[Management for type A acute dissection]

From March 1998 to May 2002, we experienced 46 patients with type A acute dissection (AAD). Fifteen patients managed initially with conservative treatment because of intramular hematoma (IH, n = 10), broad cerebral infarction (n = 3), others (n = 2). One who diagnosed IH at admission progressed to AAD and underwent surgery. However his diagnosis of IH at admission was proved to be misdiagnosis retrospectively. In 8 of the remaining 9 patients, hematoma disappeared during the follow-up of 6 months to 1 year. In patients with broad cerebral infarction, 2 died early after admission and 1 discharged with hemiplegia. Thirty-two patients underwent surgery and 1 with preoperative broad cerebral infarction died 36 days after surgery. In the remaining 31 patients, 30 patients discharged ambulatory.

Slowly developing perigraft seroma after a modified Blalock-Taussig shunt

We report a 26-year-old patient with slowly developing perigraft seroma 15 years after a modified Blalock-Taussig shunt with an expanded polytetrafluorethylene graft. The mediastinal mass was first observed on a chest x-ray film 8 years after the shunt operation. The mass contained massive gelatinous or organic tissues with a severely calcified pseudocapsule, and it was adjacent to the calcified but functioning graft. No fluid collections were noted. The histological findings were compatible with a seroma. No recurrence was noted on last follow-up 1 year postoperatively.

Wavelength stabilization of a distributed Bragg reflector laser diode by use of complementary current injection

We have demonstrated wavelength stabilization in an 821-nm AlGaAs three-section tunable distributed Bragg reflector (DBR) semiconductor laser diode (LD) that consists of active, phase-controlled, and DBR regions. We injected two separate, complementary currents into the active and the phase-controlled regions in the DBR-LD to suppress wavelength shift. This modulation method was applied to the LD fundamental wave in a second-harmonic-generation (SHG) laser, and the oscillating wavelength was maintained within the phase-matching acceptance range of the SHG device during modulation. A peak blue-violet light power of 62 mW was obtained for the ideal modulation waveform.

Treatment of myxoid liposarcoma by marginal or intralesional resection combined with radiotherapy

Local recurrence-free survival rate for myxoid liposarcoma (MLS) is related to negative surgical margins. The goal of surgery in the treatment of MLS is to obtain tumor-free surgical margins. When a tumor is adjacent to critical structures, wider resection, which can result in amputation, would be selected for local control. While recognizing that marginal or intralesional resection is associated with high risk of recurrence, circumstances occur that lead surgeons to conduct conservative surgery. To determine whether marginal or intralesional resection combined with radiotherapy can achieve local control, 10 cases (12 tumors) were reviewed involving MLS treated with marginal (8 tumors) or intralesional resection (4 tumors) followed by postoperative radiotherapy (50-70 Gy, average 59.2 Gy). No recurrences of MLS were observed locally at the mean follow-up of 58.1 months. The development of severe radiation-related complications was not detected. This medium follow-up study suggested that this method can achieve a high rate of local control.

Dipeptidyl peptidase IV on activated T cells as a target molecule for therapy of rheumatoid arthritis

The extracellular domain of the T cell co-stimulatory molecule CD26 possesses dipeptidyl peptidase IV (DP IV) enzyme activity. Activated T cells are known to increase expression of cell surface DP IV and some specific inhibitors of this enzyme have been reported to suppress T cell function. Previously we have identified a DP IV inhibitor, designated TMC-2, found in culture supernatant of Aspergillus oryzae. Administration of TMC-2 to rats with adjuvant arthritis caused marked suppression of paw swelling. To elucidate the mechanism of TMC-2 antiarthritic activity, we have studied its effects on T cell function. Here we show that TMC-2 inhibited DP IV activity of CD26 immunoprecipitated from T cell lysates, and also inhibited proliferative responses of T cells to specific antigen or anti-CD3 antibody. Suppression of IL-2 production was demonstrated at both the mRNA and protein levels. TMC-2 did not alter the PTPase activity of pure CD45, but when this molecule was co-precipitated from T cell lysates together with associated CD26, its PTPase was virtually completely abolished by TMC-2. These results suggest that modulation of CD45 PTPase activity might be responsible for functional suppression of T cells by TMC-2. Because the effects of TMC-2 on T cells were reversible and it was not toxic at the concentrations used, TMC-2 may be a candidate novel therapeutic agent for rheumatoid arthritis.

Methicillin-resistant Staphylococcus aureus endocarditis following repair of tetralogy of Fallot

Infectious endocarditis following cardiac surgery, particularly that caused by methicillin-resistant Staphylococcus, aureus is a rare and highly lethal complication. We report a case of a 2-year-old girl who developed methicillin-resistant S. aureus endocarditis and mediastinitis following the intracardiac repair of tetralogy of Fallot using Dacron patches. The patient enveloped severe bacteremia accompanied by disseminated intravascular coagulation and progressive enlargement of vegetation. Despite this condition, the patient was successfully treated by repair using double autogenous pericardial patches. Aggressive removal of foreign material and replacement with autogenous tissue resulted in a favorable outcome.

Effect of a human urinary protease inhibitor (Ulinastatin) on respiratory function in pediatric patients undergoing cardiopulmonary bypass

BACKGROUND

We performed this prospective randomized study to determine the effect of a human urinary protease inhibitor (Ulinastatin) on respiratory function in pediatric patients undergoing cardiopulmonary bypass.

METHODS

Twenty-two children were included in this study. They were randomly allocated to 1 of the following groups; a control group (n=11) or a Ulinastatin group (n=11) in which patients received 5000 U/kg of Ulinastatin. Arterial blood samples were obtained before cardiopulmonary bypass (CPB), immediately after CPB, and 30 min after protamine administration, as well as 3 hours after and 18 hours after CPB, and Interleukin-8 and neutrophil elastase concentration were evaluated.

RESULTS

CPB time and aortic clamp time did not differ between the groups. Interleukin 8 and neutrophil elastase concentrations before CPB increased significantly immediately after CPB, these concentrations did not differ between the groups. However, neutrophil elastase concentrations of a Ulinastatin group were significantly lower than that of a control group at 30 min after protamine administration (a Ulinastatin group: 1011.3+/-539.1 mg/ml, a control group: 1619.7+/-595.7 mg/ml, p<0.05) and A-aDO2 of a Ulinastatin group was significantly lower than that of a control group at 2 hours after CPB (a Ulinastatin group: 67.1+/-70.6 mmHg, a control group: 169.2+/-116.3 g, p<0.05).

CONCLUSIONS

These results suggest that Ulinastatin suppresses the increase in neutrophil elastase and protects the respiratory function in pediatric patients undergoing cardiopulmonary bypass.

Diversity among strains of Cryptococcus neoformans var. gattii as revealed by a sequence analysis of multiple genes and a chemotype analysis of capsular polysaccharide

We demonstrated the diversity of Cryptococcus neoformans var. gattii strains by a sequence analysis of multiple genes: (i) the intergenic spacer (IGS) 1 and 2 regions of the rRNA gene; (ii) the internal transcribed spacer (ITS) region, including 5.8S of the rRNA gene; (iii) TOP1 (topoisomerase); and (iv) CAP59. In these studies, we compared C. neoformans var. gattii with varieties grubii, and neoformans of C. neoformans. Phylogenetic analysis indicated that both C. neoformans var. grubii and C neoformans var. neoformans are monophyletic, but C. neoformans var. gattii showed polyphyletic. C. neoformans var. gattii can be divided into three phylogenetic groups, I, II, and III, with high bootstrap support. Phylogenetic group I contains serotype B and C strains, and groups II and III include serotype B strains. Because the serotype B strains of C. neoformans var. gattii exhibited more genetic divergence, the serological characteristics and chemotypes of their capsular polysaccharide were further investigated. No remarkable difference among the serotype B strains was found in the reactivities to factor serum 5, which is specific for serotype B. The NMR spectra of the capsular polysaccharide from serotype B strains could be divided into three characteristic patterns, but the chemical shifts were very similar. These results suggested that the serotype B strain of C. neoformans var. gattii has more genetic diversity than the serotype C strain of C. neoformans var. gattii or the varieties grubii and neoformans of C. neoformans, but there was no correlation between genotype and chemotype.

[Molecular analysis of malassezia microflora on the skin of atopic dermatitis patients and healthy subjects]

We compared cutaneous colonization levels of Malassezia species in patients with AD and healthy subjects using nested PCR. Malassezia-specific DNA was detected in all 32 of the patients with AD. M. globosa and M. restricta were detected in approximately 90% of these patients, with M. furfur and M. sympodialis being detected in approximately 40% of the cases. In healthy subjects, Malassezia DNA was detected in 78% of the samples, M. globosa, M. restricta and M. sympodialis were detected at frequencies ranging from 44 to 61%, and M. furfur was found in 11% of healthy subjects. Our results suggest that M. furfur, M. globosa, M. restricta and M. sympodialis are common inhabitants of the skin of both AD patients and healthy subjects, while the skin microflora of patients with AD shows more diversity than that of healthy subjects.

Intraspecies diversity of Cryptococcus albidus isolated from humans as revealed by sequences of the internal transcribed spacer regions

The basidiomycetous yeast, Cryptococcus albidus, shows intraspecies diversity, but it is rarely isolated from immunocompromised patients. Nineteen strains of C. albidus, including nine clinical isolates, were re-classified by sequences of their rRNA internal transcribed spacer (ITS) regions. The nine clinical isolates were genetically diverse and included both C. albidus and C. diffluens. One clinical isolate, recovered from the blood of an AIDS patient, represented a new species. Only small differences were found in the biochemical and serological characteristics of C. albidus and C. diffluens. All isolates were sensitive to amphotericin B, but several isolates were resistant to fluconazole and itraconazole. C. albidus heterogeneity should be taken into consideration when identifying clinical isolates.

Hypermutable change of human UV(r)-1 cells by p53 overexpression

The p53 protein has been reported to regulate cellular responses to genetic stress such as far-ultraviolet light (UV), protecting human cells from mutation. Levels of p53 protein in hypermutable RSa cells were found here to increase soon after UV irradiation, while those in UV(r)-1 cells, a hypomutable variant of RSa cells, showed a delayed increase. Three cell lines overexpressing wild-type p53 in UV(r)-1 cells exhibited higher sensitivity to UV mutagenicity than did control U-V-7 cells transfected with vector alone, assessed using the ouabain-resistance phenotypic mutation test and identification of K-ras codon 12 base substitution mutation. On the other hand, U-V-7 cells showed UV-induced elevation of antipain-sensitive protease activity, but p53 transfectants did not. Moreover, antipain treatment to U-V-7 cells was increased susceptibility to UV mutagenicity. Thus, p53 protein overproduction may sensitize human cells, at least those tested, to UV mutagenicity, in association with inhibition of protease activity.

[Emergent surgical treatment of type A acute aortic dissection in an elderly patient]

An 86-year-old man with severe chest pain and shock was transferred to our hospital. Computed tomography revealed type A aortic dissection with cardiac tamponade. He needed intubation and closed chest massage preoperatively. At operation, intrapericardial space was filled with clotted blood and rupture of the ascending aorta was confirmed. He underwent a successful emergency graft replacement of the ascending aorta. Postoperative course was uneventful except for mild hemianopsia due to cerebral infarction. He had recovered to be able to walk and is doing well.

Repair of articular cartilage on the surface of heat-treated bone by transplantation of cultured chondrocytes

The present study addresses clinical problems associated with the degeneration of articular cartilage, which occurs when heat-treated bone with articular cartilage is used for re-implantation after resection of malignant bone tumors adjacent to the joints. We therefore evaluated the effect of transplantation of chondrocytes embedded in collagen gel on the surface of heat-treated bone. A cylindrical complex of bone and articular cartilage 6 mm in diameter was resected from rabbits' patellar grooves and treated in saline at 60 degrees C for 30 min. In Group A, articular cartilage was resected from the complex and the remaining bone was returned to the patellar groove. Then, autologous chondrocytes cultured in collagen gel were transplanted and covered with periosteum. As controls, the original complex of heat-treated bone and articular cartilage (Group B) and heat-treated bone directly covered with periosteum (Group C) was returned to the patellar groove. In Group A, histological study showed that round cells were mainly observed and the matrix was well stained with Safranin O in the repair tissue after 24 weeks. The repair tissue was as thick as the adjacent normal cartilage. Immunohistological study detected type-II collagen and chondroitin-6-sulphate (3B3+) in the matrix of the repair tissue, but not type-I collagen. The repair tissue was consequently cartilaginous in Group A. The repair tissue was not cartilaginous or was degenerative in the control groups. We believe that this modality of heat-treated joints will contribute to limb salvage reconstruction after resection of malignant bone tumors adjacent to the joints.

Reclassification of the Cryptococcus humicola complex

Ten strains of the Cryptococcus humicola complex were reclassified on the basis of sequence analyses of 18S rDNA and internal transcribed spacer regions and DNA-DNA reassociation experiments. They were differentiated into seven species including C humicola. Five novel species are proposed: Cryptococcus daszewskae sp. nov. (type strain CBS 5123T = JCM 11166T = MUCL 30649T), Cryptococcus fragicola sp. nov. (type strain JCM 1530TT = CBS 88981), Cryptococcus longus sp. nov. (type strain CBS 5920T = JCM 11167T = MUCL 30690T), Cryptococcus musci sp. nov. (type strain JCM 1531T = CBS 8899T) and Cryptococcus pseudolongus sp. nov. (type strain JCM 9712T = CBS 8297T). A syntype of Sporobolomyces albidus JCM 1460T is also revealed to be a distinct species; the name Cryptococcus ramirezgomezianus nom. nov. is therefore proposed for Sporobolomyces albidus Ramírez Gómez (type strain IJFM 502T = CBS 2839T = JCM 1460T = NRRL Y-2478T), since the name Cryptococcus albidus (Saito) C. E. Skinner has already been recognized for a distinct species within the genus Cryptococcus. Strains possessing either Q-9 or Q-10 have been reported to occur in C. humicola; however, after reclassification, the ubiquinone type of the species in each phylogenetic group was shown to be uniform, indicating that it is a useful criterion for the taxonomy of the Trichosporonales.

A nested PCR assay to detect DNA in sera for the diagnosis of deep-seated trichosporonosis

Deep-seated trichosporonosis caused by Trichosporon asahii has a high mortality rate and a very poor prognosis. New species-specific oligonucleotide primers for T. asahii were developed from a sequence analysis of rRNA genes that included the internal transcribed spacer regions. A nested PCR assay with specific primers was used to examine 11 serum samples from 7 patients, who were diagnosed with deep-seated trichosporonosis histologically at autopsy. In addition, Trichosporon cell wall polysaccharide (PS) was detected by a latex agglutination (LA) test. Of 11 samples, seven had a positive LA test, and T. asahii DNA was also detected with the nested PCR assay. Of the four samples in which PS antigen was not detected, the nested PCR of two samples was positive. Our new nested PCR assay may be used as an adjunct to conventional methods for diagnosing T. asahii infection.

Pulmonary venous obstruction requiring lobectomy for hemoptysis after a Glenn operation

Right atrial isomerism is well known to be associated with anomalous pulmonary venous drainage and a potentially dangerous sequel to pulmonary venous obstruction, and is associated with high mortality. We report a 16-month-old girl with pulmonary venous obstruction requiring lobectomy for hemoptysis after a Glenn operation. Two years after surgery, she is doing well with 80% oxygen saturation and no further episodes of hemoptysis.

Molecular analysis of Malassezia microflora on the skin of atopic dermatitis patients and healthy subjects

Members of the genus Malassezia, lipophilic yeasts, are considered to be one of the exacerbating factors in atopic dermatitis (AD). We examined variation in cutaneous colonization by Malassezia species in AD patients and compared it with variation in healthy subjects. Samples were collected by applying transparent dressings to the skin lesions of AD patients. DNA was extracted directly from the dressings and amplified in a specific nested PCR assay. Malassezia-specific DNA was detected in all samples obtained from 32 AD patients. In particular, Malassezia globosa and M. restricta were detected in approximately 90% of the AD patients and M. furfur and M. sympodialis were detected in approximately 40% of the cases. The detection rate was not dependent on the type of skin lesion. In healthy subjects, Malassezia DNA was detected in 78% of the samples, among which M. globosa, M. restricta, and M. sympodialis were detected at frequencies ranging from 44 to 61%, with M. furfur at 11%. The diversity of Malassezia species found in AD patients was greater (2.7 species detected in each individual) than that found in healthy subjects (1.8 species per individual). Our results suggest that M. furfur, M. globosa, M. restricta, and M. sympodialis are common inhabitants of the skin of both AD patients and healthy subjects, while the skin microflora of AD patients shows more diversity than that of healthy subjects. To our knowledge, this is the first report of the use of a nested PCR as an alternative to fungal culture for analysis of the distribution of cutaneous Malassezia spp.

[Brain metastases from esophageal cancers: clinical features and treatment results]

Metastatic brain tumors from esophageal cancer are relatively rare. We analyzed the clinical features and results of treatment in 14 cases of brain metastases from esophageal carcinoma. The average time to diagnosis of brain metastases in the 11 patients with metachronous lesions was 13 months. The average age of patients at the diagnosis of brain metastasis was 65 years. Most patients had T4 or N1 disease at the time of diagnosis of esophageal cancer. Performance status of grade 3 was most frequent at the time of diagnosis of brain metastasis. Treatment for brain metastases was surgery followed by radiation in five cases, radiotherapy alone in seven cases, and conservative treatment in two cases. The median survival time of all patients from the treatment of brain metastases was 2 months, with only one patient alive after more than one year. Improvement in neurological symptoms was demonstrated in 42% of cases. These extremely poor treatment results reflect the fact that most patients at the time of diagnosis of brain metastasis had poor performance status and the presence of extracerebral metastases. Therefore, a short-course, high-dose-per-fraction treatment for brain metastases from esophageal cancer should be selected from the viewpoint of quality of life.

Effect of thermosensitive liposomal doxorubicin with hyperthermia on primary tumor and lung metastases in hamster osteosarcoma

We evaluated the effect of intravenous thermosensitive liposomal doxorubicin (TL-DOX) together with local hyperthermia on primary tumors in highly metastatic hamster osteosarcoma. This combination resulted in higher DOX concentrations in plasma, primary tumors and lungs than standard DOX under the same conditions. Tumor growth and lung metastasis were also inhibited more by TL-DOX and hyperthermia than by hyperthermia alone, DOX with or without hyperthermia, and TL-DOX without hyperthermia. In addition, gains in hamster body weight were not suppressed. These results suggest that the combination of TL-DOX and hyperthermia can control primary tumors and suppress lung metastasis in hamsters.

Increased and decreased expression of CD69 and CD23, respectively, in gravity-stressed lymphocytes

BACKGROUND

Recent studies have shown that gravity-changing stress modulates expression levels of cell surface molecules on human lymphocytes. However, previous in vitro microgravity studies have been performed with lymphocytes treated with mitogenic agents.

HYPOTHESIS

The aim of the study was to test if exposure of cells to gravity-changing stress alone alters the expression levels of cell surface molecules. Specifically, we examined whether the expression of activation markers is altered after exposure of lymphocytes to combinations of microgravity and hypergravity.

METHODS

We used free-fall in parabolic flight for human subjects and a drop-shaft to expose peripheral blood mononuclear cells (PBMC) to gravity-changing stress. After such exposure, PBMC were isolated, and expression levels of CD69, CD23 and CD38 were estimated using three-color flow cytometry.

RESULTS

Increased percentages of CD69-positive cells were observed with PBMC from 3 of 4 volunteers who undertook 10 parabolic flights. Exposure of blood to gravity-changing stress in the drop-shaft increased both ratios of CD69-positive cells and levels of CD69 expression on T and B cells. In contrast, the percentages of CD23-positive B cells was decreased. However, gravity-changing stress was not always followed by significant alteration in CD38 expression.

CONCLUSIONS

Our findings suggest that CD69 and CD23 might be useful markers that are up- and down-regulated, respectively, after exposure of lymphocytes to gravity-changing stress.

[A case of non-invasive pulmonary aspergillosis that rapidly deteriorated]

The pulmonary diseases caused by the Aspergillus species include invasive forms, for example, invasive pulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, and non-invasive pulmonary aspergillosis. Though these forms are defined pathologically by the presence of the Aspergillus species that invades the lung tissue, they are used as clinical entities. We report a case of non-invasive pulmonary aspergillosis which, from the clinical data, appeared likely to be misdiagnosed as the chronic invasive form. A 45 year-old man received chemoradiotherapy for lung cancer as well as undergoing an left upper lobectomy. Two weeks after the surgery the patient developed a cough, high fever and chest pain. Chest radiography and chest computed tomography showed a rapidly enlarging cavity with an internal mass and infiltration in the left lower lung field. A transbronchial biopsy specimen of the cavity wall showed fungal hyphae. Bronchial washing culture grew Aspergillus fumigatus. Itraconazole and amphotericin B were administered, but the patient's condition did not improve. A left lower lobectomy was performed. The histologic findings showed that the fungal hyphae were only on the surface of the cavity wall, and were surrounded by necrosis and widespread inflammatory cell infiltration. No fungal invasion of the viable lung tissue was seen. The area of infiltration revealed an organizing pneumonia without Aspergillus or other organisms. Our final diagnosis was non-invasive pulmonary aspergillosis. There has been no recurrence of the lung cancer or of the pulmonary aspergillosis in the three years since surgery. It is reported that non-invasive pulmonary aspergillosis passes through a period so active that it seems to be the invasive form for its entire clinical course. To avoid confusion in diagnosis, establishment of a comprehensive clinical classification of pulmonary aspergillosis will be needed.

Early and late results of partial plication annuloplasty for congenital mitral insufficiency

BACKGROUND

Partial plication annuloplasty is the main technique for congenital mitral insufficiency because this technique allows the mitral anulus to grow, in contrast to ring annuloplasty. However, this technique is not satisfactory for mitral insufficiency with some anomalies of the mitral valve apparatus.

METHODS

Forty-one patients underwent partial plication annuloplasty for mitral regurgitation from July 1979 to December 1998. Mitral regurgitation associated with an atrioventricular defect, an atrioventricular discordance, and a univentricular heart was excluded from this study.

RESULTS

There were no early or late deaths. In early results, partial plication annuloplasty was more effective for mitral regurgitation with abnormality of the posterior leaflet (n = 14) or normal leaflet motion (n = 8) than with abnormality of the anterior leaflet and its apparatus (n = 14) or absence of chordae (n = 4). The mean follow-up period was 145.8 months. During the follow-up period, 2 patients underwent mitral valve replacement, and a third patient underwent mitral valve repair with partial plication annuloplasty after the first repair. The main cause of mitral regurgitation of 2 of the 3 patients was absence of chordae. The actuarial freedom from reoperation rate was 94.9% +/- 3.6%, 91.9% +/- 4.7%, and 91.9% +/- 4.7% at 5, 10, and 15 years after the operation, respectively.

CONCLUSION

Early and long-term results of partial plication annuloplasty were acceptable for congenital mitral insufficiency with any type of malformation of the mitral valve, and results were excellent with abnormality of the posterior leaflet and its apparatus or normal leaflet motion. However, late results were suboptimal for mitral regurgitation with absence of chordae. Other techniques, such as artificial chorda replacement, should be adapted in these cases.

Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments

The position of the fibula around the proximal tibia varies in different people; it was therefore hypothesized that this variation would affect the orientation of the lateral collateral ligament and the popliteofibular ligament complex. This hypothesis was studied in 10 cadaveric knees by measuring the orientation and length changes in these structures as the knee was flexed. The data were correlated with tibiofibular joint position. The strength of the ligaments was also tested. There were significant correlations between fibular head position and ligament orientation with the knee extended. The lateral collateral ligament slackened significantly with knee flexion, whereas the popliteofibular ligament complex did not. The structures became significantly steeper in the sagittal plane as the knee was flexed. The lateral collateral ligament passed through vertical at 70 degrees of knee flexion and was thus poorly oriented to withstand tibial external rotation. The lateral collateral and popliteofibular ligaments had tensile strengths of 309 and 186 N, respectively. The popliteofibular ligament is dominant when the knee is flexed, because of the slackening of the lateral collateral ligament, and so it should always be reconstructed. The anatomic variation causes some knees to have better ligament orientations to withstand posterolateral tibial displacements and, conversely, other knees may be inherently more difficult to stabilize by reconstruction.

De Vega annuloplasty and Carpentier-Edwards ring annuloplasty for secondary tricuspid regurgitation

BACKGROUND AND AIM OF THE STUDY

Residual or recurrent tricuspid regurgitation (TR) has been reported after several types of surgical repair. The development of late TR is an important complication of left heart surgery. The results of De Vega annuloplasty were compared with those obtained after Carpentier-Edwards ring (CE ring) annuloplasty in patients with secondary TR.

METHODS

The records of 45 patients who underwent surgery for secondary TR between January 1995 and July 2000 were reviewed retrospectively. Twenty-eight patients underwent De Vega annuloplasty, and 17 had a CE ring annuloplasty. The groups were similar with respect to associated cardiac lesions. No significant preoperative differences were observed in NYHA functional class, TR grade, and pulmonary artery pressure between the two groups.

RESULTS

One CE patient died of left ventricular dysfunction after postoperative bleeding. The 28 De Vega patients and remaining 16 CE patients had an uneventful recovery, and were discharged. Tricuspid ring size after repair was similar between groups. Mean (+/- SD) follow up in the entire patient cohort was 39+/-23 months (range: 6 to 75 months). TR recurrence was rated as grade II or III in 13 patients (45%) after De Vega annuloplasty, but was grade II or III in only one patient (6%) patient after CE ring annuloplasty. There was a significant difference in TR recurrence between the groups (p = 0.027), but no significant difference in NYHA class.

CONCLUSION

CE ring annuloplasty significantly decreased the recurrence of TR; thus, CE ring annuloplasty is superior to De Vega annuloplasty in patients with secondary TR.

A day care program and evaluation of animal-assisted therapy (AAT) for the elderly with senile dementia

We conducted a survey to clarify the evaluation methods of animal-assisted therapy (AAT) for the elderly with senile dementia in an adult day care center. AAT was implemented for a total of six biweekly sessions. The AAT group consisted of seven subjects and the control group numbered 20 subjects. In a comparison between Mini-Mental State Exam (MMSE) scores at baseline and those measured three months later, the average MMSE score before AAT (baseline) was 11.43 (+/- 9.00), and three months later it was 12.29(+/- 9.69). In the AAT group, the average score on Nishimura's Activities of Daily Living (N-ADL) at baseline was 28.43(+/- 14.00), and after ATT it was 29.57(+/- 14.47). In the AAT group, the average baseline score on behavioral pathology of Alzheimer's disease (Behave-AD) was 11.14(+/- 4.85), and three months after AAT it was 7.29(+/- 7.11) (p < 0.05). In the control group, the average baseline score was 5.45(+/- 3.27) and three months later it was 5.63(+/- 3.59). The evaluation of salivary CgA, as a mental stress index, showed a decreasing tendency in the AAT group. Our findings demonstrate the usefulness of using several methods for evaluation of the changes in patients given AAT.

Injuries to the posterolateral aspect of the knee accompanied by compression fracture of the anterior part of the medial tibial plateau

We present 12 cases of patients with injury to the posterolateral aspect of the knee accompanied by a compression fracture of the anterior part of the medial tibial plateau. There were 11 male patients and 1 female patient with an average age of 26 years (range, 17 to 44 years). There were 4 cases of posterolateral rotatory instability and 8 cases of straight lateral instability of the knee. The size of the compression fracture was classified into 2 types, small (8 cases) and large (4 cases). Although the mechanism of injury was considered to be hyperextension and varus force, the pattern of cruciate ligament injuries varied from case to case. The following 3 questions should be considered to determine which cruciate ligament is damaged: (1) Was the ipsilateral foot fixed to the ground? (2) Was forward inertia involved? (3) Was there a direct blow to the anteromedial aspect of the tibia or to the femur? Accompanied fractures of the medial tibial plateau were considered to have been compressed by the medial femoral condyle. The size of the accompanying compression fracture varied; 7 of 8 cases with a small-type fracture had posterior cruciate ligament injuries and 3 of 4 cases with a large-type fracture had anterior cruciate ligament injuries. The size of the fracture is determined by which point of the medial tibial plateau touched the medial femoral condyle. We propose that a compression fracture of the anterior part of the medial tibial plateau indicates a coexistent posterolateral aspect injury, and that especially a small compression fracture strongly suggests an accompanying posterior cruciate ligament injury, as well.

Genetic diversity and biochemical characteristics of Trichosporon asahii isolated from clinical specimens, houses of patients with summer-type-hypersensitivity pneumonitis, and environmental materials

Trichosporon asahii, which is distributed in the environment, is the major causative agent of the opportunistic infection trichosporonosis, and it also causes summer-type hypersensitivity pneumonitis (SHP). Random amplification of polymorphic DNA analysis was used to determine the intraspecies diversity of 39 T. asahii isolates from clinical specimens, SHP patients' houses, and environmental materials. The three primers used revealed 46 polymorphic bands. A phenogram was generated by the unweighted pair-group method with arithmetic mean. Clinical isolates formed a cluster, characterized by a 90% matching coefficient, but they did not cluster with strains isolated from SHP patients' houses or environmental sources. In addition, the biochemical characteristics of 86 strains from three sources were examined with 31 compounds using an ID32C kit, and a phenogram was constructed. The phenogram consisted of three major clusters. Cluster I included most of the clinical SHP isolates, and cluster II included most of the environmental isolates. Cluster III contained only one strain. A remarkable difference was found in the abilities of the strains belonging to clusters I and II to utilize six compounds. These results suggest that the genetic diversity and biochemical characteristics of T. asahii seem to be related to the source of the isolate. We also found a specific DNA fragment for the clinical isolates and strains isolated from SHP patients' houses.

[Pneumonia caused by Nocardia nova]

This is the first clinical report of a case of pneumonia caused by Nocardia nova in Japan. A 52 year-old woman who had received steroids and cyclophosphamide for six years because of polymyositis was admitted to our hospital for further examination. On admission she had a mild cough, and her chest radiography and computed tomography revealed bilateral multiple nodules, some of which were cavitated. She developed a cough productive of yellow sputum and fever up to 38 degrees C. Examination of the sputum revealed a gram-positive branched organism and sputum cultures repeatedly grew Nocardia species. The isolate was identified as Nocardia nova later. Clinical recovery was obtained readily upon treatment with imipenem and trimethoprim methoxazole, though the latter drug was discontinued because of nausea and anorexia. This drug was therefore replaced with oral minocycline, which proved to be ineffective clinically although susceptibility testing of the drug showed positive sensitivity. Minocycline was replaced with clarithromycin, after which chest radiography and computed tomography showed almost total resolution of the infiltrates. Clarithromycin may be an alternative oral agent to sulfonamides or minocycline when these agents are ineffective or not tolerated.

Coronary artery bypass grafting for patients with an atherosclerotic ascending aorta

OBJECTIVES

We review the outcome of coronary artery bypass grafting in patients with a severe atherosclerotic ascending aorta.

METHODS

Subjects were 31 patients averaging 69.4 +/- 6.9 years old studied from 1990 through 1998. Ascending aortic lesions were assessed using epiaortic echo and 2 types of aortic nonclamping techniques applied. In 29 patients operated on in the early years, bypass grafting was conducted on the hypothermic fibrillated heart in 22 and on the beating heart in 7. The remaining 2 underwent off-pump coronary artery bypass grafting more recently. For cases with multivessel disease, we used composite grafting.

RESULTS

Three patients developed mild stroke and 5 died within 30 days of surgery--4 from multiple emboli (1 accompanied by a stroke) and 1 from perioperative myocardial infarction. One hospital death occurred due to brain damage and multiorgan failure following unexpected rupture of a saphenous vein graft. No cardiac deaths occurred in the late stage of our series. Actuarial survival was 73.0% for 3 years and 68.0% for 5 years. Freedom from cardiac events was favorable in the remaining 25 survivors.

CONCLUSIONS

Outcome was suboptimal for the risks involved. Recent technical advances, including coronary surgery on the beating heart with or without cardiopulmonary bypass using variable in-situ or free arterial grafts, associated with adequate evaluation of systemic atherosclerosis, should improve this outcome.

Clinical characteristics of patients with constrictive pericarditis after coronary bypass surgery

Constrictive pericarditis (CP) is an unusual sequela of cardiac surgery, so the present study evaluated the clinical characteristics of patients with CP after coronary artery bypass grafting (CABG). Four hundred and sixty-three patients who underwent isolated CABG between January 1989 and March 1999 were examined retrospectively. The first choice of treatment for postoperative pericardial effusion was non-steroid anti-inflammatory agents, and an increased dose of diuretics. The second treatment choice was corticosteroids or pericardial drainage. When CP was suspected during the follow-up period (mean, 54+/-31 months), cardiac catheterization was carried out to establish the diagnosis. Of the 463 patients undergoing CABG, there were 11 (2.4%) who developed CP after surgery. The median time to the onset of symptoms after CABG was 4 weeks (range, 3-96 weeks). On univariate and multivariate analysis, normal left ventricular ejection fraction, warfarin administration, and early postoperative pericardial effusion were significantly associated with a greater potential of postoperative CP. The effusion was bloody in all cases of pericardial drainage despite warfarin therapy. Not draining the postoperative effusive pericardial effusion was a risk factor for the development of CP. Pericardial drainage for patients with significant effusion after CABG is important for the prevention of subsequent CP, especially in those patients being treated with warfarin or with normal left ventricular function.

Radial displacement of the medial meniscus in varus osteoarthritis of the knee

The macroscopic and histologic findings for 31 medial menisci and medial tibial plateaus obtained during total knee arthroplasty were examined to clarify the etiology and progression of varus osteoarthritis. Medial menisci were preserved fairly well in cases of severe osteoarthritis in which the medial joint space had already disappeared. The anterior segment was preserved in 26 (84%) menisci and the posterior segment was preserved in 11 (35%). The medial meniscus may have been preserved because of its radial displacement. Exposure of subchondral bone of the medial tibial plateau occurred in all 31 knees. The exposure of subchondral bone was centered in the anterior, middle, and posterior in nine, 10, and 12 medial tibial plateaus, respectively. There was a mechanical inconsistency between the pattern of preservation of the medial menisci and the location of exposure of subchondral bone on the medial tibial plateaus. The inconsistency reflects that the segment of the medial meniscus on which the excessive load was considered to exist was preserved fairly well. The authors' hypothesis for explaining this inconsistency is that radial displacement of the medial meniscus precedes narrowing of the medial joint space during progression of varus osteoarthritis, so that the displaced meniscus is saved from severe degeneration or attrition.

Surgery for acute type A aortic dissection using retrograde cerebral perfusion

OBJECTIVE

We reviewed the surgical management of acute type A aortic dissection between 1989 and 1998.

METHODS

Subjects were 28 consecutive patients (mean age: 61.8 +/- 10.7 years) with acute type A aortic dissection were studied. The mean duration between aortic dissection onset and surgery was 17.5 +/- 17.0 hours. In surgery, aortic pathology and flow patterns in dissected aortic channels were evaluated using transesophageal and epiaortic echo. Simple, safe combination of profound hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis was used for brain protection. Hypothermic circulatory arrest was 46.9 +/- 24.8 minutes. Aortic repair consisted in ascending aortic replacement in 5 patients, with hemiarch repair in 17, and total arch repair in 6. Intimal tears were resected in all but 2 patients. Concomitantly resuspension of the aortic valve was done in 9 and aortic root replacement in 2.

RESULTS

No operative (30-day) deaths occurred, although 2 died from unrelated hepatic failure during hospitalization or late-stage pancreatic cancer in the late stage. In cerebral sequellae, 1 patient suffered a stroke and 2 patients developed temporary neurologic dysfunction.

CONCLUSION

Our experience demonstrated that the simplified conjunction of hypothermic circulatory arrest with retrograde cerebral perfusion and open aortic anastomosis, associated with real-time assessment by transesophageal and epiaortic echo, is safe and useful during emergency aortic repair for acute type A aortic dissection.

Two new yeasts, Trichosporon debeurmannianum sp. nov. and Trichosporon dermatis sp. nov., transferred from the Cryptococcus humicola complex

Cryptococcus humicola, as currently defined, shows intraspecific rRNA gene sequence differences. Three strains of this species produced arthroconidia on cornmeal agar and belonged to the genus Trichosporon in a molecular phylogeny. They clustered with the species possessing Q10 as the major ubiquinone and were serotype I. Sequence analyses clearly revealed that they were two new Trichosporon species. The names Trichosporon dermatis sp. nov. (= CBS 2043T) and Trichosporon debeurmannianum sp. nov. (= CBS 1896T) are proposed for these strains.

Aortic laceration due to prolapse of the bicuspid aortic valve: case report

Reports of aortic regurgitation due to rupture of the aortic valve commissures are rare. Prompt surgical intervention is necessary, as the condition results in rapid, progressive heart failure and subsequent death. We report the case of a 78-year-old man who presented with aortic laceration and cardiac tamponade that was probably induced by prolapse of the bicuspid aortic valve. We speculate that prompt initial surgery may have prevented aortic laceration and cardiac tamponade in this patient. Thus, in order to optimize clinical outcome, clinicians must consider early, precautionary surgical management in patients who have sudden cardiac failure due to aortic regurgitation associated with prolapse of the bicuspid aortic valve.

Localization of mitochondrial ribosomal RNA on the chromatoid bodies of marine planarian polyclad embryos

Electron-dense cytoplasmic structures, referred to as chromatoid bodies, are observed in the somatic stem cells, called neoblasts, and germline cells in adult planarians. Although it has been revealed that the chromatoid bodies morphologically resemble germline granules in Drosophila and Xenopus embryos, what essential role it plays in the planarian has remained unclear. In the present study, to examine whether chromatoid bodies in planarian embryos are responsible for germline formation, the presence and behavior of chromatoid bodies during embryogenesis were examined. Mitochondrial large ribosomal RNA and mitochondrial small ribosomal RNA were used as candidate markers for components of the chromatoid body. Starting from the fertilized egg, extramitochondrial signals of both RNA (mtrRNA) were observed. At the ultrastructural level, mtrRNA were localized on the surface of the chromatoid bodies. At subsequent stages, the signals of mtrRNA were observed in certain restricted blastomeres that contribute to the formation of larval structures. The signals gradually decreased from the gastrula stage. These results suggest that the chromatoid bodies associated with mtrRNA in embryogenesis are not germline granules. The chromatoid bodies of blastomeres may be concerned with the toti- or pluripotency and cell differentiation as proposed in adult planarian neoblasts.

Is the mechanism of traumatic posterior dislocation of the hip a brake pedal injury rather than a dashboard injury?

This study proposes that the mechanism of traumatic posterior dislocation of the hip (TPDH) is a brake pedal injury rather than a dashboard injury. A total of 168 cases of TPDH were treated during the past 10 years. Clinical records of 48 patients, who were drivers and suffered from a head-on collision accident, were examined. The right hip was involved in 45 cases. A total of 31 cases were not accompanied by knee injuries. In 11 cases with foot or ankle injuries and right hip dislocation, 10 had right foot or ankle injuries. If the mechanism of TPDH was a dashboard injury, the left hip would be involved more frequently and there would be more knee injuries. Our hypothesis about the mechanism is that, in a head-on collision, the driver presses desperately on the brake pedal with his right hip slightly flexed, adducted and internally rotated.

Inhibitory effect of liposomal MDP-Lys on lung metastasis of transplantable osteosarcoma in hamster

MDP-Lys (N2-[(N-acetylmuramyl)-L-alanyl-D-isoglutaminyl]-N6-stearoyl-L-lysine), a macrophage activator, is a lipophilic derivative of muramyl dipeptide (MDP). Multilamellar liposome incorporated MDP-Lys was prepared using phosphatidylcholine and phosphatidylserine by conventional film method, and its inhibitory effect on lung metastasis was compared with MDP-Lys as a solution in hamster's osteosarcoma. The lung metastatic rates after transplantation of the tumor to a lower extremity, in which the extremity was amputated 3 weeks later, were 50% and 100% 3 and 7 weeks, respectively, after transplantation. The rates after amputation were reduced by the treatment with MDP-Lys proportionally to the logarithmic MDP-Lys dose, and the rates 7 weeks after transplantation were 55% and 60%, respectively, in the MDP-Lys solution (50 microg/day) and liposomal MDP-Lys (20 microg twice/week) groups. Fifty percent of hamsters treated with liposomal MDP-Lys survived for more than 6 months. Considering that hamsters had a lung metastasis rate of 50% before MDP-Lys treatment, liposomal MDP-Lys given at a dose of 20 microg twice/week was effective for inhibiting lung metastasis at a far lower dose of MDP-Lys than that given as a solution (40 microg vs. 350 microg per week). No significant side effect of liposomal MDP-Lys, as evaluated by the comparison of body weight changes among differently treated hamsters, was detected. This greater inhibitory effect of liposomal MDP-Lys can be considered to be due to the longer retention of the liposomal form in the lung.

[Surgery for thoracic aortic aneurysms involving the distal arch through a left thoracotomy]

Surgical outcome for thoracic aortic aneurysms involving the distal arch via a left thoracotomy using retrograde cerebral perfusion combined with profound hypothermic circulatory arrest was reviewed. Twelve patients with a atherosclerotic aortic aneurysm between 1994 and 1997 were involved. A proximal aortic anastomosis was made by means of an open aortic technique. For the first four patients, oxygenated arterial blood from cardiopulmonary bypass was perfused retrogradely through a venous cannula positioned into the right atrium. In the last eight cases, venous blood provided by a low-flow perfusion of the lower half body via the femoral artery, which was still oxygen-saturated, was circulated passively in the brain in a retrograde fashion with the descending aorta clamped. Prosthetic replacement was done between the distal arch and the proximal descending aorta in 6 patients and from the distal arch to the entire descending thoracic aorta in 6 patients. The median duration of hypothermic circulatory arrest and continuous retrograde cerebral perfusion was 36 minutes and 33 minutes respectively. The overall outcome was satisfactory without early mortality--all patients survived, although an octogenarian died of respiratory failure 1 year postoperatively. Another octogenarian with a ruptured aneurysm developed delay of meaningful consciousness, and other two patients with a severely atherosclerotic aneurysm suffered permanent neurological dysfunction (stroke) presumably due to an embolic episode. The safe and simple combination of profound hypothermic circulatory arrest, retrograde cerebral perfusion, and open aortic anastomosis protects the brain adequately and produces satisfactory results in surgery for aortic aneurysms involving the distal arch through a left thoracotomy.

Phylogenetic and taxonomic heterogeneity of Cryptococcus humicolus by analysis of the sequences of the internal transcribed spacer regions and 18S rDNA, and the phylogenetic relationships of C. humicolus, C. curvatus, and the genus Trichosporon

The phylogenetic and taxonomic heterogeneity of a rare opportunistic yeast pathogen, Cryptococcus humicolus, was revealed by analysis of the sequence of the internal transcribed spacer (ITS) region. Sixteen strains of C. humicolus showed a wide diversity in their ITS sequences. In addition, their 18S rDNA sequences were determined and used to analyze the phylogenetic relationships among C. humicolus and related yeasts. On trees constructed by the Neighbor-Joining and Maximum Parsimony methods, C. humicolus strains were phylogenetically closely related to each other with the exception of one strain, and they clustered with C. curvatus and Trichosporon species with high bootstrap values. Three C. humicolus strains obtained from humans belonged to the group of Trichosporon serotype I species. The results suggest that C. humicolus is a genetically heterogeneous species which should be reclassified on the basis of DNA sequence data.

Optical time-domain reflectometry of bent plastic optical fibers

Optical time-domain reflectometry (OTDR) signals of step-index plastic optical fibers (POF's) and graded-index POF's were measured with a laser diode and an avalanche photodiode. When bent step-index and graded-index POF's were used, the OTDR signal behavior differed. The OTDR signal of the bent graded-index POF's had a step that corresponds to a curvature loss, but the step-index POF's had a spike signal at a bend, which indicated the occurrence of backscattering. The peak intensity was proportional to the square of the curvature. The refractive-index variation of the bent step-index POF's was measured, and the dependence of the peak intensity on the curvature was shown to agree with that predicted by the scattering from the refractive-index perturbation.

[Contents of phthalate in polyvinyl chloride toys]

The presence of plasticizers in PVC toys obtained in October 1998 was investigated. Diisononyl phthalate (DINP), di-2-ethylhexyl phthalate (DEHP), di-n-butyl phthalate (DBP), dinonyl phthalate (DNP), diheptyl phthalate (DHP), and di-2-ethylhexyl adipate (DEHA) were detected. The phthalates were found in all of the 68 samples. The principal phthalate found in toys was DINP, which was present in 48 of 68 samples. The DINP content ranged from 15 mg/g to 580 mg/g, and mean content was 308 mg/g. The highest content was found in a pacifier toy. DEHP was present in 20 of 68 samples and the content ranged from 2.0 mg/g to 380 mg/g. The mean content was 162 mg/g. It was found in 60% of domestic toys.

Aortic arch repairs through three different approaches

OBJECTIVES

The outcome of aortic arch repairs by means of three different approaches between 1990 and January 2000 was reviewed.

METHODS

In total 39 patients aged 71.5+/-6.2 years were operated on. The three different surgical approaches depended on the anatomical positions of the aneurysms and on their proximal or distal extension; a median approach was employed in 23 patients, whereas a left postero-lateral approach was used in eight patients. More recently, in eight cases a left antero-lateral approach was applied. All patients underwent open aortic anastomosis without any clamp on or around the aortic arch. During the procedure, the brain was protected by a combination of profound hypothermic circulatory arrest and several techniques of retrograde cerebral perfusion.

RESULTS

Permanent cerebral dysfunction occurred in four patients: two in the median approach and two in the left postero-lateral approach. There were two hospital deaths (5.3%) and six late deaths, all of which belonged either to the median group or to the postero-lateral group. The antero-lateral approach did not produce any cerebral dysfunction, early death, or late death.

CONCLUSIONS

The outcome of aortic arch repairs using profound hypothermic circulatory arrest and variable techniques of retrograde cerebral perfusion, by means of three different approaches, was satisfactory. Of the three approaches, the antero-lateral approach can be employed easily, whether aneurysms extend proximally or distally.

Targeted systemic chemotherapy using magnetic liposomes with incorporated adriamycin for osteosarcoma in hamsters

To control the growth of primary tumors effectively with systemic chemotherapy, we recently developed intravenously administered small-sized magnetic liposomes as an anticancer drug carrier. We previously reported that intravenously administered magnetic liposomes with incorporated adriamycin (magnetic ADR liposomes) effectively delivered ADR to the target site where a permanent magnet was implanted. In the present study, the therapeutic efficacy of this novel treatment approach, which involves a combination of magnet implantation at the target site and intravenous administration of magnetic liposomes, was further evaluated by comparing tumor growth rates among different administration modalities and by histological examination of treated tumors. Small-sized magnetic ADR liposomes with a mean diameter of 146 nm were prepared by the reverse-phase evaporation method. Syrian male hamsters inoculated with osteosarcoma, Os515, in the right hind limb were studied 7 days after inoculation. One day prior to the animal study, either a permanent magnet (with magnetic force) or non-magnetic alloy (without magnetic force) was implanted in the center of the tumors. Treatment with magnetic ADR liposomes under magnetic force showed significantly greater antitumor activity than intravenous administration of ADR solution or that of magnetic ADR liposomes without magnetic force. ADR administered as magnetic liposomes eliminated weight loss of hamsters, one of the side effects produced by ADR. Interestingly, magnetic liposomes (without incorporated ADR) given under magnetic force also suppressed the tumor growth. The selective accumulation of magnetite particles in the tumor blood vessels was observed by histological examination. These results suggest that this systemic chemotherapy can effectively control the primary tumor without significant side effects, due to the targeting of magnetic ADR liposomes.