Beat-to-beat variation of the ST segment in a patient with right bundle branch block, persistent ST segment elevation, and ventricular fibrillation: a case report

The authors describe a patient with ventricular fibrillation associated with right bundle branch block-like QRS morphology and persisting ST segment elevation in the precordial leads, in whom the morphology of the ST segment changed from the coved type to the saddle-back type or vice versa on a beat-to-beat basis. Such an observation has never been reported in the previous literature.

Cloning of a Vibrio alginolyticus rpoN gene that is required for polar flagellar formation

A fragment of DNA was cloned which complemented a polar flagellum-defective (pof) mutation of Vibrio alginolyticus. The fragment contained two complete and two partial open reading frames (ORFs) (ORF2 and -3 and ORF1 and -4, respectively). The presumed product of ORF2 has an amino acid sequence with a high degree of similarity to that of RpoN, which is an alternative sigma factor (sigma54) for other microorganisms. The other ORFs are also homologous to the genes adjacent to other rpoN genes. Deletion analysis suggests that ORF2 complements the pof mutation. These results demonstrate that RpoN is involved in the expression of polar flagellar genes.

Two cases of torsion of the gallbladder diagnosed preoperatively

BACKGROUND

The authors experienced two cases of torsion of the gallbladder, both of which were correctly diagnosed preoperatively.

METHODS

Two boys, aged 4 and 5 years, were transferred to Yokohama City Seibu Hospital because of their acute abdominal disorders. Diagnostic imaging demonstrated acute inflammatory changes in the gallbladder with an abnormal arrangement of the gallbladder and common bile duct in both cases. Laparotomy findings showed torsion of the gallbladder by 180 degrees and 360 degrees, respectively, at the cystic ducts, resulting in gangrenous change.

RESULTS

Both children recovered uneventfully after cholecystectomy. The diagnostic imaging criteria are (1) collection of fluid between the gallbladder and the gallbladder fossa of the liver, (2) a horizontal rather than vertical arrangement of the long axis of the gallbladder, (3) the presence of a well-enhanced cystic duct located on the right side of the gallbladder, and (4) signs of inflammation including marked edema with thickening of the wall.

CONCLUSIONS

The authors report the clinical characteristics of this uncommon condition, and discuss the significance of accurate preoperative diagnosis of these acute surgical disorders.

[Total synthesis of antitumor macrolide, rhizoxin and chemistry of acylsilane]

The first total synthesis of the antitumor macrolide rhizoxin in a highly stereo-controlled manner was described. The construction of the key building fragments required for the total synthesis of the antitumor macrolide rhizoxin, that arose from our retrosynthetic analysis of rhizoxin in an optically pure form by concise and efficient sequence analyses was described. Synthesis of the right-wing was started from the chiral half-ester generated by asymmetric hydrolysis of the corresponding meso-diester using pig liver esterase. The remaining chiral centers of the fragment was constracted by cyclic hydroboration. Synthesis of the left-wing was also accomplished starting from (S)-methyl 3-hydroxy-2-methylpropionate which had been prepared by enzyme mediated transformation. Coupling of the right-wing and the left-wing was accomplished by Julia coupling, and the macrocyclic lactone was constructed by the intramolecular Horner-Emmons reaction. The control of the stereoselective epoxidations was well achieved after the formation of an unsaturated 16-membered macrocyclic lactone. Chromophore-side-chain moiety was constructed at the final stage by the reaction of the phosphineoxide in 80% yield with high selectivity (E/Z = > 20/1). The present methodology will be useful for the synthesis of the homologues and man-made rhizoxin.

Case study of a five-stage sensory reeducation program

The purpose of this paper is to describe a sensory reeducation program classified into five stages: (1) feature detection and recognition of objects; (2) correction of the pattern of prehension in the hand; (3) control of precise force for grasping objects; (4) maintenance of grip force during movement of the proximal joints; and (5) manipulation of objects. The program is specific to hand function in activities of daily living and is based on recent neurophysiological findings. It is illustrated by a detailed case study. The authors report that, through sensory reeducation a patient who had an insensitive hand gained the ability to recognize objects. She learned to utilize a sense of muscle resistance and a sense of vibration in the shoulder. Her body image improved along with the usefulness of her hand in activities of daily living.

Influence of combined use of selenious acid and SH compounds in parenteral preparations

The influence of the combined use of selenious acid and SH compounds (glutathione (GSH) and cysteine (Cys), or ascorbic acid (Asc)) on cultured venous vascular cells was investigated experimentally. When cultured human umbilical venous vascular endothelial cells were exposed to 10 microM of selenious acid combined with 0.5 mM-GSH or 0.5 mM-Cys, the release rates of [3H]-adenine and lactate dehydrogenase (LDH) from cells into the medium increased significantly as compared with after exposure to selenious acid alone, and damage to the vascular endothelial cells was found to be intensified. Addition of 1 microM of selenious acid simultaneously with 0.5 mM-GSH or 0.5 mM-Cys showed no differences in toxicity for the vascular endothelial cells as compared with the addition of selenious acid alone. On the other hand, simultaneous exposure to 10 microM of selenious acid and 1 mM-Asc induced no significant differences in the release rates of [3H]-adenine and LDH, and no damage was observed to the vascular endothelial cells. These results suggest that simultaneous addition of selenious acid together with GSH or Cys, which have the SH-group, may cause damage to the vascular endothelial cells. Therefore careful attention is warranted in total parenteral nutrition (TPN).

Cross-reactivity to olive tree pollen and orchard grass pollen in patients with pollinosis

We studied 92 patients with allergic rhinitis in Syodoshima, Japan, during the pollen season between April and June to evaluate the cross-reactivity to different antigens, including pollen from the olive tree (Olea europaea) and orchard grass (Dactylis glomerata). Olive tree pollen was present in the atmosphere for 23 days, from May 19 to June 12, 1994. Specific IgE antibodies for olive tree pollen antigen were present in 21 (26.9%) of the 78 patients with allergic rhinitis. Nine (24.3%) of the 37 patients with allergic rhinitis exhibited positive skin reactivity to an extract of olive tree pollen. Fifteen (88.2%) of the 17 patients who had IgE reactivity in their sera to olive tree pollen antigen demonstrated allergic reactions to an extract of olive tree pollen. Specific IgE antibodies for orchard grass pollen antigen were present in 43 (48.3%) of the 89 patients with allergic rhinitis and 20 (95.2%) of the 21 patients who had IgE reactivity in their sera to olive tree pollen antigen. The inhibition test using the CAP System revealed that the reactivity of the IgE antibody specific for olive tree pollen antigen was inhibited dose-dependently by an extract of orchard grass pollen. These findings show that there is a reaction in some patients with grass (Gramineae) pollinosis that might be induced by olive tree pollen.

Immunologic reaction and genetic factors in biliary atresia

The characteristic histopathological features seen in the livers of patients with biliary atresia (BA) are very similar to those of primary biliary cirrhosis, which is an autoimmune disease. To clarify whether BA liver possess an immunological response similar to that in primary biliary cirrhosis, we studied HLA-DR expression in liver tissue of BA patients, using a HLA-DR staining method, and determined the frequency of HLA types in BA patients and their families. HLA-DR was expressed by the bile duct epithelium in 11 of 16 liver specimens obtained from 13 BA patients. By contrast, HLA-DR was not expressed in liver specimens from 6 patients with congenital biliary dilatation. Among the HLA types seen in BA patients and their families, HLA-A33, -B44 and -DR6 were frequently expressed in blood. These results suggest that certain immunological factors and disease-susceptible genes might be involved in the etiology of BA.

[Usefulness of the interlocking detachable coil for the repeatedly ruptured dissecting aneurysm of the vertebral artery in the acute stage]

A 44-year-old male with a repeatedly ruptured dissecting aneurysm of the vertebral artery (VA) manifesting with subarachnoid hemorrhage was successfully treated with endovascular surgery using an interlocking detachable coil (IDC). He had a dissecting aneurysm in the left VA distal to the left posterior inferior cerebellar artery (PICA). Because the dissecting aneurysm ruptured repeatedly and his clinical condition was moribund, direct surgery was not indicated. The dissecting aneurysm was embolized with an IDC and additional platinum coils. Among patients with a ruptured VA dissecting aneurysm, proximal occlusion is generally indicated. But the direct embolization of a dissecting aneurysm can be applied in cases in which the aneurysm is ruptured repeatedly in the acute stage. IDC is a useful and safe material for endovascular surgery of a ruptured VA dissecting aneurysm.

Digestive tract disorders associated with asplenia/polysplenia syndrome

The authors reviewed experience gained over a 20-year period of asplenia or polysplenia syndrome, focusing on patients with associated digestive tract disorders (DTDs). Eleven of 27 patients (40%) with asplenia/polysplenia had associated DTDs. The DTDs comprised malrotation of the intestine in nine, both preduodenal portal vein and gastric volvulus in three, esophageal hiatal hernia in two, and biliary atresia in one. Laparotomy was carried out on four patients with symptoms of acute bowel obstruction and on one patient with biliary atresia. One patient with both malrotation and gastric volvulus, and another with only associated malrotation survived. Nine patients died, eight of cardiac insufficiency and one because of hepatic insufficiency. When infants are diagnosed with heterotaxia, they should be examined for other combined DTDs, because they may have a chance for survival if they undergo surgery when their condition is still stable.

Contrast-enhanced MRI of intrasellar arachnoid cysts: relationship between the pituitary gland and cyst

We recently encountered two large intrasellar arachnoid cysts extending to the suprasellar region. The intensity of the cyst contents was identical to that of the cerebrospinal fluid on both T1- and T2- weighted MRI. On contrast-enhanced MRI, the pituitary gland was compressed posteroinferiorly and flattened in the sella turcica. In this report of rare intrasellar arachnoid cysts the discussion is focused on dislocation of the pituitary gland.

[Studies on cerebrospinal fluid penetration of cefpirome in adult with meningitis]

A patient with intracerebral hematoma suffered from postoperative bacterial meningitis. Staphylococcus aureus was found from CSF. The organism was multiple drug resistant and refractory to antibiotics including piperacillin (PIPC), cephalexin (CEX), cefotaxime (CTX), ceftazidime (CAZ) and latamoxef (LMOX). It was susceptible to cefpirome (CPR). Treatment with CPR resulted in clinical improvement associated with clearing of the organism from CSF. Serum level of CPR was high enough and CPR penetration into the CSF was satisfactory. The results suggest that CPR is an extremely effective antibiotic for meningitis caused by CPR-susceptible bacteria. Evaluation of the CPR penetration into the CSF of adult meningitis was rarely reported. The result we obtained was important in the treatment for the adult meningitis.

Selenium administration to a ten-year-old patient receiving long-term total parenteral nutrition (TPN)--changes in selenium concentration in the blood and hair

Muscle pain in the lower limbs occurred in a child with short bowel syndrome who has been receiving longterm total parenteral nutrition (TPN). Biochemical parameters revealed that the plasma and erythrocyte selenium concentrations were below the normal range for children and intravenous injection of selenium prepared from selenious acid was started at a dose of 100 micrograms per day. Muscle pain in the lower limbs disappeared one month afterwards. At this point in time, the elevation of the plasma selenium concentration was noted but the erythrocyte selenium concentration remained low. When administration was suspended due to catheter-induced fever five months later, the whole blood selenium concentration decreased again and the symptoms recurred. Accordingly, the dose of selenium was increased to 200 micrograms/day. Subsequently, the blood selenium concentration recovered to the normal range for children. After the dose increase to 200 micrograms/day, concentrations in hair samples collected at every centimeter distance from the root end were determined. The selenium concentration at the root end was found to be higher than the normal range for children, indicating that this was an excessive dose case. Although the dose was decreased from 200 micrograms/day to 120 micrograms/day, the plasma and erythrocyte selenium levels did not go down. Furthermore, the selenium level in the hair reached a plateau, and no recurrence of symptoms was observed. The above results indicate the usefulness of monitoring the selenium concentration in hair in addition to determining the blood selenium level and GSH-Px activity in administering selenium to children undergoing TPN.

Epitope analysis of HLA-DR-restricted helper T-cell responses to Der p II, a major allergen molecule of Dermatophagoides pteronyssinus

T-cell epitopes of Der p II, a major allergen of Dermatophagoides pteronyssinus, were analyzed by using human T-cell clones. We tested 38 cloned T cells from two Japanese patients with allergic rhinitis, and identified at least two peptides (K33-T47 and I58-C73) as helper T-cell epitopes. The former epitope was shown to be restricted by HLA-DRB1*1502, and the latter by HLA-DRB1*0405, both of which are typical Japanese HLA-DR alleles, suggesting that those T-cell epitopes might be important for the onset of house-dust mite allergy in the Japanese population. We prepared 15 analog peptides of the HLA- DRB1*1502-restricted 15-mer peptide. Of those 15 residues, five (F35, L37, A39, F41, and E42) were critical for the epitope activity, and three residues (F35, A39, and E42) seemed to be included in anchor motifs for HLA-DRB1*1502. The epitope peptide was also recognized by HLA-DRB1*1502-positive healthy donors; however, only allergic T cells showed Th2 functions. Antigen-presenting cells of nonallergic donors were able to activate allergic T cells to express Th2 function. This seemed to suggest that antigen recognition of T cells, as well as additional unknown factors which promote Th2, rather than Th1, responses, might be important for the onset of house-dust mite allergy.

Doppler ultrasonographic evaluation of hepatic circulation in patients following Kasai's operation for biliary atresia

The hepatic circulation of eight children who underwent Kasai's operation for biliary atresia was serially evaluated by Doppler ultrasonography (US). A total of 36 examinations were performed to evaluate the maximal velocities (mvs) of the main portal vein (MPV), splenic vein (SV), and hepatic artery (HA), and to analyze the spectral waveform and the directions of flow. The mean mvs-MPV in four patients for whom adequate biliary diversion had been achieved and whose serum bilirubin had fallen to within the normal range (group A), was 19.8 +/- 7.5 cm/s. Their MPV waveforms were constant, with blood flowing toward the liver, while their mean mvs-SV was 12.1 +/- 5.8 cm/s. In two other patients with apparent hypersplenism, but whose serum bilirubin levels had fallen to nearly normal (group B), the mean mvs-MPV was 20.7 +/- 10.4 cm/s and the mvs-SV was 22.4 +/- 10.4 cm/s. In contrast, the mvs-MPV in the two remaining patients, whose serum bilirubin levels had either not fallen to within the normal range, or had fallen initially but increased due to recurrent cholangitis (group C), was 14.2 +/- 9.1 cm/s. In these patients, the waveforms were unstable, the MPV flows were occasionally hepatofugal, and their mean mvs-SV was 18.0 +/- 5.8 cm/s. The mvs-HA were markedly increased in the latter four patients, whose clinical condition had also deteriorated. These observations led to the conclusion that hepatic circulation evaluated by serial Doppler US provides important information about liver status in children who have undergone Kasai's operation for biliary atresia.

Radiolabeling of catalytic subunits of PI 3-kinases with 17 beta-hydroxy-16 alpha(-)[125I]iodowortmannin: identification of the G beta gamma-sensitive isoform as a complex composed of 46-kDa and 100-kDa subunits

A fungal metabolite, wortmannin, is a potent inhibitor of phosphatidylinositol (PI) 3-kinases. In the present study, we prepared a radiolabeled derivative of wortmannin, 17 beta-hydroxy-16 alpha(-)[125I]iodowortmannin. The compound bound tightly to a 110-kDa subunit in the previously identified isoform of PI 3-kinase (p85/p110), and also to a 100-kDa peptide in a partially purified preparation of another isoform of PI 3-kinase whose activity was markedly stimulated by the beta gamma subunits of GTP-binding proteins (G beta gamma). The binding to both peptides was inhibited by non-radiolabeled wortmannin and also by LY294002, another inhibitor of PI 3-kinases. An antibody against p85 recognized a 46-kDa peptide in the G beta gamma-sensitive isozyme and precipitated the 100-kDa peptide specifically labeled with 17 beta-hydroxy-16 alpha(-)[125I]iodowortmannin. These results suggested that the newly found isozyme was a complex composed of 46-kDa and 100-kDa peptides.

A chimeric IgG4 monoclonal antibody directed against CD18 reduces infarct size in a primate model of myocardial ischemia and reperfusion

OBJECTIVES

This study attempted to determine whether neutrophil sequestration in reperfused myocardium can be inhibited and infarct size reduced by treatment with a chimeric, monoclonal IgG4 antibody (CLB54) directed against CD18 in a primate model of acute myocardial ischemia and reperfusion.

BACKGROUND

Reperfusion injury, in part mediated by neutrophils, may limit the potential benefit of reestablishing infarct-related artery patency in patients with acute myocardial infarction.

METHODS

Nineteen closed-chest baboons (10 control, 9 treated with CLB54) had the left anterior descending coronary artery occluded for 90 min, followed by 4 h of reflow. CLB54 (mean [+/- SD] 11 +/- 2 mg/kg body weight) or saline solution was administered intravenously 20 min before reflow. Coronary flow was determined using radiolabeled microspheres, infarct size by triphenyltetrazolium chloride staining, global and regional ventricular function by contrast ventriculography and neutrophil accumulation by a myeloperoxidase assay.

RESULTS

Risk region size was the same in both groups. CLB54 treatment reduced infarct size expressed as a percent of the risk region from 41 +/- 20% in the saline-treated group to 19 +/- 17% in the CLB54-treated group (p < 0.02). This was associated with diminished myeloperoxidase activity and greater postreperfusion coronary flow in the risk region in CLB54-treated than in control baboons. Ejection fraction declined to the same extent in both groups, whereas anterior wall regional cord shortening was better preserved in CLB54-treated baboons.

CONCLUSIONS

Inhibition of neutrophil sequestration with CLB54 administered before reperfusion reduces infarct size, preserves ischemic zone microvascular perfusion and minimizes the decline of regional wall motion.

Papillo-choledochectomy in the operative management of mucosal neoplasms of the periampullary region

Two patients with mucosal cancer of the periampullary region were treated with papillo-choledochectomy, which entails removal of the papilla of Vater and the whole length of the common bile duct. The neoplasm is dissected out through the plane between the duodenal circular and longitudinal muscles, deep to the sphincter of Oddi and the fibromuscular layer of the bile duct. Pathological examination showed that cancer was confined to the mucosal layer without stromal invasion, and that the operation achieved radical cure. For mucosal cancer, papillo-choledochectomy is an alternative to pancreatoduodenectomy, provided that repeated frozen-section studies confirm the completeness of excision.

Localization of a constant-touch and moving-touch stimulus in the hand: a preliminary study

There are limited normative data available defining a subject's ability to localize a constant-touch or moving-touch stimulus. The results that are obtainable to date have not been objectively measured so that they are reproducible. This study of a normal population suggests a standard to measure the error in a patient's capacity to localize both a constant-touch and a moving-touch stimulus. The normative data demonstrate that in considering the ability to localize a constant-touch stimulus, there was less error of localization in the fingers than in the palm. The most sensitive finger was the index. In testing for localization of a moving-touch stimulus, seven types of responses were identified and classified. The procedure outlined in this study offers a means both to document the degree of sensory impairment in a more consistent manner and to objectively measure results of early-phase sensory re-education.