[Feeding methods for long-term bedridden patients with dysphagia under home health care--percutaneous endoscopic gastrostomy (PEG) and intravenous hyperalimentation (IVH)]

We began home health care in our hospital in 1992, and the total number of patients under home health care has reached 380 so far. We report 12 bedridden patients with dysphagia, who have obtained nutrition using two feeding methods. The patients are 7 men and 5 women, with a mean age of 81.4 +/- 8.8 years. The diseases in these patients include cerebrovascular diseases, Parkinson's disease, and senile dementia of the Alzheimer type. The feeding methods include swallowing after swallowing training, percutaneous endoscopic gastrostomy (PEG), and intravenous hyperalimentation (IVH). We have fed these patients by combinating these three methods. The patients fed by swallowing and PEG, swallowing and IVH, and PEG and IVH are five, five and two, respectively. It is very important for bedridden patients to eat and swallow food by themselves, even if the amount is extremely small. Although swallowing training has been performed, the amount of food is not sufficient for life support. Therefore, additional feeding by PEG or IVH is necessary. Sufficient nutrition through a variety of feeding methods is important for patients under home health care.

[Indications for and techniques of hepatic vein reconstruction in hepatectomy for hepatocellular carcinoma]

The indications for hepatic vein reconstruction (HVR) in resection of segments 7 and 8 for hepatocellular carcinoma (HCC) have been controversial. Although right hepatic vein ligation may not cause complications in some patients, hepatic parenchymal congestion and liver dysfunction occur in others. We performed HVR using autovein grafts in 6 HCC patients, patch grafts in 3, and direct anastomosis in 1, respectively. From this experience, we consider that HVR may be indicated in patients with a discolored hepatic area after hepatic vein ligation, and without inferior right hepatic vein and intrahepatic venous communication. Furthermore, although repeat hepatectomy has resulted in improved survival in patients with recurrent hepatic tumors, when the right hepatic vein has already been ligated, numerous intrahepatic communicating vein anastomoses develop. In repeat hepatectomy in such patients, uncontrollable massive bleeding from hepatic veins occurs. Therefore, HVR is recommended to maintain the previous hepatic vein anatomy. Recently, the indications for HVR have been studied to prevent hepatic vein congestion and liver dysfunction in both the remant and graft livers in living-related donor partial liver transplantation from the standpoint of hemodynamics. Additionally, the technique of direct hepatic vein anastomosis is presented.

Intrahepatic cholangiojejunostomy for unresectable malignant biliary tumors with obstructive jaundice

We reviewed our experience with intrahepatic cholangiojejunostomy as a palliative therapy for patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Fifteen patients with malignant biliary obstruction were treated by cholangiojejunostomy at our hospital. Two patients had intrahepatic cholangiocarcinoma, 7 had gallbladder carcinoma, 5 had bile duct carcionoma, and 1 had pancreatic carcinoma. Segment III cholangiojejunostomies were performed in 14 patients and segment V cholangiojejunostomy in 1. Contraindications for surgical resection were locoregional invasion of tumors involving the proper and/or common hepatic artery and portal vein in 15 patients and the presence of hepatic metastases in 6 patients. Liver metastases were detected in 5 of the 7 patients with gallbladder carcinoma. Postoperative complications occurred in 2 patients (13%), but there was no leakage of the cholangioenteric anastomosis in our series. There was no operative mortality after cholangiojejunostomy. Of the 9 patients who survived for more than 6 months after surgery, 7 showed a significant improvement in performance status (PS) (82 +/- 10%) 3 months after the surgery compared with the preoperative PS (70 +/- 7%). Four of the 9 patients had recurrent cholangitis as a late complication, but 4 were completely free from jaundice. Median survival after cholangioenteric bypass was 9 months (range, 2-25 months). With respect to tumor location, the median survival time was 4 months (range, 2-25 months) in patients with gallbladder carcinoma and 15.5 months (range, 12-22 months) in those with bile duct carcinoma. While the median survival period after surgery was only 3 months (range, 2 to 8 months) in the 5 patients with hepatic metastases from gallbladder carcinoma, 2 patients without liver metastasis survived for 9 and 25 months after segment III cholangioenteric bypass. In conclusion, cholangiojejunostomy can provide useful palliation for malignant biliary obstruction when combined with careful patient selection.

Impact of repeat hepatectomy on recurrent colorectal liver metastases

BACKGROUND

Hepatic recurrence is seen in approximately 40% of patients undergoing hepatectomy for colorectal metastases. This study was designed to assess the risks and clinical benefits of repeat hepatectomy for those patients.

METHODS

Twenty-six patients underwent repeat hepatectomy for hepatic recurrence, and their clinical data were retrospectively reviewed for operative morbidity and mortality, performance level, and survival.

RESULTS

There was no operative mortality after repeat hepatectomy. Operative bleeding was significantly increased in the second hepatectomy; but operating time, duration of hospital stay, and performance status after the second hepatectomy were comparable with those of the initial hepatectomy. The median survival time from the second hepatectomy was 31 months, and the 3- and 5-year survival rates were 62% and 32%, respectively. A short disease-free interval (6 months or less) between the initial hepatectomy and diagnosis of hepatic recurrence in the remnant liver was significantly associated with poor survival after the second hepatectomy.

CONCLUSIONS

Repeat resection contributed to clinical benefits for selected patients with hepatic recurrence after the initial hepatectomy for colorectal liver metastases. However, appearance of hepatic recurrence within 6 months or less after the initial hepatectomy is a poor prognostic factor for repeat hepatectomy.

Simple detection of severe coronary stenosis using transthoracic doppler echocardiography at rest

Coronary flow velocity can be measured by transthoracic Doppler echocardiography (TTDE). The purpose of this study was to detect severe coronary stenosis using the diastolic-to-systolic flow velocity ratio (DSVR) determined by TTDE at rest. We prospectively examined 190 consecutive patients with angina pectoris for whom coronary angiography was planned. Doppler spectral tracings of flow velocity in the distal left anterior descending artery were recorded by TTDE at rest. The mean and peak DSVR values were computed using mean and peak coronary flow velocities. DSVR measurement by TTDE at rest was performed within 24 hours before angiography, and in patients who underwent coronary intervention it was performed again within 48 hours after the intervention. The success rate for DSVR measurement by TTDE was 83.7%. There were significant differences in peak DSVR and mean DSVR between the patients with severe stenosis (percent diameter stenosis >85%) and those without severe stenosis (1.3 +/- 0.4 vs 1.9 +/- 0.50 and 1.2 +/- 0.4 vs 1.8 +/- 0.5, respectively; p <0.0001). In the 17 patients with successful intervention, DSVR was significantly increased after the procedure (mean 1.2 +/- 0.1 vs 2.0 +/- 0.2; peak 1.2 +/- 0.2 vs 2.0 +/- 0.3, respectively; p <0.0001). For percent diameter stenosis >85%, the best cut-off points were 1.6 for peak DSVR (sensitivity 79.0%, specificity 75.7%) and 1.5 for mean DSVR (sensitivity 77.0%, specificity 77.9%). Thus, DSVR measurement by TTDE is a simple, noninvasive method for detection of severe coronary stenosis at rest.

Coronary artery bypass grafting in patients with dialysis-dependent renal failure

The aim of this study was to define short- and long-term results of coronary artery bypass grafting (CABG) in dialysis patients. A retrospective review was carried out on 73 consecutive patients dependent on chronic dialysis who underwent CABG. In 63 isolated CABGs, 9 operations were performed under normal beating heart because of severe atherosclerotic changes in the ascending aorta or carotid arteries. The operative mortality (30 days' mortality) was 4.1%, and causes of death were closely related to cardiopulmonary bypass use. In the last 29 operations after introduction of the beating heart bypass, no hospital deaths occurred. The actual survival rates dropped to 45% at 70 months mainly for noncardiac late death. CABG for dialysis patients as undertaken with an acceptable operative risk. Extended application of beating heart bypass to these patients may produce further positive early results.

Impact of repeat hepatectomy on recurrent colorectal liver metastases

BACKGROUND

Hepatic recurrence is seen in approximately 40% of patients undergoing hepatectomy for colorectal metastases. This study was designed to assess the risks and clinical benefits of repeat hepatectomy for those patients.

METHODS

Twenty-six patients underwent repeat hepatectomy for hepatic recurrence, and their clinical data were retrospectively reviewed for operative morbidity and mortality, performance level, and survival.

RESULTS

There was no operative mortality after repeat hepatectomy. Operative bleeding was significantly increased in the second hepatectomy; but operating time, duration of hospital stay, and performance status after the second hepatectomy were comparable with those of the initial hepatectomy. The median survival time from the second hepatectomy was 31 months, and the 3- and 5-year survival rates were 62% and 32%, respectively. A short disease-free interval (6 months or less) between the initial hepatectomy and diagnosis of hepatic recurrence in the remnant liver was significantly associated with poor survival after the second hepatectomy.

CONCLUSIONS

Repeat resection contributed to clinical benefits for selected patients with hepatic recurrence after the initial hepatectomy for colorectal liver metastases. However, appearance of hepatic recurrence within 6 months or less after the initial hepatectomy is a poor prognostic factor for repeat hepatectomy.

Radioimmunoassay for orexin A

A radioimmunoassay for orexin A has been developed. Anti-orexin A antiserum was raised in New Zealand white rabbits immunized with a conjugate of synthetic orexin A with bovine serum albumin. This antibody did not crossreact with orexin B, hypothalamic hormones, pituitary hormones, neuropeptides or gut hormones. Radioiodination of orexin A was performed with the chloramin T method, followed by purification of radioiodinated material on Sephadex G-25 column. Orexin A was extracted from tissues using acid-acetone. The assay was performed with a double antibody system. The dilution curve of acid-acetone-extracts of rat hypothalamus in the radioimmunoassay system was parallel to the standard curve. The recovery of tissue orexin A was about 80%,and the intra-assay and inter-assay variations were 5.2% and 7.8%, respectively. Orexin A was found in the hypothalamus, cerebrum and testis. These data suggest that this assay system is suitable for the measurement of tissue orexin A and that orexin A is found in the central nervous system and testis.

Radioimmunoassay for hypocretin-2

OBJECTIVE

To develop radioimmunoassay for hypocretin-2 (Hcrt-2). And search for its presence in certain rat tissues.

METHODS

Anti-Hcrt-2 serum has been raised in New Zealand white rabbits immunized with a conjugate of synthetic Hcrt-2 with bovine serum albumin. Radioiodination of Hcrt-2 was performed by chloramine T method, followed by purification of radoiodinated material on Sephadex G-25 column.

RESULTS

The obtained antibody did not cross react with hypocretin-2, hypothalamic hormones, pituitary hormones, neuropeptides or gut hormones. The assay was performed with a double antibody system. Hcrt-2 was extracted from the tissues with acid acetone. The dilution curve of acid acetone extracts of rat hypothalamus in the radioimmunoassay system was parallel to the standard curve. The recovery of tissue Hcrt-2 was about 85 % and the intra-assay and inter-assay variation were 5.6 % and 8.0 %, respectively. Hcrt-2 was found in the hypothalamus, cerebrum, brain stem and testes.

CONCLUSIONS

The obtained data suggest that the assay system developed is suitable to measure Hcrt-2 in tissues and that Hcrt-2 is mainly found in the hypothalamus.

Initial and long-term results and peri-procedural complication in 35 extracranial stentings

We undertook stent-supported angioplasty for 35 lesions of extracranial stenosis in 31 patients from May 1996 to October 1998. We succeeded in the stenting at the predetermined sites of all lesions and excellent initial results were obtained. The mean % stenosis decreased from 81% to 7.1% after stenting. Four patients had neurological complications related to the procedure. There were two transient ischemic attacks (one in carotid and one in vertebral stenting), and permanent deficits occurred in two patients treated for carotid stenosis. In carotid stenting, we observed long-term patency for over six months in all 17 patients (18 lesions). Mean angiographic, asymptomatic restenosis was 20% and 21% at three and six months, respectively (range, 4 to 38%). No further stenosis was observed thereafter. Deformity of the stents were not noted in any patient. In vertebral stenting, four out of nine cases revealed significant restenosis between three and six months later, while these were dilated by repeated PTA. On strict definition of indication or application of a cerebral protection, stent-supported angioplasty is an effective method for the treatment of extracranial stenotic lesions.

Distribution of thyrotropin releasing hormone receptor type 2 in rats: an immunohistochemical study

OBJECTIVE

To investigate the organ distribution of thyrotropin releasing hormone receptor (TRHR) type 2 in rats by immunohistochemical method.

METHODS

TRHR type 2 was identified immunohistochemically in the rat tissues using specific anti-TRHR antiserum raised in New Zealand white rabbits immunized with a conjugate of synthetic TRHR type 2 (5-23) with bovine serum albumin. Immunohistochemical analysis was performed by avidin-biotin complex method.

RESULTS

TRHR type 2 immunoreactivity was visualized in the central nervous system, anterior pituitary, gastric mucosa, Auerbach's and Meissner's nervous branch of the stomach, small intestine and colon, retina amd testis. Significant stain was detected in neural perikarya, axons and dendrites. When using antiserum preincubated with synthetic TRHR type 2(5-23) or anterior pituitary homogenates, no significant stain of anterior pituitary was detected.

CONCLUSIONS

These findings suggest that TRHR type 2 is widely distributed and that the method used is valuable in studying the distribution of TRHR type 2 in rats.

Origin, kinetics, and function of chimeric B lymphocytes in liver allografts

BACKGROUND

Despite the well-recognized concordance of chimerism with spontaneous acceptance of rat liver allografts, the active role and the identity of chimeric cells mediating liver allograft tolerance are unknown. Because resting B cells are endowed with a tolerogenic antigen-presenting capacity, we assessed whether donor B cells propagated from the grafted liver may be responsible for liver allograft tolerance.

METHODS

Dark Agouti or Lewis rats were grafted with Lewis or Dark Agouti livers as a tolerogenic or a rejection combination, respectively. We followed the kinetics of donor B cells in recipients by flow cytometry, and we examined the fate of liver allografts depleted of passenger B cells in either B cell-sufficient or -deficient recipients. B-cell depletion was achieved by treatment of animals with polyclonal goat anti-rat IgM antibody from birth.

RESULTS

During the first 3 days after liver allografting, donor B cells rapidly migrated from graft-infiltrating cells and appeared in systemic circulation in both the tolerogenic and rejection combinations. However, systemic chimerism was detectable in the tolerogenic combination by day 14, whereas it was undetectable in the rejection combination by day 7. In graft-infiltrating cells, a significant expansion of chimeric IgM+ (newly formed) B cells was observed on day 5 in the tolerogenic, but not in the rejection, combination. However, depletion of B cells from liver grafts and the absence of antibodies failed to alter the outcome of liver allograft survival in the tolerogenic or immunogenic combination.

CONCLUSION

Although intragraft chimeric B cells proliferated in tolerogenic liver allografts, their clonal expansion does not seem to be essential for the promotion of liver allograft tolerance.

Distribution of calcium sensing receptor in rats: an immunohistochemical study

OBJECTIVE

To investigate the organ distribution of calcium sensing receptor (CaR) in rats by immunohistochemical method.

METHODS

CaR was identified immunohistochemically in the rat tissues using specific anti-CaR antiserum raised in New Zealand white rabbits immunized with a conjugate of synthetic CaR peptide (186-204) with bovine serum albumin. Immunohistochemical analysis was performed by avidin-biotin complex method.

RESULTS

CaR immunoreactivity was visualized in the central nervous system, anterior pituitary, gastric mucosa, small intestine and colon, Auerbach,s and Meissner,s gastric nervous branch, small intestine and colon, pancreas, adrenal medulla, kidney and testis. When using antiserum preincubated with synthetic CaR peptide (186-206) or kidney homogenates, no significant stain of kidney was detected.

CONCLUSIONS

The findings suggest that CaR is widely distributed and that the method used is valuable in studying the distribution of caR in rat.

Prevention of autoimmune recurrence and rejection by adenovirus-mediated CTLA4Ig gene transfer to the pancreatic graft in BB rat

Type 1 diabetes is the result of a selective destruction of pancreatic islets by autoreactive T-cells. Therefore, in the context of islet or pancreas transplantation, newly transplanted beta-cells are threatened by both recurrent autoimmune and alloimmune responses in recipients with type 1 diabetes. In the present study, using spontaneously diabetic BB rats, we demonstrate that whereas isolated islets are susceptible to autoimmune recurrence and rejection, pancreaticoduodenal grafts are resistant to these biological processes. This resistance is mediated by lymphohematopoietic cells transplanted with the graft, since inactivation of these passenger cells by irradiation uniformly rendered the pancreaticoduodenal grafts susceptible to recurrent autoimmunity. We further studied the impact of local immunomodulation on autoimmune recurrence and rejection by ex vivo adenovirus-mediated CTLA4Ig gene transfer to pancreaticoduodenal grafts. Syngeneic DR-BB pancreaticoduodenal grafts transduced with AdmCTLA4Ig were rescued from recurrent autoimmunity. In fully histoincompatible LEW-->BB transplants, in which rejection and recurrence should be able to act synergistically, AdmCTLA4Ig transduced LEW-pancreaticoduodenal allografts enjoyed markedly prolonged survival in diabetic BB recipients. In situ reverse transcription-polymerase chain reaction revealed that transferred CTLA4Ig gene was strongly expressed in both endocrine and exocrine tissues on day 3. These results indicate the potential utility of local CD28-B7 costimulatory blockade for prevention of alloimmune and autoimmune destruction of pancreatic grafts in type 1 diabetic hosts.

Relationship between blood pressure and heart-rate variability during graded head-up tilt

To investigate the relationship between change in blood pressure and autonomic nerve activity, two types of head-up tilt experiments were performed. One was a 30 degrees, 45 degrees, 60 degrees, and 90 degrees graded tilt-up, in which tilt angles were changed at 6-min intervals and 5 min were spent at each angle. The other was a 10-min lasting head-up tilt at 60 degrees. Electrocardiogram (ECG) and blood pressure (Finapres) of 18 healthy non-smoking subjects (9 men, 9 women) were recorded during the experiments. Heart-rate variability was examined by general spectral analysis (GSA). The high-frequency/total-area ratio (HF/TO) showed a decrease as the tilt angle increased. Compared with the values at the 0 degrees position, these changes were statistically significant (P < 0.05). The low-frequency/HF ratio (LF/HF) showed a significant (P < 0.05) difference between 0 degrees and 90 degrees, and between 30 degrees and 90 degrees. Some of the subjects could not maintain their blood pressure during either of the head-up tilt experiments, and they showed only a slight change in HF/TO and LF/HF. This result confirmed that immediate responses to head-up tilt reflect autonomic nerve activity. Hence, changes in the frequency components were found to be an index of autonomic nerve activity, and they explained the individual differences observed in the ability to control blood pressure during a transition to upright posture.

Stenting of the extracranial carotid artery in a high-risk population

SUMMARY

The results of nine patients with carotid stenosis in a high-risk surgical population that were treated by stent supported angioplasty are reported. There were eight males and one female between the ages of 53 to 74. A balloon expandable stent was deployed by a transfemoral approach. Technical success was achieved in all cases. There were no periprocedural complications. The mean % stenosis decreased from 84% to 5.2% after stenting. No arterial dissection was recorded and smooth contour of the vessel was demonstrated in all patients. We have observed long term patency for over 6 months in seven patients. Mean angiographic stenosis was 20% and 21% at 3 and 6 months, respectively (range, 5 to 32%). No further stenosis was recorded. Carotid stenting is an alternative strategy to carotid endoarterectomy (CEA) for high-risk patients, for whom the complications of CEA may exceed the potential benefits.

[Clinical results of endovascular stent graft repair for fifty cases of thoracic aortic aneurysms]

Between February 1995 and December 1997, 50 cases (55 lesions) of thoracic aortic aneurysms including 20 cases of aortic dissections were treated with an endovascular technique using the stent grafts. All patients were treated in the operating room under general anesthesia and the stent grafts were implanted through 18 Fr. or 20 Fr. sheaths via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in 53 of 55 lesions (delivery success rate: 96.4%). Exclusion of the aneurysms and entry closing without endoleak were achieved within two weeks after the operation in 43 of 53 lesions (initial success rate: 81.1%). Endoleak was found in 10 lesions (minor endoleak: 8 and major endoleak: 2 lesions). Two patients died in the periopertive period of delivery failures as injury to external iliac artery and damage to the delivery sheath caused by tortuous and narrow access routes. Endovascular stent graft repair of thoracic aortic aneurysms is minimally invasive operation in comparison with conventional surgical graft replacement with extracorporeal circulation. These early results suggest that the stent graft repair is possibly safe and useful treatment for the patients of thoracic aortic aneurysms especially in high risk patients. However, careful long-term follow-up is necessary to prove the value and the effects of this endovascular treatment and improvement of the stent graft system and technical training of endovascular surgery for operators are required to reduce the delivery failure and to determine the stent graft repair is reliable treatment.

Oesophageal hiatal hernia-induced hydropneumothorax

The patient presented with acute and constant abdominal pain. He had had a lobectomy of the left lung three months before. On the 4th day in hospital the pain increased and he went into temporary shock. The next day a hydropneumothorax and incarcerated stomach were revealed by chest X-ray and computed tomography. He was transferred to the University Hospital immediately and underwent an operation. The diagnosis was an incarcerated para-oesophageal hernia with hydropneumothorax and perforation of the stomach. As a para-oesophageal hernia may be fatal, it is important to diagnose and treat it early.

[Postoperative changes in the coagulation and fibrinolytic systems in endoluminal stent-graft treatment of thoracic aortic aneurysms]

We studied changes in blood coagulation and fibrinolytic system in 18 cases of thoracic aortic aneurysm and 5 cases of aortic dissection treated with stent grafts. The mean operation time was 259 +/- 67 minutes and the amount of blood loss during operation was 472 +/- 456 ml. Although blood transfusion of 220 +/- 360 ml was performed in 7 cases, 16 of 23 cases (70%) received no homologous blood transfusion. Consequently, the endoluminal stent graft treatment was minimally invasive compared with the conventional surgical procedure. On the 1st postoperative day, platelet counts and AT-III decreased and TAT increased. The promotion of blood coagulability was found in these patients on the 1st day after the operation. Changes in the fibrinolytic system were less marked than that in coagulation. These results suggest that the thrombosed aneurysm was excluded from systemic blood flow by the stent graft. There was no consumption coagulopathy in any case with aneurysm excluded by stent graft deployment. Stent-graft treatment for thoracic aortic aneurysm can be successfully performed without consumption coagulopathy when the aneurysm is completely excluded.

Hepatic stellate cell contraction is inhibited by lipo-prostaglandin E1 in vitro

Prostaglandin E1 (PGE1) has been reported to have, experimentally and clinically, a protective effect against liver damage. This effect may result from the relaxation of hepatic stellate cells, whose contraction induces vasoconstriction of hepatic sinusoids. However, prostaglandins are unstable and a new drug delivery system is necessary to administer a sufficient amount of prostaglandin to achieve a protective effect in the liver. The aim of the study is to investigate the effects of lipo-prostaglandin E1 (lipo-PGE1) which has a novel drug delivery system on the stellate cell contraction induced by endothelin-1 in vitro. Lipo-PGE1 inhibited endothelin-1-induced stellate cell contraction in concentrations of 10, 30 and 50 ng/mL. Therefore, lipo-PGE1 may show a cytoprotective effect in the liver through the relaxation of stellate cells and an increase in the hepatic sinusoidal blood flow.

[Diagnosis of neonatal enterovirus meningitis by reverse transcription-polymerase chain reaction]

We evaluated the potential clinical utility of a reverse transcription-polymerase chain reaction (RT-PCR) for neonatal enterovirus meningitis, comparing the results with viral culture and white blood cell (WBC) counts in the cerebrospinal fluid (CSF). Of the 41 cases of enteroviral infection, 31 cases (76%) were finally diagnosed as meningitis by either viral culture, CSF WBC count or RT-PCR. Of those with culture positive and negative, the RT-PCR positive rates were 10 (100%) and 6/13 (46%), respectively. Of those with and without WBC increase in the CSF, the RT-PCR positive rates were 18/20 (90%) and 5/14 (36%), respectively. There was one RT-PCR positive case (1/6, 17%) among those with culture negative and no WBC increase in the CSF. RT-PCR performed on CSF is a sensitive and specific method for the diagnosis of neonatal enterovirus meningitis.

Effects of gamma-butyric acid on the release of thyrotropin-releasing hormone from the rat retina in vitro

Effects of gamma-butyric acid (GABA) on the release of thyrotropin-releasing hormone (TRH) from the rat retina in vitro were studied. The rat retina was incubated in medium 199 (pH 7.4) with 1.0 mg/ml of bacitracin and 100 micrograms/ml of ascorbic acid (medium). The amount of TRH release into the medium was measured by radioimmunoassay. The TRH release from the rat retina was inhibited significantly in a dose-related manner with the addition of GABA, but not with bicuculline. The inhibitory effect of GABA on TRH release from the retina was blocked by adding bicuculline to the medium. The findings suggest that the GABAergic system inhibits TRH release from the rat retina in vitro.

[Atherectomy in patients with arteriosclerosis obliterans: angiographic follow-up study of 186 lesions in 146 patients]

Atherectomy (ATE) is a new catheter-mediated technique for the removal of atheroma in patients with arteriosclerosis obliterans (ASO). ATE was performed using 7-10 Fr. Simpson Peripheral Athero Track catheters at 186 sites in 146 patients, whose lesions involved 49 common iliac arteries, 66 external iliac arteries, 68 femoral arteries and three other arteries. The initial success rate was 94.1%. The mean percent of the diameter stenosis was reduced from 79.0 +/- 1.2% (mean +/- SD) to 22.7 +/- 1.0%. There were two cases of perforation that required surgical treatment (1.1%). The complication rate was 4.4%. The 0.5-, 1-, 2- and 3-year patency rates were 87.6%, 79.6%, 62.5% and 62.5%, respectively. The rate of long-term patency in each segment of arterial lesions revealed that the patency rate in the common iliac artery was significantly higher than the rates in the external iliac artery (p < 0.05) and femoral artery (p < 0.01). The patency rates for long lesions (> or = 2.0 cm) and occluded lesions were significantly (p < 0.01) lower than those for short lesions (< 2.0 cm). Diabetic patients had a higher re-stenosis rate than nondiabetic patients (p < 0.05). In conclusion, ATE is an effective new method for the treatment of patients with ASO.

(+)-cis-3,5-dimethyl-2-(3-pyridyl) thiazolidin-4-one hydrochloride (SM-12502) as a novel substrate for cytochrome P450 2A6 in human liver microsomes

(+)-cis-3,5-dimethyl-2-(3-pyridyl)thiazolidin-4-one hydrochloride (SM-12502) was oxidized by human liver microsomes to produce the S-oxide as a sole metabolite. Indirect evidence suggested that the S-oxidation was catalyzed by cytochrome P450 (CYP). Eadie-Hofstee plots showed biphasic pattern, suggesting that at least two enzymes were involved in the S-oxidation in human liver microsomes. Kinetic parameters of the S-oxidase with high-affinity showed Km and Vmax values of 20.9 +/- 4.4 microM and 0.111 +/- 0.051 nmol/min/mg microsomal protein, respectively. The S-oxidase activity was inhibited by coumarin and anti-CYP2A antibody. Among the contents of forms of CYP 20 samples of human liver microsomes, the content of CYP2A6 correlated with S-oxidase activity measured with 50 microM SM-12502 (r = .808, P < .0005). A close correlation (r = .908, P < .0001) was observed between activities of SM-12502 S-oxidase and coumarin 7-hydroxylase. Microsomes from genetically engineered human B-lymphoblastoid cells expressing CYP2A6 metabolized SM-12502 to the S-oxide efficiently. The results indicate that CYP2A6 isozyme is a major form of CYP responsible for the S-oxidation of SM-12502 in human liver microsomes. Thus, SM-12502 will be a useful tool in further research to analyze a human genetic polymorphism of CYP2A6.

Effects of serotonin on the release of thyrotropin-releasing hormone from the rat retina in vitro

Effects of serotonin on the release of thyrotropin-releasing hormone (TRH) from the rat retina were studied in vitro. The retina was incubated in medium 199 (pH 7.4) with 1.0 mg/ml of bacitracin and 100 micrograms/ml of ascorbic acid (medium) for 20 min. The amount of TRH release into the medium was measured by radioimmunoassay. The TRH release from the rat retina was inhibited significantly in a dose-related manner with the addition of serotonin and enhanced with cyproheptadine. The inhibitory effect of serotonin on TRH release from the retina was blocked with the addition of cyproheptadine. The elution profile of methanol extract of the rat retina was identical to that of synthetic TRH. The findings suggest that the serotonergic system inhibits TRH release from the rat retina in vitro.

[Clinical features of anterior inferior cerebellar artery territory infarcts--a study of ten patients]

Clinical features of the anterior inferior cerebellar artery (AICA) territory infarcts were investigated in ten patients, ranging in age from 38 to 76 years. In all patients, there were MR images of infarction located in the area supplied by the AICA. The lesion was on the left side in 6 patients and right side in 4. The lesion of brain stem including the middle cerebellar peduncle was found in 7 patients and that extended to the cerebellum was in 3 patients. The main ipsilateral neurological signs were the VII and VIII cranial nerves palsy and cerebellar ataxia. The V and VI cranial nerves palsy. Horner's syndrome, and dysphagia were also present. The main contralateral sign was superficial sensory disturbance, but no hemiplegia. The underlying pathology included chiefly hyperlipidemia, hypertension, and diabetes mellitus. Cerebral angiography was performed in 8 patients, most of which was observed severe arteriosclerosis suggesting poor hemodynamics in the vertebral and basilar arteries. The prognosis was relatively good, but the VII, VIII, and V cranial nerves palsy and contralateral superficial sensory disturbance remained as the sequelae. As mentioned above, there were various neurological findings and MR images in AICA territory infarcts. Especially there were some patients whose lesion extended to the upper medulla and neurological findings were similar to the Wallenberg syndrome. It is important that one investigates not only axial slices but also coronal slices of MR image to estimate the extension of AICA territory infarct.

Hepatic release of endothelin-1 after warm ischemia. Reperfusion injury and its hemodynamic effect

This study investigated the release of endothelin (ET)-1 from the liver after warm ischemia/reperfusion (I/R) injury. Wistar rats were subjected to 120 min of warm hepatic ischemia by clamping the hepatic hilum under porto-jugular shunting. Reperfusion was performed by unclamping. The rats were divided into 2 groups receiving intravenous treatment with an anti-ET-1 mAb before ischemia (AET group) and with mouse immunoglobulin G (sham group). Hepatic blood flow was assessed by laser-Doppler flowmetry and reflectance spectrophotometry and was compared between the 2 groups along with the bile flow rate. The ET-1 concentrations of hepatic venous and portal blood were determined in the sham group, and the portal blood endotoxin levels were assayed in both groups. Both groups developed transient hypotension after reperfusion, but hepatic blood flow subsequently showed a significant improvement in the AET group. Hepatic congestion was detected in the sham group by both reflectance spectrophotometry and histological examination. After reperfusion, bile flow was significantly greater in the AET group. The portal endotoxin concentration showed no increase in both groups, and the hepatic venous blood ET-1 level in the sham group was significantly higher until 3 hr after reperfusion compared to the portal blood level. The 30-day survival rate was 50% in the AET group, whereas all the sham rats died within 12 hr. ET-1 was released from the liver after I/R injury and apparently participated in systemic and local hemodynamic changes that affected survival.

High levels of serum lipoprotein(a) in patients with ischemic heart disease with normal coronary angiogram and thromboangiitis obliterans

To determine whether lipoprotein(a) (Lp(a)) contributes to the acceleration of cardiovascular diseases without atherosclerotic lesion, we have measured serum Lp(a) level in male subjects aged 40-69 years with thromboangiitis obliterans (n = 40) and ischemic heart disease (IHD) with normal coronary angiogram (n = 35) in addition to subjects with arteriosclerosis obliterans (n = 123) and IHD with atherosclerotic coronary lesion (n = 203). Cases who had no IHD, arteriosclerosis obliterans or thromboangiitis obliterans were selected as a control group (n = 316). Subjects without any diseases or abnormal findings in physical examination and laboratory data were selected from the control group as the healthy control group (n = 156). The Lp(a) levels of arteriosclerosis obliterans and IHD with atherosclerotic coronary lesion were significantly higher (17.0 mg/dl and 13.1 mg/dl; median) than those of control and healthy control groups (9.9 mg/dl and 9.4 mg/dl, respectively) (P < 0.01), in agreement with previous reports. Furthermore, the Lp(a) level of IHD with normal coronary angiogram group was significantly higher (18.9 mg/dl) than those of the control and healthy control groups (P < 0.05). The Lp(a) level of thromboangiitis obliterans group was also much higher (21.3 mg/dl) than that of the healthy control group (P < 0.05). The current study suggests that Lp(a) is one of the independent risk factors for the development of atherosclerotic diseases such as arteriosclerosis obliterans and IHD with atherosclerotic coronary lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of endothelin in the pathophysiology of renal impairment during acute liver rejection

We assessed the role of endothelin in the development of renal dysfunction during acute rejection by examining the effect of a selective endothelin A (ETA) receptor antagonist BQ-123 in rats with acute liver rejection. Serum endothelin levels and endogenous creatinine clearance (Ccr) were monitored on days 1, 3, 5, 7, and 9 postoperatively. As indicators of renal hemodynamics, the estimated hemoglobin concentration of renal tissue (IHb) and the oxygen saturation of hemoglobin in renal blood (ISO2) were determined by reflectance spectrophotometry. In addition, the clearance of inulin and P-aminohippurate were determined, and the renal tissue blood flow was estimated by laser-Doppler flowmetry (LDF). As a model of allograft rejection, Lewis rats were transplanted orthotopically with DA rat livers. The serum endothelin level of allografted rejectors was significantly (P < 0.05) higher than that of isografted controls (Lewis rats with Lewis livers) on postoperative day 5, and it increased to a maximum of 5.38 +/- 0.95 pg/ml on day 9 (versus 1.23 +/- 0.18 pg/ml preoperatively). The values of Ccr, IHb, and ISO2 were all significantly (P < 0.05) lower in allografted rejectors than in isografted controls on day 5, and subsequently declined to a minimum on day 9 (P < 0.01). Treatment of allografted rejectors with BQ-123 markedly improved the renal parameters to levels similar to those in the isografted controls. These results strongly suggest that endogenous endothelin may play an important role in the development of renal impairment during acute liver rejection by reducing renal blood flow through binding with ETA receptor.

Hepatopancreatoduodenectomy for advanced gallbladder carcinoma

OBJECTIVE

To assess the effectiveness of hepatopancreatoduodenectomy (HPD) in patients with advanced gallbladder carcinoma directly invading the liver and pancreas, generally considered to be nonresectable.

PATIENTS AND METHODS

Sixty patients with gallbladder carcinoma admitted to our hospital from 1978 to 1992, of whom 55 had Nevin stage V carcinoma and 21 had resectable tumors. Of these patients, seven underwent HPD. The remaining 34 patients had nonresectable tumors. The outcomes of patients undergoing HPD and those with nonresectable tumors were compared and the effect on their quality of life was also analyzed.

RESULTS

Postoperative complications occurred in five of the seven patients after HPD, but there were no operative deaths. The 1- and 2-year survival rates were 57% and 28.6%, respectively, with a median survival time of 12 months. In contrast, the 1- and 2-year survival rates of the 34 patients with nonresectable tumors were both 5.8%, and the median survival time was 2 months. The median and mean durations of home stay after HPD were 6 and 10.5 months, respectively.

CONCLUSION

Hepatopancreatoduodenectomy has the potential to improve both survival and the quality of life for carefully selected patients with advanced gallbladder carcinoma.

[Spectrophotometric determination of uric acid in serum using a titanium (IV)-porphyrin complex]

Aqueous solution of oxo[5,10,15,20-tetra(4-pyridyl)porphyrinato]titanium (IV) complex, a Ti-TPyP reagent, was found to be very useful for the spectrophotometric determination of hydrogen peroxide. The reagent (lambda max 432 nm) reacts with hydrogen peroxide to form a monoperoxocomplex, resulting in a significant decrease of the absorbance at 432 nm. The decrease (delta A) in absorbance was proportional to the concentration of hydrogen peroxide. The Ti-TPyP reagent was successfully applied to the assay of uric acid in the serum, using uricase to produce hydrogen peroxide through enzymatic oxidation. Using only 5 microliters serum, a linear relationship was obtained between delta A and uric acid concentration in the serum ranging from 5 x 10(-6) to 1 x 10(-3) M. The apparent molar delta A of uric acid was 2.2 x 10(5) M-1 cm-1. The relative standard deviation of repeated runs (n = 8) was 2.8% at 3.77 x 10(-4) M uric acid. The analytical recovery of uric acid (5 x 10(-4) M) added to the serum was 96.8 to 105.0%. No pre-concentration and deproteinization were required to determine uric acid in the serum by the present method because of the high sensitivity and selectivity of the Ti-TPyP reagent for hydrogen peroxide.

Functional abnormalities of sinusoidal endothelial cells in rats with acute liver rejection

The purpose of this study was to determine the changes of hepatic sinusoidal endothelial cell (SEC) function in acute liver rejection with respect to receptor-mediated endocytosis. Orthotopic rat liver transplantation was performed in Lewis rats grafted with DA livers and in Lewis rats grafted with Lewis livers as rejectors and controls, respectively. Animals were killed at 1, 3, 5, 7, and 10 days after the operation. Fc receptors (FcRs) were histochemically stained on frozen liver sections by applying peroxidase-antiperoxidase IgG complex as a ligand, and the FcR activity, i.e., capacity of binding the ligands represented by the FcR staining intensity, was semiquantitatively analyzed as an indicator of SEC function. The serum level of hyaluronic acid, which is specifically cleared from the circulation by receptor-mediated SEC endocytosis, was also assayed, along with the total serum bilirubin. Three days after the operation, the SECs of rejectors showed a significantly weaker FcR staining intensity of about half the value of that seen in the controls (P < 0.05), and staining disappeared after 5 days (P < 0.01). The decrease of FcR staining intensity, i.e., FcR activity, showed a correlation with elevation of the serum hyaluronic acid level (r = -0.77; P < 0.001). Histological evidence of endothelialitis and a significant elevation of total serum bilirubin (P < 0.01) were also present at 3 and 5 days, respectively. These results suggest that impairment of the endocytic function of SECs occurs at an earlier phase of acute liver rejection when compared with development of abnormalities of traditional indicators. Determination of receptor-mediated SEC endocytic functions may thus provide useful information for the early diagnosis of acute rejection.