[Sudden syncope during spinal block under sitting position: a report of three cases]

We reported 3 cases of sudden syncope during saddle block under sitting position. Patients were healthy and had no history of fainting. Syncope occurred following hypotension and bradycardia during difficult lumbar dural punctures under sitting position. Patients were treated successfully by changing position to supine, elevating both legs and giving vasopressors. Neurocardiac syncope due to the activation of afferent cardiac C-fiber has been suggested as a possible explanation in sudden syncope, which follows head-up position or emotional change. The first sign of syncope was hypotension and bradycardia due to cardiac C-fiber reflex. How to prevent this NCS under saddle block are as follows; 1. vigorous search for history of syncope, 2. pay attention to the patients during spinal tap, 3. skillful technique in spinal tap, and 4. proper premedication including anticholinergic agents. Treatments include 1. changing position to supine, 2. elevation of both legs to increase ventricular end-diastolic pressure, and 3. use of vasopressors including phenylephrine.

Angiotensin I-converting enzyme insertion/deletion polymorphism: potential significance in nephrology

Angiotensin I-converting enzyme (ACE) plays a pivotal role in cardiovascular homeostasis and by activating angiotensin I into angiotensin II and inactivating bradykinin. These two peptides play antagonistic roles on the cardiovascular system by regulating vascular tone and vascular smooth muscle cell proliferation. Identification of the ACE gene as a genetic marker for various forms of cardiovascular disease is a recent result of the progress made in molecular biology and genetics. The insertion/deletion (ID) polymorphism of the ACE gene defined by the presence or absence of the 287 base pair Alu sequence situated in intron 16 has been investigated as a possible genetic marker for a variety of cardiovascular disease including myocardial infarction, essential hypertension, cardiomyopathy, and diabetic vascular complications. This paper reviews prior reports and briefly describes our recent study on the association of the ACE I/D polymorphism and antiproteinuric effect of ACE inhibitors in patients with proteinuria.

[MR imaging for breast cancer]

The potential role of magnetic resonance (MR) imaging in the diagnosis of breast disease has been investigated since the late 1970s. Conventional MR imaging has not been reliable for diagnosis of breast masses, and so contrast MRI using Gd-DTPA has been performed. In particular the gradient echo (GRE) technique combined with administration Gd-DTPA (i.e., dynamic MRI) improves detection and tissue characterization of breast masses. In recent studies, breast MR imaging has shown up to 100% sensitivity in the detection of breast cancer. On the other hand, its specificity varies between 37% and 98% because of the fact that may benign lesions are also enhanced with many contrast media, similar to breast cancer. To improve the specificity of MR imaging, MR-guiding localization and fine needle aspiration biopsy for breast masses will be necessary. Recently breast conserving therapy has been widely accepted in our country, so we deduce that MRI is useful method for detecting multifocal or multicentric breast cancer.

Fibroblasts synthesize kininogen in response to inflammatory mediators

Mouse fibroblasts in vitro secret kininogen (KGN). Rat fibroblasts also synthesized and secreted T-KGN in vitro. KGN production by these fibroblasts is greatly stimulated by dibutyryl cAMP, prostaglandin E2 and tumor necrosis factor. Human fibroblast WI-38 cells also express the L-KGN gene, which was stimulated by dibutyryl cAMP and prostaglandin E2. These results demonstrate that fibroblasts express the KGN gene, and suggest that the expression is regulated by inflammatory mediators. RT-PCR, using specific primers for the T-KGN and L-KGN genes, reveals that the rat hind-paw express both T- and L-KGN mRNAs, and the expression of both KGN mRNAs was increased in the hind-paw 24 h after inducing inflammation by injecting Freund's complete adjuvant into the paw. Thus, it is suggested that local connective tissues express the KGN gene, and that the expression is enhanced under pathological conditions, such as inflammation.

[Assessment of cochlear functions of patients with acoustic neuromas]

Electrocochleographic cochlear microphonics (ECochG-CM) and Evoked Otoacoustic Emissions (EOAE) were recorded for 17 patients with acoustic neuromas to assess their cochlear functions. ECochG-CM was recorded by a transtympanic needle electrode technique. The acoustic stimuli of EOAE were short tone bursts and thresholds of detection of the slow components were determined. In 13 of the 17 patients, elevated detection thresholds of ECochG-CM and/or abnormal interaural differences in detection thresholds of the slow components of EOAE were observed. The patients with hearing loss and an elevated thresholds of CM were believed to have cochlear impairments. Those with hearing loss and a relatively low detection threshold of CM were thought to have cochlear nerve damage and a smaller degree of cochlear impairment. The correlation of ECochG-CM and EAOE was 0.799. Both ECochG-CM and EOAE were useful in evaluating the cochlear functions of patients with acoustic neuromas. Although EOAE was easier to apply clinically, ECochG was indispensable when detailed examinations of cochlear functions were necessary.

A long-range physical map of human chromosome 21q22.1 band from the YAC continuum

The human Chromosome (Chr) 21q22.1 region contains several genes for cytokines and neurotransmitters and the gene for superoxide dismutase (mutant forms of which can cause familial amyotrophic lateral sclerosis). A region of approximately 5.8 Mb encompassing D21S82 and the glycinamide ribonucleotide transformylase (GART) loci was covered by overlapping YAC clones, which were contiguously ordered by clone walking with sequence-tagged site (STSs). A total of 76 markers, including 29 YAC end-specific STSs, were unambiguously ordered in this 5.8-Mb region, and the average interval between markers was 76 kb. Restriction maps of the YAC clones with rare-cutting enzymes were simultaneously prepared, and the restriction sites were aligned to obtain a consensus restriction map of the proximal region of the 21q22.1 band. The restriction map made from 44 overlapping YACs contains 54 physically assigned STSs. By integrating the consensus map of the adjacent 1.8-Mb region, we obtained a fine physical map spanning 6.5 Mb of human Chr 21q22.1. This map contains 24 precisely positioned end-specific STSs and 12 NotI-linking markers. More than 39 potential CpG islands were identified in this region and were found to be unevenly distributed. This physical map and the YACs should be useful as a reference map and as a resource for further structural analysis of the Giemsa-negative band (R-band) of Chr 21q22.1.

[The long-term results of the irradiation therapy for the dural arteriovenous malformation]

Although radiotherapy has been used to treat non-neoplastic vascular diseases, it is not widely accepted as a standardized treatment for dural arteriovenous malformations (DAVM). The uncertainties regarding the therapeutic outcome and the benign nature of DAVM are the major factors that limit the indication of radiotherapy. In an attempt to assess the long-term benefits and risks of the treatment, we analyzed 24 patients with DAVM treated with radiotherapy. The cavernous sinuses were involved in 12 and the transversesigmoid sinuses in 12. Doses ranging from 10 to 56 Gy (median 44.9 Gy) were delivered by multiple fractionation. In terms of clinical improvement, complete response was achieved in 19 patients and partial response in five. Four patients had recurrence of symptoms; two patients were reirradiated with the result of good symptomatic relief, one patient was successfully treated with transarterial embolization and the other patient with less disabling symptoms was managed conservatively. No adverse side effects attributed to radiation were encountered during the follow-up period of 0.5-17 years (median 8.5 years). Radiotherapy is a safe and effective method for the treatment of DAVM and is warranted in patients who are unsuitable for transarterial embolization or surgical procedure.

The effect of ultra-low sodium dialysate in CAPD. A kinetic and clinical analysis

In peritoneal dialysis, sodium (Na) passes through the peritoneal membrane to a lesser extent than H2O and thus hypotonic fluid is removed indicating that Na removal is inefficient. Therefore we developed an ultra-low Na dialysate (ULNaD) [Na 98 mmol/liter, osmolality 340 mOsm/kg, glucose (G), 2.48%] to facilitate trans-peritoneal Na removal. The aim of the study was to examine (a) the fluid and Na kinetics of this solution, and (b) the clinical effect in the overhydrated patient. Regarding the former, in six cases, changes in the effluent Na levels during a 240-minute dwell of ULNaD were measured at 60-minute intervals. In eighteen cases, the transperitoneal net-Na removal (Na removal) and drained ultrafiltration (UF) volume after a 240-minute dwell of ULNaD were measured and compared to two types of standard Na dialysate (SNaD) [Na 132 mmol/liter, 1.36% G (348 mOsm/kg) and 2.27% G (396 mOsm/kg)]. The effluent Na levels increased gradually until the end of the dwelling. Drained UF volume of ULNaD (224 +/- 25 ml) was more than 1.36% G SNaD (77 +/- 33 ml, p < 0.01), but it was less than 2.27% G SNaD (341 +/- 32 ml, p < 0.01). However, a significant increase in Na removal by ULNaD (78.1 +/- 5.6 mmol) was found compared with both SNaD solutions (12.6 +/- 6.4 mmol in 1.36% G solution, p < 0.001; 27.8 +/- 5.1 mmol in 2.27% G solution, p < 0.001, respectively). Regarding the latter study aim, in six overhydrated patients with a Na excess, SNaD was replaced with ULNaD once a day for 7 consecutive days. At the end of the study as compared to the pre-values, a significant reduction in body weight (-2.5 +/- 1.0%, p < 0.05) and mean arterial pressure (-12.3 +/- 3.5%, p < 0.001) was observed. An increased drainage of daily UF volume (+86.5 +/- 31.1%, p < 0.05) and a markedly increased daily Na removal (+131.1 +/- 24.2%, p < 0.01) were also observed. The results of this study suggest that ULNaD actually facilitates trans-peritoneal Na removal mainly by diffusion force, and that ULNaD could benefit overhydrated patients with a Na excess.

A low-affinity vasopressin V2-receptor gene in a kindred with X-linked nephrogenic diabetes insipidus

In this study, a mutation in vasopressin Type 2 receptor (V2R) in a patient with hereditary nephrogenic diabetes insipidus (NDI) has been identified and characterized. The sequencing of the V2R gene from the patient revealed that there was a missense mutation (TAT to TGT) resulting in the substitution of 205Tyr for Cys in the putative third extracellular domain. The expression analysis in COS cells showed that the binding affinity of the mutant receptor (KD = 19.8 nM) for arginine vasopressin was much lower than that of the wild-type receptor (KD = 1.8 nM) so that intracellular cAMP production stimulated by arginine vasopressin was impaired in cells with the mutant V2R. From these results, it was concluded that the single amino-acid substitution of V2R is responsible for this familial disease.

Effect of induced hypertension with angiotensin II infusion on biodistribution of 111in-labeled monoclonal antibody

We investigated whether induced hypertension could enhance tumor uptake of monoclonal antibody. 111In-DTPA-A7 (IgG1 against 40kD tumor associated glycoprotein) was injected into colon carcinoma xenografted mice which were subcutaneously implanted with micro-osmotic pump containing angiotensin II (AT-II). Biodistribution was observed in groups of mice infused with AT-II at rate of 0.5 micrograms/kg/min (L) or 1 microgram/kg/min (H) and compared with a group of mice infused with saline (S). Tumor uptake of 111In-A7 in L and H was 1.32 and 1.57 times greater than S at 48 h after intravenous injection of A7. Normal organ uptakes also tended to be increased by AT-II infusion. Further study is needed to get optimum effect of hypertensive treatment on biodistribution of radiolabeled MoAb.

Changes in the distribution of nerve conduction velocities in diabetics

To examine which of the faster or slower large myelinated nerve fibers (alpha fiber group) are affected earlier by diabetes mellitus (DM), the distribution of nerve conduction velocities (DCV) and conventional sensory nerve conduction velocities (SCV) in the median nerve were measured in 10 male DM patients aged 35-58 (mean 50) years. The patients had suffered from DM for 0-30 (mean 11) years; their fasting blood sugar (FBS) levels were 105-363 (mean 219) mg/100 ml. The DCV was expressed by the conduction velocities below which 10, 20, ......, 80 and 90% of active fibers lie (V10, V20, ......, V80 and V90 velocities, respectively). In DM patients, the V30 to V90 velocities of the DCV as well as the SCV were significantly smaller than those of age-matched male controls. The results of multiple regression analysis indicated that FBS was inversely related to V50 to V90 velocities; duration of the disease was also significantly related to V80 and V90 velocities. These data suggest that faster nerve fibers are more susceptible to DM than slower fibers are; changes in conduction velocities of the faster fibers are closely associated with FBS and duration of DM.

201Tl and 99Tcm-human serum albumin for assessment of the effect of hypertensive treatment with angiotensin II infusion on tumour circulation

The biodistribution of 201Tl and of 99Tcm-human serum albumin (99Tcm-HSA) was observed in tumour-bearing mice to investigate if tissue blood circulation could be evaluated in groups of mice infused with angiotensin II at a rate of 0.5 micrograms kg-1 min-1 (L) or 1 microgram kg-1 min-1 (H). Ten minutes after tracer injection, tumour uptake of 201Tl in the angiotensin II infused group showed a 2.20- and a 3.18-fold increase in the L and H groups, respectively, when compared to a group of mice infused with saline (P = 0.0478 and 0.0029, respectively). The effect of angiotensin II infusion on 201Tl uptake was minimal in normal organs. Decreased normal organ uptake of simultaneously injected 99Tcm-HSA in the L and H groups indicated the contraction of normal organ vessels, while increased tumour uptake of the tracer indicated mechanical dilatation of tumour vessels. We conclude that the effect of angiotensin II or other vasoactive agents can be non-invasively assessed by 201Tl and 99Tcm-HSA scintigraphy.

Displacement of the endotracheal tube caused by change of head position in pediatric anesthesia: evaluation by fiberoptic bronchoscopy

Displacement of the endotracheal tube (ETT) caused by flexion and extension of the neck and the placement of a tongue depressor was investigated in 10 small children between the ages of 16 and 19 mo by means of a fiberoptic bronchoscope. The ETT tip moved a mean distance of 0.9 cm toward the carina with flexion and 1.7 cm toward the vocal cords with extension of the neck. After the placement of a tongue depressor, the ETT tip, which had once moved toward the vocal cords with neck extension, was displaced a mean distance of 1.2 cm toward the carina. Our results demonstrate that endobronchial intubation and accidental extubation could occur after significant changes of the head position and careless placement of a tongue depressor in small children.

Scintigraphic study of malignant melanoma with 123I-iodoamphetamine

N-isopropyl-p-I-123-iodoamphetamine (123I-IMP) is extracted by the brain in proportion to regional blood flow. It is particularly useful in the clinical assessment of various pathological conditions related to altered cerebral flow. Moreover, it has been reported that 123I-IMP is avidly incorporated into melanin and melanotic melanoma. We evaluated 123I-IMP scintigraphy using either planar or single photon emission tomography (SPET) studies in 10 patients with malignant melanoma. The patients were classified into two groups according to the tumour site: Group A, six patients with primary or metastatic cutaneous malignant melanoma of the extremity with planar scintigraphy; Group B, four patients with primary malignant melanoma of other organs with planar scintigraphy and SPET. In Group A, tumour uptake was demonstrated in four of six patients; in Group B, three of four patients had tumour accumulation on SPET and planar scintigraphy. SPET revealed the exact tumour localization, even in the case of a tumour located in the lung. These results suggest that planar scintigraphy using 123I-IMP is useful in the detection of malignant melanoma. Furthermore, more clear tumour localization is possible with SPET, even in the case of a tumour located in the lung.

Effects of granulocyte-macrophage colony-stimulating factor on the levels of VLDL and LDL receptor mRNAs in vivo

We investigated the mechanism by which granulocyte-macrophage colony-stimulating factor (GM-CSF) lowers plasma cholesterol levels. Recombinant human GM-CSF (rhGM-CSF) was administered to normal and Watanabe heritable hyperlipidemic (WHHL) rabbits. Treatment with rhGM-CSF reduced the levels of cholesterol and triglyceride in these animals. In vitro colony assay for hematopoietic progenitors indicated that rhGM-CSF was capable of supporting granulocyte-macrophage colony formation in rabbits, suggesting that rhGM-CSF stimulates macrophage function even in rabbits. Northern blot analysis of rabbit very-low density lipoprotein (VLDL) receptor showed that rhGM-CSF elevated the levels of VLDL receptor mRNA 2.6- and 1.8-fold in muscles of normal WHHL rabbits, respectively, 1.5 hours after a single injection. Increases of 1.5- and 1.4-fold were observed in muscles of these rabbits after 5 days of administration. No changes were found in the LDL receptor mRNA levels in liver, spleen or bone marrow. These findings show that the lowering of lipids by GM-CSF may be mediated through the up-regulation of the VLDL receptor mRNA and the enhancement of macrophage function.

A potential use of a monoclonal antibody to placental alkaline phosphatase (PLAP) to detect lymph node metastases of seminoma

PURPOSE

To evaluate the ability of monoclonal antibodies against alkaline phosphatase (AL-P) for tumor immunolocalization in nude mice.

MATERIALS AND METHODS

Two monoclonal antibodies against placental alkaline phosphatase (PLAP) and liver alkaline phosphatase (LAP) were intravenously administered to nude mice bearing AL-P producing HeLa Hep 2 tumors. Sera and tumors from 65 patients with testicular germ cell tumors were examined for PLAP levels.

RESULTS

Levels of PLAP or LAP in the HeLa xenografts were shown to be comparable to levels of PLAP in seminomas, including lymph node metastases, or nonseminomas, respectively. A biodistribution study showed that the percentage of the injected dose of I-125 labelled anti-PLAP in the xenografts was rather constant at around 7% until 7 days after injection, while the percentage of the injected dose of I-125 labelled anti-LAP MAb decreased with time as in other tissues which do not contain significant amounts of PLAP or LAP. On scintiscan, the xenografts in nude mice were distinctly visualized at 7 days after injection of anti-PLAP MAb.

CONCLUSIONS

These data may support the potential use of the anti-PLAP MAb for the immunodetection of lymph node metastases of seminoma.

Accumulation of VDT work-related visual fatigue assessed by visual evoked potential, near point distance and critical flicker fusion

To confirm daily accumulation of visual fatigue induced by work with visual display terminals (VDT), visual evoked potential (VEP), near point distance (NPD) and critical flicker fusion (CFF) were measured in three VDT workers and three sex- and age-matched controls (non-VDT workers) in the morning, noontime and evening for five consecutive days (Monday to Friday), totally 15 times per subject. The workers had been engaged in wireless handling operation, with VDTs, of an unmanned power shovel (Worker 1), an unmanned 78-ton dump truck (Worker 2) and mobile monitor-cameras (Worker 3), for 10 months. Their working hours were about 6.5 hours per day; but, the Worker 2 could take a 10-minute recess (a period without VDT work) per about 30 minutes during working hours. Significant daily variations in the VEP latency, NPD and CFF were found in the Worker 1 or Worker 3 despite the absence of any significant daily or diurnal variations in the non-VDT workers; the trends in the variations were getting worse from Monday to Friday. The NPD in the VDT workers was significantly longer than that in each of the matched controls; also, the CFF in the Workers 1 and 3 was significantly depressed. The changes in the VEP latency from morning to noontime and in the NPD and CFF from noontime to evening were significantly larger in the VDT worker than in the matched control. These findings suggest that VDT work probably affects visual function assessed by the VEP, NPD and CFF. Visual fatigue due to long-term VDT work may tend to be accumulated day by day.

1.8-megabases fine physical map encompassing IFNAR and AML1 loci on human chromosome 21q22.1

A long-range restriction map of the 1.8-megabases (mb) region encompassing the area between the interferon-alpha receptor and the acute myelogenous leukemia loci on human chromosome 21q22.1 was constructed after analysis of both the contiguous yeast artificial chromosome (YAC) clones and genomic DNA. Analysis of pulsed-field gel electrophoresis of lymphoblastoid DNA digested with three rare-cutting enzymes, Not I, Mlu I, and Nru I, revealed the positions of 17 markers on each restriction map. The 1.8-mb YAC contig that covers this region was obtained through YAC walking mediated by sequence-tagged sites (STSs), with 29 STSs including 12 newly generated YAC end-specific STSs. The consensus restriction map from 15 overlapping YACs and the positioning of the STS markers on each clone allowed 24 markers including 4 Not I-linking STSs to be ordered and mapped physically. Comparison of the maps revealed that the proximal region contains more unmethylated CpG islands than the distal region, which suggests that many expressed genes are in the proximal region. This fine consensus physical map will be informative and useful for construction of contigs of cosmid, P1, or BAC clones for further large-scale sequencing in this gene-rich region.

[A case of virus-associated hemophagocytic syndrome (VAHS) complicated by rhabdomyolysis which were associated with herpes-simplex virus infection]

A 60-year-old male was admitted to our hospital complaining abdominal pain and fatigue. Complete blood count showed as follows; WBC 3,900/microliters (48% of monocytes), Hb 11.5 g/dl, Plt 0.9 x 10(4)/microliters. Marrow smears showed the presence of phagocytic histiocytes that consist 22.4% of total nuclear cells. Laboratory findings showed as follows; BUN 109.5 mg/dl, Creatinine 7.4 mg/dl, CPK 1,259 IU/l, Aldolase 195 IU/l, Myoglobin 4,200 mg/dl. Serological studies showed a 16-fold increase in herpes-simplex virus (HSV) antibody titers 4 weeks after admission. So we diagnosed his illness as virus-associated hemophagocytic syndrome (VAHS) and rhabdomyolysis that were associated with HSV. We performed three times of hemodialysis for acute renal failure and used prednisolone for VAHS. These treatments were successful, and he made a complete recovery from illness. VAHS complicated by rhabdomyolysis is very rare, and we think this case is full of suggestions.

A case of nephrotic syndrome developing during postoperative gamma interferon therapy for renal cell carcinoma

A 70-year-old man developed minimal-change nephrotic syndrome and acute interstitial nephritis while undergoing gamma interferon therapy following right nephrectomy for renal cell carcinoma. It appears that gamma interferon as well as renal cell carcinoma may have played a role as etiologic factors in this nephropathy. We report this extremely rare case of renal cell carcinoma complicated by minimal-change nephrotic syndrome and acute interstitial nephritis, and present a review of the literature.

Closed intramedullary osteotomy for rotational deformity after long bone fractures

Ten patients with rotational deformities after fractures of the femur or tibia were treated by closed intramedullary osteotomy. Eight had an external rotation deformity of the femur and 2 had deformities of the tibia. The rotational deformity varied from 30 degrees to 60 degrees and 6 patients had shortening of 15 mm to 30 mm. The osteotomies were carried out with an intramedullary saw and were fixed by an interlocking nailing. Shortening was corrected at the same time. At follow up the average rotational deformity was less than 5 degrees and shortening less than 15 mm. All the patients felt that they had a normal range of movement and equal length. There were no complications, except for one case of delayed union in which consolidation occurred at 24 months without any further procedures.