Role of controlled cardiac reoxygenation in reducing nitric oxide production and cardiac oxidant damage in cyanotic infantile hearts

Cardiopulmonary bypass (CPB) is used increasingly to correct cyanotic heart defects during early infancy, but myocardial dysfunction is often seen after surgical repair. This study evaluates whether starting CPB at a conventional, hyperoxic pO2 causes an "unintentional" reoxygenation (ReO2) injury. We subjected 2-wk-old piglets to ventilator hypoxemia (FIO2 approximately 0.06, pO2 approximately 25 mmHg) followed by 5 min of ReO2 on CPB before instituting cardioplegia. CPB was begun in hypoxemic piglets by either abrupt ReO2 at a pO2 of 400 mmHg (standard clinical practice) or by maintaining pO2 approximately 25 mmHg on CPB until controlling ReO2 with blood cardioplegic arrest. The effects of abrupt vs. gradual ReO2 without surgical ischemia (blood cardioplegia) were also compared. Myocardial nitric oxide (NO) production (chemiluminescence measurements of NO2- + NO3-) and conjugated diene (CD) generation (spectrophotometric A233 measurements of lipid extracts) using aortic and coronary sinus blood samples were assessed during cardioplegic induction. 30 min after CPB, left ventricular end-systolic elastance (Ees, catheter conductance method) was used to determine cardiac function. CPB and blood cardioplegic arrest caused no functional or biochemical change in normoxic (control) hearts. Abrupt ReO2 caused a depression of myocardial function (Ees = 25 +/- 5% of control). Functional depression was relatively unaffected by gradual ReO2 without blood cardioplegia (34% recovery of Ees), and abrupt ReO2 immediately before blood cardioplegia caused a 10-fold rise in cardiac NO and CD production, with subsequent depression of myocardial function (Ees 21 +/- 2% of control). In contrast, controlled cardiac ReO2 reduced NO production 94%, CD did not rise, and Ees was 83 +/- 8% of normal. We conclude ReO2 injury is related to increased NO production during abrupt ReO2, nullifies the cardioprotective effects of blood cardioplegia, and that controlled cardiac ReO2 when starting CPB to correct cyanotic heart defects may reduce NO production and improve myocardial status postoperatively.

[A case of pulmonary cryptococcosis diagnosed by percutaneous lung biopsy]

A 53-year-old male was admitted with complaint of bloody sputum. The chest X-ray film revealed a solitary round mass with cavity formation in the left upper lung field. A diagnosis of pulmonary cryptococcosis was made by the percutaneous lung biopsy. As his chest X-ray film did not improve even by administration of antimycotic agents for 6 months, he underwent partial resection of left upper lobe. Thus, the percutaneous lung biopsy was a significant procedure for the definitive diagnosis of this case.

Possible involvement of nitric oxide in acetylcholine-induced increase of intracellular Ca2+ concentration and catecholamine release in bovine adrenal chromaffin cells

The role of nitric oxide (NO) in neurotransmitter release was studied using bovine adrenal medullary chromaffin cells. L-Arginine and sodium nitroprusside (SNP) slightly increased the intracellular free calcium concentration ([Ca2+]i), and the effects of the agents were dependent on the presence of the extracellular Ca2+ ([Ca2+]o), but were not blocked by verapamil (30 microM) or diltiazem (30 microM). SNP enhanced the acetylcholine (ACh)-induced rise in [Ca2+]i in the presence but not in the absence of [Ca2+]o. The effects of L-arginine but not those of SNP were inhibited by N omega-nitro-L-arginine (L-NNA). L-NNA significantly reduced the ACh-induced rise in [Ca2+]i and catecholamine (CA) release, and the reduction was restored by L-arginine but not by D-arginine. These results suggest a possible involvement of NO in ACh-induced [Ca2+]i rise and CA release in bovine adrenal chromaffin cells.

Effect of 12-hydroxyeicosatetraenoic acid on cytosolic calcium in human neutrophils

12-Hydroxy-5,8,10,14-eicosatetraenoic acid (12-HETE) has been reported to be a chemoattractant for human neutrophils. To assess its cellular mechanism, we focused on the effect of 12-HETE on cytosolic Ca2+ ([Ca2+]i) and characterized the effect of 12-HETE on [Ca2+]i in human neutrophils. 12(S)- and 12(R)-HETE increased [Ca2+]i in the presence and absence of extracellular Ca2+ in a concentration-related fashion. The elevation of [Ca2+]i by 12(R)-HETE was completely abolished by pertussis toxin treatment. U-73122, a selective phospholipase C inhibitor, depressed the 12(S)- and 12(R)-HETE-induced rise in [Ca2+]i in the presence and absence of extracellular Ca2+. 12(R)-HETE resulted in the rapid production of inositol 1,4,5-trisphosphate (IP3). Furthermore, 12(R)-HETE elicited slight depolarization of neutrophils as assessed using the fluorescent dye bis-oxonol. These results provide evidence demonstrating the signal transduction pathway in human neutrophils after stimulation with 12-HETE and suggest that 12-HETE causes a rapid rise of [Ca2+]i by mobilizing Ca2+ from an IP3-sensitive intracellular Ca2+ pool in human neutrophils.

[Clinical study of 25 cases with adrenal tumor--comparison between transabdominal, translumbar, laparoscopic approach]

Adrenalectomy for adrenal tumor was performed on 25 patients at Kushiro municipal general hospital between 1982 and 1993. There were 17 women and 8 men aged 34 to 66 (mean 52.7) years. Clinical diagnoses were pheochromocytoma (6), Cushing's syndrome (8), primary aldosteronism (4), incidentaloma (7). Pathological diagnoses were pheochromocytoma (6), cortical adenoma (17), hyperplasia with hypercortisolism (1), schwannoma (1). Angiography and venous sampling were unuseful for clinical identification of adrenal tumor. After removal of the tumor, glucose-intolerance disappeared in 4 of 6 cases with pheochromocytoma and one of 7 cases with incidentaloma, mental aberration was improved in 2 of 8 cases with Cushing's syndrome, and hypertension was improved in 4 of 7 cases with incidentaloma. Since clinical symptoms (hypertension and glucose-intolerance) were improved postoperatively in 4 of 7 cases with incidentaloma, adrenalectomy is recommended for incidentaloma. Transabdominal approach was suitable for pheochromocytoma and bilateral adrenal tumor, but postoperative recovery was slow. In our experience, pleural injury was found in 40% of translumbar approach. Four laparoscopic operations were performed recently, this procedure gave most fast postoperative recovery to compare with other approach.

Lack of relationship between gamma-glutamyl transpeptidase and tyrosine transport in cultured bovine adrenal chromaffin cells

Effect of gamma-glutamyl transpeptidase (GGTP) inhibitor acivicin on tyrosine transport was investigated in cultured bovine adrenal chromaffin cells. Tyrosine transport into the cells was inhibited by acivicin at the low concentration range. This drug also caused the inhibition of GGTP in the cell lysates, but the concentration required for the inhibition of the enzyme was evidently different from that producing the inhibition of tyrosine transport into the cells. In addition, tyrosine transport was not affected by a GGTP activator hippurate even at the high concentration. These results seem to provide the evidence that GGTP may not be involved in the transport of tyrosine into the adrenal chromaffin cell.

Stereoselectivity in the hydroxylation of propafenone enantiomers in mouse hepatic microsomes

Stereoselectivity in the oxidative metabolism of propafenone (PPF) enantiomers to 5-hydroxypropafenone was studied with untreated and inducer-treated mouse hepatic microsomes. In the untreated microsomes, Lineweaver-Burk plots of the 5-hydroxylation of R(-)- and S(+) PPF. single lines, and the intrinsic clearance (Vmax/Km) value of R(-)-PPF was 1.3-fold higher than that of S(+)-PPF. When racemic PPF was used as a substrate, the plot was shifted to the upper region, in comparison with that estimated from the sum of the individual 5-hydroxylase activities of each enantiomer, suggesting enantiomer/enantiomer interaction. In phenobarbital-induced microsomes, the Lineweaver-Burk plot for R(-)-PPF was a single line, but that for S(+)-PPF was biphasic. When racemic PPF was used as a substrate, the plot was biphasic and was shifted to the upper region in comparison with that estimated from the sum of the individual 5-hydroxylase activities of each enantiomer. The observed value of intrinsic clearance of the PPF racemate at lower concentrations (Vmax/Km1) was consistent with the estimated value, suggesting no interaction between R(-)- and S(+)-PPF. These findings indicate that most of the 5-hydroxylation of R(-)- and S(+)-PPF is catalyzed by common cytochrome P-450 species, but a part of S(+)-PFF 5-hydroxylation is catalyzed by another phenobarbital inducible cytochrome P-450 species, particularly at lower substrate concentrations.

Malignant fibrous histiocytoma originating in the mediastinum: report of a case

Malignant fibrous histiocytoma (MFH) is a tumor which most often develops in the soft tissues of the extremities and retroperitoneum, but very rarely originates in the mediastinum. We report herein the case of a 63-year-old man who underwent surgical resection of a rapidly growing tumor in the right thoracic cavity which was diagnosed as an MFH of mediastinal origin on the basis of histological findings, the definitive diagnosis ultimately being made by specific immunostaining.

Changes in the concentration of serum alpha 1-acid glycoprotein in epileptic patients

Factors leading to elevation of the serum level of alpha 1-acid glycoprotein (AAG), the principal binding protein of cationic drugs in the systemic circulation, were investigated in 142 epileptic patients receiving long-term therapy with carbamazepine (CBZ), phenytoin (DPH), phenobarbital (PB), or valproate (VPA). The mean serum activity of gamma-glutamyl transpeptidase (gamma-GTP), an indicator of enzyme induction, in the groups of patients receiving enzyme inducers such as CBZ, DPH, and/or PB was at least some 5-fold higher than in patients receiving VPA alone, which is well known to be a non-inducer. There was no significant difference in the mean serum level of AAG between the former and the latter groups, i.e. there was no correlation between AAG and gamma-GTP levels in serum, and it is unlikely that the enzyme inducing properties of CBZ, DPH and PB are associated with an increased level of AAG. The mean serum level of AAG in the patients with poorly controlled seizures was significantly higher than in those with well controlled seizures (0.81 vs. 0.56 milligram). The serum AAG level in individual patients changed in parallel with the frequency of seizures. The present results strongly suggest that elevation of serum AAG level in epileptic patients may not be associated with the enzyme-inducing activities of anticonvulsants, but with the epileptic seizures per se.

ATP regulates synaptic transmission by pre- and postsynaptic mechanisms in guinea-pig myenteric neurons

Intracellular recordings were made from myenteric neurons of the guinea-pig ileum in vitro; they were classified into S and AH neurons according to electrophysiological criteria. ATP (10 nM-100 microM) inhibited excitatory synaptic potentials in the myenteric plexus; fast excitatory postsynaptic potentials and slow excitatory postsynaptic potentials of S neurons and slow excitatory postsynaptic potentials in AH neurons. This inhibitory action was reversible and dose-dependent, and was usually followed by a transient augmentation of the synaptic potentials after washing of ATP. The actions of ATP on the synaptic potentials were prevented by pretreatment with theophylline, caffeine, quinidine and 8-phenyl theophylline. The ATP analogues, ATP-gamma-s (100 nM-100 microM) and alpha-beta-methylene ATP (100 nM-100 microM) also depressed the synaptic potentials recorded from both types of neurons. The inhibitory effect of adenosine on the synaptic potentials was 10 times weaker than that of ATP. Thus, it seems clear that the presynaptic inhibition is not occurring through adenosine A1 or A2 receptors. Furthermore, ATP at high concentrations ( > or = 1 microM) augmented nicotinic fast depolarizations of S neurons produced by extracellular acetylcholine. However, ATP at the same concentrations inhibited the slow depolarizations of S and AH neurons caused by exogenous acetylcholine (muscarinic) and substance P. It is concluded that ATP regulates synaptic transmission in the myenteric plexus of the guinea-pig ileum and the sites of ATP actions are pre- and postsynaptic.

[A case of early hilar lung cancer combined with intralobar pulmonary sequestration, both of which were treated by limited lung resection]

A 59-year-old man complained of fever due to infection in the intralobar pulmonary sequestration. On bronchoscopic examination, squamous cell carcinoma was found out at orifice of the left upper division bronchus. His pre-operative pulmonary function test showed low pulmonary reserve because of myelopathy. He underwent left S1 + 2 + S3 sleeve segmentectomy and S9 + 10 segmentectomy for intralobar pulmonary sequestration. He is well without any evidence of recurrence 10 months after surgery.

Clonality in chronic myeloproliferative disorders defined by X-chromosome linked probes: demonstration of heterogeneity in lineage involvement

The restriction fragment length polymorphisms (RFLP) of the X-chromosome phosphoglycerate kinase (PGK) and hypoxanthine phosphoribosyltransferase (HPRT) genes were used to study the clonal basis of the chronic myeloproliferative disorders (CMPD). Analyses were performed on granulocyte and T-lymphocyte fractions obtained from 24 females; 13 had essential thrombocythaemia (ET), eight polycythaemia vera (PV) and three myelofibrosis with myeloid metaplasia (MMM). All 24 of these patients had monoclonal patterns of X-inactivation in the granulocyte fraction. For the T-lymphocyte fraction, non-clonal patterns of X-inactivation were observed in 8/13 patients with ET, 7/8 with PV and 1/3 with MMM, while the remaining eight subjects were found to have monoclonal patterns of X-inactivation. Our findings suggest that the majority of the CMPD in these patients originated from a relatively committed progenitor cell without the capacity to differentiate into T cells, and convincingly demonstrated heterogeneity of lineage involvement.

beta-Lactam resistance of motile Aeromonas isolates from clinical and environmental sources

The MICs of various beta-lactams for 182 isolates of Aeromonas species, i.e., A. hydrophila (n = 101), A. sobria (n = 69), and A. caviae (n = 12), from clinical and environmental sources were determined by an agar dilution technique. All strains were resistant to ampicillin and susceptible to aztreonam. A. sobria and A. caviae demonstrated lower resistance rates than A. hydrophila. Penicillin-hydrolyzing beta-lactamases were detected in all strains.

Cyclic AMP-induced depolarization measured by bis-oxonol fluorescence in bovine adrenal medullary chromaffin cells

Effects of cyclic AMP on membrane potentials were examined by measuring the changes of bis-oxonol fluorescence in bovine adrenal medullary chromaffin cells. 8-Bromo cyclic AMP (8Br-cAMP) or forskolin caused a gradual and long lasting increase of the fluorescence intensity. The effects of 8br-cAMP was blocked by cyclic AMP-dependent protein kinase inhibitor, adenosine-3', 5'-cyclic monophosphothioate, Rp-diastereomer (Rp-cAMPS) and there was no further increase in the fluorescence by 8br-cAMP in the cells depolarized with 56 mM KC1 or gramicidin D. Ouabain or the removal of extracellular K+ ([K+]0 free) which block Na+, K+-ATPase also increased the fluorescence. The effect of 8br-cAMP on the fluorescence was counteracted by ouabain or [K+]0 free and was blocked in the absence of extracellular Na+ but not by tetrodotoxin or the removal of Ca2+ from the medium. These results may suggest that cyclic AMP causes the membrane depolarization by accumulating Na+ through the inhibition of Na+, K+-ATPase in adrenal chromaffin cells.

The effect of CO2-induced acid-base changes on the potencies of muscle relaxants and antagonism of neuromuscular block by neostigmine in rat in vitro

We investigated the influence of CO2-induced acid-base changes on the potencies of the monoquaternary relaxants (rocuronium, vecuronium, and d-tubocurarine) and bisquaternary relaxants (pancuronium, pipecuronium, and metocurine), and on the antagonism of their neuromuscular block by neostigmine. Phrenic nerve-hemidiaphragm preparations of rats were used. The pH changes were induced by changing the CO2 concentration aerating the modified Krebs solution. The potencies of the monoquaternary relaxants increased at 9% CO2 (pH 7.2) and decreased at 2.5% CO2 (pH 7.6) from those of 5% CO2 (pH 7.4) both with and without neostigmine (P < 0.05), whereas the potencies of the bisquaternary drugs did not change significantly at different pH levels from control (pH 7.4) both with and without neostigmine. The slopes of the log concentration-percent response curves of each drug were not significantly different at each pH level. The ratios of inhibitory concentrations, 50% (IC50) values with and without neostigmine at each pH value for each drug were not significantly different indicating that the neostigmine-induced antagonism for each drug was not affected by the CO2-induced acid-base changes. But the ratios of the IC50 values of the steroidal relaxants (rocuronium, vecuronium, pancuronium, and pipecuronium) were significantly lower (P < 0.05) than those of the isoquinolinium drugs (d-tubocurarine and metocurine) at each pH level, suggesting that the antagonism is enhanced at each pH level for the isoquinolinium relaxants. The difference was independent of their monoquaternary or bisquaternary nature. These results suggest that CO2 increases the potency of the monoquaternary relaxants but does not affect the bisquaternary relaxants.(ABSTRACT TRUNCATED AT 250 WORDS)

New approaches to blood cardioplegic delivery to reduce hemodilution and cardioplegic overdose

These studies present modifications of the cardioplegic components of a standard cardioplegic formulation, delivered previously at 4:1, to allow an 8:1 blood:cardioplegic mixture, thereby limiting hemodilution. Data are included to show that the hyperkalemic (20 mEq/L) glutamate/aspartate enriched solution used previously for warm induction can be used also for warm reperfusion (instead of the 10 mEq/L KCl solution), thereby avoiding the need to formulate two different solutions that vary only in potassium concentration. Studies of cold (4 degrees C) retrograde noncardioplegic blood infusion after arrest with hyperkalemic blood cardioplegia document the safety of maintaining arrest with continuous retrograde infusion of cold normokalemic blood, thereby indicating that ischemia and cardioplegia are unnecessary during aspects of cardiac operations where perfusion does not impair visualization (i.e., construction of proximal anastomoses). A new cardioplegic delivery system containing a shunt line is presented to expedite conversion from blood cardioplegia to blood infusion when continuous infusion is used.

Effect of fluconazole on theophylline disposition in humans

The effect of fluconazole, an antimycotic that inhibits cytochrome P-450-mediated drug metabolism, on theophylline kinetics and the production of its metabolites were compared with those of enoxacin in 5 healthy subjects. All subjects received a single oral dose of 240 mg theophylline (aminophylline, 300 mg) after they had been given oral fluconazole 100 mg every 12 h or enoxacin 200 mg every 8 h for three consecutive days. Pretreatment with enoxacin decreased the total clearance (CLT) and elimination rate constant (Kel) of theophylline by 50% and 46%, respectively, without changing the volume of distribution (Vd), but there were no significant change in any pharmacokinetic parameter when fluconazole was administered. Enoxacin led to a 50% reduction in the metabolic clearance (CLM) of theophylline and to decreases of 69%, 59% and 38% in the formation clearance of the three theophylline metabolites, 3-methylxanthine (3-MX), 1-methyluric acid (1-MU), and 1,3-dimethyluric acid (1,3-DMU), respectively, accompanied by significant changes in the urinary recovery of theophylline and its metabolites. In contrast, treatment with fluconazole led only to a slight decrease in the CLM of theophylline (16%) and in the formation clearance of its metabolites (15%-18%), and there was no change in the renal clearance (CLR) of theophylline. The results indicate that fluconazole is a minor inhibitor of theophylline disposition compared with enoxacin, and they suggest that the inhibitory action of fluconazole is selective for certain cytochrome P-450 isozymes, but not for the cytochrome P-4501A involved in theophylline metabolism.

The new illegal immigration in Japan, 1980-1992

"This article presents some of the latest available figures on illegal immigration in Japan, a process that did not assume significant proportions until the mid-1980s. It also discusses briefly the latest developments around 'immigration' policy--more precisely, the law on the entry and exit of aliens."

A clinical analysis of small-sized lung cancer with advanced disease

A clinical analysis of small-sized lung cancers with advanced disease was conducted on a total of 58 patients: 34 diagnosed as T1N2, 6 as T1N3, 9 as T1M1, and 9 as T4 due to pleural dissemination. The cumulative 5-year survival rate after surgery for the 34 patients with a T1N2 lesion was 17.4%. Of these 34 patients, 24 underwent a curative operation resulting in a 5-year survival rate of 23.7%, but the remaining 10 patients, who underwent a non-curative operation, had a 5-year survival rate of 0%. Extended lymph node dissection for N3 disease has only been performed in recent years, so it is not yet clear whether it will affect the survival rate or not. T4 disease due to pleural dissemination and T1M1 disease associated with intrapulmonary metastasis encountered at thoracotomy could be expected to have relatively long-term survival with the combined use of systemic immunochemotherapy after surgery. In cases diagnosed as T4 due to pleural dissemination, we have recently employed resection of the primary lesion with parietal pleurectomy as the standard operative procedure. For cases of T1M1 with intrapulmonary metastasis confined to the same lobe as the primary lesion, a lobectomy is usually performed, while for cases with intrapulmonary metastasis extending to another lobe, a lobectomy with enucleation of metastatic nodules or pneumonectomy is most often performed instead of an exploratory thoracotomy.

[Clinical significance of extended mediastinal lymph node dissection on the basis of clinicopathological analysis of nodal involvement in bronchogenic carcinoma]

During the past 20 years, 1,064 cases of non-small cell lung cancer underwent resectional surgery in which all accessible mediastinal lymph nodes were dissected. Among 288 patients with histologically proven N2 disease, 182 underwent complete dissection of the mediastinal lymph nodes; 77 had one-level and 105 had multi-level metastases. Fifteen percent of the patients having primary lesions with a maximal diameter between 21 and 30 mm had N2 disease. Nodal metastases to the lower mediastinum from upper lobe cancer (nonregional metastasis) were frequently observed as were metastases of lower lobe cancer to the upper mediastinum. In addition, there were often skip metastases to the nonregional parts of the mediastinum without regional nodal involvement in the mediastinum. Among left-lung cancer patients, the group that underwent nodal dissection after mobilization of the aorta by dividing the Botallo's ligament frequently had a verified metastatic node at the tracheo-bronchial angle (#4) which might not have been detected without that procedure. In addition, many N2 and N3 diseases were detected by additional dissection through a median sternotomy. From the results of the present study, it appears that extensive mediastinal dissection should be recommended in surgery for lung cancer irrespective of the location and the size of the primary tumor.

Calyculin A and okadiac acid inhibit human platelet aggregation by blocking protein phosphatases types 1 and 2A

Two potent inhibitors of protein phosphatase type 1 (PP1) and type 2A (PP2A), calyculin A (CAL-A) and okadaic acid (OKA), inhibited human platelet aggregation induced by thrombin, collagen and 9,11-epithio-11,12-methano-thromboxane A2 (STA2). IC50 values of CAL-A and OKA for STA2-induced aggregation were 53 nM and 3.5 microM, respectively. These drugs also inhibited thrombin-induced [14C]serotonin secretion of platelets. CAL-A and OKA elicited phosphorylation of certain proteins with an apparent M(r) (x 10(-3) of 200, 60, 50 and 20 light chain of myosin (MLC). Agonist-induced 47,000 M(r) protein phosphorylation was strongly inhibited by these compounds, whereas phosphorylation of 20,000 M(r) MLC was enhanced. The increase in 50,000 M(r) protein phosphorylation by CAL-A and OKA was observed in the presence of agonists, and the 50,000 M(r) phosphorylation may be involved in the inhibition of platelet activation by these compounds. Subcellular analysis of the phosphatase activity in human platelets showed that MLC phosphatase activity was present mainly (approx. 78%) in the cytosolic fraction. Chromatography of human platelet extract on heparin-Sepharose resolved two peaks of MLC phosphatase activity: PP2A in 0.1 M NaCl eluate and PP1 in 0.5 NaCl eluate. PP2A and PP1 isozymes (PP1 alpha, PP1 gamma and PP1 delta) have also been identified in human platelets, by cross-reactivity with polyclonal antibodies against PP2A and PP1 isozymes, respectively. These results suggest that PP1 and/or PP2A may play an important role in the process of platelet activation by regulating levels of phosphorylation of certain proteins.

The safety of simultaneous arterial and coronary sinus perfusion: experimental background and initial clinical results

Concern over myocardial damage from simultaneous arterial (antegrade) and coronary sinus (retrograde) perfusion has led to alternating between these delivery routes to maximize their individual benefits. Based upon predominant retrograde drainage via Thebesian veins, this study: (1) confirms experimentally the safety of simultaneous arterial and coronary sinus perfusion; and (2) reports initial clinical application of this combined strategy in 155 consecutive patients.

EXPERIMENTAL

Five mini-pigs (25 to 30 kg) underwent 1 hour of aortic clamping with simultaneous aortic and coronary sinus perfusion at 200 mL/min with normal blood (37 degrees C) before and after 30 minutes of perfusion with either warm (37 degrees C) or cold (4 degrees C) blood cardioplegia. Coronary sinus pressure was always less than 30 mmHg. There was no right or left ventricular edema, lactate production, or lipid peroxidation as transmyocardial and myocardial conjugated dienes were unaltered, and postbypass recovered left ventricular end-systolic elastance (conductance catheter) and preload recruitable stroke work index 101% +/- 3% and 109% +/- 90%, respectively. CLINICAL: Simultaneous arterial/coronary sinus perfusion was used in 155 consecutive high risk patients (New York Heart Association Class III to IV) undergoing isolated coronary artery bypass grafting (CABG) (n = 109) and CABG+valve replacement/repair or aneurysm (n = 46). Included were 16 patients in cardiogenic shock and 24 undergoing reoperation. Mean aortic clamping time averaged 90 +/- 4 minutes (range 30 to 207), with 3.5 +/- 0.1 grafts per patient; all anastomoses were performed with the aorta clamped. Cold intermittent blood cardioplegia was used for distal anastomoses and valve implantation/repair in 123 patients, and warm continuous blood cardioplegia was used in 32 patients. Following a warm cardioplegic reperfusate, all patients received warm noncardioplegic blood perfusion simultaneously via grafts and coronary sinus. Coronary sinus pressure was always less than 40 mmHg. Of 18 patients requiring postoperative mechanical circulatory support (IABP), 16 had IABP placed preoperatively for cardiogenic shock. There were three postoperative myocardial infarctions (2%), and six patients died (3.9% mortality).

CONCLUSION

These experimental and clinical findings overcome perceived concerns about myocardial damage from simultaneous arterial and coronary sinus perfusion, and suggest this approach may add to the armamentarium of cardioprotective strategies.

Thrombomodulin levels in the plasma and joint fluid from patients with rheumatoid arthritis

The hemostatic mechanism is thought to contribute to the inflammatory process of rheumatoid arthritis (RA). Thrombomodulin (TM), an inhibitor of blood coagulation, is synthesized by various cells which are recognized in the inflammatory lesions of RA. To elucidate a possible relation of TM with the process of RA, therefore, we measured soluble forms of TM in the plasma and joint fluid (JF) from RA patients by a recently developed sandwich enzyme immunoassay using monoclonal antibodies. TM levels in the plasma and JF were not significantly elevated in RA patients, although TM levels in plasma were positively correlated with those in JF. The plasma TM levels were related to renal functions (serum creatinine levels), but the levels showed no connection with systemic inflammatory indices of RA such as erythrocyte sedimentation rates, serum C-reactive protein levels and Lansbury's activity index. In the JF, TM levels were not correlated with the numbers of neutrophils or monocytes/macrophages associated with articular inflammations. Our results indicate that TM levels in the plasma and JF do not reflect systemic and articular inflammations of RA, and suggest that TM molecules in JF are mainly recruited from circulating TM.

Comparison of antinuclear antibody and other immunohematological profiles among primary Sjögren's syndrome, secondary Sjögren's syndrome associated with rheumatoid arthritis or systemic lupus erythematosus, and corresponding systemic disease

Sjögren's syndrome (SS) is currently classified into two groups (primary and secondary), because of differences in the disease in the two groups. We determined antinuclear antibody and other immunohematological parameters by using newer, more sensitive serologic methods on patients with primary SS, or secondary SS associated with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), and patients with just the systemic disease free of SS. This study defined both distinctive and common features between primary SS and each systemic disease: High titers of fluorescent antinuclear antibodies (FANAs), anti-SS-A/SS-B antibodies, and rheumatoid factors (RFs), as well as leukocytopenia were considered the main features of primary SS. Elevated levels of RFs and C-reactive protein were prominent in RA patients. In contrast, high titers of FANAs and anti-single stranded or anti-double stranded DNA antibodies, positive anti-ribonucleoprotein or Sm antibodies, leukocytopenia, and hypocomplementemia were characteristic for SLE. Furthermore, patients with secondary SS plus RA or SLE were found to have mixed features of SS and the associated systemic disease. The results strongly suggest that patients with secondary SS have two separate diseases, SS and the associated systemic disease.