[Mitral valve replacement through a right thoracotomy, with intact coronary artery bypass grafts]

A 68-year-old male who had previously undergone aorto-coronary artery bypass grafting was admitted for mitral valve surgery. Because of the presence of anteriorly placed intact coronary artery bypass grafts, we used right thoracotomy to replace the mitral valve. Cardiopulmonary bypass was established after cannulation of the femoral artery and bicaval cannulation, and continuous retorograde cardioplegia with cold blood was infused. Residual air was evacuated through left ventricular vent catheter and aortic air vent hole. Post operative course was uneventful.

[A case of acute disseminated encephalomyelitis with lesions in the cerebral gray matter on MRI in the acute phase]

We reported a case of acute disseminated encephalomyelitis (ADEM) after Streptococcus infection. Brain MRI (T2-weighted image) showed high intensity lesion in the gray matter in the acute phase. The high intensity pattern of the lesion was different from those in previously reported cases. The boy, aged 14, had fever late in August 1993. He had lumbago and back pain since September 3 and also leg weakness developed since September 7. He became unable to urinate on September 10 and was admitted on September 12. His consciousness became indistinct. We considered ADEM on the basis of high CSF level of myelin basic protein, clinical course, symptoms and MRI findings and began to administer steroid hormone on the second day after admission. He rapidly recovered. We reported here an atypical case of ADEM as to the antecedent infection and MRI lesion.

[Characteristics and development of stump cancers of the stomach]

To clarify characteristics and development of stump cancers of the stomach, we studied 10 cases (12 lesions) of them with mucin-histochemical and immunohistochemical techniques and gene analysis using polymerase chain reaction. Sixty-seven % of the cancers were mostly composed of gastric-type cells and 67% also showed abnormal accumulation of p53 protein in their nuclei. There were scattered cells with abnormal accumulation of p53 protein in cystically dilated glands that were often found to be surrounding cancers. Immunohistochemistry of proliferating cell nuclear antigen also demonstrated proliferating activity of these cystic glands. It is suggested that the cystically dilatated gland is precancerous lesion of stump cancers of the stomach. The gene analysis showed less occurrence of K-ras abnormality, and the mutation of APC gene is suggested to be infrequent.

Different susceptibilities of lymphokine-activated killer cells (LAK cells) among primary and metastatic renal cell carcinoma derived from the same patient

OBJECTIVE

To investigate the susceptibility of primary renal cell carcinoma (RCC) and metastatic RCC to lymphokine-activated killer (LAK) cells using three RCC cell lines derived from the primary and metastatic tumours in a male patient with advanced RCC.

MATERIALS AND METHODS

Three RCC cell lines (named HANKS) were derived from a 44-year-old man with advanced RCC. HANKS-Pr, HANKS-Lu and HANKS-LN were established from the primary lesion and the metastatic lung and lymph node lesions, respectively. The susceptibility of HANKS cell lines to 18 different LAK cells obtained from either patients with urological cancer or from healthy volunteers was studied. The three groups of LAK cells were divided as follows: (A) LAK cells from RCC patients (n = 6); (B) LAK cells from patients with transitional cell carcinoma (TCC)/prostatic carcinoma (CaP) (n = 4) and (C) healthy volunteers (n = 8). A 51Cr-releasing cytotoxic assay was used to determine susceptibility.

RESULTS

The mean percentage lysis of the HANKS cell lines to the 18 allogenic LAK cells were 28.1% in HANKS-Pr, 20.2% in HANKS-Lu and 10.4% in HANKS-LN. The susceptibility of HANKS-LN to LAK cells was significantly lower than that of HANKS-Pr and HANKS-Lu in all three groups (P < 0.05). In contrast, the susceptibility of HANKS-Pr was significantly higher than HANKS-Lu in group A only (P < 0.01).

CONCLUSION

This is the first report to describe the different susceptibilities of primary RCC and metastatic RCC derived from the same patient. HANKS-LN itself might be the least susceptible to LAK cells because it was not related to the source of LAK cells. Furthermore, RCC may affect the cytotoxicity of LAK cells to HANKS-Pr. These data indicate there are at least two different types of mechanisms leading to the different susceptibilities of HANKS cells to LAK cells.

Cell type-oriented differential modulatory actions of saikosaponin-d on growth responses and DNA fragmentation of lymphocytes triggered by receptor-mediated and receptor-bypassed pathways

We examined the immunoregulatory action of saikosaponin-d (SSd), which was isolated from the root of Bupleurum talcatum L. and had a steroid-like structure, on murine thymocytes, and compared the action with that on spleen cells. Constitutive DNA synthesis or the growth response stimulated with anti-CD3mAb of thymocytes were down-regulated by 3 micrograms/ml SSd, whereas with spleen cells these were up-regulated by the same concentration of SSd. On the other hand, 3 micrograms/ml of SSd greatly up-regulated the growth response and interleukin 2 (IL-2)/interleukin 4 (IL-4) production induced through a receptor-bypassed pathway by calcium ionophore A23187 plus phorbol 12-myristate 13-acetate (PMA) in thymocytes, whereas it only slightly up-regulated them in spleen cells. Moreover, the same concentration of SSd inhibited DNA fragmentation in thymocytes induced by A23187 or PMA. These results suggest a unique cell type-dependent immuno-modulatory action of SSd.

[Surgical treatment for ischemic mitral regurgitation in patients with poor left ventricle]

Results of CABG with and without mitral valve surgery were analyzed retrospectively in 81 patients with ischemic mitral regurgitation (MR) to determine the effects of severity of MR and surgical treatment on survival. Seven of 81 patients had severe MR (more than Sellers III degrees/IV). Of these 7 patients, 5 patients underwent mitral valve replacement and 1 patient underwent mitral annuloplasty. Only one patient did not undergo valve surgery. This patient had slight improvement of the functional classification after CABG, but died of congestive heart failure 5 years after surgery. There were 3 hospital deaths and 5 late deaths in 81 patients. Among the 29 patients with poor left ventricle (EF < or = 0.3), there were 3 hospital deaths and 2 late deaths. Postoperatively, 12 patients had Sellers II degrees/IV or III degrees/IV MR. In 4 patients of these 12, the severity of MR was aggravated in comparison with the preoperative severity. Three of these 4 patients had perioperative myocardial infarction (PMI). IABP was utilized preoperatively in patients with poor left ventricle to keep the stable hemodynamics and prevent PMI. In these patients, there were no PMI, no hospital death, or no aggravation of MR. In conclusion, patients with Sellers I degree/IV or II degrees/IV MR require CABG only, whereas those with Sellers III degrees/IV or IV degrees/IV MR need CABG combined with mitral valve surgery. Preoperative use of IABP is useful for preventing PMI and aggravation of MR in patients with poor left ventricle.

Micturitional disturbance in myotonic dystrophy

Micturitional disturbance has attracted little attention in myotonic dystrophy, but detailed micturitional histories revealed that two out of six patients (33%) had micturitional symptoms. One had difficulty urinating and the other had urinary frequency, urgency and stress incontinence. Urodynamic studies were performed in all patients and the results were as follows: Two had low maximum urethral closure pressure, two had large and three had small bladder capacities, one had detrusor hyperreflexia and one had atonic cystometrogram. Urethral sphincter electromyography revealed a decreased bulbocavernosus reflex in one, and an absent anal reflex in two. Motor unit analysis of external sphincter was performed with one patient and showed polyphasic potentials. Dystrophic changes of the lower urinary tract muscles, as well as supranuclear type of pelvic nerve dysfunction, could cause micturitional disturbance in patients with myotonic dystrophy.

Duodenogastric reflux and foregut carcinogenesis

Epidemiologic cohort studies have established that after distal gastric resection, there is a higher risk of gastric carcinoma. It is likely that a main factor of this higher risk is the excessive duodenogastric reflux induced by surgery, because the incidence of stump carcinomas is higher in Billroth II than in Billroth I, and most of the stump carcinomas are located near the stoma. In addition, several groups of investigators have suggested that duodenogastric reflux per se induces stump carcinomas in rats. There is another human duodenogastric reflux, the primary duodenogastric reflux, through the pylorus. Experiments in animals have demonstrated that this type of duodenal reflux also induces gastric carcinomas in the antrum of the stomach that has not undergone surgery. Recent clinical attention has focused on the role of duodenogastric reflux in the pathogenesis of Barrett's esophagus and subsequent esophageal adenocarcinomas. Experimentally, reflux of duodenal contents into the esophagus can cause not only Barrett's esophagus and subsequent adenocarcinomas, but also squamous cell carcinomas. These findings suggest that duodenogastric reflux may be implicated in gastric and esophageal, that is, foregut carcinogenesis.

Differential regulation of the expression in transgenic tobacco of the gene for beta-glucuronidase under the control of the 5'-upstream regions of two catalase genes from castor bean

The regulatory functions of the 5'-flanking regions of two genes for catalase (cat1 and cat2) from castor bean were analyzed in transgenic tobacco plants that carried fusion constructs that included the gene for beta-glucuronidase (GUS) for Escherichia coli. Dry mature seeds from transgenic plants carrying the CAT1-GUS or CAT2-GUS constructs, in which the GUS gene was fused to the 5'-flanking region of cat1 or cat2, respectively, contained significant GUS activity, indicating that the promoters of cat1 and cat2 were active during seed development. GUS activity increased in response to germination in the seeds of transgenic tobacco that carried CAT1-GUS, as well as in those that carried CAT2-GUS. During the post-germinative stage the GUS activity directed by CAT2-GUS increased still further, whereas that directed by CAT1-GUS decreased. The changes in GUS activity in the transgenic tobacco plants that carried CAT1-GUS and CAT2-GUS were similar to the changes in the levels of transcripts of cat1 and cat2, respectively, in castor bean. The results suggest that the expression of cat1 and cat2 in the germinating seeds and post-germinative seedlings is regulated mainly at the level of transcription. However, the distribution of GUS activity among the organs of the transgenic tobacco seedlings and plantlets, which was examined by histochemical staining and by enzymatic assays of tissue extracts, was not identical to that of transcripts of cat1 and cat2 in castor bean. Histochemical analysis also revealed the interesting spatial regulation of the expression of the promoter of cat2 in the transgenic tobacco seedlings.

Use of a human immunodeficiency virus type 1 Rev mutant without nucleolar dysfunction as a candidate for potential AIDS therapy

Applications of transdominant mutants of human immunodeficiency virus type 1 (HIV-1) regulatory proteins, especially Rev mutant, have been attempted for gene therapy against AIDS, because the Rev protein is essential for viral replication. We have previously reported that a mutant Rev protein (dRev) lacking its nucleolar targeting signal remained out of nuclei in expressed cells and strongly inhibited the function of Rev. To investigate the effects of dRev on HIV-1 replication, we established several dRev-expressing human cell lines with two different vector systems and examined virus production in these cells. An HIV-1-derived vector containing drev cDNA was constructed and introduced into CD4-positive HeLa cells and cells of the human T-cell line CCRF-CEM (CEM). In dRev-expressing HeLa cells, virus replication, syncytium formation, and cell death caused by HIV-1 infection were remarkably suppressed, and the same vector also conferred a resistant phenotype on CEM cells. The production was also suppressed in CEM cells containing the drev gene driven by a cytomegalovirus promoter. In addition, we found that dRev did not cause nucleolar dysfunction in a transient assay, in contrast to other transdominant mutants and wild-type Rev. Since dRev cannot migrate into the nuclei, it is expected not to interfere with nuclear/nucleolar functions of the host cell. We conclude that dRev is one promising candidate as an antiviral molecule for gene therapy against AIDS.

[Absence of P300 in patients with bilateral hippocampal lesions caused by herpes simplex encephalitis]

In this study we investigated event-related brain potentials (ERPs) in response to somatosensory stimuli in two patients with bilateral hippocampal lesions caused by herpes simplex encephalitis. The patients had severe amnesia, but retained immediate memory, so that they could perform the odd-ball task according to experimental design with the instructions repeated at every session. The ERPs recorded from both patients were similar. In an odd-ball paradigm, early cognitive components, P100 and N140 were elicited to infrequent-target stimuli, but no P300 components were noted. Preservation of selective attention for target stimuli leading to decision was demonstrated by correct responses throughout the examinations. In one patient a clear P300 was visible after she recovered from her memory disturbance 8 months after its onset. These findings suggest that the hippocampus plays an important role in generating the P300, even if the primary generators are present elsewhere in the brain. On the other hand, our findings support the notion that the P300 is a post-decisional component, and has little relevance to decision-making in a series of information processing steps.

Suicide and suicide attempts in general hospital psychiatry: clinical and statistical study

Thirty-six psychiatric patients with completed suicide, 162 with attempted suicide and 154 patients referred for suicidal behavior, four of whom died, were investigated and classified according to the ICD-10. Thirty-six patients with completed suicide among 9085 new psychiatric patients (1969-92) gave a suicide rate of 82.6/100 000 per year. Schizoaffective and depressive disorder in psychiatric patients with completed suicide and schizophrenia, depressive disorder and adjustment disorders in patients with attempted suicide were significantly more frequent than in 312 controls. Intrafamilial conflicts, divorce or loss of love and death or severe disease of family member were the most common precipitants. Loneliness from living alone in males, losing a spouse and intrafamilial conflicts within a large family of three generations in females were supposed to be risk factors. A high referral rate of 48% in attempted suicide indicated the important role of consultation-liaison psychiatry in emergency medicine.

[Effects of Onpi-to (TJ-8117) on mesangial injury induced by anti Thy-1 antibody]

We investigated the effect of Onpi-to (TJ-8117) on the mesangial injury induced by anti-Thy-1 antibody. TJ-8117 (400 mg/kg/day, p.o.) given from the 1st day (from the day of injection of the anti-thymocyte serum) or 4th day (after mesangial proliferation), markedly inhibited the mesangial proliferation and hypercellularity in glomeruli. TJ-8117 prevented the increase in the number of PCNA or ED-1 positive cells in glomeruli. These results suggest that TJ-8117 is effective against glomerular disease with mesangial injury.

[The "pseudo-polyneuropathy" type sensory disturbances in cervical spondylotic myelopathy]

We reported the pseudo-polyneuropathy type sensory disturbances in cervical spondylotic myelopathy. We defined this clinical type by objective superficial sensory deficits of all four distal limbs, and excluded the patients having only subjective sensory disturbances. Ten out of 61 patients with cervical spondylotic myelopathy had sensory disturbances of this type. Two patients noticed difference of the subjective sensations of the upper and lower limbs. Eight patients developed sensory symptoms initially in the upper limbs. Pin-prick sensation was diminished in the upper limbs more predominantly than in the lower limbs. Vibration sense was affected in the lower limbs predominantly. Motor functions were mildly impaired, and muscle stretch reflex of triceps brachii was preserved in all ten patients. Distribution of sensory disturbances of four patients changed in their course. Nerve conduction studies and F-wave latencies were normal. Electromyography showed mild chronic denervation of the C5-C7 innervated muscles. Somatosensory evoked potentials after median or ulnar nerve stimulation showed delayed latencies or attenuated waveforms of N13 as well as P14 peaks. Spinal cord was compressed mainly at C4/5 and C5/6 intervertebral level, shown by myelography, CT-myelography or magnetic resonance imagings. We conclude that the pseudo-polyneuropathy type sensory disturbance of cervical spondylotic myelopathy indicates the lesion at mid-to-low cervical vertebral level. The anatomical substrates for this type of sensory impairment could be caused by combination of the dorsal horn/anterior comissure lesions for the upper limbs, and the anterolateral funiculi lesions for the lower limbs.

[Experience of modified Bentall's procedure for annulo-aortic ectasia]

To reduce the incidence of false aneurysm formation at the suture lines, a known complication with the inclusion technique such as Bentall's procedure or Cabrol's procedure, modified Bentall's procedure (Carrel patch technique), which is identical to Inberg's procedure, has been selected as treatment for annulo-aortic ectasia since 1991. This operation was carried out in 6 consecutive patients with annulo-aortic ectasia from July 1991 to August 1992. The aortic valve and the aneurysm were resected, the coronary ostia were dissected free, mobilized, and then implanted to the composite graft. It was necessary for one patient to undergo coronary artery bypass grafting for myocardial ischemia due to injury of the right coronary ostium. Thereafter, the button of coronary ostium was cut into a big size and then trimmed just before the implantation to the composite graft in order to prevent injury of the button of the coronary ostium. There was no hospital mortality. No pseudo-aneurysm at the coronary ostia or the distal aortic anastomosis was observed at control aortography carried out 1 month after surgery. One patient died 1 year after the first operation because of low cardiac output after the re-operation for pseudo-aneurysm at the proximal aortic anastomosis and infection of the composite graft. All the other patients have been symptom free during follow-up. The use of gelatin impregnated dacron graft and the reinforcement of the suture lines by Teflon felt strips minimized bleeding. One patient underwent this operation without blood transfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of left ventricular diastolic dysfunction on exercise capacity three to six weeks after acute myocardial infarction in men

To examine the effects of left ventricular (LV) diastolic dysfunction on exercise capacity, hemodynamic and radionuclide responses were measured at rest and during exercise in 50 patients with recent myocardial infarction. The ratio of an increase in pulmonary arterial wedge pressure (PAWP) to an increase in LV end-diastolic volume (EDV) from rest to peak exercise (delta PAWP/delta EDV) was used as an index of LV diastolic function, delta PAWP/delta EDV had modest and negative correlations with peak oxygen consumption (VO2), cardiac output, and stroke volume in all patients. Among patients with peak VO2 > or = 20 ml/min/kg (group I, n = 24) and those with peak VO2 < 20 ml/min/kg (group II, n = 26), there were no differences between the 2 groups with regard to resting LV ejection fraction, EDV, PAWP, cardiac output, and stroke volume. Although there was no significant difference in LV ejection fraction at peak exercise, group II had significantly reduced EDV, increased PAWP, and decreased cardiac output and stroke volume than those in group I. As a result, delta PAWP/delta EDV was significantly higher in group II. These results suggest that LV diastolic dysfunction has a key role in determining exercise capacity in patients with reduced exercise capacity after recent myocardial infarction.

Localization of urokinase-type plasminogen activator, plasminogen activator inhibitor-1, 2 and plasminogen in colon cancer

We examined the localization of urokinase-type plasminogen activator (u-PA), plasminogen activator inhibitors (PAI-1 and PAI-2) and plasminogen (plg) in 26 cases of colon cancer by immunohistochemical staining. The u-PA antigen was detected in the cytoplasm of cancer cells (18/26) and stromal cells adjacent to cancer tissues (9/26). The localization of u-PA mRNA examined by in situ hybridization was consistent with that of u-PA antigen. The PAI-1 antigen was detected in fibroblasts and endothelial cells (22/26), while PAI-2 antigen was found in cancer cells (20/26). The plg antigen was seen in the extracellular matrix of the cancer stroma. The u-PA expression in cancer cells was significantly more frequently detected in cases with lymph node metastasis than in cases without metastasis. In either PAI-1- or PAI-2-expressing cases, lymph node metastasis seemed to be restrained. These findings indicate that cancer cells themselves produce u-PA, and suggest that u-PA converts plg into plasmin, which dissolves the extracellular matrix surrounding cancer cells, resulting in cancer invasion and metastasis. PAI-1 and PAI-2 may have inhibitory actions on cancer invasion and metastasis mediated by u-PA.

Neurotrophic and neuroprotective effects of neuron-specific enolase on cultured neurons from embryonic rat brain

We previously reported that the gamma gamma-isozyme of enolase, NSE), one of the glycolytic enzymes, promoted the survival of embryonic rat neocortical neurons in culture, but alpha alpha-isozyme (non-neuronal enolase) had no effect. In the present study, the neurotrophic effects of NSE on cultured mesencephalic and spinal neurons from rat embryo were examined. NSE promoted the survival of neurons not only in neocortical cultures but also in mesencephalic and spinal cord cultures. Furthermore, NSE showed neuroprotective action on cultured neocortical neurons in a low-oxygen atmosphere. By contrast, non-neuronal enolase did not show any neurotrophic or neuroprotective activities. To clarify the mechanism of the neurotrophic effect of NSE, the binding of NSE to cultured neurons was determined by radio-receptor assay using 125I-labelled NSE. The specific binding, which was dose-dependent, saturable, and calcium-dependent, could be detected. These results suggest that NSE has neurotrophic and neuroprotective effects on rather a broad spectrum of neurons in the central nervous system. The existence of specific binding of NSE to cultured neurons suggests the possibility that receptor-like or carrier-like molecules on the neuronal surface are involved in the neurotrophic activity of NSE.

[3D-CT of the temporal bone area with high-speed processing]

Three-dimentional (3D)-CT was introduced to represent abnormal findings in the temporal bone area utilizing a SOMATOM DRH CT scanner with accessory 3D reconstruction software and an exclusive high-speed 3D processing system, VOXEL FLINGER. In a patient with eosinophilic granuloma, a defect in the squamous part of the temporal bone was demonstrated suggesting exposure of the dura mater during surgery. In a patient with a normal ear, well-developed mastoid cavity, a part of the handle and the head of the malleus, the incudomalleal joint, the short limb, body and a part of the long limb of the incus and the round window niche were demonstrated. In a case of chronic otitis media, poorly developed mastoid cavity and a possible defect of the tip of the long limb of the incus were demonstrated, in contrast to the patient with the normal ear. 3D-CT yields objective and solid images which are useful for diagnosis, treatment planning and explanation of the pathology to patients and their family. To obtain convincing 3D images, physicians themselves have to choose exact rotation angles. It is not adequate to reconstruct original CT data using a CT computer with accessory 3D software whose processing capability is not good enough for this purpose. The conclusion is as follows: 1) it is necessary and effective to transfer original CT data into the memory of the exclusive high-speed 3D processing system and 2) process the data by the voxel memory method to establish a clinically valuable 3D-CT imaging system.

Plasminogen binds specifically to alpha-enolase on rat neuronal plasma membrane

Plasminogen (PGn) that we identified in microglial-conditioned medium has a neurotrophic factor-like effect on cultured neurons. We have also shown that PGn binds specifically to a protein with a molecular mass of 45 kDa in the neuronal plasma membrane. As a candidate PGn receptor-like molecule on the neuronal surface, this 45-kDa protein was purified from the plasma membrane of embryonic rat brain. Amino acid sequence analysis of polypeptides derived from the cleavage of the protein with cyanogen bromide and V8 protease revealed that the 45-kDa protein is identical to rat alpha-enolase. In fact, PGn was found to bind to purified rat alpha-enolase and also to a synthetic peptide (30 residues) that corresponds to the carboxyl terminal region of rat alpha-enolase. Physical properties of the 45-kDa protein, such as molecular mass, isoelectric point, and the ability to form dimers, are quite similar to those of alpha-enolase. The 45-kDa PGn-binding protein in the plasma membrane was also recognized by anti-rat alpha-enolase antibody, and pretreatment with alpha-enolase antibody markedly diminished the PGn-binding to the plasma membrane. In addition, immunocytochemical staining of the cultured cells under the nonpermeable condition showed that alpha-enolase is present on the cell surface of a certain population of neurons. These results suggest that alpha-enolase may function as a PGn-binding molecule on the neuronal cell surface.

OK-432 chemical pleurodesis for the treatment of persistent chylothorax

A 52-year-old woman with thoracic esophageal carcinoma was admitted to our hospital. Standard radical esophagectomy was carried out via a right posterolateral thoracotomy and laparotomy. A drainage tube was removed from the right side of the chest on the 9th postoperative day. Three days later a chest roentgenogram showed massive left pleural effusion, and a tube was inserted into the left pleural cavity. The volume of the effusion was 900 ml/day and chylothorax was diagnosed. Conservative therapy was applied for 30 days, but chyle leakage persisted. Intra-pleural infusion of OK-432, a Su-strain of Streptococcus pyogenes, and doxycycline hydrochloride was carried out to seal the leakage point. The effusion stopped immediately after the procedure. There were no major side effects. This procedure should be considered the treatment of choice for patients with persistent chylothorax not responding to initial conservative management.