Nephrotic syndrome in the elderly--clinicopathological study

Clinical and pathological findings and the effects of therapy were investigated in 90 cases of nephrotic syndrome (NS) in elderly patients aged over 60 years. Membranous nephropathy was the most frequent type of primary NS. Amyloidosis and malignancy were common causes of secondary NS. Damage to the interstitium in the kidney, such as focal mononuclear cell infiltration, fibrosis and thickening of the small arterial wall in membranous cases, was often observed. Stage I and II based on electron-microscopy, were mainly observed in the patients, with membranous nephropathy. Prednisolone and immunosuppressive agent were most effective in these patients with membranous nephropathy. Prednisolone alone was the most effective on minimal change NS in the elderly. In the course of therapy, side effects such as pneumonia, sepsis due to fungus infections, such as aspergillus and candida, and infection, such as cytomegalovirus and herpes zoster, were more frequently observed, especially in the cases of MPGN, DPGN with moderate to severe mesangial proliferation, with a decline in renal function (Ccr < 50 L/day) and secondary NS. In secondary NS, the prognosis of amyloidosis was very poor and the findings pointed to a relationship between malignancy and nephrotic syndrome.

Characterization of HCV structural proteins expressed in various animal cells

Hepatitis C virus (HCV) is a main causative agent for transfusion-associated and sporadic cases of non-A, non-B hepatitis throughout the world. HCV has a positive-strand RNA of about 9,400 nucleotides as its genome, whose organization is similar to those of animal pestiviruses or human flaviviruses. In spite of the lack of an effective replication system in tissue culture cells, genes coding for viral proteins of HCV have been identified. The putative nucleocapsid (p22) and envelope (gp35 and gp60) proteins have been expressed in cells by different vectors under various foreign promoters. Furthermore, a truncated core protein and association of envelope proteins with nonstructural proteins have also been observed. These synthesized viral proteins have been shown to be useful for diagnostic assays.

OK-432-combined adoptive immunotherapy as a prognostic factor in peritoneal metastasis from gastric cancer

Prognostic factors, such as preoperative status, intraoperative findings, and postoperative treatments, were evaluated in 61 patients with peritoneal metastasis from gastric cancer treated in our facility between 1979 and 1991. Since 1986, 23 patients have been treated with OK-432-combined adoptive immunotherapy (AIT). OK-432-combined AIT is a sequential treatment via a catheter inserted into the abdominal cavity, using a streptococcal preparation, OK-432, followed by the transfer of lymphocytes cultured with T cell growth factor and sonicated tumor extract. A univariate analysis showed that six factors consisting of: (1) age, (2) resection of primary lesion, (3) grade of peritoneal metastasis or serosal invasion, (4) chemotherapy, (5) OK-432, and (6) OK-432-combined AIT influenced survival. The survival of the patients given OK-432-combined AIT (median survival time; MST = 7.5 months) was significantly (P = 0.0267) longer than that of those not receiving OK-432-combined AIT (MST = 4.3 months). A multivariate analysis showed that the most significant factors associated with survival were chemotherapy, resection of the primary lesion, and OK-432-combined AIT. Since these three factors are all therapeutic procedures, the use of combination therapy including OK-432-combined AIT is thus expected to prolong the survival of gastric cancer patients with peritoneal metastasis.

Protective role of intracellular superoxide dismutase against extracellular oxidants in cultured rat gastric cells

We examined the role of intracellular superoxide dismutase (SOD) as an antioxidant by studying the effect of diethyldithiocarbamate (DDC) on extracellular H2O2-induced damage in cultured rat gastric mucosal cells. 51Cr-labeled monolayers from rat stomachs were exposed to glucose oxidase-generated H2O2 or reagent H2O2, which both caused a dose-dependent increase in 51Cr release. DDC dose-dependently enhanced 51Cr release by hydrogen peroxide, corresponding with inhibition of endogenous SOD activity. This inhibition was not associated either with modulation of other antioxidant defenses, or with potentiation of injury by nonoxidant toxic agents. Enhanced hydrogen peroxide damage by DDC was significantly prevented by chelating cellular iron with deferoxamine or phenanthroline. Inhibition of cellular xanthine oxidase (possible source of superoxide production) by oxypurinol neither prevented lysis by hydrogen peroxide nor diminished DDC-induced sensitization to H2O2. We conclude that (a) extracellular H2O2 induces dose dependent damage to cultured gastric mucosal cells; (b) intracellular SOD plays an important role in preventing H2O2 damage; (c) generation of superoxide seems to occur intracellularly after exposure to H2O2, but independent of cellular xanthine oxidase; and (d) cellular iron mediates the damage by catalyzing the production of more reactive species from superoxide and H2O2, the process which causes ultimate cell injury.

An efficient expression vector for stable expression in human liver cells

The expression of the bacterial neomycin resistance (NmR)-encoding gene was examined under control of the promoter region of the gene encoding the human polypeptide chain elongation factor 1 alpha (EF-1 alpha). In a human liver cell line, HepG2, the plasmid pEF321-neo directed higher expression of the bacterial neo gene than the NmR gene expression vectors using other promoters, like the SV40 early region or thymidine kinase of Herpes simplex virus and SV40 early region promoter linked to human T-cell leukemia virus-1 enhancer sequences.

Binding ability of complement receptor CR1 to C3 bound on the surface of M+ group A streptococci

A previous study demonstrated that although M+ bacteria bound C3, mainly C3b and iC3b, via the classical pathway of complement activation, they were not phagocytosed by polymorphonuclear leucocytes (PMN). To elucidate this mechanism, we attempted to distinguish between the possibilities that M+ bacteria are effectively adhering to PMN but are not being endocytosed, or that the C3 deposited on M+ bacteria is not able to interact with the complement receptors on PMN. In the present study, we studied the interaction of C3-coated M+ bacteria with complement receptor CR1, which was isolated from the stroma of human erythrocytes. We show that the isolated complement receptor CR1 can associate with C3-coated M+ bacteria as well as with C3-coated M- bacteria, and the C3 deposited on M+ bacteria is cleaved and releases a C3 fragment in the presence of factor I and liquid-phase CR1. These results suggest that the C3 bound on the surface of M+ bacteria is able to promote adherence to the complement receptor CR1 on PMN. We also studied the distribution of C3 deposited on M+ bacteria in normal human serum (NHS) or normal human plasma (NHP). By immunofluorescence, we show that the C3 bound to M+ bacteria in NHS was deposited uniformly over the surface of the bacteria. On the other hand, the C3 bound to M+ bacteria in NHP was deposited at both ends between adjacent daughter cocci. The results suggest that an additional factor contained in NHP is related to the enhancement of anti-phagocytic activity of M+ bacteria.

The induction of murine tumor infiltrating lymphocytes (TIL) by interleukin-2 or T cell growth factor

Mice were injected in the foot pad with either 5 x 10(5) syngeneic plasmacytoma (MOPC104E) or fibrosarcoma cells (Meth A). Lymph nodes containing tumor cells were harvested 14 days later and cultured. In the presence of recombinant interleukin-2 (r-IL-2) predominantly tumor cells proliferated. Culture with T cell growth factor (TCGF) resulted in the growth of lymphoid cells. Concanavalin A (Con A) had only a modest effect on elimination of tumor cells in the culture. Tumor-infiltrating lymphocytes (TIL) prepared from the lymph nodes showed specific tumor-neutralizing activity when grown in the presence of TCGF. In vitro examination revealed that Meth A cells could not be lysed by TIL, while TIL from MOPC tumors showed tumor specific activity. This study may explain negative results in human trials with TIL induced by IL-2 alone.

"Paradoxical" AH shortening caused by proximal coronary sinus stimulation during orthodromic reciprocating tachycardia

INTRODUCTION

During extrastimulation or entrainment of orthodromic atrioventricular (AV) reciprocating tachycardia (ORT), the atrium-His (AH) interval as measured at the His-bundle recording site is expected to lengthen due to extrastimulation-dependent or pacing rate-dependent slowing of AV nodal conduction by impulses that penetrate the tachycardia circuit. We report 6 patients in whom the AH interval "paradoxically" shortened during ORT in response to extrastimulation and rapid pacing from the proximal coronary sinus.

METHODS AND RESULTS

Accessory pathway location was right anterior (1 patient), right anteroseptal (1 patient), and left anterior (4 patients). Cycle length of ORT was stable (variation < or = 5 msec) and ranged from 325 to 410 msec. During ORT, extrastimulation and rapid pacing were performed from the proximal coronary sinus and the right atrium. Extrastimulation from the proximal coronary sinus late in diastole caused significant shortening of AH interval in all patients by a mean of 18 +/- 3 msec (range 15 to 20 msec). AH shortening was demonstrated without a change of either the timing or morphologic appearance of the low septal right atrium at the His-bundle recording site. This phenomenon was not observed during right atrial extrastimulation. Rapid pacing from the proximal coronary sinus at cycle lengths of 305 to 390 msec (i.e., 15 to 20 msec shorter than the cycle length of each ORT) again demonstrated shortening of AH interval in all patients by a mean of 15 +/- 3 msec (range 10 to 20 msec). By contrast, rapid pacing from the right atrium demonstrated classical AH prolongation at any paced cycle length.

CONCLUSION

AH shortening without a change of either the timing or morphologic appearance of the low septal right atrium at the His-bundle recording site confirms the existence of a distinct posterior atrial input to the AV node. In this setting low septal right atrial activation is not requisite for AV nodal conduction. Whether activation of the low septal right atrium is essential for, or contributes to, AV nodal conduction of atrial impulses from locations other than the proximal coronary sinus needs to be determined.

Surgical strategy for papillary carcinoma of the thyroid in an iodine rich area: decision on the operation table

In iodine rich areas the incidence of papillary carcinoma of the thyroid is extremely high but its prognosis is favorable. When papillary carcinoma is confined to one lobe, our standard surgical procedure has been total lobectomy with isthmusectomy rather than total thyroidectomy. Our followup study of 185 such patients reveals considerable difference in the outcome between the 85 patients with gross thyroid capsular invasion and the 100 patients without, regardless of the presence of cervical lymph node metastasis. In the latter group, the tumor could be completely resected in all patients; although 4 cases had recurrence and required reoperation, 3 patients are alive and well and one died of other disease. In contrast, 20 patients in the former group had incomplete resection of the tumor, 4 patients developed recurrence and needed to be reoperated and 7 patients eventually died of thyroid cancer. One hundred thirty three patients (71.9%) underwent modified neck dissection at the time of surgery to find lymph node metastasis in 37 of 59 cases (62.7%) without gross thyroid capsular invasion and 64 of 74 cases (86.5%) with such invasion. The difference is statistically significant (P < 0.05). From these results we conclude that for papillary thyroid cancer in iodine rich areas total lobectomy with isthmusectomy is the treatment of choice when gross thyroid capsular invasion is not recognized on the operation table. However, when gross thyroid capsular invasion is recognized, total or near total thyroidectomy has to be performed.

[Late malfunction of the Björk-Shiley valve prosthesis due to Delrin disc defacement]

A 55-year-old woman eighteen years after mitral valvular replacement with Delrin disc Björk-Shiley valve prosthesis underwent a reoperation of prosthetic valve replacement for the prosthetic malfunction due to disc defacement. The patient suffered from faintness and vertigo at rest. An echocardiographic examination showed a moderate mitral insufficiency with a normal disc movement. Precise examination on the removed prosthesis revealed accelerated defacement of disc margin which made the ring-disc clearance up to 0.35 mm and strut-shaped groove formation on the inlet surface of the disc occluder. These findings suggested a pronouncedly earlier disc wear than predicted by Björk and co-workers. We concluded, therefore, that a patient undergone a valve replacement with Delrin disc Björk-Shiley valve should be examined periodically by echocardiography even though being without any symptoms.

An electrocochleographic study of acute low-tone sensorineural hearing loss

Twenty-four patients with acute low-tone sensorineural hearing loss (ALHL) were examined using electrocochleography. The negative summating potential (SP) amplitude and the summating potential/action potential (AP) ratio were significantly greater in the ALHL patients than in normals. The SP/AP ratio was smaller in the ALHL patients than in patients with known Meniere's disease and moderate hearing loss, although the SP amplitude was somewhat greater in the former. An abnormal increase in the SP amplitude following click stimuli was found in 54% of the ALHL patients, while the SP/AP ratio was increased abnormally in 63% of these patients. These findings suggest that the pathophysiology of ALHL may be similar to that for endolymphatic hydrops.

Enhanced secretion of endothelin by endothelial cells in response to hemoglobin

Confluent cultures of bovine aortic endothelium in serum-free medium were exposed to increasing concentrations (10(-6)-10(-4) M) of freshly prepared erythrocyte lysates (primarily hemoglobin). Hemoglobin increased endothelin-1 secretion into the medium in a dose-dependent manner after 24 hours. The enhanced secretion of endothelin-1 in response to hemoglobin was sustained for 72 hours, suggesting active production and secretion of endothelin-1 rather than release from intracellular pools. Secreted endothelin-1 in the medium was characterized by high-performance liquid chromatography coupled with radioimmunoassay. Endothelin-1, a potent and long-lasting vasoconstrictor, may be one of the causative factors of cerebral vasospasm after subarachnoid hemorrhage. Oxyhemoglobin, derived from periarterial clot, may play an important role in the secretion of endothelin-1 in cerebral vasospasm.

Vitamin A status in biliary atresia: intestinal absorption and liver storage of retinol

The vitamin A status of 19 patients with corrected biliary atresia was examined. They had been receiving 5,000 IU of oral vitamin A daily postoperatively. Plasma vitamin A levels in the nonjaundiced group were almost within normal range, whereas those in the jaundiced group were significantly low compared with the controls. In the oral vitamin A tolerance test, plasma vitamin A levels increased from 33.1 +/- 11.8 to 215.4 +/- 100.7 micrograms/dL in the nonjaundiced group, and from 23.1 +/- 10.3 to 209.8 +/- 154.2 micrograms/dL in the slightly jaundiced group, at 4 hours after the administration of vitamin A, showing no difference between both group and control. In the severely jaundiced group, plasma vitamin A levels increased from 13.5 +/- 3.5 to 30.0 +/- 14.6 micrograms/dL, a significantly smaller increase compared with controls. However, liver vitamin A levels were greater than 20 micrograms/g liver in all patients, irrespective of the presence of jaundice. This study suggested that nutritional support to facilitate the synthesis of retinol-binding protein may be an important factor in addition to vitamin A supplementation.

Dermis-fat graft after parotidectomy to prevent Frey's syndrome and the concave deformity

Dermis-fat grafts were performed on 7 patients at the time of parotidectomy to prevent Frey's syndrome and the characteristic concave deformity. Only 1 patient demonstrated postoperative Frey's syndrome, and 1 demonstrated a slightly concave deformity due to fat absorption. Although other barrier materials have been reported to achieve success in preventing gustatory sweating, our method simultaneously corrects the associated deformity of facial contour as well.

Primary CD8+ lymphoepithelioid lymphoma of the skin

We describe an 82-year-old man with CD8+ lymphoepithelioid lymphoma localized to the skin. The skin lesion had been present for 18 years. Histologically there was a dense infiltrate that consisted of atypical lymphoid cells and large epithelioid cells, thereby resembling the so-called Lennert's lymphoma. Local radiotherapy proved effective in reducing the size of the tumor. To the best of our knowledge, this is the first report of primary lymphoepithelioid lymphoma of the skin.

Alterations of heart rate and of heart rate variability after radiofrequency catheter ablation of supraventricular tachycardia. Delineation of parasympathetic pathways in the human heart

BACKGROUND

Persistent inappropriate sinus tachycardia has been reported as a complication after radiofrequency (RF) ablation of the fast atrioventricular (AV) nodal pathway. The purpose of this study was to evaluate the prevalence of this complication and its mechanism using heart rate variability analysis.

METHODS AND RESULTS

Time and frequency domain analysis of heart rate was performed in the electrophysiology laboratory immediately before and immediately after RF ablation in 64 patients with supraventricular tachycardia. Ablation targets in these 64 patients included the fast AV nodal pathway (n = 3), the slow AV nodal pathway (n = 14), a posteroseptal accessory pathway (n = 23), and a left lateral accessory pathway (n = 24). A control group of 21 patients undergoing diagnostic study but not ablation underwent identical analysis immediately before and at the conclusion of their procedure. Patients undergoing ablation also had time and frequency domain analysis performed on ambulatory 24-hour Holter tapes recorded before ablation and at 1 day, 1 month, and 6 months after ablation. Compared with preablation values, time domain analysis immediately after ablation revealed a significant increase in mean heart rate and significant reductions in heart rate variability expressed as SD, MSSD, and PNN50 in patients undergoing AV nodal modification or posteroseptal accessory pathway ablation. Frequency domain analysis revealed marked attenuation of high frequency (0.15 to 0.40 Hz) components, indicating parasympathetic denervation. These acute changes were not seen after ablation of left lateral accessory pathways or after diagnostic study without ablation. Time and frequency domain analysis of 24-hour ambulatory Holter monitors performed serially after ablation revealed resolution of abnormalities of heart rate and of heart rate variability 1 to 6 months after ablation, with reappearance of the high frequency parasympathetic component suggestive of reinnervation.

CONCLUSIONS

RF ablation in the anterior, mid, and posterior regions of the low interatrial septum may disrupt preganglionic or postganglionic parasympathetic fibers located in these regions that are destined to innervate the sinus node. Such fibers become more scarce along the left AV groove with increasing distance from the posteroseptal space. Parasympathetic denervation may be one mechanism for persistent inappropriate sinus tachycardia after RF ablation.

Relationship between osteopenia and clinical characteristics of Parkinson's disease

Pathological bone changes affect locomotor activity and may influence the outcome and prognosis of Parkinson's disease (PD). In this study, we determined the relationship between bone changes and PD. Bone study was performed by multiple scanning x-ray photodensitometry (MD/MS) in 64 patients with PD and 42 age-matched controls. We then compared the results with the clinical characteristics of PD. Osteopenia was detected in 22 (53.6%) of the 41 female and 6 (26%) of the 23 male patients, and in 6 (26%) of the 23 female and 2 (10.5%) of the 19 male controls. The frequency of osteopenia was significantly greater in the female patients than in the male patients or the female controls. Osteopenia was related to the duration of PD in the men, but not in the women. Twenty of 40 PD patients' hands showed side-related differences in the analysis of both hands. In 19 of the 20 patients, the side of more severe osteopenia coincided with that of parkinsonian symptoms, suggesting that osteopenia is related to the pathophysiology of PD.

[A case report of BWG syndrome in an elderly patient performed with mitral valve replacement 11 years after single CABG]

A 46-year-old female who had undergone single CABG for BWG syndrome 11 years ago was referred to our hospital for paroxysmal atrial fibrillation. The roentgenogram showed slightly cardiomegaly and the enlargement of LA. Ischemic changes of ECG appeared at I, aVL, V5, V6, as inverted T wave, and low voltage R wave at V1-V4, but non Q wave. The thallium-201 emission computed tomogram at exercise revealed poor perfusion at apical region without redistribution pattern. Catheterization showed mitral regurgitation (grade III), big right coronary artery (RCA) arising from aorta, rich collateral to poor left coronary artery (LCA), and bypass graft was obstructed. The proximal end of LCA was closed, and didn't arise from both pulmonary artery and ascending aorta. In this cases, MVR only without re-CABG to LCA was selected and performed. Postoperative course was uneventful. The result of this case suggested that MVR was an effective surgical procedure for MR of BWG syndrome in the adult case and it was better to add CABG to LCA as much as possible if the ischemic region was large.

Omentum as gliding material after extensive forearm tenolysis

Tendon adhesion occurring after major replantation can be severe and extensive due to the nature of the trauma, ischaemia, prolonged oedema and/or infection. Therefore there is a high possibility of re-adhesion after tenolysis. In two cases of tenolysis after forearm replantation omentum was used as gliding material and good results were obtained.

Surgical management of large hepatocellular carcinomas: criteria for curative hepatectomy

This study was designed to determine the criteria for curative resection in hepatectomy for large hepatocellular carcinoma. The extent of resection was closely related to recurrence rate, and complete removal of the involved segments was found to be essential for curative hepatectomy. Patients with satellite nodules had a high incidence of recurrence; in fact, carcinoma recurred in all patients, with satellite nodules scattered through more than one segment, despite whole tumor removal. However, curative resection could be achieved in patients with portal involvement confined to the second portal branches, when the tumor, including tumor thrombi, was removed en bloc. On the basis of these results, we define complete en bloc removal of the involved segments, including portal involvements, as curative resection, even though curative hepatectomy is not attainable in patients with satellite nodules in more than one segment and/or tumor thrombi in the first branches or truncus of the portal vein.