Lipophilic beta-adrenoceptor antagonist propranolol increases the hypnotic and anti-nociceptive effects of isoflurane in a swine model

BACKGROUND

We have previously reported that landiolol, an ultra-short-acting beta1-adrenoceptor antagonist, does not alter the anaesthetic effects of isoflurane. Here, we investigated the influence of propranolol on the electroencephalographic (EEG) effects and minimum alveolar concentration (MAC) of isoflurane.

METHODS

Fourteen swine [25.0 (SD 4.0) kg] were anaesthetized by isoflurane inhalation. The inhalation concentration was decreased to 0.5% and maintained for 25 min, before being returned to 2%, and maintained for a further 25 min. End-tidal isoflurane concentrations and spectral edge frequencies were recorded. Pharmacodynamic analysis was performed using a sigmoidal inhibitory maximal effect model for spectral edge frequency vs effect-site concentration. After measurement of the EEG effect, MAC was determined using the dew-claw clamp technique, in which movement in response to clamping is recorded. After completion of control measurements, a propranolol 4 mg bolus followed by an infusion (2 mg h(-1)) was started. After a 30 min stabilization period, the inhalation concentration of isoflurane was varied as in the control period and MAC was re-assessed.

RESULTS

Propranolol shifted the concentration-effect relationship to the left and decreased the effect-site concentration that produced 50% of the maximal effect from 1.30 (0.18) to 1.13 (0.17)%. Propranolol also decreased isoflurane MAC from 1.91 (0.35) to 1.54 (0.32)%.

CONCLUSIONS

Propranolol alters both the hypnotic and anti-nociceptive effects of isoflurane. In contrast to landiolol, lipophilic beta-adrenoceptor antagonists may increase the potency of inhalational anaesthetics.

Efficacy of a skin-protection powder for use as a dressing for intractable ulcers

OBJECTIVE

Stomahesive skin-protection powder has been reported to be useful as a skin-care and skin-barrier product for the management of stomas. This study aimed to evaluate its efficacy, in terms of wound healing, moisture retention and pain management, as an alternative to conventional dressing materials. Both clinical and animal studies were undertaken.

METHOD

The efficacy of the Stomahesive powder was tested by measuring the thickness of granulation tissue formed in a total skin defect in a db/db mouse model. We then compared the healing process using either the skin-protection powder or a conventional film dressing material. In the clinical study 17 patients with various intractable ulcers were treated with Stomahesive powder, and healing was evaluated.

RESULTS

In the mouse model, granulation tissue in the wounds treated with the powder was 2.86 times thicker than that of the wounds treated with the film dressing. In the clinical study, 16 out of 17 wounds healed completely.

CONCLUSION

The Stomahesive powder could be an effective treatment modality for contact ulceration, superficial ulcers with complex contours and morphology, and superficial ulcers contaminated by liquid faeces or vaginal discharge that have not responded to conventional dressings.

DECLARATION OF INTEREST

None.

Landiolol, an ultra-short-acting beta 1-adrenoceptor antagonist, does not alter the electroencephalographic effect of isoflurane in swine model

BACKGROUND

beta-Adrenergic blocking agents may interact with anaesthetics, and several studies suggest that beta-blockers attenuate electroencephalographic responses during general anaesthesia. We have investigated the influence of landiolol, an ultra-short-acting beta 1-adrenoceptor antagonist, on the electroencephalographic effect of isoflurane in pigs.

METHODS

Ten swine were anaesthetized through inhalation of 2% isoflurane. The inhalational concentration was then decreased to 0.5% and maintained for 25 min, before being returned to 2% and maintained for a further 25 min (control period). After control measurements, infusion of landiolol (at 0.125 mg kg(-1) min(-1) for 1 min, and then at 0.04 mg kg(-1) min(-1)) was started. After a 20 min stabilization period, the inhalational concentration was varied as in the control period (40 gamma landiolol). Finally, infusion of landiolol was increased from 0.04 to 0.2 mg kg(-1) min(-1), and after a 20 min stabilization period, the inhalational concentration was again varied as in the control period (200 gamma landiolol). End-tidal isoflurane concentrations and spectral edge frequencies were recorded throughout the study. Analysis of the pharmacodynamics was performed using a sigmoidal inhibitory maximal effect model for spectral edge frequency vs effect-site concentration.

RESULTS

There were no significant differences in the effect of isoflurane among the conditions used. Landiolol did not shift the concentration-effect relationship [the effect-site concentration that produced 50% of the maximal effect was 1.35 (0.17)% under control conditions, 1.30 (0.12)% at 40 gamma landiolol, and 1.38 (0.30)% at 200 gamma landiolol].

CONCLUSION

Landiolol does not alter the electroencephalographic effect of isoflurane.

Short communication: Is intrapartum temporary pacing required for women with complete atrioventricular block? An analysis of seven cases

Women with complete atrioventricular heart block without a permanent pacemaker normally receive temporary pacing for labour and birth. Here, we report seven women who were managed without pacing. All women had a temporary pacing lead inserted prior to induction of labour, but none of the women required pacing during labour or birth. Our experience suggests that women with complete atrioventricular block and without permanent pacing do not routinely require temporary pacing for labour and birth.

Comparison of isoflurane and propofol–fentanyl anaesthesia in a swine model of asphyxia

BACKGROUND

There have been few studies comparing the response to asphyxia and the effectiveness of typical cardiopulmonary resuscitation (CPR) using exogenous epinephrine administration and manual closed-chest compression between total intravenous anaesthesia (TIVA) and inhalational anaesthesia.

METHODS

Twenty pigs were randomly assigned to two study groups anaesthetized using either 2% end-tidal isoflurane (n=10) or propofol (12 mg x kg(-1) h(-1))-fentanyl (50 microg x kg(-1)) (n=10). Asphyxia was induced by clamping the tracheal tube until the mean arterial pressure (MAP) decreased to 40% of the baseline value (40% MAP time). The tracheal tube was declamped at that point, and CPR was performed. Haemodynamic parameters and blood samples were obtained before the induction of asphyxia, at 1-min intervals during asphyxia, and 1, 2, 3, 5, 10, 30 and 60 min after asphyxia.

RESULTS

TIVA maintained the MAP against hypoxia-hypercapnia stress significantly longer than isoflurane anaesthesia (mean (SD) 40% MAP time 498 (95) and 378 (104) s respectively). In all animals in the isoflurane group, spontaneous circulation returned within 1 min of the start of CPR. In six of the TIVA animals, spontaneous circulation returned for 220 (121) s; spontaneous circulation did not return within 5 min in the remaining four animals.

CONCLUSIONS

Although TIVA is less prone than isoflurane anaesthesia to primary cardiovascular depression leading to asphyxia, TIVA is associated with reduced effectiveness of CPR in which resuscitation because of asphyxic haemodynamic depression occurs.

Partial outlet obstruction of the rat bladder induces a stimulatory response on proliferation of the bladder smooth muscle cells

Outlet obstruction of the rat bladder induces hypertrophy/hyperplasia characterized by increases in bladder mass, smooth muscle content, and collagen deposition. In order to understand the mechanism of the outlet obstruction-induced hypertrophy and hyperplasia, we first determined the temporal pattern of changes in bladder mass after inducing the outlet obstruction. Histological analysis revealed that the smooth muscle cells with hypertrophy and hyperplasia, fibroblasts and connective tissue were increased in a time-dependent manner, corresponding to the temporal pattern observed in the changes in bladder mass, although the phase of changes in these tissue components was somewhat different. In order to further determine whether any proliferation-stimulatory factors were released from the bladder with obstruction in correspondence with increased bladder mass, soluble fractions were prepared from the bladders with outlet obstruction for 3-30 weeks, and their effects on proliferation of smooth muscle cells were examined. The soluble fractions prepared from the bladders at 3 to 14 weeks after obstruction slightly but significantly facilitated the proliferation of cultured smooth muscle cells, while the soluble fractions released after 20 weeks rather suppressed the proliferation. These results suggest that the initial increase in bladder mass might be in part due to the facilitated proliferation of smooth muscle cells of the bladder body induced by growth factors released into the soluble fractions, and that hypertrophy might then play a role in the increased bladder mass at later phases.

Influence of urinary sialic acid on calcium oxalate crystal formation

Using seed crystal method, whole-urine method, and scanning electron microscopy, the inhibitory effects of sialic acid and osteopontin (OPN) on aggregation/growth of CaOx crystals were investigated. Using the seed crystal method, sialic acid showed an inhibitory effect on CaOx crystal aggregation/growth in a concentration-dependent manner, but almost no effect was observed using the whole-urine method. OPN showed an inhibitory effect on aggregation/growth in both experimental systems. The inhibitory effect of asialo-OPN on aggregation/growth was approximately 20% lower than that of OPN in the experiment using the seed crystal method and approximately 15% lower in the experiment using the whole-urine method. Scanning electron microscopy showed that OPN and sialic acid inhibit the aggregation of CaOx crystals. The above findings show that sialic acid accounts for about 15-20% of the involvement of OPN in CaOx crystallization.

Abnormal response to sodium channel blockers in patients with Brugada syndrome: augmented localised wall motion abnormalities in the right ventricular outflow tract region detected by electron beam computed tomography

OBJECTIVE

To investigate the relation between the wall motion abnormalities and sodium channel abnormalities in cases of the Brugada syndrome.

DESIGN

Consecutive prospective case-control study in a single hospital.

SETTING

Tertiary referral centre.

PATIENTS

13 consecutive patients with Brugada syndrome and 13 age and sex matched control subjects.

INTERVENTIONS

Each subject underwent electron beam computed tomography (EBT) and a 12 lead ECG before and after disopyramide injection.

MAIN OUTCOME MEASURES

QRS width and the magnitude of ST segment elevation in the 12 lead ECG; wall motion by EBT.

RESULTS

After disopyramide, EBT revealed deterioration of focal wall motion abnormalities in the right ventricular outflow tract region in eight of the 13 patients (62%). Prolongation of the QRS width after disopyramide injection in lead V2, which usually reflects the electrical activity in right ventricular outflow tract region, was greater in these eight patients (p < 0.01) than in the other five patients, in whom wall motion did not change after disopyramide. The degree of augmentation of ST segment elevation did not differ significantly between the two groups

CONCLUSIONS

The deterioration of wall motion abnormalities in the right ventricular outflow tract region after disopyramide suggests the presence of functional abnormalities of the sodium channel. Some patients with Brugada syndrome may have arrhythmogenic substrates with abnormal responses to sodium channel blockers.

Gene-specific response of dynamic ventricular repolarization to sympathetic stimulation in LQT1, LQT2 and LQT3 forms of congenital long QT syndrome

AIMS

Differences in the sensitivity of the genotype of the congenital long QT syndrome to sympathetic stimulation have been suggested. This study compared the influence of sympathetic stimulation on continuous corrected QT (QTc) intervals between LQT1, LQT2 and LQT3 forms of the congenital long QT syndrome.

METHODS AND RESULTS

We recorded a 12-lead electrocardiogram continuously before and after bolus injection (0.1 microg x kg(-1)) of epinephrine followed by continuous infusion (0.1 microg x kg(-1) min(-1)) in 12 LQT1, 10 LQT2, 6 LQT3, and 13 control patients. The QT intervals and previous RR intervals of all beats were measured semi-automatically, and the QTc intervals of all beats were calculated by Bazett's method. The dynamic response of the RR interval to epinephrine was no different between the four groups. The QTc was prolonged remarkably (477+/-42 to 631+/- 59 ms; P<0.0005, % delta prolongation =+32%) as the RR was maximally decreased (at peak of epinephrine), and remained prolonged at steady state conditions of epinephrine (556+/-56 ms; P<0.0005 vs baseline, +17%) in LQT1 patients. Epinephrine also prolonged the QTc dramatically (502+/-23 to 620+/-39 ms; P<0.0005, +24%) at peak of epinephrine in LQT2 patients, but this shortened to baseline levels at steady state (531+/-25 ms; P=ns vs baseline, +6%). The QTc was much less prolonged at peak of epinephrine in LQT3 (478+/-44 to 532+/-41 ms; P<0.05, +11%) and controls (394+/-21 to 456+/-18 ms; P<0.0005, +16%) than in LQT1 and LQT2 patients, and shortened to the baseline levels (LQT3; 466+/-49 ms, -3%, controls; 397+/-16 ms, +1%; P=ns vs baseline) at steady state.

CONCLUSION

Our data suggest that the dynamic response of ventricular repolarization to sympathetic stimulation differs between LQT1, LQT2 and LQT3 syndromes, and may explain why the trigger of cardiac events differs between the genotypes.

A new enzymic method for the isolation and culture of human bladder body smooth muscle cells

Cultured cells of the human urinary bladder smooth muscle are useful for investigating bladder function, but methods for culturing them are not well developed. We have now established a novel enzymic technique. The smooth muscle layer was separated out and incubated with 0.2% trypsin for 30 min at 37 degrees C. The samples were then minced and incubated with 0.1% collagenase for 30 min and centrifuged at 900 g. The pellets were resuspended in RPMI-1640 medium containing 10% fetal calf serum (FCS) and centrifuged at 250 g. The smooth muscle cells from the supernatant were cultured in RPMI-1640 containing 10% FCS. The cells grew to confluence after 7-10 days, forming the "hills and valleys" growth pattern characteristic of smooth muscle cells. Immunostaining with anti-alpha-actin, anti-myosin, and anti-caldesmon antibodies demonstrated that 99% of the cells were smooth muscle cells. To investigate the pharmacological properties of the cultured cells, we determined the inhibitory effect of muscarinic receptor antagonists on the binding of [3H]N-methylscopolamine to membranes from cultured cells. The pKi values obtained for six antagonists agreed with the corresponding values for transfected cells expressing the human muscarinic M2 subtype. Furthermore, carbachol produced an increase in the concentration of cytoplasmic free Ca2+ an action that was blocked by 4-diphenylacetoxy-N-methylpiperidine methiodide, an M3 selective antagonist. This result suggests that these cells express functional M3 muscarinic receptors, in addition to M2 receptors. The subcultured cells therefore appear to be unaffected by our new isolation method.

Roles of p63 in differentiation of Müllerian duct epithelial cells

In the mouse female reproductive tract, p63, a homologue of the p53 tumor suppressor gene, is highly expressed in basal cells of the vaginal and cervical epithelium, but not in the uterine epithelium. P63 is undetectable in the undifferentiated epithelium of the embryonic Müllerian duct. The Mullerian vaginal epithelium becomes p63 positive and stratified during the first week of postnatal development. P63 expression in the Müllerian vaginal epithelium is induced by vaginal mesenchyme. When vaginal mesenchyme was combined with uterine epithelium from newborn mouse, the uterine epithelium was induced to undergo vaginal differentiation and to express p63. Conversely, when the vaginal epithelium from the newborn mouse was recombined with uterine mesenchyme, it underwent uterine differentiation and failed to express p63. After the uterine epithelium or vaginal epithelium differentiates, the expression status of p63 in uterine (negative) and vaginal (positive) epithelia is not altered by heterotypic mesenchyme. Studies with p63-null mice demonstrate that p63 is essential for vaginal epithelial differentiation, because p63-null Müllerian vaginal epithelium developed as uterine epithelium. Thus, p63 determines whether Müllerian duct epithelial cells become uterine or vaginal. Misexpression of p63 in uterine and vaginal epithelial lesions induced by neonatal diethylstilbestrol (DES) exposure induces pathological changes. Irregularities in p63 expression (and thus epithelial differentiation) are observed in the uterine and vaginal epithelia of neonatally DES-exposed mice during the first week of postnatal development. Thus, neonatal DES exposure abnormally transforms uterine and vaginal epithelial differentiation by perturbing epithelial expression of p63 during development.

Epithelial-stromal tissue interaction in paramesonephric (Müllerian) epithelial differentiation

During organogenesis, the middle to caudal portion of Müllerian epithelium differentiates into uterine and vaginal epithelia in females. Functional differentiation of uterine and vaginal epithelia occurs in adulthood, and is regulated by 17beta-estradiol (E(2)) and progesterone. In this report, the roles of mesenchyme/stroma in differentiation of uterine and vaginal epithelia were studied in tissue recombination experiments. At birth, Müllerian epithelium was negative for uterine and vaginal epithelial markers. Tissue recombinant experiments showed that uterine and vaginal gene expression patterns were induced in neonatal Müllerian epithelium by the respective mesenchymes. Differentiated adult uterine and vaginal epithelia did not change their original gene expression in response to heterotypic mesenchymal induction. In the adult vagina, E(2) induced expression of involucrin, a CCAAT/enhancer-binding protein beta and cytokeratin 1 via estrogen receptor alpha (ERalpha). Tissue recombination experiments with wild-type and ERalpha knockout mice demonstrated that epithelial gene expression is regulated by E(2) via epithelial-stromal tissue interactions. Uterine/vaginal heterotypic tissue recombinations demonstrated that functional differentiation of uterine and vaginal epithelia required organ-specific stromal factors. In contrast, stromal signals regulating epithelial proliferation appeared to be nonspecific in the uterus and vagina.

Paradoxic abbreviation of repolarization in epicardium of the right ventricular outflow tract during augmentation of Brugada-type ST segment elevation

We report the case of a 53-year-old Japanese man with a typical Brugada-like ECG in whom epicardial and endocardial activation-recovery intervals (ARI) in the right ventricular outflow tract (RVOT) were simultaneously measured by recording unipolar electrograms from the Pathfinder catheter introduced in the great cardiac vein as well as from the multielectrode basket catheter deployed in the RVOT. Epicardial ARI in the RVOT was abbreviated paradoxically at the beat of augmented ST segment elevation in lead V2 after a long pause or after pilsicainide injection. Endocardial ARI in the RVOT and epicardial ARI in the left ventricle were prolonged or were not changed. Our data support the hypothesis that heterogenous response of repolarization across the ventricular wall in the RVOT is responsible for accentuation of ST segment elevation in the right precordial leads.

The right ventricular outflow tract as an unusual location for an implantable defibrillator electrode in a patient with arrhythmogenic right ventricular dysplasia

A 41-year-old woman with arrhythmogenic right ventricular dysplasia (ARVD) underwent the implantation of an implantable cardioverter-defibrillator (ICD), in which the defibrillator electrode was unusually located in the right ventricular (RV) outflow tract. Although fractionated electrograms were demonstrated in the RV apex, which is the usual site for ICD electrodes, normal electrograms were recorded in the RV outflow tract during an electrophysiologic study. An electrode with a screw-in tip was used to fix the implant in the RV outflow tract and obtain successful defibrillation. If normal electrograms are recorded in the RV outflow tract, the site may prove to be an alternative location for an ICD electrode even for ARVD patients.

Acute effects of different atrial pacing sites in patients with atrial fibrillation: comparison of single site and biatrial pacing

It has been reported that a trial single site or biatrial pacing can suppress the occurrence of AF. However, its mechanism remains unclear. The study population included 32 patients with AF (n = 20: AF group), or without paroxysmal AF (n = 12: control group). The mechanism and efficacy of atrial pacing were investigated by electrophysiological studies to determine which was more effective for suppressing AF induction; single site pacing of the right atrial appendage (RAA) or distal coronary sinus (CS-d), or biatrial (simultaneous BAA and CS-d) pacing. In the AF group, AF inducibility was significantly higher with BAA extrastimulus during RAA (12/20; P < 0.0001) or biatrial paced drive (7/20; P < 0.01) than during CS-d paced drive (0/20). In the control group, AF was not induced at any site paced. In the AF group, the conduction delay and other parameters of atrial vulnerability significantly improved during CS-d paced drive. The atrial recovery time (ART) at RAA and CS-d was measured during each basic pacing mode. ART was defined as the sum of the activation time and refractory period, and the difference between ARTs at RAA and CS-d was calculated as the ART difference (ARTD). The ARTD was significantly longer during BAA pacing in the AF group than in control group (155.0 +/- 32.8 vs 128.8 +/- 32.9 ms, P < 0.05). In the AFgroup, ARTDs during biatrial (52.0 +/- 24.2 ms) and CS-d pacing (51.7 +/- 26.0 ms) were significantly shorter than ARTD during RAA pacing. The CS-d paced drive was more effective for suppressing AF induction than biatrial or RAA paced drive by alleviating conduction delay. CS-d and biatrial pacing significantly reduced ARTD compared with RAA pacing.

Identification of muscarinic receptor subtypes of cultured smooth muscle cells and tissue of human bladder body

BACKGROUND

Muscarinic receptor subtypes of cultured smooth muscle cells from the human bladder body were investigated by the receptor binding assay method. The result was compared with that obtained from the human bladder body tissue to confirm whether the receptor subtypes of the cells are not changed after several passages of cell culture.

METHODS

Inhibitory effects of various muscarinic antagonists on the binding of [3H]-N-methylscopolamine ([3H]-NMS) to membrane preparations obtained from cultured smooth muscle cells from the fourth subculture of the human bladder body were compared with those prepared from the human bladder body tissue and cells expressing human muscarinic receptor subtypes.

RESULTS

Binding-inhibition constants (pKi) for atropine, pirenzepine, methoctramine, 4-diphenylacetoxy-N-methylpiperidine methiodide (4-DAMP), oxybutynin and propiverine obtained from membrane preparations of cultured smooth muscle cells were 8.91, 6.35, 8.24, 8.53, 7.29 and 5.61, respectively. pKi values of these muscarinic receptor antagonists against the membrane preparation of human bladder body tissue were 9.08, 6.66, 8.05, 8.79, 7.53 and 6.04, respectively. pKi values of cultured smooth muscle cells and tissue from human bladder body were correlated closely with those of insect cells expressing the cloned human M2 receptor subtype.

CONCLUSION

The binding affinities for various muscarinic receptor antagonists of cultured human smooth muscle cells were maintained through the fourth subculture and it was suggested that the M2 receptor subtype is predominantly expressed in cultured smooth muscle cells of human bladder body as well as in tissue of the human bladder body.

[Renal transplant blood flow measurement using ultrasonic contrast agents]

We studied the renal transplant blood flow using an ultrasonic contrast agent. The contrast medium was injected intravenously and produced blood flow enhancement for at least 60 seconds. Measurements were made from the recorded Doppler spectra. Fourteen renal transplant recipients were investigated by color Doppler echography. Blood flow in the interlobular artery could be analyzed in all patients using a contrast, agent, as compared with 2 patients (14%) by a conventional method. The average maximum and minimum flow velocity of the interlobular arteries were 0.15 m/sec and 0.04 m/sec. In conclusion, an ultrasonic contrast agent is useful to accurately evaluate peripheral blood supply in renal transplants.

Effects of isoproterenol and butylscopolamine on the friction between an artificial stone and the intraureteral wall in anesthetized rabbits

PURPOSE

We evaluated the effects of the nonselective beta-adrenoceptor agonist isoproterenol and the nonselective muscarinic antagonist butylscopolamine on ureteral wall tension, namely friction between an artificial stone and the intraureteral wall, in anesthetized rabbits.

MATERIALS AND METHODS

The relaxing effect of the drugs on the KCl induced tonic contraction was examined in isolated rabbit ureters. The effect of the drugs on the applied force needed for the artificial stone to pass at a constant speed through the ureter, called sliding force, was evaluated in anesthetized rabbits.

RESULTS

In a concentration dependent manner isoproterenol but not butylscopolamine reduced the KCl induced contraction in isolated ureter (mean pD2 7.35 +/- 0.06). Intravenous administration of 1 and 10 microg./kg. isoproterenol significantly decreased the friction between the artificial stone and intraureteral wall in anesthetized rabbits with sliding force at 15 minutes after drug administration decreased by 54.5% and 63.6%, respectively. In contrast, 100 and 1,000 microg./kg. butylscopolamine intravenously had no evident effect on ureteral wall tension.

CONCLUSIONS

Our results strongly suggest that ureteral smooth muscle relaxation by beta-adrenergic stimulation reduces ureteral wall tension, thereby, diminishing mechanical effects impeding the movement of a ureteral stone down the ureter.

[Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps]

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.

Non-neoplastic glandular structures in a benign peripheral nerve sheath tumor

It is a recognized fact that glandular structures sometimes occur in peripheral nerve sheath tumors (PNST). Reports indicate that epithelial potential could be expressed in malignant PNST, while the glands in most benign PNST could be trapped skin adnexa. We present a case of spindle cell tumor with glandular structures. The patient was a 55-year-old man who had a subcutaneous tumor excised. The spindle cell tumor had histological characteristics of neurofibroma. The glandular structures had a pattern of immunohistochemical staining that was similar to that of the secretory coils and excretory ducts of normal eccrine glands. Therefore, the glands were thought to be naturally existing eccrine glands. The glands were completely enclosed within the tumor and not connected to one another; a cluster formation was not observed. The upper portion of tumor included some glands of skin adnexa. The spindle cell tumor may have originated from the nerves distributed around the skin adnexa, and grown to the subcutaneous tissue. The glands may have been left behind rather than have been trapped in the tumor.

Auditory evoked potential index predicts the depth of sedation and movement in response to skin incision during sevoflurane anesthesia

BACKGROUND

The auditory evoked potential (AEP) index, which is a single numerical parameter derived from the AEP in real time and which describes the underlying morphology of the AEP, has been studied as a monitor of anesthetic depth. The current study was designed to evaluate the accuracy of AEPindex for predicting depth of sedation and anesthesia during sevoflurane anesthesia.

METHODS

In the first phase of the study, a single end-tidal sevoflurane concentration ranging from 0.5 to 0.9% was assigned randomly and administered to each of 50 patients. The AEPindex and the Bispectral Index (BIS) were obtained simultaneously. Sedation was assessed using the responsiveness portion of the observer's assessment of alertness-sedation scale. In the second phase of the study, 10 additional patients were included, and the 60 patients who were scheduled to have skin incisions were observed for movement in response to skin incision at the end-tidal sevoflurane concentrations between 1.6 and 2.6%. The relation among AEPindex, BIS, sevoflurane concentration, sedation score, and movement or absence of movement after skin incision was determined. Prediction probability values for AEPindex, BIS, and sevoflurane concentration to predict depth of sedation and anesthesia were also calculated.

RESULTS

The AEPindex, BIS, and sevoflurane concentration correlated closely with the sedation score. The prediction probability values for AEPindex, BIS, and sevoflurane concentration for sedation score were 0.820, 0.805, and 0.870, respectively, indicating a high predictive performance for depth of sedation. AEPindex and sevoflurane concentration successfully predicted movement after skin (prediction probability = 0.910 and 0.857, respectively), whereas BIS could not (prediction probability = 0.537).

CONCLUSIONS

Auditory evoked potential index can be a guide to the depth of sedation and movement in response to skin incision during sevoflurane anesthesia.

The effect of osteopontin immobilized collagen granules in the seed crystal method

Osteopontin (OPN) is a urinary protein which inhibits calcium oxalate (CaOx) crystal growth in the seed crystal system. The aim of this study was to evaluate the effects of OPN immobilized on collagen granules (CG) for CaOx crystal growth and aggregation in this system. OPN-immobilized CG showed a 30% decrease in inhibitory activity compared with non-OPN-immobilized CG. Scanning electron microscopy revealed that 1) OPN-immobilized CG showed more marked aggregation and adhesion of seed crystals (smaller than 0.5 microm in diameter) than non-OPN-immobilized CG, 2) the amount of adherent large type crystals (2-3 microm in diameter) did not differ between OPN immobilized and non-OPN-immobilized CG. In conclusion, immobilized OPN promotes aggregation and adhesion of CaOx crystals smaller than 0.5 microm on CG. These observations suggest that crystal adhesion to immobilized OPN plays a role in the retention of crystals in the kidney.

Localized right ventricular morphological abnormalities detected by electron-beam computed tomography represent arrhythmogenic substrates in patients with the Brugada syndrome

AIMS

This study was designed to determine, using electron-beam CT, whether there are morphological abnormalities in patients with the Brugada syndrome and to elucidate the relationship between those abnormalities and arrhythmogenesis.

METHODS AND RESULTS

Twenty-six consecutive patients with the Brugada syndrome and 23 age- and gender-matched control subjects (controls) were evaluated for morphological abnormalities using electron beam CT. Electron beam CT demonstrated morphological abnormalities of the right ventricle in 21 (81%) of 26 patients, but in only two (9%) of 23 controls. The sites of morphological abnormalities were the right ventricular outflow tract area in 17 patients and the inferior wall of the right ventricle in four patients. Of the seven patients with monoform premature ventricular contractions recorded only in the acute phase, four of the five patients with premature ventricular contractions from the right ventricular outflow tract area had morphological abnormalities in the right ventricular outflow tract area, and the other two patients with premature ventricular contractions from the inferior wall of the right ventricle had morphological abnormalities in the inferior wall of the right ventricle.

CONCLUSION

The sites of morphological abnormalities detected by electron beam CT in patients with the Brugada syndrome were related to the origins of premature ventricular contractions recorded only in the acute phase, which may trigger ventricular fibrillation. These morphological abnormalities may be related to arrhythmogenic substrates in patients with the Brugada syndrome.

Clinical usefulness of a multielectrode basket catheter for idiopathic ventricular tachycardia originating from right ventricular outflow tract

INTRODUCTION

It often is difficult to determine the optimal ablation site for idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT) when the VT or premature ventricular complex (PVC) does not occur frequently. The aim of our study was to evaluate the usefulness of a multielectrode basket catheter for ablation of idiopathic VT originating from the RVOT.

METHODS AND RESULTS

Radiofrequency (RF) catheter ablation was performed using a 4-mm tip, quadripolar catheter in 50 consecutive patients with 81 VTs originating from the RVOT with (basket group = 25 patients with 45 VTs) or without (control group = 25 patients with 36 VTs) predeployment of a multielectrode basket catheter composed of 64 electrodes. Deployment of the multielectrode basket catheter was possible and safe in all 25 patients in the basket group. Ablation was successful in 25 (100%) of 25 patients in the basket group and in 22 (88%) of 25 patients in the control group. The total number of RF applications and the number of RF applications per PVC morphology did not differ between the two groups. However, both the fluoroscopic and ablation procedure times per PVC morphology were shorter in the basket group than in the control group (36.8+/-14.1 min vs 52.0+/-32.5 min, P = 0.04; 60.0+/-14.6 vs 81.5+/-51.2 min, P = 0.05). This difference was more pronounced in the 29 patients in whom VT or PVC was not frequently observed.

CONCLUSION

The multielectrode basket catheter is safe and useful for determining the optimal ablation site in patients with idiopathic VT originating from the RVOT, especially in those without frequent VT or PVC.

Sympathetic stimulation produces a greater increase in both transmural and spatial dispersion of repolarization in LQT1 than LQT2 forms of congenital long QT syndrome

OBJECTIVES

The study compared the influence of sympathetic stimulation on transmural and spatial dispersion of repolarization between LQT1 and LQT2 forms of congenital long QT sYndrome (LQTS).

BACKGROUND

Cardiac events are more associated with sympathetic stimulation in LQT1 than in LQT2 or LQT3 syndrome. Experimental studies have suggested that the interval between Tpeak and Tend (Tp-e) in the electrocardiogram (ECG) reflects transmural dispersion of repolarization across the ventricular wall.

METHODS

We recorded 87-lead body-surface ECGs before and after epinephrine infusion (0.1 microg/kg/min) in 13 LQT1, 6 LQT2, and 7 control patients. The Q-Tend (QT-e), Q-Tpeak (QT-p), and Tp-e were measured automatically from 87-lead ECGs, corrected by Bazett's method (QTc-e, QTc-p, Tcp-e), and averaged among all 87-leads and among 24-leads, which reflect the potential from the left ventricular free wall. As an index of spatial dispersion of repolarization, the dispersion of QTc-e (QTc-eD) and QTc-p (QTc-pD) were obtained among 87-leads and among 24-leads, and were defined as the interval between the maximum and the minimum of the QTc-e and the QTc-p, respectively.

RESULTS

Epinephrine significantly increased the mean QTc-e but not the mean QTc-p, resulting in a significant increase in the mean Tcp-e in both LQT1 and LQT2, but not in control patients. The epinephrine-induced increases in the mean QTc-e and Tcp-e were larger in LQT1 than in LQT2, and were more pronounced when the averaged data were obtained from 24-leads than from 87-leads. Epinephrine increased the maximum QTc-e but not the minimum QTc-e, producing a significant increase in the QTc-eD in both LQT1 and LQT2 patients, but not in control patients. The increase in the QTc-eD was larger in LQT1 than in LQT2 patients.

CONCLUSIONS

Our data suggest that sympathetic stimulation produces a greater increase in both transmural and spatial dispersion of repolarization in LQT1 than in LQT2 syndrome, and this may explain why LQT1 patients are more sensitive to sympathetic stimulation.

The role of Purkinje and pre-Purkinje potentials in the reentrant circuit of verapamil-sensitive idiopathic LV tachycardia

Although the mechanism of verapamil-sensitive idiopathic left ventricular tachycardia (ILVT) is usually reentry, the actual reentrant circuit is not clearly understood. This study examined the relationship between the Purkinje potential (PP) and a dull potential preceding PP (pre-PP) during ILVT to elucidate the roles of these potentials in the reentrant circuit of ILVT. Electrophysiological studies and radiofrequency catheter ablation were performed in ten patients (7 men, 3 women, mean age 29 years) who had an ILVT with a right bundle branch block configuration and left-axis deviation. Left ventricular endocardial mapping using an octapolar catheter and entrainment and resetting studies during VT was performed by pacing from the right ventricular outflow tract (RVOT) and each site of the left ventricular mapping catheter. PP and pre-PP were recorded simultaneously during VT in all patients. The earliest PP during VT was recorded at the inferoposterior septum, and PP was activated bidirectionally toward the proximal (basal) and distal (apical) sites along the left posterior fascicle. In contrast, pre-PP was recorded at sites slightly proximal to the earliest PP recording site, and was activated toward the earliest PP site. Pacing from RVOT confirmed manifest entrainment, and the stimulus to pre-PP interval was prolonged with a shorter pacing cycle length. Concealed entrainment was demonstrated by capture of the PPs of the left ventricular mapping catheter in six patients, and the postpacing interval at each PP site was equal to the tachycardia cycle length. The pre-PP was orthodromically activated from the proximal to the distal site during pacing. More rapid pacing also produced delay in activation from PP to pre-PP, indicating slow conduction in ILVT. Catheter ablation was performed at the pre-PP recording site during VT, and was successful in all patients. The reentrant circuit of ILVT could be constructed based on the pre-PP, PP, and slow conduction between the PP and pre-PP. Catheter ablation of ILVT was successful at the pre-PP recording site.

Characterization of the reversible nature of the reaction catalyzed by sphingolipid ceramide N-deacylase. A novel form of reverse hydrolysis reaction

Sphingolipid ceramide N-deacylase catalyzes a reversible reaction in which the amide linkages of the ceramides of various sphingolipids are cleaved or synthesized. Hydrolysis of sphingolipids by the enzyme proceeded efficiently at acidic pH in the presence of high concentrations of detergents, whereas the reverse reaction tended to be favored at neutral pH with a decrease in the detergent concentration. Although the catalytic efficiency (V(max)/K(m)) of the hydrolysis and reverse reactions was changed mainly by the concentration of detergents in the reaction mixture, V(max) and K(m) for the reverse reaction were relatively higher than those for the forward reaction, irrespective of the detergent concentration. The reverse reaction proceeded most efficiently when the molar ratio of lyso-sphingolipids and fatty acids was fixed at 1 : 1-2, the yield of the reaction exceeding 70-80%. The reverse and exchange (transacylation) reactions did not require ATP, CoA, metal ions or addition of organic solvents. Studies using inhibitors and chemical modifiers of the enzyme protein suggested that both the hydrolysis and condensation reactions are catalyzed at the same catalytic domain. These results indicate that the reverse hydrolysis reaction of the enzyme is unique, being completely different from those of lipases, proteases and glycosidases reported to date.

Paracrine regulation of apoptosis by steroid hormones in the male and female reproductive system

In males, androgens are essential in maintaining the integrity of the prostate. Androgen-ablation induces apoptosis of the prostatic epithelium. In females, ovariectomy induces apoptosis in uterine epithelium while progesterone inhibits this process. The objective of this study was to determine whether androgen and progesterone inhibit apoptosis, respectively, in mouse prostatic and uterine epithelia via steroid receptors in the epithelium or in the stroma. To address this question, prostatic tissue recombinants were prepared with rat urogenital sinus mesenchyme plus bladder epithelium from wild-type or testicular feminization mutant (Tfm) mice. Thus, prostatic tissue was generated having androgen receptor (AR) in both epithelium and stroma or in the stroma only. Castration of hosts induced apoptosis in the AR-negative Tfm prostatic epithelium with an epithelial apoptotic index virtually identical to prostatic tissue recombinants containing wild-type epithelium. Moreover, this castration-induced prostatic epithelial apoptosis was blocked by testosterone and dihydrotestosterone in both wild-type and Tfm prostatic tissue recombinants. Likewise, uterine tissue recombinants were prepared in which epithelium and/or stroma was devoid of progesterone receptor (PR) by using uterine epithelium and stroma of wild-type and PR knockout mice. Progesterone inhibited uterine epithelial apoptosis only in tissue recombinants prepared with PR-positive stroma. The PR status of the epithelium did not affect epithelial apoptotic index. Therefore, the apoptosis in prostatic and uterine epithelia is regulated by androgen and progesterone via stromal AR and PR, respectively. In both cases, epithelial AR or PR is not required for hormonal regulation of epithelial apoptosis in prostatic and uterine epithelium.

Evidence that epithelial and mesenchymal estrogen receptor-alpha mediates effects of estrogen on prostatic epithelium

In combination with androgens, estrogens can induce aberrant growth and malignancy of the prostate gland. Estrogen action is mediated through two receptor subtypes: estrogen receptors alpha (ERalpha) and beta (ERbeta). Wild-type (wt) and transgenic mice lacking a functional ERalpha (alphaERKO) or ERbeta (betaERKO) were treated with the synthetic estrogen diethylstilbestrol (DES). DES induced prostatic squamous metaplasia (SQM) in wt and betaERKO but not in alphaERKO mice, indicating an essential role for ERalpha, but not ERbeta, in the induction of SQM of prostatic epithelium. In order to determine the respective roles of epithelial and stromal ERalpha in this response, the following tissue recombinants were constructed with prostatic epithelia (E) and stroma (S) from wt and ERKO mice: wt-S+wt-E, alphaERKO-S+alphaERKO-E, wt-S+alphaERKO-E, and alphaERKO-S+wt-E. A metaplastic response to DES was observed in wt-S+wt-E tissue recombinants. This response to DES involved multilayering of basal epithelial cells, expression of cytokeratin 10, and up-regulation of the progesterone receptor. Tissue recombinants containing alphaERKO-E and/or -S (alphaERKO-S+alphaERKO-E, wt-S+alphaERKO-E, and alphaERKO-S+wt-E) failed to respond to DES. Therefore, full and uniform epithelial SQM requires ERalpha in the epithelium and stroma. These results provide a novel insight into the cell-cell interactions mediating estrogen action in the prostate via ERalpha.

[A case of squamous cell carcinoma of the bladder that was successfully treated with multidisciplinary therapies]

A 45-year-old man with hematopyuria detected at another hospital visited our department for further examination. Endoscopic examination revealed a disintegration abscess between the bladder neck and prostatic urethra. Transurethral biopsy demonstrated squamous cell carcinoma of the bladder. He received 40 Gy of radiation combined with M-VAC (methotrexate, vinblastine, dovorubicin cisplatin) chemotherapy. Pathologically, a complete response was found when he underwent total cystourethrectomy. There has been no sign of recurrence for one and a half years postoperatively.

[A case of renal oncocytoma with synchronous contralateral renal cell carcinoma]

A case of bilateral, synchronous renal cell carcinoma and oncocytoma is reported. The patient was a 70-year-old woman. Computed tomographic scan revealed bilateral low density masses, which had a diameter of approximately 4 cm (right kidney), and 2.5 cm (left kidney). We suspected bilateral renal cell carcinomas, and performed, right nephrectomy and left enucleation of the tumor. Pathological diagnosis was right renal cell carcinoma and left oncocytoma. To our knowledge only 5 previous cases of renal cell carcinoma associated with oncocytoma have been reported in Japan. Two cases were metachronous and three cases were unilateral and synchronous. This is the first reported case of bilateral, synchronous renal cell carcinoma and oncocytoma.

Initial experience with nifekalant hydrochloride (MS-551), a novel class III antiarrhythmic agent, in patients with acute extensive infarction and severe ventricular dysfunction

Nifekalant hydrocholoride, a novel class III antiarrhythmic agent, was used as the treatment in 4 patients with extensive anterior infarction and severe ventricular dysfunction. The malignant ventricular tachyarrhythmia was effectively suppressed at a relatively low dose, without compromising the hemodynamics, indicating that this potent K+ channel blocker has therapeutic potential for acute myocardial infarction.

Regulation of progesterone receptors and decidualization in uterine stroma of the estrogen receptor-alpha knockout mouse

Regulation of progesterone receptor (PR) in uterine stroma (endometrial stroma plus myometrium) by estrogen was investigated in estrogen receptor-alpha (ERalpha) knockout (alphaERKO) mice. 17 beta-Estradiol (E(2)) increased PR levels in uterine stroma of ovariectomized alphaERKO mice, and ICI 182 780 (ICI) inhibited this E(2)-induced PR expression. Estrogen receptor-beta(ER beta) was detected in both uterine epithelium and stroma of wild-type and alphaERKO mice by immunohistochemistry. In organ cultures of alphaERKO uterus, both E(2) and diethylstilbestrol induced stromal PR, and ICI inhibited this induction. These findings suggest that estrogen induces stromal PR via ERbeta in alphaERKO uterus. However, this process is not mediated exclusively by ERbeta+, because in ERbeta knockout mice, which express ERalpha, PR was up-regulated by E(2) in uterine stroma. In both wild-type and alphaERKO mice, progesterone and mechanical traumatization were essential and sufficient to induce decidual cells, even though E(2) and ERalpha were also required for increase in uterine weight. Progesterone receptor was strongly expressed in decidual cells in alphaERKO mice, and ICI did not inhibit decidualization or PR expression. This study suggests that up-regulation of PR in endometrial stroma is mediated through at least three mechanisms: 1) classical estrogen signaling through ERalpha, 2) estrogen signaling through ERbeta, and 3) as a result of mechanical stimulation plus progesterone, which induces stromal cells to differentiate into decidual cells. Each of these pathways can function independently of the others.

Effect of sodium channel blockers on ST segment, QRS duration, and corrected QT interval in patients with Brugada syndrome

INTRODUCTION

Brugada syndrome is characterized by an ST segment elevation in leads V1-V3 and a high incidence of ventricular fibrillation (VF). A mutation in a cardiac Na+ channel gene, SCN5A, has been linked to Brugada syndrome, and sodium channel blockers have been shown to be effective in unmasking the syndrome when concealed. The aim of this study was to examine the effects of Na+ channel blockers on ST segment elevation, QRS, corrected QT (QTc) interval, and ventricular arrhythmias in patients with Brugada syndrome.

METHODS AND RESULTS

We examined the effects of three different Na+ channel blockers (flecainide, disopyramide, and mexiletine) on the amplitude of the ST segment 20 msec after the end of QRS (ST20), QRS duration, QTc interval measured from 12-lead ECG, and ventricular arrhythmias in 12 Brugada and 10 control patients. Maximum ST20 observed in the V2 or V3 leads under baseline conditions was greater in the Brugada patients than in control patients, whereas QRS duration and maximum QTc interval were no different between the two groups. Flecainide and disopyramide, but not mexiletine, significantly increased maximum ST20 and QRS duration in both groups, although these effects were much more pronounced in the Brugada patients. The increases in ST20 and QRS duration with flecainide were significantly larger than those with disopyramide. An increase of 0.15 mV in ST20 with flecainide separated the two groups without overlap. Ventricular premature complexes developed only with flecainide in Brugada patients (3/12) displaying a marked ST elevation but not widening of QRS.

CONCLUSION

Our findings suggest that Na+ channel blockers amplify existing I(Na) and possibly other ion channel defects, with a potency inversely proportional to the rate of dissociation of the drug from the Na+ channel, thus causing a prominent elevation of the ST segment and, in some cases, prolongation of QRS duration in patients with Brugada syndrome.

Mode of onset of ventricular fibrillation in patients with Brugada syndrome detected by implantable cardioverter defibrillator therapy

OBJECTIVES

We sought to demonstrate the mode of spontaneous onset of ventricular fibrillation (VF) in patients with Brugada syndrome.

BACKGROUND

The electrophysiologic mechanisms of VF in Brugada syndrome have not been fully investigated.

METHODS

Nineteen patients (all male, mean age 47 +/- 12 years) with Brugada syndrome were treated with an implantable cardioverter defibrillator (ICD). The implanted devices were capable of storing electrograms during an arrhythmic event. We investigated the mode of spontaneous onset of VF according to the electrocardiographic features during the episode of VF, which were obtained from stored electrograms of ICDs and/or electrocardiographic (ECG) monitoring.

RESULTS

During a follow-up of 34.7 +/- 19.4 months (range 14 to 81 months), 46 episodes of spontaneous VF attacks were documented in 7/19 (37%) patients. The event-free period between ICD implantation and the first spontaneous occurrence of VF was 14.6 +/- 12.1 months (range 3.7 to 27.4 months). We investigated 33/46 episodes of VF, for which electrocardiographic features (10 to 20 s before and during VF) were obtained from ICDs and/or ECG monitoring in five patients. A total of 22/33 episodes of VF were preceded by premature ventricular contractions (PVCs), which were almost identical to the initiating PVCs of VF. Furthermore, in three patients who had multiple VF episodes, VF attacks were always initiated by the same respective PVC. The coupling interval of the initiating PVCs of VF was 388 +/- 28 ms.

CONCLUSIONS

Spontaneous episodes of VF in patients with Brugada syndrome were triggered by specific PVCs. These findings may provide important insights into the pathophysiological mechanisms causing VF in Brugada syndrome.

Existence of a beta3-adrenoceptro and its functional role in the human ureter

PURPOSE

We tried to determine the beta-adrenoceptor (AR) subtypes distributed in the human ureter and to clarify their functional role in ureteral relaxation.

MATERIALS AND METHODS

1) Effects of beta-AR agonists on either spontaneous or KCl-induced contractions of the human ureter and the antagonism by beta-AR antagonists on isoprenaline (a non-selective beta-AR agonist)-induced effects were evaluated in vitro. 2) Displacement by beta-AR antagonists of [3H]-dihydroalprenolol binding to a membrane preparation derived from human ureteral smooth muscle was evaluated. 3) A reverse transcription polymerase chain reaction assay was performed to determine the expression of the mRNA for beta1-, beta2- and beta3-ARs in human ureteral smooth muscle.

RESULTS

1) Isoprenaline and procaterol (a beta2-AR agonist) concentration-dependently suppressed both spontaneous and KCl-induced contractions of the human ureter. The beta3-AR agonists, CGP-12177A and CL-316243, also suppressed these ureteral contractions, but dobutamine (a beta1-AR agonist) had little relaxing effect. The rank order of relaxing potency for the catecholamines was isoprenaline > adrenaline > noradrenaline. ICI-118,551 (a beta2-AR antagonist) only partially antagonized the isoprenaline-induced relaxation. 2) Propranolol (a non-selective beta-AR antagonist) and ICI-118,551 concentration-dependently displaced [3H]-dihydroalprenolol binding to the membrane with Ki values of 1.5 x 10-9 M and 6.3 x 10-9 M, respectively, while metoprolol (a beta1-AR antagonist) was less effective in this assay. 3) beta1-, beta2- and beta3-AR mRNAs were all expressed in human ureteral smooth muscle.

CONCLUSION

The present results provide the first evidence that the beta3-AR subtype is distributed in human ureteral smooth muscle and that it, and beta2-AR, mediate the ureteral relaxation induced by adrenergic stimulation.

Venous anastomoses with a microvascular anastomotic device in head and neck reconstruction

The Microvascular Anastomotic System (3M coupler) uses a friction-fit union of implant rings composed of high-density polyethylene and stainless-steel pins. Several reports have described equal or greater patency rates, as well as more rapid performance, using the device, compared to conventional suturing techniques. Eighty-nine patients, who underwent head and neck surgery with free-tissue transfers, using the Microvascular Anastomotic System, were evaluated. A hundred and twenty-one venous anastomoses were done using the device. All but one was done in an end-to-end manner Arteries were anastomosed with a conventional suture technique. The flap survival rate was 100 percent. The authors conclude that the device is reliable and time-sparing for end-to-end venous anastomoses in head and neck reconstruction.