[Mitral valve aneurysm in a patient with mitral regurgitation: a case report]

A 66-year-old man admitted to our hospital complaining of severe dyspnea. Echocardiography demonstrated severe mitral regurgitation and an abnormal echo at the anterior leaflet of the mitral valve. It was a persistent bulge that protruded toward the left atrium throughout systole and diastole. Left ventriculography also demonstrated the same abnormal shadow of the mitral valve. At the operation, it was seen that two of the chordae tendineae of the anterior leaflet had ruptured and a small aneurysm, approximately 10 mm in length, originated from the lateral part of the leaflet. The aneurysm protruded into the left atrium and had neither rupture nor perforation. Because the aneurysm of the mitral valve was too large to resect and repair the valve, it was replaced with St. Jude Medical Valve (29 M). IABP was needed at the weaning from cardiopulmonary bypass, but he recovered gradually well afterwards. The excised anterior leaflet showed myxomatous degeneration, but had no vegetation and rheumatic change. Microscopic examination of the valve aslo revealed myxomatous degeneration and no signs of the inflammation.

Long-term results of primary closure for ventricular septal defects in the first year of life

The long-term results of primary closure for large ventricular septal defects (VSDs) in infants under 1 year of age with severe symptoms were studied over a period of more than 10 years. Between January, 1971 and March, 1982, 49 infants underwent primary closure of a VSD through a right ventriculotomy using complete cardiopulmonary bypass with mild hypothermia. There were four hospital deaths but no late deaths. Two of four infants with residual shunts had a left ventricular-right atrial shunt which necessitated reoperation. Surgical heart block occurred in two infants who recovered sinus rhythm in the late period. The cardiothoracic ratio decreased from 60.5% preoperatively to 50.6% in the late postoperative period. Examination by cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio (Pp/Ps) of 23 patients with a Pp/Ps of over 0.75 fell from 0.89 +/- 0.09 preoperatively to 0.42 +/- 0.12 by 1 month postoperatively, then to 0.27 +/- 0.05 in the late postoperative period. The latest values for the cardiac index and left ventricular ejection fraction were 3.4 l/min per m2 and 64.4%, respectively. More than 10 years after their operation, all the survivors were growing normally and maintaining a good quality of life, which supports our recommendation that primary repair should be performed in the first year of life for infants with large VSDs.

[Postlaminectomy kyphosis of the cervical spine complicating spinal cord tumor in the foramen magnum]

Postlaminectomy kyphosis is rarely encountered as a sequela of decompression of the upper cervical spine, especially in adults. We present a case of disabling cervical kyphosis which developed after laminectomy for excision of a foramen magnum tumor and was treated successfully by occipito-vertebral fusion. A sixty-one-year old female was treated by laminectomy of the first through to the third cervical spine for a foramen magnum meningioma. One year later, the laminectomy was extended downward to include the fourth through to the seventh cervical spine because of neurological deterioration. Seven years after the first laminectomy, she was referred to our spinal service because of severe neck pain, numbness and muscle weakness of both upper extremities. Lateral X-ray of her cervical spine presented a severe kyphosis. Roentgenogram two months after the first laminectomy already showed slight deformity and, timewise, it corresponded with the time when the patient experienced neurological deterioration. Subsequent X-rays showed progression of kyphosis. After we confirmed a lessening of the pain and improvement of the neurological symptoms during an axial traction using a halo-vest, posterior occipito-cervico-thoracic fusion was performed using Luque segmental spinal instrumentation and autogenous bone graft. After surgery the pain decreased and neurological symptoms improved. It is important to be aware of the complication of kyphotic deformity after laminectomy and once it has developed, it is recommended to stabilize the progression by early spinal fusion.

[Conduction disturbances after coronary artery bypass grafting with retrograde cardioplegia]

We studied forty-six cases, who had undergone coronary artery bypass grafting with retrograde cold blood cardioplegia for myocardial protection, to manifest the frequency and causative factors of postoperative conduction disturbances. We obtained the following conclusions. 1) Postoperative conduction disturbances developed in nineteen cases (41.3%), all of which were right bundle branch blocks, but these were usually transient and were not associated with further complications in the follow-up period. 2) There were no significant differences in many factors, including number of grafts, aortic cross-clamp times, or peak CK-MB between cases with and without postoperative conduction disturbances.

Role of vagal afferents in hypotension induced by venous air embolism

To evaluate the role of the autonomic nervous system in the development of hypotension during air embolism, we studied the effects of an intravenous bolus injection of air (0.5 ml/kg) on mean blood pressure (MBP), central venous pressure (CVP), and renal nerve activity (RNA) in urethan-anesthetized rabbits of three groups: animals with an intact neuraxis (intact group; n = 5), cervical-vagotomized animals (vagotomy group; n = 5), and sinoaortic-denervated animals (SAD group; n = 5). In the intact group, despite a significant decrease in MBP at 10 s after air injection, RNA did not increase from the preinjection level. This response of RNA was associated with a significant increase in CVP and lasted for 20 s after the injection. Vagotomized animals, however, exhibited a significant augmentation in RNA in response to a drop in MBP at 10 s after the injection. In the SAD group, profound declines in both MBP and RNA were observed at 10 s after the injection of air. Animals in these two groups showed remarkable increases in CVP. At 5 min after the air administration, MBP in the vagotomy group was significantly higher than that in the intact group. All animals in the SAD group died within 5 min of the injection. These results indicate that during hypotension induced by air injection, sympathetic activation through arterial baroreceptors may be depressed by vagal afferents emanating from cardiopulmonary receptors; the results also suggest that the arterial baroreceptor nerves may be required to overcome the lethal events that should occur during venous air embolism.

[Total aortic replacement in a patient with extensive thoracoabdominal aortic aneurysm--a case report]

A 35-year-old woman with a form fruste of Marfan's syndrome, presented the extensive thoracoabdominal aortic aneurysm. CT scan, MRI and aortogram revealed that she had a true aneurysm of ascending aorta and aortic arch and chronic DeBakey IIIb dissecting aneurysm extending throughout the descending thoracic and abdominal aorta. The surgical treatment was consisting of two staged operations. At the first operation, ascending aorta and aortic arch were reconstructed under cardiopulmonary bypass and selective cerebral perfusion. Elephant trunk method was employed for the second operation. The second operation was performed by graft replacement of the entire descending thoracic and abdominal aorta with reattachment of intercostal and visceral arteries. She discharged the hospital without any complication including paraplegia.

Parathyroid hormone-related protein during pregnancy and the perinatal period

To evaluate whether parathyroid hormone-related protein (PTHrP) plays any role in calcium metabolism during pregnancy and the perinatal period, we measured parathyroid hormone (PTH), immunoreactive PTHrP and calcium in maternal serum of women during pregnancy and puerperium, and in maternal and cord serum at delivery. Serum PTH levels in pregnant women were lower than those in nonpregnant women (p < 0.01). However, serum PTHrP levels were similar in the two groups of women. Cord serum total and ionic calcium levels were higher, and cord serum PTH levels were lower compared to maternal values (p < 0.01). Cord serum PTHrP levels were higher than maternal values, and umbilical arterial levels were higher than umbilical venous levels (p < 0.01). Higher levels of PTHrP in umbilical arterial blood than in umbilical venous blood suggest that the main source of cord blood PTHrP may be the fetus. PTHrP is reported to stimulate placental calcium transfer from mother to fetus in animals. The elevated cord blood PTHrP level in association with the decreased PTH level suggests that stimulation of placental calcium transfer by PTHrP may also be operative in humans.

A novel biological aspect of ovarian oxytocin: oxytocin gene expression in cumulus/luteal cells and the effect of oxytocin on embryogenesis in fertilized oocytes

Recently, several reports have demonstrated the presence of oxytocin (OT) in the corpus luteum of mammalian species. However, the biological role of ovarian OT remains obscure. This study was performed to examine OT gene expression in cumulus cells of mice and humans, and in human corpus luteum, and the role of OT in early embryogenesis. OT gene and OT mRNA were analyzed by reverse transcription-polymerase chain reaction, with single-strand-conformation polymorphism and heteroduplex procedures. OT-treated in-vitro-fertilized mouse oocytes were cultured and the rate of blastocyst development estimated. An immunohistochemical study was also carried out to detect OT on the surface of the mouse oocytes.

[Definitive diagnosis of Alzheimer's disease using olfactory mucosal biopsy]

Characteristic changes appearing in the biopsied olfactory mucosa of Alzheimer's disease (AD) patients were investigated using immunohistochemical staining. Specimens were obtained from 6 patients who were clinically diagnosed with AD, 2 patients with cerebrovascular dementia and 5 age-matched patients with olfactory disturbance without dementia. In most AD cases, polyclonal tau protein immunoreactivity was seen in the dendrites, perikarya of the olfactory receptor cells in the olfactory epithelium and the olfactory nerve bundles in the lamina propria. In a few cases, tau protein immunoreactivity was found in the extracellular mass in the epithelium. Ubiquitin immunoreactivity was seen is the dendrites of olfactory receptor cells. On the other hand, in control cases, only dendrites and olfactory nerve bundles reacted to anti-polyclonal tau protein antiserum in a few cases. These results indicate that the neurofibrillary tangle-like tau protein immunoreactivity in the perikarya senile plaque-like extracellular mass and ubiquitin immunoreactivity in the olfactory epithelium were characteristic changes in AD, and olfactory mucosal biopsy is a useful method for the definitive diagnosis of AD.

Mechanism of pain and cytoskeletal properties in angioleiomyomas: an immunohistochemical study

Angioleiomyoma is a solitary subcutaneous tumor characterized by pain in about half of patients with this tumor, and the pathogenesis of this pain has been a cause of much debate. To clarify the mechanism of pain and cytoskeletal property of tumor cells, 50 angioleiomyomas were studied clinicopathologically and immunohistochemically. The tumors occurred preferentially on the extremities, particularly the lower leg (46%), and the female to male ratio was 1.9:1. They were classified into three histological subtypes: (i) solid (30 cases); (ii) venous (15 cases); and (iii) cavernous (five cases). The pain and/or tenderness were present in 26 out of 49 patients (52%), in which small nerve fibers immunoreactive for S-100 protein and PGP9.5 were identified within the capsule of 20 tumors (77%) and the tumor stroma of 18 (69%), irrespective of the histological subtypes. In 24 patients where the pain was absent or unknown, nerves were observed within the capsule of 19 tumors (79%) and tumor parenchyma of 10 (42%). Many cells in all 50 tumors were positive for alpha-smooth muscle actin, and a relatively large number of cells in many tumors were positive for vimentin, desmin and collagen type IV. Also, cytokeratin (CAM5.2) reactivity was scattered in a few cells of four tumors. From these findings, the peculiar pain of angioleiomyomas could be mediated by the nerve fibers especially located within the tumor parenchyma. Although the expression of intermediate filaments in angioleiomyomas was heterogeneous, the overall cytoskeletal features were of smooth muscle cell differentiation.

Cord blood levels of calcium-regulating hormones and osteocalcin in premature infants

We measured cord blood levels of calcium-regulating hormones and osteocalcin in 34 premature infants of various gestational ages. 1,25(OH)2D levels were low in mid-gestation and increased with advancing gestation. Parathyroid hormone levels were low, and calcitonin levels were high in mid-gestation. Both of them declined with advancing gestation. Osteocalcin levels were high in mid-gestation. They increased from 22 weeks through 27 weeks of gestational age, and decreased thereafter. Circulating osteocalcin is considered as a clinical marker of bone turnover. However, cord blood osteocalcin decreased between 27 and 36 weeks of gestation during which period calcium accumulation by the fetus increases. Therefore, cord blood osteocalcin does not appear to reflect fetal bone formation.

Surgical treatment of acute aortic dissection: efficacy of retrograde cardioplegia for myocardial protection

The operative morbidity and mortality of patients with Stanford type A acute aortic dissection undergoing urgent operation using retrograde cardioplegia for myocardial protection were evaluated to assess the efficacy of such surgery. A total of 18 patients (12 men and six women, 19-71 years of age) were operated on 9-137 h after onset of dissection using cardiopulmonary bypass with deep hypothermia and retrograde cardioplegia. Graft replacement was performed in ten patients, primary anastomosis in three, and Cabrol and Bentall operations in five. All patients were weaned from cardiopulmonary bypass, but four died in hospital (mortality rate 22%). Thirteen patients were in good health at follow-up ranging from 3 to 98 months, and the remaining patient died from rectal cancer 5 months after surgery. It is concluded that urgent operation of patients with Stanford type A acute aortic dissection can be performed with reasonable operative and excellent follow-up results. Retrograde cardioplegia is an easy and reliable method of myocardial protection to repair the fragile aortic wall.

Absence of linkage disequilibrium at amyloid precursor protein gene locus in Japanese familial Alzheimer's disease with 717Val-->Ile mutation

To date, eleven independent FAD pedigrees with the 717Val-->Ile mutation have been identified. Interestingly, five pedigrees were of Japanese origin and four were of British origin. The apparent ethnic prediction of this mutation raises the possibility that there is a founder effect in these two island nations. We did not observe any significant linkage disequilibrium in any locus of APP and GT12 loci in the five Japanese FAD pedigrees with the 717Val-->Ile mutation. A founder effect would probably not be present in Japanese FAD pedgrees with the 717Val-->Ile mutation.

Giant cell tumor of tendon sheath. An immunohistochemical observation on the characteristics and the capacity of proliferation of tumor cells

To investigate character and proliferation of tumor cells of giant cell tumor of tendon sheath (GCTTS), we studied 25 cases of GCTTS by light and electron microscopic immunohistochemistry. Mononucleated stromal cells (SC) of GCTTS could be divided into three types according to their antigenic features. The first type was the histiocytic SC expressing antigens recognized by KP1, Mac387 and Ham56. The second type was the fibroblastic SC showing fibronectin immunoreactivity. The third type was the intermediate SC expressing both KP1 and fibronectin. The presence of intermediate SC suggested that the different types of SC of GCTTS would be of common origin, i.e. from the mesenchymal cells of the synovium and represented different functional phases or phenotypic alterations. The expression of proliferating cell nuclear antigen (PCNA) was observed only in SC and occasionally, in binucleated cells, but multinucleated giant cells (GC) were negative for PCNA, suggesting that GC were non-dividing cells.

Secretory cell immunoscreening assay--a highly sensitive screening method for secretory cells

We have developed a rapid and sensitive screening method to detect the secretory product from transformed secretory cells. Polyclonal antibodies against the target secretory protein are first adsorbed onto a nitrocellulose membrane and are then called solid-phase antibodies. Then this membrane is placed on top of target protein-secreting adherent animal cell colonies. After trapping the secreted protein on the membrane, the protein is detected using the highly sensitive enhanced chemiluminescence detection system. Thus, this method is named the secretory cell immunoscreening assay (SCISA). We have screened recombinant BHK-21 cells, which secrete human interleukin-6 (hIL-6) for highly productive clones. With the SCISA method, it is possible to detect less than 100 pg of hIL-6 secreted by a single colony. We are also able to select highly productive colonies rapidly and easily from a large sample population of transformed cell colonies.

Identification of hybrid-type carbohydrate chains on the light chain of human monoclonal antibody specific to lung adenocarcinoma

The carbohydrate chains on the light chains of human monoclonal antibody HB4C5 reactive to human lung adenocarcinoma tissue have been characterized. The HB4C5 antibody consists of two kinds of light chains (30 kDa and 32 kDa). Each chain has different carbohydrates of varying molecular masses linked to the variable regions. The 30 kDa light chain has been confirmed to be the active species for antibody binding. The carbohydrates on the light chains were characterized by lectin blot analysis combined with glycosidase treatment. A carbohydrate chain linked to the active 30 kDa light-chain species, and one of a few carbohydrate phenotypes on the 32 kDa light-chain species is characterized as "hybrid type". A sialylated complex-type carbohydrate could also bind to the 32 kDa light-chain species. Nucleotide sequence analysis revealed that one potential N-glycosylation site is located in the complementarity determining region 1 of the light chain, although no such site was found in the variable region of the heavy chain.

Substrate specificity of alkaline proteases from Cephalosporium sp. KM388

Serine alkaline proteases from Cephalosporium sp. KM388 were specific against esters of aromatic and hydrophobic amino acids. Against oxidized insulin B-chain, the enzymes initially cleaved the site of Leu-Tyr(15-16). The cleavage specificity of KM388 protease D was broader than those of other alkaline proteases, and the site of Arg-Gly(22-23) was cleaved, which is a specific site for trypsin-like protease.

The effects of ethanol exposure on radial arm maze learning and behavior of offspring rats

The effects of maternal drinking on offspring have been studied epidemiologically, in human beings, and experimentally, in rats. The physical growth of offspring of female alcoholic rats, including histological growth of brain, lung, thymus gland, liver, and kidney, was previously reported by us. In the present study, we observed the effect of ethanol intake by the mother rat on learning ability and behavior of offspring rats using an eight radical arm maze. At the same time histological observations of the cerebrum were carried out. The mother rat was exposed to ethanol from a young age to delivery (P-DEL) or to weaning (P-NURS). After weaning, the offspring was exposed to ethanol until the tests began (P-WEAN). Experimental groups, classified by length of ethanol exposure, as mentioned above, disclosed the following: (1) Number of trials required for fulfilling learning criterion was significantly large in P-DEL and P-NURS rat groups relative to the controls; that is, P-DEL and P-NURS rats were slow in learning. (2) Numbers of rats which did not fulfill the learning criterion were: Group P-DEL, one male of eight; Group P-NURS, three males of seven. The behavior of the rats in Group P-WEAN differed from those in other groups; while they were receiving acclimation training, they were, unlike ordinary rats, not watchful of the device, slow to find the feed, and indifferent. They seemed to lack carefulness and sometimes failed to eat the feed even though they succeeded in selecting correct arms. Their motion was abrupt and they ran at extraordinarily high speeds. (3) In the observations of correct choices in the first eight choices, groups P-DEL and P-NURS showed significantly low values. This suggested the lowering of their learning ability. (4) In the observations of continuous correct choices, Group P-DEL showed a significantly low value. This suggested the rats did not learn thoroughly enough to retain their acquisition long. (5) Body weight, learning ability, and hippocampal neurons were affected by ethanol exposure more severely in Group P-NURS than in Group P-DEL. An even more severe effect was observed in Group P-WEAN.

Thyrotropin-releasing hormone produces different hemodynamic effects in vegetative and brain-dead patients

To define a mechanism for the pressor effects of thyrotropin-releasing hormone (TRH), we evaluated changes in mean blood pressure (MBP) when a synthetic form of TRH (0.1 mg/kg, i.v.) was injected into two types of comatose patients: vegetative and brain dead. The patients in the vegetative group (n = 7, age 58 +/- 6) retained spontaneous respiration and brainstem function, whereas the brain-dead (BD) patients (n = 7, age 68 +/- 4) lacked these functions. In the vegetative group, TRH caused significant increases in MBP (from 91 +/- 8 mm Hg to 110 +/- 10 mm Hg) at 2 min after the injection [p < 0.05, analysis of variance (ANOVA) with a Scheffé F-test]. In contrast, five of the seven BD patient showed no alterations in the measured parameter in response to the TRH injection. However, the remaining two BD patients, who had spinal reflexes, exhibited an elevation in MBP. In such BD patients, baroreceptor reflex function was virtually absent, suggesting that the blood pressure regulation mediating through the baroreceptor reflex system might be abolished. These results indicate that in comatose patients, the hemodynamic effects of TRH may differ depending on impairments in the central nervous system; the results support previous reports indicating a mediation of the central sympathetic nervous system in the development of pressor effects of TRH. Furthermore, because brain-dead patients with spinal reflexes showed hypertensive responses to TRH, there is a possibility that these responses may have resulted from an activation of TRH receptors in the spinal cord.

[Clinical trial of IVC filter to temporary placement]

We developed a new inferior vena caval filter to prevent pulmonary embolism for a patient with IVC thrombus. This filter made by covering top half of Dotter Intravascular Retriever catheter with Dacron mesh sheet, was placed in IVC through a 10 F sheath from right jugular vein. In one case, after anticoagulant therapy and thrombectomy using balloon catheter, many free-floating thrombus were trapped in this filter and were taken out from the IVC. This filter was useful for preventing pulmonary embolism when removing thrombus in IVC, iliac and lower extremity veins. We propose to call this device "Hino's filter".