Detection of diaphragmatic defect as the cause of severe hepatic hydrothorax with magnetic resonance imaging

Severe right-sided hepatic hydrothorax occurred in an 83-yr-old Japanese woman with a 7-yr history of cryptogenic liver cirrhosis. Transdiaphragmatic communication was indirectly suggested by rapid migration of dye (indocyanine green) from the peritoneal to the pleural space. Magnetic resonance imaging studies also demonstrated a diaphragmatic defect as a characteristic hypointense jet flow across the diaphragm on both T1- and T2-weighted sagittal scans. Although no firm treatment for hepatic hydrothorax has been established and direct demonstration of diaphragmatic defect with noninvasive imaging is extremely rare, testing for diaphragmatic integrity is meaningful to provide a radical or less invasive treatment. Magnetic resonance imaging, as well as color Doppler ultrasonography, may be useful for the detection of diaphragmatic defects as the cause of hepatic hydrothorax.

Usefulness of extracorporeal membrane oxygenation for treatment of fulminant myocarditis and circulatory collapse

Prognosis for fulminant myocarditis with cardiogenic shock refractory to conventional therapy is poor. This report describes mechanical circulatory support with extracorporeal membrane oxygenation as an effective alternative for treating fulminant myocarditis with circulatory collapse.

Prognosis of patients with resection of stage IV gastric cancer

We retrospectively analyzed 116 patients who underwent resection of stage IV gastric cancer to investigate the prognostic factors responsible for long-term survival. Statistically significant clinicopathological differences between patients surviving 3 years or more (n = 9) and those surviving less than 3 years (n = 107) were observed in regard to macroscopic type, curability of surgery, lymph node metastasis and blood vessel invasion. These four variables also had a statistically significant influence on survival by univariate analysis. Multivariate analysis revealed that no residual tumor (R0) surgery was a significantly beneficial factor for long-term survival. However, no patients with the diffusely infiltrative type of tumor survived for more than 2 years even if they underwent R0 surgery. Patients without the diffusely infiltrative type who underwent R0 surgery had better survival rates: a 27.3% and 13.6%, 3 and 5 year survival rate, respectively. In conclusion, R0 surgery contributes to long-term survival even in stage IV gastric cancer, and some patients with the not diffusely infiltrative type, in particular, may receive a survival benefit by R0 surgery.

Resection of both hepatic and pulmonary metastases in patients with colorectal carcinoma

BACKGROUND

More than 40% of patients who undergo curative resection of advanced colorectal carcinoma can be expected to have recurrence of the disease. The most frequent sites of recurrence are the liver (33% of patients) and lung (22%). Interest has therefore focused on treating hepatic or pulmonary metastases, or both, to improve the outcomes of these patients. Although surgical resection has become an increasingly accepted treatment for resectable localized hepatic or localized pulmonary metastases from colorectal carcinoma, the value of aggressive surgery for the removal of both hepatic and pulmonary metastases from patients with primary colorectal carcinoma remains to be clarified.

METHODS

Data on 30 patients who had undergone resection of both hepatic and pulmonary metastases from colorectal carcinoma were included in the study.

RESULTS

Independent, significant prognostic features were found to be the time that hepatic or pulmonary metastases occurred and the distribution of pulmonary metastases. Median survival times were 30 months (range, 7-108 months) after resection of both hepatic and pulmonary metastases and 48.5 months (range, 11-149 months) after excision of the primary colorectal tumor. Actuarial 1-, 3-, and 5-year survival after resection of both hepatic and pulmonary metastases was 86.7%, 49.3%, and 43.8%, respectively. No perioperative mortality occurred. There were three cases of minor morbidity, which the authors considered acceptable.

CONCLUSIONS

Resection of both hepatic and pulmonary metastases from colorectal carcinoma may help to prolong the survival of a small group of patients with these metastases.

Resection of both hepatic and pulmonary metastases in patients with colorectal carcinoma

BACKGROUND

More than 40% of patients who undergo curative resection of advanced colorectal carcinoma can be expected to have recurrence of the disease. The most frequent sites of recurrence are the liver (33% of patients) and lung (22%). Interest has therefore focused on treating hepatic or pulmonary metastases, or both, to improve the outcomes of these patients. Although surgical resection has become an increasingly accepted treatment for resectable localized hepatic or localized pulmonary metastases from colorectal carcinoma, the value of aggressive surgery for the removal of both hepatic and pulmonary metastases from patients with primary colorectal carcinoma remains to be clarified.

METHODS

Data on 30 patients who had undergone resection of both hepatic and pulmonary metastases from colorectal carcinoma were included in the study.

RESULTS

Independent, significant prognostic features were found to be the time that hepatic or pulmonary metastases occurred and the distribution of pulmonary metastases. Median survival times were 30 months (range, 7-108 months) after resection of both hepatic and pulmonary metastases and 48.5 months (range, 11-149 months) after excision of the primary colorectal tumor. Actuarial 1-, 3-, and 5-year survival after resection of both hepatic and pulmonary metastases was 86.7%, 49.3%, and 43.8%, respectively. No perioperative mortality occurred. There were three cases of minor morbidity, which the authors considered acceptable.

CONCLUSIONS

Resection of both hepatic and pulmonary metastases from colorectal carcinoma may help to prolong the survival of a small group of patients with these metastases.

Conflict among individual mitochondrial proteins in resolving the phylogeny of eutherian orders

The phylogenetic relationship among primates, ferungulates (artiodactyls + cetaceans + perissodactyls + carnivores), and rodents was examined using proteins encoded by the H strand of mtDNA, with marsupials and monotremes as the outgroup. Trees estimated from individual proteins were compared in detail with the tree estimated from all 12 proteins (either concatenated or summing up log-likelihood scores for each gene). Although the overall evidence strongly suggests ((primates, ferungulates), rodents), the ND1 data clearly support another tree, ((primates, rodents), ferungulates). To clarify whether this contradiction is due to (1) a stochastic (sampling) error; (2) minor model-based errors (e.g., ignoring site rate variability), or (3) convergent and parallel evolution (specifically between either primates and rodents or ferungulates and the outgroup), the ND1 genes from many additional species of primates, rodents, other eutherian orders, and the outgroup (marsupials + monotremes) were sequenced. The phylogenetic analyses were extensive and aimed to eliminate the following artifacts as possible causes of the aberrant result: base composition biases, unequal site substitution rates, or the cumulative effects of both. Neither more sophisticated evolutionary analyses nor the addition of species changed the previous conclusion. That is, the statistical support for grouping rodents and primates to the exclusion of all other taxa fluctuates upward or downward in quite a tight range centered near 95% confidence. These results and a site-by-site examination of the sequences clearly suggest that convergent or parallel evolution has occurred in ND1 between primates and rodents and/or between ferungulates and the outgroup. While the primate/rodent grouping is strange, ND1 also throws some interesting light on the relationships of some eutherian orders, marsupials, and montremes. In these parts of the tree, ND1 shows no apparent tendency for unexplained convergences.

[Concomitant cardiac and pulmonary operation, the profits of not using cardio-pulmonary bypass]

We performed off pump CABG (coronary artery bypass grafting) and right upper lobectomy with R2a lymph nodes dissection on the patient suffered from both lung cancer in the right S1 and stenotic lesion in the left anterior descending artery. Because the coronary lesion was long-segmented one, it was not suitable for percutaneous transluminal coronary angioplasty. To perform absolutely curative operation for the lung cancer, CABG was undergone simultaneously under off pump condition. It is generally feared that the cardiovascular surgery under CPB may have adverse effect for the patient with malignant lesion. Off pump CABG is expected to avoid such disadvantage of CPB, and thought to be suitable method for such a patient as we present above.

Vascular endothelial growth factor in angiosarcoma

Angiosarcoma(AS) is a malignant tumour of the endothelium of lymphatic or blood vessels. Vascular endothelial growth factor (VEGF), a specific mitogen of endothelial cells, is considered essential for the growth of many tumours including AS. We have recently treated several patients with AS; in two of them, using a newly developed enzyme-linked immunosorbent assay (ELISA) for VEGF, we sequentially measured serum VEGF concentrations. While serial serum VEGF levels reflected tumour burden, the various VEGF concentrations were within the normal range we reported previously. Furthermore, the VEGF concentrations were not remarkably elevated in AS tumour tissue compared with benign vascular lesions and hypervascular tumours.

Pharmacological profile of T-0201, a highly potent and orally active endothelin receptor antagonist

The authors studied the pharmacological properties of N-(6-(2-(5-bromopyrimidin-4-yl)-4-(2-hydroxy-1, 1-dimethylethyl)benzensulfonamide sodium salt sesquihydrate (T-0201), a new nonpeptide endothelin (ET) receptor antagonist, in vitro and in vivo. In binding studies, T-0201 competitively antagonized the specific binding of [125I]-ET-1 to human cloned ETA receptors (the Ki value was 0.015 +/- 0.004 nM). T-0201 weakly inhibited [125I]-ET-1-binding to human cloned ETB receptors; the Ki value was 41 +/- 21 nM. T-0201 shifted the concentration-response curve of ET-1-induced contraction of the isolated rat aorta (ETA receptors) to the right (pA2 = 9.0 +/- 0.2). In the isolated rat trachea, a selective ETB agonist sarafotoxin S6c-induced contraction was inhibited by T-0201 (pA2 = 6.8 +/- 0.3). T-0201 also caused the inhibition of ET-1-induced contraction of the isolated rabbit pulmonary artery (pA2 = 5.7 +/- 0.3). In anesthetized rats, T-0201 (0.01-1 mg/kg) inhibited the pressor response to exogenous big ET-1 (1 nmol/kg i.v.), after both i.v. and p.o. administration, in a dose-dependent manner. The significant inhibitory effect of orally administered T-0201 on big ET-1-induced pressor response lasted for 4 hr at 0.1 mg/kg and for 8 hr at 1 mg/kg. Thus the present study demonstrates that T-0201 is a highly potent, long-lasting, orally active and selective ETA receptor antagonist.

[Postoperative follow-up of acute aortic dissection and the result of second operations]

Between January 1990 and March 1998, surgical treatment was performed in 75 patients with acute aortic dissection at Omiya Medical Center. Seventy-three patients (97%) of them were classified type A aortic dissection. Thirteen of them died due to hemorrhage (5 cases), cardiac failure (3 cases), visceral ischemia (3 cases) and others (2 cases) after the operation. Hospital mortality rate was 17.3%. Sixty-two survivors were followed up to 8 years. During the follow up period, five patients died due to pneumonia, gastric cancer, cardiac failure, brain hemorrhage and unknown event. Five-year survival rate including hospital death was 77% evaluated by Kaplan-Meier method. Second operations for the enlargement of residual false lumen with the entry were performed in 4 patients (6.5%) of 62 survivors. Second operations were also performed in other 6 patients referred to us from other hospitals because of the enlargement of false lumen. Nine of them survived (90%) and returned to their daily life.

Cloning of hamster preproendothelin-1 cDNA and its expression in the heart

To elucidate the pathophysiologic roles of endothelin-1 (ET-1) in the heart, we first cloned and sequenced a part of hamster preproET-1 cDNA from the heart of the CHF146 hamsters. The amino acid sequence has 89% homology to that of rat preproET-1 in the cloned part. The deduced hamster 21-residue mature ET-1 is identical to human, rat, canine, and mouse ET-1. In the next step we investigated the expression of preproET-1 mRNA in the failing heart of CHF146 hamsters. For this purpose, we used 46-week-old CHF146 hamsters and age-matched control healthy hamsters. Left ventricular (LV) + dP/dtmax was significantly lower in CHF146 hamsters than in control hamsters. LV end-diastolic pressure was significantly higher in CHF146 hamsters than in control hamsters, as was central venous pressure. These results suggested that the CHF146 hamsters developed congestive heart failure. The expression of preproET-1 mRNA was greatly enhanced in the LV of the CHF146 hamsters. Because it has been reported that ET-1 induces cardiac hypertrophy and injury to cardiac myocytes in addition to its potent positive inotropic and chronotropic actions, the present findings suggest that endogenous ET-1 plays pathophysiologic roles in the failing heart of CHF146 hamsters.

A combination of preductal aortic coarctation and type B dissection: report of a case

We present herein the case of a 39-year-old man found to have significant coarctation of the preductal aorta combined with a type B dissection, associated with Marfan's syndrome. This extremely rare pathological combination could be defined preoperatively only by a three-dimensional computed tomography scan. By means of selective cerebral perfusion, the coarctation was resected, and the total aortic arch was replaced with a Dacron graft.

Alpha1-adrenoceptor subtypes and two receptor systems in vascular tissues

The subtypes of alpha1-adrenoceptor are coexpressed in many tissues. We examined the relationship between coexpressed alpha1-adrenoceptor subtypes and their functions in blood vessels. Rat and rabbit aortas coexpressed three subtypes (alpha1A, alpha1B, alpha1D) and four subtypes (alpha1A, alpha1B, alpha1D, alpha1L), respectively. In rat aorta however, noradrenaline-induced contraction was mediated predominantly through the alpha1D subtype, and oxymetazoline produced alpha1B-mediated contraction. In rabbit aorta, concentration-response curves for noradrenaline were composed of two components (alpha1B and alpha1L-mediated), while oxymetazoline produced alpha1L-mediated contraction. Therefore, the inhibitory actions of some antagonists varied markedly among tissues and agonists. These results demonstrate diversity of the two receptor systems and suggest that the heterogeneity of physiological responses reflects the differences in functional subtypes among tissues and in their sensitivities to agonists and antagonists.

Pharmacologic profile of TA-606, a novel angiotensin II-receptor antagonist in the rat

This study was carried out to characterize a novel angiotensin II-receptor antagonist, TA-606, (3-pentyloxy) carbonyloxymethyl-5-acetyl-2-n-propyl-3-[2'(1H-tetrazole-5-yl) biphenyl-4-yl]methyl-4,5,6,7-tetrahydro imidazo [4,5-c] pyridine-4-carboxylate hydrochloride, which is a newly synthesized prodrug of 606A. In anesthetized rats, 606A inhibited angiotensin II-induced pressor response with a median inhibitory concentration (IC50) of 6 microg/kg, i.v., and was 8 times more potent than EXP3174, an active metabolite of losartan. Bioavailability of TA-606 was 11 times higher than that of 606A in Sprague-Dawley rats, with consistent hypotensive potencies in spontaneously hypertensive rats (SHRs). In conscious renal hypertensive rats (RHRs) and conscious SHRs, TA-606 lowered the blood pressure without any effects on the heart rate, and its effective dose for 30 mm Hg (ED30) values were 0.14 and 0.21 mg/kg, p.o., respectively. The effect of TA-606 lasted > 10 h in both models. Moreover, the effect of TA-606 was approximately 30 and 10 times more potent than those of losartan in RHRs and SHRs, respectively. TA-606 did not affect the blood pressure in deoxycorticosterone acetate (DOCA)-salt hypertensive rats. TA-606 given for 12 weeks attenuated the development of hypertension in stroke-prone SHRs. These results indicate that TA-606 is a potent angiotensin II-receptor antagonist with antihypertensive efficacy. Thus TA-606 is suggested to be a possible useful agent in the treatment of hypertension.

Antithrombotic action of TA-993, a new 1,5-benzothiazepine derivative, in a canine model of femoral arterial thrombosis

TA-993 is a novel 1,5-benzothiazepine derivative of l-cis configuration, having a potent antiplatelet action and an increasing action on femoral blood flow. We evaluated the antithrombotic effect of TA-993 in a canine model of femoral arterial thrombosis. Thrombus was induced by both application of direct anodal current to the femoral artery and partial occlusion of the artery. The partial occlusion by placing an adjustable occluder on the artery and the current application were carried out 40 and 60 min after the intraduodenal administration of drugs, respectively. In control dogs, complete sustained occlusion of the femoral artery due to thrombus occurred 55.4 +/- 9.2 min after the onset of current application. TA-993 (3 and 10 mg/kg) dose-dependently prolonged the time for occlusion. Aspirin (30 mg/kg) also prolonged it. TA-993, 10 mg/kg, significantly inhibited whole-blood aggregation 60 min after the administration with a weaker potency than that of aspirin (30 mg/kg), whereas 3 mg/kg of TA-993 did not. The inhibitory effect of TA-993 (10 mg/kg) on platelet aggregation was maintained for >7 h. Moreover, TA-993 (10 mg/kg) increased femoral blood flow in spite of the partially occluded condition. These results indicate that TA-993 has an antithrombotic effect on femoral arterial thrombosis and suggest that an increasing action on femoral blood flow of TA-993 is more relevant than its antiplatelet action to the antithrombotic effect in this model.

[Detection of apolipoproteins E5 and E7 by a widely used commercial ApoE IFE kit--evidence provided by genotyping]

The purpose of this study is to examine a possibility to detect apolipoprotein (apo) E5 and E7 isoproteins with a commercial kit widely used (Phenotyping Apo E IFE System, Jokoh Co. LTD., Tokyo) and to clarify the frequency of the rare alleles in Central Japan. A total of 1,445 subjects living in Central Japan (1,030 hemodialysis patients and 415 apparently healthy individuals) was phenotyped for apo E isoproteins with the kit using isoelectric focusing with immunoblotting. In 23 subjects, unique apo E4 isoproteins, which migrate more basically than apo E4 isoprotein, were found. These unique isoproteins were proved to be apo E5 or E7 isoproteins by PCR with restriction fragment length polymorphism and with amplification refractory mutation systems, respectively. No significant differences in the frequencies of apo E5 or apo E7 alleles were observed between healthy individuals and hemodialysis patients (0.011 vs. 0.018, NS). The frequencies of apo E5 and E7 alleles were 0.001 and 0.005, respectively, in healthy individuals, and 0.003 and 0.005, respectively, in hemodialysis patients. These data in Central Japan were consistent with those in Western Japan (Matsunaga, et al, Clin Genet, 1995). These results indicate that the commercial kit is applicable to detect the rare alleles, apo E5 and E7 alleles and that the frequencies of the rare alleles in Central Japan are similar to those in Western Japan.

[Two surgical cases of right parasternal minimal incision for aortic valve replacement]

Although median sternotomy has been used as a good approach to all cardiac valves and coronary arteries, advantages of the minimal invasive cardiac operation have been reported recently. We employed the right parasternal minial incision, reported by Cosgrove et al. for two cases of aortic valve replacement. In the first case, we were able to get a good operation field and easily implanted a mechanical prosthesis. In contrast, we had some difficulties with the second case where in addition to the third and fourth cartilages, a second cartilage resection was necessary because the aortic root lay at a cephalic level. Moreover, the operation field was restricted because we left several rib cartilages to preserve the right internal thoracic artery. The cannula had to be inserted via the right atrium as we failed to insert it in the right femoral vein, and the aortic root deviated more medially than usual. From these experiences, it is important to check the position of aortic root, and if the cannula cannot be inserted in the femoral vein, cannulation via the right atrium can ve utilized in the minimal invasive cardiac operation.

Cardiovascular effect of a new 1,5-benzothiazepine derivative TA-993 in anesthetized dogs

TA-993 is a new 1,5-benzothiazepine derivative having l-cis configuration and shows a potent antiplatelet aggregating action. We studied its cardiovascular effect in anesthetized dogs by using diltiazem as a reference compound. TA-993 (> or = 10 microg/kg, i.v.) significantly increased blood flows of common carotid, brachial, and femoral arteries. The peak of its effect was observed approximately 60 min after the administration, and the peak level was maintained until > or = 300 min after the administration. TA-993 (100 microg/kg, i.v.) slightly increased cardiac output in the same manner. However, TA-993 did not cause any persistent effects on arterial pressure, LVdP/dtmax, or vertebral, coronary, superior mesenteric, and renal blood flows. TA-993 caused concentration-dependent vasorelaxation in the isolated canine femoral artery contracted with 40 mM K+, but its potency was approximately 1/20 that of diltiazem. The increasing action of TA-993 on femoral blood flow was completely inhibited by pretreatment with hexamethonium in anesthetized dogs. These results indicate that TA-993 has a selective increasing action on common carotid, brachial, and femoral blood flows and suggest that the action is mediated by the autonomic nervous system.

[Intraoperative assessment of the ascending aorta by echogram during the CABG operation for the prevention of cerebral infarction]

While coronary artery bypass grafting operations (CABG), we started to use the echogram to evaluate the ascending aorta intraoperatively from December 1993. During a period from January, 1990, to June, 1995, 379 patients were treated with CABG. Intraoperative echogram was used in 127 cases (group I) and 252 cases unused (group II). The sites of the aorta for evaluation were following: site of cannulation, aortic clamping, and proximal anastomosis respectively. Depending on the echographical findings the operative procedures were changed as required. The incidence of postoperative cerebral embolism in group I was 0.8% (one patient) and in group II, 2.4% (6 patients). Although no significant difference was found in the cohort, rate of incidence in the group II was high. There were 4 cases who had significant atheromatous lesions clearly evaluated by echogram, which were not detected by palpation. We conclude that the intraoperative assessment of the ascending aorta by echogram is beneficial in prevention of cerebral infarction.

Left ventricular volume predicts postoperative course in patients with ischemic cardiomyopathy

BACKGROUND

The left ventricular end-systolic volume index (LVESVI) helps to predict postoperative left ventricular function in patients with ischemic cardiomyopathy.

METHODS

We retrospectively assessed the ability of preoperative variables to predict death and the development of postoperative congestive heart failure in 41 patients with a preoperative ejection fraction of less than 0.30.

RESULTS

A preoperative LVESVI of greater than 100 mL/m2 was identified as an independent predictor of death by Cox's proportional hazards model. Diabetes and a preoperative LVESVI of greater than 100 mL/m2 were independent predictive risk factors for the development of postoperative congestive heart failure. Postoperative congestive heart failure developed in 2 of the 23 patients (8.7%) who had a preoperative LVESVI of less than 100 mL/m2 and in 10 of the 16 patients (62.5%) who had a preoperative LVESVI of greater than 100 mL/m2. The actuarial survival rate during follow-up in patients who had a preoperative LVESVI of less than 100 mL/m2 was significantly greater than that in patients who had a preoperative LVESVI of greater than 100 mL/m2. The actuarial rate of freedom from congestive heart failure during the follow-up period also was greater in patients who had a preoperative LVESVI of less than 100 mL/m2.

CONCLUSIONS

Our results suggest that the preoperative LVESVI predicts the development of postoperative congestive heart failure and the actuarial survival rate in patients with ischemic cardiomyopathy.

Cystic dilatation of ventriculus terminalis in adults: MRI

We report the MRI findings in two patients with cystic dilatation of the ventriculus terminalis. The latter is usually a tiny ependyma-lined cavity of the conus medullaris. In both cases the markedly dilated ventriculus terminalis was seen as a rounded cavity with regular margins, the content of which gave the same signal as cerebrospinal fluid with all MR pulse sequences. No contrast enhancement was seen.

[HLA antigens are associated in seronegativity to cytomegalovirus(CMV)]

Cytomegalovirus(CMV) is ubiquitous in the world, but the rate of CMV antibody positivity (seropositivity) in adults varies geographically. In Japan, CMV seropositivity in adults in 90% and we perceived seronegative adults tend to remain seronegative in 10 years follow up study. We have performed HLA typing 125 seronegative healthy donors of 28 years and up (28-57, Ave.35), and the results were compared with those of healthy donors in same area and whole Japan (data from 10th HLA workshop). Incidence of HLA-A33 and HLA-Cw4 were significantly higher in seronegatives than control groups. This report suggests possible involvement of HLA type in CMV negativity.

Malignant schwannoma-derived cells support human skin mast cell survival in vitro

We have recently observed mast cell infiltration in malignant schwannoma (MS) arising in the patient with von Recklinghausen's disease. To determine the cell to cell interactions between human skin mast cell (HSMC) and MS cell, we investigated the HSMC survival and the morphological changes when cultured with MS-derived cells isolated from the patient. Partially purified HSMCs obtained from normal adult skin and cutaneous neurofibroma by enzymatic digestion were cocultured with MS-derived cells on the coverslips. The number of HSMCs stained with crystal violet were directly counted by light microscope. HSMCs cocultured with MS-derived cell feeder layer revealed significantly increased HSMC survival compared to that with normal human skin fibroblast layer at 1 and 2 weeks. Conditioned medium of cultured MS-derived cell did not influence HSMC survival. In the morphology HSMCs cultured with MS-derived cells demonstrated spindle form in close contact with the adjacent MS-derived cells, suggesting cell to cell interactions. We failed to detect stem cell factor (SCF) mRNA in cultured MS-derived cell by RT-PCR. These results suggest that MS-derived cell is capable of supporting HSMC survival in vitro. Some factor(s) other than SCF, which is associated with direct contact between HSMCs and MS-derived cells, might relate to these observations.