[Reoperation after correction of total anomalous pulmonary venous connection: particularly for postoperative pulmonary vein stenosis]

Postoperative pulmonary vein stenosis is a major complication after the correction of the total anomalous pulmonary venous connection. Six patients developed this complication 2 to 3 months after surgery. Five underwent reoperation (3 had the third operations) with only one survivor. Risk factors for developing the stenosis were 1. small common pulmonary vein with small branches occurring in the patients with the ages at the operation below 2 days and accordingly with the infradiaphragmatic connection and 2. Y-shaped common pulmonary vein with the confluence situated far below the left atrium. Turbulence seemed the major cause of the intimal thickening occurring in the common pulmonary vein shortly distant from the orifices of the branches. Typically the anastomotic orifice was not narrowed. Relief of the stenosis was done by the excision of the hypertrophied intimal tissue frequently cutting into the branches. Severe stenosis recurred in 4 patients necessitating another operation in 3 patients which was fatal in two. Prevention is important. Creation of a large anastomosis with the incision not extending into the branches and the use of the absorbable suture materials were effective. In the infradiaphragmatic connection incorporation of the divided stump of the descending vein into the anastomosis and a T-shaped incision of the left atrium were also important.

Effect of digoxin on exercise performance in mildly symptomatic patients with idiopathic dilated cardiomyopathy and sinus rhythm

The purpose of this investigation was to evaluate the effect of digoxin on aerobic performance in mildly symptomatic patients with congestive heart failure and sinus rhythm. Ten patients (8 men and 2 women) with idiopathic dilated cardiomyopathy (ejection fraction 17 to 33%, mean 27 +/- 4%) who were stable and mildly symptomatic with maintenance digoxin and diuretic therapy were studied. All patients underwent maximal symptom-limited ergometer exercise with analysis of respiratory gases during maintenance digoxin therapy, 4 weeks after digoxin withdrawal, and 4 weeks after digoxin readministration. Exercise capacity was assessed by peak oxygen uptake and anaerobic threshold. Serum digoxin concentration was 1.0 to 1.8 (mean 1.3 +/- 0.2) ng/ml during digoxin therapy, and less than the detectable level after digoxin withdrawal. No patients showed clinical deterioration after digoxin withdrawal. Peak oxygen uptake after digoxin withdrawal (23.7 +/- 3.0 ml/kg/min) did not differ significantly from that during maintenance digoxin therapy (23.8 +/- 2.5 ml/kg/min) or after digoxin readministration (24.1 +/- 2.9 ml/kg/min). The anaerobic threshold after digoxin withdrawal (14.9 +/- 2.5 ml/kg/min) did not differ significantly from that during maintenance digoxin therapy (15.0 +/- 2.1 ml/kg/min) or after digoxin readministration (14.9 +/- 2.2 ml/kg/min). No differences in heart rate and diastolic blood pressure were observed during exercise, but systolic blood pressure during exercise was significantly higher with digoxin therapy (p < 0.05). These results suggest that digoxin has no effect on aerobic performance in mildly symptomatic patients with idiopathic dilated cardiomyopathy and sinus rhythm.

Angiotensin II inhibits cytokine-stimulated inducible nitric oxide synthase expression in vascular smooth muscle cells

In cultured vascular smooth muscle cells (VSMC), inflammatory cytokines such as interleukin 1 beta (IL-1 beta) and tumor necrosis factor alpha stimulated nitric oxide (NO) production via the expression of an inducible type of NO synthase (iNOS). A potent vasoconstrictor, angiotensin II (Ang II), which causes a rapid phospholipase C-mediated phosphoinositide hydrolysis via the Ang II type 1 (AT1) receptor in VSMC, by itself did not stimulate the production of nitrite, a stable metabolite of NO, but dose dependently inhibited the IL-1 beta-induced nitrite production. This inhibitory effect of Ang II was blocked by an AT1 receptor antagonist, CV-11974, but not by an Ang II type 2 receptor antagonist, PD 123319. The presence of Ang II during the early induction phase of iNOS was required for this inhibition. Consistently, Ang II suppressed IL-1 beta-induced increases in iNOS mRNA and protein levels. Ang II also inhibited increases in nitrite production and iNOS mRNA and protein levels caused by tumor necrosis factor alpha. A protein kinase C-activating phorbol ester, phorbol 12-myristate 13-acetate, and a membrane-permeable diacylglycerol, 1,2-dioctanoyl-glycerol, similarly inhibited the IL-1 beta-induced nitrite production and iNOS mRNA and protein expression, although repetitive additions were needed in the case of diacylglycerol. These results indicate that Ang II negatively modulates cytokine-induced NO production by blocking iNOS expression via the AT1 receptor in VSMC and suggest that protein kinase C could be involved in this process.

[Extended aortic arch anastomosis for coarctation of the aorta and interruption of the aortic arch in early infancy]

We performed extended aortic arch anastomosis, which was so called EAA procedure, for Coarctation of the Aorta (CoA) with hypoplastic aortic arch (HAA) and interruption of the aortic arch (IAA) in 17 infants under three months of age. The proximal anastomosis site was extended into ascending aorta in order that we could make non-obstructive pathway of systemic flow. During anastomosis, we employed mild systemic hypothermia and topical cooling of head and lumber lesion. Satisfactory anastomoses were performed without any neurological and renal complications except one case. Postoperative Doppler echographic evaluation revealed that the mean peak flow velocities at anastomotic site were under 2.0 m/sec at 1 and 2 years after surgery. We concluded that EAA procedure was useful for CoA with HAA and IAA in early infancy.

[Quantification of reversible perfusion abnormality using exercise-stress thallium SPECT before and after coronary revascularization]

Reversible myocardial perfusion abnormality was quantified by bull's eye and unfolded surface mapping methods in exercise thallium SPECT before and after coronary revascularization in 47 patients with angina pectoris, including 34 patients with previous myocardial infarction (PMI) and 13 with effort angina (AP). There was no difference in the incidence or extent of myocardial ischemia between the 2 groups before revascularization. However, the ischemic scores were significantly smaller in PMI group preoperatively than the reductions of the ischemic scores after revascularization. The ischemic scores, preoperatively estimated reversible perfusion abnormality was 32%, 69% and 48% of the improvement of the ischemic score (extent score, severity score, and ischemic area, respectively). Using the 3 ischemic scores, the improvement of perfusion abnormality was well predicted in 70-89% of AP patients but 35-57% of PMI patients. Thus, quantitative analysis in stress thallium SPECT is useful for detecting myocardial ischemia and evaluating the effect of coronary revascularization. However, about a half of myocardial viability was underestimated in one third of PMI patients by the conventional exercise-stress thallium SPECT study.

[A case of pulmonary sarcoidosis with circulatory insufficiency of segmental and subsegmental branches of pulmonary arteries]

A 50-year-old woman was admitted to our hospital on April 4, 1992, because of progressive worsening of dry cough and exertional dyspnea. Moderate hypoxemia and obstructive ventilatory impairment were present. Her chest roentgenogram and CT films showed thickened bronchovascular bundles in the absence of significant parenchymal fibrosis. Transbronchial lung biopsy revealed the formation of noncaseous epithelioid cell granulomas. Pulmonary perfusion scintigraphy showed multiple perfusion defects predominantly in the upper lung fields. Pulmonary ventilation scintigraphy showed a normal pattern. After administration of prednisolone for 3 months, her chest roentgenogram and CT films demonstrated marked decrease of infiltrates, but there was no improvement of hypoxemia and perfusion defects on pulmonary perfusion scintigraphy. Pulmonary angiography revealed multiple stenoses and occlusions of segmental and subsegmental branches of pulmonary arteries. Long-term steroid treatment will be necessary for this rare form of pulmonary sarcoidosis to prevent the development of pulmonary hypertension.

Pyridoxal 5'-phosphate probes at Lys-480 can sense the binding of ATP and the formation of phosphoenzymes in Na+,K(+)-ATPase

The Lys-480 in the alpha-subunits of Na+,K(+)-ATPase from pig kidneys was specifically modified with pyridoxal 5'-phosphate (PLP) or pyridoxal 5'-diphospho-5'-adenosine (AP2PL) probes in the presence of NaCl. The site was shown to be the same as the ATP-protectable binding of these probes (Hinz, H.R., and Kirley, T.L. (1990) J. Biol. Chem. 265, 10260-10265). Modifications strongly reduced both Na+,K(+)-ATPase activity and the amount of Na(+)-dependent phosphoenzyme from [32P]ATP but not from [32P]acetyl-phosphate (AcP). Addition of AcP to the enzyme induced a slight decrease in the fluorescence of the PLP probe in the presence of 2 M NaCl and 4 mM MgCl2 but a single exponential increase in the presence of 16 mM NaCl and 4 mM MgCl2. The addition of ATP induced single exponential fluorescence increases at both Na+ concentrations. The data show that these probes can sense molecular events related to the formation of phosphoenzymes induced by AcP and presumably to the formation of Mg-Na-ATP-enzyme complex. The data also suggest that PLP or AP2PL probes at Lys-480 in the presence of Na+ and Mg2+ do not affect the transphosphorylation from AcP to Asp-369 to form phosphoenzymes but that they inhibit the transphosphorylation from the gamma-phosphoryl group of ATP and also ATP binding in the absence of Mg2+.

SOD1 missense mutation in an Italian family with ALS

We have discovered a new Italian pedigree with autosomal-dominant ALS. The pedigree, at present, comprises 75 members distributed in five generations. ALS was diagnosed in eight patients. The mean +/- SD age of onset of the disease was 46.8 +/- 13.5 years, with a range of 29 to 63 years. The mean +/- SD duration of the disease was 11.6 +/- 1.7 months. Molecular genetic studies showed a missense mutation (Gly-->Ser, codon 41) in exon 2 of the Cu/Zn superoxide dismutase gene (SOD1) on chromosome 21 in the available affected member and in 45% of the at-risk subjects of the pedigree. This study confirms the presence of SOD1 point mutations in families with autosomal-dominant ALS and suggests that additional genetic or environmental factors may be involved in the full expression of the disease.

Autoradiographic analysis of [14C]deoxy-D-glucose in thyroid cancer xenografts: a comparative study with pathologic correlation

An experimental model of thyroid cancer was prepared for evaluating the accumulation of [14C]deoxy-D-glucose ([14C]DG) in thyroid cancer xenografts (AC2). A continuous cell line established from a biopsy specimen of a metastatic thyroid carcinoma possessed the ability to synthesize the cellular protein without increase in cell division after adding bovine TSH in vitro. The histological sections of the xenografts resected from the 131I treated nude mice mainly consisted of structures showing follicular and trabecular growth. Immunohistochemically the cytoplasm of the tumor cells was positive for human thyroglobulin(hTg). These observations provide strong evidence that the AC2 cell originates in the thyroid follicular epithelium. By comparing autoradiographic accumulation patterns of [14C]DG and histopathological examinations, it was found that the uptake of [14C]DG was higher in the granulation tissues surrounding necrosis than in viable tumor cells of trabeculary growing and follicle forming tissues. It is suggested that the degree of [14C]DG content reflects not only tumor cell viability and proliferation but also the inflammatory and degenerative reaction accompanying tumor cell growth.

Primary health care in Japan and the United States

Japan has universal health insurance and its total health expenditure as a percentage of the gross domestic product is almost 50% less than that of the United States where 15% of persons under age 65 are uninsured. The health of the Japanese population as judged by neonatal, postnatal, and total infant mortality, percent of infants born with birth weights below 2500 g, and life expectancy at birth and ages 20 and 65 is superior to the health of Americans. Primary care, however, as an academic discipline and primary care training programs are absent in Japan. Physician training, incongruent with need, combined with government controlled low professional medical fees contribute to an extraordinarily high annual ambulatory patient contact rate (14 compared with 2.8 for Americans) and excessive use of diagnostic testing. Although primary care training is better developed in the U.S.A., interest in receiving, such training among medical school graduates is declining. Several factors that contribute to quality of care are examined. Comparisons between countries, however, must be viewed with caution because of the multitude of demographic, genetic, historical, economic and cultural variables that influence how health care is delivered and received. Both countries face major challenges. The projected rapid increase in the relative ratio of the elderly to total population in Japan will severely strain its ability to contain health care costs. Interest in primary care training in Japan dates back to 1978 but its implementation has been largely unsuccessful. The challenges in the U.S.A. are far more formidable.(ABSTRACT TRUNCATED AT 250 WORDS)

Superior vena cava syndrome caused by a right apical tense bulla

Superior vena cava (SVC) syndrome is caused by several diseases, although to our knowledge, a bullous lesion has not been reported previously. In the present case, severe pleural adhesion prevented the expanding bulla from stretching the visceral pleura and from compressing the residual lung, subsequently causing compression of the SVC and thus SVC syndrome.

Resistance to pseudorabies virus with enhanced interferon production and natural killer cell activity in mice treated with serum thymic factor

Susceptibility to pseudorabies virus (PRV) infection in mice, which were continuously depleted of natural killer (NK) cell activity by injection of anti-asialo GM1, was examined. Effects of serum thymic factor (FTS) on susceptibility of mice to PRV were also investigated. In mice with depleted NK cell activity, the mortality of PRV-infected mice was markedly high, whereas that of FTS-pretreated mice was significantly lower than the controls. Reduced susceptibility to PRV was demonstrated in mice treated with anti-asialo GM1 antisera before the PRV infection. Such a reduced susceptibility was not observed in mice inoculated with the antisera on day 1 post-infection (PI). To analyze the FTS-induced resistance to PRV infection, NK cell activity, macrophage activity, and interferon (IFN) productions were studied. Interferon production and NK cell activity were enhanced in the FTS-pretreated mice, suggesting that interferon may play an important role in this FTS-induced resistance to PRV infection.

A case of malignant hemangiopericytoma: an immunohistochemical and ultrastructural study

We report one case of malignant hemangiopericytoma which started with a tumor in the lower jaw and multiple nodules in the lung. The tumor quickly metastasized to the brain and chemotherapy was not at all effective. Hemangiopericytoma is generally diagnosed by its histological characteristics. Recently, however, electron microscopy and immunohistochemical methods have been used for its diagnosis. In our case, electron micrograph showed the growth of hemangiopericytoma cells around immature endothelial cells. In addition, the tumor cells reacted positively only with anti-vimentin antibodies, and the endothelial cells in the tumor tissue were positive for antifactor VIII antibodies. The observed features were consistent with the characteristics of hemangiopericytoma.

Expression of nitric oxide synthase by cytokines in vascular smooth muscle cells

In cultured vascular smooth muscle cells, the baseline mRNA and protein levels of an inducible type of nitric oxide synthase were barely detectable. Interferon gamma, tumor necrosis factor-alpha, and interleukin-1 beta each markedly increased mRNA and protein levels of this enzyme in parallel with the production of nitrite, a stable oxidative metabolite of nitric oxide. Actinomycin D abolished the cytokine-induced increases in mRNA levels and nitrite production. Cycloheximide, which abolished the cytokine-induced increase in nitrite production, had no effect on the interferon-gamma-induced increase in mRNA levels but partially inhibited that induced by interleukin-1 beta and markedly inhibited that induced by tumor necrosis factor-alpha. Transforming growth factor-beta 1, which inhibited the interferon gamma-, interleukin-1 beta-, and tumor necrosis factor-alpha-induced nitrite production, did not affect the increases in mRNA levels caused by these cytokines. Transforming growth factor-beta 1, however, significantly inhibited the increase in protein levels caused by these cytokines. These findings suggest that interferon gamma directly induces the expression of the inducible nitric oxide synthase gene, whereas tumor necrosis factor-alpha and interleukin-1 beta induce it, at least in part, via the induction of intermediary protein(s), and that transforming growth factor-beta 1 inhibits cytokine-induced nitric oxide production by blocking the posttranscriptional synthesis of inducible nitric oxide synthase.

Radical scavenger effect of Boschniakia rossica

To elucidate the mechanism of the invigorating and antisenile action of the dried herb of Boschniakia rossica (Boschniakiae Herba), the free radical scavenging activity of its 50% ethanol extract (BR) was examined using an electron spin resonance spectrometer. The scavenging activity of plasma from Fisher-334 rats with continuous administration of BR was also examined. The concentrations showing 50% inhibition of the free radical of BR on the 1,1-diphenyl-2-picrylhydrazil (DPPH) radical, superoxide radical and hydroxyl radical were 0.003%, 0.06% and 9.67%, respectively. Plasma from the rats with BR administered clearly showed higher free radical scavenging activity compared with that of normal control rats. These findings suggest that Boschniakia rossica has strong free radical scavenging activity and consequently it has inhibitory effects on the disorders caused by free radical production in living tissue.

Cyclic AMP-elevating agents induce an inducible type of nitric oxide synthase in cultured vascular smooth muscle cells. Synergism with the induction elicited by inflammatory cytokines

In cultured vascular smooth muscle cells, interferon gamma (IFN-gamma) induced the accumulation of nitrite, a stable metabolite of nitric oxide, in a dose- and time-dependent manner. In parallel with this reaction, this cytokine increased the mRNA and protein levels of an inducible macrophage-type of nitric oxide synthase (iNOS). Forskolin, a direct activator of adenylate cyclase, or dibutyryl cAMP alone caused small increases in nitrite accumulation and iNOS mRNA and protein levels and synergistically enhanced the IFN-gamma-stimulated reactions. 8-Bromo-cGMP neither increased by itself nor synergized with IFN-gamma to increase the same reactions. Prostaglandin E1 and beraprost, a stable analogue of prostaglandin I2, which by themselves showed only marginal effects on these reactions, also synergized with IFN-gamma to stimulate the reactions. Interleukin 1 beta or tumor necrosis factor alpha stimulated the same reactions which were similarly enhanced by forskolin. These results indicate that an elevation of intracellular cAMP, particularly in combination with inflammatory cytokines, positively regulates nitric oxide production at the level of iNOS mRNA expression in vascular smooth muscle cells.

Analysis of the c-FOS gene on chromosome 14 and the promoter of the amyloid precursor protein gene in familial Alzheimer's disease

The c-FOS gene product, a putative transacting transcriptional regulator of the amyloid precursor protein (APP) gene, is a candidate locus for the familial Alzheimer's disease (FAD) mutation on chromosome 14 (FAD14). In light of this functional relationship, we investigated the nucleotide sequence and segregation of c-FOS and the nucleotide sequence of the 5' APP promoter. Single-stranded conformational polymorphisms (SSCPs) in the c-FOS gene revealed that c-FOS closely cosegregates with the FAD14 gene but does not show allelic association with FAD. A conservative third-position T-->C mutation was demonstrated in exon 2 (codon 84) of c-FOS, and a C-->G substitution was detected at -209 bp in the 5' promoter of APP. Neither were unique to FAD and are unlikely to be pathogenic or secondary modifiers of the FAD phenotype. We conclude that the c-FOS open reading frame is probably not the site of the FAD14 locus, but we cannot exclude the existence of modifier loci on chromosome 21.

Local spread of HDV infection transiently occurring in Japan

Hepatitis B virus (HBV) carriers and patients with acute hepatitis B living in the Kamigoto islands, a part of Japan with a high incidence of HBV carriage, were retrospectively tested for serum anti-hepatitis D virus (anti-HDV) and they were compared with the inhabitants of Oita City (an area with an average HBV carriage rate). The prevalence of anti-HDV in HBV-infected individuals was 8.3% (42/507) in Kamigoto and 0% (0/101) in Oita City. With one exception, all of the positive serum samples in Kamigoto were collected before 1986, and the mean age of the positive individuals was significantly younger than that of the negative individuals (P < 0.005). Among the 42 anti-HDV-positive patients, nine (21%) had definite liver disease. The route of infection was uncertain in most cases (i.e. sporadic), but two pairs of mothers and children were detected. Although the prevalence of anti-HDV positivity in Japan has been reported to be very low (about 1% or less), the present investigation showed that the local spread of HDV infection in Kamigoto occurred on a minor scale up to 1986. The infections presumably resulted from the closed environment and the high incidence of HBV carriage in these islands. Accordingly, there could be a considerable risk of the outbreak of HDV infection in the future under similar conditions, even in countries where the disease has never been detected previously.

Intermittent high-dose vitamin C therapy in patients with HTLV-I associated myelopathy

The efficacy of intermittent high-dose vitamin C therapy was evaluated in seven patients with HTLV-I-associated myelopathy (HAM). All HAM patients responded well to this therapy without serious side effects. Grade of disability score improved at 9.7 (SD 5.8) months after the therapy from 7.1 (3.3) to 3.6 (2.0) (p < 0.01). Serum immunosuppressive acidic protein was elevated before and decreased after the therapy from 747 (316) to 398 (86) micrograms/ml (p < 0.05), suggesting favourable immunomodulatory action of vitamin C therapy in HAM patients.