Atrial double potentials associated with the elimination of the electrical connection between the coronary sinus (CS) and the left atrium in two cases of Wolff-Parkinson-White syndrome with a CS-connected accessory pathway

A curious retrograde conduction in connection with the coronary sinus (CS) musculature was observed in 2 patients. After the failed ablation procedure, the atrial electrogram during ventricular pacing presented double potentials, the first component of which was sharp and with an activation sequence that was the same before ablation (CS distal to proximal). The second component of the double potentials was dull and had a decremental property; its activation sequence was in reverse (proximal to distal). In both cases, the first component disappeared after successful ablation. These findings suggest that the first component was the CS electrogram conducted over the accessory pathway and the second component was the left atrial electrogram conducted through the inter-atrial septum. The separation of each electrogram is probably the result of a block between the accessory pathway connected to the CS musculature and the left atrium. These are unusual cases of an accessory pathway connected to the CS musculature, which separates the left atrial myocardium at the distal portion from the ostium.

Development and sexual difference in embryonic heart rates in pregnancies resulting from in vitro fertilization

The purpose of this study was to investigate the gestational change of embryonic heart rates (EHRs) and to estimate the influence of embryonic sex on the EHR in pregnancies resulting from in vitro fertilization in the early first trimester. With transvaginal ultrasonography, we performed 92 and 105 examinations, on 27 male and 30 female embryos, respectively. The EHR increased gradually from 87 beats per min at 38 days of gestation to 189 beats per min at 62 days of gestation. The relationship between gestational age and EHR was explored by regression analysis: male EHR (beats per min) = 3.78 x gestational age (days) - 51.30 (r = 0.95), female EHR = 3.65 x gestational age - 44.56 (r = 0.95). These regression lines were mutually included in the 95% confidence intervals for each other. Our results indicate both a close positive correlation between the EHR and gestational age and no statistically significant difference in the EHR between male and female embryos. These findings suggest that the EHR measurement is a novel method for very early ultrasound dating with the identical EHR criterion without regard to embryonic sex.

Autologous dendritic cells or cells expressing both B7-1 and MUC1 can rescue tumor-specific cytotoxic T lymphocytes from MUC1-mediated apoptotic cell death

We attempted to induce MUC1-specific cytotoxic T lymphocytes (CTLs) by mixed-lymphocyte tumor cell culture (MLTC) using two allogeneic MUC1-positive cancer cell lines, T-47D and MCF7. The induced CTLs exhibited MUC1-specific cytotoxicity 16 days after the initial stimulation. However, these CTLs underwent apoptotic death within 16 days. To examine whether the B7-1 molecule is required for the expansion of the responder cells, a B7-1(+)/MUC1(-) cell line was transfected with MUC1 cDNA, and the resulting transfectant was employed as a stimulator in an autologous MLTC. The CTLs exhibited MUC1 specificity but also continued to propagate. In parallel, autologous dendritic cells (DCs) were added to an MLTC containing peripheral blood lymphocytes (PBLs) and the allogeneic MUC1-positive stimulators. The CTLs demonstrated MUC1 specificity and their number increased. This suggests that the B7-1 molecule is required for rescuing CTLs from MUC1-mediated apoptotic death, but not for the induction of MUC1-specific responsiveness. This strategy to obtain the CTLs efficiently may be useful for adoptive immunotherapy against cancer.

[Evaluation of coronary flow reserve in patients with vasospastic angina]

OBJECTIVES

The presence of microvascluar impairment was evaluated in 154 patients with vasospastic angina identified by the acetylcholine provocation test.

METHODS

Coronary flow reserve was evaluated with a Doppler flow guidewire in 128 vessels of 72 patients with chest pain, but no significant coronary stenosis(less than 50% stenosis) and no clinical factors that affect coronary flow reserve. Coronary flow reserve was obtained from the ratio of adenosine triphosphate-induced maximum/baseline averaged peak velocity. These vessels were classified into 2 categories according to whether acetylcholine-induced vasospasm was positive or negative. Vasospasm positive was defined as more than 90% stenosis provoked with chest pain and/or ischemic ST change. Positive vessels were subdivided according to focal or diffuse vasospasm. These vessels were also classified into 2 other categories according to whether vasospasm in the distal artery was positive or negative.

RESULTS

Coronary flow reserve was significantly lower in vessels with vasospasm than in vessels without vasospasm in patients without vasospasm(2.9 +/- 0.8 vs 3.6 +/- 1.0, p = 0.0005). Coronary flow reserve was significantly lower in vessels without vasospasm in patients with vasospasm than in vessels without vasospasm in patients without vasospasm(3.0 +/- 0.8 vs 3.6 +/- 1.0, p = 0.03). There was no significant difference in coronary flow reserve between vessels with vasospasm and vessels without vasospasm in patients with vasospasm(2.9 +/- 0.8 vs 3.0 +/- 0.8, p = 0.8). There was no significant difference in coronary flow reserve between focal and diffuse vasospasm(3.2 +/- 0.8 vs 2.9 +/- 0.8, p = 0.3). Coronary flow reserve was significantly lower in vessels with vasospasm in the distal artery than in vessels without vasospasm in the distal artery (2.8 +/- 0.8 vs 3.4 +/- 1.0, p = 0.004).

CONCLUSIONS

Patients with vasospastic angina have microvascular impairment in both vessels with vasospasm, and vessels without vasospasm. Microvascular impairment is prominent in vessels with vasospasm in the distal artery.

Lack of an association between T-wave alternans and ST-segment depression during exercise-induced ambulatory ischemia

It is known that T-wave alternans (TWA), which identify patients at risk for arrhythmic events, often occur during acute coronary occlusion in association with ST-segment elevation. To test the hypothesis that TWA is associated with a certain state/severity of myocardial infarction/ischemia, we assessed the association between TWA and ST-segment depression during exercise-induced ambulatory ischemia. Of 351 consecutive patients with coronary artery disease who underwent assessment of microvolt TWA by exercise, 23 patients with effort angina without a history of infarction with ST depression (> or =0.11 mV) during TWA test were selected. These patients were compared with 222 postinfarction patients consisting of 38 patients with, and 184 patients, without the ST depression, and 18 normal individuals. The incidence (9%) of determinate TWA in the patients with angina was significantly (P < .0001) lower than that (52%) in the postinfarction patients. There was no significant difference between the angina patients and the controls (6%). There was also no difference between the patients with (58%) and without the ST depression (51%) in the postinfarction patients. Moreover, no correlation existed between the TWA voltage and the ST-depression magnitude in both angina and postinfarction patients. We concluded that there is no association between TWA and ambulatory ischemia with ST depression.

Results of combined resection of adjacent organs in lung cancer

BACKGROUND

Indications for surgical treatment in advanced lung cancer still remain to be established.

METHODS

The outcomes of combined resection of adjacent organs in lung cancer were assessed in terms of complications and the invasiveness of surgery, using intraoperative blood loss and operation time as indices.

RESULTS

In 68 patients undergoing combined resection between 1980 and 1997, the 5-year-survival rates and the incidence of complications and hospital deaths were 24.5%, 52.9%,and 10.3%, respectively. The mean blood loss and operation time were 1,200 ml and 396 minutes. The rares of complications and hospital deaths were significantly higher in the group with 1,000 ml or more blood loss, and in the group with 360 minutes or longer operation time.

CONCLUSIONS

In terms of the survival rate, invasiveness of surgery, and complications, the pleura and pericardium were the best indications for combined surgery. For the thoracic wall, blood loss was greater and the rates of complications and hospital deaths tended to be higher among T3 cases. Both blood loss and operation time tended to be greater in T4 cases. Indications for surgery need to be carefully determined with respect to curability.

[Squamous cell type lung cancer that produced granulocyte colony-stimulating factor]

A 73-year-old man was hospitalized because of weight loss and fever. Laboratory data showed marked leukocytosis (21,200/mm3), granulocytosis (89.7%), thrombocytosis (47.8 x 10(4)/mm3), increased CRP (15.8 mg/dl), and increased SCC (5.0 ng/ml). Chest X-ray films demonstrated a mass shadow in the right upper lung field. Chest computed tomographic scans revealed a mass shadow 58 mm in diameter with mediastinal pleural invasion in the right S1. Right upper lobectomy and dissection of regional lymph nodes was performed under a diagnosis of lung cancer (squamous cell carcinoma, T3 N0 M0 stage IIB) with concomitant infection. Serum G-CSF was 234 pg/ml pre-operatively and 68.8 pg/ml postoperatively. The cytoplasm of tumor cells stained positively with anti-recombinant human G-CSF monoclonal antibody. No general bacteria or mycobacteria were detected within the specimen. Postoperatively, the patient's white blood cell count, platelet count, and CRP level soon decreased, and the fever disappeared. We diagnosed the disease as G-CSF-producing squamous cell type lung cancer.

[Mistaken grafting to diagonal branch in minimally invasive direct coronary artery bypass: a case required reoperation]

The patient was a 75 year-old male who was admitted with recurrent chest pain during hemodialysis one year after PTCA to the right coronary artery and left circumflex branch (LCX). He had the history of cerebral infarction and chronic renal insufficiency. Coronary angiography showed severe stenosis from the left main trunk to left anterior descending artery (LAD) and restenosis at the PTCA site of LCX. The LCX lesion was dilated with PTCA. Minimally invasive coronary artery bypass (MIDCAB) with left internal thoracic artery (LITA) to LAD was carried out uneventfully. However, chest pain appeared on 1 POD. LITA angiography revealed that LITA was anastomosed to the diagonal branch that had occluded completely in the preoperative angiography. Off-pump CAB to LAD using inferior epigastric artery was carried out through median sternotmy on the same day. He recovered smoothly, and LITA angiography before discharge demonstrated that both grafts to LAD and diagonal branch are patent.

Combined assessment of T-wave alternans and late potentials used to predict arrhythmic events after myocardial infarction. A prospective study

OBJECTIVES

The aim of the present study was to determine whether the combination of two markers that reflect depolarization and repolarization abnormalities can predict future arrhythmic events after acute myocardial infarction (MI).

BACKGROUND

Although various noninvasive markers have been used to predict arrhythmic events after MI, the positive predictive value of the markers remains low.

METHODS

We prospectively assessed T-wave alternans (TWA) and late potentials (LP) by signal-averaged electrocardiogram (ECG) and ejection fraction (EF) in 102 patients with successful determination results after acute MI. The TWA was analyzed using the power-spectral method during supine bicycle exercise testing. No antiarrhythmic drugs were used during the follow-up period. The study end point was the documentation of ventricular arrhythmias.

RESULTS

The TWA was present in 50 patients (49%), LP present in 21 patients (21%), and an EF <40% in 28 patients (27%). During a follow-up period of 13 +/- 6 months, symptomatic, sustained ventricular tachycardia or ventricular fibrillation occurred in 15 patients (15%). The event rates were significantly higher in patients with TWA, LP, or an abnormal EF. The sensitivity and the negative predictive value of TWA in predicting arrhythmic events were very high (93% and 98%, respectively), whereas its positive predictive value (28%) was lower than those for LP and EF. The highest positive predictive value (50%) was obtained when TWA and LP were combined.

CONCLUSIONS

The combined assessment of TWA and LP was associated with a high positive predictive value for an arrhythmic event after acute MI. Therefore, it could be a useful index to identify patients at high risk of arrhythmic events.

Physical development of surgically treated patients with primary spontaneous pneumothorax

STUDY OBJECTIVES

There have been many studies on the physical characteristics at the time of contraction of a primary spontaneous pneumothorax (PSP), but it has not been shown when and how such physical characteristics develop. These issues were investigated.

PATIENTS AND DESIGN

Physical development of 27 male patients with PSP were examined. Their physical records were collected with the patients' permission, and standard curves, estimated from the Japanese nationwide records in the year corresponding to the ages of the patients, were plotted as control values.

RESULTS

The height of patients was already greater at 6 years of age. It showed a marked increase from 11 to 14 years. The body weight was more than the standard until 9 years, but it became less after age 11, and this difference increased after age 15. Rohrer's index was significantly lower than the standard at all ages, and the difference was particularly large from 11 to 15 years. In the standard group, there was a balance between the annual height and weight gain. In the patient group, annual weight gain was similar to that in the standard group whereas height began to increase 2 years earlier, and as a result, ectomorphy, which was also observed before this age, became marked at this age.

CONCLUSIONS

The rapid increase in the vertical dimension of the thorax compared with the horizontal dimension during the period of rapid physical development is considered to affect intrathoracic pressure at the apex of lung, which would have some influence on enhancing cyst formation.

A simple technique for anatomical slow pathway ablation in atrioventricular nodal reentrant tachycardia

The slow pathway potential or the slow potential serves as a useful marker in catheter ablation of the slow pathway. However, an anatomical approach without recording of these potentials is also an effective way to cure atrioventricular nodal reentrant tachycardia (AVNRT). Moreover, the origin of these potentials is a matter of controversy. We compared 2 approaches to ascertain whether or not recording of these potentials is necessary in eliminating the slow pathway and to estimate the usefulness of the simple anatomical approach. The study population consisted of 24 patients with a conventional approach (Group P) and 19 patients with an anatomical approach (Group A). In group A, the ablation site was determined by fluoroscopy, which was the lowest one-third of the area between the His bundle electrogram recorded position and the coronary sinus orifice at the right anterior oblique view, and just in front of and above the coronary sinus orifice also posterior to the His catheter at the left anterior oblique view where the His catheter was seen tangentially. The slow pathway was successfully ablated in all patients without any complications, including more than first-degree AV block. Although there were no significant differences in total energy or number of applications between the 2 groups, the procedure time was significantly shorter in group A (p < 0.01). In conclusion, recording of the slow pathway potential or the slow potential is not always necessary for slow pathway ablation in the treatment of AVNRT. Because our anatomical approach was performed simply, effectively and safely, it is recommended for the slow pathway ablation of AVNRT.

Role of transforming growth factor-beta1 and decorin in development of central fibrosis in pulmonary adenocarcinoma

Transforming growth factor-beta1 (TGF-beta1) is known as the growth factor that stimulates the synthesis of extracellular matrix. Recently, TGF-beta has been found to control the growth of cancer cells. Small chondroitin-dermatan sulfate (decorin) is an abundant extracellular matrix component. TGF-beta1 stimulates the synthesis of decorin, and decorin is considered to bind TGF-beta1. The activity of decorin in neutralizing TGF-beta1 activity suggests that decorin serves as a negative-feedback regulator of TGF-beta1 activity. To investigate the role and relationship of TGF-beta1 and decorin in the formation of central fibrosis in pulmonary adenocarcinoma, we performed an immunohistochemical study of TGF-beta1 and decorin in 61 cases of T1 pulmonary adenocarcinoma. Positive stainings for TGF-beta1 were shown in 40 cases and negative in 21 cases. Twenty-seven of 32 cases with central fibrosis were positive for TGF-beta1. Positive staining for TGF-beta1 was significantly related to the appearance of central fibrosis in pulmonary adenocarcinoma. When central fibrosis was composed of proliferative connective tissue with loose staining for decorin, cancer cells showed intense staining for TGF-beta1. When central fibrosis was composed of old fibrotic tissue with dense staining for decorin, cancer cells showed weak staining for TGF-beta1. Our results suggest that TGF-beta1 has an important role in the formation of central fibrosis in pulmonary adenocarcinoma, and decorin may play a role as a negative feedback regulator in the production of TGF-beta1 in pulmonary adenocarcinoma.

Giant hamartoma of the lung

In the following case of giant pulmonary hamartoma, a 62-year-old woman exhibited a huge tumor shadow in the right lung field, whilst remaining asymptomatic. A thoracotomy revealed a solid intrapulmonary mass histologically diagnosed as a cartilaginous hamartoma with no evidence of malignancy. The tumor was resected by enucleation and there has been no recurrence for 40 months since surgery. Parenchyma-saving enucleation or excision is a safe and sufficient procedure for peripheral hamartomas of any size.

[Intraabdominal organ injury due to blunt chest trauma--report of two cases]

Two cases of intraabdominal organ injuries due to blunt chest trauma are reported. A 58-year-old man was admitted to our hospital with multiple rib fractures, hemopneumothorax and left flail chest. An emergency operation was performed and intraoperative findings revealed that the fractured rib was penetrating through the diaphragm to the stomach. A 52-year-old woman was admitted to our hospital with left multiple rib fractures and hemopneumothorax. Her treatment included chest tube drainage, but a week after admission, intraabdominal bleeding occurred due to a ruptured spleen, necessitating an emergency operation (splenectomy). Blunt chest trauma injury is usually accompanied by multisystem injury. Therefore, it is important to detect intraabdominal injury during an emergency operation and the follow-up period.

Reconstruction of the aortic arch in invasive thymoma under retrograde cerebral perfusion

Extensive en-bloc resection of the aortic arch and anterior wall of the main pulmonary artery was performed in a 46-year-old man with invasive thymoma. The aortic arch was replaced with a Hemashield vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion. Patch plasty with Xenomedica was performed for the anterior wall of the main pulmonary artery under cardiopulmonary bypass. The patient was treated with postoperative radiotherapy and has remained asymptomatic for 15 months after the operation. An extensive operation is considered necessary to improve the prognosis of invasive thymoma.

[A case report of anomalous systemic arterial supply to the left basal lung]

A 38-year-old woman with a history of hemosputum once in a several years was admitted to our hospital because of a mass shadow in the left lower lung field on chest X-ray film. Physical examination revealed neither cardiac murmur nor any sign of heart failure. Chest X-ray film showed a tumorous shadow in the left posterior basal segment. Chest CT scan showed that this shadow was consisted of enhanced, dilated and torutuous vessel and was connected to the descending thoracic aorta. Angiographic examinations showed that there was no normal left basal trunk of the pulmonary artery, and revealed an anomalous arterial supply to the basal segments from the descending thoracic aorta, with an expanded left inferior pulmonary vein. Broncho-fiberscopy showed no abnormal findings in the bronchial tree except for mild stenosis of the left basal bronchus. This case was diagnosed as an anomalous systemic arterial supply to the left basal lung (Pryce type I). The left lower lobe without pulmonary sequestration and the anomalous systemic artery were resected. Microscopically, the anomalous artery showed an elastic type, and the peripheral lung areas showed congestion. The postoperative course was uneventful. We collected reports of 26 cases of the same anomalies in Japan and discussed the difference of this anomaly from pulmonary sequestration.

Incidence of apoptotic bodies in membrana granulosa of the patients participating in an in vitro fertilization program

OBJECTIVE

To investigate the incidence of apoptotic bodies in mural granulosa cell masses and cumulus cell masses.

DESIGN

Nonrandomized, prospective study.

SETTING

Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Yamagata, Japan.

PATIENT(S)

One hundred twenty-nine normally ovulating women underwent ovulation induction for IVF-ET with GnRH analogue (GnRH-a) and gonadotropins.

INTERVENTION(S)

Patients underwent follicle aspiration after the administration of hCG.

MAIN OUTCOME MEASURE(S)

The nuclei of recovered granulosa cells were examined by fluorescence microscopy and the incidence of apoptotic bodies was tabulated.

RESULT(S)

The incidence of apoptotic bodies was significantly higher in mural granulosa cell masses than in cumulus cell masses in the entire group of 129 patients. Both incidence of apoptotic bodies of mural granulosa cell masses and cumulus cell masses were significantly higher in patients with less than six follicular oocytes compared with patients with six or more oocytes. Nonpregnant patients showed significantly higher incidence of apoptotic bodies in mural granulosa cell masses compared with pregnant patients.

CONCLUSION(S)

These results indicate that mural granulosa cell masses and cumulus cell masses may have different functions in follicular maturation. The incidence of apoptotic bodies in mural granulosa cell masses can be used as an indicator of success of IVF.

Sequential observation of micrometastasis formation by bacterial lacZ gene-tagged Lewis lung carcinoma cells

Sequential events in micrometastasis formation including entry into the blood circulation and arrest, extravasation and initial growth in the lung was investigated using bacterial lacZ gene-tagged Lewis lung carcinoma cells (4A1-1). Micrometastases in the lung could thereby be specifically detected at the single cell level by X-Gal staining. After intravenous injection, X-Gal positive tumor cells appeared to extravasate within hours, but most cells then degenerated or died in the alveolar space by 2-3 days postinjection. A decreased BrdU labeling index to a negligible level at 2 days postinjection and reduction of X-Gal positive foci to a basal level (less than 0.1% of injected cells) by 4 days are in line with rapid clearance of tumor cells from the lung. The size and BrdU labeling indices of the persisting X-Gal positive foci, however, started to increase from 4 days postinjection. Type IV collagen immunostaining demonstrated loss of pre-existing basement membranes with growth of micrometastases: When 4A1-1 cells were inoculated subcutaneously, lung micrometastases from resulting tumors were detected as single or small numbers of X-Gal positive cells at 2 weeks postinjection. Progressive development of micrometastasis to macroscopic metastasis was noted by 4-5 weeks postinjection. The results indicate that micrometastasis formation by Lewis lung carcinoma cells involves a sequence of events starting with rapid extravasation after arrest in the lung within 1 day, followed by death of most cells at 2-3 days and subsequent new growth and expansion of persisting tumor cells from 4 days postinjection.

Induction of invasive squamous cell carcinomas in the forestomach of (C3H x MSM)F1, MSM, and C3H mice by N-methyl-N-nitrosourea and mutational analysis of the H-ras and p53 genes

Genetic analysis of tumors developing in F1 hybrids between genetically separate strains of mice makes it possible to search for loss of heterozygosity (LOH), information on which provides clues to finding tumor-suppressor genes. For this purpose, however, reproducible carcinogenic conditions for the organ of interest need to be first determined. In the present study, a forestomach model of squamous cell carcinomas (SCCs), induced in (C3H x MSM)F1 mice by N-methyl-N-nitrosourea (MNU), was established and mutational changes in the H-ras and p53 genes were examined in tumors. Male (C3H x MSM)F1, MSM and C3H mice were given MNU by i.g. intubation once a week at a dose of 0.03 mg/g body weight for 10 weeks, then kept without further treatment. At experimental weeks 38-46, markedly invasive SCCs were observed in the forestomach at incidences of 9/14 (64.3%), 9/16 (56.3%), and 2/10 (20.0%), respectively. In the three strains of mice, DNA analysis of SCCs by PCR-SSCP analysis followed by direct DNA sequencing revealed low incidences of point mutations in the H-ras (4/20, 20%) and p53 (3/20, 15%) genes. The results demonstrate the usefulness of the present animal experimental protocol for induction of high grade SCC in the forestomach of (C3H x MSM)F1 mice, and suggest the possibility that point mutations in the H-ras or p53 genes may play some role in pathways leading to the development of such lesions.