Direct hemoperfusion under infrahepatic inferior vena caval isolation for the intraarterial chemotherapy of pelvic tumors

A new simple technique consisting of direct hemoperfusion under infrahepatic inferior vena caval isolation for intraarterial chemotherapy of pelvic tumors is herein described. The inferior vena cava is occluded at the infrahepatic level by means of balloon inflation using a balloon-tipped catheter (16F), which is placed through the right greater saphenous vein. The isolated infrahepatic vena caval blood is withdrawn by a centrifugal pump through a catheter (16F) in the contralateral greater saphenous vein and is filtered by direct hemoperfusion during intraarterial infusion of anticancer drugs. Venous reentry is provided by the central lumen of the balloon-tipped catheter. This procedure was used sequentially on two different occasions to treat a patient with an extensive pelvic tumor. Good hemodynamic stability and a reduction of the systemic drug toxicities were confirmed in both trials. Therefore, we believe that this technique is technically feasible and highly effective in reducing systemic toxicities during high-dose intraarterial chemotherapy for pelvic tumors.

Diminished erythropoietin-induced erythroid growth in patients with renal anemia is restored by recombinant human erythroid differentiation factor

An examination of the in vitro sensitivity of marrow burst-forming units for erythroid (BFU-E) to various concentrations of human recombinant erythropoietin (rEpo) and interleukin-3 (IL-3, 20 ng/mL) in serum-deprived methylcellulose cultures revealed that cells obtained from patients with chronic renal failure showed a defective response to rEpo, particularly at lower concentrations. This poor response was not corrected by the addition of neutralizing antibodies to antitumor necrosis factor-alpha or antiinterleukin-1 alpha/beta. When purified CD34+ cells from these patients were tested for dose-dependent growth to rEpo, the curve resembled that of normal donors, indicating that there was an intrinsic defect in the patients' progenitor/accessory cell interactions. Using unseparated cells from the patients, we then tested whether the interaction between erythroid differentiation factor (EDF) and rEpo affected BFU-E growth. Although EDF, either alone or in combination with IL-3, did not affect the growth of BFU-E in the absence of rEpo, the reduced sensitivity to rEpo in the patients was brought closer to normal limits by the addition of 10 ng/mL EDF to the cultures. The present results may suggest the possibility that, in patients with renal anemia, concomitant administration of EDF may increase the therapeutic ratio of rEpo therapy by enhancing the sensitivity of progenitor cells to rEpo, thereby decreasing the therapeutic dose of costly rEpo.

Astrocytic contribution to functioning synapse formation estimated by spontaneous neuronal intracellular Ca2+ oscillations

Glial contribution to in vitro synaptic function was investigated in a neuron-glia co-culture system by monitoring spontaneous oscillations of intracellular Ca2+ in neurons. Rat cortical neurons, grown stably on a cortical astrocyte monolayer, extended neurites resulting in marked functional synapse formation. Little synapse formation was observed in neuronal co-culture with meningeal fibroblasts or endothelial cells. Aged astrocytes in vitro (C35) were found to attenuate synaptic development, while young astrocytes (C5) markedly promoted synaptic function. C5 and C35 astrocyte media conditioned yielded no significant synaptogenic effect, indicating diffusible factor(s) are not responsible for our observation. Modulation of astrocytic proliferation and differentiation by gliostatin, a glial growth inhibitor, or dibutyryl cAMP affected neuronal synaptic function on the co-cultures. Site-specific analysis in homologous and heterologous neuron-astrocyte co-cultures among cortex, hippocampus, septum, and striatum revealed that homologous combinations of neurons and astrocytes derived from identical brain regions elicited the largest number of synchronizing neurons. These results suggest that in vivo neuronal synaptic function essentially requires the participation of adjacent astrocytes, which is site-specific and age-dependent.

Molecular analysis of abnormal pyruvate dehydrogenase in a patient with thiamine-responsive congenital lactic acidemia

A patient who responded to thiamine therapy with reduction of lactate in the blood and cerebrospinal fluid and clinical improvement was studied. Cultured lymphoblastoid cells of this patient were found to show reduced activities of pyruvate dehydrogenase complex (PDHC) and pyruvate dehydrogenase, decreased affinity of PDHC for thiamine pyrophosphate, and defective activation of PDHC by pyruvate dehydrogenase phosphatase. PDHC deficiency in fibroblasts and biopsied muscle of this patient was also due to the decreased affinity of PDHC for thiamine pyrophosphate. A mutation in the E1 alpha subunit containing the thiamine binding site and serine phosphorylation site regulating the activation/inactivation of PDHC was characterized by the polymerase chain reaction and DNA sequencing. A single A-->G transition was identified at position 131, resulting in the substitution of Arg-44 for His-44. This mutation must be a de novo mutation because it was not found in either parent's genomic DNA. In this study, we have obtained the first evidence at the molecular level for a mutation of thiamine-responsive PDHC deficiency.

[A new method of high-dose intraarterial chemotherapy of the pancreas using direct hemoperfusion (DHP) under portal venous isolation (PVI)]

Surgical resection for pancreatic cancer is severely limited by the extent of the disease at the time of diagnosis. Chemotherapy has been the treatment of choice for unresectable cases. We developed a new method of intraarterial chemotherapy for pancreatic body and tail cancers using direct hemoperfusion (DHP) under portal venous isolation (PVI). Adriamycin (ADR, 3 mg/kg) was infused into the splenic arteries of mongrel dogs for 5 min after clamping off blood flow to the stomach and the duodenum. In group A (n = 5), this was simply done, and in group B (n = 5) the portal venous blood was isolated by clamping at the porta hepatis and pumped through the DHP circuit to the jugular vein for 20 min from the start of drug infusion. The peak systemic level (microgram/ml) of group B (0.78 +/- 0.03) was significantly reduced by PVI.DHP as compared to that of group A (3.49 +/- 1.15, P < 0.01). The pancreatic tissue levels (microgram/g. tissue) 30 min after drug infusion of group A (61.2 +/- 13.4) were slightly lower than those in group B (88.9 +/- 27.8), although not statistically significant. However, tissue levels of group B in the liver (27.3 +/- 9.2) and heart (1.8 +/- 0.8) were significantly lower than those of group A (liver; 52.3 +/- 18.5, heart; 4.9 +/- 0.6, P < 0.05). In conclusion, PVI.DHP achieved a significant reduction in systemic drug exposure during intraarterial chemotherapy. Therefore, we consider that this system will allow dose escalation of ADR during intraarterial chemotherapy for pancreatic body and tail cancers.

Hyperuricemia in an infant with Taussig-Bing anomaly and interruption of the aortic arch

Hyperuricemia is commonly recognized in adolescents and adults with cyanotic congenital heart disease. We report a case of a male infant with hyperuricemia, Taussig-Bing anomaly, and interruption of the aortic arch. The patient underwent correction of interrupted aortic arch and pulmonary arterial banding at the age of 7 days. Hyperuricemia appeared when he was 2 months old (max 17.7 mg/dl) and persisted until he underwent a Jatene operation at the age of 10 months. The hyperuricemia improved gradually after the disappearance of hypoxia and polycythemia. The laboratory findings suggest that hyperuricemia can result from uric acid overproduction due to secondary polycythemia, impairment of uric acid excretion by the kidney, or the acceleration of anaerobic metabolism. Allopurinol and benzbromarone together were partially effective treatments for hyperuricemia in this patient with cyanotic congenital heart disease.

Infantile spasms: localized cerebral lesions on SPECT

Ten infantile spasms (IS) patients had single photon emission computed tomography (SPECT) with [99mTc]HMPAO, EEG, and magnetic resonance imaging (MRI) studies. SPECT showed localized cerebral hypoperfusion in 7 infants (4 unifocal; 3 multifocal) always involving the temporal regions either unilaterally or bilaterally. EEGs obtained in near time of the SPECT studies showed focal abnormalities in all 7 infants with hypoperfusion on SPECT, with complete correspondence of the abnormalities in 5. MRI showed localized cerebral lesions in only 3 of the 10 infants, all of whom had corresponding areas of hypoperfusion on SPECT. Our study indicates that localized cerebral abnormalities (especially of the temporal lobes) may often be associated with IS and that such patients may have localized cerebral hypoperfusion on SPECT even when the MRI is normal.

Synergy among erythropoietin, interleukin 3, stem cell factor (c-kit ligand) and interferon-gamma on early human hematopoiesis

The stimulatory effect of interferon-gamma (IFN-gamma) on human early hematopoiesis was investigated using CD34+ cells that were purified from peripheral blood as a target. In the presence of human interleukin 3 (IL-3) and stem cell factor (SCF), the growth of colony forming units for granulocyte/macrophage (CFU-GM) in serum-free methylcellulose culture was enhanced up to 5.5-fold over baseline colony formation (n = 10, mean +/- SE, 3.18 +/- 1.00) by coculture with 2.5 x 10(3) U/ml IFN-gamma, whereas burst forming units-erythroid (BFU-E) growth induced by additional erythropoietin (Epo) was reduced dose-dependently. Liquid-suspension culture of the target cells for 24 h with IFN-gamma before secondary plating in serum-free methylcellulose resulted in a marked increase in the colony numbers; 3.62 +/- 1.04-fold for CFU-GM and 5.72 +/- 2.32-fold for BFU-E (n = 5). The effect was most striking in the growth of erythroid lineage supported by Epo alone in serum-free culture. Delayed addition of IFN-gamma between days 4 and 7 of methylcellulose culture suppressed CFU-GM growth, but not that of BFU-E. These results suggest that IFN-gamma is an essential cytokine that affects human hematopoiesis and exerts a bimodal effect on stem cell maturation; potentiating or replacing the effect of early-acting cytokines such as SCF or IL-3, and suppressing the growth of matured progenitor cells.

Serial EEG and sleep polygraphic studies on lissencephaly (agyria-pachygyria)

We carried out serial EEG studies on 12 cases of lissencephaly (6 of agyria and 6 of pachygyria), polysomnograms being recorded in 8 of the 12 cases. Fourteen Hz sleep spindles appeared from early infancy in all cases. They were poorly observed after the age of 1 year, and 5-11 Hz high-amplitude rhythmic activity (HARA) of more than 300 microV appeared predominantly in place of the 14 Hz spindles. Both the 14 Hz spindles and HARA showed asymmetry, but the dominant cerebral area for both types of waves was much the same. Four of the 6 agyria cases showed hypsarrhythmia within the first 6 months after birth, 3 of the 4 cases showing asymmetric hypsarrhythmia at first. Their hypsarrhythmia consisted of very high-voltage 5-7 Hz slow sharp waves and delta waves. The EEG abnormalities transformed from hypsarrhythmia to focal spikes in the 6 pachygyria cases. The polygraphic study on 8 cases revealed that the proportion of REM sleep decreased in 3 cases and the REMs/min values decreased in 7. Infantile spasms occurred in 4 of the 8 cases. The REM/min values decreased in all of these 4 cases, and, furthermore, the proportion of REM sleep decreased in 3 of the 4 cases. These findings suggest that lissencephaly involves a disorder of the brainstem, and that the combination of brainstem lesions and severe cerebral dysplasia is important for the manifestation of infantile spasms in lissencephaly.

Importance of recall and follow-up screening for chronic hepatitis C in children receiving blood products prior to 1990 in Japan

The objective was to detect chronic hepatitis C virus infection in recipients of blood products using retrospective analysis by recall and enrollment of recipients. 226 patients who received blood products for open heart surgery from January 1983 to June 1992 were examined for HCV antibody by using a second generation assay and liver function test. 22 (14%) of the 161 patients who received blood products before November 1989 had detectable HCV antibody, but none of the 65 recipients receiving blood products after 1990, the year the Japanese blood bank began to screen for HCV-antibody. Abnormal alanine aminotransferase (ALT) levels, more than 25 iu/L, during the chronic phase of HCV infection was recognized in nine of 22 (41%) seropositive patients. The liver function test and second generation HCV antibody in the serum are effective markers to screen for chronic hepatitis C in blood product recipients transfused before 1990.

Cell processing protocol for allogeneic peripheral blood stem cells mobilized by granulocyte colony-stimulating factor

Although there is a growing body of information available regarding restoration of hematopoiesis with peripheral blood stem cell (PBSC) autografts, few studies have explored this procedure using allografts. In this study with healthy donors, we investigated the feasibility of a protocol for mobilizing PBSC using recombinant human granulocyte colony-stimulating factor (G-CSF) and subsequent bulk depletion of T cells from apheresis-harvested cells. Nine informed healthy donors were given G-CSF subcutaneously at two different dosing schedules (5 micrograms/kg/d in five donors and 2 micrograms/kg/d in four) for 5 consecutive days, and serial changes in blood components, including hematopoietic progenitor cells, were monitored. After 5 days of stimulation with G-CSF, PBSCs were collected by apheresis, and yields were compared. The number of white blood cells (WBC) reached a plateau level on either day 2 (5 micrograms) or 3 (2 micrograms), but the numbers of red blood cells and platelets were not affected. Circulating colony-forming unit-granulocyte/macrophage (CFU-GM) levels started to increase 1 or 2 days after the increase in the WBC count. By performing a 3L apheresis, the number of CFU-GM harvested was 4.6 +/- 3.3 x 10(6) (mean +/- standard error of the mean [SEM]) in the 5-micrograms group and 1.8 +/- 0.7 x 10(6) in the 2-micrograms group. Different procedures for depleting T cells, including the use of L-phenylalanine methyl ester (PME) and flasks coated with anti-CD5/CD8 monoclonal antibodies or neuraminidase-treated sheep red blood cells (SRBC), were also tested on the harvested cells. We found that cell lysis with PME before selective removal of T cells was very effective in reducing the number of cells that required further processing and was suitable for routine use. However, our current procedure resulted in unsatisfactory depletion of T cells (99.5% removal) while retaining hematopoietic progenitor cells (7.5% recovery). Further research is required in this area.

[A case of dementia associated with multiple iron deposits in the brain on MRI]

We report a 63-year-old man presenting with dementia and cerebellar ataxia associated with multiple iron deposits in the brain on MRI. Numerous small lesions of low-intensity on both T1- and T2-weighted images were found in the parenchyma and surface of the cerebrum, cerebellum and brain stem. The number and size of lesions were increased on MRI with the method of gradient recalled acquisition in the steady state (GRASS), indicating that they were composed of iron. The similar lesions were not found in any organs on the abdominal GRASS-MRI. Any abnormalities were also not found in the cerebral angiography. Meanwhile, the protein and IgG levels and activated CD4-cells were increased in the cerebrospinal fluid, indicating the involvement of chronic inflammation in the iron deposits in this case.

Cooperative deformation of a de novo designed protein

A de novo protein design has been made to understand the unique packing of natural proteins that have a beta/alpha-barrel fold. A carefully designed 207 amino acid sequence was synthesized using an Escherichia coli expression system and the structural and thermodynamic characteristics of the purified protein were studied. At neutral pH the protein is soluble and monomeric, with large amounts of secondary structure and a hydrophobic core, although the broad resonance peaks of its NMR spectrum suggest that the designed protein does not have a unique structure with tightly packed side chains. In an H-D exchange experiment, no amido protons of the designed protein exchanged slowly with deuterons. At acidic pH, thermal unfolding was observed with a remarkable change in the excess heat capacity measured directly by a differential scanning microcalorimeter. The enthalpy and entropy differences at 110 degrees C, extrapolated from analyzed thermodynamic parameters, are approximately 1/3 of the common values for natural proteins. These measurements indicate that the folding is significantly cooperative as expected, but that the protein is still loosely packed.

Immunoblastic lymphadenopathy in a five-month-old girl: successful treatment with immunosuppressants

A five-month-old girl developed high fever, erythema, hepatosplenomegaly and generalized lymphadenopathy. Laboratory examinations revealed elevated peripheral leukocyte counts, C-reactive protein, lactate dehydrogenase and serum ferritin level. Pathologic examination of the lymph nodes revealed immunoblastic lymphadenopathy (IBL) on the basis of the complete effacement of the normal architecture, replacement by a diffuse infiltrate composed of immunoblasts, plasmacytoid cells and small lymphocytes, and an abortive proliferation of blood vessels. B-cells and T-cells were nearly equally mixed throughout the lymph nodes. No rearrangements of the B-cell immunoglobulin and T-cell receptor genes were detected. The patient was initially treated with alpha-interferon with dramatic efficacy. After relapse, however, the disease was well controlled with cyclosporin A (CyA) and subsequently with combination regimens of CyA, deoxyspagarin and azathioprine with fair success. An alternating regimen of 6-mercaptopurine, cyclophosphamide and methotrexate was then instituted which continued the complete remission for 12 months. The effects of immunosuppressants in the treatment of IBL merit investigation.

Endoglycoceramidase treatment inhibits synchronous oscillations of intracellular Ca2+ in cultured cortical neurons

Gangliosides are major components of nerve cell membranes and are especially rich in synaptic areas. In order to evaluate the role of endogenous gangliosides in synapse formation, endoglycoceramidase (EGCase) was used to remove oligosaccharides of gangliosides from the cell surface. We have reported previously that synapse formation between cultured rat cerebral cortical neurons can be estimated by the synchronous oscillation of synaptic activity monitored by fura-2 calcium imaging. Continuous application of endoglycoceramidase (EGCase) together with its activator protein dose-dependently decreased the frequency of synchronous oscillations without any morphological changes in neurons and their neurites. The result suggests that oligosaccharides liberated from glycosphingolipids on cultured cortical cell surface with EGCase are important for synapse formation between cortical neurons.

Time course of oxygen uptake and heart rate during Bruce treadmill test in patients following surgery for tetralogy of Fallot

Exercise performance was examined in 14 patients with a prior history of surgical repair for tetralogy of Fallot. Using a Bruce protocol, we evaluated the time course of oxygen uptake and heart rate in these patients and compared them with a standard curve obtained from 63 sex- and age-matched healthy children. Five of the 14 patients had unusual findings. The heart rate increased rapidly in four of them, while the oxygen uptake increased gradually (95% confidence lower limit). It is hypothesized that a reduction in stroke volume during exercise was responsible for these abnormal findings. The remaining unusual finding was in a patient who was known to have myocardial fibrosis and vacuolization. In this particular case, the time course of oxygen uptake and heart rate were both below the 95% coefficient of variation from the beginning to the end of exercise. In patients who have undergone surgical repair for tetralogy of Fallot, the analysis of oxygen uptake time course and the heart rate may provide valuable information for the long-term follow-up.

[Neurophysiologic studies on patients with migration disorder]

Neurophysiologic studies on six patients (five lissencephaly and one schizencephaly) with migration disorder were performed in order to evaluate the CNS function by multimodality evoked potentials. All cases revealed abnormalities in SSEP, four cases lost components below P 3 or had low voltage of P 3 indicating brainstem dysfunction in the somatosensory pathway. Two cases lost component below N 1 indicating sensory cortical dysfunction. Three cases revealed ABR abnormalities including a low amplitude of wave V, and one case revealed a prolonged peak latency of wave I and a low amplitude of all components. Two cases revealed abnormalities of poor cortical components in SEP, two cases in VEP, and three cases in MLR. Five cases had normal findings in P-SEP and three cases in VEP. The result of this study demonstrates that patients with migration disorder are frequently associated with cortical, brainstem and peripheral dysfunctions and has heterogeneity in pathophysiology.

Ringed grafting for an abdominal aortic aneurysm in a 92-year-old patient: report of a case

We report herein the case of a 92-year-old man with an abdominal aortic aneurysm who underwent successful surgical resection using a ringed graft. His postoperative course was uneventful, and he was discharged after 42 days, following which he attended the outpatient department twice a month for regular check-ups. He finally died of pneumonia which developed from an upper respiratory tract infection 6 months after his operation. Thus, surgical treatment should always be considered when an aneurysm is detected, even in very aged patients for whom the activities of daily living are possible.

Splenectomy for treatment of immunoblastic lymphadenopathy

A 5-month-old girl was diagnosed with immunoblastic lymphadenopathy (IBL) on the basis of clinical symptoms and pathological findings. alpha-interferon, immunosuppressive agents such as cyclosporin A, deoxyspagarine, and azathioprine, and an alternating regimen of low-dose 6-mercaptopurine, cyclophosphamide and methotrexate were tried with partial success. Finally, splenectomy was carried out at 58 months of age, inducing prolonged complete remission without any medication.

Effect of neuroprotective N-methyl-D-aspartate antagonists on increased intracranial pressure: studies in the rat acute subdural hematoma model

Glutamate antagonists are the most powerful neuroprotective drugs in laboratory studies of focal cerebral ischemia. Because the majority of clinical conditions in which focal brain ischemia occurs are associated with high intracranial pressure (ICP), we have used the rat acute subdural hematoma model to evaluate the effects of three glutamate N-methyl-D-aspartate antagonists, MK-801, CGS 19755 (SELFOTEL), D-CPP-ene, and mannitol, upon ICP and also upon the volume of ischemic brain damage. Only mannitol produced a significant reduction in ICP and improved cerebral perfusion pressure. The three glutamate antagonists did not significantly affect ICP or cerebral perfusion pressure, but they were associated with a significantly smaller zone of focal brain damage, when compared to the mannitol and saline groups. N-methyl-D-aspartate antagonists do not increase ICP or jeopardize cerebral perfusion pressure when administered under anesthesia with a controlled PaCO2 level. Further studies in humans are indicated.

Tianeptine decreases both serotonin transporter mRNA and binding sites in rat brain

In situ hybridization histochemistry and quantitative autoradiography were used to evaluate the effects of repeated administration of the serotonin reuptake enhancer, tianeptine. Tianeptine (10 mg/kg twice daily, for 14 days) significantly reduced both the expression of serotonin transporter mRNA and serotonin transporter binding sites labeled by [3H]paroxetine in rat dorsal raphe nucleus. In median raphe nucleus, tianeptine did not change either expression of serotonin transporter mRNA or binding. This effect, which is similar to a reported effect for serotonin reuptake inhibitors, may help to explain the antidepressant effect of tianeptine.