Reconstruction using an autograft containing tumour treated by liquid nitrogen

We describe a method of reconstruction using tumour-bearing autograft treated by liquid nitrogen in 28 patients. The operative technique consisted of en bloc excision of the tumour, removal of soft tissue, curettage of the tumour, drilling and preparation for internal fixation or prosthetic replacement before incubation for 20 minutes in liquid nitrogen, thawing at room temperature for 15 minutes, thawing in distilled water for ten minutes, and internal fixation with an intramedullary nail, plate or composite use of prosthetic replacement. Bone graft or cement was used to augment bone strength when necessary. The limb function was rated as excellent in 20 patients (71.4%), good in three (10.7%), fair in three (10.7%), and poor in two (7.1%). At the final follow-up six patients had died at a mean of 19.8 months after the operation, while 21 remained free from disease with a mean follow-up of 28.1 months (10 to 54). One patient is alive with disease. Bony union was seen at a mean of 6.7 months after the operation in 26 patients. Complications were encountered in seven patients, including three deep infections, two fractures, and two local recurrences. All were managed successfully. Our results suggest that this is a simple and effective method of biological reconstruction.

Cell lineage and timing of fate restriction, determination and gene expression in ascidian embryos

Tadpole larvae of ascidians show the basic body plan of chordates. An ascidian larva consists of only few types of cells and has a relatively small number of cells. Cell lineages are simple and invariant among individuals and have been described in detail. The clonal restriction of developmental fate takes place considerably early in development. I review here the temporal relationship between fate restriction, determination and initiation of lineage-specific gene expression during ascidian embryogenesis. In several cases, determination and initiation of gene expression precede fate restriction and occur during the last cell cycle before fate restriction. Such a phenomenon contradicts the traditional view of fate specification and has several important implications for the understanding of the way in which cells execute the developmental pathway.

[Mitral regurgitation due to sole punched out lesion of the mitral anterior leaflet in infective endocarditis; report of a case]

Mitral regurgitation (MR) due to only punched out lesion is extremely rare in infective endocarditis. A 31-year-old male was admitted to our hospital due to unusual cause of MR. Echocardiography showed MR due to punched out lesion of the mitral anterior leaflet, which is extremely rare. A round shape punched out lesion (about 16 mm in size) was found intraoperatively in the anterior leaflet of the mitral valve. The surface around the punched out lesion was smooth, and the leaflet displayed good movability. Neither vegetation nor calcification was found. Punched out lesion was successfully closed with autologous pericardial patch and annuloplasty was performed.

Intrapancreatic accessory spleen: evaluation by CT arteriography

BACKGROUND

Intrapancreatic accessory spleens are frequently confused with primary pancreatic tumors, and differentiation from neoplastic lesions is important to avoid an unnecessary laparotomy. We present three cases of intrapancreatic accessory spleen evaluated by computed tomographic arteriography (CTA) and discuss the characteristic findings.

METHODS

CTA was performed, followed by digital subtraction angiography, with an injection of contrast material through a 4-F catheter placed in the celiac artery. Single-level dynamic CTA was also performed in two patients with a 30-s continuous scan in one breath-hold.

RESULTS

CTA clearly demonstrated early inhomogeneous enhancement of the lesion, similar to the splenic parenchyma. On single-level dynamic CTA, inhomogeneous enhancement of the lesion in the early phase was diminished in the late phase. Multiplanar reformatted images obtained in two cases showed the deep cleft between the lesion and the pancreas, which suggested that the lesion was originally extrapancreatic.

CONCLUSIONS

These two findings on CTA, inhomogeneous enhancement of the lesion and the deep cleft between the lesion and the pancreas, may help to confirm the diagnosis of an intrapancreatic accessory spleen.

Autoantibodies to NMDA receptor in patients with chronic forms of epilepsia partialis continua

BACKGROUND

Antibody-mediated and cytotoxic T cell-mediated pathogenicity have been implicated as the autoimmune pathophysiologic mechanisms in Rasmussen's encephalitis.

METHODS

The authors investigated autoantibodies against the NMDA glutamate receptor (GluR) epsilon2 subunit and their epitopes in serum and CSF samples from 15 patients with chronic epilepsia partialis continua (EPC), 17 with West syndrome, 10 with Lennox-Gastaut syndrome, and 11 control subjects.

RESULTS

In 15 patients with chronic EPC, we detected NMDA-type GluR epsilon2 autoantibodies in histologically proven Rasmussen's encephalitis (3/3 patients), clinical Rasmussen's encephalitis (6/7 patients), acute encephalitis/encephalopathy (2/3 patients), and nonprogressive EPC (2/2 patients). Serum IgM autoantibodies were found in the early phase of EPC and became negative later in four patients. The autoantibodies were not detected in West syndrome, Lennox-Gastaut syndrome, or controls. Among 10 patients with histologically proven or clinical Rasmussen's encephalitis, epitope analyses showed that the autoantibodies were predominantly against C-terminal epitopes and rarely against N-terminal epitope, with inconsistency in profile during the courses of disease. Epitope recognition spectrum of autoantibodies was broader in CSF than in serum, and the serum or CSF profile showed an increase in number of epitopes as disease progressed in some patients.

CONCLUSIONS

The presence of autoantibodies against NMDA GluR epsilon2 suggests autoimmune pathologic mechanisms but is not a hallmark of Rasmussen's encephalitis. Patients with Rasmussen's encephalitis may have autoantibodies against several neural molecules, and these autoantibodies may be produced in the CNS after cytotoxic T cell-mediated neuronal damage.

[Selection of surgical strategy for abdominal aortic aneurysm coexisting with coronary artery disease; one-stage versus two-stage, and off-pump versus on-pump]

BACKGROUND

In patients having a combination of severe coronary artery disease (CAD) and expanding abdominal aortic aneurysm (AAA), one-stage operation of simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended.

METHODS AND RESULTS

Of 96 patients (94 men, average 65 year) with AAA and CAD, 21 patients underwent one-stage operation of simultaneous CABG and AAA repair (Group A-1: off-pump CABG in 10 and on-pump in 11), and 75 underwent two-stage operation of CABG followed by AAA with an interval of less than 6 months in 23 patients (Group A-2) and more than 6 months in 52 patients (Group B). Baseline characteristics were similar between the one-stage and two-stage groups, and off-pump and on-pump subgroups, except the proportion of single vessel disease. Mean number of distal anastomoses was significantly lower in the off-pump subgroup than in the on-pump subgroup (p = 0.011) and the two-stage group (p = 0.0057). There was 1 hospital death among on-pump patients but none among off-pump patients. Mortality rate was 4.8% in the one-stage group. Two patients (8.7 &) in the two-stage group, who had AAA was 7.0 cm and 7.5 cm diameter, died of AAA rupture prior to repair. The 10-year all death free rates were 44% in Group A (A-1 and A-2), and 86% in Group B (p = 0.0004).

CONCLUSIONS

Our data suggest that one-stage operation with off-pump CABG is an attractive option in selected patients with a large AAA (> 7 cm).

[Surgical repair of left ventricular aneurysm; long-term results]

OBJECTIVE

The aim of this study was to evaluate the late results of left ventricular (LV) aneurysm repair.

METHODS

From July 1968 to 1999, 86 consecutive patients (74 male, 12 female, mean age 56.0 +/- 9.3) underwent LV aneurysm repair at our institute. The surgical methods were as follows; linear repair in 71 patients, endoaneurysmorrhaphy in 5, endoventricular circular plasty in 4, Jatene method in 1 and plication of aneurysm in 5. Thirty-nine patients underwent concomitant myocardial revascularization. Major arrhythmias occurred in 38 patients. The results were retrospectively reviewed and follow-up was achieved in 95.3%.

RESULTS

There were 6 operative deaths and 4 hospital deaths. Actuarial survival rate including the 10 deaths was 72.7% at 5 years and 46.3% at 10 years. In patients with coronary artery bypass grafting (CABG), survival rate was 82.2% at 5 years and 56.3% at 10 years, and was significantly higher than that in those without revascularization (p = 0.01). In patients without arrhythmias, survival rate was 79.2% at 5 years and 55.0% at 10 years, and was significantly higher than that in patients with arrhythmias.

CONCLUSIONS

The patients were not homologous and the techniques were not the same; however, in spite of these study limitations, patients who underwent revascularization, and were without major arrhythmias preoperatively, had better long-term survival.

[Off-pump versus standard on-pump reoperative coronary artery bypass grafting]

BACKGROUND

Using standard on-pump procedures, repeat coronary artery bypass grafting (re-CABGs) are associated with a higher morbidity and mortality than first-time CABGs. This retrospective study assessed the clinical outcomes of off-pump re-CABG versus on-pump re-CABG.

METHODS

From 1983, 2nd CABG and 3rd CABGs were performed in 162 patients at our institute. The early and late results of 142 patients who received standard on-pump re-CABGs and 20 patients who received off-pump re-CABGs were evaluated. The 2 groups were similar in age, sex, preoperative ejection fraction (EF) and number of coronary lesions. However, mean number of distal anastomoses per patient was significantly higher in on-pump (2.0 +/- 0.8) than in off-pump re-CABG (1.4 +/- 0.6) [p = 0.0009].

RESULTS

Hospital mortality tended to be higher in the on-pump group (5.6%) than in the off-pump group (0%) [p = 0.6]. Morbidity in term of total postoperative complications tended to be higher for on-pump (14.1%) than in off-pump (0%) [p = 0.14]. The 5-year survival rate tended to be higher in the off-pump group (100%) than in the on-pump group (80.8 +/- 3.5%) [p = 0.096].

CONCLUSIONS

In selected patients, off-pump re-CABG can be a reliable and safe option. The mid-term survival and event-free survival rates achievable with the off-pump option are encouraging.

[Total arch replacement for right aortic arch with Kommerell diverticulum and aberrant left subclavian artery]

A 57-year-old man suspected of having angina pectoris underwent coronary angiography and comprehensive examination, which revealed a right-side aortic arch accompanying Kommerell diverticulum and a aberrant left subclavian artery. Esophagography indicated that the esophagus was compressed on its right posterior side and the computed tomography (CT) revealed that the posterior side of the tracheal was compressed, however, the patient experienced no difficulty in breathing, hoarseness of voice or dysphasia. The size of the aortic diverticulum was less than 5 cm and the patient showed no symptom, however, if it was left untreated, there was a risk of rupture in the future. Also the esophagus and tracheal may develop complications due to prolonged compression. Therefore, we decided that the case required surgical operation. Total arch replacement was performed through mediastinotomy and right posterolateral in the 4th intercostal. The postoperative condition was good, and the patient was discharged without any complications.

[Early and mid-term results of all arterial graft coronary artery bypass grafting using bilateral internal thoracic and radial arterial conduits]

From March 1996 to May 2000, 41 patients [age 39-78 (mean 63.5 +/- 8.8) years, 90.2% male] underwent all arterial multiple coronary artery bypass grafting (CABG) using bilateral internal thoracic (BiITA) and radial (RA) arterial conduits. The reason for using RA was that the right gastroepiploic artery (RGEA) was small or occluded on preoperative angiography, a history of upper abdominal surgery or disease, or the right coronary arterial lesion was proximal and mild. The BiITA were used as in situ grafts and the proximal anastomosis of RA was to the ascending aorta in all cases. All patients underwent conventional elective CABG with median sternotomy using cardiopulmonary bypass. The mean number of anastomoses was 3.3 +/- 0.5 branches and complete revascularization rate was 80.5%. Postoperative follow-up averaged 20 months and the longest was 50 months. There was no early death, and overall graft patency 2-3 weeks after surgery was 96.2% (LITA 94.0%, RITA 97.6%, RA 97.6%). Four-year actuarial survival rate was 96.4 +/- 3.5% (1 patient: 9 months, no cardiac death), and cardiac event-free rate after surgery was 89.7 +/- 4.9% [4 patients: percutaneous transluminal coronary angioplasty (PTCA)]. However, once patients were discharged from hospital, cardiac event-free rate was 100%. These excellent results suggest that all arterial graft CABG was satisfactory, and RA can be used as a third suitable arterial bypass conduit, if RGEA cannot be used or is unsuitable for use.

Analysis of SIDS-related civil and criminal court cases in Japan

Thirty-three sudden infant death syndrome (SIDS)-related civil and criminal lawsuits in Japan were retrieved from judicial precedent databases "Hanrei Masutar (Judicial Decisions Master)" and "Hanrei Taikei (Judicial Decisions System) using "SIDS" as a keyword. Sleeping posture and developmental stage of occurrence were studied in each of the cases retrieved, whether or not a legal autopsy had been performed. The influence exerted on court decisions by Japanese definitions of SIDS as well as the relationship between causes of death and court decisions were studied. Of 33, two were criminal cases (business/professional negligence on the part of the defendants, leading to death), and the rest were civil cases (claims for damages). Because the decision handed down in both criminal cases was "cause of death unknown", these defendants were found innocent. One of these cases was argued in both the court of appeals and the superior court: these courts found SIDS to be the cause of death and consequently the claim for damages was rejected. Both criminal and civil courts dealt with another case: the former found the cause of death to be "unknown" and the defendant innocent, while the latter, finding SIDS the cause of death, declined to review. In cases where the sleeping posture was prone, courts tended to decide the cause of death to be suffocation, especially with neonates. Because diagnosis by exclusion is required in cases of a legal autopsy for SIDS, the diagnosis is difficult without an autopsy. Disagreements between the results of legal autopsy and court decisions occurred in eight cases. With such a discrepancy, a detailed case examination is necessary. In 1983, SIDS was defined in Japan in two different ways; one in a more strict sense and the other being more inclusive. The wider and narrower definitions were unified in 1995 by requiring a survey of the circumstances of death in addition to the narrower definition. Because of this situation, the two cases in the 1980s when legal autopsy was not enforced fell into the category of "SIDS in a wider sense." In no case was a defendant found guilty when the cause of death was judged to be either SIDS/ALTE or unknown. Four cases were rejected when the cause of death was judged to be neither due to suffocation nor SIDS, while seven were accepted either as cases of "joint faults that canceled each other," or as "partial acceptance." In Japan, official views concerning a SIDS diagnosis differ among pediatricians, legal scholars of forensic medicine and pathologists. These differences appeared to influence the legal decisions. Several conferences should be convened as soon as possible to provide an opportunity to resolve the main points of difference between these three professional groups and, thus, attain a unified view.

Quantification of trace elements in the brain of SIDS victims

In this report, the quantification and analysis of trace elements in the frontal lobes of the brains of sudden infant death syndrome (SIDS) cases were carried out. In all materials, V, Cr, Sn and Sb were not observed and Mg, Na, K, Fe, Zn and Br were observed. As for all of these trace elements, there was no significant difference between SIDS and non-SIDS. Only Ca was not observed in SIDS and observed only in non-SIDS. It is well known that Ca moves from outside of cells to inside of cells and induces cell damage by membrane disturbance in a hypoxic situation. The result in this report suggests that the deaths in SIDS cases are so sudden and are not sufficient for the kinetics of Ca into brain cells in the hypoxic situation.

Study on social responses (encouraging public awareness) to sudden infant death syndrome: evaluation of SIDS prevention campaigns

The sudden infant death syndrome (SIDS) prevention campaign promulgated by the SIDS Family Associations was initiated and directed to medical professionals in 1996 and to mothers in 1997. In mid-1998, the Ministry of Health and Welfare began to support this campaign. In parallel with these moves and with cooperation from the study group of the Ministry of Health and Welfare and the SIDS Family Associations of Japan, a Japanese segment of the International Child Care Practices Survey (ICCPS) was conducted in two phases--from 1996 to 1997 and from 1998 to 1999--to observe the trends in risk factors for SIDS that may exist in the child rearing environment in Japan. Consequently, after the SIDS prevention campaign, the risk factors for SIDS, such as the practice of placing infants in a prone posture, smoking, and formula feeding, were reduced. Correspondingly, it was shown that the incidence of SIDS in Japan and in Kanagawa Prefecture where the survey was carried out considerably decreased (0.42-0.24 per 1000 live births). These data indicate that this prevention campaign has been effective.

Comparison between SIDS-related court cases in the United States and Japan--a trend seen in legal precedents in the United States

A bibliographic search of "Lexis", a database on foreign legal cases, was conducted, using sudden infant death syndrome (SIDS) as a key word to retrieve legal cases related to SIDS in the United States. The procedure yielded 156 cases, which included many that were brought to the courts for reasons other than SIDS. The following explanation was given for this outcome: because the public in the United States is much better informed about SIDS than in Japan, few cases are brought to the courts with SIDS as the main cause of the argument; the acronym, SIDS, is simply quoted during the court proceedings. Nevertheless, 26 cases that were particularly related to SIDS were selected and compared against 33 cases recorded and retrieved in the previous year in Japan to find the difference in the trends in legal disputes. The difference in the trends in litigation in the two countries was evident: in most cases in Japan, the legal dispute was over the recognition of SIDS or asphyxiation as the cause of death that had occurred in a nursery or hospital, with the family acting as the plaintiff and the nursery or hospital as the defendant. In the majority of cases in the United States, on the other hand, the state was the plaintiff and the family or baby sitter the defendant; the focal point of the dispute was the distinction between SIDS and child abuse. Compared with the trend in Japan, a much greater number of cases were brought before the court of final appeals in the United States. As the public becomes more aware of SIDS through campaigns and other means, the pattern seen in the legal disputes refer to SIDS lawsuits in Japan may change into that seen in the United States.

Study to increase the frequency of autopsies performed for cases of infant deaths--proposed revision of the law on postmortem examination and corpse preservation and other related regulations

By definition, sudden infant death syndrome (SIDS) requires diagnosis through exclusion by conducting an autopsy. To obtain a reliable diagnosis of this disease, an autopsy is essential. However, the frequency with which autopsies are conducted in Japan is not sufficient to meet the need associated with the diagnosis of SIDS. To improve this frequency, various public policies, such as nationwide implementation of the administrative autopsy system (medical examiner system), the application of the practice of autopsy approved by families, and legally required autopsies, are being considered; but none has been put into practice. On the other hand, attention has been called to the fact that the Law on postmortem examination and corpse preservation, which was instituted at the end of the Second World War, requires updating. In the current report, it is proposed that the following be added to Article 8, item 3 of this Law: "the Metropolitan or Prefectural Governor must insist that an autopsy be conducted on all cases of a sudden and unexpected death of an infant to investigate the cause of this death." At present, the annual incidence of SIDS in Japan is reported to be 500. To put the above-recommended legal requirement into practice, the estimated annual addition to the budget, if conducted as approved or an administrative autopsy, will be in the order of 150,000-500,000 dollar, which is within the prescribed limits for an appropriation.

Variation in mortality and intraventricular haemorrhage in occupants of Pacific Rim nurseries

OBJECTIVE

A network of neonatal intensive care units in Pacific Rim countries was formed to compare infant risk factors, clinical practices, and outcomes for very low birthweight infants.

METHODOLOGY

A multicentre, prospective study compared outcomes for infants born smaller than 1501 g or at less than 31 weeks gestation.

RESULTS

Gestational age-specific survival and incidence of intracranial haemorrhage varied for infants born in these nurseries. We found differences in infant risk factors among the nurseries. There were also significant differences in the use of antenatal steroids, but similar rates for Caesarean section and surfactant treatment. The factor most predictive of neonatal death and severe intracranial abnormality was an elevated Clinical Risk Index for Babies (CRIB) score. Antenatal steroid treatment (>24 h prior to delivery) was associated with improved survival and decreased incidence of severe intracranial abnormalities. Antenatal steroid treatment for less than 24 h prior to delivery was not associated with improved survival. Caesarean delivery was associated with improved survival, but showed no benefit regarding the incidence of severe intracranial abnormality.

CONCLUSIONS

Our Pacific Rim nursery network found differences in neonatal outcomes that correlated best with measures of neonatal risk at birth, antenatal steroid treatment, and Caesarean delivery. These data emphasize the importance of obstetric care to improve postnatal outcomes in premature infants, and highlight the usefulness of CRIB scores in these patients.

Immunomodulatory action of chronic exercise on macrophage and lymphocyte cytokine production in mice

This study was designed to evaluate the effects of 8-week voluntary running exercise on cytokine production of macrophages and lymphocytes. Seven-week-old-male BALB/c inbred mice were divided into two groups: a group given voluntary exercise (exercise group, n=32), and the other, a non-exercise group (control group, n=32). Exercise consisted of spontaneous running in wheels for 3 days per week over 8 weeks. The levels of nitric oxide (NO2-) and interleukin (IL)-1 beta production by lipopolysaccharide (LPS)-stimulated peritoneal macrophages from the exercise group was significantly higher than that in the control group (P < 0.05-P < 0.01). In the exercise group, stimulation indices by concanavalin A (Con A) was significantly higher than they were in the control group (P < 0.05-P < 0.001). When compared with the control group, the exercise group showed a significant (P < 0.05) increase in the splenic lymphocyte production of IL-2 stimulated by Con A (449.5 +/- 28.2 and 853.7 +/- 116.0 pg 4 x 10(5) cells(-1) 48 h(-1) for the control group and the exercise group, respectively). IL-4 production of splenocytes stimulated by Con A in the exercise group (37.6 +/- 5.1 pg 4 x 10(5) cells(-1) 48 h(-1)) was higher than that in the control group (30.9 +/- 3.9 pg 4 x 10(5) cells(-1) 48 h(-1)); however, the difference was not statistically significant. These results suggest that 8-week voluntary running exercise effectively enhanced macrophage and lymphocyte functions in mice.

[Dissecting aneurysm of ventricular septum following acute inferior myocardial infarction]

Dissecting aneurysm of the ventricular septum as a complication after myocardial infarction (MI) is very rare. The patient was a 70-year-old women who was diagnosed with acute inferior MI. Three months after MI, catheterization showed a left ventricular aneurysm of the inferior wall, and left-to-right ventricular shunt flow was detected in the aneurysm. Echocardiography showed that the inferior left ventricular free wall was aneurysmal and dissected from the septal wall. Nine months after MI, chronic heart failure was uncontrollable by medication. At surgery, a tear (5 mm long) in the dissecting aneurysm of the ventricular septum was found and closed directly using 2 felt patches, and aneurysmectomy was performed using felt strips. The postoperative course was uneventful and she has been free from any complication for over 1 year.

CJ-13,981 and CJ-13,982, new squalene synthase inhibitors

Two new squalene synthase (SSase) inhibitors, CJ-13,981 (I) and CJ-13,982 (II), were isolated from the fermentation broth of an unidentified fungus CL 15036. They inhibited human liver microsomal SSase with IC50s of 2.8 and 1.1 microM, respectively, but showed no inhibitory activity against human brain protein farnesyltransferase (PFTase) at 100 microM. Based on FAB-MS and NMR analyses, the structures of I and II were determined to be 3-hydroxy-3,4-dicarboxy-15-hexadecenoic acid and 3-hydroxy-3,4-dicarboxyhexadecanoic acid, respectively.

Evolution of amino acid biosynthesis and enzymes with broad substrate specificity

I selected 82 proteins that were related to amino acid biosynthesis in the genome of Escherichia coli. I then searched the extensive sequence homology for each of the selected proteins from among the proteins of E.coli. The result showed that 30 proteins of the selected proteins had extensive sequence homology within the selected proteins, and 21 proteins had extensive sequence homology to proteins outside the selected proteins. In addition, the enzymes with broad substrate specificity play an important role in the amino acid biosynthesis. I demonstrate here that some substrate-specific enzymes evolved from an ancestor enzyme with broad substrate specificity.

CONTACT

hnishida@iam.u-tokyo.ac.jp