Immunoreactive localization of transforming growth factor-beta type II receptor-positive cells in rat tibiae

To identify the target cells of transforming growth factor-beta (TGF-beta) in normal bone tissue, we examined TGF-beta type II receptor expression using immunohistochemistry, reverse transcription-polymerase chain reaction (RT-PCR), and in situ hybridization in young rat tibiae. In the epiphyseal growth plate, the TGF-beta type II receptor cDNA was detected by RT-PCR and, alternatively, the TGF-beta type II receptor protein and mRNA expression were observed in the chondrocytes in the lower part of the proliferative cell layer, and in maturative and hypertrophic cell layers by immunohistochemistry and in situ hybridization. Of these, proliferative and maturative chondrocytes, in particular, revealed strong mRNA expression. In the cortical bone area, immunoreactivity for the TGF-beta type II receptor was detected in the fibroblastic cells near the osteoblasts on the endosteal surface of cortical bone. In conclusion, our findings suggest that target cells of TGF-beta in normal bone tissue could be considered mainly as extracellular matrix-producing chondrocytes and undifferentiated preosteoblasts, and TGF-beta may affect matrix production and differentiation of these cells.

Ca2+/CaM-sensitive adenylyl cyclase activity is decreased in the Alzheimer's brain: possible relation to type I adenylyl cyclase

Immunoreactivities of four subtypes of adenylyl cyclase (AC) (types I, II, IV and V/VI), and basal, forskolin- and Mn(2+)-stimulated AC activities with or without calcium and calmodulin (Ca2+/CaM) were estimated in parietal cortex membranes from cases with dementia of the Alzheimer type (DAT) and age-matched controls. Immunoreactivities of AC-I and AC-II were significantly decreased, but those of AC-IV and AC-V/VI did not change in DAT brains. There was a significant correlation of AC-I immunoreactivity with Ca2+/CaM-sensitive AC activity, but not with the Ca2+/CaM-insensitive activity. Ca2+/CaM-sensitive AC activity was significantly lower in DAT than in the control, indicating that impairment of Ca2+/CaM-sensitive AC-I is clearly involved in the pathophysiology of DAT.

Potential antidepressant properties of forskolin and a novel water-soluble forskolin (NKH477) in the forced swimming test

The mechanisms of the antidepressant activity of forskolin and a novel water soluble forskolin analog (NKH477) were studied using the forced swimming method in rats. Forskolin (0.01-0.1 mg/kg) and NKH477 (0.01-0.1 mg/kg) dose-dependently decreased ratings of immobility, with effects similar to those of amitriptyline treatment. The maximum effects of forskolin and NKH477 were observed at 0.01 mg/kg dose which is 150 more times potent than that (15 mg/kg) of amitriptyline. At a high dose (1.0 mg/kg) of forskolin and NKH477, the duration of immobility was returned to control levels. Forskolin and NKH477 did not influence the spontaneous locomotor activity at intraperitoneal injection doses from 0.01 to 1 mg/kg. Furthermore chronic administration with NKH477 at oral dose from 0.5 to 1.5 mg/kg significantly decreases the duration of immobility. These data indicate that both forskolin and NKH477 have strong antidepressive potency, consistent with the hypothesis that elevation of the cAMP cascade system may have an important role in antidepressive effects.

Urodynamic changes after endoscopic correction of vesicoureteral reflux

Massive bilateral vesicoureteral reflux (VUR) in a 7-year-old girl with spinal scoliosis was successfully treated by endoscopic correction. She was admitted due to a febrile urinary tract infection and urinary incontinence. A cystometrogram demonstrated normal detrusor function during storage. The endoscopic subureteric injection of polytetrafluoroethylene (Teflon) was performed, resulting in the disappearance of the VUR. A postoperative cystometrogram demonstrated overactive detrusor function during storage, necessitating anticholinergic medication. She has been free of febrile urinary tract infections and incontinence for 2 years postoperatively, although self-catheterization is necessary. In a case of neurogenic vesical dysfunction with massive reflux, endoscopic subureteric injection is not only a therapeutic tool, but also a useful diagnostic option for detecting occult detrusor overactivity during storage prior to open surgery.

Adrenalectomy-induced granule cell death is predicated on the disappearance of glucocorticoid receptor immunoreactivity in the rat hippocampal granule cell layer

In this study, we observed the changes of glucocorticoid receptor (GR)-immunoreactivity (ir) and cell death in the rat hippocampal granule cell layer at various periods after adrenalectomy (ADX). Our results revealed that all of the rats shortly after ADX showed a rapid loss of GR-ir and subsequent appearance of degenerating cells in the granule cell layer. One month after ADX, however, about 80% of the rats displayed a restoration of GR-ir and the absence of degenerating cells in the granule cell layer, and this phenomenon was successively noted for 6 months. Hippocampal structural destruction 3 and 6 months after ADX was found in about 20% of the rats with loss of GR-ir in the granule cell layer; the ADX rats with even weak GR-ir in this area had a normal hippocampus. The treatment of rats with synthetic GR agonist, dexamethasone, immediately after ADX prevented the loss of GR-ir and significantly reduced the number of degenerating cells in the granule cell layer. Our results clarified that granule cell death after ADX was necessarily accompanied by the disappearance of GR-ir in the granule cell layer, suggesting that ADX-induced granule cell death is predicated on the loss of GR-ir and that the presence of GR-ir in this area may be important for granule cell survival.

Prevalence of risk factors for coronary heart disease among Dominicans in the Dominican Republic: comparison with Japanese and Americans using existing data

Risk factors of coronary heart disease (CHD) in Dominicans were compared with those of Japanese and Americans for the presumption of prevalence of CHD in about 2000 persons. Dominican adults aged 20 through 76 years were medically examined in 1993. Data of nationally representative Japanese and Americans which included serum lipid levels were compared. Total cholesterol levels(TCH) in Dominicans were lower than those in Americans. High-density lipoprotein cholesterol levels in Dominicans were lower than those in Japanese and Americans. The prevalence of hypertension and current smoking rates in Dominicans were similar to that of Americans and lower than that of Japanese. TCH in Americans have substantially been declining and those in Japanese were inadequate for preventing CHD. The prevalence of CHD in Dominicans may be lower than that of Americans viewed from the recent levels of main risk factors. Community wide health programs have spread to people with hypertension a decrease in the incidence of CHD should occur.

Immunolocalization of CD44 and the ezrin-radixin-moesin (ERM) family in the stratum intermedium and papillary layer of the mouse enamel organ

We studied the immunohistochemical localization of CD44 and the ezrin-radixin-moesin (ERM) family of actin binding proteins in mouse enamel organ, using confocal laser scanning microscopy and transmission electron microscopy to clarify their role in cytoskeletal organization. At the differentiation stage of ameloblasts, immunoreactivity to CD44 was detected on the plasma membrane of the inner enamel epithelium, the stellate reticulum, the stratum intermedium, and the external enamel epithelium. In accordance with the differentiation of preameloblasts into secretory ameloblasts, immunoreactivity increased in the stratum intermedium cells. At the maturation stage, intense immunoreactivity was observed on the papillary layer cells. For the ERM family, the stratum intermedium and the papillary layer cells were stained with anti-ezrin and -radixin monoclonal antibodies but not with the anti-moesin antibody. Electron microscopic observations revealed that CD44, ezrin, and radixin were localized in the region at which preameloblasts came into contact with the stratum intermedium at the differentiation stage. At the secretory and maturation stages, they were concentrated in the microvilli of the stratum intermedium and the papillary layer cells. These findings suggest that the CD44-ezrin-radixin-actin filament system is involved in cell-cell interaction between preameloblasts and the stratum intermedium, and in the cytoskeletal organization of the cells in the stratum intermedium and the papillary layer.

Endoscopic correction of vesicoureteral reflux by subureteric Teflon (polytetrafluoroethylene) injection: review of 6-year experience

BACKGROUND

Endoscopic correction of vesicoureteral reflux (VUR) was first proposed in 1981 and the first series of patients treated by subureteric polytetrafluoroethylene paste injection (STING) was reported in 1984. Although many successful studies, primarily European, have been undertaken since then, this technique has recently been rejected in the United States. In this paper, we report our 6-year experience and discuss indications for this technique.

PATIENTS AND METHODS

Since February 1990, we have used the STING technique to endoscopically correct VUR. In this analysis, 38 ureters in 24 patients (mean age, 47.3 years; range, 7 to 79 years), with at least 1 year of follow-up were included.

RESULTS

The first injection resulted in disappearance of VUR in 34 ureters (89.5%). A second injection was done for 2 failed and 3 recurrent ureters during follow-up, resulting in disappearance of VUR in the 3 recurrent ureters. The final success rates were 100% for both primary VUR and secondary VUR due to neurogenic bladder, but only 55.6% (5/9) for secondary VUR following transurethral resection of bladder tumors. No postoperative early or delayed complications were noted in any case.

CONCLUSION

The procedure is simple and effective for the treatment of all grades of VUR. However, the procedure should be performed after careful consideration of the indications, since theoretically the risk of distant migration of the paste cannot be ignored.

[Mismatch negativity of patients with hydranencephaly]

We examined auditory evoked potentials and passive event-related potentials in two patients with hydranencephaly. In the middle latency response, a Na component was observed in both cases. Mismatch negativity was elicited in response to tone bursts and three patterns of vowel sounds in Patient 1, and three patterns of vowel stimuli in Patient 2. These results implicate the subcortical components of the auditory system in the generation of mismatch negativity.

[Significance of rectal contractions during multichannel urodynamic study]

BACKGROUND

The influence of rectal contractions on urination was examined using multichannel urodynamic study.

METHODS

We reviewed a total of 246 consecutive urodynamic studies. Each study consisted of a uroflow measurement and multi-channel urodynamic study, evaluating total vesical pressure, abdominal (rectal) pressure, subtracted detrusor pressure and perianal electromyography. Rectal contractions were defined as periodic fluctuations over 5 cmH2O in abdominal pressure detected by a rectal balloon catheter. No relationship of these contractions with cough and breathing was observed.

RESULTS

Of the 246 patients, 17 (6.9%) had a positive study for rectal contractions. The patients, who had positive rectal contractions, averaged 70-year-old were older than negative subjects averaged 62-year-old. In multichannel urodynamics, the flow rate was significantly decreased, and electromyographic activity was increased at the moment of each rectal contractions.

CONCLUSIONS

The rectal contractions are not artifactual and may be regarded as one of causes responsible for urinary difficulty in the elderly.

Gracilis urethral myoplasty: preliminary experience using an autologous urinary sphincter for post-prostatectomy incontinence

PURPOSE

We investigated the effect of a neurovascular intact gracilis muscle urethral wrap to restore urinary continence in men with severe stress urinary incontinence after radical retropubic prostatectomy.

MATERIALS AND METHODS

Three men with stress incontinence after radical retropubic prostatectomy and external beam radiation therapy for adenocarcinoma of the prostate underwent gracilis urethral myoplasty. Video urodynamic evaluation and cystourethroscopy revealed Valsalva leak point pressure of less than 40 cm. water and a damaged urinary sphincter mechanism in all 3 patients. One man underwent concomitant ileocystoplasty.

RESULTS

At 6 to 24-month followup all patients reported improved continence. Mean Valsalva leak point pressure increased from 26.3 +/- 3.2 cm. water before to 83.0 +/- 32.1 cm. water after surgery. The gracilis muscle urethral wrap did not have a deleterious effect on erectile function or ambulation. Complications included 1 wound infection.

CONCLUSIONS

An autologous gracilis muscle urinary neosphincter can be constructed in the bulbous urethra in a fashion similar to that of the artificial urinary sphincter with encouraging results in this preliminary series. The gracilis neosphincter may be an alternative to the artificial sphincter, especially in patients at higher risk for complications, such as after radiation and cryotherapy.

Fibroblasts of spinal ligaments pathologically differentiate into chondrocytes induced by recombinant human bone morphogenetic protein-2: morphological examinations for ossification of spinal ligaments

To elucidate the process of ossification in spinal ligaments, an aqueous solution containing recombinant human bone morphogenetic protein (BMP)-2 (40 micrograms/100 microL) was injected into murine ligamenta flava, and the ossification process was analyzed morphologically. In the control group, the solution administered lacked the protein; these flattened ligamentous fibroblasts possessing BMP receptors type IA and type II existed among type I collagen bundles. In the week immediately following the injection of BMP-2, ligamentous fibroblasts began to proliferate, differentiating into alkaline phosphatase-positive chondrocytes surrounded by an extracellular matrix composed of type I and II collagen. By the second week, differentiated chondrocytes of various stages were observed in type II collagen-rich matrix. These chondrocytes showed an abundance of BMP receptors type IA and II. The pathologically induced cartilage was resorbed by chondroclasts, permitting migration of blood vessels and osteogenic cells, as well as providing a site for endochondral ossification. By the third week, BMP-induced ossification had compressed the spinal cord, and by the sixth week, the ligamentous tissue had been almost completely replaced by bone. Ligamentous fibroblasts appeared to possess BMP receptors, as well as the potentiality to differentiate into chondrocytes. BMP receptors were upregulated during chondrification of ligamentous fibroblasts induced by exogenous BMP-2, suggesting that BMPs may play an important role in ossification of spinal ligaments.

Chronic loss of glucocorticoids following adrenalectomy down-regulates the expression of glucocorticoid receptor mRNA in the rat forebrain

In the negative feedback model, loss of endogenous glucocorticoids up-regulates the expression of glucocorticoid receptor mRNA. To elucidate further the effect of chronic lack of glucocorticoids on the expression of glucocorticoid receptor mRNA and protein, in situ hybridization and immunohistochemical methods were used to examine the long-term alteration of glucocorticoid receptor mRNA and its immunoreactivity in the forebrain of adrenalectomized rats. Constant lack of glucocorticoids resulted in marked decrease in the expression of glucocorticoid receptor mRNA and disappearance of glucocorticoid receptor immunoreactivity in many forebrain structures. In particular, in the suprapyramidal blade of the hippocampal granule cell layer and cerebral cortex, many cells showed almost no glucocorticoid receptor mRNA signals. These results suggest that long-term loss of endogenous glucocorticoids down-regulates the levels of glucocorticoid receptor mRNA, leading to reduction in the synthesis of glucocorticoid receptors in the rat forebrain. Therefore, the presence of endogenous glucocorticoids is vital to the continued expression of glucocorticoid receptor mRNA.

[A case of juvenile Huntington's disease presenting dystonia and confirmed by DNA analysis]

We reported a 13-year-old boy with juvenile Huntington disease diagnosed by DNA analysis. Symptoms started with dysarthria at 6 years of age, which was followed by progressive dysgraphia and gait disturbance due to dystonia from 7 years, and by epileptic seizures from 12 years. Magnetic resonance imaging revealed atrophy of the bilateral caudate nuclei and T2- and proton-weighted high intensity area in both putamina. The CAG (cytosine-adenine-guanine) trinucleotide repeat on chromosome 4 p16 was markedly expanded to 81. For a child with dystonia with mental deterioration, juvenile Huntington disease should be considered in the differential diagnosis.

Saccharated ferric oxide (SFO)-induced osteomalacia: in vitro inhibition by SFO of bone formation and 1,25-dihydroxy-vitamin D production in renal tubules

A 60-year-old man with portal hypertensive gastropathy due to type C liver cirrhosis developed severe bone pains, marked hypophosphatemia with inappropriately increased urinary excretion of phosphate (%TRP; 9.6%), and hyperalkaline phosphatasia, after intravenous administration of saccharated ferric oxide (SFO) at a dose of 80-240 mg/week over a period of more than 5 years. The total iron infused was estimated to be more than 25 g. On a diagnosis of SFO-induced osteomalacia, the infusion of iron was immediately discontinued, and phosphate and vitamin D2 (1000 IU/day) were administered. Serum levels of 25-OHD2 increased after 1 week, whereas levels of 1,25-(OH)2D2 did not increase until 3 months later, accompanied by improvement of renal tubular reabsorption of phosphate and gradual improvement of the bone pains. The patient has been doing well for the last 2 years, with normal serum levels of phosphate, calcium, and alkaline phosphatase, without any supplementation of phosphate, vitamin D, or iron-containing agents. In primary culture of neonatal mouse renal tubules, in which 1,25-(OH)2D3 was produced from 25-OHD3 in response to PTH, SFO significantly inhibited PTH-induced production of 1,25-(OH)2D3 at 30 mumol/L, which is attainable in the urine of patients receiving a therapeutic intravenous dose of SFO. Furthermore, SFO decreased the calcium content and inhibited 45Ca incorporation in cultured fetal mouse parietal bones at 3 mumol/L. Such SFO concentration may be transiently observed in the plasma of patients receiving excessive intravenous doses of SFO for a prolonged period. These in vitro findings together with the clinical observations suggest that SFO, after filtration through the glomerulus and reabsorption in the proximal renal tubules, impaired proximal renal tubular function, such as tubular reabsorption of phosphate and 1 alpha-hydroxylase activity, leading to hypophosphatemic osteomalacia. Furthermore, it is highly likely that SFO in the peripheral blood, when transferrin is saturated with iron, may impair bone formation and aggravate osteomalacia. Although SFO-induced osteomalacia is reversible simply by discontinuation of the agent, excessive and prolonged administration of SFO should be avoided.

Generation and characterization of mouse monoclonal antibodies specific for N-linked neutral oligosaccharides of glycoproteins

We generated four monoclonal antibodies (MAbs) specific for asparagine-linked neutral oligosaccharides of glycoproteins by immunizing mice with neoglycolipids, which were derived from glycoproteins by conjugation to phosphatidylethanolamine dipalmitoyl. The binding specificity of these MAbs was determined by an enzyme-linked immunosorbent assay and immunostaining on thin-layer chromatography. The four MAbs designated OMB3, OMB4, OMR5, and OMR6 reacted strongly with the neoglycolipids, Gal beta1-4GlcNAc beta1-2Man alpha1-6(Gal beta1-4GlcNAc beta1-2Man alpha1-3)Man beta1-4GlcNAc-PD, GlcNAc beta1-2Man alpha1-6(GlcNAc beta1-2Man alpha1-3)(GlcNAc beta1-4)Man beta1-4GlcNAc beta1-4GlcNAc-PD, Man alpha1-6Man beta1-4GlcNAc beta1-4(Fuc alpha1-6)GlcNAc-PD, and Man alpha1-3Man beta1-4GlcNAc-PD, respectively, that were used as immunogens. All of these MAbs exhibited a high binding specificity. The epitopes of the MAbs OMB3 and OMB4 were suggested to be nonreducing terminal trisaccharides, Gal beta1-4GlcNAc beta1-2Man-, and nonreducing beta-GlcNAc residues, respectively. MAbs OMR5 and OMR6 showed a highly restricted binding specificity, reacting only with the immunizing neoglycolipids. Subsequently, MAbs OMB3 and OMB4 were shown to react strongly with asialo-alpha1-acid-glycoprotein and asialo-agalacto-alpha1-acid-glycoprotein, respectively, by Western blotting. Furthermore, it was shown that these MAbs reacted specifically with the epitope on Chinese hamster ovary cells by an immunofluorescence technique. MAb OMB4 was also shown to detect the accumulated oligosaccharides with nonreducing terminal beta-GlcNAc residues as granular inclusions in the cultured fibroblasts from a classical Sandhoff disease patient.

The in vivo time course for elimination of adrenalectomy-induced apoptotic profiles from the granule cell layer of the rat hippocampus

Although apoptotic cellular degeneration has been reported to be extremely rapid with the use of in vitro models, the time needed to clear apoptotic neurons in the in vivo brain is unknown. In this study we used a simple morphological approach to solve this problem. Four days after adrenalectomy (ADX), all of the operated rats morphologically displayed hippocampal granule cell apoptosis that was prevented completely by corticosterone replacement immediately after ADX. Therefore, we intravenously injected the rats with corticosterone 4 d after ADX and subsequently maintained them on corticosterone replacement in saline drinking water. This corticosterone replacement could protect healthy granule cells promptly and continuously against hormone-deficient apoptosis, because the normal glucocorticoid receptor immunoreactivity within the granule cell nuclei, which disappeared after ADX, was identified 1 hr after corticosterone replacement was started, and this effect persisted for several days. However, this corticosterone treatment could not prevent the irreversible apoptosis of the already degenerated granule cells at various stages of the same progressive apoptotic process. Then we successively traced the disappearance of apoptotic granule cells throughout the hippocampus at different time points by Nissl and silver staining. Given that the apoptotic cells at the earliest stage of the degenerating process when the ADX rats received corticosterone injection were the last to disappear, the period from corticosterone injection until the disappearance of the last degenerating debris of apoptotic cells was taken to represent the time course for elimination of apoptotic neurons in vivo. We discovered that the elimination of apoptotic granule cells took 72 hr.

Gangliosides involved in activation of rat T lineage cells

Gangliosides have long been known to be involved in T-cell activation. In our previous studies, a unique GMlb-derived ganglioside, GD1c(NeuGc,NeuGc), was shown to be the predominant ganglioside in rat thymocytes and T-cells. Upon the activation of the thymocytes, the amount of GD1c(NeuGc,NeuGc) increases remarkably, and additionally a novel species of GD1b, GD1b(NeuGc,NeuGc), appears as the other major ganglioside (Nohara, et al. (1993) J. Biol. Chem. 268, 24997-25000). In the present study, monoclonal antibodies (MAbs) against these two gangliosides have been generated. The MAb AC1 established by immunizing mice with purified GD1c(NeuGc,NeuGc) reacted strongly with GD1c(NeuGc,NeuGc) and weakly with GD1b(NeuGc,NeuGc) by enzyme-linked immunosorbent assay (ELISA). The other MAb AB1 obtained by immunization with GD1b(NeuGc,NeuGc) showed a strong binding activity to GD1b(NeuGc,NeuGc) and no reactivity to GDlc(NeuGc,NeuGc) by ELISA. Flow cytometry analyses using these MAbs have revealed that an AC1-positive subset exists in a portion of resting CD4+CD8- thymocytes and CD4+ splenic T-cells. When the thymocytes were activated with 12-O-tetradecanoylpholbol-13-acetate (TPA) and calcium ionophore A23187, the proportion of AC1+ cells increased remarkably and were detected not only in CD4+ cells but also in CD8+ cells. An increase in the proportion of AC1+ cells was also seen in activated T-cells. In contrast, AB1-positive cells were only detected in activated thymocytes, not in resting thymocytes, or resting or activated T-cells. These results implicate GD1c(NeuGc,NeuGc) in the activation of thymocytes as well as T-cells, whereas GD1b(NeuGc,NeuGc) appears to be specifically related to the activation of thymocytes.

[Reevaluation of heart disease deaths on death certificates and trends for ischemic heart disease mortality during the last five years in Oita city]

To evaluate heart disease deaths and clarify trends for ischemic heart disease (IHD) mortality during the last five years in Oita City, we reevaluated causes of death on death certificates. In 1993, there were 253,000 people aged 25-74 in Oita City. In this population age group, there were 1,996 deaths from January 1992 through December 1993. Our subjects were 982 deaths recorded as caused by heart disease and IHD related diseases. Subjects were reevaluated on the basis of physician's interview, clinical records and police records. This IHD reevaluation was conducted by the WHO MONICA criteria. The death certificates identified 321 heart disease deaths, of which there were 80 (24.9%) acute myocardial infarctions (AMI), 22 (6.9%) other IHD, 180 (56.1%) heart failures, and 39 (12.1%) other heart diseases. The remaining 61 deaths were caused by other diseases. After reevaluation, 40 'definite' AMI and 60 'possible' AMI were recognized through the MONICA criteria, 86 sudden deaths (SD) which were defined as, 'death within 24 hours of the onset of acute symptoms and without clear signs suggesting what disease was the cause,' were also classified. Assuming that 50% of SD were due to IHD, according to some postmortem autopsy studies, aged-standardized IHD mortality per 100,000 for males was 38.3 per year and for females 17.3 per year in this period. Both mortality rates, 31% for males and 38% for females, were higher than IHD mortality statistics. Moreover, in comparison with IHD mortality estimated by reevaluation of heart disease in Oita City in 1987-88, age-standardized IHD mortality per 100,000 for males has remained basically stable, increasing from 37.8 to 38.4 during the last five years. On the other hand, mortality for females has increased from 11.2 to 17.3. Our results suggest that mortality from IHD actually was about 30% more than mortality statistics, and does not show a declining trend as mortality statistics have stated.

Heart disease deaths on death certificates re-evaluated by clinical records in a Japanese city

In order to estimate the number of deaths from ischemic heart disease (IHD) in a Japanese city, we reevaluated heart disease deaths among residents aged 25-74 years by examining their clinical records. During the 2-year period from 1987 to 1988, 271 deaths among this population were attributed to heart disease. The recorded underlying cause of death was IHD in 96 cases, heart failure in 123 cases, and other heart disease in 52 cases. Re-evaluation of the cause of death yielded 57 cases of acute myocardial infarction (AMI), 85 cases of sudden death, 37 cases of heart disease other than IHD, and 63 cases of non-heart disease. In the remaining cases, there was insufficient information for evaluation. According to some autopsy studies, about 50% of sudden deaths are due to IHD. Thus, 50% of the number of sudden death cases may be added to the total number of IHD deaths. Accordingly, the total number of IHD deaths may have been 100, ie, 57 cases of AMI plus 43 cases of sudden death. The difference between the number of IHD deaths after re-evaluation and the number for which IHD was recorded as the underlying cause was small, with the former only 4% higher than the latter. The number of false-positives was equal to the number of false-negatives, and hence the number of IHD deaths recorded in this area seems to be close to the actual figure. We speculate that more accurate death certification will result in a decrease in the total number of deaths attributable to heart disease, as in 23% of deaths attributed to heart disease the underlying cause of death was not in fact heart disease.