[Anticoagulant related hemorrhage and thromboembolism after valvular surgery]

We reviewed anticoagulant related hemorrhage (ACRH) and thromboembolism (TE) in 84 patients after valvular surgery. There were 45 females and 39 males with a mean age of 51.8 years (range 30.5-71.2 years), who underwent valvuloplasty in 14, bioprosthetic valve replacements in 17, mechanical valve replacements in 13. A mean period from the operation to the event were 2.7 years (range 0.01-12.3 years). There were 25 ACRH events after one valvuloplasty, 4 bioprosthetic valve replacements, 20 mechanical valve replacements. About half of them, the prothrombin time were less than 25%, which was considered the effect of warfarin is high, and 8% of them had infective endocarditis (IE) previously. There were 59 TE events after 13 valvuloplasties, 13 bioprosthetic valve replacements, 33 mechanical valve replacements. In the patients with atrial fibrillation, TE occurred irrespective of operative procedures. And in the patients with mechanical valve, severely impaired left ventricular function and past history of IE, thrombi of left ventricule were caused of TE. It was suggested that past history of IE was a risk factor ACRH and TE, and severely depressed left ventricular function and atrial fibrillation were for TE.

Outbreaks of fowl cholera in Muscovy ducks (Cairina moschata) on a farm in Aomori Prefecture

Outbreaks of a subacute disease characterized by lameness, corneal turbidity, dysstasia and depression occurred in Muscovy ducks (Cairina moschata) on a farm in Aomori Prefecture in February and May 1991. Nine strains of Pasteurella multocida were isolated from 5 to 6 dead ducks, and 4 of 8 ducks with clinical signs. Serotypes of the isolates were identified as Heddleston's serotype 1, 10 or 12 and Namioka's serotypes 5:A, 8:A, 9:A or 9:UT. These isolates were highly susceptible to 12 antibiotics, although, some of them were considerably resistant to chloramphenicol. Mouse LD50 values of the 9 isolates ranged from 10(1.0) to 10(5.3). The most virulent strain for the mouse killed 2 to 4 ducks when inoculated intramuscularly at a concentration of 10(3.3). This is the first report of outbreaks of fowl cholera in Muscovy ducks infected with various serotypes strains of P. multocida in Japan.

Modulation of endotoxin-induced histamine synthesis by cytokines in mouse bone marrow-derived macrophages

The aim of this study was to examine the roles of various cytokines in histamine synthesis by macrophages in bone marrow. Pure (> 99% nonspecific esterase-, CD14-, and Mac-1-positive) macrophage populations were obtained after long term culture of bone marrow cells (bone marrow-derived macrophages). Culture of the cells in the presence of Escherichia coli LPS caused a slight, but dose-dependent, increase in histidine decarboxylase-associated histamine synthesis with a concomitant increase in the expression of CD14, a LPS receptor, as well as the Mac-1 Ag on their surface. Granulocyte/macrophage CSF (GM-CSF) or IL-3 strongly enhanced LPS-induced histamine formation and expression of CD14 on bone marrow-derived macrophages, without affecting the expression of Mac-1 Ag. GM-CSF and IL-3 also caused a marked accumulation of both histidine decarboxylase and IL-6 mRNAs in the cells. Macrophage CSF and IL-1-alpha also potentiated LPS-dependent histamine formation when it was stimulated with GM-CSF or IL-3. In contrast to these cytokines, IFN-gamma suppressed LPS-induced histamine production regardless of whether it was stimulated by GM-CSF or IL-3, and inhibited CD14 expression. Neither IL-6 nor granulocyte CSF had any appreciable effect on LPS-induced histamine production even in combination with GM-CSF or IL-3. These results suggest that GM-CSF and IL-3 enhance LPS-induced histamine production in bone marrow-derived macrophages and that macrophage CSF and IL-1 alpha augment the actions of GM-CSF and IL-3. Possible implication of CD14 molecule in the reactions is discussed.

Modulation of endotoxin-induced histamine synthesis by cytokines in mouse bone marrow-derived macrophages

The aim of this study was to examine the roles of various cytokines in histamine synthesis by macrophages in bone marrow. Pure (> 99% nonspecific esterase-, CD14-, and Mac-1-positive) macrophage populations were obtained after long term culture of bone marrow cells (bone marrow-derived macrophages). Culture of the cells in the presence of Escherichia coli LPS caused a slight, but dose-dependent, increase in histidine decarboxylase-associated histamine synthesis with a concomitant increase in the expression of CD14, a LPS receptor, as well as the Mac-1 Ag on their surface. Granulocyte/macrophage CSF (GM-CSF) or IL-3 strongly enhanced LPS-induced histamine formation and expression of CD14 on bone marrow-derived macrophages, without affecting the expression of Mac-1 Ag. GM-CSF and IL-3 also caused a marked accumulation of both histidine decarboxylase and IL-6 mRNAs in the cells. Macrophage CSF and IL-1-alpha also potentiated LPS-dependent histamine formation when it was stimulated with GM-CSF or IL-3. In contrast to these cytokines, IFN-gamma suppressed LPS-induced histamine production regardless of whether it was stimulated by GM-CSF or IL-3, and inhibited CD14 expression. Neither IL-6 nor granulocyte CSF had any appreciable effect on LPS-induced histamine production even in combination with GM-CSF or IL-3. These results suggest that GM-CSF and IL-3 enhance LPS-induced histamine production in bone marrow-derived macrophages and that macrophage CSF and IL-1 alpha augment the actions of GM-CSF and IL-3. Possible implication of CD14 molecule in the reactions is discussed.

Pallido-thalamo-motor cortical connections: an electron microscopic study in the macaque monkey

We combined the retrograde transport of horseradish peroxidase conjugated to wheat germ agglutinin (WGA-HRP) technique and degenerating electron microscopic investigations to confirm the motor cortical area projection from the medial pallidal segment (GPm) via the thalamic nucleus ventralis lateralis pars oralis (VLo). We found first degenerated boutons arising from the GPm make synaptic contact with the somata and proximal dendrites of VLo neurons containing WGA-HRP reaction products transported retrogradely from motor area.

Acute renal failure in a patient with chronic glomerulonephritis after the administration of luteinizing hormone-releasing hormone analogue given for rectal obstruction due to prostate cancer

We report a case in which rectal obstruction due to prostate cancer was exacerbated due to an ileus after the administration of luteinizing hormone-releasing hormone analogue. The obstruction to led to copious vomiting, dehydration and renal failure which necessitated hemodialysis. Improvement of the patient was noted four weeks after the start of hormonal treatment with a decrease in rectal obstruction concomitant with decreases in testosterone and prostate specific antigen levels.

Surgical stratification of patients with atrial fibrillation secondary to organic cardiac lesions

BACKGROUND

While the maze procedure does not always eliminate atrial fibrillation (AF) secondary to organic cardiac lesions, concomitant performance of the procedure is associated with increased surgical complexity and potential risks.

METHODS

To stratify the surgical approach for patients with AF secondary to underlying cardiac lesions, we analyzed 24 preoperative and perioperative variables in 115 consecutive patients with AF undergoing a modified maze procedure combined with valvular intervention (101), repair of congenital anomalies (13) and coronary revascularization (1).

RESULTS

Patients who remained in AF (18) compared to patients with restored atrial rhythm (97), had a higher incidence of giant left atrium (56% vs 10%, P < 0.0001), larger cardiothoracic ratio (70 +/- 13 vs 62 +/- 8%, P = 0.001) and left atrial dimension (64 +/- 12 vs 55 +/- 12 mm, P = 0.004), a longer history of AF (13.7 +/- 6.8 vs 8.3 +/- 6.9 years, P = 0.003) and lower f-wave voltage (0.10 vs 0.15 mV, P = 0.004). Multivariate logistic regression analysis of 24 preoperative and perioperative variables identified the presence of giant left atrium, cardiothoracic ratio and age at operation as the significant risk factors predisposing patients to persistent postoperative AF. Retrospective estimation identified 73 (63.5%) patients with a high probability of atrial defibrillation (97.3%) and 42 (36.5%) patients with a high risk of failure (38.1%). Regardless of the preoperative risk analysis or the performance of left atrial plication, every patient with a postoperative left atrial dimension less than 40 mm or cardiothoracic ratio below 55% was successfully defibrillated.

CONCLUSION

The results suggest performing the maze procedure before "risk factors" develop for patients with predicted maze-amenable AF. While omitting the maze procedure may be prudent for patients with suspected maze-refractory AF, the simultaneous reduction of left atrial size may offset the increased risk from preoperative size factors. A prospective study seems warranted to examine the effects of left atrial plication on postoperative rhythm.

Correlation between occurrence of exudative epidermitis and exfoliative toxin-producing ability of Staphylococcus hyicus

Staphylococcus hyicus was isolated from healthy pigs and pigs affected with exudative epidermitis (EE). Thirty seven strains (P-7 to P-43) were isolated from pigs affected with EE on 8 farms while 131 strains were isolated from healthy pigs bred on 2 farms in Japan. Isolation rate for pigs affected with EE was 100% while that for healthy pigs was 35.4%. The biochemical and cultural characteristics of the isolates from healthy and diseased pigs were identical except for the Voges-Proskauer reaction. The culture supernatant of many isolates caused skin exfoliation in 1-day-old chickens. Therefore, many isolates were considered to produce S. hyicus exfoliative toxin (shET). The rate of shET production by the isolates from piglets affected with EE was 87.5%, while that of the isolates from healthy pigs was 76.1%. shETs were divided in two serotypes by immunodiffusion. Piglets experimentally infected with shET-producing and nonproducing strains were observed. Local skin erythema at the inoculation site was observed with nonproducing strains and disappeared within 48 h, while the skin erythema at the sites inoculated with shET-producing strains did not disappear until 7 days after inoculation. Typical clinical signs, such as exfoliation, exudation and crusting were observed only in the piglets inoculated with shET-producing strains.

Diabetic renal failure and serum accumulation of the creatinine oxidative metabolites creatol and methylguanidine

Diabetic patients (n = 23) with chronic renal failure (CRF) accumulate the creatinine (Cr) oxidative metabolites creatol (CTL) and methylguanidine (MG; a uremic toxin) in their sera. Analysis of serum CTL, a key intermediate in mammalian Cr catabolism into MG, is shown to offer some useful diagnostic information on CRF, especially in the determination of an initial stage of pathological renal failure. The sera of all diabetic (n = 23) and nondiabetic (n = 20) patients with CRF (s-Cr > 1.25 mg/dl) contained s-CTL (> 2 micrograms/dl), whereas those from normal subjects (n = 18) and diabetic patients (n = 18) without CRF contained no detectable s-CTL. A similar accumulation of s-MG was observed, but only when s-Cr was higher than 2.0 mg/dl. Although each s-CTL (Y: microgram/dl, Y': mol/l) and s-MG level (Z: microgram/dl, Z': mol/l) is highly correlated with s-Cr (X: mg/dl, X': mol/l) in a normal equation, Y or Z = AX + B, an alternative correlation in a second-order equation, Y or Z = alpha X2 + beta X, could also fit well. Since the quadratic equation can be convertible to Y/X or Z/X = alpha X + beta [Y'/X' or Z'/X' = alpha' X+ beta'] and active oxygen species, especially hydroxyl radicals, convert Cr into CTL, Y/X, Y'/X', Z/X and Z'/X' values which might be a kind of indices for oxygen stress (oxidative stress) increased in proportion to the increased severity of CRF in such patients. Although its meaning and interpretation are still debatable, diabetic CRF patients had a significantly higher alpha' value (2.2) than that (0.89) of nondiabetic CRF patients. All serum values for Cr, CTL and MG were measured with HPLC.

[Concurrent high-dose thoracic irradiation plus daily low-dose cisplatin and vindesine in locally advanced unresectable stage III non-small cell lung cancer]

Patients with unresectable non small-cell lung cancer were treated to evaluate the toxicity and efficacy of high-dose thoracic irradiation (RT) combined with concurrent daily cisplatin plus vindesine. Fourteen evaluable patients with unresectable stage III non small-cell lung cancer treated with continuous-course RT (70 Gy in 35 fractions of 2 Gy once daily) and concurrent daily intravenous cisplatin (6 mg/m2) plus vindesine (3 mg/m2 on day 1 and day 8). The objective response rate was 86%, and two patients achieved a radiographic complete response. Leukocytopenia was the severe toxicity, but there were no episodes of discontinuation of treatment. Only one patient had grade 3 acute radiation esophagitis. Ten patients experienced late radiation pneumonitis and nine of those had grade 1 or grade 2. There was only one life-threatening case of toxicity (grade 5 pneumonitis). We concluded that the regimen of high-dose thoracic RT combined with concurrent daily cisplatin plus vindesine obtained a high response rate. Further testing on late toxicities and survival time is required.

Positive and negative association of HLA-DR genotypes with Japanese rheumatoid arthritis

OBJECTIVE

To clarify the relationship between the HLA-DR genotype and susceptibility to rheumatoid arthritis (RA) in Japanese patients.

METHODS

HLA-DR typing and DRB1* genotyping were carried out by PCR and PCR-SSCP (single stranded DNA conformation polymorphism), respectively.

RESULTS

In RA, the prevalence of HLA-DR4 was significantly higher (57.3%, p < 0.05). In particular, DRB1*0405 was predominantly higher (46.9%, p < 0.05) and DRB1*0401 was also increased although not significantly. HLA-DR8, especially DRB1*0802, was significantly lower (1.0%, p < 0.01). RA patients homozygous for DRB1*0405 showed slightly higher values for the erythrocyte sedimentation rate, gamma-globulin, and IgG, as well as positivity for rheumatoid factor and high titers for the Waalar-Rose test, and a decrease in the albumin/globulin ratio, albumin, and hemoglobin in comparison to patients without RA susceptibility genes, although the difference for each of these parameters was not significant.

CONCLUSION

DRB1*0405 and DRB1*0802, which are both rare alleles in Caucasians, are positively and negatively correlated, respectively, with the pathogenesis of RA in Japan.

Transurethral balloon laser thermotherapy: effects of a directionally shielded balloon in canine prostates

BACKGROUND

Transurethral balloon laser thermotherapy (TUBAL-T) improves objective, but not subjective, symptoms of benign prostatic hyperplasia (BPH). We studied whether or not an Nd:YAG laser beam with a shielded balloon could successfully irradiate the prostate during TUBAL-T in selective manner, to improve the subjective symptoms.

METHODS

TUBAL-T was performed on canine prostates using the balloon with a laser probe, which was shielded anteriorly at 90 degrees (from the center of the balloon) and posteriorly at 90 degrees.

RESULTS

At 20 watts laser power, the relative power density in the bilateral non-shielded areas was 17.4 and 17.8, and in the shielded area it was 1.0. Observation by thermography revealed that the temperature after laser radiation in a non-shielded area of a fish cake phantom was higher than in a shielded area. Following transurethral thermotherapy using a shielded balloon in dogs, a cavity was formed bilaterally around the urethra, and the tissues at the anteroposterior sides and the urethra were preserved.

CONCLUSIONS

TUBAL-T, which has been performed in clinical cases of benign prostatic hyperplasia, might be useful in selective irradiation of adenoma if a shielded balloon is used.

The vestibular nuclei of the rat project to the lateral part of the thalamic parafascicular nucleus (centromedian nucleus in primates)

To clarify the vestibular projections to the centromedian-parafascicular nuclear complex, the Phaseolus vulgaris leucoagglutinin (PHA-L) and horseradish peroxidase conjugated to wheat germ agglutinin (WGA-HRP), tracing studies have been done in rats. The data demonstrated that the lateral parafasicular nucleus received vestibular afferents mainly from the ventral part of medial vestibular nucleus, and the superior and inferior vestibular nuclei, with an ipsilateral predominance. These findings suggest the vestibular influence to the motor loop of the basal ganglia thalamocortical projections.

[Evaluation of surgical procedures based on the types of hypertrophied obstructive cardiomyopathy]

The surgical procedures were reviewed based on the types of hypertrophied obstructive cardiomyopathy in 20 patients. The patients were classified in three groups: (1) Asymmetric septal hypertrophy (ASH), (2) Atypical or diffuse concentric hypertrophy (DIF), (3) Mid ventricular obstructive hypertrophy (MID). Among 11 patients with ASH, the ventricular septal myotomy (My) or the myotomy-myectomy (Mye) were performed in 9 patients and MVR was performed in 2 patients. Among 6 patients with DIF, My or Mye were performed in 4 and MVR was performed in 2. All three patients with MID were treated with MVR. The intraventricular systolic pressure gradient greater than 40 mmHg was still existent postoperatively in one ASH patient on whom Mye was performed and in 3 DIF patients on whom My or Mye were performed. The four patients had III degree mitral regurgitation preoperatively and were successfully treated. The postoperative NYHA functional class became II or less in all patients. For ASH, the My was effective in 9 patients except one earlier patient. For DIF, further consideration of surgical procedure might be required. For MID, a MVR is recommended.

Left ventricular function on exercise after surgical treatment of small aortic annuli

To evaluate left ventricular function during exercise after aortic annular enlargement 15 patients with either aortic (group I, n = 8) or aortomitral (group II, n = 7) annuloplasty for small aortic annuli and eight patients (group III) with standard valve replacement for aortic stenosis without small aortic annuli received gated cardiac pool imagining by technetium-99m-labelled red blood cells at rest and during exercise at a mean of 23 months after operation. Left ventricular ejection fraction, preload requitable stroke work and stroke power index (preload requitable stroke work/systolic ejection period) were measured. Compared with resting values, left ventricular performance and stroke work rate on exercise after aortic annular enlargements increased significantly, as did those after standard aortic valve replacement. These results suggest that aortic annular enlargement can be indicated for surgical treatment of valvular heart diseases associated with small aortic annuli.

Role of histamine produced by macrophages in mouse bone marrow

Promyelocytic HL-60 cells differentiated into mature cells when they were cultured in the presence of dimaprit (10(-4) M), a histamine H2 agonist. An injection of Escherichia coli lipopolysaccharide increased the activity of histidine decarboxylase in bone marrow cells in C3H/HeN mice to a much greater extent than in C3H/HeJ mice, which are resistant to various effects of lipopolysaccharide. Histamine production increased concomitantly. In WBB6/F1 (W/W(v)) mice, which are genetically deficient in mast cells, histidine decarboxylase activity increased more than in C3H/HeN mice. Pure (>99% nonspecific esterase, CD14 and Mac-1 positive) macrophage populations were obtained from long-term culture of the bone marrow cells (bone marrow-derived macrophages, BMDM). Culture of the cells in the presence of lipopolysaccharide caused a slight, but dose-dependent increase in histidine decarboxylase-associated histamine synthesis. Granulocyte/macrophage colony-stimulating factor (rmGM-CSF) or interleukin 3 (rmIL-3) potently increased lipopolysaccharide-induced histamine formation.

Increase in the level of mRNA for 3-hydroxyanthranilate 3,4-dioxygenase in brain of epilepsy-prone El mice

We had shown that production of quinolinic acid is high in the brain of epilepsy-prone El mice and that this is due to an increase in the activity of 3-hydroxyanthranilate 3,4-dioxygenase (3-HAO, EC 1.13.11.6). We demonstrated here that the level of mRNA for 3-HAO was markedly increased in the brain of El mice.

[Augmentation of chemotherapeutic efficaciousness of UFT by oral l-leucovorin--growth-inhibitory activity of combination against human tumor xenograft]

Combination chemotherapy with FUra and LV has been reported as a useful treatment for patients suffering from colon carcinoma. Usually, both FUra and LV are administered by intravenous infusion, but not orally. UFT, an anti-neoplastic agent consisting of FT and uracil, is widely used for oral administration in Japan. Using human tumor xenografts of 10 cell lines, we evaluated the efficacy of UFT combined with l-LV, which is the active form of LV, by oral administration. Combined treatment of UFT with l-LV was more effective than UFT alone on the growth suppression of colon carcinoma (KM 20 C, Col-1) and mammary carcinoma (H-31, MX-1). When 1.85 mg/kg (5.55 mg/m2) of LV was given to tumor bearing mice, the antitumor activity of UFT was augmented and at a dose of 5.56 mg/kg (16.7 mg/m2) of LV, it was significantly augmented. Among various 5-FU derivatives, such as UFT, 5'-DFUR or FUra, combined treatment using UFT with l-LV was the most effective by oral administration. l-LV did not improve the anti-tumor efficacy or toxicity of 5'-DFUR. l-LV seemed to augment the anti-tumor activity of FUra, but not significantly. These results suggest that combination chemotherapy of UFT with LV is a promising approach for the clinical treatment of human colon cancer.

Deletion in the L1 open reading frame of human papillomavirus type 6a genomes associated with recurrent laryngeal papilloma

Human papillomavirus (HPV) type 6a genomes with a large deletion in their L1 open reading frames (ORF) were found in two of five recurrent cases of laryngeal papilloma. One of these mutant HPVs had a 186 base pair (bp) deletion near the N-terminus end of the L1 ORF, which encodes a major capsid protein. The other had a 454 bp deletion at the C-terminus end of L1 at which is located a nuclear localising signal (NLS). No other large deletion or insertion was found in the remaining regions of all five HPV6a genomes. The laryngeal papillomas which harboured the mutant viruses showed typical hyperplasia and pathological changes as observed in tumours induced by the wild-type virus. The biological significance of the two large deletions in the late region of HPV6a associated with laryngeal papilloma is discussed.

Modified maze procedure for patients with atrial fibrillation undergoing simultaneous open heart surgery

BACKGROUND

Persistent atrial fibrillation (AF) leaves patients symptomatic and at increased risk of thromboembolism even after otherwise successful cardiac surgery.

METHODS AND RESULTS

To treat AF secondary to cardiac lesions requiring surgery, we combined a modified maze procedure in 101 patients simultaneously undergoing valvular procedures (87), repair of congenital anomalies (12), and other procedures (2), including 24 repeat operations. Duration of AF varied from 0.1 to 30 years (average +/- SD, 8.8 +/- 7.0 years); the f-wave voltage ranged from 0 to 0.45 mV (0.15 +/- 0.09 mV); and cardiothoracic ratio varied from 40% to 99% (63 +/- 9%). Aortic cross-clamp time varied from 75 to 229 minutes (138 +/- 31 minutes), with bypass time ranging from 119 to 326 minutes (217 +/- 42 minutes). There were two early deaths (2%), no late deaths, and one episode of transient neurological ischemic attack in follow-up ranging from 1.0 to 3.1 years, for a total of 190 patient-years. Postoperative rhythms were sinus in 83 patients (82%), junctional in 4 (4%), and persistent AF in 14 (14%), each of whom had mitral valve disease. Patients with other underlying pathology had complete recovery of atrial rhythm. A normal-sized A wave was detected in 88% for transtricuspid flow and in 73% for transmitral flow, suggesting concomitant recovery of atrial contraction. Among 36 patients without mechanical valves, 30 (83%) with atrial rhythm and contraction have been taken off anticoagulation therapy, including 10 who are free of all medication.

CONCLUSIONS

The results suggest that the combined approach is safe, effective, and indicated in patients who are judged capable of tolerating the procedure and likely to regain atrial rhythm.