Staurosporine, a potent protein kinase C inhibitor, augments phorbol ester-caused ornithine decarboxylase induction in mouse epidermis

A single topical application of 12-O-tetradecanoylphorbol-13-acetate (TPA) to mouse skin caused an induction of epidermal ornithine decarboxylase (ODC) activity. When mice were topically pretreated with staurosporine, a most potent protein kinase C inhibitor, 6-84 h prior to TPA treatment, TPA-caused ODC induction was markedly enhanced. The enhancement of TPA-caused ODC induction by staurosporine was most pronounced when the time interval between staurosporine and TPA treatment was 36 h. Staurosporine elicited this enhancing effect in a dose-related manner. Staurosporine by itself also induced epidermal ODC activity. But the activity induced was very slight and would not directly contribute to the enhancing effect of this compound. Although staurosporine markedly augmented TPA-caused ODC induction, staurosporine-caused ODC induction was not augmented by this compound. Other protein kinase C inhibitors, such as 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine, sphingosine and palmitoylcarnitine did not mimic the enhancing effect of staurosporine. These results indicate that the enhancement of ODC induction by staurosporine is specific for the induction caused by TPA and that this enhancing effect is not related to the protein kinase C inhibitory action of staurosporine. TPA-caused epidermal ODC induction was inhibited by indomethacin, and this inhibition was reversed by prostaglandin E2 (PGE2). Staurosporine-caused ODC induction was also inhibited by indomethacin but the inhibition was not reversed by PGE2, indicating that the mechanism of staurosporine-caused ODC induction is different from that of TPA.

Differential sensitivities of transplacentally initiated newborn mouse epidermal cells to different tumor promoters

Epidermal cells isolated from newborn mice and cultured in low Ca2+ (0.02 mM) medium showed typical basal cell morphology and proliferated as monolayer. An increase in the medium Ca2+ concentration to normal level (1.8 mM) induced terminal differentiation of epidermal cells. Epidermal cells obtained from newborn mice transplacentally initiated with 7,12-dimethylbenz[a]anthracene (DMBA) produced a small number of rapidly growing cellular foci with epidermal morphology when the medium Ca2+ concentration was raised to normal level. The number of these Ca(2+)-induced differentiation-resistant colonies increased with increasing doses of DMBA, indicating that the differentiation-resistant colonies are the cells initiated by DMBA. Three differentiation-resistant colonies were cloned and designated as WY-1, WY-18 and WY-20 cells. All of these cell lines grew rapidly in the normal Ca2+ medium but not in the low Ca2+ medium. A potent skin tumor promoter, 12-O-tetradecanoyl-phorbol-13-acetate (TPA), and other TPA-type second-stage tumor promoters such as mezerein and 12-O-retinoylphorbol-13-acetate, stimulated the growth of WY-18 and WY-20 cells in the low Ca2+ medium, but did not stimulate the growth of WY-1 cells. TPA stimulated DNA synthesis and ornithine decarboxylase induction in WY-18 and WY-20 cells but not in WY-1 cells. A non-TPA-type tumor promoter, okadaic acid, failed to stimulate the growth of these three cell lines. Another non-TPA-type tumor-promoting agent, 7-bromo-methylbenz[a]anthracene, also failed to stimulate the growth of WY-1 and WY-20 cells but stimulated the growth of WY-18 cells. WY-18 and WY-20 cells formed colonies in soft agar but WY-1 cells did not form colonies. When these cell lines were injected s.c. into nude mice, WY-1 cells produced fast-growing tumors, whereas WY-18 and WY-20 cells produced relatively slow-growing tumors. Our present results indicate that each initiated cell has different sensitivities for different types of tumor promoters, and each type of promoter acts on corresponding types of initiated cells.

Prediction of the outcome of postoperative hypocalcemia in Graves' disease

Symptomatic hypocalcemia sometimes follows subtotal thyroidectomy for Graves' disease. Irreversible damage to the parathyroids contributes to permanent hypocalcemia and the mechanism for a transient hypocalcemia is thought to be different from that of a permanent one. However, sensitive assays for parathyroid hormones (PTH), which had recently become available, revealed that levels of PTH decrease in patients with transient hypocalcemia. In order to differentiate a prolonged hypocalcemia from a transient one, calcium and inorganic phosphate concentrations in serum as well as in urine, and whole molecule-PTH levels were determined in 18 Graves' disease patients with postoperative hypocalcemia just after the initial symptoms for hypocalcemia appeared. In 13 patients, medication was withdrawn within one month since serum calcium levels had returned to normal (transient hypocalcemia). In five other patients, medication was required for six months or more to maintain normocalcemia (prolonged hypocalcemia). The same parameters were determined after surgery in eight Graves' disease patients without hypocalcemia. Urinary inorganic phosphate concentrations in patients with prolonged hypocalcemia (0.02 +/- 0.01 mmol/mmol Cr) were significantly lower (P less than 0.01) than those in patients with transient hypocalcemia (1.59 +/- 1.59 mmol/mmol Cr) or those in control patients (1.27 +/- 0.70 mmol/mmol Cr). Preoperative concentrations of calcium and inorganic phosphate in serum and urine, and serum alkaline-phosphatase activities were also determined. However, there were no significant differences in these parameters between patients with prolonged and those with transient hypocalcemia. It is concluded that prolonged hypocalcemia is discriminated from the transient type by determining the urinary inorganic phosphate at the time of appearance of the initial symptoms for hypocalcemia.(ABSTRACT TRUNCATED AT 250 WORDS)

N-nitrosodialkylamine dealkylation in reconstituted systems containing cytochrome P-450 purified from phenobarbital- and beta-naphthoflavone-treated rats

Five cytochrome P-450 forms were purified from livers of rats pretreated with phenobarbital (PB) or beta-naphthoflavone (BNF), and the oxidative dealkylation of N-nitrosodialkylamines by the reconstituted cytochrome P-450 systems was measured. PB-II (P450IIB1) showed very high N-nitrosomethybutylamine (NMBA) debutylase activity, high NMBA demethylase activity and high N-nitrosomethyl-benzylamine (NMBeA) debenzylase activity, suggesting that the increase following PB treatment in hepatic microsomal NMBA debutylation and NMBeA debenzylation was due to the induction of PB-II. BNF-H (P450IA2) showed very high NMBA debutylase and high NMBeA debenzylase activities, and BNF-L (P450IA1) showed NMBA debutylase and high NMBeA debenzylase activities. These results suggested that the increase by BNF pretreatment in hepatic microsomal NMBA debutylation was due mainly to the induction of BNF-H and in some part to that of BNF-L. PB-II also showed very high dealkylation activity of lipophilic N-nitrosodialkylamines with long alkyl moieties. On the other hand, BNF-H dealkylated N-nitrosodipropylamine (NDPA), N-nitrosomethylbutylamine (NMBA) and N-nitrosoethylbutylamine (NEBA) at higher rates than N-nitrosodibutylamine (NDBA). BNF-L dealkylated NEBA at higher rates than NMBeA and NDBA. These results reveal that substrate specificity of each cytochrome P-450 form in N-nitrosodialkylamine metabolism is different from each other and several forms of cytochrome P-450 support each N-nitrosamine dealkylase activity in mammalians.

[Nd-YAG laser therapy of tracheobronchial lesions by malignant tumor]

Thirty-seven patients with tracheobronchial lesions by malignant tumor were treated with Nd-YAG laser. Thirty-seven patients were twenty-three males and fourteen females and ages ranged from 34 to 79 years. Diseases included were primary tracheal tumor in 3 cases, lung cancer in 16 (8 squamous cell carcinoma, 5 adenocarcinoma, 2 large cell carcinoma, 1 small cell carcinoma), cancer of adjacent organs in 9 (5 thyroid cancers, 4 esophageal cancers), and metastatic cancer to the lung or mediastinal lymph nodes in 9 (4 renal cell carcinoma, 2 thyroid cancer, one patient respectively, colon cancer and breast cancer). Intermittent irradiation of YAG laser was done for 0.5 second at 30-40 Watt through flexible bronchoscope under local anesthesia. It was repeated 1 to 41 times (mean 4.1 times) and energy amount was 148 Joules to 18,513 Joules (mean 3,305 J). The result was; stenosis disappeared in 22 cases (59.4%), improved in 14 (37.8%), and in one case YAG laser therapy discontinued due to intractable bleeding. The Nd-YAG laser therapy for tracheobronchial lesions by malignant tumor is very useful to improve dyspnea or atelectasis.

Effect of systemic L-arginine administration on hemodynamics and nitric oxide release in man

The effects of L-arginine administration on systemic hemodynamics and plasma concentrations of neuro-endocrine hormones and amino acids were investigated in 10 normotensive healthy volunteers. Nitrite/nitrate in urine and cyclic guanosine monophosphate (c-GMP) in plasma were also measured as indicators of release of nitric oxide (NO). L-arginine administration (30 g/300 ml/30 min) caused hypotension (mean arterial pressure; 79.3 +/- 3.9 mmHg fell to 68.8 +/- 2.2 mmHg) with tachycardia (62.3 +/- 2.3 beats/min increased to 67.5 +/- 1.9 beats/min). The plasma concentration of L-arginine before administration was 98.8 +/- 8.2 mumol/l and increased to 7263 +/- 567 mumol/l 20 min after administration. Cardiac output also increased to 127.2 +/- 3.9% by L-arginine administration. Total peripheral resistance was calculated to fall to 65.9 +/- 2.0%. L-arginine administration slightly changed several hormones, but all values were within normal ranges. Nitrite/nitrate in urine increased 142.1 +/- 12.4% compared to the values before L-arginine administration. Plasma concentrations of c-GMP and L-citrulline, the by-product of NO from L-arginine, were also significantly increased by L-arginine administration. All our results provide evidence for the first time that systemically administered L-arginine releases NO in man.

Assay for type III collagenolytic activity in lung cancer tissue

We developed a method for measuring the activity of type III collagenolytic enzyme in lung cancer tissue, using as substrate, type III collagen purified from human placenta. In this method [3H]propionate is used for labeling type III collagen, with bacterial collagenase used for making the standard curve. It, therefore, becomes possible to compare type III collagenolytic activity with those of other collagen subtypes (types I and IV). As this method is a fibril assay it is not susceptible to trypsin or other proteases. The average type III collagenolytic enzyme activity was higher in squamous cell carcinoma than in adenocarcinoma, while that of lung cancer tissue exceeded that of normal lung tissue. The activity of type III collagenase increased with the progression from one disease stage to the next.

Serum free triiodothyronine to free thyroxine ratio enables early prediction of the outcome of antithyroid drug therapy in patients with Graves' hyperthyroidism

This study scrutinizes the correlation between serum free triiodothyronine (FT3) to free thyroxine (FT4) ratios and the eventual outcome of antithyroid drug (ATD) therapy in patients with Graves' disease. Forty-four patients with Graves' thyrotoxicosis were treated with methylmercaptoimidazole (methimazole). During the follow-up, 16 patients relapsed in the short period of one to five months after cessation of the drug (relapse group), and 28 patients remained in remission when checked at 12 to 20 months after treatment (remission group). Serum FT3 to FT4 ratios [(pg/ml/ng/dl) x 10] were less than 55 throughout ATD therapy in 27 of the 28 remission patients whereas the ratios of the relapse group exceeded 55 from the early phase of methimazole treatment in 10 of 16 patients. In eight of these 10 patients the increased ratios were detected within three months of therapy (1 month, 3 patients; 2 months, 4 patients; 3 months, 1 patient). The ratios for the remaining two patients rose above 55 at the fifth and sixth months. There was no statistical difference between the remission and relapse groups in the FT3 to FT4 ratios either before nor at the completion of the treatment. However, a clear difference could be measured at a point during the therapy. Those in whom this difference was pronounced later underwent relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Two possibly distinct prostaglandin E1 receptors in N1E-115 clone: one mediating inositol trisphosphate formation, cyclic GMP formation, and intracellular calcium mobilization and the other mediating cyclic AMP formation

Prostaglandin E1 (PGE1)-mediated transmembrane signal control systems were investigated in intact murine neuroblastoma cells (clone N1E-115). PGE1 increased intracellular levels of total inositol phosphates (IP), cyclic GMP, cyclic AMP, and calcium ([Ca2+]i). PGE1 transiently increased inositol 1,4,5-trisphosphate formation, peaking at 20 s. There was more than a 10-fold difference between the ED50 for PGE1 at cyclic AMP formation (70 nM) and its ED50 values at IP accumulation (1 microM), cyclic GMP formation (2 microM), and [Ca2+]i increase (5 microM). PGE1-mediated IP accumulation, cyclic GMP formation, and [Ca2+]i increase depended on both the concentration of PGE1 and extracellular calcium ions. PGE1 had more potent intrinsic activity in cyclic AMP formation, IP accumulation, and cyclic GMP formation than did PGE2, PGF2 alpha, or PGD2. A protein kinase C activator, 4 beta-phorbol 12 beta-myristate 13 alpha-acetate, had opposite effects on PGE1-mediated IP release and cyclic GMP formation (inhibitory) and cyclic AMP formation (stimulatory). These data suggest that there may be subtypes of the PGE1 receptor in this clone: a high-affinity receptor mediating cyclic AMP formation, and a low-affinity receptor mediating IP accumulation, cyclic GMP formation, and intracellular calcium mobilization.

Inhibition by prostacyclin and carbacyclins of endothelin-induced DNA synthesis in cultured vascular smooth muscle cells

Effects of prostacyclin and carbacyclins on endothelin-induced DNA synthesis were investigated in vascular smooth muscle cells. DNA synthesis was estimated by [3H]thymidine incorporation. Five carbacyclins used in this report were 5-[(1S, 5S, 6R, 7R)-7-hydroxy-6-[(E)-(S)-3-hydroxy-1-octenyl]bicyclo [3.3.0]oct-2-en-3-yl) pentanoic acid (TEI-7165), methyl 5-[(1S, 5S, 6R, 7R)-7-hydroxy-6-[(E)-(S)-3-hydroxy-1-octenyl]bicyclo[3.3.0]oct-2-en-3- yl]pentanoate (TEI-9090), 5-[(1S, 5S, 6R, 7R)-7-hydroxy-6-[(E)-(3S, 5S)-3-hydroxy-5-methyl-1-nonenyl]bicyclo[3.3.0]oct-2-en-3-yl)penta noic acid (TEI-9063), methyl 5-[(1S, 5S, 6R, 7R)-7-hydroxy-6-[(E)-(3S, 5S)-3-hydroxy-5-methyl-1- nonenyl]bicyclo[3.3.0]oct-2-en-3-yl)pentanoate (TEI-1324), 5-[(1S, 5S, 6R, 7R)-7-hydroxy-6-[(E)-(S)-4-hydroxy-4-methyl-1- octenyl]bicyclo[3.3.0]oct-2-en-3-yl] pentanoic acid (TEI-3356). Prostacyclin and the carbacyclins inhibited the endothelin-induced DNA synthesis within the nanomolar range. These results suggest that prostacyclin and carbacyclins are possibly effective in inhibiting the proliferation of vascular smooth muscle cells under some situations in vivo.

Vascular smooth muscle contraction induced by Na+ channel activators, veratridine and batrachotoxin

The effects of the sodium channel activators veratridine and batrachotoxin on isolated rat aorta were investigated. Veratridine caused gradual contraction, independent of the presence of endothelium, with an EC50 of 35 microM. Batrachotoxin (1 microM) also induced contraction. Both effects were completely inhibited by the sodium channel blocker tetrodotoxin (1 microM). The veratridine (60 microM)-induced contraction was inhibited by nifedipine (0.1 microM). In the absence of extracellular Ca2+, veratridine (60 microM) did not cause contraction. Sodium nitroprusside (80 nM), acetylcholine (10 microM) and isoproterenol (1 microM) caused relaxation of rings precontracted with veratridine (60 microM). An inhibitor of endothelium-derived relaxing factor (EDRF) synthase, N omega-nitro-L-arginine methyl ester (L-NAME) (0.65 mM), enhanced the veratridine-induced contraction in rings with an intact endothelium, which suggests that EDRF was being released during the veratridine-induced contraction. These results show that the activation of sodium channels on smooth muscle cells induces a contraction that is probably mediated by Ca2+ influx through voltage-dependent Ca2+ channels.

Synergistic stimulation of prostaglandin E2 release by epidermal growth factor and a tumor promoter anthralin from primary cultures of mouse epidermal cells

The tumor promoter anthralin stimulated prostaglandin E2 (PGE2) and arachidonic acid release from primary cultures of mouse epidermal cells. Epidermal growth factor (EGF) hardly stimulated PGE2 release by itself; however, a combination of anthralin and EGF synergistically stimulated PGE2 release. Neither anthralin, EGF nor EGF plus anthralin affected the incorporation of arachidonic acid into cellular phospholipids at least up to 2 hr after the stimulation by these agents. In the presence of EGF, however, [3H]arachidonic acid in the medium decreased substantially 4-8 hr after the addition of this agent, indicating that EGF suppresses [3H]arachidonic acid release and stimulates the incorporation of [3H]arachidonic acid into the cells during this time period. Cellular cyclooxygenase activity was increased by treating the cells either with anthralin or EGF, and it was synergistically increased by EGF plus anthralin. Both cycloheximide and actinomycin D inhibited the increase in cyclooxygenase activity caused by EGF plus anthralin. These results indicate that the synergistic stimulation of PGE2 release caused by EGF plus anthralin is due to a synergistic stimulation of arachidonic acid release (in the early phase of stimulation) and a synergistic increase in cyclooxygenase activity, probably a synergistic induction of cyclooxygenase, by these agents.

Surgical treatment of advanced thyroid carcinoma invading the trachea

Operative methods, in relation to the completeness of resection and surgical results, and postoperative complications, in relation to operative methods, were discussed in 60 patients with advanced thyroid carcinoma in whom tumor invading the trachea was resected along with thyroid carcinoma. Laryngotracheal anastomosis was performed in 41 patients and tracheotracheal anastomosis in 19 patients. Complete resection was performed in 22 patients in the former group and in 12 patients in the latter group. Three-, 5-, and 10-year survival rates in patients undergoing complete resection were 87.0%, 78.1%, and 78.1%, respectively. Those for patients undergoing incomplete resection were 64.9%, 43.7%, and 24.3%, respectively. The locations of remaining tumor were the tracheal stump in patients in whom resection was incomplete. In four patients with esophageal invasion, the muscular layer of the esophagus was resected. Three of these patients had good postoperative results. Postoperative complications consisted of stenosis at the anastomosis in two patients, temporary mis-swallowing in three patients, temporary lower pharyngeal stenosis in one patient, temporary vocal cord edema in one patient, and tetany in two patients.

Active site of mu-conotoxin GIIIA, a peptide blocker of muscle sodium channels

The amino acid sequence of mu-conotoxin GIIIA (otherwise called geographutoxin I), a peptide having 22 amino acid residues with three disulfide bridges, was modified by replacing each residue with Ala or Lys to elucidate its active center for blocking sodium channels of skeletal muscle. NMR and CD spectra were virtually identical between native and modified toxins, indicating the similarity of their conformation including disulfide bridges. The inhibitory effect of these modified peptides on twitch contractions of the rat diaphragm showed that Arg at the 13th position and the basicity of the molecule are crucial for the biological action. The segment Lys11-Asp12-Arg13 has been reported to be flexible (Lancelin, J.-M., Kohda, D., Tate, S., Yanagawa, Y., Abe, T., Satake, M., and Inagaki, F. (1991) Biochemistry, in press), and this may represent a clue for the subtle fit of Arg13 to the specific site of sodium channels. Since known ligands to sodium channels, such as tetrodotoxin, anthopleulin-A, etc., contain guanidino groups as a putative binding moiety, Arg may be a general residue for peptide toxins to interact with the receptor site on sodium channels.

Regulations of male-dominant P-450Md mRNA in rat liver by hormonal factors and xenobiotics

Male-dominant P-450Md mRNA was undetectable in the livers of newborn rats. In female rat livers, the mRNA appeared at 17 days of age and then decreased to very low levels in the adult periods. The level of P-450Md mRNA in female rats was increased by phenobarbital or dexamethasone treatment, whereas the level in the males was depressed by methylcholanthrene. Hypophysectomy decreased the level of P-450Md mRNA in male rat livers, and continuous infusion or twice-daily injections of growth hormone to hypophysectomized rats caused further suppression or clear restoration, respectively, of the mRNA level.

[Tracheal surgery to preserve or improve pulmonary and laryngeal functions]

One hundred and two patients underwent tracheal surgery to preserve or improve pulmonary and laryngeal functions. For pre- and post-operative functional examinations of tracheal stenotic patients, the flow volume curve and frequency analysis of tracheal stenotic sounds were very useful. As a results of tracheal surgery in 76 malignant cases, vocal cord stenosis due to bilateral laryngeal nerve paralysis was occurred in 21 patients. For vocal cord stenosis, T tube insertion was very effective and we were able to close the orifice of tracheostomy in 11 out of 15 cases by this method.

Purification of hepatic N-hydroxyarylamine sulfotransferases and their regulation by growth hormone and thyroid hormone in rats

From liver cytosols of male Sprague-Dawley rats, two N-hydroxyarylamine sulfotransferases (HASTs) which sulfate N-hydroxy-2-acetylaminofluorene and a phenolsulfotransferase (PST-I) have been purified about 290-, 690-, and 210-fold, respectively, by the use of DEAE-anion exchange, Blue-Sepharose CL-6B, DEAE-HPLC, and ATP-agarose affinity chromatography. All three enzymes showed almost the same molecular weight of 33 kDa on SDS-polyacrylamide gel electrophoresis. In Western blots using antibody raised against HAST I, the two HASTs, but not PST-I, were detected. The content of total HAST in male rats was estimated as 4-5 micrograms/mg cytosolic protein, about 4 times higher than that in female rats. Direct comparison of the DEAE-HPLC elution profiles of cytosol showed that HAST I and HAST II were male-dominant and male-specific, respectively, in their expression in the livers. Hypophysectomy decreased the level of HAST by 60% in male rats, but had no obvious effect in female rats. Intermittent injection of growth hormone to mimic the male secretory pattern raised the content in hypophysectomized rats of both sexes close to that in intact male rats, while the continuous infusion of growth hormone to mimic the female secretory pattern showed limited effects. In addition, the administration of triiodothyronine stimulated HAST in hypophysectomized rats of both sexes, and the extent of stimulation was nearly the same as observed in the male-type growth hormone treatment. PST-I, in contrast to HAST, showed no clear sex-related difference in hepatic content, and was not apparently affected by growth hormone or triiodothyronine.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of acute myocardial infarction due to coronary spasm]

The patient was a 47 year-old man, who has been known to have effort angina since September 1989. His exercise stress ECG has revealed ST elevation in V2-V4 with maximum exercise. He experienced severe chest pain lasting for an hour on the way to his office in the early morning on November 16, 1989, and was admitted to our hospital. His ECG and laboratory findings indicated typical acute anteroseptal myocardial infarction, but the coronary arteriography (CAG) which was performed 7 hours after the onset showed no significant stenotic lesion. After administrating nitrate and calcium antagonist, he has had no attack of angina pectoris and his exercise stress test has revealed no ST-T changes on his ECG. 1 month later, while antianginal drugs were discontinued in order to perform an ergonovine stress test, the patient frequently complained of left anterior chest pain with remarkable ST elevation in precordial leads on his ECG. The CAG at chronic stage revealed that there was a 99% stenosis at Segment 6 of the left anterior descending artery (LAD) which was supplied with good collateral flow from the right coronary artery. The LAD was completely occluded at Segment 6 after intracoronary administration of ergonovine maleate 0.005 mg to the left coronary artery. After the intracoronary infusion of isosorbide dinitrate, there was no significant stenosis seen in the LAD except the minimum wall irregularity at Segment 6. These findings suggested that coronary spasm might play a major role of the occurrence of acute myocardial infarction in this case.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of quadricuspid aortic valve associated with coronary arterial legion]

A case of quadricuspid aortic valve is reported in a patient with coronary artery disease and abdominal aortic aneurysms. A 54-year-old male who had undergone aortic replacement because of abdominal aortic aneurysms three years before presentation was readmitted due to complaints of angina pectoris and palpitations. Aortography and coronary arteriography revealed severe aortic regurgitation and proximal occlusion of LAD and RCA. Surgical correction consisted of aortic valve replacement with a Björk-Shilely valve and coronary revascularization of LAD. During the operation, a quadricuspid aortic valve with one smaller and three larger cusps that showed mild myxomatous degeneration without dystrophic calcification and normal coronary arterial orifices were noted. Accordingly, severe aortic regurgitation may have resulted from the dysfunction of congenital malformed cusps and acquired sclerotic coronary disease was the main cause of the chest pain.