[A patient operated for occlusion of the superior mesenteric artery]

A 40-year-old woman presented with fever, dysarthria, and left hemiparesis. Diagnostic imaging detected an infarction in the right cerebrum; lupus anticoagulant was positive. A T4N3M0 adenocarcinoma coexisted in the left lung, which was irradiated once. Two days later, the superior mesenteric artery was occluded. The bowel was widely resected but she died of hepatic infarction. The lung cancer may have triggered catastrophic antiphospholipid syndrome.

Malignant basal cell tumor in a Djungarian hamster

A malignant basal cell tumor was found in the skin of the abdomen of a female Djungarian hamster of unknown age and weighing 40 g. Histologically, the tumor mass was composed of cells resembling the basal cells of the epidermis, and these cells exhibited solid type proliferation. In the tumor tissue and necrotic foci, horn cysts were observed. Immunohistochemically, cytokeratin was present in the tumor cells and horncysts. By electron microscopic examination, the tumor cells had scanty cell organelles and a few desmozomes. This paper describes a rare malignant basal cell tumor in a Djungarian hamster.

Retrograde intra-arterial infusion of prostaglandin E1 and heparin for the no-reflow phenomenon after oromandibular reconstruction with a free fibular flap

The authors encountered a patient with a tumor of the floor of the mouth in whom the no-reflow phenomenon occurred after excision of the lesion and the mandible, followed by reconstruction using a free fibular flap. A catheter was inserted retrogradely from the point where the peroneal artery had been ligated at the time of flap preparation. Continuous intra-arterial infusion of prostaglandin E1 and heparin was performed, and the flap survived. This method salvaged free flaps subject to the no-reflow phenomenon.

Chondroid syringoma of the orbit

Chondroid syringoma is a rare subcutaneous tumor that mainly affects the face and the neck. The authors present an occurrence in the orbit, which they believe to be the first reported at that site. Computed tomography and magnetic resonance imaging suggested that the tumor had invaded the globe, but at surgery the mass was well circumscribed and did not invade or adhere to other structures. The tumor was resected easily under general anesthesia. Epithelial cells of characteristic appearance within a chondroid matrix were demonstrated histologically. No recurrence has been evident in more than 1 year of follow-up. Most chondroid syringomas are benign, but because several cases have exhibited malignant behavior, periodic observation following complete resection is required.

Obstructive Ileus caused by blood clot after emergency total gastrectomy in a patient with hemophilia A: report of a case

We report herein the extremely unusual case of a patient with hemophilia A who developed a hematoma ileus soon after undergoing an emergency total gastrectomy. Postoperatively, the patient was found to have an obstruction in the small intestine that was difficult to differentiate from intussusception. Reoperation revealed the cause of the obstruction to be a large blood clot. This case report serves to demonstrate that careful hemostasis and observation during surgery is essential in patients with hemophilia.

Diagnostic value of plasma levels of brain natriuretic peptide in arrhythmogenic right ventricular dysplasia

BACKGROUND

Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by local or diffuse wall motion abnormalities in the right ventricle (RV), associated with recurrent ventricular tachycardia (VT) of RV origin. Brain natriuretic peptide (BNP) was first isolated from a porcine brain extract. In humans, BNP is expressed predominantly in the ventricles of failing hearts, and its expression has been observed primarily in myocytes in the interstitial fibrous area in dilated cardiomyopathy. We hypothesized that BNP is increasingly secreted from the residual myocytes within the atrophic tissue in patients with ARVD.

METHODS AND RESULTS

Plasma BNP levels were measured in 17 patients with ARVD, 12 patients with idiopathic RV outflow tract tachycardia (RVOT), and 120 control subjects. We performed cardiac catheterization, RV endomyocardial biopsy, electron- beam CT, and biventricular endomyocardial mapping in the ARVD patients. There was a significant increase in plasma BNP levels in the ARVD patients compared with the RVOT patients and control subjects (61.4+/-59.6 pg/mL versus 8.3+/-5. 5 pg/mL and 9.3+/-5.8 pg/mL; P<0.0001, respectively). The plasma BNP levels had no correlation with any of the hemodynamic data, but they had a significant correlation with the RV ejection fraction (r=-0. 588, P=0.025) and with the fractionated-area scores (r=0.705, P=0. 005). Light microscopic immunohistochemistry showed strong BNP immunoreactivity in residual myocytes with fibrofatty replacement.

CONCLUSIONS

These results suggest that plasma BNP levels were not increased in RVOT patients but were increased in ARVD patients, and that the increased BNP levels indicate the severity of both the RV dysfunction and the arrhythmogenic substrate.

[Nucleic acid components of mycobacteria: recent studies on secreted protein genes]

Among the nucleic acid components of mycobacteria, secreted protein genes have been attractive targets in relation to the role in the bacteria-host cell interaction. The alpha antigen gene family is of particular interest from its evolutional constitution process and as a candidate of protective antigen for tuberculosis (TB). Recent studies on DNA vaccination revealed that the antigen 85A, a member of the alpha antigen family, could induce protective immunity against TB. The other studies on the development of recombinant BCG vaccines demonstrated that alpha antigen gene is applicable to a foreign antigen carrier which could obtain protective immunity against human immunodeficiency virus and malaria parasite infections. In this paper, advanced applications of such mycobacterial secreted protein genes are reviewed.

Microstructure and homogeneity of dental porcelain frits

The microstructure and homogeneity of three commercial dentin and incisal unfired porcelain frits (one conventional and two ultra-low fusing types, fused-to metal were analyzed by X-ray diffractometry, scanning electron microspectroscopy, and wavelength- and energy dispersive X-ray microspectroscopy. The average contents of tetragonal and cubic leucite for the conventional and one of the ultra-low fusing type frits were 20.1-22.6 wt% and 0-2.6 wt%, respectively, whereas those of another of the ultra-low fusing type frits were about 11.5-11.6 wt% and 2.9-4.6 wt%, respectively. The conventional type frits seemed to be admixtures of three kinds of glass frits. One of the ultra-low fusing type frits seemed to be an admixture of four kinds of glass frits. Another ultra-low fusing frits seemed to be only one kind of glass frit dispersed with small size, less than 1 micron, leucite crystals. There were no remarkable differences in microstructure and homogeneity between dentin and incisal porcelain frits in each brand.

Serum and tissue vascular endothelial growth factor levels in hydatidiform mole

Using a specific and sensitive enzyme immunoassay for vascular endothelial growth factor (VEGF), we measured the circulating levels of VEGF in patients with hydatidiform mole as well as in maternal serum during normal pregnancy. VEGF levels in maternal serum were elevated at 7 weeks and then fell to a plateau. Serum VEGF levels were increased in patients with hydatidiform mole above the normal pregnant levels, while no differences were seen related to the development of persistent trophoblastic disease. By semi-quantitative RT-PCR in molar tissue for VEGF and placenta growth factor, a member of VEGF family, neither of the mRNA levels have no relation to the development of persistent trophoblastic disease. These observations suggest serum VEGF levels will be of value as a new circulating marker of hydatidiform mole.

Vascular endothelial growth factor in patients with rheumatoid arthritis

To examine the role of vascular endothelial growth factor (VEGF), an endothelial cell specific growth factor, in rheumatoid arthritis (RA), serum concentration of VEGF was examined in patients with RA, osteoarthritis (OA), systemic lupus erythematosus (SLE), systemic sclerosis (SS) and control subjects. Serum C-reactive protein (CRP) level, erythrocyte sedimentation rate, white blood cell count and rheumatoid factor titer were also determined in patients with RA. The serum concentration of VEGF was significantly higher in patients with RA than in controls (p < 0.01), and patients with OA (p < 0.05), SLE (p < 0.05), and SS (p < 0.05). The serum concentration of VEGF correlated with serum levels of CRP (r = 0.698, p < 0.0001). The serum concentration of VEGF before treatment was significantly higher than that after treatment in patients with RA who experienced clinical remission (p < 0.05). Our data suggest that VEGF is involved in the pathogenesis of RA and that measurement of serum concentration of VEGF is a noninvasive, useful method for monitoring the disease activity of RA.

[Total cavopulmonary connection for grown diminutive pulmonary artery after staged Blalock-Taussig shunt]

We report a two-year-old girl with asplenia, [A, L, L] DORV, pulmonary atresia, common AV valve, PDA, and TAPVC, who successfully underwent total cavo pulmonary connection (TCPC). Deep cyanosis was pointed out since birth. Cardiac catheterization performed on the sixth day after birth revealed a diminutive pulmonary artery tree of which PA index was 41 mm2/m2. Left modified Blalock-Taussig shunt was created at 27 days of age. The PA index increased to 282 mm2/mm2, but disparity in diameter between the left and the right pulmonary artery was yielded by PDA subsidence. Therefore additional contralateral B-T shunt was made at one year of age. Follow-up cardiac catheterization at 28 months of age showed well developed pulmonary artery; PA index of 460 mm2/m2, right pulmonary resistance (Rp) of 3.49 units, left Rp of 2.33 units, and estimated total Rp was 1.39. According to study, bidirectional Glenn procedure or TCPC was indicated. Considering necessity of urgent repair of common pulmonary vein obstruction, regurgitation of the common atrio-ventricular valve and pulmonary artery stenosis, TCPC was performed with concomitant repair of the associated lesions. Severe butterfly-figure stenosis of the central PA was augmented by anastomosing both the left SVC and the left-sided atrium. In conclusion, diminutive pulmonary artery could be adequately grown by phase-in Blalock-Taussig shunts. Pulmonary blood flow scintigraphy was thought to be useful for estimation of pulmonary resistance in such cases with different pulmonary resistance between right and left PA.

Overproduction of vascular endothelial growth factor/vascular permeability factor is causative in Crow-Fukase (POEMS) syndrome

Crow-Fukase or POEMS syndrome of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes is a rare multisystem disorder of obscure pathogenesis that is associated with microangiopathy, neovascularization, and accelerated vasopermeability. We examined the levels of the vascular endothelial growth factor/vascular permeability factor (VEGF) in the serum and cerebrospinal fluid (CSF) from 10 patients with this syndrome. Serum VEGF levels were about 15-30 times those in control subjects or patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and other neurological disorders. The CSF VEGF levels, however, were similar to those found in GBS and CIDP. Elevated VEGF levels in the serum decreased in 7 patients with Crow-Fukase syndrome after conventional therapy. The principal isoform of VEGF in Crow-Fukase syndrome was VEGF165. Elevated VEGF was independent of M-protein. Our results suggest that the overproduction of VEGF is important in the pathogenesis of this disorder.

A follow-up of rhabdomyosarcoma of the infratemporal fossa region in adults based on the magnetic resonance imaging findings: case reports

Two adult patients with rhabdomyosarcoma of the infratemporal fossa region were evaluated by computed tomography and magnetic resonance imaging both before and after treatment. Successful treatment accompanied by reduction of the tumor mass as a result of chemotherapy was demonstrated in one patient. In the other patient a subsequent increase in the tumor mass was documented. Information on not only the size but also the internal architecture of the tumor may be useful when tumor response to therapy is being investigated. Magnetic resonance imaging is recommended as a method for outcomes evaluation in adult rhabdomyosarcoma cases.

Concentrations of vascular endothelial growth factor in the sera of gastric cancer patients

VEGF (vascular endothelial growth factor) is known to play crucial roles in tumor angiogenesis. In 281 gastric cancer patients, aberrant increase of VEGF level was observed in 36 patients (12.8%). In 14 recurrent patients, 8 showed an increase of VEGF. The serum VEGF levels of stage IV cancer were significantly higher than those of stage I. The serum levels of recurrent patients were significantly higher than those of stage I, II and III. VEGF levels of patients with serosal invasion were significantly higher than those of patients without serosal invasion. In depth of invasion (t-factor), VEGF levels of t4 cancer were significantly higher than those of t1-t3. In venous infiltration of tumors, VEGF levels of v3 were significantly higher than v0 and v1. There was no significant difference with respect to H-factor and P-factor status. In eleven recurrent or advanced gastric cancer patients, serum VEGF was sequentially examined between pre- and post-chemotherapy. All of them showed a decrease of serum VEGF concentration after partial response by chemotherapy. The patients who had progressive disease after chemotherapy showed an increase of VEGF levels. Serum VEGF levels were closely related to the extent of gastric cancer and the response of chemotherapy.

[Vascular endothelial growth factor levels in the aqueous and serum in diabetic retinopathy with or without neovascular glaucoma]

We determined the levels of vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) in the aqueous and serum in non-insulin dependent diabetic patients with proliferative retinopathy (n = 12) and neovascular glaucoma (n = 11). The aqueous levels of PEGF/VPF were significantly higher in both groups than in 10 diabetics without such complications. The levels were very high in patients with neovascular glaucoma, suggesting that VEGF/VPF is involved in the pathogenesis and progression of diabetic neovascular glaucoma. The serum levels were not significantly related to the presence or the stage of retinopathy. The findings suggest the possibility of treatment of neovascular glaucoma using anti- VRGF/VFP preparations.

Localization of optimal ablation site of idiopathic ventricular tachycardia from right and left ventricular outflow tract by body surface ECG

BACKGROUND

Idiopathic ventricular tachycardia (VT) is known to arise from the right ventricular (RV) and left ventricular outflow tracts (LVOT). However, reliable noninvasive methods to localize the optimum ablation site for VT have not been reported.

METHODS AND RESULTS

Body surface maps (BSM) and 12-lead ECGs were investigated in 35 VTs from the RVOT and 5 VTs from the LVOT in which the origin was confirmed during the ablation procedure. The RVOT was classified into 8 subdivisions with the use of a 3-dimensional anatomic relation: anterior (A) posterior (P), right (R) left (L), and superior (S) inferior (I). On the BSM, the following 3 indexes differentiated each location of the origin, with a diagnostic accuracy of 88% (A-P), 92% (R-L), and 77% (S-I): (1) the location of the minimum at the early-to-mid QRS (right, A; left, P), (2) the isopotential distribution in the left shoulder area after 30 ms of QRS (positive, R; negative, L), and (3) the downward moving time of the minimum at the early-to-mid QRS (>/=50 ms, S; <50 ms, I). On the 12-lead ECG, (1) the QRS duration (>140 ms, A; </=140 ms, P) and the R-wave pattern in leads II and III (RR' or Rr', A, R, P), (2) the QS wave amplitude in aVR and aVL (aVR>/=aVL, R; aVR<aVL, L), and (3) the r-wave amplitude in V1 and V2 (high, S; low, I) localized the origin with 80%, 86% (A-P), 80% (R-L), and 66% (S-I) accuracy. R/S>/=1 in lead V3 was an index suggesting the LVOT origin.

CONCLUSIONS

The origin or the optimum ablation site of idiopathic VT from RVOT and LVOT can be localized with the use of indexes obtained with a BSM or 12-lead ECG.

Comparison of the ability of viral protein-expressing plasmid DNAs to protect against influenza

The ability of plasmid DNA encoding various influenza viral proteins from the A/PR/8/34 (H1N1) virus to protect against influenza was compared in BALB/c mice. The plasmid DNA encoded hemagglutinin (HA), neuraminidase (NA), matrix protein (M1), nucleoprotein (NP) or nonstructural protein (NS1) in a chicken beta-actin-based expression vector (pCAGGS). Each DNA was inoculated twice 3 weeks apart at a dose of 1 microgram per mouse by particle-mediated DNA transfer to the epidermis (gene gun). Seven days after a second immunization, mice were challenged with the homologous virus and the ability of each DNA to protect mice from influenza was evaluated by decreased lung virus titers and increased survival. Mice, given HA- or NA-expressing DNA, induced a high level of specific antibody response and protected well against the challenge virus. On the other hand, mice given M1-, NP-, or NS1-DNA failed to provide protection, although M1- and NP-DNAs did induce detectable antibody responses. These results indicate that both HA- and NA-expressing DNAs for the surface glycoproteins are most protective against influenza from among the various viral protein-expressing DNAs used here.

Increased serum levels of vascular endothelial growth factor in Kawasaki disease

Vascular endothelial growth factor (VEGF) is an angiogenic mitogen that specifically targets vascular endothelial cells. The objective of this study was to evaluate the role of VEGF in Kawasaki disease (KD), the most common cause of systemic vasculitis in childhood. Serum VEGF levels were measured by ELISA in 22 patients with KD, 22 febrile children with infection, and 19 healthy children. Samples from KD patients were divided into three groups: acute stage (n = 20), subacute stage (n = 13), and convalescent stage (n = 15). The results showed that KD patients in the acute and subacute stages had significantly higher levels of VEGF than did patients with infectious diseases and the healthy control subjects. When compared with the VEGF levels of patients with and without coronary artery lesions (CAL), significantly higher levels of VEGF were observed in the subacute stage in patients with CAL and in patients without CAL in the acute stage. Serial examination revealed that the serum VEGF levels in KD patients with CAL increased from a relatively low level in the acute stage to an extremely high level in the subacute stage. In contrast, patients without CAL were found to have extremely high levels of VEGF only in the acute stage of KD. In KD patients, the serum VEGF levels did not correlate with the inflammatory markers and clinical symptoms. Our results raise the possibility that VEGF is involved in the pathogenesis of KD, especially in the development of CAL. Further study is needed to clarify the biologic effect of VEGF on coronary arteries in KD.

Radiofrequency catheter ablation of concealed atrioventricular accessory pathways using a "simultaneous pacing method"

The retrograde atrial potential at a successful ablation site is usually obscured by the wide and large ventricular potential during atrioventricular reentrant tachycardia or ventricular pacing, which makes it difficult to determine the appropriate ablation site for a concealed accessory pathway. A pacing maneuver named the "simultaneous pacing method" is proposed herein to differentiate the retrograde atrial potential from the ventricular potential for a successful ablation of the concealed accessory pathway. Catheter ablation was performed in 12 patients with a single left free-wall concealed accessory pathway. The atrial insertion site was determined by the simultaneous pacing method in six patients (group I) and by ventricular pacing in six patients (group II). In the simultaneous pacing method, electrograms recorded during ventricular pacing in the earliest retrograde atrial activation site are a fusion of the ventricular potential and the following retrograde atrial potential. When atrial and ventricular pacings are performed simultaneously (simultaneous pacing), the end portion of the electrograms recorded at the same site is solely the ventricular component, because atrial is activated earlier. The atrial potential can be confirmed during ventricular pacing in comparison with the electrograms during the "simultaneous pacing." Radiofrequency catheter ablation was successful in eliminating conduction through the accessory pathway in all 12 patients. The radiofrequency applications in group I were significantly fewer than those in group II (1.7 +/- 1.0 in group I, 5.3 +/- 3.2 in group II, P < 0.05). The total procedure time in group I was significantly shorter than in group II (57.8 +/- 15.7 vs 106.7 +/- 41.6 mins in group II, respectively, P < 0.05). The fluoroscopy time in group I was significantly shorter than in group II (54.0 +/- 7.9 vs 81.3 +/- 26.3 mins, respectively, P < 0.05). We were able to determine the atrial insertion site of accessory pathways by the simultaneous pacing method. The simultaneous pacing method was useful in eliminating concealed left free-wall accessory pathways.

[A surgical case of supravalvular aortic stenosis with severe hypoplastic ascending aorta (diffuse type) in Williams-Beuren syndrome]

We report a six-year-old boy who underwent ascending aortic reconstruction for supravalvular aortic stenosis of diffuse type associated with Williams-Beuren syndrome. The diagnosis was first made at the age of six months. Because of progressive left ventricular hypertrophy, cardiac catheterization was performed at the age of five years and showed left ventricular pressure of 200 mmHg, the ascending aortic pressure of 202 mmHg, the descending aortic pressure of 115 mmHg, and left ventricular end-diastolic volume of 33.5 ml (90% of normal). Whole ascending aorta except sinus Valsalva was severely hypoplastic, so called diffuse type of supravalvular aortic stenosis. The ascending aorta was only 6.3 mm in diameter, whereas the diameter of the aortic annulus was 20.6 mm. The ascending aortic reconstruction of Doty's type was performed from the aortic root to the distal aortic arch with a equine pericardium reinforced by Dacron velour using selective perfusion to the right bracheocepharic artery, the left common carotid artery and the right femoral artery to avoid circulatory arrest. Postoperative course was uneventful and post operative catheterization revealed left ventricular pressure of 128 mmHg, the ascending aortic pressure of 126 mmHg and the descending aortic pressure of 90 mmHg. Mild residual pressure gradient was probably due to hypoplastic descending aorta. In conclusion, patch aortic reconstruction for ascending aorta under selective cerebral perfusion for a six-year old boy can be performed without postoperative neurological complication.

Mid-diastolic potential is related to the reentrant circuit in a patient with verapamil-sensitive idiopathic left ventricular tachycardia

We report a case of verapamil-sensitive idiopathic ventricular tachycardia in which a mid-diastolic potential (MDP) 45 msec preceding the Purkinje potential (P potential) was recorded. Pacing during the tachycardia caused concealed entrainment, and the stimulus-QRS interval was equal to the P potential-QRS interval. The interval between the last pacing stimulus and the next P potential (postpacing interval) was longer than the ventricular tachycardia cycle length, but the MDP was orthodromically activated. These findings suggest that the MDP was on the reentrant circuit and the P potential was not on the reentrant circuit, but a bystander.

[Color M-mode Doppler analysis of left ventricular inflow in pediatric patients]

This study evaluated the clinical usefulness of analyzing left ventricular (LV) filling by color M-mode Doppler echocardiography in pediatric patients. The LV-filling patterns of color M-mode Doppler echocardiography were obtained by LV inflow in the apical 4-chamber or long-axis view, and the time difference between the occurrence of peak velocity at the mitral tip and in the apical region (M-AP) was calculated. The peak velocity at each depth was determined by adequate selection of the Nyquist limit by shifting the zero point after freezing the color M-mode. LV volume and posterior wall motion velocity were obtained simultaneously. The catheter-derived data were compared with echo-derived data in 7 patients (mean age 12.0 years). The M-AP correlated positively with the time constant of LV relaxation (tau; r = 0.83, p < 0.05), pulmonary capillary wedge pressure (r = 0.83, p < 0.05), and negatively with peak diastolic posterior wall motion velocity (r = -0.78, p < 0.05). The M-AP was compared with other echo-derived data between Group N (35 children with normal cardiac function, mean age 4.3 years) and Group F (12 children with LV ejection fraction less than 40%, mean age 9.5 years). The M-AP was significantly longer in Group F (53.3 +/- 14.0 vs 116.5 +/- 30.5 msec; p < 0.001), but there was no significant difference in the E/A or deceleration time of E between the 2 groups. In Group N, the E/A correlated to LV end-diastolic volume and heart rate, but the M-AP showed no correlation. In Group F, the M-AP correlated with the percentages of normal LV end-diastolic volume (r = 0.76, p < 0.01) and LV ejection fraction (r = -0.58, p < 0.05). The M-AP was not influenced by LV size or heart rate and could easily differentiate normal heart from failing heart, and thus this is a useful parameter for evaluating diastolic function in pediatric patients.

Vascular endothelial growth factor in angiosarcoma

Angiosarcoma(AS) is a malignant tumour of the endothelium of lymphatic or blood vessels. Vascular endothelial growth factor (VEGF), a specific mitogen of endothelial cells, is considered essential for the growth of many tumours including AS. We have recently treated several patients with AS; in two of them, using a newly developed enzyme-linked immunosorbent assay (ELISA) for VEGF, we sequentially measured serum VEGF concentrations. While serial serum VEGF levels reflected tumour burden, the various VEGF concentrations were within the normal range we reported previously. Furthermore, the VEGF concentrations were not remarkably elevated in AS tumour tissue compared with benign vascular lesions and hypervascular tumours.

Hypoxia and endothelin-1 induce VEGF production in human vascular smooth muscle cells

Vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) is a secreted mitogen for vascular endothelial cells, and it promotes vascular permeability and neovascularization in vivo. We investigated the mechanisms by which low oxygen tension modulates the expression of VEGF in human aortic vascular smooth muscle cells (h-SMC) in vitro. Moreover, we measured VEGF levels in the cultured medium with or without endothelin-1 (ET-1) using a newly developed, highly sensitive, enzyme-linked immunosorbent assay. Hypoxia resulted in a substantial induction of VEGF transcripts at 3 and 24 hr. VEGF levels were significantly higher when h-SMC were cultured in medium containing ET-1 than when cultured in medium without ET-1. In conclusion, hypoxia and ET-1 constitute potent stimuli for VEGF production in h-SMC.