Control of actin conformation in AML myeloblasts: the effects of bryostatin and TPA.

Protein kinase C (PKC), an enzyme involved in signal transduction, is the receptor for both the tumor-promoting phorbol esters and the anti-neoplastic bryostatins. In many cells, phorbol esters and bryostatins cause similar effects; we have found that both agents increase actin polymerization in neutrophils. In some cells, however, the two agents result in different cell processes; we have found consistently different effects of these agents on actin conformation in myeloblasts obtained from leukemic patients. The patients tested all had increases in F-actin in response to 12-O-tetradecanoylphorbol-13-acetate (TPA) and most had decreases in F-actin in response to bryostatin. The data suggests that leukemic myeloblasts have a different cytoskeletal response to a tumor promoter and an antineoplastic agent despite their common receptor.

Functional characteristics of mature granulocytes in a patient with acute promyelocytic leukemia treated with all-trans retinoic acid.

All-trans retinoic acid (ATRA) is a differentiating agent that has been successfully used in the treatment of patients with acute promyelocytic leukemia (APL). Functional properties of peripheral blood neutrophils from a patient with APL during treatment with ATRA have been studied. Wright stain of patient neutrophils showed hypogranulation and loose nuclear chromatin when compared with normal neutrophils. These cells were of lower density than normal neutrophils and separated on density gradient centrifugation with mononuclear cells. Surface antigen expression by FACS distinguished these cells from lymphocytes. The histograms showed a population of larger cells expressing CD18 and CD11b, distinct from the smaller cells which did not express CD11b. fMLP caused an increase in intracellular calcium (measured spectrophotometrically) that was inhibited by the calcium chelator BAPTA. Actin polymerization following cell activation was measured using NBD-phallacidin staining and FACS. Both IL-8 and fMLP caused rapid increases using F-actin content (2.5-3.0 fold), which were of greater magnitude than generally seen with normal neutrophils. Treatment with BAPTA before activation with fMLP did not blunt the actin responses, despite complete inhibition of an intracellular calcium increase. In summary, neutrophils derives from differentiated APL cells express CD18/CD11b, and exhibit a similar degree of actin polymerization in response to fMLP and IL-8, independent of an increase in intracellular calcium. Although the actin responses are greater than normal neutrophils, most properties are similar, supporting the contention that these cells can protect the host. The exaggerated actin response to inflammatory mediators, however, may play a role in the 'retinoic acid syndrome'.

Functional properties of HL60 cells matured with all-trans-retinoic acid and DMSO: differences in response to interleukin-8 and fMLP.

All-trans-retinoic acid (ATRA) causes granulocyte differentiation in patients with acute promyelocytic leukemia. HL60 cells are frequently used as an in vitro model for studying granulocytes during maturation. We have previously studied actin polymerization in response to fMLP in HL60 cells undergoing DMSO induced maturation, and reported that IL-8 causes actin polymerization in neutrophils in a manner similar to fMLP. We now compare chemotaxis and actin polymerization in response to IL-8 and fMLP, and nitroblue tetrazolium (NBT) reduction in HL60 cells matured with ATRA and DMSO. Cells cultured for 4 days with ATRA and DMSO showed morphologic evidence of maturation. NBD-phallacidin staining and flow cytometry were used to measure changes in F-actin content in response to IL-8 and fMLP. Uninduced cells were not capable of actin polymerization or chemotaxis. Cells matured with ATRA exhibited a 2.6-fold increase in F-actin content in response to IL-8, but only a 1.2-fold increase in response to fMLP. Cells matured with DMSO responded to both IL-8 and fMLP in an equal manner with 1.6-fold increases in F-actin. The 2 h migration for ATRA induced cells was 124 microns in response to IL-8, 107 microns with fMLP, and 105 microns in buffer. DMSO induced cells migrated 89 microns in response to IL-8, 106 microns with fMLP, and 66 microns in buffer. With maturation, 65% of the ATRA induced cells reduced NBT compared with only 15% of the DMSO induced cells. In summary, HL60 cells cultured in ATRA develop greater functional maturity than those cultured in DMSO, and a greater responsiveness to IL-8 than fMLP, a finding distinct from previously reported work in neutrophils.

Use of cell surface antigen phenotype in guiding therapeutic decisions in chronic myelomonocytic leukemia.

The myelodysplastic syndromes are a heterogeneous group of hematopoietic stem cell diseases in which both diagnosis and prognosis are determined by cellular morphologic criteria. In some patients, prognosis is poor due to proliferation of immature cells, i.e. development of acute leukemia. An important clinical decision for patients with myelodysplastic syndromes is whether to treat with supportive care or to use cytoreductive drugs to control the proliferative component of these illnesses. Two cases of chronic myelomonocytic leukemia are presented where cell surface antigen phenotype analysis showed characteristics suggestive of proliferative disease and the patients were treated and obtained remission with cytoablative therapy. Cell surface marker analysis may be useful in guiding therapeutic decisions in myelodysplasia.

Erroneous thyroid-stimulating hormone radioimmunoassay results due to interfering antibovine thyroid-stimulating hormone antibodies.

Apparent elevation of serum thyroid-stimulating hormone (TSH) levels was found in a case of a patient receiving adequate replacement therapy after thyroidectomy for a follicular carcinoma. This was an artifact due to interference with the radioimmunoassay by circulating antibovine TSH antibodies. The double-antibody technic showed spuriously elevated levels, and the single-antibody technic showed low levels of serum TSH by radioimmunoassay in the presence of antibodies.

Visualization of a bullet track on brain imaging. Case report.

A case is reported in which an intracerebral bullet track was demonstrated by brain imaging, The possible advantages of technetium-99-m localization and the role of brain imaging in gunshot injuries of the head are discussed.

Hypertrophic Riedel's lobe of the liver.

Riedel's lobe, noted on 99mTc-sulfur colloid liver scintigraphy, was present in 86 (3.3%) of 2604 patients reviewed. Hypertrophied Riedel's lobe was found in 30 cases of which 25 (83%) were females and 5 (17%) were males. Liver scintigraphy will detect the presence of a hypertrophied Riedel's lobe and is recommended in all cases of right sided abdominal masses.

Bone scan in sickle cell crisis.

99mTc-diphosphonate bone scans of 13 patients in acute sickle crisis were analyzed. Twelve of the 13 patients had abnormal scans, with increased activity in joints and skull being a common finding. One patient with splenic calcification and two patients without splenic calcification had splenic uptake of diphosphonate. Most of the abnormal scans showed hot areas, with cold areas seen only in four cases. There was no correlation between the site of pain clinically and the abnormal areas on scanning. The pathophysiology of the abnormal uptake of radioactivity and the role of bone scanning on sickle cell disease are discussed.

Increased 99mTc-pyrophosphate uptake with radiation pneumonitis.

A case of radiation pneumonitis confirmed by tissue biopsy is presented with demonstration of increased uptake of 99mTc-pyrophosphate.