Prevention of experimental autoimmune uveoretinitis by monoclonal antibody to interleukin-12

Experimental autoimmune uveoretinitis (EAU) induced by immunization with interphotoreceptor retinoid-binding protein (IRBP), a retinal self antigen, has been regarded to be a typical T helper type 1 (Th1)-mediated inflammatory disease. In this study, we examined the effect of a neutralizing monoclonal antibody (mAb) to interleukin-12 (IL-12), which has been known to play a critical role in the Th1 differentiation, on the development of EAU. While 9 of 13 control mice developed EAU by the immunization with IRBP, none of 12 mice developed EAU when given anti-IL-12 mAb 1 day before immunization. These mice did not develop EAU even after a rechallenge with IRBP on day 30, indicating that a protective mechanism had been established by the anti-IL-12 treatment. The proliferative response of splenocytes to IRBP in vitro was not significantly impaired, but the production of IL-2 and IFN-gamma was greatly reduced by the anti-IL-12 treatment. Moreover, production of IL-5 and expression of IL-4 mRNA were increased by the anti-IL-12 treatment. Consistently, IgG2a anti-IRBP serum antibodies were decreased and IgG1 were increased. Administration of a neutralizing anti-IL-4 mAb at the time of IRBP rechallenge reversed the protection established by the anti-IL-12 treatment at the primary immunization. These results indicate that the anti-IL-12 treatment at the IRBP priming not only prevented the development of pathogenic Th1 cells, but also induced suppressive Th2 cells that protect the animals from further challenge with the same antigen.

[A study of 44 patients with Kirisawa type uveitis]

We studied 50 eyes of 44 patients with acute retinal necrosis, Kirisawa type uveitis (KU), in order to examine clinical symptoms, pathogenic viruses, clinical grading, therapy and prognosis for this disease. Varicella-zoster virus (VZV) was the pathogenic organism in 37 eyes of 31 patients, while herpes simplex virus (HSV) was responsible in 13 eyes of 13 patients. There were more elderly patients in the VZV-KU group than in the HSV-KU group. In addition, mutton fat keratic precipitates and retinal exudates were more common in VZV-KU than in HSV-KU. We divided KU eyes into 3 clinical grades: severe, serious, and mild. Using statistical analysis, we found that the VZV-KU group had a significantly greater number of severe and serious cases than the HSV-KU group. Furthermore, some HLA antigens were found to be statistically more common in the VZV-KU group, although no associations were found in the HSV-KU group. 32% of VZV-KU and 67% of HSV-KU eyes had a final visual acuity (fVA) of greater than 0.5. When eyes with an fVA of greater than 0.1 were compared to eyes with an fVA of less than 0.1, we found that combined therapy using acyclovir, interferon beta, and prednisolone was especially effective for VZV-KU, although no significant difference was found for HSV-KU. Thus, it is essential to determine the pathogenic virus causing KU, in order to understand the disease pathogenesis as well as to select appropriate treatment.

IFN-gamma-inducing factor (IGIF) is a costimulatory factor on the activation of Th1 but not Th2 cells and exerts its effect independently of IL-12

We have previously reported the cloning of a novel cytokine, IFN-gamma-inducing factor (IGIF), which shared some biologic activities with IL-12. In this study, we analyzed the effects of murine IGIF on the activation of T cells, and compared the effects with those of IL-12. IGIF alone had no effect on the activation of T cell lines or Th1 clones, while IGIF increased the IFN-gamma production by antigen-stimulated T cell lines, but had no effect on IL-4 or IL-10 production. As reported with IL-12, IGIF served as a costimulatory factor for Th1 clones stimulated with Ag on B cell APC, immobilized anti-CD3, Con A, or IL-2 to augment IFN-gamma production and to induce IL-2R alpha-chain expression and proliferation of the Th1 clones, whereas IGIF had little or no effect on the IL-4 production and proliferation of Th2 clones stimulated with anti-CD3 or Ag. However, IGIF synergized with IL-12 to further augment the IFN-gamma production of the Th1 clones. Even in the presence of saturated amounts of IL-12, IGIF still augmented the IFN-gamma production and proliferation and enhanced the IL-2R alpha-chain expression of the Th1 clones. In contrast with IL-12, IGIF induced IL-2 production by Ag- or anti-CD3-stimulated Th1 clones. These two findings indicate that IGIF and IL-12 are utilizing different signal transduction pathways. We also found that IGIF as well as IL-12 was endogenously released through interaction between Th1 cells and spleen cell APC in the presence of specific Ag, and that it regulated IFN-gamma production. These results further suggest that IGIF may act as an immunoregulatory factor in the immune response.

IFN-gamma-inducing factor (IGIF) is a costimulatory factor on the activation of Th1 but not Th2 cells and exerts its effect independently of IL-12

We have previously reported the cloning of a novel cytokine, IFN-gamma-inducing factor (IGIF), which shared some biologic activities with IL-12. In this study, we analyzed the effects of murine IGIF on the activation of T cells, and compared the effects with those of IL-12. IGIF alone had no effect on the activation of T cell lines or Th1 clones, while IGIF increased the IFN-gamma production by antigen-stimulated T cell lines, but had no effect on IL-4 or IL-10 production. As reported with IL-12, IGIF served as a costimulatory factor for Th1 clones stimulated with Ag on B cell APC, immobilized anti-CD3, Con A, or IL-2 to augment IFN-gamma production and to induce IL-2R alpha-chain expression and proliferation of the Th1 clones, whereas IGIF had little or no effect on the IL-4 production and proliferation of Th2 clones stimulated with anti-CD3 or Ag. However, IGIF synergized with IL-12 to further augment the IFN-gamma production of the Th1 clones. Even in the presence of saturated amounts of IL-12, IGIF still augmented the IFN-gamma production and proliferation and enhanced the IL-2R alpha-chain expression of the Th1 clones. In contrast with IL-12, IGIF induced IL-2 production by Ag- or anti-CD3-stimulated Th1 clones. These two findings indicate that IGIF and IL-12 are utilizing different signal transduction pathways. We also found that IGIF as well as IL-12 was endogenously released through interaction between Th1 cells and spleen cell APC in the presence of specific Ag, and that it regulated IFN-gamma production. These results further suggest that IGIF may act as an immunoregulatory factor in the immune response.

Limb allografts in rats treated with anti-ICAM-1 and anti-LFA-1 monoclonal antibodies

This study examined whether administration of anti-ICAM-1 mAb (monoclonal antibody) and anti-LFA-1 mAb were effective for inhibition of the acute rejection reaction in a rat-limb allograft model. The grafts were carried out using major histocompatibility complex mismatch pairs of rats: ACI rats as the donors and Lewis rats as the recipients. The subjects were of species with completely different major histocompatibility complexes. The average length of survival in this combination was 4.7 +/- 0.6 days. When anti-ICAM-1, anti-LFA-1 mAb, or a combination of both were administered intraperitoneally at 1 mg/kg body weight daily for 7 days after the graft, the mean survival times were 4.3 +/- 0.6, 4.7 +/- 0.6, or 4.7 +/- 0.6 days, respectively. The agents were found to exercise no beneficial effects for transplants. Transplants were then carried out with a single intramuscular administration of FK506 at 3mg/kg body weight on the day of the operation to observe the effect of this adjunct therapy. The mean survival time averaged 16.0 +/- 5.5 days with FK506 alone. Administration of anti-ICAM-1, anti-LFA-1, and both antibodies together with FK506 resulted in mean survival times of 15.4 +/- 3.0, 25.0 +/- 5.8 and 13.2 +/- 5.8 days, respectively. Thus, a significant prolongation of survival time was observed when the combination of anti-LFA-1 mAb and FK506 was used. In contrast, anti-ICAM-1 mAb and FK506 or both mAb and FK506 showed no beneficial effects.

Immunogenetic study of sympathetic ophthalmia

Sympathetic ophthalmia (SO) is very rare but it remains one of the most intractable eye diseases. In clinical manifestations and histopathologic features SO is known to resemble closely Vogt-Koyanagi-Harada's disease (VKH disease). We had reported that VKH disease was significantly associated with HLA-DRB1*04 and -DQB1*04 in Japanese patients. In this study, to investigate an HLA association with SO we performed HLA serological and PCR-based DNA typing in 16 patients and 50 healthy controls. Our study revealed that HLA-DRB1*04 (0405; Pc < 5 x 10(-4)), DQA1*03 (Pc < 5 x 10(-3)), and DQB1*04 (0401; Pc < 5 x 10(-4)) were significantly associated with SO as compared to the healthy controls but there was no significant difference in the frequencies of any DPB1 alleles between the patients and healthy controls. It can be postulated that not only the clinical manifestations but also the genetic predisposition of SO are very similar to those of VKH disease.

Important role of tissue angiotensin-converting enzyme activity in the pathogenesis of coronary vascular and myocardial structural changes induced by long-term blockade of nitric oxide synthesis in rats

The long-term administration of N(omega)-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide synthesis, produces coronary vascular remodeling and myocardial hypertrophy in animals. This study used a rat model to investigate the role of angiotensin I converting enzyme (ACE) in the pathogenesis of such changes. We studied the following groups, all of which received drug treatment in their drinking water: untreated controls, and those administered L-NAME, L-NAME, and an ACE inhibitor (ACEI), and L-NAME and hydralazine. Cardiovascular structural changes and tissue ACE activities were evaluated after the first, fourth, and eighth week of treatment. In rats treated with L-NAME alone, vascular remodeling was evident at the fourth and eighth week, and myocardial hypertrophy was present at the eighth week of treatment. The vascular and myocardial remodeling were characterized by increased tissue ACE activities and immunodetectable ACE in those tissues. These changes were markedly reduced by ACEI, but not by hydralazine treatment. Increased local ACE expression may thus be important in the pathogenesis of cardiovascular remodeling in this model.

Inactivation of the tumor suppressor gene on 11q13 in brothers with familial acrogigantism without multiple endocrine neoplasia type 1

Two of three brothers (the second and third brothers) and their uncle (their mother's brother) presented acrogigantism without multiple endocrine neoplasia type 1 (MEN 1). An invasive macroadenoma was found in the second brother, and it was histologically confirmed as a sparsely granulated GH cell adenoma. Two distinct microadenomas were found in the third brother, and these were histologically diagnosed as a mixed GH cell and PRL cell adenoma and a sparsely granulated GH cell adenoma, respectively. The loss of heterozygosity (LOH) was analyzed in two adenomas (GH cell adenoma from the second brother and a mixed GH cell and PRL cell adenoma from the third brother) by determining microsatellite polymorphisms of DNAs from tumors and patients' leukocytes. The LOH was found on the chromosome 11q13, whereas LOH was not detected on 1p31-36, 2p, 3p, 4, 5, 6p, 7, 8, 9p21-22, 12p, and 19q13 in both pituitary adenomas examined. The haplotype analysis showed that the same haplotype on 11q13 was found in their mother and the unaffected first brother as well as in the affected uncle and two brothers. The deleted alleles on chromosome 11q13 in the tumors of two affected brothers were, however, restricted to those transmitted from their unaffected father. These data suggest that inactivation of the MEN 1 gene or other tumor suppressor genes on chromosome 11q13 plays an important role for the development of our familial acrogigantism without MEN 1.

Cranial fasciitis

We report a case of cranial fasciitis in a 14-month-old boy. The lesion grew at the site of a previous head trauma, rapidly destroying the skull. Surgery disclosed that the lesion was highly vascular and adhered to the dura. Because histopathological study of a frozen section did not show malignancy, the authors decided not to perform dural excision after total removal of the lesion. No recurrence of the lesion was seen. The authors stress that this rate fibroblastic lesion must be included in the differential diagnosis of pediatric skull tumors and that careful histopathological observation is needed to avoid extensively invasive surgery.

Pit-1 gene expression in human pituitary adenomas using the reverse transcription polymerase chain reaction method

OBJECTIVE

Previous studies of Pit-1 expression in human pituitary tumours have produced conflicting results. We have studied expression of Pit-1 mRNA in human pituitary adenomas, as well as in normal human and rat pituitaries, and results were compared with clinical, histological, and immunohistochemical features. In addition, expression of GH, PRL, and TSH-beta mRNA was also studied and compared with Pit-1 gene expression.

MATERIAL AND METHODS

The adenomas consisted of 13 GH cell adenomas, 7 PRL cell adenomas, 3 TSH cell adenomas, 4 ACTH cell adenomas, and 10 clinically non-functioning adenomas. Expression of the Pit-1, its isoforms, and each hormone, was studied using the reverse transcription polymerase chain reaction.

RESULTS

Pit-1 mRNA was expressed not only in normal human and rat pituitaries, but also in all GH, PRL and TSH cell adenomas. There was no correlation between Pit-1 transcripts and biological behaviour or histological findings in these three types of adenoma, suggesting that Pit-1 is generally required for the determination of cell phenotype but is insufficient for the regulation of hormonal activity and tumour growth in these pituitary adenomas. In addition, Pit-1 was also expressed in some ACTH cell (2/4) and non-functioning adenomas (7/10). Although there were no GH, PRL or TSH-beta transcripts in Pit-1 mRNA-negative ACTH cell and non-functioning adenomas, PRL mRNA was detected in all Pit-1 mRNA-positive ACTH cell adenomas and GH, PRL and/or TSH-beta mRNA were found in four of seven Pit-1 mRNA-positive non-functioning adenomas. In contrast, Pit-1 mRNA was expressed without any GH, PRL, or TSH-beta transcripts in only three non-functioning adenomas. These data suggest that expression of Pit-1 mRNA in these two types of adenomas can be mainly attributed to the presence of GH, PRL and/or TSH-beta mRNA expressing cells and that true Pit-1 transcripts found in non-functioning adenomas may be a rare event. Moreover, there were two cases which expressed Pit-1 alpha mRNA, but failed to show other Pit-1 isoform mRNA. There were, however, no clinical or histological differences between these two adenomas showing only Pit-1 alpha mRNA and the others expressing both Pit-1 alpha mRNA and other Pit-1 isoform mRNA.

CONCLUSIONS

Pit-1 mRNA was expressed not only in GH, PRL and TSH cell adenomas but also in other types of adenoma. However, it is suggested that expression of Pit-1 mRNA in most ACTH cell and non-functioning adenomas can be attributed to GH, PRL and/or TSH-beta mRNA expressing cells. Further studies are necessary to elucidate the role of Pit-1 transcripts in the three non-functioning adenomas without GH, PRL and/or TSH-beta mRNA expression.

Peptide-mediated suppression of experimental autoimmune uveoretinitis in mice: development of a peptide vaccine

Experimental autoimmune uveoretinitis (EAU) is an animal model of antigen-specific, Th cell-mediated, organ-specific autoimmune disease. EAU is induced by immunization of B10.A mice with interphotoreceptor retinoid-binding protein (IRBP). Pre-treatment with synthetic peptide 518-529 derived from IRBP prevented IRBP-mediated EAU. This was accompanied by augmentation of the IRBP-specific IgG1 antibody (Th2) response and down-regulation of the IRBP-specific IgG2a (Th1) response. Consistent with this is the observation that two of two T cell lines established from p518-529-primed mice produced Th2-type cytokines (IL-4 and IL-10), whereas three of three T cell lines obtained from IRBP-primed mice produced Th1-type cytokines (IL-2 and IFN-gamma). Together this suggests the possibility that p518-529 priming causes a shift from a Th1-to a Th2-dominated immune response, thereby playing a pivotal role in the prevention of IRBP-mediated EAU. Furthermore, co-transfer of cells from a CD4+ p518-529-specific T cell line prevented the development of EAU after adoptive transfer of spleen cells from mice with EAU into normal mice. These findings contribute to our understanding of the mechanism of EAU, particularly with respect to the down-regulation of Th1-initiated inflammation, and may prove valuable for designing a peptide vaccine for EAU in the future.

Visceral leishmaniasis misdiagnosed as malignant lymphoma

Visceral leishmaniasis is a chronic infectious disease caused by a protozoan parasite of the genus Leishmania, characterized by intermittent fever, monocytosis, hepatosplenomegaly and hypergammaglobulinemia. This morbid condition is rather difficult to diagnose correctly, especially at its early stage, because it is rarely encountered in Japan. Recently we treated a case of visceral leishmaniasis in which the patient was misdiagnosed as malignant lymphoma, and went through splenectomy and steroid administration, which made the diagnosis more difficult.

A preliminary report of neoadjuvant chemotherapy NSH-7 study in osteosarcoma: preoperative salvage chemotherapy based on clinical tumor response and the use of granulocyte colony-stimulating factor

Eleven patients with high-grade osteosarcoma of an extremity were treated with neoadjuvant chemotherapy with NSH-7 protocol. NSH-7 is a refinement of the T-12 Rosen protocol. Preoperative chemotherapy is initiated with a doxorubicin (ADM) and high-dose methotrexate combination. If the primary tumor progresses after the first cycle, the preoperative chemotherapy is switched to a combination of cisplatin and ADM. Postoperative adjuvant chemotherapy was selected based on histological response of the primary tumor. In addition, recombinant human granulocyte colony-stimulating factor was used to prevent leukocytopenia and to increase the dose intensity of the chemotherapy. In 1 patient, preoperative chemotherapy was switched to salvage treatment. Of the 156 courses given, there were 10 delays and 4 dose reductions. Leukocytopenia accounted for only 1 delay. All 11 patients completed the chemotherapy and 5 patients were fully able to tolerate the protocol without delay or dose reduction. Nine patients remained alive and continuously free of disease at an average follow-up of 35 months. The rate of continuous disease-free survival at 3 years was 81%, which was significantly better than that of the T-12 study of our group. These observations suggest that the NSH-7 protocol is a safe and effective treatment regimen for osteosarcoma.

[A case report of concomitant carotid and coronary artery reconstruction]

We reported a case of a 70-year-old female who underwent simultaneous carotid endarterectomy and coronary artery bypass surgery. Preoperatively, cardiac catheterization demonstrated three vessel coronary artery disease. Her carotid angiogram revealed a 90% stenosis in the left common carotid artery. The cerebral blood flow scintigram on acetazolamide stress detected severely reduced cerebral blood flow on her left anterior and temporal lobe. Her postoperative course was uneventful. Postoperatively, no reduced cerebral blood flow was detected on the acetazolamide stress image. In patients with significant carotid artery stenosis, the cerearal blood flow scintigraphy on acetazolamide stress was a useful method for the simultaneous carotid endarterectomy and coronary artery bypass surgery.

Femoral neck fracture following avascular necrosis of the femoral head

Four cases of femoral neck fracture following avascular necrosis of the femoral head were studied histologically. All four patients were women who had received steroid therapy, three of them for systemic lupus erythematosus and the other for idiopathic thrombocytopenic purpura. Two types of fracture were found according to the site and the mechanism of fracture. One was at the junction between the necrotic bone and the repairing bone, and it can thus be regarded as a stress fracture. The other type of fracture commenced at the superior portion of the junction between the femoral head and neck, which was weak due to the repair reaction. The fracture line extended to the inferior cortex of the femoral neck, as often occurs in the elderly. In one patient, the femoral neck fracture was the first sign of avascular necrosis of the femoral head.

Epicardial sock mapping following monophasic and biphasic shocks of equal voltage with an endocardial lead system

INTRODUCTION

The reason for the increased defibrillation efficacy of biphasic shocks over monophasic shock is not definitely known.

METHODS AND RESULTS

In six anesthetized pigs, we mapped the epicardium after transvenous defibrillation shocks to compare the activation patterns following successful biphasic shocks with unsuccessful monophasic shocks of the same voltage. The heart was exposed and a 510-electrode sock with approximately 4-mm interelectrode spacing was pulled over the entire ventricular epicardium and sutured to the pericardium. Defibrillation catheters were placed in the right ventricular apex and in the superior vena cava. Paired monophasic 12 msec and biphasic 6/6 msec defibrillation shocks were given using an up-down protocol to keep shock strength between the defibrillation thresholds for the two waveforms so that the biphasic shock was successful while the monophasic shock was not. Activation fronts immediately following 60 paired shocks were recorded and analyzed by animated maps of the first derivative of the electrograms. The ventricles were divided into apical (I), middle (II), and basal (III) thirds, and early sites, i.e., the sites from which activation fronts first appeared on the epicardium following the shock, were grouped according to their location. Postshock intervals, i.e., the time from the shock until earliest epicardial activation occurred, were also determined. No ectopic activation fronts followed the shock in 20 biphasic episodes. In the other 40 paired episodes, the number of early sites was smaller after biphasic shocks than after monophasic shocks [monophasic: 198 (total), 3.3 +/- 0.9 (mean +/- SD) per shock episode; biphasic: 67, 1.1 +/- 1.0, P < 0.05]. For biphasic but not monophasic shocks, early sites were less likely to arise from the middle (II) and basal (III) thirds than from the apical third (I) [monophasic: I: 84 (42%), II: 68 (34%), III: 46 (23%); biphasic: I: 49 (73%), II: 10 (15%), III: 8 (12%), P < 0.05]. Postshock intervals were significantly shorter for monophasic shocks (54 +/- 14 msec) than for biphasic shocks (75 +/- 23 msec, P < 0.05).

CONCLUSION

The decreased number of activation fronts and the longer delay following the shock for the earliest epicardial appearance of those activation fronts that do occur may be responsible for the increased defibrillation efficacy for biphasic shocks.

[Single-stage surgery for annulo aortic ectasia, Stanford type-A aortic dissection and pectus excavatum in a patient with Marfan's syndrome]

A 43-year-old female was hospitalized on October 25, 1993, due to severe back pain. She was diagnosed with annulo aortic ectasis, Stanford type-A acute aortic dissection and pectus excavatum caused by Marfan's syndrome. On November 30, 1993, single-stage surgery was performed, including modified Bentall procedure, aortic arch replacement, elephant trunk method and sternoplasty. Concerning the procedure for pectus excavatum, sternoplasty was selected because we thought that sternoplasty could endure the long procedure which would cause infection compared with sternal turnover. Postoperative course was satisfactory, and she is well 18 months after surgery.

Regulation of cytokine production by sugi allergen-pullulan conjugate

Sugi basic protein (SBP), a major allergen of Japanese cedar (Cryptomeria japonica) pollen, conjugated to pullulan (alpha-1,4'-, alpha-1,6'-glucan) reportedly suppresses IgE anti-SBP antibody production and enhances IgG anti-SBP antibody production in mice. We analyzed cytokine production by SBP-specific T cells after stimulation with an SBP-pullulan conjugate (SBP-P), native SBP, or a mixture of SBP and pullulan. When SBP-specific T cell lines were stimulated with the SBP-P conjugate in the presence of antigen-presenting cells (APC), the production of IFN-gamma, IL-4, IL-5, and IL-10 decreased compared with the cytokine levels produced by SBP-stimulated T cells. However, when these T cells were repeatedly stimulated with the SBP-P conjugate, the production of IFN-gamma increased progressively, while that of IL-4, IL-5, and IL-10 remained decreased compared with the T cells that were repeatedly stimulated with native SBP. Stimulation of the T cells with the mixture of SBP and pullulan showed little difference in the cytokine production profile from that observed after stimulation with native SBP alone. Interestingly, when the T cell lines stimulated repeatedly with SBP-P were subsequently stimulated with native SBP, a further increase in IFN-gamma production was observed, while IL-10 production decreased. Inhibition of IL-4 production was also observed when SBP-specific Th2 clones were stimulated with SBP-P. These results indicate that stimulation of T cells with SBP-P up-regulates Th1 cytokine production, while down-regulating that of Th2. It is, therefore, conceivable that immunotherapeutic treatment with the SBP-P conjugate rather than with conventional SBP solutions is preferable for improving Japanese cedar pollen allergy.

[Coronary artery bypass grafting for ischemic heart disease associated with acromegaly: a case report]

Coronary artery bypass grafting (CABG) for ischemic heart disease associated with acromegaly has never been reported in Japan, though coronary artery sclerosis is known as complicating factor in acromegaly. A 44-year-old man with ischemic heart disease was admitted to our hospital and emergency percutaneous transluminal coronary recanalization was performed. After admission, he was diagnosed as acromegaly from endocrinological studies and operated on CABG. The peri- and post-operative course was uneventful in spite of our fear for complications due to acromegalic heart muscle disease.

Vasospastic angina in patients with systemic triglyceride storage disease with Jordans' anomaly and cardiomyopathy

Vasospastic angina was demonstrated clinically and angiographically in a 54-year-old patient with systemic triglyceride storage disease and cardiomyopathy. He and his younger sister had been diagnosed in 1985 as having systemic triglyceride storage with Jordans' anomaly. In 1993, he began complaining of rest and effort chest pain in the morning, which was accompanied by ST depression by ECG. Sublingual nitroglycerine was effective for treating this pain. Intracoronary injection of acetylcholine induced severe coronary vasoconstriction in the left anterior descending artery. Left ventricular contraction was diffusely impaired. Deposits of numerous triglyceride droplets and a decrease in the density of myofibrils in cardiocytes were found in the specimens obtained by endomyocardial biopsy. The impaired left ventricular contraction may have been due to the changes in myocardial cells. His sister complained of a similar chest pain that was completely controlled by calcium channel antagonis. Thus, our cases demonstrated vasospastic angina associated with cardiomyopathy secondary to systemic triglyceride storage disease with Jordans' anomaly, though the causal relationship between these conditions remains unclear.

[Systemic vascular change associated with moyamoya-like cerebrovascular disease and microvascular coronary artery disease]

A 34-year-old man with hypertension and diabetes mellitus developed dizziness and visited our institute. He had history of headache with numbness of the right hand since age 15 years and left occipital lobe infarction at age 28 years. The cerebral angiogram showed several changes peculiar to advanced stage of moyamoya disease (spontaneous occlusion of the circle of Willis), i.e. segmental stenoses or occlusions of bilateral internal carotid arteries, left vertebral artery and left posterior cerebral artery with abnormal vascular networks at the bilateral basal ganglia. He was also diagnosed to have asymptomatic ischemic heart disease. The coronary angiogram showed diffuse sclerotic lesions of left anterior descending and right coronary arteries without significant stenosis, which suggested the presence of microvascular lesion as a cause of myocardial ischemia. Coronary disease has been rarely reported as a complication of moyamoya disease, and microvascular coronary artery disease has never been described. Moyamoya disease should be regarded as a part of systemic vascular disorders, and the evaluation of extracerebral cardiovascular system is necessary to clarify pathophysiology of this disease.

Some problems in wrist reconstruction after tumor resection with vascularized fibular-head graft

Restoration of wrist function was attempted in six patients with aggressive or malignant bone tumor of the distal end of the radius with free vascularized fibular graft including the fibular head, and following wide resection of tumor. There was no local recurrence in all six cases. In one case, pulmonary metastasis occurred, but was successfully treated. Secondary bone graft was necessary in two cases for non-union. Additional procedures, such as partial or total wrist fusion, were necessary in three cases due to collapse of the grafted fibular head. Corrective osteotomy or a Sauve-Kapandji procedure were also needed in two cases for improvement of forearm rotation. Grip strength ranged from 41 to 68 percent of the contralateral side, with an average of 54.6 percent in five cases; it was only 6 percent in one patient because of flexion contracture at the wrist joint. Final functional results, evaluated by a modified system of Enneking, ranged from 73 to 92 percent, with an average of 83.2 percent. Indications for this procedure seem to be limited to patients engaged in non-heavy manual work, in whom the proximal carpal row can be preserved during tumor resection, and who have given consent for additional secondary procedures, if they prove necessary.

[Cytomegalovirus retinitis and Pneumocystis carinii choroidopathy in a patient with AIDS]

A case of Pneumocystis carinii (P. carinii) choroidopathy is reported. The patient was a 17-year-old man with acquired immunodeficiency syndrome (AIDS) who developed bilateral, multifocal, yellow-white, round, flat choroidal lesions ranging in size from 1/8 to 1/6 of the disc diameter while undergoing treatment for cytomegalovirus retinitis. He had had P. carinii pneumonia 43 months previously, and received inhaled pentamidine as suppressive therapy. Over a 4-week period of observation, the choroidal lesions appeared to enlarge slowly and increased in number in the posterior pole, with no clinical evidence of intraocular inflammation and retinal involvement. He was diagnosed as having P. carinii choroidopathy and treated with intravenous pentamidine. Three months after systemic pentamidine therapy was begun the choroidal lesions disappeared. Despite the fact that P. carinii choroidopathy is a rare opportunistic ocular infection, ophthalmic manifestations may be an important initial marker of extrapulmonary disseminated infection in some patients. Therefore we recommend ophthalmologic examinations in patients with AIDS who receive long-term aerosolized pentamidine prophylaxis for pneumonia.

Effects of polarity for monophasic and biphasic shocks on defibrillation efficacy with an endocardial system

Electrode polarity has been reported to be one of the factors that affect defibrillation efficacy. We studied the influence of polarity on defibrillation efficacy when monophasic and biphasic waveforms were used with an endocardial lead system. In six anesthetized pigs, defibrillation catheters were placed in the right ventricular (RV) apex and at the junction of the superior vena cava (SVC) and right atrium. Monophasic shocks were 6 ms in duration, while for biphasic shocks the first phase was 6 ms and the second was 4 ms in duration. Four electrode configurations were tested: R:S, M (the RV electrode, cathode; the SVC electrode, anode, with a monophasic shock); S:R: S, B(the RV electrode, first phase cathode; the SVC electrode, first phase anode, with a biphasic shock); S:R, B. Defibrillation probability of success curves were determined using an up/down protocol requiring 15 shocks for each configuration. For monophasic shocks, total delivered energy at the 50% probability of success point was significantly lower when the RV electrode was an anode than when it was a cathode (R: S, M: 24.4 +/- 7.4 J [mean +/- SD] vs S:R, M: 16.4 +/- 5.5 J; P < 0.05). For biphasic shocks, total energy was not affected by polarity reversal of the electrodes (R:S, B: 8.7 +/- 1.4 J vs S:R, B: 8.4 +/- 2.5 J; P = NS). The endocardial electrode configuration with the RV electrode as an anode requires less energy for defibrillation with a monophasic but not a biphasic waveform.