[Cell kinetics of rat lens epithelium by cytofluorometric nuclear DNA determination]

The cell kinetics of rat lens epithelium was assessed by measuring the changes in the nuclear DNA contents during sugar cataract formation. Six-and-12-week-old Sprague-Dawley male rats were used and divided into the following groups: fed on normal chow, fed on 25% galactose diet, and fed on normal chow after 5 days on the 25% galactose diet. Every second day following the beginning of each chow feeding, lenses were extracted, and lens capsules with epithelial cells were obtained. After a few day's fixation in 4% paraformaldehyde dissolved in 0.1M phosphate buffer (pH 7.4), DAPI (4'6-diamidino-2-phenylindole)-stained lens epithelial cells were measured by fluorescence cytophotometry. The epithelia in the normal chow-fed rats contained many 2C and a few 4C nuclei. In the 25% galactose-fed rats, 4C nuclei increased gradually in number until the fifth day, and then decreases slowly day by day. Abnormal polyploid nuclei (8C) were observed in the 25% galactose-fed rats. 4C nuclei decreased rapidly after the diet reversal. These results indicate that galactose feeding caused higher DNA synthesis of rat lens epithelial cells and a higher possibility of abnormal cell division.

Systemic amyloidosis following ankylosing spondylitis associated with congestive heart failure. A case report

We report the case of a 38-year-old man who developed fatal, systemic amyloidosis following ankylosing spondylitis. He was admitted for symptoms of congestive heart failure. Based on parotid gland biopsy and echocardiography, he was diagnosed as having systemic amyloidosis following active ankylosing spondylitis. However, the clinical course was rapidly progressive and eventually the patient died of acute necrotizing pancreatitis. The association has been reported thus far in a limited number of cases worldwide. The literature has featured localized lesions and a benign clinical course of the amyloidosis. This case, the first report from Japan, indicates that the amyloidosis associated with ankylosing spondylitis might exhibit a rapidly progressive clinical course, thereby suggesting that in such a case, meticulous treatment is required.

Differential display identifies developmentally regulated genes during somatic embryogenesis in eggplant (Solanum melongena L.)

Changes in gene expression patterns during early somatic embryogenesis of eggplant (Solanum melongena L.) were characterized by means of differential display. Eight products of polymerase chain reaction (PCR) derived from newly expressed mRNAs after four days of culture were identified and cloned. One clone, pTM002, was found to contain a 416 bp insert and identical to the proximal arbitrary primer at both ends. Based on the terminal sequences, reverse-transcription PCR (RT-PCR) was carried out to monitor the expression level of pTM002. The results indicated that the message of pTM002 was increased to correlate with the intensities obtained in the differential display. The significance of this method in investigation of differentially expressed genes is also discussed.

A new strategy of gene trapping in ES cells using 3'RACE

"Gene trapping" in embryonic stem (ES) cells is a novel approach to identify a series of genes in mammals concomitant with the production of the corresponding mutant mice. However, this approach is currently unable to identify genes that are not expressed in ES cells. Here we describe a strategy to identify gene trapping clones which is not based on expression of a reporter gene. It uses the neor gene which lacks a polyadenylation signal and has a splice donor signal. Expression of the neor gene as fusion transcripts with the 3' end containing the polyadenylation signal of tagged genes allows the identification of these clones by 3' rapid amplification of the cDNA end in undifferentiated ES cells, even if the genes are not expressed in ES cells. Amplification was observed in about 25% of G418-resistant clones. Sequence analyses suggested the amplifications represent gene trapping events. The feasibility of this approach was further assessed by analysing one clone, PAT-12, in detail.

Spinal cord injury in a child: a long term follow-up study. Case report

The main features of spinal cord injuries in children are known to be that (1) plain radiographs do not show the bony injury; (2) many of the injuries are complete spinal cord injuries; (3) many involve the upper thoracic spine; and (4) the duration of spinal shock is short. Complications such as pressure sores occur just as easily in children as in adults and the injuries are intractable. Typical complications in children with spinal cord injuries are spinal deformity and hip dislocation. We discuss a patient with a C7 spinal cord injury caused by a fall when the patient was 3 years old, and the physical complications occurring during the 15 years following the injury.

Heart failure progression due to secondary organ dysfunction in acute heart failure

Although the pathophysiology of heart failure progression is important to survival it is not fully understood. In 92 patients with acute heart failure due to myocardial infarction or dilated cardiomyopathy, secondary organ dysfunction was evaluated to determine whether this factor contributed to heart failure progression and death. Forty-one patients had renal dysfunction, hepatic disease or loss of consciousness after the onset of the acute heart failure, and 26 of them (63%) died of progressive heart failure during the follow-up period of 20 months on average. The one-year survival rate was 22%. Although 51 other patients showed the same initial clinical features and cardiac function, they did not develop concurrent organ dysfunction during the course and only 11 (22%, p < 0.001) died of progressive heart failure. The one-year survival rate was 67%. The survival rate decreased in the order of renal dysfunction, hepatic disease and loss of consciousness. Transient low cardiac output of less than 2.2 l/min/m2 was more frequent in patients with organ dysfunction. It is suggested that heart failure progresses, in part, due to organ dysfunction secondary to heart failure and careful treatment to prevent organ dysfunction is important to long term survival.

Acute torn meniscus combined with acute cruciate ligament injury. Second look arthroscopy after 3-month conservative treatment

The purpose of this study was to evaluate arthroscopically the natural healing of an acute torn meniscus combined with an acute cruciate ligament injury treated nonoperatively. There were 30 lateral and 10 medial meniscus tears associated with 25 acute anterior cruciate ligament and 7 posterior cruciate ligament injuries in 32 patients. There was more than 1 tear on some menisci for a total of 51 tear sites. Injuries to the menisci and ligaments were allowed to heal without surgery, but were given protective mobilization immediately in order to stimulate stress oriented healing of injured collagen fibers and promote circulation of synovial fluid to the meniscus and ligament. A Kyuro knee brace with a coil spring traction system was used to add adequate but not excessive stress to the associated injured cruciate ligament. All knees were examined and arthroscoped before and after a 3-month treatment period. Results indicated that 69% of the lateral menisci healed completely and 18% healed partially, whereas 58% of the medial menisci healed completely and none healed partially. Twenty of 25 anterior cruciate ligaments and 3 of 7 posterior cruciate ligaments healed satisfactorily. This study indicated that acute tears of the meniscus, even when they occur in association with a cruciate ligament injury, can heal morphologically with nonsurgical treatment.

New approach to assess quality of life in neonatal surgical cases: medical providers' subjective assessment of disease- and condition-related factors, using the linear analogue scale

A new questionnaire survey of pediatric surgeons and nurses, using the linear analogue scale, was used to determine subjective assessments of patients' quality of life (QOL) with regard to neonatal surgical diseases and conditions, including those involving anal and urinary functions. The results were analyzed according to the medical providers' years of professional experience. For six neonatal surgical diseases, QOL was assessed more favorably by less experienced surgeons and nurses. The result was similar for adulthood diseases. The development of medical technology can be attributed to this trend; however, QOL for patients with diaphragmatic hernia was assessed less favorably by less experienced surgeons (as 66.1%) than by more experienced surgeons (as 81.6%). Current technology has enabled the survival of neonatal surgical patients who are born prematurely and/or who have serious diseases or anomalies. Consequently this leads to poorer assessment of the surviving patients' QOL. QOL for patients with imperforate anus and spina bifida remained less favorably assessed. That of patients with conditions related to anal and urinary dysfunctions also scaled in the same manner. Anal dysfunction was less favorably assessed by less experienced surgeons (as 40.0%) than by more experienced surgeons (as 49.4%). In part, this discrepancy could be attributed to (1) better adjustment by the patients to their condition over time, and (2) greater focus on QOL issues in recent years. With regard to anal function, low QOL assessment correlated strongly with imperforate anus, Hirshsprung's disease, and spina bifida (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Torsades de pointes in paced patients with sick sinus syndrome after disopyramide administration

Three ventricular inhibited mode (VVI) pacemaker implanted patients, all above 65 years, female and having sick sinus syndrome suffered from torsades de pointes; one patient after 2.5 years and the other two patients within a day of disopyramide therapy. All had hypopotassemia and plasma disopyramide was below the therapeutic range in two patients. Torsades de pointes was induced following ventricular paced beats and suppressed by cessation of disopyramide in all or by setting a higher pacing rate in one. In our department, permanent VVI pacemakers were implanted in 43 patients with sick sinus syndrome including 26 with bradycardia-tachycardia syndrome, nine of whom were treated by disopyramide. Torsades de pointes was observed only in those disopyramide treated bradycardia-tachycardia patients. Our report stresses the proarrhythmic nature of combined VVI pacing and antiarrhythmic agents in the presence of hypopotassemia.

Days required for 75% suppression of ventricular premature contractions by antiarrhythmic agents obtained from continuous in-hospital ECG monitoring

To determine the number of days required to obtain 75% suppression of ventricular premature contractions (VPCs) by antiarrhythmic agents, which was expressed as t1/4, we performed 32 in-hospital continuous all day ECG monitoring trials in four groups of 28 symptomatic patients (ages; 54 +/- 20 years-old) with frequent VPCs. Nine patients had no organic heart disease (group 1, 11 trials), nine had valvular heart disease (group 2, 10 trials), three had dilated cardiomyopathy (group 3, 3 trials) and seven had myocardial infarction within two to four weeks onset (group 4, 8 trials). All patients were monitored by ECG telemetry with an arrhythmia analyzer, which could count hourly and daily VPCs. Class I antiarrhythmic agents were given in 18 trials, class II in two trials and class I+ class II in 12 trials. Plasma concentrations of the antiarrhythmic agents were monitored in 11 trials. In 21 trials, t1/4 could be obtained; ten (91%), six (60%), three (100%) and two trials (25%) in the four groups, respectively (p < 0.05). The value of t1/4 in the four groups was 6 +/- 6, 7 +/- 6, 14 +/- 11 and 13 +/- 2 days, respectively (mean 8 +/- 7 days; N.S.). Immediate response to the initial antiarrhythmic agent administration, expressed as percent VPC count after three hours, correlated significantly with t1/4 (r = 0.696, p = 0.0006), but ejection fraction, patient's age, control VPC counts or plasma antiarrhythmic agent level did not correlate with t1/4. In conclusion, t1/4 is a useful index for the evaluation of VPC suppression, revealing wide inter-individual variations and can be roughly estimated from the immediate response to the initial antiarrhythmic agent administration.

Vasodilatory capacity of coronary resistance vessels in dilated cardiomyopathy

Both the endothelium-dependent and endothelium-independent vasodilatory responses of coronary resistance vessels were studied in patients with dilated cardiomyopathy (DCM). A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery in 14 patients with DCM and in 10 patients with chest pain syndrome and a normal heart (control subjects). The ratio of maximum mean coronary blood flow velocity after intracoronary administration of the endothelium-independent vasodilator papaverine (10 mg) to resting mean coronary blood flow velocity (Vp/Vo) in patients with DCM was diminished compared with that in control subjects (2.2 +/- 0.6 vs 4.1 +/- 0.9, p < 0.001). The ratio after administration of the endothelium-dependent vasodilator acetylcholine (40 micrograms) (Va/Vo) in 10 DCM patients was also diminished compared with that in seven control subjects (1.3 +/- 0.5 vs 2.4 +/- 0.8, p < 0.01). In DCM patients, Vp/Vo was correlated with left ventricular end-diastolic pressure (r = -0.48, p < 0.05), left ventricular end-diastolic volume index (r = -0.68, p < 0.01), ejection fraction (r = 0.75, p < 0.01), and left ventricular end-diastolic wall stress (r = -0.73, p < 0.01). However, Va/Vo was not correlated with any of these parameters. These results indicate that impairment of the vasodilatory capacity of coronary resistance vessels in DCM may be related to endothelial dysfunction and to an extravascular factor resulting from left ventricular dysfunction.

QT prolongation and possibility of ventricular arrhythmias after intracoronary papaverine

The incidence of ventricular arrhythmias following the intracoronary injection of papaverine was assessed. A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery and 6-12 mg of papaverine was injected into the left coronary artery in 42 patients. After intracoronary papaverine, the corrected QT interval on the electrocardiogram was prolonged from 0.43 +/- 0.03 to 0.49 +/- 0.07 s (p < 0.001). Occasional premature beats were observed in 2 patients (4.5%) with dilated cardiomyopathy. In 1 patient (2.3%) with 99% stenosis of the left anterior descending artery, polymorphous ventricular tachycardia with marked QT prolongation occurred. This patient also had hypokalemia (2.5 mEq/l) due to primary aldosteronism. In conclusion, careful use of intracoronary papaverine is necessary because of the risk of occasional serious ventricular arrhythmias.

Swine interleukin 2 activity produced by mesenteric lymph node cells

Swine interleukin 2 (IL-2) activity was assayed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) colorimetric assay using murine IL-2 dependent cell line (CTLL-2). The culture supernatant of mesenteric lymph node (MLN) cells stimulated with phytohemagglutinin-P (PHA) induced a generation of MTT formazan in a dose-dependent manner, suggesting dose-dependent proliferation of CTLL-2. The maximal swine IL-2 activity was observed in the culture of MLN cells at 1 to 2 x 10(7) cells/ml when stimulated with 20 to 40 micrograms/ml PHA for 48 hr. Based on these findings, a large culture of MLN cells to prepare swine IL-2 were performed under the following condition; cell concentration of 1 x 10(7) cells/ml, PHA concentration of 20 micrograms/ml, a culture scale of 200 to 400 ml, and a stirring speed of 30 rpm. Swine IL-2 activity was detected from 4 hr after PHA stimulation, and rapidly increased until 16 hr. Almost maximal IL-2 activity in stirring culture was observed at the incubation of 20 hr. Swine IL-2 was partially purified by Sephacryl S-200 gel filtration and the estimated molecular weight was about 32 kD based on the peak of IL-2 activity. The pI value of swine IL-2 was estimated to be approximately pH 5.3. Swine IL-2 was sensitive to acid (pH 3.2) or alkaline (pH 10.5), 4 or 8 M urea, trypsin, and the heating at 70 degrees C. These physico-chemical properties of swine IL-2 was similar to those of human, murine or feline IL-2.

Features of coronary artery lesions related to left ventricular aneurysm formation in anterior myocardial infarction

To determine the factors of left ventricular aneurysm formation in acute myocardial infarction, the authors studied the distribution of coronary artery lesions and the left ventricular wall motion of 43 patients with anterior myocardial infarction. Of 15 patients with aneurysm, 9 (60%) showed a single-vessel disease with severe stenosis of the proximal left anterior descending artery. Of 9 patients with triple-vessel disease, 8 (89%) had no aneurysm. In patients with the aneurysm, the Gensini score of the culprit lesion was significantly higher (p < 0.05) and the score except for the culprit lesion was less (chi 2 = 5.7, p < 0.05). In 23 patients with single-vessel disease, the collateral score was significantly less (p < 0.05) in patients with the aneurysm. The systolic wall motion on the ventriculogram appeared more impaired in the anterior infarct area but well maintained in the posterior noninfarct area in patients with the aneurysm. In conclusion, the important factors of left ventricular aneurysm formation were as follows: (1) A culprit lesion of the myocardial infarction was severe, but other coronary artery lesions were mild. (2) Collateral vessels were poor. (3) The left ventricular wall motion of the infarct area was impaired, but that of the noninfarct area was relatively good.

Pronounced ST-segment depression during paroxysmal supraventricular tachycardia

To determine the clinical significance of ST-segment depression observed in paroxysmal supraventricular tachycardia (PSVT), we evaluated the 12-lead electrocardiogram (ECG) during spontaneous PSVT in 54 patients (27 men and 27 women: mean age +/- SD; 47 +/- 18 years), who came to our clinic for the treatment of PSVT. Coronary angiography was performed in 16 patients (16 to 74 years; mean = 50 +/- 18) and treadmill exercise testing was performed in 21 patients. A cardiac electrophysiological study was carried out in 24 patients. During PSVT, ST-segment score was calculated as the sum of the ST-segment depression in 12 leads. The correlations between the ST-segment score, PSVT rate and age of the patient were analyzed as follows: The most significant positive correlation was observed between the ST-segment score and the PSVT rate (r = 0.615, p < 0.000001). The next most significant correlation was found between the PSVT rate and the age of the patient (r = -0.500, p = 0.00011). A negative correlation was also observed between the ST-segment score and the age of the patient (r = -0.429, p = 0.0012). In 13 of 16 patients, coronary angiography did not reveal any significant (> or = 75% in area) stenosis. Exercise testing induced significant ST-segment depression in 3 patients, of whom two had significant coronary artery lesions. PSVT was due to atrioventricular reentry via an overt (n = 3) or concealed accessory pathway (n = 15), atrioventricular nodal reentry (n = 5) and sinus node reentry (n = 1). In conclusion, patients with a faster PSVT rate revealed more pronounced ST-segment depression than did those with a slower PSVT rate, possibly reflecting the modified repolarization process instead of coronary artery involvement.

Venoarterial carbon dioxide tension gradient in acute heart failure

The venoarterial carbon dioxide tension gradient (P[v-a]CO2) was studied in patients with acute myocardial infarction. Seven patients with congestive heart failure (CHF group) and 10 patients without heart failure (control) were enrolled in this study. In all patients, hemodynamics were continuously monitored. Simultaneously, arterial and mixed venous blood were sampled, and blood gases and lactate concentration were analyzed. At the initial measurement before therapy, arterial and mixed venous pH and bicarbonate values were within the normal range, and there was no significant difference between the CHF group and controls. There was also no difference in arterial oxygen tension under the differential conditions of oxygen inhalation. However, cardiac index and mixed venous oxygen saturation (SvO2) were significantly lower, while the oxygen extraction ratio (OER) and arterial lactate were significantly higher in the CHF group than in the controls. On the other hand, P[v-a]CO2 was significantly higher in the CHF group (7.8 +/- 2.6 vs. 3.5 +/- 2.2 mm Hg, p < 0.01). This finding was due to the elevated mixed venous carbon dioxide tension in the CHF group, since arterial carbon dioxide tension was the same in both groups. Analysis of a total of 42 measurements obtained during the therapeutic course in the CHF group revealed a correlation of P[v-a]CO2 with cardiac index (r = -0.3, p < 0.05), OER (r = 0.57, p < 0.001), SvO2 (r = -0.56, p < 0.001) and lactate (r = 0.62, p < 0.001). The increase in P[v-a]CO2 observed in acute heart failure suggests the evidence of intracellular acidosis despite the absence of acidemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary flow reserve in patients with dilated cardiomyopathy

Coronary flow reserve was studied in patients with dilated cardiomyopathy. A 3F coronary Doppler catheter was placed in the proximal left anterior descending artery in each of 10 patients with dilated cardiomyopathy (CDM group), seven patients with coronary artery disease that involved only the left anterior descending artery (CAD group), and seven patients with chest pain syndrome and normal hearts (control group). Coronary flow reserve was calculated as the ratio of the maximum mean coronary blood flow velocity after intracoronary administration of papaverine (10 mg) to resting flow velocity (M/R). The time until maximum flow velocity was reached after papaverine administration (Tmax) was also measured. M/R was lower in the DCM (p < 0.001) and CAD (p < 0.001) groups when compared with the control group. Tmax was not abnormal in the DCM group but was prolonged in the CAD group (p < 0.05). In the DCM group, the M/R ratio correlated with the left ventricular end-diastolic pressure (r = -0.69; p < 0.05), the left ventricular end-diastolic volume index (r = -0.7; p < 0.05), the ejection fraction (r = 0.82; p < 0.01), the left ventricular mass (r = -0.7; p < 0.05), and the left ventricular end-diastolic wall stress (r = -0.84; p < 0.001). These results indicate that coronary flow reserve was decreased in patients with dilated cardiomyopathy and that the mechanism of its reduction may differ from that in patients with coronary artery disease.

[A case of coronary artery embolism associated with combined valvular heart disease]

A 53-year-old-man afflicted with combined valvular heart disease and atrial fibrillation was admitted to our department complaining of chest pain. ST elevation on ECG (II, III, aVF) and elevated CPK value were recognized. He was diagnosed as having acute myocardial infarction, and percutaneous transluminal coronary recanalization was performed immediately. The coronary angiogram showed occlusions at the proximal left branch (#12). But these lesions could not be recanalized by 960000 IU urokinase administration. The cineangiogram after one month revealed perfect recanalization of these occlusions. Mitral stenosis with neovascularity to the left atrium and aortic regurgitation were recognized. We supposed this infarction caused by coronary embolism originated from left atrial thrombi. Acute myocardial infarction associated with mitral stenosis has been reported in fifteen cases previously in Japan, but only three cases revealed coronary occlusion in the acute phase with normal coronary artery in the chronic stage. However, there has been no report, except for this case, demonstrating occlusion in two coronary arteries at the same time. So, our case is the first report of the involvement of two coronary artery occlusions.

The role of the Maternal and Child Health Handbook system in reducing perinatal mortality in Japan

OBJECTIVE

The purpose of this paper is to demonstrate the direct and indirect roles of the Maternal and Child Health (MCH) Handbook in promoting overall improvement in maternal health and child care and to attempt to clarify the relationship between the use of the MCH Handbook and the reduced perinatal mortality in Japan. Another important objective is to propose possible future applications of the MCH Handbook, especially with respect to the networking function of providing client-care provider feedback, and the exchange of health data between the authorities and relevant medical societies.

RESULTS

Japan has achieved a decline in neonatal mortality in the 30-year period from 1960 to 1990, from 17.0 to 2.6 per 1,000 live births. There is a correlation between the ratio of the number of Handbooks distributed and the actual number of births and the perinatal mortality.

CONCLUSIONS

The wide use of the MCH Handbook system seems to have played an important role in bringing about this reduction and in maintaining the figure as one of the lowest in the world. The reduction of perinatal mortality through the use of the MCH Handbook in this country suggests a similar possibility for application in other nations. The Handbook could aid in the early recognition of high-risk pregnancy and thus reduce inappropriate use of medical resources. The system, with the establishment of a feedback system between the client and the authorities via the care provider, may improve health care in such areas as maternal mortality, toxemia of pregnancy, and diabetes mellitus.

Left ventricular diastolic dysfunction in coronary artery disease: effects of coronary revascularization

Left ventricular diastolic dysfunction was studied globally and regionally in patients with coronary artery disease, and the effects of coronary revascularization were evaluated. A total of 25 patients with angina pectoris who had a stenotic lesion (greater than or equal to 90%) in only left anterior descending branch underwent coronary revascularization [percutaneous transluminal coronary angioplasty (PTCA) in 13 patients and coronary artery bypass graft (CABG) in 12]. Nine patients with normal coronary artery were studied as controls. Left ventricular volume and radial axes were measured on serial frames of one cardiac cycle by cine left ventriculography. The radial axes were drawn from the left ventricular gravity to left ventricular wall at every 20 degrees. Left ventricular filling fraction and distension rate of radial axes were calculated at the times of 25%, 50%, 75%, and 100% of diastolic period, 100% being end-diastole. Although there were no significant changes of the systolic function by revascularization, the filling fraction increased from 11.2 +/- 2.6 to 14.5 +/- 3.5% (p less than 0.001) at 25% time of diastole, from 29.9 +/- 4.9 to 32.5 +/- 5.0% (p less than 0.05) at 50% time in the PTCA group, and from 11.8 +/- 3.7 to 13.4 +/- 3.8% (p less than 0.01) at 25% time in the CABG group. The distension rate of radial axis to the anterior wall also increased significantly at 25% and 50% time of diastole after revascularization, and the change was marked in the PTCA group. However, these increases did not apply to the control patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Quality management in healthcare. Evaluation and improvement]

Quality in healthcare is a concept ultimately determined by the satisfaction of the patient, or more broadly stated, society's needs. Improvement in quality begins with the review of health care organizations, in the degree to which their current role and function can and do meet these needs. Recent trends in quality evaluation have been along the lines of patients satisfaction, as well as structure, process, and outcome oriented aspects of health care delivery. Quality entails not only the science of medicine itself, but also health care delivery, as well as social and individual concerns. In 1990, Japan Hospital Quality Assurance Society was founded. The secretariat is located at this department. Currently, more than 60 hospitals participate for the development of standards and survey to the hospitals. The quality improvement effort has slowly begun to put the concept into practice. The public's growing concern is directed toward holding healthcare organizations accountable for the services they provide. The healthcare field, in turn, is recognizing the needs and merit of voluntary commitment to quality, and are placing emphasis on identifying pressing society needs, and developing effective leadership. Moving the entire healthcare field in the direction of continuous quality improvement will be the key to the survival into the 21st century.

Hemofiltration as treatment for patients with refractory heart failure

Hemofiltration was performed in 15 patients with refractory congestive heart failure. All of these patients had oliguria, although intensive treatment with diuretics, digitalis, vasodilators, and catecholamines was prescribed. Hemofiltration was performed under hemodynamic monitoring in 14 patients. The water removal by hemofiltration decreased pulmonary arterial pressure, pulmonary capillary wedge pressure and right atrial pressure. Despite these hemodynamic improvements, nine patients (60%) died within one month after the start of hemofiltration; the causes were fatal arrhythmia in three, renal failure in two, sepsis in one and irreversible cardiogenic shock in three. Oliguria for over 15 h or a serum creatinine concentration of more than 4.0 mg/dl at the start of hemofiltration related to poor prognosis. In view of these results, hemofiltration for refractory heart failure should be started earlier and performed carefully in order to avoid arrhythmia, cardiogenic shock, and other complications.

Activation of the osmoregulated ompF and ompC genes by the OmpR protein in Escherichia coli: a study involving chimeric promoters

The expression of each of the Escherichia coli ompF and ompC genes is activated by the common positive regulator, OmpR, in response to the medium osmolarity. The promoters for these genes consist of canonical -35 and -10 regions, and upstream OmpR-binding sites. In this study, we constructed a functional ompF-ompC chimeric promoter consisting of the OmpR-binding site of ompF, and the -35 and -10 regions of ompC, which was fused to the lacZ gene on a low-copy-number plasmid. It is known that the ompF and ompC genes are expressed in a different manner in cells with mutations in the ompR gene. In this respect, it was found that the ompF-ompC chimeric promoter behaves just like ompF promoter with respect to an ompR mutation (ompR472). It was revealed that, in this chimeric promoter, the OmpR-binding site must be located stereospecifically with respect to the -35 and -10 regions for OmpR-dependent transcription of the ompF-ompC chimeric promoter to occur. These results are discussed in relation to the structures and functions of the ompF and ompC promoters, the occurrence of a DNA curvature in the promoter regions being implied, which may be an important parameter for the transcription activation by the OmpR protein.

[A case of angina pectoris with cardiac arrest at treadmill stress test]

We reported a case of angina pectoris with cardiac arrest immediately after treadmill exercise test, and the effect of PTCA in the same case. A 69-year-old Japanese male had chest oppression on exertion. Initial treadmill test showed 2 mm ST-segment depression in leads V4-6. Two minutes after exercise, he had atrio-ventricular (A-V) block and cardiac arrest with episodes of fainting. He was resuscitated by chest thump. Coronary angiography showed 90% stenosis in the right coronary artery (RCA). PTCA for RCA was able to dilate the stenotic lesion. The second treadmill test after PTCA did not induce bradycardia nor A-V block. It was suggested that the RCA lesion may play a critical role.

Effects of secondary organ failure on compensation of acute heart failure in patients with myocardial infarct and dilated cardiomyopathy

Compensation for heart failure can be influenced by cardiac loads due to organ failure. This investigation studied the effect of secondary organ failure on the hemodynamics of acute heart failure. Of 106 patients with acute heart failure due to myocardial infarction or dilated cardiomyopathy, 49 (46%) patients had secondary organ failure, either kidney, liver, brain or blood. Their acute heart failure was sustained for significantly longer than that of 57 patients without organ failure. A transient but severe decompensation induced secondary organ failure, although the left ventricular ejection fraction was not different from that of the control without heart failure. Hypervolemia in cases of renal failure, bradycardia in loss of consciousness, hyperdynamic state in anemia and low blood pressure in liver dysfunction caused the sustained acute heart failure. These results suggested that secondary organ failure might occur in 46% of patients with acute heart failure, and might disrupt compensation by different kinds of hemodynamic loads in low cardiac function.

Human fibroblast cells synthesize and secrete nerve growth factor in culture

Using our enzyme immunoassay system developed for recombinant hNGF, we examined the synthesis and secretion of human NGF (hNGF) by human fibroblast (WS-1) cells. The amount of the factor secreted by WS-1 cells increased linearly and a significant amount of NGF was detected in the conditioned medium of WS-1 cultures. WS-1 NGF showed properties identical to those of recombinant human NGF in immunoreactivity and molecular weight. An increase in cell density or the withdrawal of serum from the culture medium caused a drastic decrease in the rate of NGF secretion. These results suggest that WS-1 cells are able to synthesize and secrete hNGF in culture and that the synthesis/secretion is regulated in a growth phase-dependent manner.

Higher Gensini score of coronary arteries in acute inferior myocardial infarction with precordial ST-segment depression

To investigate the significance of precordial ST-segment depression in acute inferior myocardial infarction, we compared the Gensini score of coronary artery stenosis between 2 groups of patients with and without precordial ST-segment depression. Group I consisted of 28 patients who showed ST-segment depression on admission (greater than or equal to 1 mm in V2-V6) and Group II (n = 16) those without ST-segment depression (less than 1 mm). The Gensini score of the coronary arteries (56 +/- 29 vs. 28 +/- 18; p less than 0.001), the partial score of the infarction-related artery (29 +/- 16 vs. 17 +/- 11; p less than 0.01) and of the infarction-nonrelated artery (27 +/- 24 vs. 11 +/- 12; p less than 0.02) were significantly higher in Group I than in Group II. The Killip score (greater than or equal to II) (34% vs. 6%; p less than 0.05), frequency of arrhythmias (75% vs. 38%; p less than 0.02) and peak CK value (3,676 +/- 2,290 vs. 1,818 +/- 1,153 IU/L; p less than 0.005) were higher in Group I than in Group II. Four patients in Group I died following admission, while no patient died in Group II (N.S.). Autopsy findings from the 4 Group I patients revealed fresh extensive inferior infarction and healed diffuse subendocardial infarction which could not be predicted from electrocardiograms. All patients who survived the acute stage performed treadmill exercise testing and 22 patients underwent exercise thallium-201 single photon emission computer tomography (SPECT). On treadmill exercise test, there was no significant difference between the 2 groups in the frequency of angina pectoris and ST-segment depression. On SPECT, the perfusion defect area under 55% of maximum uptake at the redistribution phase was 45.8 +/- 19.6 cm2 in Group I (n = 14) and 34.7 +/- 21.3 cm2 in Group II (n = 8; N.S.). In conclusion, precordial ST-segment depression in acute inferior myocardial infarction suggested advanced atherosclerosis in both the infarction-related and nonrelated coronary arteries, indicating a larger infarct size.

Survival from acute occlusion of the left main coronary artery with preexisting collateral vessels--a case report

A thirty-two-year-old man suffered from evolving acute myocardial infarction caused by total occlusion of the left main coronary artery, which was 95% stenosed before the onset. Nevertheless, he had a good clinical course. The myocardium may have been protected by well-developed preexisting collateral vessels as evidenced by serial coronary angiograms.

Aortic dissection associated with aortitis syndrome

A 50-year-old woman with aortitis syndrome complicated by aortic dissection, is reported. The dissection was observed at the level of the descending thoracic aorta by aortography and at the intimal side of the dilated aorta on CT. An aneurysm of the right subclavian artery and a diffusely thick wall of the abdominal aorta were also observed. This case suggests that the uneven wall of the aorta in aortitis syndrome might be dissected at the intimal side by dilatation.

Lower pacemaker in high degree atrioventricular block is modulated electrotonically by atrial excitations

To see if the lower pacemaker in patients with atrioventricular (AV) block was modulated electrotonically by atrial excitation, we studied R-R intervals in two groups of AV block patients using a phase response curve (PRC). Group I consisted of 20 patients with high degree AV block, including seven patients in whom complete AV block was transiently observed in the course of acute inferior myocardial infarction. Group II consisted of 19 patients with complete AV block. In every patient, PRC was obtained from the continuous electrocardiogram by plotting each R1-R2 interval (response) on the ordinate as a function of the R1-Px interval (phase, x = 1, 2 ...) on the abscissa. In Group I, the R-R interval was prolonged when the P wave fell in the initial half of the R-R interval, and was abbreviated when the P wave fell in the later half of the cycle. In Group II, the fluctuation of the R-R interval was minimum. In ten group I patients, with the improvement of the AV block, PRC became sharper and transition from prolongation to shortening occurred at shorter R-P intervals. We conclude that, in Group I, lower pacemaker was modulated electrotonically by atrial excitations through decreased electrical coupling along the AV node.

Expression of micF involved in porin synthesis in Escherichia coli: two distinct cis-acting elements respectively regulate micF expression positively and negatively

micF RNA, whose sequence is highly complementary to a 5'-portion of ompF mRNA, has been implicated in the osmoregulation and thermoregulation of the ompF porin gene in Escherichia coli. To define and characterize cis-acting regulatory regions upstream of the micF promoter, a series of deletions of the micF promoter fused to the lacZ gene were constructed. Two distinct regions, which function differently, were identified as cis-acting regulatory elements, namely, one responsible for OmpR-dependent activation and the other for OmpR-independent repression of micF expression. The former contains the OmpR-binding site, which simultaneously regulates both the genes, micF and ompC, in response to the medium osmolarity. The latter may be involved in an unknown regulatory process of micF expression.

Activation of the osmoregulated ompC gene by the OmpR protein in Escherichia coli: a study involving synthetic OmpR-binding sequences

Expression of the Escherichia coli outer membrane proteins, OmpC and OmpF, is regulated in response to the medium osmolarity. The OmpR and EnvZ proteins are transcriptional factors involved in this osmotic regulation of the ompC and ompF genes. In particular, expression of the ompC gene is activated by the positive regulator, OmpR, in response to high osmolarity of the medium. In this study, we succeeded in defining a functional OmpR-binding sequence by analyzing a set of synthetic oligonucleotides, and propose a consensus motif for OmpR-binding. It was also demonstrated that the asymmetric OmpR-binding sequence, thus identified, can activate the canonical ompC promoter in an orientation independent-manner, providing that this sequence is placed closely and stereo-specifically with respect to the -35 region.

Left ventricular diastolic filling in patients with coronary artery disease without myocardial infarction

Left ventricular diastolic dysfunction at rest was studied in 24 patients with coronary artery disease but no evidence of previous myocardial infarction. Seven patients with normal coronary arteries were studied as control. Diastolic filling was analyzed by the serial left ventricular volume and 14 radial axes from the gravity point of the left ventricle with cine left ventriculography. There were no differences in the systolic function between coronary artery disease and the normal control. Peak filling rate was decreased significantly in the groups with left anterior descending artery disease (LAD, p less than 0.05) and multivessel disease (MVD, p less than 0.05), but not in the group with right coronary artery disease (RCA). Time to peak filling rate was prolonged in each group of LAD (p less than 0.05), RCA (p less than 0.05), and MVD (p less than 0.001), compared with controls. The time-volume curve showed disturbed rapid filling in the LAD and RCA groups, and also both depressed rapid and slow filling in the MVD group. In the LAD group, the filling fraction was decreased significantly at the time of 25% of the diastolic period (p less than 0.001) and radial distension to the anterior wall was decreased at the time of 25%, 50%, and 75% of the diastolic period, compared with controls. In the RCA group, the filling fraction (p less than 0.001) and radial distension to the posterior wall were decreased only at the time of 25% of the diastolic period. In the MVD group, filling fraction and radial distension to the most wall were decreased at 25%, 50%, and 75% of the diastolic period.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitroglycerin-induced transient coronary artery occlusion

Nitroglycerin induced a paradoxical disappearance of a stenosed coronary artery in a 57-year-old man with non-Q wave myocardial infarction. On the coronary angiogram, the left anterior descending coronary artery (with a 95% stenosis) became completely invisible 2 min after 0.3 mg sublingual nitroglycerin. Three minutes later, the artery was opacified again. This transient occlusion may have resulted from a passive collapse of the distal portion of the artery, due to insufficient access of nitroglycerin across the stenotic region.

Global and regional abnormalities of left ventricular diastolic filling in hypertrophic cardiomyopathy

Left ventricular diastolic filling was studied by left ventriculography in 17 patients with hypertrophic cardiomyopathy (HCM). In 8 patients this manifested as a spadelike shape (HCM-S type) on the left ventriculogram, and in 9 patients as a banana shape (HCM-B type). Seven patients were studied as controls. Left ventricular end-diastolic pressure was higher in HCM than in controls. In HCM, peak filling rate was decreased from 1.57 +/- 0.28 of the control to 1.28 +/- 0.20 (p less than 0.05), and the time to peak filling rate was prolonged from 27 +/- 6%DT of the control to 37 +/- 7%DT (p less than 0.01). Serial volume analysis in diastole showed filling fraction was also significantly decreased to 8.2 +/- 4.1 (p less than 0.001) at the 25% diastole time and 29.6 +/- 7.2 (p less than 0.01) at half time, compared with 19.8 +/- 6.3 and 32.8 +/- 5.8 for controls, respectively. In HCM-S type, the rate of distention of left ventricular radial axes at the apical area was lower at early and mid-diastole. In HCM-B type, the rate at the basal area was lower at early and mid-diastole. Results suggest that the left ventricular diastolic filling in HCM was impaired not uniformly but regionally in the hypertrophic area at early and mid-diastole.

[Role of carcinoembryonic antigen, carbohydrate antigen 19-9 and cytology of bile in diagnosis of biliary and pancreatic cancer]

To evaluate the clinical value in diagnosis of biliary and pancreatic cancer carcinoembryonic antigen (CEA), carbohydrate antigen (CA19-9) and cytology in the bile were examined in 343 patients with benign biliary disease and 71 patients with biliary and pancreatic cancer. An abnormal CEA level was defined as a level of more than 500 ng/ml in the gallbladder bile and 40 ng/ml in the bile duct bile. Increased bile CEA levels were observed in 50.0% in 22 patients with bile duct cancer, 60.0% in 20 with gallbladder cancer and 23.8% in 21 with pancreas cancer. False positive rate in 343 patients with benign diseases was only 1.2%. Bile CA19-9 levels were measured in 195 patients with benign disease and 30 with malignancy. However, the overlap between the values of the 2 groups was too great for differentiation of malignancy from benign disease. The positive rates of bile cytology were 52.2% in 23 patients with bile duct cancer, 40.0% in 15 with gallbladder cancer and 27.3% in 22 with pancreatic cancer. The diagnostic accuracies of combined assessment of bile CEA and cytology were 68.0% in 25 patients with bile duct cancer, 77.3% in 22 with gallbladder cancer and 37.5% in 24 with pancreatic cancer. The sensitivity of this combined test was 60.6% (43/71), and the specificity was 98.8% (339/343). This combined test is considered to be reliable screening test especially for biliary cancer.

A rare case of caudal duplication

A rare case of caudal duplication is reported. The infant had two well-formed lower limbs and pelvis with external male genitalia attached to the epigastrium. This is only the second reported case in which the parasite was attached to the epigastrium and it is the first reported case of caudal duplication without omphalocele.

Coronary artery disease associated with aortitis syndrome in older patients

Coronary artery disease associated with aortitis syndrome was studied in relation to the coronary artery lesions and age. Four (21%) of 19 patients with aortitis syndrome had coronary artery disease and the mean age of the 4 patients was 53 +/- 14 years. The coronary artery lesions included ostial stenosis in 2 patients and main branch stenosis in 2, but both types of lesion were isolated. The latter patients were older and had coronary lesions like arteriosclerosis on angiogram. Myocardial infarction and congestive heart failure were not present, but a severe coarctation of the aorta was observed in the latter. It was suggested that coronary artery disease might not be rare past middle age, and might include coronary ostial stenosis caused by aortitis and coronary main branch stenosis probably based on secondary arteriosclerosis whose onset was past middle age.

Cardiac rupture following acute myocardial infarction in systemic lupus erythematosus: case report

A thirty-three year-old woman with systemic lupus erythematosus (SLE) suffered from acute myocardial infarction. Prednisolone 20 mg/day was used because the signs of SLE, such as fever and decreased serum C3, levels, became aggravated on the fifth hospital day of acute myocardial infarction. Fatal cardiac rupture occurred on the twenty-second hospital day. At autopsy, extensive myocardial infarction with coronary artery thrombi and diffuse coronary arteritis were revealed. The rare clinical picture of a fatal cardiac rupture in the later phase of acute myocardial infarction and the precise dosage of prednisolone for her SLE are described.

Headache angina with fatal outcome

We report 2 fatal cases of angina pectoris in patients who complained primarily of headache during the ischemic attack. The first patient, who was hospitalized because of headache and chest pain, demonstrated repeated ST-segment elevation and fatal ventricular fibrillation on ambulatory ECG monitoring. The second patient had post-infarction angina preceded by headache and by ST-segment elevation in the precordial leads. She eventually died of reinfarction. The mechanism of the headache in relation to the angina pectoris is discussed.

Surface structure analysis by transmission electron diffraction: effects of the phases of structure factors

To solve the problems related to the phases of the structure factors in surface structure analysis by transmission electron diffraction, the dynamical diffraction in the bulk crystal underneath the surface layer is considered by the many-beam theory. In the case of normal beam incidence, the intensities of superlattice reflections from surfaces and/or adsorbed layers are used to discriminate whether the surface structure is substitutional or displacive in type. In the case where only two beams are strongly excited in the bulk crystal, the phases of the structure factors of the surface layer are determined by the rocking curve of the superlattice reflections.