[Diagnostic imagings and embolotherapy for the superior mesenteric vein-inferior vena cava shunt]

Diagnostic imaging and embolization therapy for the uncommon portal and mesenteric vein-inferior vena cava shunt (PV.SMV-IVC shunt) are reported. As the frequency of clinical symptoms such as hematemesis, melena and confusion caused by gastrointestinal varices, or hepatoencephalopathy was about 40%, it was important for this disease entity to be diagnosed with noninvasive diagnostic images. The careful examination of the area around the right renal vein was able to overcome the low diagnostic rate of 20-40% obtained with US and CT images. In cases of simple PV.SMV-IVC shunt without gastrointestinal varices, embolization therapy using steel coils and done by the intravenous approach is easy and noninvasive. On the other hand, in cases of complex PV-SMV-IVC shunt with gastrointestinal varices, dual balloon occluded embolization therapy using a liquid sclerosing agent and done by the intravenous and portal approaches is preferable.

Proliferative response of synovial fluid mononuclear cells of patients with rheumatoid arthritis to mycobacterial 65 kDa heat shock protein and its association with HLA-DR+.gamma delta+ T cells

OBJECTIVE

The proliferative response of mononuclear cells (MNC) in synovial fluid (SF) and peripheral blood (PB) of patients with rheumatoid arthritis (RA) to mycobacterial 65 kDa heat shock protein (HSP65) was tested and the response compared with the percentage of HLA-DR+.gamma delta+ T cells in lymphocytes of SFMNC or PBMNC:

METHODS

Proliferative response of MNC was measured by means of 3H-thymidine incorporation and expressed by means of the stimulation index. Percentage of HLA-DR+.gamma delta+ T cells in lymphocytes was measured by means of the 2-color flow cytometry method.

RESULTS

Higher response of SFMNC than PBMNC to HSP65 was noted in 14 of 19 patients with RA. Stimulation indexes of RA-SFMNC correlated significantly with HLA-DR+.gamma delta+ T cell percentage in lymphocytes.

CONCLUSION

In the SF of patients with RA, an accumulation of HSP65 reactive and HLA-DR+.gamma delta+ T cells was noted.

A case of Behçet's disease with occlusion of both caval veins and "downhill" esophageal varices

A case of Behçet's disease (BD) with occlusion of both caval veins and "downhill" esophageal varices is reported. A 59-year-old male patient had esophageal varices, established as the "downhill" type by endoscopy, venography, and contrast-enhanced computed tomography (CE-CT) scan. Venography via both jugular veins did not lead to the visualization of the superior vena cava (SVC), but revealed numerous collateral veins, which formed esophageal varices en route. Venography via both femoral veins did not lead to the visualization of the inferior vena cava (IVC), but revealed numerous collateral veins, which flowed into the portal vein together with the jugular flow. CE-CT scan revealed the disappearance of the SVC and the lower part of the IVC, below the hepatic vein. The patient was diagnosed as having BD, based on his history of recurrent oral and skin lesions over the past 26 years.

Successful methods of pancreas transplantation in the rat using a cuff technique

Two models of pancreas transplantation were examined in the rat with a view to choosing one for regular use in functional experiments. A cuff technique applied to the renal vessels of the recipient was used. The histology and endocrine functioning of whole pancreas-duodenal transplant (Tx) plus bladder drainage (drainage model), and the pancreatic duct ligated segmental pancreas Tx (ligated model) were examined. Syngeneic operations were performed using either Lewis or Wistar rats. Streptozotocin (STZ) 60 mg/kg intravenously (i.v.) was used to render the recipient rats diabetic. A cuff technique was used with both models to anastomose the grafts to the renal vessels instead of the conventional technique of hand suturing to the abdominal vessels. This allows a shorter warm ischaemia time for the donor pancreas and leaves the systemic circulation intact leading to a high success rate for both techniques. Operation survival rates were 93% (n = 30) and 90% (n = 10) in the ligated and drainage models, respectively. The recipients in both groups were normoglycaemic for > 100 days. Histological examination revealed atrophic exocrine tissue early in the ligated group but only two from the drainage group showed exocrine atrophy at > 100 days. There was no statistical difference in i.v. glucose tolerance tests with both models showing a normal pattern. Thus, endocrine function remained independent of exocrine function. Both models are quicker than the conventional techniques. The duct ligation model was a simpler transplant to perform, suggesting that this should be the technique of choice in future experiments.

Beneficial effects of cyclosporine on reoxygenation injury in hypoxic rat liver

The effect of CsA on hypoxia-reoxygenation injury was studied in perfused rat livers. CsA did not attenuate hypoxic injury, as assessed by the release of lactate dehydrogenase and mitochondrial aspartate aminotransferase. During reoxygenation, the release of lactate dehydrogenase was also not affected by CsA. However, the release of mitochondrial aspartate aminotransferase into the cytosol, which indicates mitochondrial injury, was significantly reduced by CsA. The effect of CsA on mitochondrial function during hypoxia-reoxygenation was also investigated. CsA administration increased both the respiratory control ratio and the adenine nucleotide content after reoxygenation in both isolated mitochondria and perfused livers. In addition, glucose production by perfused livers after reoxygenation was increased by CsA. We conclude that the beneficial effect of CsA on hypoxia-reoxygenation injury may be partly due to protection of the mitochondria against reoxygenation injury.

Antibodies to 65Kd heat-shock protein were elevated in rheumatoid arthritis

Antibodies to 65Kd heat-shock protein (hsp) of mycobacterium leprae were measured by enzyme-linked immunosorbent assay (ELISA) in the three immunoglobulin classes in paired sera and synovial fluids of patients with rheumatoid arthritis (RA). Titers of anti-hsp antibody were expressed by optical density (OD) values for sera or indexes (OD values divided by amounts of immunoglobulin in each class) for synovial fluids and for their paired sera. Indexes of anti-hsp antibody were higher in synovial fluids than those in sera at 15/18 for IgG, 17/18 for IgA and 16/18 for IgM class. These results suggest the participation of anti-hsp antibodies to synovitis in RA.

Henoch-Schönlein purpura associated with pregnancy in a patient with chronic thyroiditis

A case of Henoch-Schönlein purpura with chronic thyroiditis associated with pregnancy is reported. A 27-year-old woman had a struma since age 14. She felt easily fatigable along with enlargement of the struma after the delivery of her first child, and was diagnosed as having chronic thyroiditis. She developed hematuria between the first delivery and the second pregnancy. The hematuria continued during the second pregnancy and in the postpartum period. Immediately after the delivery of her second child, she developed purpura followed by arthralgia and melena. Renal biopsy revealed focal segmental and global type Henoch-Schönlein nephritis. We reviewed five cases of Henoch-Schönlein purpura associated with pregnancy and found that our case is the first in which purpura developed immediately after delivery. Our patient would have developed Henoch-Schönlein nephritis between the first delivery and the second pregnancy. She developed Henoch-Schönlein purpura possibly due to rebound activation of immune response in the postpartum period after the disappearance of dramatic suppression of both humoral and cell-mediated immunity in the pregnant period.

A technique for complete thymectomy in adult rats

50 open thymectomies were performed in adult rodents using intubation combined with a fibrin glue able to prevent hemorrhage and pulmonary air leakage. This method had a 100% success rate and lower mortality than the ordinal suction procedure. Although the conventional suction thymectomy has been widely used, the open thymectomy method would permit more complete thymectomies for immunological studies.

Serum lidocaine and MEGX concentrations after pharyngeal anesthesia for gastroscopy

In 20 patients undergoing topical anesthesia for gastroscopic examination, serum concentrations of lidocaine and its metabolite, monomethylglycinexylidide (MEGX), were measured. Patients were divided randomly into two groups: a gel group, in which 5 ml of 2% lidocaine gel was applied to the throat for 20 minutes; and a solution group, in which 40 ml of 2% lidocaine solution was administered by gargling for five minutes. The effect of oropharyngeal anesthesia was comparable in both groups. In the gel group, the serum levels of lidocaine and MEGX were not elevated at 15 minutes after application of the anesthetic. However, in the solution group, a rise in both serum lidocaine and MEGX at 15 minutes after anesthesia was detected in some of the patients (40%). Increased serum MEGX concentrations, which correlated well with serum lidocaine concentrations, were associated with the age of the patient (r = 0.606; p < 0.05), but not with height or weight. As a topical anesthetic for endoscopic examination, we prefer lidocaine gel to lidocaine solution, because the latter might be absorbed more rapidly and unpredictably in some, especially aged patients.

Early assessment of reperfusion therapy using cardiac troponin T

OBJECTIVES

The purpose of this study was to investigate the utility of cardiac troponin T for early assessment of reperfusion therapy.

BACKGROUND

Several biochemical markers are used for early noninvasive detection of reperfusion during intravenous thrombolytic therapy. However, cardiac troponin T, a new myocardial-specific marker, has not been used previously for this purpose.

METHODS

We measured troponin T and creatine kinase, MB isoenzyme (CK-MB) levels in 38 patients with acute myocardial infarction whose infarct-related artery was totally occluded before reperfusion therapy. Subjects comprised 14 patients with successful angioplasty (group 1), 12 patients with successful thrombolytic therapy (group 2) and 12 patients with unsuccessful attempted reperfusion (group 3). Blood samples were taken every 15 min, and coronary angiography was performed every 5 to 8 min until 60 min after reperfusion (groups 1 and 2) or after the initiation of treatment (group 3). We calculated the increase in troponin T (delta troponin T) and CK-MB (delta CK-MB) 60 min after treatment was initiated and 60 min after reperfusion in groups 1 and 2.

RESULTS

Mean (+/- SD) delta troponin T and delta CK-MB levels were 9.35 +/- 7.83 ng/ml and 125 +/- 83 mU/ml in group 1 and 3.23 +/- 3.08 ng/ml and 130 +/- 137 mU/ml in group 2, respectively, 60 min after treatment and were 10.1 +/- 8.35 ng/ml and 131 +/- 84 mU/ml in group 1 and 6.84 +/- 8.30 ng/ml and 158 +/- 146 mU/ml in group 2, respectively, 60 min after reperfusion. These values were significantly higher than those 60 min after treatment in group 3: 0.16 +/- 0.19 ng/ml and 10 +/- 9 mU/ml, respectively. The predictive accuracy for detecting reperfusion using a threshold value of 0.50 ng/ml of delta troponin T and 25 mU/ml of delta CK-MB was 100% in group 1 and 92% in group 2 60 min after treatment, respectively. There was significant correlation between delta troponin T and delta CK-MB.

CONCLUSIONS

Serial measurements of cardiac troponin T as well as of CK-MB are useful for early assessment of reperfusion therapy.

The rejection mechanism of rat pancreaticoduodenal allografts with a class I MHC disparity

The present study has demonstrated for the first time that PVG.R1 (RT1.AaBcDcCc) pancreatic grafts are rejected by so-called "low"-responder PVG (RT1.AcBcDcCc) recipients with an isolated class I MHC disparity (mean survival time; MST: 21.4 +/- 1.8 days, n = 5), whereas PVG.R1 heart grafts are able to survive indefinitely (MST: > 100 days, n = 5). Splenic CD4+ T cells but not CD8+ T cells from the PVG recipients of PVG.R1 pancreatic grafts show a remarkable proliferative response against donor class I RT1.Aa alloantigens, while only a minimal proliferation is observed in the PVG recipients of PVG.R1 heart grafts or naive PVG rats. Naive PVG rats display an extremely low frequency of IL-2-producing helper T cell precursors (fThp) of 1/40,609 +/- 15,441 against class I RT1.Aa alloantigen. The PVG recipients of PVG.R1 heart grafts have a slightly greater fThp of 1/17,326 +/- 6822. On the other hand, the PVG recipients that rejected PVG.R1 pancreatic grafts show a significantly increased fThp of 1/5030 +/- 3396 compared with those of PVG.R1 heart grafts (P < 0.05) or naive PVG rats (P < 0.01). The frequency of cytotoxic T cell precursors (fTcp) increases slightly in the PVG recipients of PVG.R1 pancreatic grafts (1/1848 +/- 330) compared with those of PVG.R1 heart grafts (1/2215 +/- 2131) or naive PVG rats (1/2476 +/- 585). The size of cytotoxic T cell clones alone does not adequately account for a proliferation sufficient to complete the rejection of pancreatic grafts. The PVG recipients of PVG.R1 pancreatic grafts, but not heart grafts, demonstrate a strong cytotoxic alloantibody response to donor class I RT1.Aa alloantigens. In the study of alloantibodies, IgM is detected mainly in the early phase and IgG in the late phase during the course of pancreatic rejection. It is determined that in blocking studies by FACS analysis these antibodies target class I MHC antigens. These results suggest that cytotoxic T cells do not appear to be responsible for the rejection of PVG.R1 pancreatic grafts in PVG recipients. Rather, the rejection is mediated by CD4+ T cells and complement-fixing antibodies directed at class I MHC antigens.

Rapid diagnosis of coronary reperfusion by measurement of myoglobin level every 15 min in acute myocardial infarction

OBJECTIVES

The purpose of this study was to examine whether coronary reperfusion can be diagnosed rapidly and accurately by myoglobin measurements.

BACKGROUND

When intravenous thrombolysis is used for acute myocardial infarction, it is important to determine coronary reperfusion rapidly and noninvasively so that further treatment can be initiated.

METHODS

We determined myoglobin, creatine kinase (CK) and creatine kinase, MB fraction (CK-MB) isoenzyme levels in 63 patients with acute myocardial infarction with total occlusion of the infarct-related artery that was confirmed by coronary angiography. Myoglobin was measured by turbidimetric latex agglutination, which has an assay time of 10 min. We measured myoglobin, CK and CK-MB every 15 min in 45 patients with and 18 patients without reperfusion. The condition of the infarct-related artery was confirmed every 5 to 8 min by coronary angiography.

RESULTS

The rate of increase in myoglobin, CK, and CK-MB at 15, 30, 45 and 60 min after treatment and reperfusion was significantly higher in the reperfused than in the nonreperfused group. In the reperfused group, the rate of increase in myoglobin was significantly higher than the corresponding rate of increase in CK and CK-MB at 15, 30 and 45 min after reperfusion. When reperfusion was evaluated on the basis of a cutoff level (myoglobin > or = 2.0, CK > or = 1.8, CK-MB > or = 1.5), the predictive accuracy of myoglobin (95%) was significantly higher than that of CK (68%) and CK-MB (73%) at 15 min after reperfusion.

CONCLUSIONS

Coronary reperfusion can be rapidly and accurately detected by measurement of the plasma myoglobin every 15 min.

Primary structure and molecular basis of polymorphic appearance of an acetyltransferase (AT-II)* in hamsters

Three hamster clones (clones 1, 2 and 3) were isolated from a genomic library constructed from a homozygote rapid acetylator using a cDNA (hamAT-101) of a monomorphic acetyltransferase (AT-I) as a probe. Clone 1 (13 kbp) was found to contain a gene corresponding to AT-I. The entire coding region was located in an exon and completely identical to that of AT-I cDNA. Clones 2 and 3 (14.5 and 15 kbp) each contained identical information to the AT-I-related protein (AT-B protein). The intronless coding region shared 83.7% of sequence similarly to the AT-I cDNA, and its length was identical to that of the AT-I cDNA. Clone 2 also included a nucleotide sequence identical to the 3'-portion of the AT-I gene, which is located 5'-upstream of the AT-B gene. Restricted fragment lengths of clone 3, which encompassed the entire coding region was expressed in COS-1 cells. The expressed protein migrated at a position identical to that of AT-II purified from a hamster liver on Western blots. AT-B-expressed protein catalysed acetyl CoA-dependent N-acetylation of 2-aminofluorene and p-aminobenzoic acid, but had marginal activities for O-acetylation of 2-N-hydroxyamino-6-methyl-6-methyldipyrido[1,2-a:3',2'-d]imidazole and N-hydroxyarylacetamide-dependent N-acetylation of 4-aminoazobenzene. These results are in good agreement with the data of AT-II purified from hamster livers, indicating that the AT-B gene encodes a polymorphic acetyltransferase (AT-II) in hamsters. Although the AT-II protein was undetectable in slow acetylators, specific mRNA, hybridizing with a selective oligonucleotide probe for the AT-II gene (AT-B), was detected in livers of both homozygous acetylators. Analysis of genomic DNA of a homozygous slow phenotype hamster indicates that AT-II DNA from the slow phenotype has a point mutation which causes premature termination at the 243th (Arg to stop codon) position of the deduced amino acid sequence. PCR-RFLP analysis further confirmed that the point mutation conferred a defective AT-II protein in slow phenotype hamsters.

[Traumatic middle cerebral artery occlusion]

A 16-year-old boy developed motor aphasia and right hemiplegia after head trauma caused during Rugby football club activity. About 2 hours after trauma, these neurological deficits improved dramatically. CT scan on admission revealed no abnormal finding. But, on the next day, CT scan revealed an irregular low density area at the left basal ganglia. Cerebral angiography showed a slight narrowing at the left carotid siphon, severe stenosis at M1 portion of the left middle cerebral artery with vasospasm of its distal branches and occlusion of the left anterior temporal artery. The extracranial portion of the left internal carotid artery was intact. Clinically, the patient recovered from the right hemiparesis almost fully and was discharged after 1 month with mild dyscalculia. Three months later, follow-up angiography disclosed stenosis of the left M1 portion but the narrowing of the carotid siphon and vasospasm of the peripheral branches of the middle cerebral artery had been normalized, and the anterior temporal artery was recanalized. The pathogenesis of the occlusion is classified into 4 causes, 1) embolism from internal carotid artery, 2) vasospasm, 3) thrombus formation, 4) dissection. However, the demonstration of this by angiography is difficult. In our case, the injury of the intracranial portion of the internal carotid artery, which caused the intimal injury, spasm or thrombus formation, might have happened and resulted in embolisation and recanalization of the middle cerebral artery.