[Ventricular septal defect, pulmonary hypertension and 3C (cranio-cerebello-cardiac) syndrome: report of a case]

We report a case with the rare association of craniofacial anomalies, cerebellar vermis hypoplasia (Dandy-Walker variant) and congenital heart disease referred to as 3C (cranio-cerebello-cardiac) syndrome. A male infant was born at 40 weeks' gestation. The birth weight was 2,896 g. At birth he had macrocephaly, widely open metopic suture, ocular hypertelorism, cleft palate, apparently low-set ears, cerebellar vermis hypoplasia and ventricular septal defect (VSD) with pulmonary hypertension. Chromosomes were normal and we diagnosed 3C syndrome. At 8 months of age we performed a cardiac catheterization. The pulmonary artery pressure was 70/26 (48) mmHg and pulmonary vascular resistance (RpU) was 8.5 U/m2. But under the oxygenation RpU decreased to 1.5 U/m2. At 10 months of age we performed VSD patch closure. After operation his pulmonary artery pressure was 39/13 (25) mmHg under the oxygen therapy. He was on good course and discharged at 58 post operative day.

Narrow band imaging for detecting superficial squamous cell carcinoma of the head and neck in patients with esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIMS

Narrow band imaging combined with magnifying endoscopy (NBI-ME) is useful for the detection of superficial squamous cell carcinoma (SCC) within the oropharynx, hypopharynx, and oral cavity. The risk of a second primary SCC of the head and neck is very high in patients with esophageal SCC. This prospective study evaluated the detection rate of superficial SCC within the head and neck region (superficial SCCHN) with NBI-ME in patients with esophageal SCC.

PATIENTS AND METHODS

Between March 2006 and February 2008, 112 patients with a current or previous diagnosis of esophageal SCC were enrolled. All patients underwent endoscopic screening of the head and neck by NBI-ME. The primary end point was the detection rate for superficial SCCHN. Secondary end points were to compare demographic characteristics between patients with and without superficial SCCHN and to assess the clinical course of patients with superficial SCCHN.

RESULTS

The detection rate for superficial SCCHN was 13 % (15/112). The prevalence of multiple Lugol-voiding lesions, observed endoscopically throughout the esophageal mucosa after application of Lugol dye solution, was significantly higher in patients with superficial SCCHN than in those without (100 % vs. 24 %, P < 0.0001). Minimally invasive curative treatment with organ preservation was feasible without severe complications in patients with superficial SCCHN after curative treatment of esophageal SCC.

CONCLUSIONS

In patients with esophageal SCC, NBI-ME is useful for detecting superficial SCCHN, thereby facilitating minimally invasive treatment.

[Ascending aortic aneurysm and aortic valve regurgitation long after operative repair of coarctation of the aorta: report of a case]

We report a case of surgical treatment for ascending aortic aneurysm and aortic valve regurgitation (AR) 24 years after operative repair of coarctation of the aorta (CoA). The patient was a 32-year-old man who had undergone operative repair of CoA and patent ductus arteriosus (PDA) ligation when 8 years old, and was followed since then. However, since 14 years after the operation, dilation of his ascending aorta and AR was observed. Then the AR deteriorated and the ascending aorta dilated, and at 24 years after operation he had symptoms of heart failure. So we performed ascending aorta replacement and aortic root replacement (reimplantation). Despite primary success of the operative repair of CoA, however. 9% of patients develop aortic aneurysms long after the operation. Therefore, long-term follow-up is needed after repair of coarctation of the aorta.

Insulin2 gene (Ins2) transcription by NOD bone marrow-derived cells does not influence autoimmune diabetes development in NOD-Ins2 knockout mice

Insulin is a critical autoantigen for the development of autoimmune diabetes in non-obese diabetic (NOD) mice. About 80% of NOD females and 30-40% of NOD males develop diabetes. However, Insulin2 (Ins2) knockout NOD mice develop autoimmune diabetes with complete penetrance in both sexes, at an earlier age, and have stronger autoimmune responses to insulin. The severe diabetes phenotype observed in NOD-Ins2-/- mice suggests that lack of Ins2 expression in the thymus may compromise immunological tolerance to insulin. Insulin is a prototypical tissue specific antigen (TSA) for which tolerance is dependent on expression in thymus and peripheral lymphoid tissues. TSA are naturally expressed by medullary thymic epithelial cells (mTEC), stromal cells in peripheral lymphoid tissues and bone marrow (BM)-derived cells, mainly CD11c(+) dendritic cells. The natural expression of TSA by mTEC and stromal cells has been shown to contribute to self-tolerance. However, it is unclear whether this also applies to BM-derived cells naturally expressing TSA. To address this question, we created BM chimeras and investigated whether reintroducing Ins2 expression solely by NOD BM-derived cells delays diabetes development in NOD-Ins2-/- mice. On follow-up, NOD-Ins2-/- mice receiving Ins2-expressing NOD BM cells developed diabetes at similar rates of those receiving NOD-Ins2-/- BM cells. Diabetes developed in 64% of NOD recipients transplanted with NOD BM and in 47% of NOD mice transplanted with NOD-Ins2-/- BM (P = ns). Thus, NOD-Ins2-/- BM did not worsen diabetes in NOD recipients and Ins2 expression by NOD BM-derived cells did not delay diabetes development in NOD-Ins2-/- mice.

[Ventricular septal defect with aortic valvular regurgitation complicated with infective endocarditis; report of a case]

We report a case of ventricular septal defect (VSD) associated with infective endocarditis complication of aortic and pulmonary valvular regurgitation. He received treatment for pyelonephritis and after 2 months he was suffering from congestive heart failure. Echocardiography showed vegetation on the aortic valve and the anterior semilunar cusp of the pulmonary valve. He was referred to our department for surgical repair. Aortic valvular replacement, pulmonary valvular repair and direct closure of VSD were performed. The postoperative course was uneventful and the patient discharged at 28 postoperative day.

[Noonan syndrome with atrial septal defect and hypertrophic cardiomyopathy]

Noonan syndrome is one of the most common nonchromosomal syndromes seen in children with congenital heart disease. The major cause of death is congestive heart failure. We report a case of Noonan syndrome with hypertrophic cardiomyopathy and arterial septal defect (ASD). Since 10 years old he had been suffering from congestive heart failure. ASD patch closure with a fenestrated flap valve patch was performed at 12 years of age. After operation, left-to-right shunt flow through the patch gradually decreased and he was discharged at 19 postoperative day in good condition.

[Aortic valve repair and patch closure for unruptured aneurysm of non-coronary sinus of valsalva with aortic regurgitation]

The patient was a 53-year-old woman who complained of chest pain. Echocardiography and angiography revealed mild aortic regurgitation (AR) with an eccentric jet and an unruptured aneurysm of the non-coronary sinus of Valsalva which protruded into the left atrium. Operative findings showed that tethering due to elongation of the circumference of the aortic wall at the level of the non-coronary sinus commissures caused AR. Then patch closure and partial sino-tubular (ST) junction plication were carried out. Postoperative echocardiography showed decrease of AR and complete repair of the aneurysm of Valsalva sinus.

[Aortoesophageal fistula due to thoracic aortic aneurysm; report of a case]

We report a 74-year-old man with aortoesophageal fistula due to aotic aneurysm. He underwent 2 stage operations. At the 1st operation the graft replacement of thoracic aorta and esophagectomy were performed. Inflammatory reactions improved with systemic administration of antibiotics and continuous irrigation of the thoracic cavity. On the 21st postoperative day, the esophagus was reconstructed by gastrointestinal interposition technique via ante-thoracic route. On the 58th post operative day he was discharged.

Erythrocyte magnesium and prostaglandin dynamics in chronic sleep deprivation

BACKGROUND AND HYPOTHESIS

The mechanism of sudden cardiac death occurring in patients with chronic fatigue is controversial. This study was designed to define a hypothesis that coronary arterial spasm and thrombus formation can occur during chronic fatigue.

METHODS

For evaluating the feasibility of coronary arterial spasm, erythrocyte magnesium (Mg) was measured. Blood coagulability was evaluated by the change of prostaglandin concentration. Subjects included 16 healthy male volunteers (mean age 21.6 +/- 2.5 years). Test conditions were as follows: (A) control state: a day following a night of good sleep; (B) temporary sleep deprivation: a day preceded by < 3 h of sleep; (C) chronic sleep deprivation: a day preceded by a month during which sleep lasted < 60% of that in condition (A) above. The erythrocyte Mg concentration was measured by the atomic absorption method. The plasma concentration of thromboxane B2 and 6-keto-prostaglandin F1 alpha were measured in eight subjects by radioimmunoassay method.

RESULTS

(1) Mean erythrocyte Mg concentration was significantly less in chronic sleep deprivation (1.1 +/- 0.4 mg/dl) than in the control state (1.8 +/- 0.4 mg/dl, p < 0.01) or in temporary sleep deprivation (1.6 +/- 0.4, p < 0.01). (2) The level of thromboxane B2 was significantly higher during chronic sleep deprivation than under control conditions (104.4 +/- 78.0 vs. 20.4 +/- 9.0 pg/ml, p < 0.05). (3) There were no significant intergroup differences in 6-keto-prostaglandin F1 alpha level.

CONCLUSION

These findings could support the hypothesis that coronary arterial spasm and thrombus formation occur in chronic sleep deprivation.

Vascular endothelial growth factor in dialysate in relation to intensity of peritoneal inflammation

BACKGROUND

Peritoneal inflammation may induce changes in peritoneal microvessels, including neoangiogenesis/vasculogenesis, leading to increased peritoneal solute transport rate (PSTR) and loss of ultrafiltration capacity. We hypothesized that an inflammatory reaction in the peritoneal cavity during peritonitis induces increased synthesis of vascular endothelial growth factor (VEGF). We therefore studied the relationship between peritoneal inflammation markers, VEGF, and transport of fluid and solutes in rats during acute peritoneal inflammation induced by lipopolysaccharide (LPS) added to standard glucose-based dialysis solution.

METHODS

Under ether anesthesia, male Wistar rats were injected intraperitoneally with 30 mL Dianeal 3.86% without (Control; n=6) or with LPS (microg/mL): 0.001 (LPS 0.001; n=6), 0.01 (LPS 0.01; n=7), 0.1 (LPS 0.1; n=7), 1.0 (LPS 1.0; n=8). After 8 hours, dialysate volume (IPV), peritoneal solute transport rate (PSTR) and dialysate cell count (DCC) were measured and effluent samples were collected.

RESULTS

LPS i.p. resulted in increased PSTR and decreased IPV (p<0.005). DCC (cells/microL) and the neutrophil/macrophage ratio were higher for all LPS concentrations compared to the control group. After 8 hours, LPS-exposed rats had significantly higher dialysate levels of all investigated cytokines (TNF-alfa, MCP-1 and IL-10) than the control group. Addition of LPS resulted in increased dialysate VEGF concentrations (pg/mL) (LPS 0.001, 28.2+/-5.9; LPS 0.01, 38.9+/-11.6; LPS 0.1, 43.0+/-5.9; LPS 1.0, 46.6+/-11.3; Control, 14.5+/-9.8; p<0.0005 for all LPS vs. Control).

CONCLUSIONS

The infusion of Dianeal 3.86% with different doses of LPS induced a strong acute intraperitoneal inflammatory reaction with increased DCC and cytokine levels, resulting in increased peritoneal solute transport and decreased IPV. LPS induced a dose-dependent parallel increase of the intraperitoneal concentrations of MCP-1, IL-10 and TNF-alfa, as well as of VEGF. These results suggest that intraperitoneal VEGF synthesis is induced in response to inflammation, and that this may be an important component in the process leading to peritoneal transport alterations.

[Angiographic findings of right gastroepiploic artery grafts in early and late phases]

Five hundred and eighty-nine patients underwent isolated coronary artery bypass grafting (CABG) using the right gastroepiploic artery (GEA) in our institute from 1993 to 2004. Early and late results were reviewed retrospectively. Early results: Patients were divided into 2 groups according to target vessel stenosis (group A: degree of stenosis 75% , n=98, 82 men and 16 women, mean age 61.4+/-8.0. Group B: degree of stenosis more than 90%, n=491, 409 men and 82 women, mean age 62.3+/-8.8). Mortality is 0% in group A and 1.0% in group B. Coronary angiography (CAG) revealed patent grafts without stenosis or string sign were 49% in group A and 96% in group B. Forty % of grafts in group A showed string sign. Neither free flow nor harvesting fashion affected the occurrence of string sign. Late results: Twenty-five patients in group A and 53 patients in group B underwent CAG in the late phase (mean interval from CABG to CAG was 4.7+/-2.0 years). Eight grafts were patent but 14 grafts showed string sign in group A. Among the 53 grafts in group B, 49 were patent without stenosis or string sign in the early phase. Forty-seven of them remained patent in the late phase. In conclusion, GEA can achieve good results when target vessels have severe stenosis.

[Patch closure and patch angioplasty for a coronary aneurysm after percutaneous coronary intervention]

The patient was a 67-year-old man who complained of shortness of breath. Coronary angiography showed 90% stenosis in proximal left anterior descending (LAD). He therefore underwent a directional coronary atherectomy (DCA). During the procedure, coronary artery perforation occurred at the origin of the LAD, which caused cardiac tamponade. Surgical pericardial drainage was done. Though bleeding was successfully controlled and his general condition improved, coronary angiography showed a coronary aneurysm at the site of the perforation 2 weeks later. Patch closure of the coronary aneurysm and patch angioplasty of the left main coronary artery were performed. Distal LAD was bypassed with the left internal thoracic artery in case of acute thrombosis. He recovered uneventfully and was discharged 14 days after operation.

[Stabilizing technique of intra-fat coronary artery in off-pump coronary artery bypass grafting]

Suction type stabilizers are popular for off-pump coronary artery bypass. However, arteries running deeply underneath fatty tissue are not stabilized well because the soft tissues act as cushions between the coronary artery and the stabilizer. We propose a simple method to stabilize and visualize intra fat coronary arteries. After dissection of target arteries, 5-0 polypropylene continuous over-and-over sutures are placed on the fat tissues along both sides of the coronary artery. These sutures are pulled laterally, and a suction stabilizer is placed so that the sutures lie under the legs of the stabilizer. Sutures fixed to the stabilizer legs with suction force reduce motion of the target vessel. Visualization of the coronary arteries is also improved because the banks of fat tissue become flat by pulling the sutures laterally.

[Abnormalities in the central nervous system and alterations in the upper limbs in patients with myelomeningocele]

INTRODUCTION

Myelomeningocele is a neural tube defect resulting in motor and sensory deficit below the level of the lesion, bowel and neurogenic bladder, sexual dysfunction, cognitive dysfunction, neurodevelopment delay and motor skills disability. During the past decades, hand function impairment has been described in myelomeningocele patients, probably due to central nervous system abnormalities. AIM. To determine the occurrence of upper limb impairment and additional central nervous system abnormalities in patients with myelomeningocele.

SUBJECTS AND METHODS

A transversal study including 33 patients with myelomeningocele, 6 years and older, referred to pediatric rehabilitation program at Sarah Network of Rehabilitation Hospital (Fortaleza, Brazil), and 33 control subjects. All patients underwent brain and spinal cord magnetic resonance imaging.

RESULTS

Hydrocephalus, Chiari type II malformation with or without kinking of the medullocervical junction, hydrosyringomyelia, spinal cord and brain atrophy were the most common central nervous system abnormalities. Dysmetria, evaluated by the Index-Index Test, was exhibited by 87.9% of the patients and 21.2% of them exhibited dysdiadochokinesia. The mean hand grip strength of the myelomeningocele group was significantly lower compared with the control group (p < 0,001).

CONCLUSIONS

High occurrence of upper limb dysfunction and additional central nervous system abnormalities was detected in patients with myelomeningocele, supporting previous studies. Further investigation is still necessary to elucidate the upper limb impairment impact on the daily live activities of the patient with myelomeningocele.

RETRACTED: Dexamethasone for reduction of nausea, vomiting and analgesic use after gynecological laparoscopic surgery

OBJECTIVE

To evaluate the prophylactic use of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic use after gynecological laparoscopic surgery.

METHODS

In a prospective randomized, double-blind, placebo-controlled trial, 90 women received either intravenous placebo, 4 mg dexamethasone or 8 mg dexamethasone at the end of surgery. PONV and analgesic requirements were evaluated.

RESULTS

The rate of patients experiencing PONV within 24 h after anesthesia was 53% in the 4 mg dexamethasone group (P=0.3) and 20% in the 8 mg dexamethasone group (P=0.001), compared with the placebo group (63%). Requests for indomethacin to relieve intolerable pain were less in patients in the 8 mg dexamethasone group compared with the 4 mg dexamethasone (P=0.047) or placebo (P=0.029) groups.

CONCLUSION

Prophylactic use of 8 mg dexamethasone is effective for reducing PONV and analgesic requirements after gynecological laparoscopic surgery.

Decreased number of mast cells infiltrating into needle biopsy specimens leads to a better prognosis of prostate cancer

Mast cell infiltration is often observed around human tumours. Inflammatory cells such as macrophages, neutrophils and mast cells infiltrating around tumours are known to contribute to tumour growth; however, the clinical significance of mast cell invasion in prostate cancer (PCa) has not been investigated. Mast cell infiltration was evaluated in 104 patients (age range, 45-88 years; median, 72 years), who underwent needle biopsy of the prostate and were confirmed to have PCa. Needle biopsy specimens of prostate were sliced into 5-microm-thick sections and immunostained for mast cells with monoclonal antibody against mast cell-specific tryptase. Mast cells were counted systematically under a microscope (x 400 magnification), and the relations between mast cell numbers and clinicopathologic findings were evaluated. The mast cell count was evaluated for prognostic value by multivariate analysis. Mast cells were immunostained around the cancer foci. The median number of mast cells in each case was 16. The mast cell count was higher around cancer foci in patients with higher Gleason scores than in those with low Gleason scores. The mast cell number correlated well with clinical stage (P<0.001). Prostate-specific antigen-free survival of patients with higher mast cell counts was better than that in patients with lower mast cell counts (P<0.001). Multivariate analysis revealed that mast cell count was a significant prognostic factor (P<0.005). The number of mast cells infiltrating around cancer foci in prostate biopsy specimens can be a significant prognostic factor of PCa.

[Tricuspid valve repair for active infective endocarditis in a drug addict]

We report a case of tricuspid valve endocarditis in a drug addict. A 30-year-old man who had a history of intravenous drug abuse was admitted with complaints of high fever and dyspnea. Chest computed tomography showed multiple thromboembolism in the bilateral lungs. Blood culture was positive with methicillin sesitive Staphylococcus aureus, and echocardiography showed severe tricuspid valve regurgitation and vegetations attached to the tricuspid valve. Because infection was uncontrollable, he underwent surgery. We removed a part of posterior leaflet including vegetations, and performed tricuspid valve repair using the autologous pericardium. The patient's postoperative course was uneventful. Subsequent echocardiography showed no vegetations and regurgitation of the tricuspid valve. He has remained free from endocarditis for 10 months after surgery.

Downregulation of c-FLIP promotes caspase-dependent JNK activation and reactive oxygen species accumulation in tumor cells

Nuclear factor-kappa B (NF-kappaB) inhibits cell death through suppression of the caspase cascade, the c-Jun N-terminal kinase (JNK) pathway, and reactive oxygen species (ROS) accumulation. To suppress this antiapoptotic function of NF-kappaB might be a promising strategy to increase susceptibility of tumor cells to stress-induced cell death. We have recently shown that tumor necrosis factor (TNF)alpha induces caspase-dependent and -independent JNK activation and ROS accumulation in cellular FLICE-inhibitory protein (c-Flip)(-/-) murine embryonic fibroblasts (MEFs). To apply this observation to tumor therapy, we knocked down c-FLIP by RNA interference in various tumor cells. Consistent with the results using c-Flip(-/-) MEFs, we found that TNFalpha stimulation induced caspase-dependent prolonged JNK activation and ROS accumulation, followed by apoptotic and necrotic cell death in various tumor cells. Furthermore, TNFalpha and Fas induced the cleavage of mitogen-activated protein kinase/ERK kinase kinase (MEKK)1, resulting in generation of a constitutive active form of MEKK1 leading to JNK activation in c-FLIP knockdown cells. Given that ROS accumulation and necrotic cell death enhance inflammation followed by compensatory proliferation of tumor cells, selective suppression of caspase-dependent ROS accumulation will be an alternative strategy to protect cells from ROS-dependent DNA damage and compensatory tumor progression.

Effectiveness of concurrent radiation therapy combined with peroral chemotherapy (UFT or TS-1 ) for T2N0 glottic cancer in Japanese population

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Background: The current study retrospectively reviewed 147 T2N0 glottic cancer patients treated at Kitasato University Hospital to compare concurrent radiation therapy combined with chemotherapy (most of them: UFT or TS-1, peroral anti-cancer drugs), with conventional radiation therapy. Methods: One-hundred and forty-seven patients with T2N0 glottic cancer treated with radiation therapy alone or radiation therapy combined with peroral (UFT or TS-1)or intravenous chemotherapy between 1974 and 2005 at Kitasato University Hospital. The median age of all patients was 64 years (range; 45–86 years). As for gender, 145 were males and the others were females. As for radiation therapy protocol, all except one were treated with 2 Gy per fraction, 5 fractions per week and a total of 60 Gy. Only one patient was treated with 1.8 Gy per fraction, 5 fractions per week and a total of 61.2 Gy. As for chemotherapy protocol, 83 patients were concurrently given UFT, (UFT group). 24 patients given TS-1, (TS-1 group) and 23 patients underwent intravenous chemotherapy using mainly cisplatin (Pt. group). The other 23 patients underwent no chemotherapy. Results: The median follow-up time was 61 months (range; 3–372 months). The 5-year local control rates of all patients was 83.4 %. Stratified by radiation therapy alone group (RT group) and concurrent chemoradiation therapy (CCRT group), The 5-year local control rates of RT group and CCRT group were 82.7%, 83.4%, respectively (p=NS). Stratified by chemotherapy regimens of CCRT group, 3-year local control rates of UFT group, TS-1 group and Pt. group were 90.1%, 100.0% and 73.4%, respectively, which indicated the peroral chemotherapy was not inferior to intravenous chemotherapy. As for morbidity, 2 patients of UFT group experienced severe enteritis . Conclusion: Concurrent radiation therapy combined with UFT or TS-1 for T2N0 glottic cancer might be the one of standard treatments in Japanese Population. Furthermore, concurrent use of TS-1 might perform break-through for T2N0 glottic cancer in terms of local control rate, overall survival and burdens of treatment on patients.

No significant financial relationships to disclose.

[Curative gastrectomy with reconstruction of a right gastroepiploic artery graft]

We report a case of a 66-year-old man who developed gastric cancer 5 years after coronary artery bypass grafting using right gastroepiploic artery graft (RGEA). Some authors reported successful gastrectomy preserving a functional RGEA, but it carries the risk of injury of the graft or graft spasm. Preoperatively, catheter intervention for target vessels of RGEA (right coronary artery: RCA) was tried but failed. We performed re-do coronary artery bypass grafting (CABG) via right thoracotomy with right internal thoracic artery (RITA)-radial artery (RA) composite graft. The composite graft was drawn into the peritoneal cavity through the diaphragm, and anastomosed to the RGEA on the anterior plane of the liver. After that, partial gastrectomy was performed with resection of the RGEA and dissection of the #6 lymph nodes. We consider this method is safe to treat such cases.

Depressed contractile reserve and impaired calcium handling of cardiac myocytes from chronically unloaded hearts are ameliorated with the administration of physiological treatment dose of T3 in rats

AIM

Chronic cardiac unloading causes a time-dependent upregulation of phospholamban (PLB) and depression of myocyte contractility in normal rat hearts. As thyroid hormone is known to decrease PLB expression, we examined whether thyroid hormone restores the depressed contractile performance of myocytes from chronically unloaded hearts.

METHODS

Cardiac unloading was induced by heterotopic heart transplantation in isogenic rats for 5 weeks. Animals were treated with either vehicle or physiological treatment dose of 3,5,3'-triiodo-L-thyronine (T3) that does not cause hyperthyroidism for the last 3 weeks (n=20 each).

RESULTS

In vehicle-treated animals, myocyte relaxation and [Ca2+]i decay were slower in unloaded hearts than in recipient hearts. Myocyte shortening in response to high [Ca2+]o was also depressed with impaired augmentation of peak-systolic [Ca2+]i in unloaded hearts compared with recipient hearts. In vehicle-treated rats, protein levels of PLB were increased by 136% and the phosphorylation level of PLB at Ser16 were decreased by 32% in unloaded hearts compared with recipient hearts. By contrast, in the T3-treated animals, the slower relaxation, delayed [Ca2+]i decay, and depressed contractile reserve in myocytes from unloaded hearts were all returned to normal levels. Furthermore, in the T3-treated animals, there was no difference either in the PLB protein level or in its Ser16-phosphorylation level between unloaded and recipient hearts.

CONCLUSION

These results suggest that the treatment with physiological treatment dose of thyroid hormone rescues the impaired myocyte relaxation and depressed contractile reserve at least partially through the restoration of PLB protein levels and its phosphorylation state in chronically unloaded hearts.

Long-term prevention of diabetes and marked suppression of insulin autoantibodies and insulitis in mice lacking native insulin B9-23 sequence

We analyzed double native insulin gene knockout NOD mice with a mutated (B16:alanine) proinsulin transgene at multiple ages for the development of insulin autoantibodies, insulitis, and diabetes. In contrast to mice with at least one copy of a native insulin gene that expressed insulin antibodies, only 2 out of 21 (10%) double native insulin gene knockout mice with a mutated insulin transgene developed insulin autoantibodies. Of 21 double insulin knockout mice sacrificed between 10 to 48 weeks of age, only 5 showed minimal insulitis versus 100% of wild-type NOD and more than 90% of insulin 1 knockout mice. Consistent with robust suppression of insulin autoantibodies and insulitis, no double insulin knockout mice developed diabetes. In that the B9-23 peptide with B16A is an altered peptide ligand inducing Th2 responses, we analyzed transfer of splenocytes into NOD.SCID mice. There was no evidence for regulatory T cells able to inhibit transfer of diabetes by diabetogenic NOD splenocytes. Insulin peptide B9-23 is likely a crucial target for initiation of islet autoimmunity and further mutation of the sequence will be tested to attempt to eliminate all anti-islet autoimmunity.

Electromyography of the cricoarytenoid unit during supracricoid laryngectomy with a cricohyoidoepiglottopexy procedure

Two patients who received supracricoid laryngectomy with cricohyoidoepiglottopexy to treat laryngeal cancers, underwent intra-operative electromyography analysis. After the lesion was removed and the electrodes were inserted into the remaining intrinsic laryngeal muscles, the depth of anaesthesia was carefully reduced. Gentle tactile stimulations were applied to the pharynx to trigger the reflex movement of the remaining arytenoids. Recordings were made when reflex movement was achieved.

Case one: Electromyography (EMG) of the remaining arytenoid demonstrated clear phase differences indicating reciprocal activities between the adductor group (lateral cricoarytenoid muscle, interarytenoid muscle) and the abductor muscle (posterior cricoarytenoid muscle). Case two: EMG of the remaining arytenoid demonstrated reciprocal activities between the interarytenoid muscle and the posterior cricoarytenoid muscle. Activity of the lateral cricoarytenoid muscle was not evident because the muscle was excised during removal of the paraglottic space. Mobility of the arytenoid was attributed to interaction between the interarytenoid muscle and posterior cricoarytenoid muscle. Reciprocal interaction between the interarytenoid muscle and posterior cricoarytenoid muscle alone is also capable of maintaining post-operative laryngeal functions after supracricoid laryngectomy with cricohyoidoepiglottopexy.

Low-dose prednisolone ameliorates acute renal failure caused by cholesterol crystal embolism

AIMS

The prognosis of renal cholesterol crystal embolism (CCE) is poor. Although various treatments for CCE have been attempted, there is no optimal therapy. We tested the effect of low-dose prednisolone (PS) on CCE-related acute renal failure (ARF).

PATIENTS AND METHODS

7 patients (mean age 69 years) diagnosed with CCE-related ARF were treated with oral PS at 15-20 mg/day for 2-4 weeks, which was then tapered at 5 mg/day over 2-4 weeks, followed by 5 mg/day maintenance dose. Recurrent ARF during PS tapering was treated with a larger dose of PS.

RESULTS

Inciting factors were identified in four patients: coronary angiography (n=3) and cerebral angiography (n=1). On admission, serum creatinine (SCr) was 2.1 +/- 0.3 mg/dl (mean +/- SEM). SCr and eosinophil count before treatment were 4.2 +/- 0.4 mg/dl and 682 +/- 73/microl, respectively. PS therapy improved ARF in all cases at week 2 (SCr 3.8 +/- 0.5 mg/dl) parallel to a decrease in eosinophilia (116 +/- 30/microl), and at week 4 (3.1 +/- 0.4 mg/dl and 134 +/- 20/microl, respectively). At last follow-up, renal function was improved or maintained in 5 patients compared with that at week 4 post-treatment. One patient died of lung cancer. Another required LDL apheresis and hemodialysis but died due to CCE-related multi-organ failure. A third patient had recurrent ARF and was re-treated with a larger dose of PS, which resulted in an immediate decrease in SCr. However, the patient developed acute renal dysfunction due to congestive heart failure, and required hemodialysis.

CONCLUSIONS

Low-dose PS improved CCE-related ARF, probably through amelioration of inflammatory reaction surrounding affected renal vessels.

Statin attenuates high glucose-induced and angiotensin II-induced MAP kinase activity through inhibition of NAD(P)H oxidase activity in cultured mesangial cells

An increased oxidative stress may contribute to the development of diabetic nephropathy. We have recently reported that high glucose level stimulated superoxide production through protein kinase C (PKC)-dependent activation of NAD(P)H oxidase in cultured vascular cells. Here we show that 3-hydroxy-3-methylglutaryl CoA reductase inhibitor (statin) attenuates both high glucose level-induced and angiotensin II (Ang II)-induced activation of p42/44 mitogen-activated kinase (MAP kinase) in cultured human mesangial cells through inhibition of NAD(P)H oxidase activity. The intracellular oxidative stress in cultured mesangial cells was evaluated by electron spin resonance (ESR) measurement. MAP kinase activity was evaluated by western blot analysis using anti phospho-specific MAP kinase antibody and anti-ERK-1 antibody. Exposure of the cells to high glucose level (450 mg/dl) for 72 hrs significantly increased MAP kinase activity as compared to normal glucose level (100 mg/dl). This increase was completely blocked by the treatment of pitavastatin (5x10(-7) M) as well as a NAD(P)H oxidase inhibitor (diphenylene iodonium, 10(-5) M) in parallel with the attenuation of oxidative stress. Ang II-induced activation of MAP kinase was also completely blocked by pitavastatin as well as a diphenylene iodonium in parallel with the attenuation of oxidative stress. In conclusion, pitavastatin attenuated high glucose-induced and Ang II- induced MAP kinase activity in mesangial cells through inhibition of NAD(P)H oxidase. Thus, statins may have a potential as a therapeutic tool for early diabetic nephropathy.

An ionic polymer bead-supported lipid system

In this paper, we report on the preparation of an ionic polymer bead-supported lipid system several hundred micrometers in diameter. The electrostatic attractive interactions between anionic lipids and cationic polymer beads served as a "molecular glue" to immobilize the lipids on the beads, and then the immobilized lipids prompted the spontaneous formation of lipid bilayer membranes. Confocal fluorescence microscopic techniques revealed that the lipid bilayer membranes were located along the outline of the beads. In addition, the integrity of the lipid bilayer membranes was microscopically confirmed by a low-molecular-weight dye (trypan blue) exclusion test.

Effects of thiopental on bispectral index and heart rate variability

BACKGROUND AND OBJECTIVE

Thiopental has been reported to reduce sympathetic tone, however, it is not clear whether change in heart rate variability is associated with depth of anaesthesia. The purpose of the present study was to evaluate changes in heart rate variability at different depths of hypnosis during induction of anaesthesia with thiopental.

METHODS

We studied 17 ASA I patients scheduled for minor surgery. The depth of hypnosis was monitored by the BIS. Spectral analysis of heart rate variability using a maximum entropy method resulted in a characteristic power spectrum with two main regions, a high frequency and a low frequency. Haemodynamics, entropy, low frequency, high frequency and low frequency/high frequency were monitored in an awake state and after the induction of anaesthesia.

RESULTS

Heart rate increased in a BIS-dependent manner, whereas blood pressure showed no significant changes during the study period. High frequency, entropy and low frequency decreased with a reduction in the BIS value. Low frequency/high frequency showed no significant change during the study period.

CONCLUSIONS

Induction of anaesthesia with thiopental increased heart rate and decreased high frequency, entropy and low frequency in a BIS-dependent manner, indicating that thiopental reduces cardiac parasympathetic tone depending on the depth of hypnosis.

A new model of insulin-deficient diabetes: male NOD mice with a single copy of Ins1 and no Ins2

AIMS/HYPOTHESIS

We describe a novel model of insulin-deficient diabetes with a single copy of the gene encoding insulin 1 (Ins1) and no gene encoding insulin 2 (Ins2).

MATERIALS AND METHODS

We constructed five lines of mice: mice with two copies of Ins1 (NOD( Ins1+/+,Ins2-/-)), mice with a single copy of Ins1 (NOD( Ins1+/-,Ins2-/-)), mice with two copies of Ins2 (NOD( Ins1-/-,Ins2+/+)), mice with a single copy of Ins2 (NOD( Ins1-/-,Ins2+/-)) and NOD( Ins1+/-,Ins2-/-) mice with a transgene encoding B16:Ala proinsulin.

RESULTS

By 10 weeks of age, all male NOD( Ins1+/-,Ins2-/-) mice were diabetic, whereas all female NOD( Ins1+/-,Ins2-/-) were not diabetic (p < 0.0001). In contrast, neither male nor female NOD( Ins1-/-,Ins2+/-) with a single copy of Ins2 (rather than single copy of Ins1) developed early diabetes and no mice with two copies of either gene developed early diabetes. Islets of the diabetic male NOD( Ins1+/-,Ins2-/-) at this early age had no lymphocyte infiltration. Instead there was heterogeneous (between islet cells) weak staining for insulin. Although only male NOD( Ins1+/-,Ins2-/-) mice developed diabetes, both male and female NOD( Ins1+/-,Ins2-/-) mice had markedly decreased insulin content. In NOD( Ins1+/+,Ins2-/-), there was also a significant decrease in insulin content, whereas NOD( Ins1-/-,Ins2+/+) mice, and even NOD( Ins1-/-,Ins2+/-) mice, were normal. Male NOD( Ins1+/-,Ins2-/-) mice were completely rescued from diabetes by introduction of a transgene encoding proinsulin. On i.p. insulin tolerance testing, male mice had insulin resistance compared with female mice.

CONCLUSIONS/INTERPRETATION

These results suggest that Ins1 is a 'defective gene' relative to Ins2, and that the mouse lines created provide a novel model of sex-dimorphic insulin-deficient diabetes.

The effect of angiotensin receptor blockade ARB on the regression of left ventricular hypertrophy in hemodialysis patients: comparison between patients with D allele and non-D allele ACE gene polymorphism

OBJECTIVE

It is revealed that LVH is one of risk factors for the development of cardiac complications in long-term HD patients. Therefore, maneuvers to reduce hypertrophy of cardium are very important for improving life prognosis. Angiotensin II receptor blockade (ARB) could reduce LVH in general populations without renal failure. However, no conclusive data has been available regarding the clinical consequences of ARB administration on the regression of LVH in HD patients. Furthermore, it has not clearly determined if ACE gene polymorphism has a possible influential effect on it. This study is conducted to clarify these issues.

SUBJECTS AND METHOD

32 hypertensive patients on regular HD (male/female: 21/11, mean age: 60.5 years, mean duration of HD: 52.8 months) were studied. Patients were classified into two groups according to the different type of ACE gene polymorphism: cases with D allele (DD/ID; D group: n = 13) and those without (II; non-D group: n = 19). All patients were administered ARB (losartan 50 - 100 mg/day) and echocardiography (UCG) was performed at 6-month-interval regularly until the end of observation (24 months).

RESULTS

Before the commencement of ARB, no differences were found between the two groups, neither in mean blood pressure (MBP: D group/non-D group: 120 +/- 13 vs. 115 +/- 14 mmHg) nor in left ventricular mass index (LVMI: D/non-D: 172 +/- 41 vs. 165 +/- 41 g/m2). During the 24r-month follow-up, there were significant and similar reductions in MBP in both groups. In respect to LVMI, a significant reduction of LVMI was found in the D group after six months (p < 0.01 vs. basal) with a final reduction rate (FRR) -26 +/- 13%, whereas in the non-D group it was found at 24 months (p < 0.01 vs. basal) with FRR -11 +/- 16% (p < 0.01 vs. D group). There were significant differences between the two groups at all points (p < 0.05 at 6, 18 and 24 months, p < 0.005 at 12 months, respectively).

CONCLUSION

It is indicated that ARB could insert a regression effect on LVH predominantly in patients with D allele ACE polymorphism, due partly to factor (s) independent of its anti-hypertensive effect.

Use of percutaneous cardiopulmonary support in catastrophic massive pulmonary fat embolism

We report a patient who sustained massive catastrophic pulmonary fat embolism while undergoing surgery for intramedullary nail of femur. Application of percutaneous cardiopulmonary support, in our view, saved the patient from cardiopulmonary collapse.

Thymic expression of mutated B16:A preproinsulin messenger RNA does not reverse acceleration of NOD diabetes associated with insulin 2 (thymic expressed insulin) knockout

We detected insulin2 mRNA but not insulin1 in thymus using real-time PCR analysis. Transgenic expression of a mutated insulin message (alanine rather than tyrosine at insulin B chain amino acid 16) was variably induced in thymus of four transgenic founder strains. The transgenic message levels were as high or higher than native insulin2 message. Lack of the insulin2 gene resulted in the enhancement of anti-insulin autoantibodies (regular NOD vs insulin2-knockout NOD, P<0.001) and in the presence of the B16:A insulin transgenes, levels of insulin autoantibodies remained elevated (regular NOD vs insulin2-knockout NOD with B16:A insulin, P<0.01). Diabetes acceleration by the knockout of the insulin2 gene was not influenced by the presence of the B16:A insulin transgenes. These data suggest that the B16:A insulin does not compensate for lack of native insulin expression in thymus. If lack of thymic insulin message of the insulin2 knockout is the cause of diabetes acceleration, this suggests that native insulin B:9-23 sequences may be crucial in thymus for insulin mediated immunomodulation. Further experiments varying native insulin message expression in thymus is necessary for direct comparison, but the current study provides additional evidence of the potential important role of a specific insulin B chain epitope.

[Advantages of side-to-side anastomosis in the assessment and revision of coronary artery bypass grafting]

With the advent of drug eluting stents in percutaneous coronary intervention, required quality level of coronary artery bypass grafting (CABG) has been elevating. To obtain nearly perfect patency of bypass grafts, intraoperative assessment and repair of abnormal grafts are helpful. We report systematic revision and safe repair technique of arterial grafts in CABG. Side-to-side instead of commonly used end-to-side anastomosis of arterial grafts is the first step in this technique. When any abnormalities are noted in intraoperative flowmetry of a graft, the distal surgical clip is removed. Free flow of the graft is measured. A coronary probe is gently inserted into the graft and the coronary artery. Vasodilators can be injected into the graft if necessary. When direct revision of the anastomosis is indicated, the graft is cut longitudinally from the distal end up to just proximal to the anastomotic site. The shape of the anastomosis can be observed directly without removing sutures. When re-anastomosis is not indicated, the distal remnant graft tissue is folded back and utilized as a patch. Thus the graft can be easily closed without narrowing.

A possible association of Pro12Ala polymorphism in peroxisome proliferator-activated receptor gamma2 gene with obesity in native Javanese in Indonesia

BACKGROUND

Peroxisome proliferators-activated receptor gamma (PPAR gamma) is a nuclear hormone receptor that serves as a master regulator of adipocytes-specific genes contributing to adipocytes differentiation, susceptibility to obesity, and insulin sensitivity. The substitution of proline to alanine at codon 12 of the PPAR gamma2 gene (Pro12Ala polymorphism) is most frequently identified and the associations with diabetes, obesity, and other clinical parameters have been reported and discussed in several ethnic groups. Among native Javanese ethnicity, however, there is no report about this polymorphism.

AIMS AND METHODS

Aims of this study were to estimate the allele frequency of the Pro12Ala polymorphism of PPAR gamma2 gene among native Javanese in Indonesia and to investigate the relationship between this polymorphism and obesity or diabetes. This study included 540 native Javanese subjects consisting of 337 diabetic patients and 203 normal glucose tolerance subjects. Both groups included totally 160 obese subjects (body mass index > or = 25 kg/m(2)). PCR-restriction fragment length polymorphism was used for the genotype determination.

RESULTS

The allele frequency of Pro12Ala polymorphism in PPAR gamma2 gene among native Javanese is lower than that in other ethnic groups. No association is seen between the Pro12Ala and diabetes (0.01 vs 0.017%, p = 0.404), a trend of the higher BMI was observed in Pro12Ala carriers in nondiabetic subjects, although this association is limited by small numbers.

CONCLUSION

In this study, no association is seen between the Pro12Ala polymorphism in PPAR gamma2 gene and diabetes; a weak association with obesity is seen.

Resolution of primary amyloidosis by melphalan and prednisolone: a case report

We here report a case of a 50-year-old man who showed histologically evident resolution of primary amyloidosis by melphalan and prednisolone. The patient was admitted to our hospital for further evaluation of nephrotic syndrome and remarkable hepatomegaly with refractory ascites, on September 11, 1998. Laboratory tests at presentation showed nephrotic syndrome with slight renal impairment and elevation of the enzymes of the biliary system. Monoclonal light chains were not detected in the serum or urine by immunoelectrophoresis. A renal biopsy revealed global deposition of amyloid in all glomeruli, interstitium and blood vessels. Immunofluorescence staining was positive for kappa light chains. Liver biopsy specimens showed extensive deposition of amyloid along sinusoid walls. Bone marrow aspiration contained 7% plasma cells but no clusters or abnormal cells. Based on these findings, systemic AL- (amyloid light chain) amyloidosis was diagnosed, and the treatment with combinations of melphalan and prednisolone was started from October 1998 at intervals of 4-6 weeks. Renal impairment progressed, resulting in the initiation of maintenance hemodialysis in February 1999. Reinfusion of ascitic fluid into the hemodialysis circuit had been performed from March 1999 for refractory ascites, and ascites disappeared in July 1999. Furthermore, urinary output increased after 14 courses of chemotherapy. Renal function gradually ameliorated with a concomitant reduction in the enzymes of biliary system, and finally hemodialysis was discontinued in April 2001. Sixteen courses of chemotherapy were administered by April 2001. Proteinuria was negative in August 2001. A second renal biopsy was performed on November 20, 2001, which showed markedly decreased amyloid deposition and a proliferation of mesangial cells and increase in matrix in various degrees. We report a case of a patient with primary amyloidosis who was successfully treated by melphalan and prednisolone, resulting in marked resolution of renal amyloidosis.