[Perioperative management for cardiovascular operations in two patients with cold agglutinin disease]

Cold agglutinin (CA) reacts reversibly with red blood cells at a low temperature and may cause thromboembolism of various organs. Therefore, special consideration is required in patients with cold agglutinin disease (CAD) undergoing cardiovascular surgery requiring hypothermia. Case 1: A 71-year-old man with elevated CA was scheduled to undergo total aortic arch replacement. Preoperatively, the patient received double filtration plasmapheresis to reduce CAs. The operation was performed at a higher temperature than the patient's thermal amplitude (TA) of 30 degrees C. Case 2: A 72-year-old man with CAD underwent a coronary artery bypass grafting. The patient's TA was 32 degrees C. The operation was performed on the beating heart with normothermic cardiopulmonary bypass. We performed an agglutination test at the temperature of 24 degrees C using the blood sample from the cardiopulmonary bypass circuit and no signs of agglutination were found. In both cases, no symptom of microembolism due to cold agglutination was recognized. This may indicate the possibility that the clinical risk is smaller than the risk recognized in vitro analysis. However, no safety standards for perioperative management of patients with CA are clearly established. Generally, it is more important to figure out the TA and to prevent the low-temperature exposure below the TA. In cases of normothermic procedures, further consideration for cerebral and myocardial protection is important.

Incidence and Risk Factors of Postoperative Vocal Cord Paralysis in 987 Patients After Cardiovascular Surgery

BACKGROUND

Vocal cord paralysis (VCP) after cardiovascular surgery can affect the postoperative outcome. The aim of the present study was to clarify the incidence of VCP after cardiovascular surgery and the relationship between the surgery characteristics and the risk of VCP.

METHODS

A total of 987 consecutive patients who underwent cardiovascular surgery (cardiac, n = 895; aortic, n = 92) were enrolled. We retrospectively assessed the incidence and the risk of VCP according to the length and types of surgery and the details of each VCP case and compared them between the aortic and the nonaortic group.

RESULTS

Twenty-three patients (2.3%: cardiac, n =15; aortic, n = 8) were expertly diagnosed with VCP (left, n = 19; right, n = 2; bilateral, n = 2). In the multivariate analysis, the risk for VCP increased with the duration of the operation (odds ratio [OR], 4.4, 95% confidence interval [CI] 1.7 to 11.4), and aortic procedures (OR, 5.6, CI 2.3 to 13.5) exhibited higher risk compared with coronary artery bypass grafting. Among the VCP cases, the incidence of poor outcomes (ie, bilateral VCP, repeated airway treatment, death within 6 months) was significantly higher in the aortic group (p = 0.016). All patients that were intubated for longer than 100 hours exhibited poor outcomes.

CONCLUSIONS

Aortic procedures and prolonged operation increase the risk of VCP. Severe VCP tended to be associated with aortic surgery and intubation for more than 100 hours.

Outbreak of human metapneumovirus detected by use of the Vero E6 cell line in isolates collected in Yamagata, Japan, in 2004 and 2005

A number of epidemiological studies have shown human metapneumovirus (hMPV) to be one of the most important viral agents associated with acute respiratory infections in humans. However, due to the difficulty in growing the virus, all epidemiological studies of hMPV infection have been performed on the basis of the molecular method. Thus, the development of a cell line suitable for the isolation of hMPV from clinical specimens is a crucial step for further research. Using the Vero E6 cell line, which could be stably maintained for 1 month without passage or medium change, we succeeded in isolating 79 strains from 4,112 specimens obtained in Yamagata, Japan, in 2004 and 2005. The total isolation rate was 1.9% (79/4,112). The monthly distribution revealed that hMPV infections occurred between February and April in 2004 and throughout most of the year in 2005. Phylogenetic analysis indicated that subgenogroup B2 was predominant in 2004, whereas three subgenogroups, A2, B1, and B2, had cocirculated in 2005. Although multiple subgenogroups cocirculated in 2005, each individual subgenogroup strain was found to predominate at specific sites. An infectivity assay of hMPV strains also indicated that the infection efficiency in Vero E6 cells was better than that in LLC-MK2 cells. Finally, we found that Vero E6 cells are useful for the isolation of hMPVs and that this utility might aid further research into hMPVs beyond the epidemiological data shown in this study.

Age and comorbidity as risk factors for vocal cord paralysis associated with tracheal intubation

BACKGROUND

Vocal cord paralysis after tracheal intubation may be attributed to ageing and comorbidity. However, the relationship between patient characteristics and the risk of vocal cord paralysis is unknown.

METHODS

We prospectively analysed data representing 31 241 consecutive surgery patients who underwent tracheal intubation to determine whether duration of intubation, age, sex, and cardiovascular, cerebrovascular, and metabolic diseases were risk factors for vocal cord paralysis associated with intubation. Patients with vocal cord paralysis from any other causes were excluded.

RESULTS

Twenty-four (0.077%) suffered vocal cord paralysis (left, 16 patients; right, 8 patients). The risk was increased when intubation lasted 3-6 h (odds ratio, 2.0; 95% confidence interval, 1.1-5.6; P = 0.002) or 6 h or more (odds ratio, 14.5; 95% confidence interval, 5.2-40.9; P < 0.0001). The risk was increased in patients aged 50-69 (odds ratio, 3.6; 95% confidence interval, 1.2-11.1; P = 0.02) and 70 yr or above (odds ratio, 3.9; 95% confidence interval, 1.2-12.8; P = 0.02). The risk was increased with diabetes mellitus (odds ratio, 2.5; 95% confidence interval, 1.1-7.3; P = 0.03) and hypertension (odds ratio, 2.1; 95% confidence interval, 1.1-6.0; P = 0.03).

CONCLUSIONS

The risk of vocal cord paralysis was increased three-fold in patients aged 50 or above, two-fold in patients intubated 3-6 h, 15-fold in patients intubated 6 h or more, and two-fold in patients with a history of diabetes mellitus or hypertension. Our results are informative for informed consent, patient counselling, and intubation decision-making.

[A case of a pediatric patient with tuberous sclerosis (Bourneville-Pringle disease) and frequent epileptic seizure for intensive dental treatment under general anesthesia]

Tuberous sclerosis (Bourneville-Pringle disease) is a rare disease with a triad of mental retardation, epilepsy, and facial spot. Management of the patients with tuberous sclerosis under general anesthesia has been previously reported. However, there are few case reports about management under general anesthesia of a pediatric patient with tuberous sclerosis with frequent epileptic seizure. Here, we report a case of a pediatric patient with tuberous sclerosis and frequent epileptic seizure who underwent intensive dental treatment under general anesthesia with careful management of epilepsy. The patient was discharged on the day of surgery without any complications. In this case report, we discussed the appropriate assessment of the complications of tuberous sclerosis; such as, of central nervous, circulatory, respiratory, endocrine, and urinary systems including the management of general anesthesia.

Frequent importation of enterovirus 71 from surrounding countries into the local community of Yamagata, Japan, between 1998 and 2003

Phylogenetic analysis of 45 enterovirus 71 (EV71) isolates for 6 years in Yamagata, Japan, clarified that the annual outbreak of hand-foot-and-mouth disease was due to four genetically distinct subgenogroups, including a novel "B5." Our results suggest that the importation of EV71 from surrounding countries has had a major epidemiological impact on the local community used in our study.

Opposing effects of oestradiol and progesterone on intracellular pathways and activation processes in the oxidative stress induced activation of cultured rat hepatic stellate cells

BACKGROUND

Oxidative stress, including the generation of reactive oxygen species (ROS), is involved in hepatofibrogenesis. The authors' previous studies have shown that oestradiol suppresses hepatic fibrosis in animal models and attenuates the activation of cultured rat hepatic stellate cells (HSCs), which possess oestrogen receptor subtype beta and are also activated by ROS.

AIMS

To define the mechanisms by which female sex hormones play an antifibrogenic role in activated HSCs, the effects of oestradiol and progesterone on ROS generation processes and intracellular pathways, leading to the activation of HSCs undergoing oxidative stress, was examined.

METHODS

HSCs, isolated from rats, were cultured for 7 days with oestradiol or progesterone for 24 hours as pretreatment, and oxidative stress was then induced by exposure to low doses of hydrogen peroxide for another 24 hours.

RESULTS

Oestradiol inhibited ROS generation and antioxidant enzyme loss via the suppression of NADH/NADPH oxidase activity, and attenuated hydrogen peroxide induced transforming growth factor-beta1 (TGF-beta1) expression, HSC proliferation and transformation, and the activation of mitogen activated protein kinase (MAPK) pathways and transcription factors. Progesterone exerted a stimulatory effect through the progesterone receptor on the induction of ROS generation processes and intracellular pathways, resulting in TGF-beta1 expression and HSC activation, and fibrogenic effects were inhibited by oestradiol.

CONCLUSION

These findings show for the first time that oestradiol inhibits the activation of transcription factors by suppressing ROS generation processes and the MAPK pathways, and inactivates the downstream transcription processes involved in TGF-beta1 expression and HSC activation, whereas progesterone acts in opposition to the favourable effects of oestradiol and its effects are blocked by oestradiol.

Opposing effects of oestradiol and progesterone on intracellular pathways and activation processes in the oxidative stress induced activation of cultured rat hepatic stellate cells

BACKGROUND

Oxidative stress, including the generation of reactive oxygen species (ROS), is involved in hepatofibrogenesis. The authors' previous studies have shown that oestradiol suppresses hepatic fibrosis in animal models and attenuates the activation of cultured rat hepatic stellate cells (HSCs), which possess oestrogen receptor subtype beta and are also activated by ROS.

AIMS

To define the mechanisms by which female sex hormones play an antifibrogenic role in activated HSCs, the effects of oestradiol and progesterone on ROS generation processes and intracellular pathways, leading to the activation of HSCs undergoing oxidative stress, was examined.

METHODS

HSCs, isolated from rats, were cultured for 7 days with oestradiol or progesterone for 24 hours as pretreatment, and oxidative stress was then induced by exposure to low doses of hydrogen peroxide for another 24 hours.

RESULTS

Oestradiol inhibited ROS generation and antioxidant enzyme loss via the suppression of NADH/NADPH oxidase activity, and attenuated hydrogen peroxide induced transforming growth factor-beta1 (TGF-beta1) expression, HSC proliferation and transformation, and the activation of mitogen activated protein kinase (MAPK) pathways and transcription factors. Progesterone exerted a stimulatory effect through the progesterone receptor on the induction of ROS generation processes and intracellular pathways, resulting in TGF-beta1 expression and HSC activation, and fibrogenic effects were inhibited by oestradiol.

CONCLUSION

These findings show for the first time that oestradiol inhibits the activation of transcription factors by suppressing ROS generation processes and the MAPK pathways, and inactivates the downstream transcription processes involved in TGF-beta1 expression and HSC activation, whereas progesterone acts in opposition to the favourable effects of oestradiol and its effects are blocked by oestradiol.

The First Record of Dirofilaria immitis Infection in a Humboldt Penguin, Spheniscus humboldti

Dirofilaria immitis infection is an important parastic disease in many mammals, especially canids, but has not been reported in bird hosts. Filarial worms were isolated from the lumen of the right atrium of the heart and the connective tissue of the lung of a captive female Humboldt penguin, Spheniscus humboldti, that died at a zoo in Japan. One of these worms was observed morphologically and identified as D. immitis by features such as 4 pairs of cephalic papillae, 1 pair of cervical papillae, esophagus divided into 2 regions, 4 pairs of pre-anal papillae, 5 pairs of post-anal papillae, and unequal spicules. In addition, the partial DNA sequence (234 bp) of mitochondrial CO / gene of the filarial worm was identical to that of D. immitis. This is the first report of D. immitis infection in a bird.

Genetic characterization of parthenogenic Fasciola sp. in Japan on the basis of the sequences of ribosomal and mitochondrial DNA

Accurate identification of aspermic Fasciola forms in Japan remains difficult because of their morphological variations. In order to characterize the forms genetically, nucleotide sequences of ribosomal internal transcribed spacer (ITS1 and ITS2) and mitochondrial cytochrome c oxidase I (COI) and NADH dehydrogenase I (NDI) genes in 34 liver flukes from 16 prefectures in Japan were analysed. Two major forms represented by Fsp 1 and Fsp 2 had sequences identical to or closely resembling those of F. hepatica and F. gigantica, respectively, in all the 4 DNA markers and were mainly distributed in northern and eastern-western parts of Japan, respectively. Fsp 1 and Fsp 2 would have been introduced into Japan with infected cattle of 2 distinct lineages via the Korean Peninsula and spread through limited parts of Japan (northern and eastern-western parts) together with the movement of each cattle lineage. The Japanese form (Fsp 1/2), which showed heterozygosity in ribosomal DNA and Fsp 2 haplotype in mitochondrial DNA, may have originated in interspecific cross hybridization between paternal F. hepatica and maternal F. gigantica.

Epidemics of two Victoria and Yamagata influenza B lineages in Yamagata, Japan

We attempted to predict epidemics of influenza B, focusing on B/Victoria/2/87-like (V) and B/Yamagata/16/88-like (Y) lineages, in Yamagata, Japan. We collected 9624 nasopharyngeal swabs for virus isolation from patients with respiratory infections between 1996 and 2003 and 237 sera for seroepidemiological analysis by haemagglutination-inhibition test in 2001. We isolated 424 V-lineage and 246 Y-lineage viruses during the study period. Three herald viruses in the 2000--2001 season enabled us to predict a V-lineage epidemic in the following season. However, another V-lineage epidemic occurred in the 2002--2003 season, although we caught four herald Y-lineage viruses, whose antigenic drift was suggested by seroepidemiological study, at the end of the previous season. Since the epidemiology of the two influenza B lineages remains unclear, a careful watch should be kept on these lineages in order to provide effective public-health strategies against future epidemics.

[Endobronchial brachytherapy for intra-luminal recurrence after lung cancer resection]

A 63-year-old man who had squamous cell carcinoma in left lung was received left lower lobectomy with lymph node dissection (pT3N0M0). Twenty months after surgery, the patient showed bloody sputum and bronchofiberscopy revealed intra-luminal recurrence on trachea. Endobronchial brachytherapy in combination with external beam radiotherapy was selected and complete remission was achieved. After the brachytherapy, bronchitis was observed and was healed 23 months after the therapy.

Amino acid sequence of a trypsin inhibitor from a Spirometra (Spirometra erinaceieuropaei)

A trypsin inhibitor that is highly homologous with bovine pancreatic trypsin inhibitor (BPTI) was co-purified along with RNase from Spirometra (Spirometra erinaceieuropaei). The amino acid sequence of this inhibitor (SETI) and the nucleotide sequence of the cDNA encoding this protein were determined by protein chemistry and gene technology. SETI contains 68 amino acid residues and has a molecular mass of 7,798 Da. SETI has 31 amino acid residues that are identical with BPTI's sequence, including 6 half-cystine and 5 aromatic amino acid residues. The active site Lys residue in BPTI is replaced by an Arg residue in SETI. SETI is an effective inhibitor of trypsin and moderately inhibits a-chymotrypsin, but less inhibits elastase or subtilisin. SETI was expressed by E. coli containing a PelB vector carrying the SETI encoding cDNA; an expression yield of 0.68 mg/l was obtained. The phylogenetic relationship of SETI and the other BPTI-like trypsin inhibitors was analyzed using most likelihood inference methods.

Linking phenomenon in dual atrioventricular nodal pathways

The linking phenomenon is an electrophysiological phenomenon of conduction between 2 different pathways, such as bundle branches, atrioventricular node (AVN) and accessory pathways. The present study used electrophysiological studies to investigate this phenomenon in 14 patients with dual AVN pathways. Decremental ramp pacing at intervals of 10 ms was carried out in high right atrium until the atrio-His (A-H) interval was abruptly prolonged (onset), then subsequent incremental ramp pacing at intervals of 10 ms proceeded until the A-H interval abruptly shortened (offset). The linking window (LW) was defined as the difference between the paced cycle lengths of the offset and the onset. The linking phenomenon occurred in 9 patients (64%). The onset depended on the functional refractory period of the fast pathway and once the linking was established in the dual pathways, the LW was related to the difference between the A-H interval immediately before and after the restoration of anterograde fast pathway conduction. These findings suggest that the linking phenomenon in dual AVN pathways occurs because of anterograde conduction block in the fast pathway and the subsequent concealed retrograde conduction of impulses propagated from the slow pathway.

Molecular characterization of Cryptosporidium isolates obtained from human and bovine infections in Japan

Cryptosporidium oocysts, morphologically identified as Cryptosporidium parvum, were isolated from 22 human and 14 bovine cases in Japan, and were genotyped by means of a PCR/RFLP analysis of the polythreonine gene. DNA profiles of human isolates gave three distinct genotypes, namely an anthroponotic genotype 1, zoonotic genotype 2 and a new genotype. Isolates from bovine samples gave zoonotic genotype 2. The unusual genotype of Cryptosporidium was isolated from the feces of three immunologically healthy adults, and was further characterized by the sequence analysis of the 18S rRNA gene. The third genotype was identified as Crypto sporidium meleagridis, demonstrating that C. meleagridis, which occurs worldwide, has the potential to infect humans regardless of their immunological condition.

Prevalence of Giardia lamblia infection in household dogs

A total of 1035 household dogs were examined for the presence of Giardia lamblia (G. lamblia) in their feces. Fecal samples from 151 (14.6%) of the dogs were positive for Giardia. The protozoan was more often detected in soft feces (26.4%) than in normal (10.0%) or diarrheic feces (13.7%) (p < 0.001 and p < 0.01, respectively). The forms of the organisms obtained from the 151 dogs were cysts (77.5%), trophozoites (9.9%), or both cysts and trophozoites (12.6%). Dogs kept indoors had a higher prevalence (18.5%) of Giardia than dogs kept outdoors (4.8%) (p < 0.001). Giardia infection was also more prevalent in 1-6 months old puppies (21.7%) compared to other groups (2.4%-7.5%) (p < 0.001). The prevalence of Giardia in dogs originally purchased from pet shops or breeding kennels was extremely high (21.5%) compared to that of dogs from individual households (4.3%) (p < 0.001). With regard to human public health, the high infection rate of Giardia in puppies and dogs kept indoors is a serious problem because G. lamblia in infected dogs may have zoonotic potential. No reports of human giardiasis transmitted from dogs have been made. However, the results of this study suggest that the risk of Giardia transmission from household dogs to humans is not negligible. Pet owners should be taught appropriate hygiene measures to prevent Giardia transmission from dogs to humans.

Comparative study of the reproductive organs of Fasciola groups by optical microscope

Reproductive organs of stained and mounted whole specimens of different types of Fasciola (F. hepatica, F. gigantica, and parthenogenetic diploid and triploid flukes) were observed to clarify the structure of their reproductive organs. The results are as follows; 1. Basic structure differences could not be identified. 2. The flukes without sperm, or those with an extremely small quantity in the seminal vesicle. are parthenogenetic Fasciola sp. 3. It was newly discovered that the surface of the cirrus is surrounded by many shallow gutters, and that spines form a line in the gutters. 4. The structure of the reproductive organ on the genus Fasciola are shown in detail in the figures.

Amino acid sequence and characterization of a rice bran ribonuclease

A base-nonspecific and acid ribonuclease (RNase Os) belonging to the RNase T2 family was purified from rice bran to a homogeneous state by SDS-PAGE. The primary structure of RNase Os was determined by protein chemistry and molecular cloning. The RNase Os was a simple protein and consisted of 205 amino acid residues. Its molecular weight was 22578 and its amino acid sequence showed that it was most similar to barley RNase among the known RNase T2 family enzymes having 157 amino acid residues identical with barley RNase. However, its N-terminus was blocked by a gamma-pyroglutamyl residue. The optimal pH of RNase Os was around 5.5. The base preference at the B1 and B2 site of RNase Os was estimated from the rates of hydrolysis of 16 dinucleoside phosphates, to be guanine as the case of RNase LE from tomato. RNase Os was successfully expressed from yeast cells using the E. coli yeast expression vector pYE-RNAP.